Outcomes of patients presenting with acute coronary syndromes on workdays vs. rest days (SPUM-ACS substudy)

Introduction

Conflicting data exist upon whether patients presenting with acute coronary syndromes (ACS) during on- or off-hours differ regarding outcomes. Moreover, definitions of on- and off-hours vary in literature. The notion of a weekend effect with increased mortality has been raised, mostly seen in relation to lesser use of invasive treatment.

Purpose

This multi-center study investigated the baseline characteristics and associated outcomes of patients presenting with ACS undergoing coronary angiography on weekdays compared to those presenting on weekends or holidays.

Methods

Data from the prospective SPUM-ACS (Special Program University Medicine Acute Coronary Syndromes and Inflammation) Cohort were examined, with patients recruited between 2009 and 2012. Patients were divided into two groups according to whether they presented for coronary angiography for ACS on workdays (Monday-Friday, 00:00–23:59) or on rest days (Saturday or Sunday, 00:00–23:59, and public holidays shared by all centers). Time of presentation was defined as time point of catheter sheath insertion.

Results

From a total of 2168 patients (21.4% females), 1828 (84.3%) presented on workdays, 340 (15.7%) on rest days without difference in female/male ratio. On rest days, patients more often showed signs of advanced heart failure (Killip Class III–IV 3.9% vs. 7.1%, p=0.009). Patients presented more frequently with ST-segment elevation ACS (STE-ACS) than non-ST-segment elevation ACS (STE-ACS on workdays vs. rest days: 50.4% vs. 65.0%, p<0.001).

In- and out-of-hospital time delay metrics did not differ between groups, apart from symptom onset-to-balloon time, which was shorter on rest days (598 vs. 520 min, p=0.040). There was a trend towards more frequent use of percutaneous (89.2% vs. 92.6%, p=0.053) or surgical (3.3% vs 5.0%, p=0.131) revascularization on rest days.

30-day all-cause mortality was higher on rest days for any ACS (1.75% vs 3.82%, p=0.007) and for STE-ACS only (2.39% vs 4.98%, p=0.019, Fig. 1). Notably, the same trend was seen when comparing only patients presenting with Killip Class III/IV, both for any ACS (11.27% vs. 20.83%, p=0.119) and for STE-ACS (14.00% vs. 26.32%, p=0.114). On rest days, female patients showed higher 30-day all-cause mortality than males for any ACS (7.46% vs 2.93%, p=0.042); the same trend was observed for STE-ACS (8.89% vs. 3.98%, p=0.088).

Conclusions

On rest days, patients more often presented with STE-ACS and more frequently showed signs of advanced heart failure, with similar use of invasive revascularization as for patients presenting on workdays. This might contribute to higher early mortality observed in ACS patients on rest days. These differences persisted within the subgroups STE-ACS and Killip Class III/IV. Interestingly, female patients showed increased early mortality on rest days compared to males. Thus, patients presenting with ACS on rest days warrant particular attention.

Funding Acknowledgement

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

Interrelation between baseline plaque characteristics and changes in coronary atherosclerosis with the PCSK9-inhibitor alirocumab: insights from the PACMAN-AMI randomized trial

Background

Patients with acute myocardial infarction (AMI) frequently experience recurrent atherothrombotic events, largely attributable to non-culprit lesions with high-risk characteristics. Statins can halt the progression of coronary atherosclerosis, and addition of protein convertase subtilisin/kexin type 9-inhibitors (PCSK9i) results in incremental low-density lipoprotein cholesterol (LDL-C) lowering and atheroma regression.

Purpose

We sought to examine the interrelation between baseline imaging characteristics, on-treatment LDL-C levels, and changes in coronary atherosclerosis as assessed by serial, multi-modality intracoronary imaging in patients with AMI.

Methods

This is a post hoc analysis from the PACMAN-AMI randomized trial. Patients were randomly allocated to biweekly alirocumab 150 mg vs. placebo on top of high-intensity statin initiated within 24h of presentation with AMI, and underwent serial imaging of the two non-infarct-related arteries at baseline and after 52 weeks. The primary endpoint was percent atheroma volume (PAV) by intravascular ultrasound (IVUS). Powered secondary endpoints were maximal lipid core burden index (maxLCBI4mm) by near-infrared spectroscopy (NIRS) and minimum fibrous cap thickness (FCTmin) by optical coherence tomography (OCT).

Results

Of 300 randomized patients (mean age 58.5±9.8 years, 18.7% women, baseline LDL-C 3.94±0.87 mmol/L), IVUS was serially performed in 265 patients (537 arteries). LDL-C levels decreased to 1.92±0.79 mmol/L with placebo and 0.61±0.61 mmol/L with alirocumab (p<0.001). Compared with placebo (statin alone), alirocumab added to statin resulted in greater PAV reduction (−2.13% vs. −0.92%; p<0.001), greater maxLCBI4mm reduction (−79.42 vs. −37.60; p=0.006), and greater increase in FCTmin (62.67 vs. 33.19 μm; p=0.001). Changes in PAV and maxLCBI4mm were inversely related to on-treatment LDL-C levels, and change in FCTmin was positively related to on-treatment LDL-C levels (Figure 1). Across all patients, we found significant, inverse relationships between change in PAV and baseline PAV [slope: −0.072 (95% CI −0.101 to −0.042); p<0.001], between change in maxLCBI4mm and baseline maxLCBI4mm [slope: −0.437 (95% CI −0.505 to −0.369); p<0.001], and between change in FCTmin and baseline FCTmin [slope: −0.436 (95% CI −0.541 to −0.332); p<0.001]; these findings indicate greater PAV and maxLCBI4mm regression in lesions with greater PAV and LCBI4mm at baseline, and greater fibrous cap thickening in lesions with thinner fibrous caps at baseline.

Conclusion

In this study of intensive LDL-C lowering treatment initiated in the acute AMI setting, more favorable plaque changes were observed in patients with lower on-treatment LDL-C levels and in lesions with more adverse baseline plaque characteristics. Whether AMI patients with high-risk plaque features might derive greater clinical benefit from early initiation of intensive LDL-C-lowering therapies requires further investigation.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Sanofi, Regeneron

Optimal CW-Doppler derived parameter for the diagnosis of iatrogenic mitral stenosis during transcatheter edge-to-edge repair for mitral regurgitation

Introduction

Transcatheter Edge-to-Edge repair (TEER) for mitral regurgitation (MR) is a minimal invasive alternative to surgery for high risk patients. One of the principal disadvantage is the risk of creating a stenosis (MS). The optimal parameter and its cut-off to monitor mitral valve area (MVA) during TEER is currently not defined and usually only the mean transmitral gradient (Gd) is used.

Method

116 patients with complete 3D MVA measurements and CW-Doppler derived mean and maximal diastolic transmitral Gd, and pressure half time (PHT) before the intervention and after each TEER device implantation were included in this study. A clinically significant MS was defined as a 3D MVA <1.5 cm2 according to the ESC guidelines. Because the mean Gd is known to be extremely dependent on the heart rate (HR) this parameter was “normalized” for a frequency of 60/min: norm. mean Gd = (mean Gd/HR) × 60. The accuracy of the different CW-derived parameters to diagnose or predict a MS was evaluated using a ROC analysis.

Results

47% of the patients suffered from a secondary MR, 53% were treated with one device and 47% with two. According to the 3D MVA measurements, after one device 16 and after two devices 12 patients had a clinically significant MS. The ROC analyses for the diagnosis of a significant MS after one device (Figure 1) show a maximal AUC of 0.99 for PHT with an optimal cut-off of 151ms (sensitivity 94%, specificity 95%), followed by norm. mean Gd (AUC 0.96, 3.16mmHg, 100%, 82%), mean Gd (AUC 0.92, 3.6mmHg, 88%, 83%) and max. Gd (AUC 0.92, 8.5mmHg, 94%, 83%). Combining three different cut-offs (PHT 164ms or norm. mean Gd 4.7mmHg or max. Gd 12mmHg) a sensitivity of 100% and a specificity of 98% was achieved. The prognostic value of these same parameters to predict a MS after two devices was much less optimal according to the ROC analyses: PHT, AUC 0.82, 100ms, 83%, 59%; norm. mean Gd AUC 0.73, 2.8mmHg, 67%, 81%; mean Gd AUC 0.70, 2.4mmHg, 83%, 51%; max. Gd AUC 0.69, 8.4mmHg, 50%, 85%. The diagnostic value of the CW-derived parameters measured after the implantation of two devices to detect a MS was better (Figure 2): PHT, AUC 0.92, 142ms, 92%, 78%; norm. mean Gd, AUC 0.87, 3.4mmHg, 92%, 73%; mean Gd, AUC 0.81, 3.9mmHg, 92%, 71%; max. Gd AUC 0.74, 8.6mmHg, 83%, 66%. The cut-offs for PHT without false negative and with the maximal specificity were: 140ms (specificity 86%) to diagnose a MS after one device, 93ms (specificity 56%) to predict a MS after a second device implantation and 133ms (specificity 63%) to detect a MS after two devices.

Conclusion

PHT is the most accurate CW-derived parameter to diagnose or make a prognostic of clinically significant mitral stenosis after TEER. Given the possible disastrous consequence of a iatrogenic stenosis, these parameters should only be used with cut-offs offering a sensitivity of 100% and when a value above these limits is measured, then decisions should be based of 3D MVA measurements.

Funding Acknowledgement

Type of funding sources: None.

Heavy weekly alcohol consumption versus binge drinking after an acute coronary syndrome and risk of major adverse cardiovascular events at one year follow up

Background

The association between heavy weekly alcohol consumption or binge drinking and the risk of major adverse cardiovascular events (MACE) after acute coronary syndromes (ACS) is still unclear.

Purpose

To determine the risks of MACE at one year follow up according to baseline alcohol consumption, especially in patients with heavy weekly alcohol consumption or binge drinking.

Methods

We analyzed data of 6053 patients hospitalized in 4 Swiss centres for an ACS and followed over 12 months. Data on alcohol consumption were collected at baseline and at one year follow up after ACS. Binge drinking was defined as the consumption of ≥6 units of alcohol on one occasion, for the 12-months period preceding the one-year follow up. We defined MACE as a composite of cardiac death, myocardial infarction, stroke or clinically indicated target vessel coronary revascularization. We applied Cox regression to assess the risk of MACE associated with heavy alcohol weekly consumption (>14 standard units/week) compared to light consumption (<1 standard unit/week) or abstinence, as well as the risk with binge drinking, compared to no binge drinking, adjusting for baseline differences (age, sex, body-mass index, smoking, diabetes, peripheral artery disease, stroke, hypertension, use of aspirin, anticoagulation, statin, beta-blocker, ACE-inhibitor or ATII receptor blocker).

Results

At baseline, 817 (13.4%) patients reported heavy weekly alcohol consumption and 717 (11.8%) reported to have at least one episode of binge drinking per month. The risk for MACE at one year follow up was not increased in those with heavy weekly consumption compared to light consumption (8.7% vs. 8.5%, HR 0.96, 95% CI 0.69–1.33, P=0.80) or no consumption (8.7% vs. 10.3%, HR 1.26, 95% CI 0.88–1.80, P=0.21). However, the risk of MACE was higher in those reporting binge drinking with less than one episode a month (9.4% vs. 7.7%, HR 1.67, 95% CI 1.32–2.12, P<0.001), as well as in those with at least one episode of binge drinking per month (13.4% vs. 7.7%, HR 2.07, 95% CI 1.62–2.65, P<0.001), when compared to no binge drinking.

Conclusion

In contrast to regular heavy alcohol consumption, binge drinking behavior is associated with significant increased risk of MACE 12 months after ACS.

Funding Acknowledgement

Type of funding sources: None.

Statin therapy intensity and physical activity after acute coronary syndrome

Introduction/Purpose

High-intensity statin after acute coronary syndrome (ACS) may cause reduced physical activity because of statin-associated muscle symptoms. We aimed to assess the association between statin intensity and physical activity one year after ACS.

Methods

We studied patients from the Special Program University Medicine-Acute Coronary Syndromes (SPUM-ACS) study, a large multicenter prospective Swiss cohort. In a cross-sectional assessment one year after the index ACS, we identified high-intensity, low/moderate intensity, and no statin users. Physical activity was assessed with the International Physical Activity Questionnaire (IPAQ). Using a multivariable adjusted negative binomial hurdle model, metabolic equivalent-minutes per week (MET-min/week) were first stratified into sedentary and physically active categories, and then analyzed continuously among physically active patients. Models were adjusted for age, sex, education, body mass index, depression, type of ACS, pre-existing chronic disease, premature coronary heart disease, LDL-cholesterol, anti-hypertensive treatment, cardiac rehabilitation, and follow-up medical visits after hospital discharge.

Results

Among the 2274 patients included in the SPUM-ACS cohort, 1222 (53.7%) were on high intensity statin, 890 (39.1%) on low/moderate intensity statin, and 162 (7.1%) were not on statin. Compared to no statin users, low/moderate intensity statin users were more likely to be physically active than sedentary, with a fully adjusted odds ratio (OR) of 2.78, 95% confidence interval (CI) 1.11–6.93. A similar association was found when comparing non-users with high-intensity statin users, with a fully adjusted OR of 4.18, 95% CI 1.65–10.60. Among physically active patients, physical activity level median scores were 2792.5 MET-min/week in no statin category, 2712.0 and 2839.5 in moderate/low statin category and high statin category respectively (p=0.307), showing no statistically significant difference with median ratios of 1.02, 95% CI 0.84–1.22 and 1.06, 95% CI of 0.88–1.27 for low/moderate intensity and high-intensity statin use, respectively.

Conclusion

One year after an ACS, neither low/moderate nor high-intensity statin was associated with reduced physical activity compared to no statin use. These findings go against the belief that statin therapy may lead to reduced physical activity among ACS patients because of associated muscular symptoms.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Center for primary care and public health (Unisanté)

Impact of alirocumab added to high-intensity statin therapy on platelet function in AMI patients: a pre-specified substudy of the randomized, placebo-controlled PACMAN-AMI trial

Background

Previous small observational studies have suggested a potential association of proprotein convertase subtilisin kexin type 9 (PCSK9) and platelet reactivity. However, the role of the PCSK9 inhibitor alirocumab on platelet aggregation among patients with acute myocardial infarction (AMI) remains unknown.

Purpose

We investigated the effect of alirocumab on P2Y12 reaction unit (PRU) on top of high-intensity statin therapy among AMI patients receiving dual antiplatelet therapy (DAPT) with a potent P2Y12 inhibitor (ticagrelor or prasugrel).

Methods

This was a pre-specified, powered, pharmacodynamic substudy nested within the PACMAN (effects of the PSCK9 antibody AliroCuMab on coronary Atherosclerosis in patieNts with Acute Myocardial Infarction) trial, a randomized, double-blind trial comparing biweekly alirocumab (150mg) versus placebo in AMI patients undergoing percutaneous coronary intervention (PCI). Patients recruited at Bern University Hospital, receiving DAPT with either ticagrelor or prasugrel at 4 weeks and adherent to the study drug (alirocumab or placebo) were analyzed for the current study. The VerifyNow P2Y12 point-of-care assays were used to measure PRU at baseline (i.e. before first study drug administration), 4 weeks, and 52 weeks after study drug administration (higher PRU levels indicating greater platelet aggregation). The primary endpoint was PRU at 4 weeks.

Results

Among 139 randomized patients (mean age 58.2 years [SD, 9.5], 21 [15.0%] women, mean LDL-C level 150.6mg/dL [SD, 30.9]), baseline characteristics were well balanced between groups including baseline PRU (50.0 [IQR, 120.0] in the alirocumab group vs. 62.0 [IQR, 122.0] in the placebo group, P=0.75). At 4 weeks, mean LDL-C was significantly lower in the alirocumab group (23.5 [SD, 23.7] mg/dL vs. 74.4 [SD, 30.5] mg/dL, P<0.001). The majority of patients received ticagrelor DAPT at 4 weeks (57 [86.4%] vs. 69 [94.5%], P=0.14). There were no significant differences in PRU at 4 weeks (12.5 [IQR, 27.0] vs. 19.0 [IQR, 30.0], P=0.26) and at 52 weeks (25.0 [IQR, 37.0] vs. 34.0 [IQR, 59.0], P=0.07) (Figure). Consistent results were observed in 126 patients treated with ticagrelor (i.e. after excluding 13 patients treated with prasugrel) at 4 weeks (13.0 [IQR, 20.0] vs. 18.0 [IQR, 27.0], P=0.28).

Conclusion

Among AMI patients receiving DAPT with potent P2Y12 inhibitors, alirocumab had no significant effect on platelet function as assessed by PRU.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Bern University Hospital

Acute impact of transcatheter edge-to-edge repair for mitral regurgitation on left ventricular function

Introduction

Transcatheter Edge-to-Edge repair (TEER) for the therapy of mitral valve regurgitation (MR) is an alternative to surgery for high risk patients. It is a minimal invasive procedure but the acute impact of the pre- and afterload decrease, due to the reduction of both MR and mitral valve area (MVA), on the left ventricle (LV) systolic function was never formally evaluated.

Method

Fifty patients with mixed MR etiologies from our TEER register with complete 3D datasets of the LV before and after TEER were included in this study. LV volumes and function, as evaluate by ejection fraction (LVEF), global longitudinal strain (LV-GLS) and global circumferential strain (LV-GCS), and the MR (3D vena contracta area, 3D VCA) were evaluated before and at the end of the therapy.

Results

The majority of patients suffered from secondary MR (54%), one TEER device was implanted in 64% and two in 36% of the population. TEER leads to a significant reduction of all the LV volume and function parameters excepted for the end-diastolic volume which increased non-significantly (Table 1). The decrease of the LVEF was linked to a decrease of both GLS and GCS in a multivariate analysis (r 0.85), the decrease of GCS having a higher influence (beta −0.606 vs −0.435). In the univariate linear analysis, the reduction of LVEF, GLS and GCS were inverse proportional to the LVEF before TEER and direct proportional to the reduction of the 3D VCA. LVEF decrease was also directly linked to MVA percental reduction. After multivariate evaluation, LVEF reduction kept linked to LVEF before TEER and VCA 3D reduction (r=0.51, p=0.001), GCS decrease only to VCA 3D reduction (r=0.371, P=0.08) and GLS diminution only to LVEF before TEER (r=0.313, p=0.027).

Conclusion

After TEER, left ventricular function reduction seems principally linked to the afterload increase (i.e. the MR reduction); the circumferential function and the left ventricles with the highest ejection fractions being apparently maximally impacted.

Funding Acknowledgement

Type of funding sources: None.

Causes of death in patients with atrial fibrillation and a recent acute coronary syndrome or percutaneous coronary intervention: insights from the AUGUSTUS trial

Background

Patients with atrial fibrillation (AF) and concomitant coronary artery disease are at increased risk for poor outcomes. Less is known about specific causes of death in this population.

Methods

We describe specific causes of death among patients with AF and acute coronary syndrome and/or percutaneous coronary intervention included in the AUGUSTUS trial and followed for 6 months. An independent clinical events committee, blinded to treatment assignment, adjudicated cause of death according to pre-defined criteria. The association between baseline factors and all-cause death was evaluated using Cox proportional hazards modeling.

Results

A total of 151 deaths occurred in 4614 patients and were adjudicated as follows: 111 (73.5%) deaths due to cardiovascular (CV) causes and 40 (26.5%) due to non-CV causes. The most common cause of CV death was sudden death (n=39 [35.1%]), followed by myocardial infarction (n=29 [26.1%]) and heart failure (n=24 [21.6%]). The most common causes of non-CV death were infection (n=11 [27.5%]), bleeding (n=8 [20.0%]), and malignancy (n=5 [12.5%]). Increasing age, African American race, history of heart failure, treatment with diuretics, and lower body weight were associated with an increased risk of all-cause death (Table).

Conclusions

Among patients with AF and coronary artery disease, cardiovascular causes were responsible for the majority of deaths within 6 months. Our findings provide relevant information to inform the design of future studies in this population.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): AUGUTUS was funded by Bristol Myers Squibb and Pfizer.

Effect of alirocumab added to high-Intensity statin therapy on endothelial function in patients with acute myocardial infarction: a sub-study of the randomized placebo-controlled PACMAN-AMI trial

Background

Endothelial dysfunction is involved early in the development of vascular dysfunction leading to atherosclerosis and cardiovascular diseases. Statins have shown to improve endothelial function. The role of the protein convertase subtilisin/kexin type 9-inhibitor (PCSK9) alirocumab on endothelial function among patients with acute myocardial infarction (AMI) remains unknown.

Purpose

We investigated the effect of alirocumab on endothelial function among AMI patients receiving PCSK9i alirocumab in addition to high intensity statin therapy.

Methods

This is a pre-specified, sub-study nested within the PACMAN-AMI (effects of the PCSK9 antibody AliroCuMab on coronary Atherosclerosis in patieNts with Acute Myocardial Infarction) trial, a randomized trial that compared the effects of biweekly PCSK9-inhibitor alirocumab 150 mg vs. placebo, initiated within 24h of presentation in patients with AMI on top of high-intensity statin. Patients recruited at Bern University Hospital and adherent to the study drug (alirocumab or placebo) were analysed for the current study. Endothelial function was assessed by flow mediated dilation (FMD) of the brachial artery at week 4 and 52 after treatment initiation.

Results

Among 139 patients (68 alirocumab, 71 placebo) completing the sub-study, baseline characteristics were well balanced between groups (alirocumab vs. placebo: mean age 57.5±10.1 years vs. 58.7±8.4 years, p=0.45; mean LDL-C 4.03±0.93 mmol/L vs. 4.05±0.74 mmol/L, p=NS). At week 52 LDL-C levels decreased to 0.65±0.71 mmol/L in the alirocumab group and to 1.98±0.71 mmol/L in the placebo group (p<0.001). There was no difference in FMD at 52 weeks in the alirocumab (5.44±2.24%) versus placebo (5.45±2.19%) group (between groups difference FMD, −0.21% (95% CI −077 to 0.35), p=0.47). Compared to baseline, follow-up FMD was improved in both groups (from 4.52±1.87 to 5.44±2.24%, p<0.001 in the alirocumab group and from 4.32±1.62 to 5.45±2.19%, p<0.001 in the placebo group).

Conclusion

Among patients with acute myocardial infarction, the addition of subcutaneous biweekly alirocumab, compared with placebo, to high-intensity statin therapy did not result in additional improvement of endothelial function after 52 weeks of treatment.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): The PACMAN-AMI study was supported by a research grant from Sanofi, Regeneron and Infraredx. This substudy was funded by the University of Bern.

Efficacy and safety of early aspirin withdrawal and continuation of ticagrelor monotherapy post PCI for STEMI. A post hoc analysis of the randomized global leaders trial

Background

Clinical presentation with STEMI is considered as a highly prothrombotic condition often associated with recurrent ischemic events. The role of aspirin as part of antiplatelet regimens in STEMI patients needs to be clarified especially in the context of new potent P2Y12 inhibitors

Aim

To assess the benefit and risk of 23-month ticagrelor monotherapy after one month of DAPT against the conventional 12-month DAPT with aspirin and ticagrelor followed by aspirin monotherapy among STEMI patients in the GLOBAL LEADERS trial.

Methods

We did a post hoc analysis of STEMI patients in the GLOBAL LEADERS trial (2092 patients). We compared the experimental ticagrelor monotherapy group (1062 patients) with the standard 12-month DAPT group (1030 patients) in rates of GLOBAL LEADERS predefined primary (composite of all-cause mortality or non-fatal, new Q-wave myocardial infarction (MI) and secondary end points (BARC 3 or 5 bleeding). NACE (Net Adverse Clinical Events) and POCE (Patient- Oriented Composite End points). We also compared GLOBAL LEADERS predefined end points in STEMI, UA, NSTEMI and CCS in both treatment arms.

Results

At two years, there were no significant differences in rates of GLOBAL LEADERS primary end points in patients who had or did not have STEMI. BARC bleeding in either treatment group didn't vary significantly among STEMI, NSTEMI and UA. Nevertheless, the experimental strategy had led to significant increase in BARC bleeding in CCS compared with STEMI at 1 and 2 years. There were similar rates of NACE and POCE in both the experimental and reference treatment groups at 1 and 2 years post PCI.

Conclusions and relevance

The incidence of GLOBAL LEADRER defined end points has not been impacted by STEMI presentation. Our findings suggest that an earlier cessation of DAPT at 1 month post primary PCI, with continuation of a potent P2Y12 antagonist monotherapy, could be safe and avoids additional bleeding risk in the STEMI setting. Given the post-hoc nature of the analysis, our findings should not necessitate changes in recommendations for practice by professional associations and regulatory agencies. However, all reported findings should rather be considered only as hypothesis-generating and need be replicated in dedicated large-scale randomized trials to further assess the role of Aspirin free antithrombotic strategies post PCI in STEMI.

Funding Acknowledgement

Type of funding sources: None.

Frequency and prognostic impact of periprocedural myocardial infarction determined by various MI definitions in patients with chronic coronary syndromes undergoing percutaneous coronary intervention

Background

Several definitions of peri-procedural myocardial infarction (MI) requiring different biomarker thresholds with or without ancillary criteria for myocardial ischemia are currently recommended without being fully validated in real-world patients with chronic coronary syndrome (CCS) undergoing percutaneous coronary intervention (PCI).

Objectives

We aimed to evaluate the prevalence and prognostic value of high-sensitivity cardiac troponin-based peri-procedural MI according to contemporary MI definitions using a large real-world PCI cohort.

Methods

In CCS patients undergoing elective PCI enrolled to the Bern PCI registry (NCT02241291) between 2010 and 2018, peri-procedural myocardial injury and infarction were assessed according to the 4th and 3rd universal definition of MI (UDMI), academic research consortium (ARC)-2, and Society for Cardiovascular Angiography and Interventions (SCAI) criteria. The primary endpoint was cardiac death at 1 year.

Results

Among 4404 CCS patients, peri-procedural MI defined by the 4th UDMI, 3rd UDMI, ARC-2, and SCAI were observed in 14.9%, 18.0%, 2.0%, and 2.0% of patients, respectively. Cardiac mortality at 1 year in patients with peri-procedural MI defined by 4th UDMI, 3rd UDMI, ARC-2, and SCAI were 3.0%, 2.9%, 5.8%, and 10.0%, respectively. After multivariate adjustments, peri-procedural MI defined by the ARC-2 and SCAI were independently associated with cardiac death at 1 year, while those defined by the 4th and 3rd UDMI were not.

Conclusion

Among CCS patients undergoing PCI, periprocedural MIs defined by theARC-2 and SCAI occurred 7 to 9 times less frequently as compared with the 4th and 3rd UDMI, and were the only definitions significantly associated with cardiac mortality.

Funding Acknowledgement

Type of funding sources: None. Cardiac death at 1 year

Systemic immune-inflammation index predicts major adverse cardiovascular events in patients with ST-elevation myocardial infarction

Background

ST-elevation myocardial infarction (STEMI) represents the life-threatening manifestation of atherosclerosis, a chronic inflammatory disease of arterial wall, and is associated with high rate of morbidity and mortality. Thus, inflammatory biomarkers may be useful in identifying high inflammatory burden patients who may benefit from tailored high-intensity secondary prevention therapy.

Purpose

We therefore assessed the relationship between the systemic immune-inflammation index (SII) and CV outcomesamong 1144 all-comers patients admitted to four Swiss University Hospital for STEMI and enrolled in the prospective multicenter SPUM registry cohort I (NCT 01000701).

Methods

SII was calculated as platelet counts x neutrophil counts / lymphocyte counts. Patients were subdivided into three groups according to SII tertiles. The composite primary endpoint was major adverse cardiac and cerebrovascular events (MACCE: stroke, myocardial infarction, CV death). Adjusted Cox proportional hazards regression models were implemented to determine the risk associated with SII and outcomes.

Results

Out of 1144 STEMI patients, 912 patients (79,7%) had available for SII. Patients within the highest tertile were slightly more frequently male (23.0 vs 22.0%, p=0.05), with higher plasma values of neutrophils (11.4±2.4 vs 6.5±3.7 G/l, p<0.001), platelets (275.3±97.5 vs 202.5±51.6 G/l, p<0.001) and lower levels of lymphocytes (1.0±0.6 vs 2.1±1.1 G/l, p<0.001) and LVEF (46.4±11.5% vs 50.4±10.3%, p<0.001) (Fig. 1A). At 1 year, these patients presented the highest rate of all-cause mortality (7.2% vs 2.6%, p=0.02) and MACCE (8.2% vs 3.3, p=0.03). This enhanced risk persisted for all-cause mortality and MACCE, after adjustment for age, sex, ace-inhibitors and statin therapy (Adj. HR 2.85, 95% CI 1.30–6.70, p=0.03 and Adj. HR 2.63, 95% CI 1.25–5.55, p=0.03, respectively, Fig. 1B).

Conclusions

Among a real-world cohort of STEMI-patients, SII highlights the highest inflammatory risk phenotype, being associated with significant increased rates of MACCE and all-cause of death. These observations might help clinicians to furtherly identify patients who may derive the greatest benefit from tailored more intense secondary prevention therapies including inflammatory modulation.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Mortality after bleeding versus myocardial infarction in coronary artery disease: a systematic review and meta-analysis

Background

Bleeding is the principal safety concern of antithrombotic therapy and occurs frequently among patients with coronary artery disease (CAD).

Aims

We aim to evaluate the prognostic impact of bleeding on mortality compared with that of myocardial infarction (MI) in patients with CAD.

Methods

We searched Medline and Embase for studies that included patients with CAD and that reported both, the association between the occurrence of bleeding and mortality, and between the occurrence of MI and mortality within the same population. Adjusted hazard ratios (HRs) for mortality associated with bleeding and MI were extracted and ratio of hazard ratios (rHRs) were pooled by using inverse variance weighted random effects meta-analyses. Early events included periprocedural or within 30-day events after revascularization or acute coronary syndrome (ACS). Late events included spontaneous or beyond 30-day events after revascularization or ACS.

Results

141,059 patients were included across 16 studies and 128,660 (91%) underwent percutaneous coronary intervention. Major bleeding increased the risk of mortality to the same extent of MI (ratioHR bleedingvsMI 1.10, 95% CI, 0.71–1.71, P=0.668). Early bleeding was associated with a higher risk of mortality than early MI (ratioHR bleedingvsMI 1.46, 95% CI, 1.13–1.89, P=0.004), although this finding was not present when only randomized trials were included. Late bleeding was prognostically comparable to late MI (ratioHR bleedingvsMI 1.14, 95% CI, 0.87–1.49, P=0.358).

Conclusions

Compared with MI, major and late bleeding is associated with a similar increase in mortality, whereas early bleeding might have a stronger association with mortality.

Impact on daily practice. Major and late bleeding should be considered prognostically equivalent to MI, given the similar association with mortality. Early bleeding has even a stronger association with mortality than early MI, emphasizing the importance of bleeding avoidance strategies among patients undergoing PCI.

Funding Acknowledgement

Type of funding sources: None. Visual AbstractBleeding vs MI risk of mortality

Impact of left ventricular ejection fraction on clinical outcomes in females undergoing percutaneous coronary intervention with drug-eluting stents

Background

Reduced left ventricular ejection fraction (LVEF) is associated with increased risk of adverse events among patients undergoing percutaneous coronary intervention (PCI). Due to under-enrollment of females in randomized trials, there is limited data on the impact of LVEF on post-PCI outcomes in female patients.

Purpose

To evaluate the impact of varying degrees of LVEF impairment on 3-year outcomes in female patients undergoing PCI with drug-eluting stents (DES).

Methods

We pooled patient-level data of female patients from 26 randomized trials of coronary stents. The study population was stratified into three groups according to the 2016 European Society of Cardiology Heart Failure guidelines: LVEF ≥50% (normal), LVEF 40–49% (mid-range), and LVEF <40% (reduced). The primary outcome was major adverse cardiac events (MACE), a composite of cardiac death, myocardial infarction (MI), or stent thrombosis (ST) at 3-year follow-up. The Kaplan-Meier method was used for time-to-event analyses, with comparative risks being assessed using Cox regression.

Results

Out of 5672 female patients with available LVEF values at baseline, 4427 (78.1%) had normal LVEF, 602 (10.6%) had mid-range LVEF, and 643 (11.3%) had reduced LVEF. Patients with reduced LVEF were older and had a higher prevalence of smoking, prior MI, and multi-vessel disease. There was a stepwise increase in 3-year event rates moving from normal, to mid-range and reduced LVEF (Figure 1). After multivariable adjustment, hazard ratio (HR) for MACE was 1.45 (95% CI: 1.10–1.92) in patients with mid-range LVEF and 2.43 (95% CI: 1.84–3.22) in patients with reduced LVEF (trend p-value <0.0001). The risk of ST was more than doubled in both mid-range LVEF (HR 2.30, 95% CI: 1.30–4.06, p=0.004) and reduced LVEF patients (HR 2.18, 95% CI: 1.11–4.28, p=0.02), as compared with normal LVEF.

Conclusion

The presence of an even mild degree of LVEF impairment confers an increased risk of ischemic events, including ST, among females undergoing PCI with DES.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Impact of center-volume on outcomes in myocardial infarction complicated by cardiogenic shock – a CULPRIT-SHOCK sub-study

Background

Little is known about the impact of center-volume on outcomes in acute myocardial infarction complicated by cardiogenic shock (AMI-CS). The aim of this study was to investigate the association between center-volume, treatment strategies and subsequent outcome in patients with AMI-CS.

Methods

In this subanalysis of the randomized CULPRIT-SHOCK trial, study sites were categorized based on the annual volume of AMI-CS into low/intermediate/high volume centers (<50; 50–100;>100 cases/year). Subjects from the study/compulsory registry with available volume data were included. Baseline/procedural characteristics, overall treatment and 1-year all-cause mortality were compared across categories.

Results

N=1032 patients were included in this study (537 treated at low-volume, 240 at intermediate-volume and 255 at high volume centers). Baseline risk profile of patients across the volume categories was similar, although high volume centers included more older patients. Low/intermediate-volume centers had more resuscitated patients (57.5%/58.8% vs. 42.2%; p<0.01), and more patients on mechanical ventilation in comparison to high volume centers. Mechanical circulatory support differed with more use in low/intermediate-volume centers and overall lower use in high-volume centers (30.7%/36.7% vs. 19.2%; p<0.001). There were no differences in reperfusion success despite considerable differences in adjunctive pharmacological/device therapies (figure 1). There was no difference in 1-year all-cause mortality across volume categories (51.1% vs. 56.5% vs. 54.4%; p=0.34).

Conclusion

In this study of patients with AMI-CS, considerable differences in adjunctive medical and mechanical support therapies was observed. However, we could not detect an impact of center volume on reperfusion success or mortality.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): The CULPRIT-SHOCK trial was funded by European Union, Seventh Framework Programme (FP7/2007-2013) Grant agreement n°602202, German Heart Research Foundation Treatment according to center volumeLong-term survival

Comparison of risk prediction models in infarct-related cardiogenic shock

Background

Several prediction models have been developed to allow accurate risk assessment and provide better treatment guidance in patients with infarct-related cardiogenic shock (CS). However, comparative data between these models are still scarce.

Objectives

To externally validate different risk prediction models in infarct-related CS and compare their predictive value in the early clinical course.

Methods

The Simplified Acute Physiology Score (SAPS)-II Score, the CardShock score, the IABP-SHOCK II score and the Society for Cardiovascular Angiography and Intervention (SCAI) classification were each externally validated in a total of 1055 patients with infarct-related CS enrolled into the randomized CULPRIT-SHOCK trial or the corresponding registry. Discriminative power was assessed by comparing area under the curves (AUC) in case of continuous scores.

Results

In direct comparison of the continuous scores in a total of 161 patients, the IABP-SHOCK II score revealed best discrimination (AUC=0.74), followed by the CardShock score (AUC=0.69) and the SAPS-II score, giving only moderate discrimination (AUC=0.63). All of the three scores revealed acceptable calibration by Hosmer-Lemeshow test. The SCAI classification as a categorical predictive model displayed good prognostic assessment for the highest risk group (stage E), but showed poor discrimination between stages C and D with respect to short-term-mortality.

Conclusion

Based on the present findings, the IABP-SHOCK II score appears to be the most suitable of the examined models for immediate risk prediction in infarct-related CS. Prospective evaluation of the models, further modification or even development of new scores might be necessary to reach higher levels of discrimination.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union, German Centre for Cardiovascular Research Survival probabilities continuous scoresSurvival probabilities SCAI

Impact of smoking cessation on depression after acute coronary syndrome

Background

Smoking and depression are two risk factors for acute coronary syndrome (ACS) that often go hand-in-hand, as smokers are more likely to be depressed and people that are depressed are more likely to be smokers. Smoking cessation in depressed patients with ACS may worsen depressive symptoms, which could increase the risk of recurrence of cardiac events and decrease adherence to other cardiac risk-reducing lifestyle changes.

Purpose

We aimed to investigate the evolution of depression according to smoking cessation one-year after ACS. Furthermore, we investigated if there was a higher incidence of one-year depression among ACS smokers who quit in comparison to continuous smokers.

Method

Data from 1,822 patients with ACS of the Swiss multicenter SPUM-ACS cohort study were analysed over a one-year follow-up period. Participants were classified in three groups based on smoking status one-year post-ACS – continuous smokers, smokers who quit within the year post-ACS, and non-smokers. Depression status at baseline and at one-year after the index ACS event was assessed with the Center for Epidemiologic Studies Depression scale (CES-D) and antidepressant drug use. A multivariate adjusted logistic regression model was used to calculate the risk ratio (RR) between groups.

Results

In comparison to depressed smokers who continued to smoke one year post-ACS, depressed smokers who quit smoking had an adjusted RR of 2.02 (95% CI 1.04–3.92) of improving their depression. Among 543 non-depressed ACS smokers, new depression at one-year was found in 57/266 (21.4%) smokers who quit, and 68/277 (24.6%) continuous smokers, with an adjusted RR of 0.89 (95% CI 0.58–1.36) of incidence of new depression.

Conclusion

Smokers with depression at the time of ACS who quit smoking improved more frequently their depression compared to those who continued smoking. Although not statistically significant, there was a smaller incidence of new depression among smokers who quit after ACS in comparison to continuous smokers.

Funding Acknowledgement

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

Doppler echocardiographic predictors of low mitral valve area after implantation of one MitraClip: time for a paradigm shift?

Introduction

During edge-to-edge therapy using MitraClip (MC) for severe mitral regurgitation (MR) the interventional cardiologists usually rely on the mean transmitral gradient to decide if they “go for” a second clip in case of suboptimal MR reduction or to stabilise the first MC in the context of prolapse or flail leaflet. The value of this parameter to detect low mitral valve area (MVA) is unknown.

Method

During each intervention of the last two years, high quality volumes focused on the MV were acquired. Using a dedicated 3-D analysis software and a new planimetry method, we measured the MVA before and after the implantation of one MC (each orifice was evaluate independently on the most optimal plane). The usual transmitral CW-Doppler parameters (mean gradient (MG), VTI, PHT) were evaluated.

Results

We included 120 patients, 69 primary (PMR) and 51 secondary (SMR) mitral regurgitation. For all the parameters, the best model for the curve fitting was y = a + b / x and the two parameters who best correlated with the MVA after MC were PHT (R2 0.67, p=0.0001) and MG (R2 0.28, p. 0001). Looking at SMR, the correlation with PHT was even better but there was no correlation with MG. In PMR, the correlation with MG was good but still lower than with PHT (Figure 1). The ROC analysis for PHT showed an AUC of 0.948 and defined an optimal cut-off of 127ms with sensibility and specificity 91% to detect a MVA <2 cm2 after one MC.

Conclusion

The transmitral MG appears as a poor parameter to predict low MVA after the implantation of one MC, especially in SMR probably because in this population the MG depends more on the flow than on the MVA. In the contrary PHT appears as a robust parameter.

Figure 1

Funding Acknowledgement

Type of funding source: None

Choice of P2Y12 inhibitor and clinical outcomes in the AUGUSTUS study: support for an individualised approach

Background

AUGUSTUS randomized patients with atrial fibrillation and ACS and/or PCI to apixaban or VKA and aspirin or placebo for 6 months on background P2Y12 inhibitor.

Purpose

To characterise the clinical outcomes in patients receiving clopidogrel or ticagrelor.

Methods

Patients enrolled in AUGUSTUS (n=4614) were grouped by P2Y12 inhibitor at randomization. Baseline characteristics were compared among groups. Rates of ISTH major or CRNM bleeding, definite/probable stent thrombosis (ST), stroke, MI, and death or ischaemic event were quantified and treatment groups were compared according to treatment with clopidogrel or ticagrelor.

Results

At randomization, patients were treated with clopidogrel (n=4165), ticagrelor (n=280), prasugrel (n=51) or no P2Y12 inhibitor (n=118). Median ages were 71, 69, 66 and 72 years (P<0.001). Ticagrelor and prasugrel were more commonly used in PCI-managed ACS (53% and 55%) whilst clopidogrel or no P2Y12 inhibitor was more common in medically-managed ACS (25% and 36%); elective PCI was the index event in 37–41% for each group. Irrespective of P2Y12 inhibitor used, bleeding risk was lower with apixaban vs. VKA and higher with aspirin vs. placebo (Table). ST rate was lowest but major/CRNM bleeding rate highest with ticagrelor + aspirin vs ticagrelor without aspirin or clopidogrel with or without aspirin.

Conclusions

Apixaban is safer than VKA regardless of P2Y12 inhibitor used. Dropping aspirin reduces bleeding but is associated with numerically higher ST rates regardless of P2Y12 inhibitor used. These data support current recommendations for preferential use of NOAC vs. VKA and individualised choice of P2Y12 inhibitor and timing of aspirin cessation after PCI according to the patient's risks of bleeding and stent thrombosis.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Bristol-Myers Squibb/Pfizer

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

Residual inflammatory risk at 12 months after acute coronary syndromes is associated with cardiovascular outcome

Background

C-reactive protein measured by high sensitivity assays (hsCRP) is an established biomarker of systemic inflammation and a cut-off at 2 mg/L has been widely studied and proposed to identify patients at residual inflammatory risk (RIR).

Purpose

It remains unclear how many patients remain at residual inflammatory risk (RIR) at 12 months after acute coronary syndromes (ACS) in a contemporary real-world cohort and if RIR is associated with cardiovascular outcome.

Methods

Patients included in the SPUM-ACS cohort (NCT01000701) with a primary diagnosis of ACS referred for coronary angiography between 2009 and 2012 and available hsCRP measurements at baseline and at 1 year follow-up. High RIR was defined as hsCRP ≥2mg/L. Patients were divided into four groups: persistently high RIR, increased RIR (first low-, then high hsCRP), attenuated RIR (first high-, then low hsCRP), or persistently low RIR. Adjudicated major adverse cardiac and cerebrovascular events (MACCE) at 365 days were defined as the composite of MI, clinically indicated coronary revascularization or stroke. Logistic regression models were used to evaluate associations between MACCE and RIR groups and continuous long-term GRACE risk score. Adjustment was made for long-term GRACE risk score.

Results

1209 patients had available serial biomarker measurements (baseline and 12 months) with clinical and demographic data. Among those, 295 (24.4%) patients (UA 3.4%, NSTEMI 47.5%, STEMI 49.2%) fell in the category persistently high RIR (delta hsCRP median (IQR): −2.3 (−9.9; 0.3) (mg/L) and 72 (5.96%) patients (UA 8.3%, NSTEMI 47.2%, STEMI 44.4%) were in category increased RIR (delta hsCRP median (IQR): +2.45 (1.2; 8.35) (mg/L). Conversely, 390 (32.26%) patients (UA 3.3%, NSTEMI 46.9%, STEMI 49.7%) fell in the category attenuated RIR (delta hsCRP median (IQR): −3.55 (−10; −2) (mg/L) and 452 (37.38%) patients (UA 5.5%, NSTEMI 33.2%, STEMI 61.3%) were in category persistently low RIR (delta hsCRP median (IQR): −0.2 (−0.6; 0.1) (mg/L). Of 90 MACCE, 31 (10.5%) were found in the persistently high RIR group yielding a significantly higher event rate (adjusted HR: 1.71, (95% CI 1.08; 2.7), p-value: 0.02) compared with the three other groups combined (increased RIR: 3 (4.2%), attenuated RIR 30 (7.7%), persistent low RIR 26 (5.8%)). Of note, in that group the long-term GRACE risk score was significantly higher compared with the three other groups (adjusted HR: 1.1, (95% CI 1.0; 1.17), p-value: 0.04).

Conclusion

Residual inflammatory risk at 12 months after an ACS is found in nearly a third of patients. Patients with persistently elevated hsCRP throughout the first year post-ACS suffered most adverse events warranting studies of anti-inflammatory drugs in these patients.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Swiss Heart Foundation, Swiss National Science Foundation

Outcomes associated with respiratory failure for patients with cardiogenic shock and acute myocardial infarction: a substudy of the culprit-shock trial

Background

Respiratory insufficiency with the need for mechanical ventilation (MV) is one of the most common indications for admission to intensive care units. However, little is known about the clinical outcomes of patients with acute myocardial infraction (AMI) complicated by cardiogenic shock (CS) who require mechanical ventilation (MV). The aim of this study was to identify the characteristics, risk factors, and outcomes associated with the provision of MV in this specific high-risk population.

Methods

Patients with CS complicating AMI and multivessel coronary artery disease from the CULPRIT-SHOCK trial were included. We explored clinical outcome within 30 days in patients not requiring MV, those with MV on admission, and those in whom MV was initiated within the first day after admission.

Results

Among 683 randomized patients included in the analysis, 17.4% received no MV, 59.7% were ventilated at admission and 22.8% received MV within or after the first day after admission. Patients requiring MV were younger, more frequently non-smokers, had higher body mass indices, presented more often with clinical signs of impaired organ perfusion including worse renal function, higher burden of coronary artery disease, were more likely to have experienced resuscitation within 24h before admission, had worse left ventricular function, and presented more often with non-ST-segment elevation myocardial infarction. The primary endpoint of all-cause death or need for renal replacement therapy occurred in 21.8% of patients without MV, in 53.3% of patients with MV at admission (adjusted odds ratio [aOR] 6.03, 95% confidence interval (CI) 3.17–11.47, p=0.002, compared to patients without) and 65.4% of patients with MV initiated within the first day after admission (aOR 8.09 95% CI 4.32–15.16, p<0.001, compared to patients without). Factors independently associated with the provision of MV on admission included higher body weight, resuscitation within 24h before admission, elevated heart rate and evidence of triple vessel disease.

Conclusions

Requiring MV in patients with CS complicating AMI is common and independently associated with mortality after adjusting for covariates. Patients with delayed MV initiation appear to be at higher risk of adverse outcomes. Further research is necessary to identify the optimal timing of MV in this high-risk population.

Funding Acknowledgement

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

Safety and efficacy of antithrombotic therapy according to stroke and bleeding risk in patients with atrial fibrillation and acute coronary syndrome or PCI: insights from AUGUSTUS

Background

The AUGUSTUS trial showed that patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) and/or PCI treated with a P2Y12 inhibitor and apixaban resulted in less bleeding and comparable ischemic events compared with regimens that included a vitamin K antagonist (VKA), aspirin, or both. We assessed the effect of apixaban versus VKA and aspirin versus placebo according to patients' baseline risk of stroke and bleeding.

Methods

AUGUSTUS randomized 4614 patients in a two-by-two factorial design to open label apixaban or VKA and blinded aspirin or placebo. The primary endpoint was major or clinically relevant nonmajor (CRNM) bleeding over 6 months of follow-up. The effects were assessed stratified by baseline CHA2DS2-VASc and HAS-BLED score using Cox proportional hazards models.

Results

4386 patients were included for this analysis. The median age was 71 (64–77) years, 29.4% were female, 81.7% had a CHA2DS2-VASc score≥3, and 66.8% a HAS-BLED score≥3. As shown in the table, rates of bleeding were lower with apixaban (vs VKA) irrespective of baseline bleeding risk (p-value interaction: 0.23). Aspirin (vs placebo) was associated with increased bleeding irrespective of baseline risk (p-value interaction: 0.88). Apixaban use was associated with a lower risk of death or hospitalization without a significant interaction with stroke risk (p-value of interaction=0.53). No differences were found for ischemic outcomes.

Conclusion

An antithrombotic regimen including a P2Y12 inhibitor and apixaban is associated with less bleeding and hospitalization compared to a regimen with VKA, aspirin, or both with results consistent across CHA2DS2-VASc, and HAS-BLED scores. Our findings support the use of apixaban and a P2Y12 inhibitor without aspirin during the first 6 months for most patients with AF and ACS and/or PCI, regardless of stroke and bleeding risk.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): The Augustus trial was sponsored by Bristol-Myers Squibb and Pfizer, Inc

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

Uncontrolled hypertension and elevated NT-proBNP predict acute kidney injury and cardiac death in all-comer patients 1 year after acute coronary syndromes

Background

Hypertension is a recognized cardiovascular (CV) risk factor and, although many highly effective antihypertensive drugs have been developed, most patients fail to achieve recommended blood pressure target levels. This may increase major adverse CV events after acute coronary syndromes (ACS) such as acute kidney injury (AKI) and cardiac death (CD).

Purpose

We assessed the prognostic value of uncontrolled hypertension (UH) and elevated NT-proBNP among 2,168 all-comer patients admitted to 4 Swiss University Hospitals for acute coronary syndromes (ACS) enrolled in the prospective multicenter SPUM registry.

Methods

Patients with UH defined as a systolic blood pressure≥140 mmHg, and a NT-proBNP>900 ng/l were considered for the analysis. The composite primary endpoint was AKI and CD. Adjusted Cox proportional hazards regression models were implemented to determine risk prediction for UH and elevated NT-proBNP levels.

Results

Out of 2,168 ACS patients, 235 patients (10.8%) showed UH and NT-proBNP>900 ng/l (Fig. 1A). Compared to the general ACS population, those with UH and elevated NT-proBNP were more likely to be older (41.7% vs 20.0%, p<0.001), of female sex (36.2% vs 19.7%, p<0.001) and with a more complex history of CV disease, such as hypertension (77.0% vs 56.2%, p<0.001), diabetes (24.7% vs 17.5%, p=0.006), peripheral artery disease (9.4% vs 5.2%, p=0.011), cerebrovascular disease (6.8% vs 3.4%, p=0.013), chronic heart failure (3.4% vs 1.3%, p=0.025), dialysis (2.1% vs 0.3%, p=0.004) as well as prior CABG (9.4% vs 5.2%, p=0.010) and more often admitted as NSTEMIs (59.6% vs 40.9%, p<0.001). Although these patients were on a more aggressive antihypertensive therapy at admission (all p<0.05 for ACEi, ARB, Beta-blockers, calcium antagonists, nitrates and diuretics), there was a higher rate of death (OR 1.83, 95% CI 1.07–3.14, p=0.027), CD (OR 2.13, 95% CI 1.19–3.81, p=0.009), AKI (OR 2.83, 95% CI 1.41–5.67, p=0.002) and composite endpoint AKI+CD (OR 2.46, 95% CI 1.56–3.90, p<0.001) at one year. This combined risk persisted after adjustment for baseline differences, with a 71% (Adj. HR 1.71, 95% CI 1.44–1.84, p=0.003) increase for the composite endpoint (Fig. 1B).

Conclusions

Among a real-world cohort of ACS patients, coexistence of UH with elevated levels of NT-proBNP confers increased risk for AKI and CD up to one year after ACS. These observations might help clinicians to identify ACS patients at risk using simple clinical parameters and biomarkers and to target them for more intense preventive therapies.

Figure 1. A: GRADE1 = 140–159 mmHg and/or 90–99 mmHg; GRADE2 = 160–179 mmHg and/or 100–109 mmHg; GRADE3 = ≥180 mmHg and/or ≥110 mmHg; ISH (isolate systolic hypertension) = ≥140 mmHg and <90 mmHg; NT-proBNP = N-terminal-pro B-type natriuretic peptide. B: UH = uncontrolled hypertension; AKI = acute kidney injury; CD = cardiac death.

Funding Acknowledgement

Type of funding source: None

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

Infective endocarditis after transcatheter or surgical aortic valve implantation: pooled results from three randomized controlled trials

Background

Infective endocarditis is a rare complication of aortic valve replacement with high morbidity and mortality. Data of randomized trials comparing the incidence and outcomes between surgical (SAVR) and transcatheter aortic valve replacement (TAVR) are scarce.

Purpose

To compare the frequency, timing and outcomes of infective endocarditis after TAVR and SAVR from 3 prospective randomized trials and examine the clinical outcomes.

Methods

Clinical data from the CoreValve Pivotal High-Risk, the intermediate-risk SURTAVI and the Evolut Low Risk randomized trials, which compared TAVR with a supra-annular, self-expanding transcatheter valve to SAVR, was pooled. Cases of infective endocarditis were independently adjudicated based on Duke's criteria necessitating 2 major criteria, or 1 major and 3 minor criteria, or 5 minor criteria. Baseline clinical and procedural characteristics for patients with and without endocarditis were obtained. The cumulative incidence of endocarditis through 5 years after TAVR or SAVR was determined using death as a competing risk. Kaplan-Meier estimates of all-cause mortality and the composite of all-cause mortality or stroke through 2 years were calculated for both treatment groups.

Results

Among 2249 TAVR patients, 12 cases of endocarditis (0.5%) were documented and among 1828 SAVR patients, 21 (1.1%) over a mean follow-up time of 2.25±1.58 years. Baseline characteristics were well-balanced between the TAVR and SAVR patients with endocarditis. The cumulative incidence of endocarditis at 5 years was significantly different between the two groups (figure). The prevalence of diabetes was significantly higher in patients with endocarditis than in those without (57.6% vs. 34.2%, p=0.005). In endocarditis patients the rate of all-cause mortality was 39.4% for TAVR patients and 67.8% for SAVR patients at 2 years (log-rank p=0.133). The rates of all-cause mortality or stroke were 55.0% for TAVR and 64.6% for SAVR patients (log-rank p=0.078).

Conclusions

In this pooled analysis of three randomized trials comparing TAVR with a supra-annular, self-expanding bioprosthesis to SAVR, overall rates of endocarditis were low. The cumulative incidence of infective endocarditis at 5 years was lower in the TAVR group. Mortality after endocarditis was high.

Figure 1

Funding Acknowledgement

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

Ticagrelor monotherapy beyond 1 month versus standard dual antiplatelet therapy after drug-eluting coronary stenting: a pre-specified per-protocol analysis of the GLOBAL LEADERS trial

Background

In the GLOBAL LEADERS trial, the intention-to-treat (ITT) effect of ticagrelor monotherapy after 1 month of dual antiplatelet therapy (DAPT) was not superior to that of 12-month DAPT followed by aspirin alone in the prevention of 2-year all-cause mortality or new Q-wave myocardial infarction (MI) after coronary stenting. Intention-to-treat analyses can be affected by incomplete protocol adherence. We present a pre-specified per-protocol analysis.

Purpose

To determine whether 1 month of ticagrelor plus aspirin followed by 23 months of ticagrelor monotherapy is superior to 12 months of DAPT followed by aspirin alone in the per-protocol population of the GLOBAL LEADERS (NCT01813435).

Methods

The GLOBAL LEADERS compared two antiplatelet strategies after drug-eluting stenting for stable coronary artery disease or acute coronary syndromes. Per-protocol population consisted of randomized patients fulfilling enrollment criteria and receiving protocol-mandated treatment. Adherence to the allocated antiplatelet therapy was evaluated at discharge, 30 days, and 3, 6, 12, 18, and 24 months, with non-adherence reasons categorized following a hierarchical approach. A protocol-deviation was defined in the case of high perceived bleeding/thrombotic risk, a medical decision without evident clinical reason, patients unwilling to take study drugs, prescription error, logistical issues, unclear reasons. Baseline characteristics, including (but not limited to) age, sex, diabetes, prior PCI, were used to construct time-varying inverse probabilities for not deviation from the protocol to reconstruct a study population with no protocol-deviations. Protocol deviators were artificially censored at the time at which they deviated. The primary endpoint was the composite of 2-year all-cause mortality or non-fatal new Q-wave MI. We used a weighted pooled logistic regression to estimate the per-protocol rate ratio (RR) of experimental vs. control treatment for the primary endpoint.

Results

Of the 15,968 randomized patients, 805 out of 7,980 (10.1%) in experimental group and 537 out of 7,988 (6.7%) in control group were classified as protocol deviators and artificially censored by month 12, not contributing events in the second year. The events for the adherence-adjusted analysis were 279 in experimental group and 325 in control group (25 and 24 less than in ITT analysis, respectively). The estimated adherence-adjusted RR was 0.87 (95% CI: 0.74–1.02; p=0.09), comparable to the ITT RR (0.87; 95% CI: 0.75–1.01; p=0.07).

Conclusion

At per-protocol analysis, ticagrelor monotherapy after 1 month of DAPT was not superior to conventional treatment, in line with the previously reported ITT effect. Similar per-protocol and ITT effects can be accounted for similar per-protocol and ITT populations, as a substantial proportion of patients were non-adherent due to clinically grounded reasons (anticipated in the protocol) and, accordingly, not considered as protocol deviators.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): GLOBAL LEADERS was sponsored by the European Clinical Research Institute, which received funding from Biosensors International, AstraZeneca, and the Medicines Company.

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

P3589New generation stents for primary percutaneous coronary intervention in patients with acute myocardial infarction: evidence from an individual patient data network meta-analysis of randomized clinical

Background

Drug-eluting stents have shown their superiority in primary percutaneous intervention in patients with ST-segment elevation myocardial infarction (STEMI). No specific stent type has fully proven its superiority over others.

Purpose

We sought to compare the safety and efficacy of coronary artery stents in STEMI patients undergoing primary PCI through comprehensive network meta-analysis (NMA).

Methods

We performed an individual patient data (IPD) NMA of dedicated randomized trials in STEMI patients treated with coronary stents. The primary endpoint of interest was the composite outcome of cardiac death, any myocardial infarction (MI) or target lesion revascularization (TLR). Secondary outcomes were the individual component of the primary endpoint and definite or probable stent thrombosis. Outcomes were analyzed at the longest available follow-up. The primary analysis was performed using a one-stage random-effects meta-analysis.

Results

IPD from 15 randomized trials in STEMI patients were obtained including a total of 10,979 patients. Six different stent types were studied including bare metal stents (BMS), durable-polymer paclitaxel-eluting stents (DP-PES), durable-polymer sirolimus-eluting stents (DP-SES), durable-polymer zotarolimus-eluting stents (DP-ZES), durable-polymer everolimus-eluting stents (DP-EES) and biodegradable-polymer biolimus-eluting stent (BP-BES).

Mean patient age was 60.7±11.9 years; 22.7% were female and 16.1% were diabetic. Median symptom onset to balloon time was 210 min.

At a median follow-up of 3 years (interquartile range 2–4.9 years), patients treated with second-generation (DP-EES and BP-BES) or first-generation DES (DP-PES, DP-SES and DP-ZES) had significantly lower risk of the primary endpoint than patients treated with BMS (BMS vs. second-generation DES; HR 0.69, 95% CI 0.57–0.82, BMS vs. first-generation DES; HR 0.70, 95% CI 0.61–0.80). The differences were driven by the significant reduction of TLR associated with first- and second-generation DES compared with BMS. A trend towards lower risk of MI with second-generation DES compared with BMS or first-generation DES was observed (BMS vs. second-generation DES; HR 0.79, 95% CI 0.58–1.06, first- vs. second-generation DES; HR 0.75, 95% CI 0.54–1.03). Second-generation DES was associated with a significantly lower risk of definite or probable stent thrombosis compared with BMS (HR 0.62, 95% 0.40–0.97) and first-generation DES (HR 0.55, 95% CI 0.34–0.91). DP-EES and BP-BES had a similar risk of the primary endpoint, individual components of the primary endpoint, and definite or probable stent thrombosis.

Conclusions

In this larger-scale IPD NMA in STEMI patients, second-generation DES were superior to BMS with respect to long-term efficacy and safety outcomes. Second-generation DES were associated with a significant reduction of stent thrombosis compared with BMS and first-generation DES. Similar long-term outcomes were observed between DP-EES and BP-BES.

Acknowledgement/Funding

This study was funded by Biosensors International

P1222Intensification of lipid lowering therapy before and after publication of the IMPROVE-IT trial: A temporal analysis from the SPUM-ACS cohort

Background

The gradual implementation of evidence-based treatment strategies has improved outcomes in patients with acute coronary syndromes (ACS). The Improved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) was published on June 3rd, 2015, but its relevance on real life practice has not been explored.

Methods

We analyzed a prospective Swiss cohort of 6266 patients hospitalized for ACS between 2009 and 2017. The primary endpoints were the ezetimibe use overall or in combination with high-intensity statin at discharge and at one year after ACS. Secondary endpoint was LDL-C target achievement at one year in a subsample of 2984 patients. Relative Ratios (RR) were used to assess changes in primary endpoints before and after the publication of IMPROVE-IT, adjusting for age, sex, pre-existing diabetes, history of myocardial infarction, baseline low-density lipoprotein cholesterol (LDL-C) and attendance to cardiac rehabilitation.

Results

The period following the publication of the IMPROVE-IT trial was associated with an overall increase in the use of ezetimibe at discharge (from 1.8% to 3.8%, P<0.001, adjusted RR 2.85, 95% CI 1.90–4.25) and at one year (from 5.0% to 13.8%, P<0.001, adjusted RR 3.00, 95% CI 2.40–3.75). Before IMPROVE-IT trial, ezetimibe use at one year was stable around 5%, then steadily increased after its publication until 20% for patients included in 2017. The combination of high-intensity statin and ezetimibe increased from 0.9% to 2.1% at discharge (P<0.001, adjusted RR 3.35, 95% CI 1.90–5.89) and from 2.1% to 7.8% at one year (P<0.001, adjusted RR 3.98, 95% CI 2.90–5.47). The period following the publication of the IMPROVE-IT trial was associated with an improvement of LDL-C target <1.8 mmol/L (adjusted RR 1.37, 95% CI 1.12–1.68).

Conclusion

After the publication of the IMPROVE-IT trial, the use of ezetimibe was increased by three-fold in a large contemporary cohort of ACS patients, concomitant with an improved LDL-C target achievement.

P6408Potential benefit of ticagrelor monotherapy for patients with hypertension undergoing percutaneous coronary intervention: insights from the Global Leaders trial

Background

Hypertension is one of the most frequent modifiable risk factors for coronary artery disease. Due to the increased risk of bleeding associated with it, hypertensive patients might benefit from an antiplatelet monotherapy following percutaneous coronary intervention.

Purpose

We sought to investigate the effect of 1-month DAPT followed by 23-month ticagrelor monotherapy (ticagrelor monotherapy) compared with the reference arm, 12-month DAPT followed by 12-month aspirin monotherapy (standard DAPT), on clinical outcomes in patients with hypertension undergoing PCI.

Methods

This is a post-hoc analysis of the prospective, multi-center, open-label, all-comers, randomized controlled trial Global Leaders, that tested ticagrelor monotherapy versus standard DAPT in patients receiving PCI with biolimus A9-eluting stent. Patients were stratified by the hypertension status. The primary endpoint for the present analysis was the patient oriented composite endpoint (POCE - defined as composite of all-cause death, any stroke, any MI, or all revascularization) and safety endpoint of BARC type 3 or 5 bleeding, both at 2 years. Event rates are presented as Kaplan-Meier estimates (%).

Results

In Global Leaders 15,991 patients were randomized, 23 (0.14%) requested complete deletion of their data from the database and 54 (0.34%) had no information on hypertension status. Of the 15,914 (99.52%) included in the analysis 11,715 were hypertensive. In the non-hypertensive patients, comparing ticagrelor monotherapy with standard DAPT, no difference was found regarding POCE (12.17% vs. 12.13%, HR 1.004, 95% CI 0.843 to 1.195, p=0.965) nor bleeding (1.71% vs. 1.72%, HR 1.0, 95% CI 0.628 to 1.592, p=1.0, respectively). In hypertensive patients the experimental treatment of ticagrelor monotherapy resulted in less POCE (13.62% vs. 15.04%, HR 0.898, 95% CI 0.816 to 0.988, p=0.028, p for interaction=0.271) with similar bleeding (2.21% vs. 2.26%, HR 0.976, 95% CI 0.765 to 1.246, p=0.846), compared with the standard DAPT at 2 years.

Conclusion

In this sub-group analysis of Global Leaders, in patients with hypertension undergoing PCI the experimental treatment of 1-month DAPT followed by 23-month ticagrelor monotherapy may offer ischemic protection without increasing bleeding. The results must be interpreted cautiously as there was no interaction between treatment strategy and the status of hypertension. Thus, the present results are hypothesis generating.

Acknowledgement/Funding

ECRI - Astra Zeneca - Biosensors - Medicine Company

P2531Impact of age on clinical outcomes after PCI in patients with ACS and stable CAD treated with 23-month ticagrelor monotherapy following 1-month DAPT in the randomized GLOBAL LEADERS study

Background

The efficacy and safety of ticagrelor monotherapy in elderly patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS) or stable coronary artery disease (CAD) has not been evaluated.

Purpose

To evaluate the efficacy and safety of ticagrelor monotherapy following 1-month dual antiplatelet therapy (DAPT) after PCI in relation to age and clinical presentation in the GLOBAL LEADERS study cohort.

Methods

This is a subanalysis of the randomized multicentre GLOBAL LEADERS study, comparing the experimental strategy of 23-month ticagrelor monotherapy after 1 month of ticagrelor and aspirin with the reference strategy of 12-month DAPT followed by 12-month aspirin monotherapy in 15991 patients undergoing PCI. Patients were categorized into elderly and very elderly according to a pre-specified cut-off of 75 years and a post-hoc defined cut-off of 80 years. Impact of age and clinical presentation (ACS versus stable CAD) on clinical outcome at 2 years was evaluated. The primary endpoint was a composite of all-cause mortality or nonfatal, centrally adjudicated, new Q-wave myocardial infarction.

Results

In the overall elderly (>75 years) population (n=2565), primary endpoint occurred in 7.2% of patients in the experimental group and in 9.4% of patients in the reference group (p=0.041) at 2 years (p int =0.23). Elderly patients in the experimental group had a lower rate of definite stent thrombosis (ST) (0.2% vs. 0.9%, p=0.043, p int=0.03), definite or probable ST (0.4 vs. 1.3%, p=0.015, p int=0.01) and a numerically higher rates of BARC 3 or 5 type bleeding (5.0% vs. 3.9%, p=0.192, p int=0.06), when compared to the reference arm.

Among elderly patients presenting with ACS both treatment groups did not differ in the rates of primary endpoint (9.1% vs. 10.8%, p=0.367) and BARC 3 or 5 type bleeding (4.7% vs. 5.7%, p=0.458), whereas among elderly patients with stable CAD the experimental strategy was associated with numerically lower rates of the primary endpoint (5.7% vs. 8.4%, p=0.046) (p int =0.42) and a higher rate of BARC 3 or 5 type bleedings (5.3% vs. 2.6%, p=0.012) (p int =0.02) at 2 years.

Exploratory analyses among very elderly (≥80 years) patients (n=1169) indicated no significant differences between treatment groups in the rates of the primary endpoint (10.2% vs. 11.7% p=0.411, p int=0.940) and BARC 3 or 5 type bleeding (6.0% vs. 5.3%, p=0.630, p int=0.514) at 2 years.

Conclusions

The efficacy and safety of the experimental treatment strategy of 23-month ticagrelor monotherapy after 1-month DAPT following PCI was not identified as age-dependent. Among elderly patients the anti-ischemic benefit was derived at the expense of increased rate of BARC 3 or 5 type bleeding in stable CAD subgroup, but not in ACS subgroup.

Acknowledgement/Funding

European Clinical Research Institute, which received unrestricted grants from Biosensors International, AstraZeneca, and the Medicines Company.

4181Prognosis of patients with mid-range left ventricular ejection fraction treated with PCI: insight from the global leaders study

Background

Heart failure with mid-range ejection fraction (left ventricular ejection fraction between 40 to 49%) was introduced in the 2016 European Society of Cardiology guidelines for heart failure. The prognosis of the mid-range of left ventricular ejection fraction (LVEF) was less well assessed in patients treated with percutaneous coronary intervention (PCI).

Purpose

We aimed to assess the 2-year outcomes of patients with mid-range ejection fraction (LVEF between 40 to 49%) after PCI compared with reduced LVEF (<40%) and preserved LVEF (≥50) in the GLOBAL LEADERS study.

Methods

The GLOBAL LEADERS study was a multicenter, randomized trial comparing the efficacy and safety of two antiplatelet strategies in all-comers patients undergoing PCI with biolimus-A9 eluting stent.

Patients with available information of LVEF were eligible in the present analysis. Patients were classified according to their LVEF into three groups; preserved (LVEF ≥50), mid-range (LVEF 40–49%) and reduced (LVEF <40%) left ventricular ejection fraction. Clinical outcomes at 2 years after PCI were compared among three groups in the multivariable Cox regression analysis.

The primary outcome of present study was all-cause mortality at 2 years after PCI. The secondary outcomes were patient-oriented composite endpoint (POCE). Individual components of the composite endpoint, definite or probable stent thrombosis and bleeding academic research consortium (BARC) type 3 or 5 were also reported.

Results

Out of 15968 patients included in the GLOBAL LEADERS study, information of LVEF was available in 15008 patients (93.99%); 12,128 patients (80.81%) were in the group of preserved LVEF, 1,737 patients (11.57%) were in the mid-range LVEF group and 1,143 patients (7.62%) were in the reduced LVEF group.

The risk of all-cause mortality and POCE at 2 years were significantly different among the three groups. In an adjusted model, compared with the group of preserved LVEF, the hazard ratio for the all-cause mortality at 2 years rose from 1.89 (95% CI, 1.46–2.45) to 3.72 (95% CI, 2.95–4.70) in the group of mid-range and reduced LVEF respectively. Similar rises were observed for the POCE at 2 years from 1.27 (95% CI, 1.11–1.44) in the group of mid-range LVEF to 1.63 (95% CI, 1.42–1.87) in the group of reduced LVEF.

The risk of stroke, myocardial infarction, and definite or probable stent thrombosis in patients with mid-range LVEF was not different from patients with reduced LVEF (see figure). A similar risk of revascularization was observed among the three groups.

Outcomes among three LVEF categories

Conclusion

Patients with mid-range LVEF undergoing PCI had a different prognosis from patients with reduced LVEF and preserved LVEF in term of survival and composite ischemic endpoints at 2 years.

P869Predictive value of the endothelial shear stress distribution in three-dimensional quantitative coronary angiography models in detecting vulnerable plaques

Background

Low Endothelial shear stress (ESS) is a well-known instigator of coronary atherosclerosis. Prospective intravascular ultrasound (IVUS)-based imaging studies with computational fluid dynamic analysis revealed its predictive merit in-vivo. However, whether coronary modelling derived from quantitative coronary angiography (QCA) is equally effective in detecting high-risk plaques remains to be established.

Purpose

To examine the value of endothelial shear stress (ESS) estimated in three-dimensional (3D) QCA models in detecting plaques that are likely to progress and cause events.

Method

We analysed the baseline intravascular ultrasound virtual histology (IVUS-VH) and angiographic data from 28 non-culprit lesions with a vulnerable phenotype (i.e., fibroatheroma or thin cap fibroatheroma) that caused major adverse cardiac events or required revascularization (nc-MACE-R) at 5-year follow-up and from a control group of 119 vulnerable plaques that remained quiescent. The segments studied by IVUS-VH at baseline were reconstructed using 3D-QCA software and in the obtained geometries blood flow simulation was performed and we estimated the resting Pd/Pa across the vulnerable plaque and the mean ESS values in 3mm sub-segments. A propensity score was built by the baseline plaque characteristics and the hemodynamic indices and its efficacy in detecting nc-MACE-R lesions was examined.

Results

Nc-MACE-R lesions were longer (32.5mm [18.0, 41.6], vs. 19.6mm [12.7, 31.3], p=0.03), had smaller minimum lumen area (MLA) (3.65mm2 [3.26, 4.36] vs. 5.03mm2 [3.98, 6.66], p<0.01), increased plaque burden (PB) (69.4% [63.5, 72.0] vs. 60.8% [53.7, 66.5], p<0.01), were exposed to higher ESS (9.40Pa [6.3, 12.5] vs. 4.1Pa [3.0, 6.9], p<0.01), and exhibited a lower resting Pd/Pa (0.97 [0.95, 0.98] vs. 0.98 [0.97, 0.99], p<0.01]. In multivariable analysis the only independent predictor of nc-MACE-R was the maximum 3mm ESS value (hazard ratio: 1.08 [1.02, 1.16], P=0.016). Lesions exposed to high ESS (>4.95Pa) with a high-risk anatomy (MLA<4mm2and PB>70%) had a higher nc-MACE-R rate (53.8%) than those with a low-risk anatomy exposed to high ESS (31.6%) or those exposed to low ESS that had high (20.0%) or low-risk anatomy (7.1%, P<0.001).

Conclusion

In the present study, 3D-QCA-derived local hemodynamic variables provided useful prognostic information and in combination with lesion anatomy enabled more accurate identification of nc-MACE-R lesions. Further research in a larger number of patients is need to confirm these findings before the conduction of large scale prospective studies that will combine intravascular imaging and 3D-QCA modelling to more accurately detect vulnerable plaques.

P6138Quality of clinical trial evidence on devices and drugs approved to treat coronary artery disease

Background

Regulatory approval of drugs and devices follow two different pathways. Whether different approval pathways underlie meaningful differences in quality of clinical trial evidence is unknown. We aimed to compare the quality of evidence of clinical trials that served as a basis for approval by the U.S. Food and Drug Administration (FDA) of drugs and devices used for the treatment of coronary artery disease.

Methods

FDA databases were searched for devices (i.e., coronary artery drug-eluting stents) and drugs (i.e., agents targeting atherothrombosis) approved between January 1st, 2001 and December 31st, 2017. FDA medical reviews were screened to identify trials that served for approval purposes. The pre-specified primary outcome was the prevalence of randomized trials used for approval (i.e. number of randomized trials/overall number of trials).

Results

A total of 97 trials were identified, 39 serving for approval of 13 devices and 58 serving for approval of 8 drugs. Devices were evaluated by fewer trials per item as compared with drugs (3.0±1.4 vs. 7.3±5.3, P=0.012) with similar study size (501 [100–1314] vs. 379 [183–904] patients per trial, P=0.55). Trials evaluating devices were less frequently randomized (56.4% vs. 94.8%, P<0.001) and more frequently designed powered for clinical endpoints (53.8% vs. 17.2%, P<0.001) as compared to those evaluating drugs. Use of randomization declined over time among trials supporting FDA approval of devices. In addition, significant differences were present between trials evaluating devices and those evaluating drugs in terms of study design, comparator used, blinding to treatment allocation, primary hypothesis, primary endpoint, and type of patients included.

Use of randomized trials for approval

Conclusions

There are substantial differences in clinical trial evidence serving for FDA approval of devices and drugs used for treatment of coronary artery disease. The lower degree of randomized evidence used for approval of devices as compared to drugs raises some concerns, particularly in view of its decline over time.

P5500Acute coronary syndrome in young patients: frequency, mechanisms and clinical outcomes following percutaneous coronary intervention

Introduction

Acute coronary syndromes (ACS) mainly affect older patients and little is known on the frequency, the underlying causes and outcomes following ACS in young.

Purpose

To investigate the frequency, mechanisms and clinical outcomes of young patients suffering from ACS and undergoing percutaneous coronary intervention (PCI).

Methods

Between February 2009 and December 2016, 6720 consecutive patients undergoing PCI for an ACS were prospectively enrolled. We defined young patients as male <45 years or female <50 years. The primary endpoint was the patient-oriented composite endpoint (POCE) defined as the composite of all-cause death, myocardial infarction or any revascularization at 12 months. The mechanisms of ACS in young patients (atherosclerotic vs. embolic vs. spontaneous coronary artery dissection) were retrospectively assessed by an adjudication committee based on clinical and angiographic criteria.

Results

Among 6720 ACS patients, 378 (5.6%) patients were young (41±5 years, 73% male). Young patients, as compared to old patients, presented more frequently with STEMI (64% vs. 45%; p<0.001) and single vessel disease (85% vs. 74%; p<0.001). Cardiovascular risk factors were more frequent in young patients including BMI>30 kg/m2 (34% vs. 22%; p<0.001), smoking (68% vs. 31%; p<0.001), positive family history of coronary artery disease (35% vs. 23%; p<0.001) and baseline LDL-C levels (3.3±1.1 mmol/l vs. 2.9±1.1 mmol/l; p<0.001). Diabetes mellitus was less frequent in the young patient group (10% vs. 21%; p<0.001). The mechanisms of ACS in young patients were atherosclerotic in 87%, coronary embolism in 9%, and spontaneous coronary artery dissection in 4%. At 12 months, the primary endpoint POCE occurred less frequently in young patients (9.3% vs. 17%; HR 0.52, 95% CI 0.37–0.73; p<0.001). The rates of the individual components of the primary endpoint were lower in young patients including all-cause death (3.4% vs. 9.4%; HR 0.36, 95% CI 0.21–0.62; p<0.001), myocardial infarction (1.9% vs. 3.7%; HR 0.48, 95% CI 0.22–1.01; p=0.053) and any revascularization (5.6% vs. 7.7%; HR 0.68, 95% CI 0.44–1.05; p=0.083). Young patients with coronary embolism or spontaneous coronary artery dissection had a higher rate of cardiac death at 12 months as compared to young patients with atherosclerotic disease (embolic vs. atherosclerotic: 9.4% vs. 2.2%; HR 4.3, 95% CI 1.11–16.71; p=0.02; spontaneous coronary artery dissection vs. atherosclerotic: 17.6% vs. 2.2%; HR 8.1, 95% CI 2.1–31.1; p<0.001).

Conclusions

Approximately one out of 20 ACS patients undergoing PCI was young and the main presumed mechanism of ACS was atherosclerosis (87%) followed by coronary embolism (9%) and spontaneous coronary artery dissection (4%). While young ACS patients carry a lower risk for future cardiovascular events as compared with older patients, the high cardiac death rates following embolic disease or spontaneous coronary artery dissections deserves particular attention.

P2817Efficacy and safety of ticagrelor monotherapy in patients with complex percutaneous coronary intervention: insights from the Global Leaders trial

Background/Introduction

Purpose

Methods

The Global Leaders trial recruited 15,991 patients treated by default with a biolimus A9-eluting stent, and randomised in a 1:1 ratio either to the experimental strategy (1-month dual antiplatelet therapy [DAPT] followed by 23-month ticagrelor monotherapy) or to the reference regimen (12-month DAPT followed by 12-month aspirin monotherapy). Complex PCI includes at least one of the following characteristics; left main and/or multivessel PCI, long stenting (defined as total stent length≥46mm), and bifurcation treatment with two stents. The present sub-analysis of the trial evaluated at two years the primary endpoint (composite of all-cause death and new Q-wave myocardial infarction [MI] centrally adjudicated with the Minnesota code). In addition, the patient-oriented composite endpoint (POCE) (composite of all-cause death, any stroke, any MI, and any revascularization) and the net adverse clinical events (NACE) (composite of POCE and Bleeding Academic Research Consortium [BARC] type 3 or 5 bleeding) were also evaluated at two years.

Results

Of 15,450 patients included in the present analysis, 5,188 (26.7%) patients underwent complex PCI. The experimental strategy, when compared with the reference one, had a significantly lower risk of the primary endpoint (3.56% vs. 5.33%, HR: 0.66; 95% CI: 0.51–0.86; p-value= 0.002; p-value for interaction= 0.019) in patients with complex PCI. Similarly, the experimental treatment was associated with a significantly reduced risk of POCE (14.41% vs. 16.88%, HR: 0.84; 95% CI: 0.74–0.97; p=0.016, p-value for interaction= 0.099) and NACE (15.77% vs. 18.37%, HR: 0.85; 95% CI: 0.74–0.97; p=0.014; p-value for interaction= 0.096). The reduction in ischemic events was predominantly observed in patients with 2 or more characteristics of complex PCI (Figure). In contrast, there was no significant difference in the risk of BARC type 3 or 5 bleeding between the two regimens (2.40% vs. 2.38%, HR: 1.01; 95% CI: 0.71–1.44; p-value=0.956; p-value for interaction= 0.935).

Central illustration

Conclusion

Together with other well-established clinical risk factors, the extent and complexity of stenting should be taken into account in tailoring antiplatelet regimens for secondary prevention. The 1-month DAPT followed by 23-month ticagrelor monotherapy reduced the ischemic events without increasing the risk of bleeding in patients who underwent complex PCI, when compared with the conventional DAPT.

Acknowledgement/Funding

The Global Leaders trial was supported by the resource from AstraZeneca, Biosensors, and The Medicines Company.

2213Impact of BMI on clinical outcomes in all-comers patients with coronary artery disease undergoing PCI: insights from the Global Leaders study

Background

It is uncertain if the obesity paradox still exists in contemporary PCI practice.

Purposes

We aimed to assess an association between baseline BMI and clinical outcomes at 2 years after PCI and to determine if the outcomes between two antiplatelet strategies depend on baseline BMI.

Methods

Global Leaders study compared 23-month ticagrelor monotherapy after 1 month of dual antiplatelet therapy (experimental strategy) with 12-month aspirin monotherapy after 12 months of conventional DAPT (reference strategy) in patients undergoing PCI with biolimus-A9 eluting stent.

Primary outcome of current study was 2-year all-cause mortality after PCI. Secondary outcomes were net adverse clinical event (NACE) and individual components of the composite endpoint.

Association between baseline BMI and outcomes were determined in the Cox model. Non-linearity was assessed using restrict cubic spline function. Patients were categorized according to WHO BMI categories; underweight (BMI <18.5), healthy weight (BMI 18.5–24.9), pre-obese state (BMI 25–29.9) and obesity (BMI ≥30). Interaction between BMI categories and antiplatelet strategies were assessed.

Results

BMI was available in 15,966 out of 15,968 patients with a median of 27.7 kg/m2 (IQR 25.0–30.7). Baseline BMI had a reverse J-shaped association with 2-year all-cause mortality. 3901 patients (24.4%) were in the group of healthy weight, 79 patients (0.5%) were under-weight, 7220 patients (45.2%) were pre-obese and 4766 patients (29.8%) were obese. Due to small number of underweight patients, outcomes after PCI were compared among three groups; healthy weight, overweight, and obesity.

Pre-obese and obese patients had lower risk of 2-year all-cause mortality than healthy-weight patients (HR pre-obesity vs. healthy-weight 0.71, 95% CI 0.58–0.88, HR obesity vs. healthy-weight 0.69, 95% CI 0.54–0.87). The risk of 2-year NACE was similar among three groups (healthy weight vs. pre-obesity; HR 1.04, 95% CI 0.94–1.16, healthy weight vs. obesity; HR 1.04, 95% CI 0.93–1.16). No significant difference in risk of any stroke, any MI, and BARC3 or 5 bleeding was found among three groups. Pre-obese patients had higher risk of revascularization than patients with healthy weight (HR 1.19, 95% CI 1.04–1.35). The risk of revascularization in obese patients was numerically higher than healthy-weight patients (HR 1.14, 95% CI 0.99–1.31).

For BARC 3 or 5 bleeding at 2 years, ticagrelor monotherapy was more favorable in obese patients (HR reference/experimental 1.63, 95% CI 1.06–2.52) while conventional DAPT strategy was more favorable in pre-obese patients (HR experimental/reference 0.76, 95% CI 0.55–1.05) (P interaction 0.02). No interaction between treatment strategy, BMI, and other outcomes was seen.

BMI and all-cause mortality and NACE

Conclusions

An obesity paradox, an association between elevated BMI and lower mortality, is still evident in this large PCI population. Effect of two antiplatelet strategies on bleeding may depend on baseline BMI.

P6411Dyspnea in ticagrelor treated patients in the all-comer randomized GLOBAL LEADERS study and its association with clinical outcomes

Background

Dyspnea represents a drug adverse effect reported with a higher frequency for ticagrelor, as compared with other P2Y12 antagonists. The impact of dyspnea on clinical outcomes has not been yet evaluated in the context of aspirin-free therapies after percutaneous coronary intervention (PCI).

Purpose

The study aimed to evaluate the incidence of dyspnea and its associations with demographic characteristics and clinical outcomes in patients undergoing PCI treated with ticagrelor either as monotherapy or as a part of a dual antiplatelet therapy (DAPT) in the GLOBAL LEADERS cohort.

Methods

This is a sub-analysis of the randomized all-comer GLOBAL LEADERS study (n=15991), comparing the experimental strategy of ticagrelor monotherapy following one-month DAPT after PCI with the reference strategy of 12-month DAPT followed by 12-month aspirin monotherapy. The incidence of dyspnea reported as adverse event (AE) and its relation to demographic characteristics and 2-year clinical outcomes was evaluated (intention-to-treat analysis). Multivariable Cox proportional hazards models were performed, including randomized treatment and incidence of first dyspnea event as a time-dependent covariate. The primary endpoint was a composite of 2-year all-cause mortality or centrally adjudicated, new Q-wave myocardial infarction (MI). Patient-oriented clinical endpoints (POCE) comprised all-cause death, any stroke, MI or revascularization, whereas net adverse clinical events (NACE) included POCE and Bleeding Academic Research Consortium (BARC)-defined bleeding type 3 or 5.

Results

Overall, dyspnea was reported as an AE in 2101 patients (13.2%) up to two years of follow-up, with a higher frequency in the experimental arm (16.4%) as compared with the reference group (11.1%) (hazard ratio [HR]1.70, 95% confidence interval [CI] 1.56–1.86, p=0.001).

Predictors of dyspnea AE up to 2 years by multivariate analyses were: chronic obstructive pulmonary disease (HR1.71, 95% CI 1.56–1.87, p=0.001), female gender (HR1.31, 95% CI 1.18–1.44, p=0.001), hypertension (HR1.31, 95% CI 1.19–1.44, p=0.001, prior coronary artery bypass grafting (HR1.30, 95% CI 1.10–1.54, p=0.003), left ventricle ejection fraction below 40% (HR1.22, 95% CI 1.04–1.42, p=0.012), presentation with acute coronary syndrome (HR1.19, 95% CI 1.09–1.29, p=0.001) and body mass index (≥27kg/m2) (HR1.17, 95% CI 1.08–1.28, p=0.001).

In patients who reported dyspnea AE, the two-year rates of the efficacy and safety endpoints in the experimental and reference arm were: for the primary endpoint 3.4% vs. 4.3% (p adjusted=0.807), for POCE 15.8% vs. 17.6% (p adjusted=0.218), for NACE 17.2% vs. 19.6% (p adjusted=0.082), for BARC 3 or 5 type bleeding 17.2% vs. 19.6% (p adjusted=0.082), respectively.

Conclusions

The occurrence of dyspnea AE up to two years after PCI appeared not to affect the safety of the experimental treatment strategy of 23-month ticagrelor monotherapy following one-month DAPT after PCI.

Acknowledgement/Funding

Study founded by European Cardiovascular Research Institute, which received unrestricted grants from Biosensors Int., AstraZeneca, Medicines Company.

98Mitral annular calcification, mitral valve diseases and clinical outcomes in patients undergoing transcatheter aortic valve replacement for severe aortic stenosis

Background

Mitral annular calcification (MAC) and mitral valve diseases (MVD) have been identified as strong predictors of mortality in patients undergoing transcatheter aortic valve replacement (TAVR). However, the association between MAC and MVD, and the prognostic implications in these patients remain unclear.

Purpose

This study sought to investigate the association between severity of MAC and the prevalence of MVD as well as to assess the prognostic impact of MAC depending on the presence or absence of MVD in patients undergoing TAVR.

Methods

We identified 967 patients who have comprehensive echocardiographic and computed tomographic assessment of MVD and MAC from our institutional registry that is a part of the Swiss TAVI registry (NCT01368250) between August 2007 and June 2017.

Results

Among these patients, mild or moderate MAC was present in 45.2% and severe MAC was present in 17.8%. The prevalence of MVD was significantly higher in severe MAC patients, while the prevalence in patients with mild and moderate MAC was similar to patients without MAC. Compared to patients without severe MAC and MVD, an increased risk of all-cause death at 1 year was observed in patients with severe MAC and MVD (hazard ratio [HR]: 2.81, 95% confidence interval [CI]: 1.72–4.59, p<0.001) as well as in patients with non-severe MAC and MVD (HR: 2.80, 95% CI: 1.87–4.20, p<0.001) but not in patients with severe MAC and non-MVD (HR: 0.68, 95% CI: 0.27–1.70, p=0.409). In a multivariable analysis, severe MAC concomitant with MVD was found to be an independent predictor of new permanent pacemaker implantation after TAVR (Odds ratio: 2.08, 95% CI: 1.27–3.41, p=0.004).

Conclusions

Severe MAC was associated with higher prevalence of MVD. Severe MAC concomitant with MVD was associated with increased risks of mortality at 1 year and conduction abnormalities after TAVR, whereas severe MAC without MVD was not.

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

P1952Value of GRACE risk score in risk stratification in acute coronary syndrome patients undergoing PCI in the Global Leaders study

Aims

We sought to evaluate the value of GRACE risk score in stratifying acute coronary syndrome patients undergoing percutaneous coronary intervention in the Global Leaders study.

Methods

Global Leaders study was a prospective, multi-center, open-label, all-comers, randomized controlled trial comparing ticagrelor monotherapy after 1 month of dual antiplatelet therapy (DAPT) as experimental therapy with aspirin monotherapy after 12 months of conventional DAPT (reference therapy) in patients who received PCI with biolimus-A9 eluting stent. We assessed the predictive value of GRACE risk score in ACS patients undergoing PCI in the present analysis. Patients were stratified according to GRACE risk score into low (1–108), moderate (109–140), High (141–372) risk group. Clinical outcomes at 2 years after PCI were assessed and compared among risk groups. Interaction between GRACE risk score and antiplatelet regimen were analyzed by the interaction term in Cox model.

Results

GRACE risk score was calculated from 8 clinical parameters at presentation. Among ACS patients, 1664 patients were categorized in low risk group, 2903 patients were in moderate risk group, and 2028 patients were in high risk group. The rate of all-cause mortality, any stroke, patient-oriented composite endpoint (POCE) were highest in the high-risk group at 2 years (All-cause mortality; low risk 1.4%, moderate risk 2.5%, high risk 6.1%, log rank test p value <0.0001, any stroke; low risk 0.7%, moderate risk 1.0%, high risk 2.0%, log rank test p value 0.001, POCE; low risk 12.4%, moderate risk 11.9%, high risk 16.61%, log rank test p value <0.0001). The rate of myocardial infarction, all revascularization and definite or probable stent thrombosis were not different among three groups. There was no interaction between GRACE risk score and treatment regimen on clinical outcomes at 2 years.

Conclusion

GRACE risk score is valuable in identifying ACS patients with highest risk of all-cause mortality, any stroke and POCE at 2 years after PCI. In ACS, ticagrelor monotherapy did not improve the outcomes at 2 years in the three strata of the GRACE risk score.

P6440The perils of polyvascular disease with concomitant type 2 diabetes in a real-world cohort of patients with acute coronary syndrome

Background

Despite substantial improvement in type 2 diabetes (DM2) care, the burden of recurrent cardiovascular (CV) events remains high. Polyvascular disease (PVD), has recently emerged as a potential marker of heightened residual ischemic risk in DM2 patients, that are likely to derive a greater absolute risk reduction from more intense, individualized therapy.

Purpose

We sought to assess the relationship between DM2, PVD and CV outcomes among 2,168 all-comers patients admitted to four Swiss University Hospital for acute coronary syndrome (ACS) and enrolled in the prospective multicenter SPUM registry (NCT 01000701).

Methods

PVD was defined as concomitant peripheral artery disease, stroke or transient ischemic attack, or both. The composite primary endpoint was major adverse cardiac and cerebrovascular events (MACCE: Stroke, myocardial infarction, CV death). Adjusted Cox proportional hazards regression models were implemented to determine the risk associated with PVD disease in DM2 and outcomes, and intention-to-treat analysis was performed.

Results

Out of 2,168 ACS patients, 396 patients (18.3%) had DM2; of these 62 (15%) had PVD. Despite compared with the general ACS population, those with PVD + DM2 were more likely to have a complex history of CV disease, such as previous MI (27.4% vs 14.7%, p=0.021), prior percutaneous (37.1% vs 17%, p<0.001) or surgical (24.2% vs 5.1%, p<0.001) coronary revascularization, one third was not on statin therapy. At 1 year, patients with PVD + DM2 had a higher rate of MACCE compared to those presenting with PVD or DM2 alone. Rates of the single components of the primary endpoint and all-cause of death were all significantly higher in patients with PVD + DM2 vs. PVD or DM2 alone (Fig. 1A, all p<0.001). This enhanced risk persisted after adjustment for significant baseline differences, with a 34% (Adj. HR 1.34, 95% CI 1.15–1.49, p=0.02) increase in MACCE and a 44% increment of all cause of death (Adj. HR 1.44, 95% CI 1.06–1.54, p=0.02, Fig. 1B).

Outcomes by PVD and DM2 status.

Conclusions

Among a real-world cohort of ACS-patients, the coexistence of PVD and DM2 highlights the highest CV risk phenotype, being associated with significant increased rates of MACCE and all-cause of death. These observations might help clinicians to furtherly stratify the very high risk population and to identify patients who may derive the greatest benefit from more intense secondary prevention therapies.

3331Impact of baseline hemoglobin level and white blood cell count in real-world patients undergoing contemporary percutaneous coronary intervention: insights from the GLOBAL LEADER study

Introduction

The impact of hemoglobin (Hb) level and white blood cell count (WBC) on the outcomes in all-comers PCI patients is unknown.

Purpose

We sought to assess the association between baseline Hb level, WBC count on 2-year outcomes after PCI in all-comers patients in the GLOBAL LEADERS study. We compared the outcomes between anemic and non-anemic patients according to WHO definition.

Methods

GLOBAL LEADERS study assessed the efficacy and safety of two antiplatelet strategies in 15,991 patients undergoing PCI. The primary endpoint was all-cause mortality or new Q wave myocardial infarction (MI) at 2 years. Secondary safety endpoint was BARC 3 or 5 bleeding at 2 years.

The association between WBC count, Hb level and outcomes at 2 years were assessed in the multivariable Cox model adjusted for age, diabetes, ejection fraction and renal impairment. For Hb level, patients were categorized according to the WHO definition of anemia (Hb <12 g/dL in women, Hb <13 g/dL in men).

Results

Of 15991 patients randomized in the GLOBAL LEADER study, baseline WBC count and Hb levels were available in 14960 (93.7%) patients and 15215 (95.3%) patients, respectively.

Hb level had an inverse association with adverse events after PCI. In the multivariable Cox model, Hb level was an independent predictor for ischemic and bleeding outcomes at 2 years while the WBC count was not (see table).

Compared with non-anemic patients, anemic patients had significantly higher risk of primary endpoint (adjusted HR 2.07, 95% CI 1.72–2.49), BARC 3 or 5 bleeding (adjusted HR 1.49 95% CI 1.14–1.96), all-cause mortality (adjusted HR 2.33, 95% CI 1.89–2.86), any MI (adjusted HR 1.41, 95% CI 1.11–1.80), and any revascularization (adjusted HR 1.20, 95% CI 1.03–1.39).

Hb level, WBC count and 2-year outcomes Outcomes at 2 years Hemoglobin level (mg/dL) WBC count (109/L) HR (95% CI) P value HR (95% CI) P value All-cause mortality or new Q wave MI 0.87 (0.82–0.91) <0.0001 1.00 (0.999–1.002) 0.33 All-cause mortality 0.82 (0.78–0.87) <0.0001 1.00 (0.999–1.002) 0.37 Any myocardial infarction 0.93 (0.87–0.99) 0.0165 1.00 (0.996–1.001) 0.23 Any revascularization 0.96 (0.93–1.00) 0.0302 1.00 (1.00–1.001) 0.25 BARC 3 or 5 bleeding 0.85 (0.79–0.91) <0.0001 1.00 (0.997–1.002) 0.76

Conclusion

In the all-comers patients undergoing PCI, the baseline Hb level was significantly associated with the ischemic and bleeding outcomes at 2 years whereas baseline WBC count was not. Baseline WBC count may not be useful as a prognostic factor after PCI.

P2811Impact of ticagrelor monotherapy on two-year clinical outcomes in patients with long stenting: insights from the Global Leaders trial

Background/Introduction

Data on the efficacy and safety of different antiplatelet regimens are limited in patients with increasing total stent length (TSL).

Purpose

To evaluate the impact of the experimental strategy (1-month dual antiplatelet therapy [DAPT] followed by 23-month ticagrelor monotherapy) vs. the reference regimen (12-month DAPT followed by 12-month aspirin monotherapy) in patients with increasing TSL.

Methods

The present post-hoc analysis of the Global Leaders trial evaluated the primary endpoint (the composite of the all-cause death and new Q-wave myocardial infarction [MI]) at two years in patients with increasing TSL. In addition, the patient-oriented composite endpoint (POCE) (the composite of all-cause death, any stroke, any MI, and any revascularization) and the net adverse clinical events (NACE) (the composite of POCE and Bleeding Academic Research Consortium [BARC] type 3 or 5 bleeding) were also assessed.

Results

The cohort of 15,450 patients treated with a biolimus-eluting biodegradable polymer stents were included in this analysis. In the longer TSL group (≥46mm), the experimental strategy significantly reduced the risk of the primary endpoint (3.78% vs. 5.68%, hazard ratio (HR): 0.67, 95% confidence interval (CI): 0.49–0.90, p=0.008, P interaction=0.042) as well as POCE (14.57% vs. 18.11%, HR: 0.79, 95% CI: 0.67–0.92, p=0.003, P interaction=0.010) and NACE (16.07% vs. 19.64%, HR: 0.80, 95% CI: 0.69–0.93, p=0.004, P interaction=0.012) at two years. The risk of BARC type 3 or 5 bleeding at two years was similar between the two antiplatelet regimens.

KM in patients with long stenting

Conclusion

Ticagrelor monotherapy significantly reduced the risk of the primary endpoint, POCE and NACE with a similar risk of BARC type 3 or 5 bleeding at two years in patients with the longer TSL.

Acknowledgement/Funding

The Global Leaders trial was supported by unrestricted grants from AstraZeneca, Biosensors, and The Medicines Company. ECRI (European Cardiovascular R