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Jamal J, Idris H, Faour A, Yang W, McLean A, Burgess S, Shugman I, Oloughlin A, Leung D, Mussap CJ, Juergens CP, Lo S, French JK. Reperfusion strategy and late clinical outcomes of patients with ST-elevation myocardial infarction (STEMI) in the absence of standard modifiable risk factors (SMuRFs). Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
There is growing evidence that patients presenting with STEMI in the absence of standard modifiable cardiovascular risk factors (SMuRFs; smoking, hypertension, hypercholesterolemia, diabetes) have poorer outcomes compared to those with atleast one SMuRF. It has been hypothesised that this may be in part due to decreased administration of pharmacotherapies in the post-infarct period due to perceived low risk. Long term outcomes of patients without SMuRFs based on reperfusion strategy received during the index admission have not been investigated.
Purpose
We sought to analyse late clinical outcomes of STEMI patients with and without SMuRFs based on reperfusion strategy received during the index admission.
Methods
All patients who underwent PCI between 2003 and 2014 were identified from a PCI centre STEMI database. Late clinical outcomes of patients with and without SMuRFs were analysed overall and based on reperfusion strategy [primary PCI (pPCI) vs pharmaco-invasive PCI (PI-PCI)]. Propensity matching was used to account for differences in baseline characteristics between the groups.
Results
Amongst 2,091 STEMI patients, 531 (25%) had no SMuRFs (51% pPCI, 49% PI-PCI) and 1560 (75%) had ≥1 SMuRF (52% pPCI, 48% PI-PCI). Unadjusted late mortality in SMuRF-less patients was 13.4% (18.8% pPCI, 7.7% PI-PCI) and for those with ≥1 SMuRF was 9.7% (11.0% pPCI, 8.4% PI-PCI). After propensity-matching clinical and angiographic characteristics, 5 year mortality rates were significantly higher for patients without SMuRFs compared to those with SMuRFs [HR 1.36, CI: 1.03–1.81, p=0.031]. This difference was attenuated for patients who underwent pPCI [HR 1.72, CI: 1.22–2.43, p=0.002]. Interestingly, this discrepancy was not observed amongst individuals who underwent pharmaco-invasive PCI [HR 1.13, CI: 0.53–1.48, p=0.638], as SMuRF-less patients had similar mortality rates to their counterparts. Long term rates of reinfarction, stent thrombosis and target vessel revascularisation were similar between the groups. Additionally, there was no significant difference in rates of stroke and major bleeding amongst all 4 subgroups.
Conclusion
Patients presenting with STEMI in the absence of SMuRFs have increased overall late mortality compared to those with at least one SMuRF. However, this difference was not observed in patients who underwent a pharmaco-invasive strategy, whereby patients without SMuRFs had similar outcomes to those with SMuRFs after adjusting for confounders. Our findings suggest the use of a pharmaco-invasive strategy in appropriate SMuRF-less patients presenting with STEMI.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- J Jamal
- Liverpool Hospital , Sydney , Australia
| | - H Idris
- Liverpool Hospital , Sydney , Australia
| | - A Faour
- Liverpool Hospital , Sydney , Australia
| | - W Yang
- Liverpool Hospital , Sydney , Australia
| | - A McLean
- Liverpool Hospital , Sydney , Australia
| | - S Burgess
- Liverpool Hospital , Sydney , Australia
| | - I Shugman
- Liverpool Hospital , Sydney , Australia
| | | | - D Leung
- Liverpool Hospital , Sydney , Australia
| | | | | | - S Lo
- Liverpool Hospital , Sydney , Australia
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Cho K, Shugman I, Veale K, Femia G, Nguyen T, Premawardhana U. The Role of Tilt-Table Testing in the Diagnostic Evaluation of Syncope–A Single Centre Experience. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Cho K, Hopkins A, Shugman I, Akrawi D, Nguyen T, Nguyen P, Premawardhana U. Supraventricular and Atrial Tachycardia Radiofrequency Catheter Ablation Without On-Site Surgical Backup – Single Centre Experience. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Shugman I, Tran T, Broyd P, Nguyen N, Nguyen T, Premawardhana U. 796 Atrioventricular Accessory Pathway Radiofrequency Catheter Ablation - a Single Centre Experience. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Shugman I, Tran T, Broyd P, Dang V, Nguyen T, Premawardhana U. 797 Cardiac Invasive Electrophysiology Studies and Radiofrequency Catheter Ablation - Single Centre Experience. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Thakur A, Thananjeyan A, Garrett C, Reeks M, Khaja S, Shugman I, Premawardhana U, Kadappu KK. P1530 Dense spontaneous echo contrast and thrombus in patients on new oral anticoagulant and warfarin therapy: a retrospective audit. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Cardioembolic stroke is a known complication of atrial fibrillation (AF), which is increasing in global prevalence. Spontaneous echo contrast (SEC) in the left atrium (LA) is a precursor for thrombus formation detected on transesophageal echocardiography (TEE). There is limited data regarding the prevalence of dense SEC and/or left atrial thrombus (LAT) detected by TEE in patients on novel oral anticoagulants (NOACs) compared with Warfarin.
Purpose
To determine and compare the prevalence of dense SEC and/or LAT among patients with AF/atrial flutter undergoing TEE while on continuous NOAC or Warfarin therapy.
Methods
Retrospective analysis of prospectively entered data for all patients who were on continuous oral anticoagulants and underwent TEE with DC cardioversion, over a 9-year period (1st January 2011 to 31st December 2018) at a public teaching hospital in NSW, Australia. SEC was classified according to emptying flow velocities, as per the European Association of Cardiovascular Imaging guidelines.
Results
Among the 195 patients, 94 (48%) patients were on NOAC therapy (52% Apixaban, 25% Rivaroxaban, 23% Dabigatran) while 101 (52%) patients were on Warfarin. There was no difference in age (mean ± SD: 64 ± 12 vs. 65 ± 13, p = 0.71) or proportion of males (71% vs 69%, p = 0.76) between patients on NOAC therapy compared with Warfarin. However, the NOAC therapy group had a lower prevalence of ischaemic heart disease (IHD) (18% vs. 33%, p < 0.05) and chronic kidney disease (CKD) (2% vs. 19%, p < 0.001), in addition to a lower CHA2DS2-VASc score (2.1 ± 1.7 vs 2.7 ± 1.7, p = 0.03) and higher haemoglobin levels (145.3 ± 19 vs 133.8 ± 24, p = 0.001). The overall rate of dense SEC and/or LAT detected by TEE was 9.7%. There was no significant difference in the prevalence of dense SEC and/or LAT between patients on NOACs and Warfarin (6.4% vs. 12.9%, p = 0.13). On multivariable analysis of IHD, CKD, Warfarin, NOACs and CHA2DS2-VASc score, there was no significant difference in prevalence of SEC/LAT between Warfarin and NOACs.
Conclusions
In this study, 6.4% of patients on continuous NOACs and 12.9% of patients on Warfarin therapy had dense SEC and/or LAT detected by TEE. Although the trend towards higher rates of dense SEC and pre-thrombus in the Warfarin group did not reach statistical significance, it still holds clinical significance as these patients cannot be cardioverted. Therefore, these data support the need to consider anticoagulant optimisation in the overall management of patients with SEC.
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Affiliation(s)
- A Thakur
- Western Sydney University, Sydney, Australia
| | | | - C Garrett
- Western Sydney University, Sydney, Australia
| | - M Reeks
- Western Sydney University, Sydney, Australia
| | - S Khaja
- Western Sydney University, Sydney, Australia
| | - I Shugman
- Campbelltown Hospital, Cardiology, Campbelltown, Australia
| | | | - K K Kadappu
- Campbelltown Hospital, Cardiology, Campbelltown, Australia
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Nguyen Nguyen N, Shugman I, Nguyen T, Dimitri H, Premawardhana U. 239 Novel 3D Electroanatomical Mapping Guided Radiofrequency Ablation Technique for Left-Sided Accessory Pathways. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Nayyar D, Shugman I, Nguyen Nguyen N, Nguyen T, Premawardhana U. 248 Real-World Experience Using 3D Electroanatomical Mapping to Reduce Fluoroscopy Time and Radiation Dose in Electrophysiology Studies and Ablation. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Tran T, Al-Fahali Z, Tessa Pei-Yi L, Kachwalla H, Shugman I, Dang V, Vijayarajan V, Premawardhana U. 285 An Unusual Cause of Shortness of Breath. Heart Lung Circ 2020. [DOI: 10.1016/j.hlc.2020.09.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Alazrag W, Saad Y, Alazhary A, Shugman I, Mussap C, Juergens C, Ferguson I, French J. Use of a High Sensitivity Troponin T Assay in the Assessment and Disposition of Patients Attending a Tertiary Australian Emergency Department. Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.06.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Kadappu P, Shugman I, Michael A, Rajaratnam R, Premawardhana U, Kadappu K. Anaemia Predicts Mortality in Patients with Heart Failure. Heart Lung Circ 2018. [DOI: 10.1016/j.hlc.2018.06.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Shugman I, Randall C, Premawardhana U, Kadappu K, Kachwalla H, O’Loughlin A, Nguyen T, Green L, Badie T, Nguyen P. Coronary Angiography and Angioplasty Without Onsite Cardio-Thoracic Surgical Backup in a New Cardiac Catheterisation Lab: A Single-Centre Experience. Heart Lung Circ 2018. [DOI: 10.1016/j.hlc.2018.06.913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Shugman I, Charna Randall C, Tuan Nguyen T, Kadappu K, Nguyen P, O’Loughlin A, Kachwalla H, Badie T, Green L, Premawardhana U. Cardiac Invasive Electrophysiology Studies with Radiofrequency Ablation Without Onsite Cardiothoracic Surgical Back-Up in a New Cardiac Electrophysiology Laboratory: Single-Centre Experience. Heart Lung Circ 2018. [DOI: 10.1016/j.hlc.2018.06.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Etaher A, Saad Y, Nguyen T, Frost S, Shugman I, Mussap C, Juergens C, French J. Late Mortality Rates of Patients with Type 2 MI Compared to Type 1 MI and Stable Troponin Elevation. Heart Lung Circ 2017. [DOI: 10.1016/j.hlc.2017.06.094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Idris H, Shugman I, Saad Y, Lo S, Hopkins A, Hee L, Thomas L, Mussap C, Juergens C, French JK. Has the frequency of peri-procedural myocardial infarction reduced using third universal definition? Eur Heart J 2013. [DOI: 10.1093/eurheartj/eht308.p1249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Idris H, Shugman I, Thomas L, Hee L, Mussap C, Lo S, Leung D, Hopkins A, Juergens C, French J. Clinical Outcomes for Percutaneous Coronary Intervention Following Acute Coronary Syndromes Using Selective use of 1st and 2nd Generation Drug-Eluting Stent in Patients at High Risk of Restenosis. Heart Lung Circ 2013. [DOI: 10.1016/j.hlc.2013.05.309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Idris H, Shugman I, Lo S, Hopkins A, Hee L, Mussap C, Leung D, Juergens C, French J, Thomas L. Influence of Age and Gender on Clinical Outcomes Following Percutaneous Coronary Intervention for Acute Coronary Syndromes. Heart Lung Circ 2013. [DOI: 10.1016/j.hlc.2013.05.330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Saad Y, Kumar M, Shugman I, Pauk I, Leung D, Mussap C, Hopkins A, Rajaratnam R, Lo S, Juergens C, French J. Safety and Efficacy of Same-Day Discharge Following Elective Percutaneous Coronary Intervention. Heart Lung Circ 2013. [DOI: 10.1016/j.hlc.2013.05.366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Luu J, Hopkins A, Lo S, Mussap C, Shugman I, Thomas L, French J, Juergens C. Transradial Access in Coronary Catheterisation to Reduce Bleeding Complications. Heart Lung Circ 2013. [DOI: 10.1016/j.hlc.2013.05.380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Idris H, Shugman I, Saad Y, Lo S, Hopkins A, Hee L, Mussap C, Leung D, Thomas L, Juergen C, French J. Has the Frequency of Peri-Procedural Myocardial Infarction Reduced Using Third Universal Definition? Heart Lung Circ 2013. [DOI: 10.1016/j.hlc.2013.05.327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Rajendran S, Gupta R, Luu J, Parikh D, Diu P, Shugman I, Lo S, French J, Juergens C. Impact of Three Different Glycoprotein IIb/IIIa Antagonists on Glycoprotein IIb/IIIa Platelet Receptor Inhibition, Tissue Level Perfusion and Clinical Outcomes. Heart Lung Circ 2012. [DOI: 10.1016/j.hlc.2012.05.397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Shugman I, Parikh D, Cheng S, Hsieh V, Lo Q, Tobing D, Lo S, Leung D, Hopkins A, Juergens C, French J. Safety and Efficacy of Rescue Angioplasty for ST-Elevation Myocardial Infarction with High Utilisation Rates of Glycoprotein IIb/IIIa Inhibitors. Heart Lung Circ 2011. [DOI: 10.1016/j.hlc.2011.05.362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Shugman I, Diu P, Gohil J, Kadappu K, Leung M, Lo S, Leung D, Hopkins A, Juergens C, French J. Evaluation of the New Definition of Peri-Procedural Myocardial Infarction in Patients with Acute Coronary Syndromes. Heart Lung Circ 2010. [DOI: 10.1016/j.hlc.2010.06.974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Shugman I, Diu P, Parikh D, Gohil J, Kishor K, Lo S, Leung D, Taylor D, Rajaratnam R, Nguyen P, Hopkins A, Juergens C, French J. Clinical Outcomes for Percutaneous Revascularization Following ST-Elevation Myocardial Infarction Selective Drug-Eluting Stent use in Patients at High Risk of Restenosis. Heart Lung Circ 2010. [DOI: 10.1016/j.hlc.2010.06.958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Rajendran S, Parikh D, Shugman I, French J, Juergens C. Antiplatelet Resistance and Thrombosis in Stents. Heart Lung Circ 2010. [DOI: 10.1016/j.hlc.2010.06.950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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French J, Ranasinghe I, Shugman I, Leung M, Juergens C, Aliprandi-Costa B, Devlin G, Brieger D. Symptom-onset to First Medical Contact Times for ACS Patients have Reduced Recently in Australia and New Zealand. Heart Lung Circ 2009. [DOI: 10.1016/j.hlc.2009.05.278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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