Optimal medical therapy improves outcomes in patients with diabetes mellitus and acute myocardial infarction

AIMS

We aimed to explored the association between the use of optimal medical therapy (OMT) in patients with myocardial infarction (AMI) and diabetes mellitus (DM) and clinical outcomes.

METHODS

Bleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coronary Syndrome (BleeMACS) is an international registry that enrolled participants with acute coronary syndrome followed up for at least 1 year across 15 centers from 2003 to 2014. Baseline characteristics and endpoints were analyzed.

RESULTS

Among 3095 (23.2%) patients with AMI and DM, 1898 (61.3%) received OMT at hospital discharge. OMT was associated with significantly reduced mortality (4.3% vs. 10.8%, p < 0.001), re-AMI (4.4% vs. 8.1%, p < 0.001), and composite endpoint of death/re-AMI (8.0% vs. 17.6%, p < 0.001). No difference was observed among regions. Propensity score matching confirmed that OMT significantly associated with lower mortality. After adjusting for confounding variables, OMT, drug-eluting stents, and complete revascularization were independent protective factors of 1-year mortality, whereas left ventricular ejection fraction and age were risk factors.

CONCLUSIONS

Guideline-recommended OMT was prescribed at suboptimal frequencies with geographic variations in this worldwide cohort. OMT can improve long-term clinical outcomes in patients with DM and AMI.

CLINICAL TRIAL REGISTRATION

NCT02466854 June 9, 2015.

Rationale and design of the iCORONARY trial: improving the cost-effectiveness of coronary artery disease diagnosis

BACKGROUND

In patients with stable coronary artery disease (CAD), revascularisation decisions are based mainly on the visual grading of the severity of coronary stenosis on invasive coronary angiography (ICA). However, invasive fractional flow reserve (FFR) is the current standard to determine the haemodynamic significance of coronary stenosis. Non-invasive and less-invasive imaging techniques such as computed-tomography-derived FFR (FFR-CT) and angiography-derived FFR (QFR) combine both anatomical and functional information in complex algorithms to calculate FFR.

TRIAL DESIGN

The iCORONARY trial is a prospective, multicentre, non-inferiority randomised controlled trial (RCT) with a blinded endpoint evaluation. It investigates the costs, effects and outcomes of different diagnostic strategies to evaluate the presence of CAD and the need for revascularisation in patients with stable angina pectoris who undergo coronary computed tomography angiography. Those with a Coronary Artery Disease-Reporting and Data System (CAD-RADS) score between 0-2 and 5 will be included in a prospective registry, whereas patients with CAD-RADS 3 or 4A will be enrolled in the RCT. The RCT consists of three randomised groups: (1) FFR-CT-guided strategy, (2) QFR-guided strategy or (3) standard of care including ICA and invasive pressure measurements for all intermediate stenoses. The primary endpoint will be the occurrence of major adverse cardiac events (death, myocardial infarction and repeat revascularisation) at 1 year.

CLINICALTRIALS

gov-identifier: NCT04939207.

CONCLUSION

The iCORONARY trial will assess whether a strategy of FFR-CT or QFR is non-inferior to invasive angiography to guide the need for revascularisation in patients with stable CAD. Non-inferiority to the standard of care implies that these techniques are attractive, less-invasive alternatives to current diagnostic pathways.

Antithrombotic Strategy in Secondary Prevention for High-Risk Patients with Previous Acute Coronary Syndrome: Overlap between the PEGASUS Eligibility and the COMPASS Eligibility in a Large Multicenter Registry

BACKGROUND

Patients with previous acute coronary syndrome (ACS) are at high risk of recurrent adverse cardiovascular events. Recently, prolonged dual antiplatelet therapy (DAPT) and oral anticoagulation therapy (OAT) have been shown to reduce recurrent ischemic events to the expense of an increase in bleeding events. The number of patients potentially eligible for these therapies in real life remains to be determined.

METHODS

Among ACS patients from five registries and one randomized controlled trial, we assessed the proportion of patients eligible for the PEGASUS strategy only and the proportion of patients eligible for the COMPASS strategy only, and set out the proportion of patients with an overlap between the strategies.

FINDINGS

Among the 10,048 evaluable patients, we found that 5373 (53.4%) were eligible for the PEGASUS strategy and 3841 (38.2%) were eligible for the COMPASS strategy, with a group of 3444 (34.4%) overlapping between the two strategies. The number of patients eligible for the PEGASUS strategy only was 1929 (19.2%) and the number eligible for the COMPASS strategy only was 397 (4.0%); 4278 (42.6%) were eligible for neither a PEGASUS strategy nor a COMPASS strategy.

INTERPRETATION

In a large cohort of ACS patients, one in three patients was eligible for either a prolonged DAPT with ticagrelor 60 mg and low-dose aspirin or a dual pathway inhibition approach with rivaroxaban 2.5 mg and low-dose aspirin.

Safety and efficacy of different P2Y12 inhibitors in patients with acute coronary syndromes stratified by the PRAISE risk score: a multicentre study

AIMS

To establish the safety and efficacy of different dual antiplatelet therapy (DAPT) combinations in patients with acute coronary syndrome (ACS) according to their baseline ischaemic and bleeding risk estimated with a machine learning derived model [machine learning-based prediction of adverse events following an acute coronary syndrome (PRAISE) score].

METHODS AND RESULTS

Incidences of death, re-acute myocardial infarction (re-AMI), and Bleeding Academic Research Consortium 3-5 bleeding with aspirin plus different P2Y12 inhibitors (clopidogrel or potent P2Y12 inhibitors: ticagrelor or prasugrel) were appraised among patients of the PRAISE data set grouped in four subcohorts: low-to-moderate ischaemic and bleeding risk; low-to-moderate ischaemic risk and high bleeding risk; high ischaemic risk and low-to-moderate bleeding risk; and high ischaemic and bleeding risk. Hazard ratios (HRs) for the outcome measures were derived with inverse probability of treatment weighting adjustment. Among patients with low-to-moderate bleeding risk, clopidogrel was associated with higher rates of re-AMI in those at low-to-moderate ischaemic risk [HR 1.69, 95% confidence interval (CI) 1.16-2.51; P = 0.006] and increased risk of death (HR 3.2, 1.45-4.21; P = 0.003) and re-AMI (HR 2.23, 1.45-3.41; P < 0.001) in those at high ischaemic risk compared with prasugrel or ticagrelor, without a difference in the risk of major bleeding. Among patients with high bleeding risk, clopidogrel showed comparable risk of death, re-AMI, and major bleeding vs. potent P2Y12 inhibitors, regardless of the baseline ischaemic risk.

CONCLUSION

Among ACS patients with non-high risk of bleeding, the use of potent P2Y12 inhibitors is associated with a lower risk of death and recurrent ischaemic events, without bleeding excess. Patients deemed at high bleeding risk may instead be safely addressed to a less intensive DAPT strategy with clopidogrel.

Radial crossover and unsuccessful radial access during coronary angiography or percutaneous coronary intervention: insights from the FORCE-ACS registry

Background

Radial crossover and unsuccessful radial access during coronary angiography or percutaneous coronary intervention (PCI) are associated with worse outcomes compared to successful radial access. The MATRIX score estimates the risk of radial crossover, but the predictive value of this novel risk score has not been evaluated in real-world acute coronary syndrome (ACS) patients.

Purpose

To evaluate (i) the temporal trends in the incidence for radial crossover and unsuccessful radial access, (ii) the reasons for unsuccessful radial access and (iii) the odds ratio for radial crossover and unsuccessful radial access in patients with a high MATRIX score.

Methods

Data from 4,514 ACS patients managed invasively and enrolled in the FORCE-ACS registry between January 2015 and December 2019 were used. Radial crossover was defined as a failure to either start or complete coronary angiography or PCI via radial access and subsequent crossover to femoral or brachial access. Unsuccessful radial access was defined as failure to complete the procedure via radial access and crossover to the femoral or brachial access. Reasons for unsuccessful radial access were: (i) issues during puncture or sheath insertion, (ii) failure to complete angiography and (iii) failure to complete PCI. The odds ratio for radial crossover and unsuccessful radial access of patients with a high MATRIX score (≥41) compared to patients with a low score (&lt;41) was calculated using logistic regression.

Results

The observed rate of radial crossover was 20.7%. The radial crossover rate decreased throughout the years from 38.8% to 14.8% as shown in Figure 1A. The most common reasons for radial crossover was that the operator did not choose radial access as the initial access site and proceed directly to a femoral or brachial approach (18.3% of all procedures). If radial access was attempted but ultimately unsuccessful (2.9% of all radial access attempts), the most common reasons were failure to start or complete coronary angiography and issues with atrial puncture or sheath insertion (Figure 1B). Failure to complete PCI after successfully coronary angiography was rare. The rate of unsuccessful radial access relative to all radial access attempts was consistent over time between 1.8% and 4.2%. Patients with a high MATRIX score had a fourfold higher risk of radial crossover as compared to patients with a low score (odds ratio 4.07, 95%-CI: 3.47–4.78) and an almost twofold risk of unsuccessful radial access (odds ratio 1.87, 95%-CI: 1.19–2.93) (Figure 2).

Conclusion

The incidence of radial crossover declined throughout the years, while the rate of unsuccessful radial access was consistent over time. The MATRIX score is able to identify patients at higher risk of radial crossover and unsuccessful radial access.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The FORCE-ACS registry is supported by grants from ZonMw, the St. Antonius Research Fund and AstraZeneca.

Conservative management in a contemporary cohort of patients with acute coronary syndrome: results from the FORCE-ACS registry

Background

Contemporary real-world data on conservatively managed patients with acute coronary syndrome (ACS) is scarce.

Objective

To evaluate conservative management compared with revascularization therapy in ACS patients, focused on ischemic and bleeding outcomes at one year follow-up, and to provide insight in physician's rationale of choice for conservative management.

Methods

From January 2015 to January 2020, ACS patients were enrolled in the FORCE-ACS registry. Patients without coronary revascularization were identified and classified into three groups: 1) No coronary angiography (CAG) performed (CAG−), 2) documented obstructive coronary artery disease (CAD) with CAG (CAG+, CAD+) and 3) no obstructive CAD found with CAG (CAG+, CAD−). The first two groups were established as conservatively managed ACS patients, and were compared with those who received coronary revascularization. Survival analyses were used to assess differences in clinical endpoints and were adjusted for potential confounders using cox proportional hazard models. The primary endpoint was all-cause mortality, secondary endpoints included myocardial infarction (MI), stroke and major bleeding defined as Bleeding Academic Research Consortium (BARC) 3 or 5. Reasons for conservative management were assessed in all patients without coronary revascularization and details on antithrombotic therapy (type and duration) were explored.

Results

In 5,379 patients admitted with ACS, 93.8% underwent CAG. In total, 19.9% of patients did not receive coronary revascularization. In the non-revascularized patients, CAG was not performed in 34.8% (CAG−), documented CAD was found during CAG in 32.4% (CAG+, CAD+) and 32.7% of patients did not show obstructive CAD on CAG (CAG+, CAD−). Conservatively managed patients (14.2%) had lower survival rates compared with revascularized patients (HR 2.68; 95% CI: 1.89–3.81; p&lt;0.0001). No significant differences were found in MI, stroke, or major bleeding between the two groups. The estimated one-year survival was the lowest in CAG− group compared to the CAG+, CAD+ group (adjusted HR 12.24; 95% CI: 4.15–36.07; p&lt;0.001). Most frequent reasons for choosing conservative management in ACS patients included multi-comorbidity, complex coronary anatomy or a “watchful waiting” strategy. Conservatively treated patients received dual or triple antithrombotic therapy less often than the revascularized group (84.5% vs 94.6%).

Conclusion

In this contemporary ACS cohort, conservatively managed patients are at higher mortality risk than revascularized patients. This heterogeneous group of conservatively managed patients less often received guideline-recommended therapy.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Netherlands Organisation for Health, Research and Development (ZonMw)AstraZeneca

Machine learning-based prediction of insufficient contrast enhancement in coronary computed tomography angiography

OBJECTIVES

Patient-tailored contrast delivery protocols strongly reduce the total iodine load and in general improve image quality in CT coronary angiography (CTCA). We aim to use machine learning to predict cases with insufficient contrast enhancement and to identify parameters with the highest predictive value.

METHODS

Machine learning models were developed using data from 1,447 CTs. We included patient features, imaging settings, and test bolus features. The models were trained to predict CTCA images with a mean attenuation value in the ascending aorta below 400 HU. The accuracy was assessed by the area under the receiver operating characteristic (AUROC) and precision-recall curves (AUPRC). Shapley Additive exPlanations was used to assess the impact of features on the prediction of insufficient contrast enhancement.

RESULTS

A total of 399 out of 1,447 scans revealed attenuation values in the ascending aorta below 400 HU. The best model trained using only patient features and CT settings achieved an AUROC of 0.78 (95% CI: 0.73-0.83) and AUPRC of 0.65 (95% CI: 0.58-0.71). With the inclusion of the test bolus features, it achieved an AUROC of 0.84 (95% CI: 0.81-0.87), an AUPRC of 0.71 (95% CI: 0.66-0.76), and a sensitivity of 0.66 and specificity of 0.88. The test bolus' peak height was the feature that impacted low attenuation prediction most.

CONCLUSION

Prediction of insufficient contrast enhancement in CT coronary angiography scans can be achieved using machine learning models. Our experiments suggest that test bolus features are strongly predictive of low attenuation values and can be used to further improve patient-specific contrast delivery protocols.

KEY POINTS

• Prediction of insufficient contrast enhancement in CT coronary angiography scans can be achieved using machine learning models. • The peak height of the test bolus curve is the most impacting feature for the best performing model.

Evaluation of optimal medical therapy in acute myocardial infarction patients with prior stroke

Background

Treatment of acute myocardial infarction (AMI) patients with prior stroke is a common clinical dilemma. Currently, the application of optimal medical therapy (OMT) and its impact on clinical outcomes are not clear in this patient population.

Methods

We retrieved 765 AMI patients with prior stroke who underwent percutaneous coronary intervention (PCI) during the index hospitalization from the international multicenter BleeMACS registry. All of the subjects were divided into two groups based on the prescription they were given prior to discharge. Baseline characteristics and procedural variables were compared between the OMT and non-OMT groups. Mortality, re-AMI, major adverse cardiovascular events (MACE), and bleeding were followed-up for 1 year.

Results

Approximately 5% of all patients presenting with AMI were admitted to the hospital for ischemic stroke. Although the prescription rate of each OMT medication was reasonably high (73.3%-97.3%), 47.7% lacked at least one OMT medication. Patients receiving OMT showed a significantly decreased occurrence of mortality (4.5% vs 15.1%, p < 0.001), re-AMI (4.2% vs 9.3%, p = 0.004), and the composite endpoint of death/re-AMI (8.6% vs 20.5%, p < 0.001) compared to those without OMT. No significant difference was observed between the groups regarding bleeding. After adjusting for confounding factors, OMT was the independent protective factor of 1-year mortality, while age was the independent risk factors.

Conclusions

OMT at discharge was associated with a significantly lower 1-year mortality of patients with AMI and prior stroke in clinical practice. However, OMT was provided to just half of the eligible patients, leaving room for substantial improvement.

Clinical Trial Registration

NCT02466854.

External validation of the Global Registry of Acute Coronary Events (GRACE) risk score: insights from the FORCE-ACS registry

Background

Acute coronary syndrome (ACS) patients are a heterogeneous group with a varying risk of in-hospital and long-term mortality. Clinical risk scores play an important role in estimating these risks. Among the available risk scores, the Global Registry of Acute Coronary Events (GRACE) risk score is most used in routine clinical practice. Given the temporal improvements in both the in-hospital and long-term survival for ACS patients, continued validation of the GRACE risk score in contemporary patient cohorts is warranted. Moreover, the performance of the GRACE risk score in important subgroups with specific risk profiles has received limited attention.

Purpose

To assess the performance of the GRACE risk score for predicting in-hospital and one-year mortality in a contemporary, unselected cohort of ACS patients.

Methods

The study population consisted of ACS patients enrolled in the FORCE-ACS registry. To assess model discrimination, c-statistics were computed from the area under the receiver operator characteristic curve. Calibration was visually assessed by plotting observed versus predicted mortality and tested using the Hosmer-Lemeshow goodness-of-fit test. Indices of calibration and discrimination were also assessed in subgroups based on sex, age, type of ACS and bleeding risk (according to the PRECISE-DAPT score).

Results

In total, 2,587 ACS patients (median age 68 years, 28.4% women) who were enrolled in the FORCE-ACS registry between January 2015 and June 2018 were used for model validation. The in-hospital and one-year mortality rates were 2.4% and 6.3%, respectively. The discriminative ability of the GRACE risk score was good for in-hospital mortality (c-statistic 0.87, 95% CI: 0.82–0.91) and one-year mortality (c-statistic 0.82, 95% CI: 0.78–0.85) (Figure 1). The GRACE risk score predicted one-year mortality less well in patients at high risk of bleeding (c-statistic 0.68 vs. 0.78 in patients at low risk of bleeding, p=0.04). We did not observe statistically significant differences in discrimination for predicting in-hospital or one-year mortality between other subgroups. In the overall cohort, calibration of the GRACE risk score for in-hospital morality was adequate (Hosmer-Lemeshow test: p=0.11), but the GRACE risk score overestimated the in-hospital mortality risk in patients &lt;75 years and patients at low risk of bleeding (Figure 2). The GRACE risk score overestimated the one-year mortality risk (Hosmer-Lemeshow test: p&lt;0.01) in the overall cohort, particularly in patients &lt;75 years, men and patients at low risk of bleeding (Figure 2).

Conclusion

The GRACE risk score remains a useful tool for predicting in-hospital and one-year mortality, although absolute risk at one year might be overestimated in contemporary ACS patients.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The FORCE-ACS registry is supported by grants from ZonMw, the St. Antonius Research Fund and AstraZeneca Figure 1. Discrimination of the GRACE risk scoreFigure 2. Calibration of the GRACE risk score

Machine learning-based prediction of adverse events following an acute coronary syndrome (PRAISE): a modelling study of pooled datasets

BACKGROUND

The accuracy of current prediction tools for ischaemic and bleeding events after an acute coronary syndrome (ACS) remains insufficient for individualised patient management strategies. We developed a machine learning-based risk stratification model to predict all-cause death, recurrent acute myocardial infarction, and major bleeding after ACS.

METHODS

Different machine learning models for the prediction of 1-year post-discharge all-cause death, myocardial infarction, and major bleeding (defined as Bleeding Academic Research Consortium type 3 or 5) were trained on a cohort of 19 826 adult patients with ACS (split into a training cohort [80%] and internal validation cohort [20%]) from the BleeMACS and RENAMI registries, which included patients across several continents. 25 clinical features routinely assessed at discharge were used to inform the models. The best-performing model for each study outcome (the PRAISE score) was tested in an external validation cohort of 3444 patients with ACS pooled from a randomised controlled trial and three prospective registries. Model performance was assessed according to a range of learning metrics including area under the receiver operating characteristic curve (AUC).

FINDINGS

The PRAISE score showed an AUC of 0·82 (95% CI 0·78-0·85) in the internal validation cohort and 0·92 (0·90-0·93) in the external validation cohort for 1-year all-cause death; an AUC of 0·74 (0·70-0·78) in the internal validation cohort and 0·81 (0·76-0·85) in the external validation cohort for 1-year myocardial infarction; and an AUC of 0·70 (0·66-0·75) in the internal validation cohort and 0·86 (0·82-0·89) in the external validation cohort for 1-year major bleeding.

INTERPRETATION

A machine learning-based approach for the identification of predictors of events after an ACS is feasible and effective. The PRAISE score showed accurate discriminative capabilities for the prediction of all-cause death, myocardial infarction, and major bleeding, and might be useful to guide clinical decision making.

FUNDING

None.

Incidence and outcomes of chronic total occlusion percutaneous coronary intervention in the Netherlands: data from a nationwide registry

Background

Patients with chronic total coronary occlusions (CTO) are at increased risk for poor clinical outcomes. We aimed to determine the incidence of CTO percutaneous coronary intervention (PCI) and to identify CTO patients at risk for cardiac events in the nationwide Netherlands Heart Registration (NHR).

Methods

We included all PCI procedures with ≥1 CTO registered in the NHR from January 2015 to December 2018, excluding acute interventions. We used multivariable logistic regression of baseline characteristics to calculate the risk for events as odds ratios (OR) with 95% confidence intervals (CI).

Results

Of the PCIs performed during the study period, 6.3% (8,343/133,042) were for CTOs, with the percentage increasing significantly over time from 5.9% in 2015 to 6.6% in 2018 (p < 0.001). Coronary artery bypass grafting <24 h was carried out in 0.3%, and the only significant predictor was diabetes mellitus (OR 2.97, 95% CI 1.04–8.49, p = 0.042). Myocardial infarction (MI) <30 days occurred in 0.5%, and renal insufficiency (i.e. estimated glomerular filtration rate <30 ml/min per 1.73 m²) was identified as an independent predictor (OR 4.70, 95% CI 1.07–20.61, p = 0.040). Among patients undergoing CTO-PCI, 1‑year mortality was 3.7%, and independent predictors included renal insufficiency (OR 5.59, 95% CI 3.25–9.59, p < 0.001), left ventricular ejection fraction <30% (OR 3.43, 95% CI 2.00–5.90, p < 0.001), previous MI (OR 1.62, 95% CI 1.14–2.31, p = 0.007) and age (OR 1.06 per year increment, 95% CI 1.04–1.07, p < 0.001). Target-vessel revascularisation <1 year occurred in 11.3%.

Conclusion

CTO-PCI is still infrequently performed in the Netherlands. The most important predictor of mortality after CTO-PCI was renal insufficiency. Identification of patients at risk may help improve the prognosis of CTO patients in the future.

Electronic supplementary material

The online version of this article (10.1007/s12471-020-01521-y) contains supplementary material, which is available to authorized users.

Percutaneous coronary intervention versus medical therapy for chronic total coronary occlusions: a systematic review and meta-analysis of randomised trials

BACKGROUND

The results of chronic total occlusion percutaneous coronary intervention (CTO-PCI) trials are inconclusive. Therefore, we studied whether CTO-PCI leads to improvement of clinical endpoints and patient symptoms when combining all available randomised data.

METHODS AND RESULTS

This meta-analysis was registered in PROSPERO prior to starting. We performed a literature search and identified all randomised trials comparing CTO-PCI to optimal medical therapy alone (OMT). A total of five trials were included, comprising 1790 CTO patients, of whom 964 were randomised to PCI and 826 to OMT. The all-cause mortality was comparable between groups at 1‑year [risk ratio (RR) 1.70, 95% confidence interval (CI) 0.50-5.80, p = 0.40] and at 4‑year follow-up (RR 1.14, 95% CI 0.38-3.40, p = 0.81). There was no difference in the incidence of major adverse cardiac events (MACE) between groups at 1 year (RR 0.69, 95% CI 0.36-1.33, p = 0.27) and at 4 years (RR 0.85, 95% CI 0.60-1.22, p = 0.38). Left ventricular function and volumes at follow-up were comparable between groups. However, the PCI group had fewer target lesion revascularisations (RR 0.28, 95% CI 0.15-0.52, p < 0.001) and was more frequently free of angina at 1‑year follow-up (RR 0.65, 95% CI 0.50-0.84, p = 0.001), although the scores on the subscales of the Seattle Angina Questionnaire were comparable.

CONCLUSION

In conclusion, in this meta-analysis of 1790 CTO patients, CTO-PCI did not lead to an improvement in survival or in MACE as reported at long-term follow-up of up to 4 years, or to improvement of left ventricular function. However, CTO-PCI resulted in less angina and fewer target lesion revascularisations compared to OMT.

Incidence, predictors and prognostic impact of intracranial bleeding within the first year after an acute coronary syndrome in patients treated with percutaneous coronary intervention

Background:

The rate of intracranial haemorrhage after an acute coronary syndrome has been studied in detail in the era of thrombolysis; however, in the contemporary era of percutaneous coronary intervention, most of the data have been derived from clinical trials. With this background, we aim to analyse the incidence, timing, predictors and prognostic impact of post-discharge intracranial haemorrhage in patients with acute coronary syndrome undergoing percutaneous coronary intervention.

Methods:

We analysed data from the BleeMACS registry (patients discharged for acute coronary syndrome and undergoing percutaneous coronary intervention from Europe, Asia and America, 2003–2014). Analyses were conducted using a competing risk framework. Uni and multivariate predictors of intracranial haemorrhage were assessed using the Fine–Gray proportional hazards regression analysis. The endpoint was 1-year post-discharge intracranial haemorrhage.

Results:

Of 11,136 patients, 30 presented with intracranial haemorrhage during the first year (0.27%). The median time to intracranial haemorrhage was 150 days (interquartile range 55.7–319.5). The fatality rate of intracranial haemorrhage was very high (30%). After multivariate analysis, only age (subhazard ratio 1.05, 95% confidence interval 1.01–1.07) and prior stroke/transient ischaemic attack (hazard ratio 3.29, 95% confidence interval 1.36–8.00) were independently associated with a higher risk of intracranial haemorrhage. Hypertension showed a trend to associate with higher intracranial haemorrhage rate. The combination of older age (⩾75 years), prior stroke/transient ischaemic attack, and/or hypertension allowed us to identify most of the patients with intracranial haemorrhage (86.7%). The annual rate of intracranial haemorrhage was 0.1% in patients with no risk factors, 0.2% in those with one factor, 0.6% in those with two factors and 1.3% in those with three factors.

Conclusion:

The incidence of intracranial haemorrhage in the first year after an acute coronary syndrome treated with percutaneous coronary intervention is low. Advanced age, previous stroke/transient ischaemic attack, and hypertension are the main predictors of increased intracranial haemorrhage risk.

Efficacy and Safety of Clopidogrel, Prasugrel and Ticagrelor in ACS Patients Treated with PCI: A Propensity Score Analysis of the RENAMI and BleeMACS Registries

INTRODUCTION

Real-life data comparing clopidogrel, prasugrel, and ticagrelor for unselected patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) are lacking, as are data for the temporal distribution of ischemic and bleeding risks.

METHODS

A total of 19,825 patients were enrolled from the RENAMI and BleeMACS registries. Both were multicenter, retrospective, observational registries including the data and outcomes of consecutive patients with ACS who underwent primary PCI and were discharged with dual antiplatelet therapy (DAPT). We evaluated the long-term outcome stratified by the different antiplatelet agents.

RESULTS

A total of 14,105 patients (71.2%) were treated with clopidogrel, 2364 patients (11.9%) with prasugrel and 3356 patients (16.9%) with ticagrelor. After propensity score matching, at 1 year, prasugrel reduced the incidence of net adverse clinical events (NACE; a composite endpoint of all-cause death, myocardial infarction [MI] and Bleeding Academic Research Consortium [BARC] 3-5 bleeding) (4.2% vs.7.6%, p = 0.002) and of major adverse cardiovascular events (MACE; a composite endpoint of death and MI) compared with clopidogrel (2.6% vs. 5.2%, p = 0.007). Ticagrelor decreased rates of MACE compared with clopidogrel (2.7% vs. 6.2%, p < 0.001), but not of NACE (6.6% vs. 8.7%, p = 0.07). Ticagrelor presented similar performance in terms of MACE compared with prasugrel (2.8% vs. 2.4%, p = 0.56), with a trend towards a reduction in MI (0.2% vs. 0.4%, p = 0.56), but with higher risk of BARC 3-5 bleedings (3.8% vs. 1.7%, p = 0.04). In the daily risk analysis, clopidogrel presented a binomial distribution with a peak of ischemic risk at 3 months, which decreased towards bleedings; prasugrel had a constant equivalence between opposite risks; and ticagrelor constantly reduced recurrent MIs despite higher risk of BARC 3-5 events.

CONCLUSION

In real life, ticagrelor is more effective in reducing ischemic events during the first year after ACS, despite an increased risk of major bleedings, while prasugrel assures a better balance between ischemic and bleeding recurrent events.

Acute alterations in glucose homeostasis impact coronary microvascular function in patients presenting with ST-segment elevation myocardial infarction

Background

Microvascular dysfunction in the setting of ST-segment myocardial infarction (STEMI) is thought to be related to stress-related metabolic changes, including acute glucose intolerance. The aim of this study was to assess the relationship between admission glucose levels and microvascular function in non-diabetic STEMI patients.

Methods

92 consecutive patients with a first anterior-wall STEMI treated with primary percutaneous coronary intervention (PPCI) were enrolled. Blood glucose levels were determined immediately prior to PPCI. After successful PPCI, at 1‑week and 6‑month follow-up, Doppler flow was measured in culprit and reference coronary arteries to calculate coronary flow velocity reserve (CFVR), baseline (BMR) and hyperaemic (HMR) microvascular resistance.

Results

The median admission glucose was 8.3 (7.2–9.6) mmol/l respectively 149.4 mg/dl [129.6–172.8] and was significantly associated with peak troponin T (standardised beta coefficient [std beta] = 0.281; p = 0.043). Multivariate analysis revealed that increasing glucose levels were significantly associated with a decrease in reference vessel CFVR (std beta = −0.313; p = 0.002), dictated by an increase in rest average peak velocity (APV) (std beta = 0.216; p = 0.033), due to a decreasing BMR (std beta = −0.225; p = 0.038) in the acute setting after PPCI. These associations disappeared at follow-up. These associations were not found for the infarct-related artery.

Conclusion

Elevated admission glucose levels are associated with impaired microvascular function assessed directly after PPCI in first anterior-wall STEMI. This influence of glucose levels is an acute phenomenon and contributes to microvascular dysfunction through alterations in resting flow and baseline microvascular resistance.

The Absorb bioresorbable vascular scaffold in real-world practice: long-term follow-up of the AMC Single Centre Real World PCI Registry

BACKGROUND

Bioresorbable scaffolds have been introduced to overcome the shortcomings of drug-eluting stents. Higher rates of device thrombosis, however, have been reported up to 3 years after implantation of the Absorb bioresorbable vascular scaffold (BVS). In the current article, we therefore report long-term clinical outcomes of the AMC Absorb Registry.

METHODS AND RESULTS

In the AMC Absorb Registry, all patients who underwent a percutaneous coronary intervention with Absorb BVS implantation between 30 August 2012 and 5 August 2013 at the Amsterdam University Medical Centre-Academic Medical Centre were included. The composite endpoint of this analysis was target-vessel failure (TVF). The median follow-up of the study cohort of the AMC Absorb Registry was 1534 days. At the time of the cross-sectional data sweep the clinical status at 4 years was known in 124 of 135 patients (91.9%). At long-term follow-up, the composite endpoint of TVF had occurred in 27 patients. The 4‑year Kaplan-Meier estimate of TVF was 19.8%. At 4 years cardiac death had occurred in 4 patients (3.2%) and target-vessel myocardial infarction in 9 (6.9%) patients. Definite scaffold thrombosis occurred in 5 (3.8%) patients. We found 1 case of very late scaffold thrombosis that occurred at 911 days after device implantation in a patient who was not on dual anti-platelet therapy.

CONCLUSION

In a patient population reflecting routine clinical practice, we found that cases of TVF continued to accrue beyond 2 years after Absorb BVS implantation.

Outcome of Patients With Prior Stroke/Transient Ischemic Attack and Acute Coronary Syndromes

The association between prior stroke/transient ischemic attack (TIA) and clinical outcomes in patients with acute coronary syndrome (ACS) has not been well explored. We evaluated the impact of prior stroke/TIA on this specific patient population. We conducted an international multicenter study including 15 401 patients with ACS from the Bleeding Complications in a Multicenter Registry of Patients Discharged With Diagnosis of Acute Coronary Syndrome registry. They were divided into 2 groups: patients with and without prior stroke/TIA. The primary end point was death at 1-year follow-up. Prior stroke/TIA was associated with higher rate of 1-year death (8.7% vs 3.4%; P < .001). It was an independent predictor of 1-year death even after adjustment for confounding variables (odds ratio, 1.705; 95% confidence interval, 1.046-2.778; P = .032). Besides, patients with prior stroke/TIA had significantly increased 1-year reinfarction (5.6% vs 3.8%, P = .015), in-hospital bleeding (8.7% vs 5.8%, P < .001), and 1-year bleeding (5.2% vs 3.0%, P < .001). No difference of antithrombotic therapies or dual antiplatelet therapy (DAPT) types on outcomes was observed in patients with prior stroke/TIA. Prior stroke/TIA was associated with higher 1-year death for patients with ACS who underwent percutaneous coronary intervention. No benefits or harms were observed with different antithrombotic therapies or DAPT types in these patients.

P1849Predictors of high radiation exposure in patients undergoing contemporary transfemoral transcatheter aortic valve implantation (TF-TAVI)

Background

Transfemoral transcatheter aortic valve implantation (TF-TAVI) is a minimally invasive and life-saving treatment option in patients with severe aortic valve stenosis. The number of TAVI procedures has rapidly expanded over the past decade and will continue to expand, as will the total occupational radiation exposure for the interventional cardiologist. Therefore, interventional cardiologist are at increasing risk for developing radiation induced diseases like cataract, premature vascular aging and left-sided brain tumors.

Objectives

In the current study we determined pre-procedural characteristics associated with high radiation exposure during transfemoral TAVI to raise awareness and increase the use of adequate radiation protection.

Methods

Radiation exposure (patient exposure in DAP in mGy·cm2) was collected during (TF)-TAVI procedures (July 2014- August 2018). Univariate and multiple regression analyses were performed to identify pre-procedural factors associated with high radiation exposure.

Results

A total of 654 TF-TAVI procedures were included. Patients had a median STS-score of 4% and 47% was male. The median radiation exposure was 38,016 mGy·cm2 (24,451–55,747) and the median fluoroscopy time was 16 minutes (IQR: 11–19). During the four year study period, the mean radiation exposure per TAVI procedure decreased with 30%, while the total fluoroscopy time declined with 28%.

The majority of the population underwent the TAVI procedure under local anesthesia (99%) and were implanted with the Edwards SAPIEN 3 valve (92%). Balloon predilatation was used during 88% and balloon post-dilatation was performed in only 5% of the procedures.

Patient characteristics associated with high radiation exposure included BMI >25 (OR: 6.0, 95% CI: 3.9–9.4, p<0.001), male gender (OR: 2.8, 95% CI: 1.8–4.4, p<0.001), a large pre-procedural CT-measured valve area (>450 mm2) (OR: 1.8, 95% CI: 1.1–2.8, p=0.01), presence of a pacemaker or ICD (OR: 2.0, 95% CI: 1.0–3.9, p=0.04) and a history of atrial fibrillation (OR: 1.5, 95% CI: 1.0–2.3, p=0.04). Moreover, the performance of predilatation (OR: 2.7, 95% CI: 1.5–4.8, p=0.001) and valve-in-valve procedures (OR: 3.3, 95% CI: 1.1–10.2, p=0.04) was associated to high radiation exposure.

Predictors of radiation exposure

Conclusions

The performance of transfemoral TAVI in patients with a large stature (male, BMI >25, valve area >450 mm2), in certain groups of fragile patients (presence of pacemaker or ICD, atrial fibrillation), and performing relatively complex procedures (predilatation and valve-in-valve) was associated with high radiation exposure. These patient characteristics and procedural strategies are known before the patient enters the catheterization laboratory. Hence, in the current era of a rapidly expanding number of TAVI procedures, operators should minimize their own health risk in these high-radiation-exposure-risk TAVI procedures.

Acknowledgement/Funding

None

P6409Ticagrelor and prasugrel versus clopidogrel in patients with acute coronary syndromes and chronic renal dysfunction: safety and efficacy

Introduction

Safety and efficacy of prasugrel and ticagrelor in real-life ACS (Acute Coronary Syndrome) with renal dysfunction remain to be established.

Methods

Consecutive patients from RENAMI and BLEEMACS were stratified according to renal function and estimated glomerular filtration rate (eGFR<60 mL/min/1.73 m2). Myocardial infarction (MI) and BARC major bleedings (MB; BARC type 3 or 5) were the primary end-point. Independent impact of clopidogrel, prasugrel and ticagrelor were evaluated with Cox multivariate analysis.

Results

19255 patients were enrolled (mean eGFR: 90±39 ml/min/1.73m2). Patients with eGFR<60 mL/min/1.73m2, constituted the 12.9% of the population (2490 pts). After a mean follow up of 13±5 months, the global incidence of re-AMI was of 5.8% and 2.9% in patients with and in those without eGFR<60 mL/min/1.73m2 (p<0.0001) respectively. MB occurred in 5.7% and 3% (p<0.0001). At Cox multivariate analysis, clopidogrel compared to prasugrel and ticagrelor was associated with increased risk of MI both in those with eGFR>60 mL/min/1.73m2 (HR=3.3: 2.4–4.4, p<0.0001) as well as in patients with eGFR<60 mL/min/1.73m2 (HR=10.04: 3.1–32.3, p<0.0001). In contrast, both prasugrel (HR=0.07: 0.01–0.54, p=0.01) and Ticagrelor (HR=0.36: 0.16–0.81, p=0.01) were associated with decreased risk of MI in the latters. DAPT with ticagrelor or prasugrel did not increased risk of MB in patients with eGFR<60 mL/min/1.73m2, while in patients with eGFR>60 mL/min/1.73m2, ticagrelor was associated to a slightly higher risk of MB (HR=1.43: 1.09–1.89, p=0.009).

Conclusion

In ACS patients with eGFR<60 mL/min/1.73m2, prasugrel and ticagrelor are associated with lower risk of recurrent MI without significant increase in the risk of MB.

462Impact of severe anemia (hemoglobin <10 g/dl) in the ischemic-bleeding profile during treatment with dual antiplatelet therapy after hospital discharge for acute coronary syndrome

Introduction

Anemia is strongly associated with increased risk of morbidity and mortality in patients after acute coronary syndromes (ACS). The aim of our study was to determine, after matching the baseline characteristics, the bleeding-ischemic risk profile during treatment with Dual Antiplatelet Therapy (DAPT) of patients with severe anemia (hemoglobin <10 g/dL) after an ACS undergoing Percutaneous Coronary Intervention (PCI).

Methods

The data analyzed in this study were obtained from the fusion of 3 clinical registries of ACS patients: BleeMACS (2004–2013), CardioCHUVI/ARRITXACA (2010–2016) and RENAMI (2013–2016). All 3 registries include consecutive patients discharged after an ACS with DAPT and undergoing PCI. The merged data set contain 26,076 patients. A propensity-matched analysis was performed to match the baseline characteristics of patients according to presence or not of severe anemia (hemoglobin <10 g/dL). The impact of severe anemia in the ischemic and bleeding risk was assessed by a competitive risk analysis, using a Fine and Gray regression model, with death being the competitive event. For ischemic risk we have considered a new acute myocardial infarction, whereas for bleeding risk we have considered major bleeding defined as bleeding requiring hospital admission. Follow-up time was censored by DAPT suspension/withdrawal.

Results

From the 26,076 ACS patients, 630 had severe anemia (2.4%). During a mean follow-up of 12.2±4.8 months, 964 patients died (3.7%), 640 had myocardial infarction (2.5%) and 685 had major bleeding (2.6%). After propensity-score matching, we obtained two matched groups (with hemoglobin < and ≥10 g/dL) of 621 patients. In comparison with patients without severe anemia, patients with hemoglobin <10 g/dL had similar risk of myocardial infarction (sHR 1.37, 95% CI 0.82–2.31, p=0.231) with higher risk of major bleeding (sHR 1.89, 95% CI 1.18–2.72, p=0.006). After propensity score matching, the cumulative incidence of myocardial infarction was 6 and 5 per 100 patients/year in patients with and without severe anemia, respectively, during DAPT. And the cumulative incidence of major bleeding was 12 and 6 per 100 patients/year in patients with and without severe anemia, respectively. The difference between myocardial infarction rate and major bleeding rate was −6 in patients with severe anemia (more bleeding than ischemic event rates; p<0.05) and −1 in patients with hemoglobin ≥10 g/dL (similar bleeding and ischemic event rates; p>0.05), per 100 patient-years (Figure).

Conclusions

After an ACS underwent PCI, during DAPT, the ischemic-bleeding balance of patients with severe anemia (hemoglobin <10 g/dL) is not favorable. In those patients, a short-term DAPT (<6 months) should be recommended.

P2Y12 inhibitors in acute coronary syndrome patients with renal dysfunction: an analysis from the RENAMI and BleeMACS projects

Aims

The aim of the present study was to establish the safety and efficacy profile of prasugrel and ticagrelor in real-life acute coronary syndrome (ACS) patients with renal dysfunction.

Methods and results

All consecutive patients from RENAMI (REgistry of New Antiplatelets in patients with Myocardial Infarction) and BLEEMACS (Bleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coronary Syndrome) registries were stratified according to estimated glomerular filtration rate (eGFR) lower or greater than 60 mL/min/1.73 m2. Death and myocardial infarction (MI) were the primary efficacy endpoints. Major bleedings (MBs), defined as Bleeding Academic Research Consortium bleeding types 3 to 5, constituted the safety endpoint. A total of 19 255 patients were enrolled. Mean age was 63 ± 12; 14 892 (77.3%) were males. A total of 2490 (12.9%) patients had chronic kidney disease (CKD), defined as eGFR &lt;60 mL/min/1.73 m2. Mean follow-up was 13 ± 5 months. Mortality was significantly higher in CKD patients (9.4% vs. 2.6%, P &lt; 0.0001), as well as the incidence of reinfarction (5.8% vs. 2.9%, P &lt; 0.0001) and MB (5.7% vs. 3%, P &lt; 0.0001). At Cox multivariable analysis, potent P2Y12 inhibitors significantly reduced the mortality rate [hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.54–0.96; P = 0.006] and the risk of reinfarction (HR 0.53, 95% CI 0.30–0.95; P = 0.033) in CKD patients as compared to clopidogrel. The reduction of risk of reinfarction was confirmed in patients with preserved renal function. Potent P2Y12 inhibitors did not increase the risk of MB in CKD patients (HR 1.00, 95% CI 0.59–1.68; P = 0.985).

Conclusion

In ACS patients with CKD, prasugrel and ticagrelor are associated with lower risk of death and recurrent MI without increasing the risk of MB.

Impact of renin-angiotensin system blockade on the prognosis of acute coronary syndrome based on left ventricular ejection fraction

INTRODUCTION AND OBJECTIVES

For patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI), it is unclear whether angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) are associated with reduced mortality, particularly with preserved left ventricular ejection fraction (LVEF). The goal of this study was to determine the association between ACEI/ARB and mortality in ACS patients undergoing PCI, with and without reduced LVEF.

METHODS

Data from the BleeMACS registry were used. The endpoint was 1-year all-cause mortality. The prognostic value of ACEI/ARB was tested after weighting by survival-time inverse probability and after adjustment by Cox regression, propensity score, and instrumental variable analysis.

RESULTS

Among 15 401 ACS patients who underwent PCI, ACEI/ARB were prescribed in 75.2%. There were 569 deaths (3.7%) during the first year after hospital discharge. After multivariable adjustment, ACEI/ARB were associated with lower 1-year mortality, ≤ 40% (HR, 0.62; 95%CI, 0.43-0.90; P=.012). The relative risk reduction of ACEI/ARB in mortality was 46.1% in patients with LVEF ≤ 40%, and 15.7% in patients with LVEF> 40% (P value for treatment-by-LVEF interaction=.008). For patients with LVEF> 40%, ACEI/ARB was associated with lower mortality only in ST-segment elevation myocardial infarction (HR, 0.44; 95%CI, 0.21-0.93; P=.031).

CONCLUSION

The benefit of ACEI/ARB in decreasing mortality after an ACS in patients undergoing PCI is concentrated in patients with LVEF ≤ 40%, and in those with LVEF> 40% and ST-segment elevation myocardial infarction. In non-ST-segment elevation-ACS patients with LVEF> 40%, further studies are needed to assess the prognostic impact of ACEI/ARB.

Short versus conventional hydration for prevention of kidney injury during pre-TAVI computed tomography angiography

BACKGROUND

Computed tomography angiography (CTA) is required in the work-up for transcatheter aortic valve implantation (TAVI). However, CTA may cause contrast-induced acute kidney injury (CI-AKI). We hypothesised that a short (1 h, 3 ml/kg/h sodium bicarbonate) hydration protocol is not inferior to conventional (24 h, 1 ml/kg/h saline) hydration in avoiding a decline in renal function in patients with impaired renal function.

METHODS AND RESULTS

Single-centre randomised non-inferiority trial in patients with impaired renal function who underwent pre-TAVI CTA. Patients were randomised on a 1:1 ratio to short hydration (SHORT; 1 h sodium bicarbonate, 3 ml/kg/h) or conventional hydration (CONV; 24 h saline, 1 ml/kg/h). Outcomes included percentage change in serum creatinine until 2-6 days after CTA with a non-inferiority margin of 10% and an increase on the Borg dyspnoea scale ≥1 point. Seventy-four patients were included. Increase in creatinine was 6 µmol/l (95% CI 2.5-9.3) in the SHORT versus 2 µmol/l (95% CI-1.4 to 6.3) in the CONV arm (p = 0.167). The percentage change was 4.6% (95% CI 2.0-7.3%) in the SHORT arm versus 2.5% (95% CI: 0.8 to 5.8%) in the CONV arm. The difference in percentage increase in creatinine between the two arms was 2.1% (95% CI: 2.0-6.2%; p-value non-inferiority: <0.001). CI-AKI and a need for dialysis were not observed. An increase of ≥1 point on the Borg scale (dyspnoea scale ranging from 1 (lowest) to 10 (highest)) was seen in 1 patient in the SHORT arm versus 5 patients in the CONV arm (2.9% vs 16.1%, p = 0.091).

CONCLUSION

For patients with impaired renal function undergoing pre-TAVI CTA, a short 1‑h, low-volume hydration protocol with sodium bicarbonate is not inferior to conventional 24-h, high-volume saline hydration.

Association of Beta-Blockers with Survival on Patients Presenting with ACS Treated with PCI: A Propensity Score Analysis from the BleeMACS Registry

PURPOSE

The aim was to evaluate prognostic value of beta-blocker (BB) administration in acute coronary syndromes (ACS) patients in the percutaneous coronary intervention (PCI) era.

METHODS AND RESULTS

The BleeMACS project is a multicenter, observational, retrospective registry enrolling patients with ACS worldwide in 15 hospitals. Patients discharged with BB therapy were compared to those discharged without a BB before and after propensity score with matching. The primary endpoint was all-cause mortality at 1 year. Secondary endpoints included in-hospital reinfarction, in-hospital heart failure, 1-year myocardial infarction, 1-year bleeding and 1-year composite of death and recurrent myocardial infarction. After matching, 2935 patients for each group were enrolled. The primary endpoint of 1-year death was significantly lower in the group on BB therapy (4.5 vs 7%, p < 0.05), while only a trend was noted for recurrent acute myocardial infarction (4.5 vs 4.9%, p = 0.54). These results were consistent for patients older than 80 years of age, for ST-elevation myocardial infarction (STEMI) patients, and for those discharged with complete versus incomplete revascularization, but not for non-STEMI/unstable angina patients.

CONCLUSIONS

BB therapy was related to 1-year lower risk of all-cause mortality, independently from completeness of revascularization, admission diagnosis, age and ejection fraction. Randomized controlled trials for patients treated with PCI for ACS should be performed.

Trends in patient characteristics and clinical outcome over 8 years of transcatheter aortic valve implantation

Aim

In the evolving field of transcatheter aortic valve implantations (TAVI) we aimed to gain insight into trends in patient and procedural characteristics as well as clinical outcome over an 8‑year period in a real-world TAVI population.

Methods

We performed a single-centre retrospective analysis of 1,011 consecutive patients in a prospectively acquired database. We divided the cohort into tertiles of 337 patients; first interval: January 2009–March 2013, second interval: March 2013–March 2015, third interval: March 2015–October 2016.

Results

Over time, a clear shift in patient selection was noticeable towards lower surgical risks including Society of Thoracic Surgeons predicted risk of mortality score and comorbidity. The frequency of transfemoral TAVI increased (from 66.5 to 77.4%, p = 0.0015). Device success improved (from 62.0 to 91.5%, p < 0.0001) as did the frequency of symptomatic relief (≥1 New York Heart Association class difference) (from 73.8 to 87.1%, p = 0.00025). Complication rates decreased, including in-hospital stroke (from 5.0 to 2.1%, p = 0.033) and pacemaker implantations (from 10.1 to 5.9%, p = 0.033). Thirty-day mortality decreased (from 11.0 to 2.4%, p < 0.0001); after adjustment for patient characteristics, a mortality-risk reduction of 72% was observed (adjusted hazard ratio [HR]: 0.28, 95% confidence interval [CI]: 0.13–0.62). One-year mortality rates decreased (from 23.4 to 11.4%), but this was no longer significant after a landmark point was set at 30 days (mortality from 31 days until 1 year) (adjusted HR: 0.69, 95% CI: 0.41–1.16, p = 0.16).

Conclusion

A clear shift towards a lower-risk TAVI population and improved clinical outcome was observed over an 8‑year period. Survival after TAVI improved impressively, mainly as a consequence of decreased 30-day mortality.

Electronic supplementary material

The online version of this article (10.1007/s12471-018-1129-x) contains supplementary material, which is available to authorized users.

Prediction of Post-Discharge Bleeding in Elderly Patients with Acute Coronary Syndromes: Insights from the BleeMACS Registry

BACKGROUND

A poor ability of recommended risk scores for predicting in-hospital bleeding has been reported in elderly patients with acute coronary syndromes (ACS). No study assessed the prediction of post-discharge bleeding in the elderly. The new BleeMACS score (Bleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coronary Syndrome), was designed to predict post-discharge bleeding in ACS patients. We aimed to assess the predictive ability of the BleeMACS score in elderly patients.

METHODS

We assessed the incidence and characteristics of severe bleeding after discharge in ACS patients aged ≥ 75 years. Bleeding was defined as any intracranial bleeding or bleeding leading to hospitalization and/or red blood transfusion, occurring within the first year after discharge. We assessed the predictive ability of the BleeMACS score according to age by Fine-Gray proportional hazards regression analysis, calculating receiver-operating characteristic (ROC) curves and the area under the ROC curves (AUC).

RESULTS

The BleeMACS registry included 15,401 patients of whom 3,376/15,401 (21.9%) were aged ≥ 75 years. Elderly patients were more commonly treated with clopidogrel and less often treated with ticagrelor or prasugrel. Of 3,376 elderly patients, 190 (5.6%) experienced post-discharge bleeding. The incidence of bleeding was moderately higher in elderly patients (hazard ratio [HR], 2.31, 95% confidence interval [CI], 1.92-2.77). The predictive ability of the BleeMACS score was moderately lower in elderly patients (AUC, 0.652 vs. 0.691, p = 0.001).

CONCLUSION

Elderly patients with ACS had a significantly higher incidence of post-discharge bleeding. Despite a lower predictive ability in older patients, the BleeMACS score exhibited an acceptable performance in these patients.

Prevalence and outcome of patients with cancer and acute coronary syndrome undergoing percutaneous coronary intervention: a BleeMACS substudy

BACKGROUND

The prevalence and outcome of patients with cancer that experience acute coronary syndrome (ACS) have to be determined.

METHODS AND RESULTS

The BleeMACS project is a multicentre observational registry enrolling patients with acute coronary syndrome undergoing percutaneous coronary intervention worldwide in 15 hospitals. The primary endpoint was a composite event of death and re-infarction after one year of follow-up. Bleedings were the secondary endpoint. 15,401 patients were enrolled, 926 (6.4%) in the cancer group and 14,475 (93.6%) in the group of patients without cancer. Patients with cancer were older (70.8±10.3 vs. 62.8±12.1 years, P<0.001) with more severe comorbidities and presented more frequently with non-ST-segment elevation myocardial infarction compared with patients without cancer. After one year, patients with cancer more often experienced the composite endpoint (15.2% vs. 5.3%, P<0.001) and bleedings (6.5% vs. 3%, P<0.001). At multiple regression analysis the presence of cancer was the strongest independent predictor for the primary endpoint (hazard ratio (HR) 2.1, 1.8-2.5, P<0.001) and bleedings (HR 1.5, 1.1-2.1, P=0.015). Despite patients with cancer generally being undertreated, beta-blockers (relative risk (RR) 0.6, 0.4-0.9, P=0.05), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (RR 0.5, 0.3-0.8, P=0.02), statins (RR 0.3, 0.2-0.5, P<0.001) and dual antiplatelet therapy (RR 0.5, 0.3-0.9, P=0.05) were shown to be protective factors, while proton pump inhibitors (RR 1, 0.6-1.5, P=0.9) were neutral.

CONCLUSION

Cancer has a non-negligible prevalence in patients with acute coronary syndrome undergoing percutaneous coronary intervention, with a major risk of cardiovascular events and bleedings. Moreover, these patients are often undertreated from clinical despite medical therapy seems to be protective. Registration:The BleeMACS project (NCT02466854).

Optimal Medical Therapy in Patients with Malignancy Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndrome: a BleeMACS Sub-Study

OBJECTIVE

Our objective was to define the most appropriate treatment for acute coronary syndrome (ACS) in patients with malignancy.

METHODS AND RESULTS

The BleeMACS project is a worldwide multicenter observational prospective registry in 16 hospitals enrolling patients with ACS undergoing percutaneous coronary intervention. Primary endpoints were death, re-infarction, and major adverse cardiac events (MACE; composite of death and re-infarction) after 1 year of follow-up. The secondary endpoint was bleeding events during follow-up. We performed sub-study analyses according to whether β-blockers (BBs), angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), statins, or proton pump inhibitors (PPIs) were prescribed at discharge. We also calculated the propensity score for optimal medical therapy (OMT; combination of BB, ACEI/ARB, and statins). The study included 926 patients. According to the multivariate analysis, ACEIs/ARBs (hazard ratio [HR] 0.58, 95 % confidence interval [CI] 0.36-1.94; p = 0.03) and statins (HR 0.37, 95 % CI 0.23-0.61; p < 0.01) reduced the risk of MACE, while the effects of BBs (HR 0.85, 95 % CI 0.55-1.32; p = 0.48) and PPIs (HR 1.33, 95 % CI 0.83-2.12; p = 0.23) were not significant. OMT was prescribed at discharge in 300 (32.4 %) patients; after propensity score analysis, OMT showed a significant reduction in death (3 % vs. 12.5 %, HR 0.21, 95 % CI 0.1-0.4; log-rank p < 0.001) and MACE (6.7 vs. 15.2 %, log-rank p = 0.01).

CONCLUSION

In patients with ACS and malignancy, OMT reduces the risk of adverse events at 1 year; in particular, ACEIs/ARBs and statins were the most protective drugs. (Clinical trials identifier: NCT02466854).

[Support of damaged heart with the Impella pump]

Temporary mechanical circulatory support is increasingly used, particularly in patients with cardiogenic shock or during high-risk percutaneous coronary interventions. In the last five years there have been numerous developments in this field. Experience has been gained from usage of temporary heart pumps, and new pumps have arrived on the market. Until recently, the intra-aortal balloon pump was the standard treatment for patients with cardiogenic shock; however, results from the latest research into the effectiveness of this pump have rendered it less popular. An alternative modality is the Impella system. Since 2012, usage of a heart pump in cardiogenic shock treatment is reimbursed by healthcare insurers in the Netherlands. Recently, the FDA approved the Impella system for said indication.

Mechanical circulatory support with the Impella 5.0 device for postcardiotomy cardiogenic shock: a three-center experience

AIM

Postcardiotomy cardiogenic shock (PCCS) is associated with high mortality rates, despite full conventional treatment. Although the results of treatment with surgically implantable ventricular assist devices have been encouraging, the invasiveness of this treatment limits its applicability. Several less invasive devices have been developed, including the Impella system. The objective of this study was to describe our three-center experience with the Impella 5.0 device in the setting of PCCS.

METHODS

From January 2004 through December 2010, a total of 46 patients were diagnosed with treatment-refractory PCCS and treated with the Impella 5.0 percutaneous left ventricular assist device at three european heart centers. Baseline and follow-up characteristics were collected retrospectively and entered into a dedicated database.

RESULTS

Within the study cohort of 46 patients, mean logistic and additive EuroSCORES were 24 ± 19 and 10 ± 4. The majority of patients underwent coronary artery bypass grafting (48%) or combined surgery (33%). Half of all patients had been treated with an intra-aortic balloon pump before 5.0-implantation, 1 patient had been treated with an Impella 2.5 device. All patients were on mechanical ventilation and intravenous inotropes. The Kaplan-Meier estimate of overall 30-day survival was 39.5%.

CONCLUSION

Thirty-day survival rates for patients with PCCS, refractory to aggressive conventional treatment and treated with the Impella 5.0 device, are comparable to those reported in studies evaluating surgically implantable VADs, whereas the Impella system is much less invasive. Therefore, mechanical circulatory support with the Impella 5.0 device is a suitable treatment modality for patients with severe PCCS.

Coronary microcirculatory dysfunction is associated with left ventricular dysfunction during follow-up after STEMI

BACKGROUND

Coronary microvascular resistance is increased after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI), which may be related in part to changed left ventricular (LV) dynamics. Therefore we studied the coronary microcirculation in relation to systolic and diastolic LV function after STEMI.

METHODS

The study cohort consisted of 12 consecutive patients, all treated with primary PCI for a first anterior wall STEMI. At 4 months, we assessed pressure-volume loops. Subsequently, we measured intracoronary pressure and flow velocity and calculated coronary microvascular resistance. Infarct size and LV mass were assessed using magnetic resonance imaging.

RESULTS

Patients with an impaired systolic LV function due to a larger myocardial infarction showed a higher baseline average peak flow velocity (APV) than the other patients (26 ± 7 versus 17 ± 5 cm/s, p = 0.003, respectively), and showed an impaired variable microvascular resistance index (2.1 ± 1.0 versus 4.1 ± 1.3 mmHg cm(-1)∙s(-1), p = 0.003, respectively). Impaired diastolic relaxation time was inversely correlated with hyperaemic APV (r = -0.56, p = 0.003) and positively correlated with hyperaemic microvascular resistance (r = 0.48, p = 0.01). LV dilatation was associated with a reduced variable microvascular resistance index (r = 0.78, p = 0.006).

CONCLUSION

A larger anterior myocardial infarction results in impaired LV performance associated with reduced coronary microvascular resistance variability, in particular due to higher coronary blood flow at baseline in these compromised left ventricles.

Efficacy and timing of intra-aortic counterpulsation in patients with ST-elevation myocardial infarction complicated by cardiogenic shock

BACKGROUND

Guidelines strongly recommend additional intra-aortic balloon pump (IABP) therapy in STEMI patients with cardiogenic shock (CS) treated by primary percutaneous coronary intervention (PCI). However, there is no randomised evidence suggesting survival benefit of IABP treatment in CS. It is suggested that timing of initiation of IABP therapy could be of great importance. Therefore, we compared mortality rates of IABP therapy versus no IABP therapy in the setting of STEMI complicated by CS. In addition, we investigated the effect of initiation of IABP therapy on mortality.

METHODS

From a cohort of 292 STEMI patients with CS treated by primary PCI, 199 patients received IABP therapy (IABP group) and 93 patients received no support (no IABP group). The IABP group was divided into two subgroups based on timing of initiation of support, i.e. 'IABP pre PCI' (n = 59) and 'IABP post PCI' (n = 140). Outcomes were assessed by propensity stratification and multivariate logistic regression.

RESULTS

All-cause 30-day mortality for the IABP versus the no IABP group was 47 % vs. 28 %, respectively, in univariate analysis resulting in an odds ratio (OR) of 1.67 (95%CI, 1.16 to 2.39). However, analyses adjusting outcomes by propensity stratification and logistic regression, respectively, neutralised this OR. In the IABP pre-PCI group vs. the post-PCI group 30-day mortality was 64 % vs. 40 %, resulting in an OR of 1.56 (95 % CI, 1.18 to 2.08). However, after propensity stratification analysis and multivariate logistic regression analysis, there were no significant differences in odds of 30-day mortality.

CONCLUSION

In our cohort of patients with STEMI complicated by CS treated with primary PCI we observed a difference in mortality between those treated with IABP and those treated without IABP in favour of the 'no IABP' group. The mortality difference was eliminated after adjustment for differences in case mix by propensity stratification or by logistic regression analysis. Neither did we observe any difference in mortality between patients whose IABP treatment was initiated before or immediately after PCI.

Cardiogenic shock: role of revascularization

The most common cause of cardiogenic shock is myocardial ischemia developing early or late in the course of acute myocardial infarction. The incidence of cardiogenic shock (CS) is around 7% in ST-segment elevation myocardial infarction (STEMI) patients and has remained constant over the last 20 years. Therapy should be chain based by increased patient's awareness. Early and prehospital diagnosis and treatment, with prompt transfer to a catheterization laboratory. Early revascularization is the cornerstone treatment of acute myocardial infarction complicated by cardiogenic shock. According to the guidelines, revascularization is effective up to 36 hours after the onset of CS and performed within 18 hours after the diagnosis of CS. Primary percutaneous coronary intervention (PCI) is the most efficient and easily available therapy to restore coronary flow in the infarct related artery. Although recommended, there is little evidence that immediate multivessel PCI is beneficial for CS. The growing numbers of reports suggest staged PCI procedures or CABG is preferred in CS patients with significant LM disease or 3-vessel disease. The use of hemodynamic support with newly available percutaneous left ventricular unloading devices may herald a new era enabling preservation of adequate perfusion to other vital organs such as the brain, kidney and bowel. Despite all current efforts, in-hospital mortality for CS remains around 50%. However, long-term outcome and quality of life in hospital survivors is similar to patients with ST-segment elevation myocardial infarction patients presenting without CS.

Guideline adherence for antithrombotic therapy in acute coronary syndrome: an overview in Dutch hospitals

OBJECTIVE

To assess current Dutch antithrombotic treatment strategies for acute coronary syndrome (ACS) in light of the current European Society of Cardiology (ESC) guidelines.

METHODS

For every Dutch hospital with a coronary care unit (CCU) (n = 93) a single cardiologist was interviewed concerning heparin, thienopyridine and GP IIb/IIIa inhibitor (GPI) treatment. In each hospital, we randomly approached one cardiologist assuming equal policy among physicians employed at the same hospital.

RESULTS

The response rate was 90%. In 59% of hospitals, treatment of ST-elevation myocardial infarction (STEMI) occurred according to the 2008 ESC STEMI guideline, with unfractionated heparin. In contrast, although not recommended, low-molecular-weight heparin (LMWH) was used in 39% (enoxaparin 19%, dalteparin 12%, nadroparin 8%). In non-STEMI, low-molecular-weight-heparins (LMWHs) were used in 97% of all hospitals. Fondaparinux, agent of choice in a noninvasive strategy for the treatment of non-STEMI, was applied in only 2% of hospitals. Although recommended by the ESC, dose adjustment of LMWH therapy for patients with renal failure is not applied in 71% of hospitals. Likewise, LMWH dose adjustment is not applied for patients aged over 75 years in 92% of hospitals.

CONCLUSION

To a great extent treatment of ACS in the Netherlands occurs according to ESC guidelines. Additional benefit may be achieved by routine dose adjustment of LMWH for patients with renal insufficiency and aged >75 years, since these patients are at high risk of bleeding complications secondary to antithrombotic treatment. Periodical evaluation of real-life practice may improve guideline adherence and potentially improve clinical outcome. (Neth Heart J 2010;18:291-9.).

Primary percutaneous coronary intervention versus thrombolytic treatment: long term follow up according to infarct location

OBJECTIVES

To study the clinical significance of infarct location during long term follow up in a trial comparing thrombolysis with primary angioplasty.

DESIGN

Retrospective longitudinal cohort analysis of prospectively entered data.

SETTING

Patients with acute ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI).

PATIENTS

In the Zwolle trial 395 patients with acute STEMI were randomly assigned to intravenous streptokinase or PCI.

MAIN OUTCOME MEASURES

Survival according to infarct location and treatment after 8 (2) years of follow up.

RESULTS

105 patients died: 63 patients in the streptokinase group and 42 patients in the primary PCI group (relative risk (RR) 1.6, 95% confidence interval (CI) 1.0 to 2.6; p = 0.03). In patients with non-anterior STEMI there was no difference in mortality between streptokinase and PCI treated patients (RR 1.1, 95% CI 0.6 to 2.1; p = 0.68) but the streptokinase group had significantly more major adverse cardiac events (MACE) than the PCI group (RR 2.1, 95% CI 1.2 to 3.6). The number needed to treat to prevent one MACE was four. In patients with anterior STEMI, mortality was higher in the streptokinase group than in the PCI group (RR 2.7, 95% CI 1.4 to 5.5; p = 0.004). The number needed to treat to prevent one death was five. Kaplan-Meier analysis confirmed the benefits of primary angioplasty in the first year and showed additional benefit of PCI compared with streptokinase between 1-8 years after the acute event.

CONCLUSIONS

Patients with anterior STEMI have better long term survival when treated with PCI than with streptokinase. In patients alive one year after the acute event, PCI confers a significant additional survival benefit, probably due to better preserved residual left ventricular function.

Large pseudo aneurysm due to ruptured ostial coronary button after Bentall procedure in a patient with Marfan syndrome

Images

Predictors of early ventricular fibrillation before reperfusion therapy for acute ST-elevation myocardial infarction

BACKGROUND

Early VF accounts for the majority of deaths during the acute phase of acute MI. In patients treated with fibrinolytics, in-hospital VF occurs most frequently with inferior MI. Contrariwise, out-of-hospital VF seems to be associated with anterior wall MI and preinfarction angina (preconditioning) may protect against VF.

AIM

To study clinical characteristics of patients with or without VF before or during reperfusion therapy.

STUDY DESIGN AND METHODS

From January 1995 until December 2001, we treated 2826 patients for acute MI and reviewed the clinical records of all patients. Patients who developed early VF were classified according to the first episode of VF: either before or during the angioplasty procedure.

RESULTS

VF developed in 219 (8%) patients. Early VF before reperfusion therapy (n=145, 5%) was independently related to anterior MI (RR 2.3 (95% CI 1.53-3.50), p<0.001), absence of preinfarction angina (RR 2.1 (95% CI 1.38-3.24), p=0.001) and Killip class >1 (RR 3.8 (95% CI 2.34-6.10), p<0.001). The majority of patients with VF during angioplasty (n=74, 3%) had inferior MI (61%).

CONCLUSION

Early VF before reperfusion therapy is independently associated with anterior MI, absence of preinfarction angina and Killip class >1, whereas the majority of patients with VF during angioplasty have inferior MI.