The role of metabolites and metabolomics in clinically applicable biomarkers of disease

Metabolomics allows the simultaneous and relative quantification of thousands of different metabolites within a given sample using sensitive and specific methodologies such as gas or liquid chromatography coupled to mass spectrometry, typically in discovery phases of studies. Biomarkers are biological characteristics that are objectively measured and evaluated as indicators of normal biological processes, pathological processes or pharmacologic responses to a therapeutic intervention. Biomarkers are widely used in clinical practice for the diagnosis, assessment of severity and response to therapy in a number of clinical disease states. In human studies, metabolomics has been applied to define biomarkers related to prognosis or diagnosis of a disease or drug toxicity/efficacy and in doing so hopes to provide greater pathophysiological understanding of disease or therapeutic toxicity/efficacy. This review discusses the application of metabolomics in the discovery and subsequent application of biomarkers in the diagnosis and management of inborn errors of metabolism, cardiovascular disease and cancer. We critically appraise how novel biomarkers discovered through metabolomic analysis may be utilized in future clinical practice by addressing the following three fundamental questions: (1) Can the clinician measure them? (2) Do they add new information? (3) Do they help the clinician to manage patients? Although a number of novel biomarkers have been discovered through metabolomic studies of human diseases in the last decade, none have currently made the transition to routine use in clinical practice. Metabolites identified from these early studies will need to form the basis of larger, prospective, externally validated studies in clinical cohorts for their future use as biomarkers. At this stage, the absolute quantification of these biomarkers will need to be assessed epidemiologically, as will the ultimate deployment in the clinic via routine biochemistry, dip stick or similar rapid at- or near-patient care technologies.

Fractional flow reserve derived from computed tomography coronary angiography in the assessment and management of stable chest pain: the FORECAST randomized trial

Aims 

Fractional flow reserve (FFR_CT) using computed tomography coronary angiography (CTCA) determines both the presence of coronary artery disease and vessel-specific ischaemia. We tested whether an evaluation strategy based on FFR_CT would improve economic and clinical outcomes compared with standard care.

Methods and results 

Overall, 1400 patients with stable chest pain in 11 centres were randomized to initial testing with CTCA with selective FFR_CT (experimental group) or standard clinical care pathways (standard group). The primary endpoint was total cardiac costs at 9 months. Secondary endpoints were angina status, quality of life, major adverse cardiac and cerebrovascular events, and use of invasive coronary angiography. Randomized groups were similar at baseline. Most patients had an initial CTCA: 439 (63%) in the standard group vs. 674 (96%) in the experimental group, 254 of whom (38%) underwent FFR_CT. Mean total cardiac costs were higher by £114 (+8%) in the experimental group, with a 95% confidence interval from −£112 (−8%) to +£337 (+23%), though the difference was not significant (P = 0.10). Major adverse cardiac and cerebrovascular events did not differ significantly (10.2% in the experimental group vs. 10.6% in the standard group) and angina and quality of life improved to a similar degree over follow-up in both randomized groups. Invasive angiography was reduced significantly in the experimental group (19% vs. 25%, P = 0.01).

Conclusion 

A strategy of CTCA with selective FFR_CT in patients with stable angina did not differ significantly from standard clinical care pathways in cost or clinical outcomes, but did reduce the use of invasive coronary angiography.

Patient response, treatments, and mortality for acute myocardial infarction during the COVID-19 pandemic

Aim

COVID-19 might have affected the care and outcomes of hospitalised acute myocardial infarction (AMI). We aimed to determine whether the COVID-19 pandemic changed patient response, hospital treatment and mortality from AMI.

Methods and Results

Admission were classified as non ST-elevation myocardial infarction (NSTEMI) or STEMI at 99 hospitals in England through live feeding from the Myocardial Ischaemia National Audit Project between 1^st January, 2019 and 22^nd May, 2020. Time series plots were estimated using a 7-day simple moving average, adjusted for seasonality. From 23^rd March, 2020 (UK lockdown) median daily hospitalisations decreased more for NSTEMI (69 to 35; IRR 0.51, 95% CI 0.47-0.54) than STEMI (35 to 25; IRR 0.74, 95% CI 0.69-0.80) to a nadir on 19th April, 2020. During lockdown, patients were younger (mean age 68.7 years vs. 66.9 years), less frequently diabetic (24.6% vs. 28.1%) or had cerebrovascular disease (7.0% vs. 8.6%). STEMI more frequently received primary PCI (81.8% vs 78.8%%), thrombolysis was negligible (0.5% vs. 0.3%), median admission-to-coronary angiography duration for NSTEMI decreased (26.2 vs. 64.0 hours), median duration of hospitalisation decreased (4 to 2 days), secondary prevention pharmacotherapy prescription remained unchanged (each >94.7%). Mortality at 30 days increased for NSTEMI (from 5.4% to 7.5%; OR 1.41, 95% CI 1.08-1.80), but decreased for STEMI (from 10.2% to 7.7%; OR 0.73, 95% CI 0.54-0.97).

Conclusions

During COVID-19, there was a substantial decline in admissions with AMI. Those who presented to hospital were younger, less co-morbid and, for NSTEMI, had higher 30-day mortality.

Impact of COVID-19 on percutaneous coronary intervention for ST-elevation myocardial infarction

BACKGROUND

The objective of the study was to identify any changes in primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) in England by analysing procedural numbers, clinical characteristics and patient outcomes during the COVID-19 pandemic.

METHODS

We conducted a retrospective cohort study of patients who underwent PCI in England between January 2017 and April 2020 in the British Cardiovascular Intervention Society-National Institute of Cardiovascular Outcomes Research database. Analysis was restricted to 44 hospitals that reported contemporaneous activity on PCI. Only patients with primary PCI for STEMI were included in the analysis.

RESULTS

A total of 34 127 patients with STEMI (primary PCI 33 938, facilitated PCI 108, rescue PCI 81) were included in the study. There was a decline in the number of procedures by 43% (n=497) in April 2020 compared with the average monthly procedures between 2017 and 2019 (n=865). For all patients, the median time from symptom to hospital showed increased after the lockdown (150 (99-270) vs 135 (89-250) min, p=0.004) and a longer door-to-balloon time after the lockdown (48 (21-112) vs 37 (16-94) min, p<0.001). The in-hospital mortality rate was 4.8% before the lockdown and 3.5% after the lockdown (p=0.12). Following adjustment for baseline characteristics, no differences were observed for in-hospital death (OR 0.87, 95% CI 0.45 to 1.68, p=0.67) and major adverse cardiovascular events (OR 0.71, 95% CI 0.39 to 1.32, p=0.28).

CONCLUSIONS

Following the lockdown in England, we observed a decline in primary PCI procedures for STEMI and increases in overall symptom-to-hospital and door-to-balloon time for patients with STEMI. Restructuring health services during COVID-19 has not adversely influenced in-hospital outcomes.

Plasma membrane calcium pump (PMCA4)-neuronal nitric-oxide synthase complex regulates cardiac contractility through modulation of a compartmentalized cyclic nucleotide microdomain

Identification of the signaling pathways that regulate cyclic nucleotide microdomains is essential to our understanding of cardiac physiology and pathophysiology. Although there is growing evidence that the plasma membrane Ca(2+)/calmodulin-dependent ATPase 4 (PMCA4) is a regulator of neuronal nitric-oxide synthase, the physiological consequence of this regulation is unclear. We therefore tested the hypothesis that PMCA4 has a key structural role in tethering neuronal nitric-oxide synthase to a highly compartmentalized domain in the cardiac cell membrane. This structural role has functional consequences on cAMP and cGMP signaling in a PMCA4-governed microdomain, which ultimately regulates cardiac contractility. In vivo contractility and calcium amplitude were increased in PMCA4 knock-out animals (PMCA4(-/-)) with no change in diastolic relaxation or the rate of calcium decay, showing that PMCA4 has a function distinct from beat-to-beat calcium transport. Surprisingly, in PMCA4(-/-), over 36% of membrane-associated neuronal nitric-oxide synthase (nNOS) protein and activity was delocalized to the cytosol with no change in total nNOS protein, resulting in a significant decrease in microdomain cGMP, which in turn led to a significant elevation in local cAMP levels through a decrease in PDE2 activity (measured by FRET-based sensors). This resulted in increased L-type calcium channel activity and ryanodine receptor phosphorylation and hence increased contractility. In the heart, in addition to subsarcolemmal calcium transport, PMCA4 acts as a structural molecule that maintains the spatial and functional integrity of the nNOS signaling complex in a defined microdomain. This has profound consequences for the regulation of local cyclic nucleotide and hence cardiac β-adrenergic signaling.

What can we learn from patients with heart failure about exercise adherence? A systematic review of qualitative papers

OBJECTIVES

Keeping physically active has been shown to bring positive outcomes for patients diagnosed with heart failure (HF). However, a number of individuals with this health problem do not undertake regular exercise. A review of extant qualitative research was conducted to explore what it can tell us about barriers and enablers to physical activity among people with HF.

METHODS

A systematic search, involving electronic databases and endeavors to locate gray literature, was carried out to identify relevant qualitative studies published from 1980 onward. Data from retrieved papers were combined using framework analysis. Papers read in full numbered 32, and 20 were included in the review.

RESULTS

Synthesis of results from the 20 studies resulted in 4 main themes: Changing soma, negative emotional response, adjusting to altered status, and interpersonal influences. How individuals responded to their diagnosis and their altered physical status related to their activity levels, as did the degree of encouragement to exercise coming from family, friends, and professionals. These findings can be connected to the theory of behavioral change developed by Bandura, known as social cognitive theory (SCT).

CONCLUSIONS

SCT may be a useful framework for developing interventions to support patients with HF in undertaking and maintaining regular exercise patterns. Specific components of SCT that practitioners may wish to consider include self-efficacy and outcome expectancies. These were issues referred to in papers for the systematic review that appear to be particularly related to exercise adherence.

Intra-arterial vasodilators to prevent radial artery spasm: a systematic review and pooled analysis of clinical studies

OBJECTIVES

The aim of this study is to review the available literature on the efficacy and safety of agents used for prevention of RAS.

BACKGROUND

Different vasodilator agents have been used to prevent radial artery spasm (RAS) in patients undergoing transradial cardiac catheterization.

METHODS

We included studies that evaluated any intra-arterial drug administered in the setting cardiac catheterization that was undertaken through the transradial access site (TRA). We also compared studies for secondary outcomes of major bleeding, procedure time, and procedure failure rate in setting of RAS prevention, patent hemostasis and radial artery occlusion.

RESULTS

22 clinical studies met the inclusion criteria. For placebo, RAS rate was 12% (4 studies, 638 participants), which was similar to 2.5mg of verapamil 12% (3 studies, 768 participants) but greater than 5mg of verapamil (4%, 2 studies, 497 participants). For nicorandil, there was a much higher RAS rate compared to placebo (16%, 3 studies, 447 participants). The lowest rates of RAS was found for nitroglycerin at both 100 μg (4%) and 200 μg (2%) doses, isosorbide mononitrate (4%) and nicardipine (3%). We found no information regarding the procedure failure rates, patent hemostasis, and radial artery occlusion in these studies.

CONCLUSIONS

In this largest and up-to-date review on intra-arterial vasodilators use to reduce RAS, we have found that the verapamil at a dose of 5mg or verapamil in combination with nitroglycerine are the best combinations to reduce RAS.

Risk Factors for Heart Failure

Background:

There are multiple risk factors for heart failure, but contemporary temporal trends according to sex, socioeconomic status, and ethnicity are unknown.

Methods:

Using a national UK general practice database linked to hospitalizations (1998–2017), 108 638 incident heart failure patients were identified. Differences in risk factors among patient groups adjusted for sociodemographic factors and age-adjusted temporal trends were investigated using logistic and linear regression.

Results:

Over time, a 5.3 year (95% CI, 5.2–5.5) age difference between men and women remained. Women had higher blood pressure, body mass index, and cholesterol than men ( P <0.0001). Ischemic heart disease prevalence increased for all to 2006 before reducing in women by 0.5% per annum, reaching 42.7% (95% CI, 41.7–43.6), but not in men, remaining at 57.7% (95% CI, 56.9–58.6; interaction P =0.002). Diabetes mellitus prevalence increased more in men than in women (interaction P <0.0001). Age between the most deprived (74.6 years [95% CI, 74.1–75.1]) and most affluent (79.9 [95% CI, 79.6–80.2]) diverged (interaction P <0.0001), generating a 5-year gap. The most deprived had significantly higher annual increases in comorbidity numbers (+0.14 versus +0.11), body mass index (+0.14 versus +0.11 kg/m 2 ), and lower smoking reductions (−1.2% versus −1.7%) than the most affluent. Ethnicity trend differences were insignificant, but South Asians were overall 6 years and the black group 9 years younger than whites. South Asians had more ischemic heart disease (+16.5% [95% CI, 14.3–18.6]), hypertension (+12.5% [95% CI, 10.5–14.3]), and diabetes mellitus (+24.3% [95% CI, 22.0–26.6]), and the black group had more hypertension (+12.3% [95% CI, 9.7–14.8]) and diabetes mellitus (+13.1% [95% CI, 10.1–16.0]) but lower ischemic heart disease (−10.6% [95% CI, −13.6 to −7.6]) than the white group.

Conclusions:

Population groups show distinct risk factor trend differences, indicating the need for contemporary tailored prevention programs.

ESC working group on e-cardiology position paper: use of commercially available wearable technology for heart rate and activity tracking in primary and secondary cardiovascular prevention-in collaboration with the European Heart Rhythm Association, European Association of Preventive Cardiology, Association of Cardiovascular Nursing and Allied Professionals, Patient Forum, and the Digital Health Committee

Commercially available health technologies such as smartphones and smartwatches, activity trackers and eHealth applications, commonly referred to as wearables, are increasingly available and used both in the leisure and healthcare sector for pulse and fitness/activity tracking. The aim of the Position Paper is to identify specific barriers and knowledge gaps for the use of wearables, in particular for heart rate (HR) and activity tracking, in clinical cardiovascular healthcare to support their implementation into clinical care. The widespread use of HR and fitness tracking technologies provides unparalleled opportunities for capturing physiological information from large populations in the community, which has previously only been available in patient populations in the setting of healthcare provision. The availability of low-cost and high-volume physiological data from the community also provides unique challenges. While the number of patients meeting healthcare providers with data from wearables is rapidly growing, there are at present no clinical guidelines on how and when to use data from wearables in primary and secondary prevention. Technical aspects of HR tracking especially during activity need to be further validated. How to analyse, translate, and interpret large datasets of information into clinically applicable recommendations needs further consideration. While the current users of wearable technologies tend to be young, healthy and in the higher sociodemographic strata, wearables could potentially have a greater utility in the elderly and higher-risk population. Wearables may also provide a benefit through increased health awareness, democratization of health data and patient engagement. Use of continuous monitoring may provide opportunities for detection of risk factors and disease development earlier in the causal pathway, which may provide novel applications in both prevention and clinical research. However, wearables may also have potential adverse consequences due to unintended modification of behaviour, uncertain use and interpretation of large physiological data, a possible increase in social inequality due to differential access and technological literacy, challenges with regulatory bodies and privacy issues. In the present position paper, current applications as well as specific barriers and gaps in knowledge are identified and discussed in order to support the implementation of wearable technologies from gadget-ology into clinical cardiology.

The collateral damage of COVID-19 to cardiovascular services: a meta-analysis

AIMS

The effect of the COVID-19 pandemic on care and outcomes across non-COVID-19 cardiovascular (CV) diseases is unknown. A systematic review and meta-analysis was performed to quantify the effect and investigate for variation by CV disease, geographic region, country income classification and the time course of the pandemic.

METHODS AND RESULTS

From January 2019 to December 2021, Medline and Embase databases were searched for observational studies comparing a pandemic and pre-pandemic period with relation to CV disease hospitalisations, diagnostic and interventional procedures, outpatient consultations, and mortality. Observational data were synthesised by incidence rate ratios (IRR) and risk ratios (RR) for binary outcomes and weighted mean differences for continuous outcomes with 95% confidence intervals. The study was registered with PROSPERO (CRD42021265930). A total of 158 studies, covering 49 countries and 6 continents, were used for quantitative synthesis. Most studies (80%) reported information for high-income countries (HICs). Across all CV disease and geographies there were fewer hospitalisations, diagnostic and interventional procedures, and outpatient consultations during the pandemic. By meta-regression, in low-middle income countries (LMICs) compared to HICs the decline in ST-segment elevation myocardial infarction (STEMI) hospitalisations (RR 0.79, 95% confidence interval [CI] 0.66-0.94) and revascularisation (RR 0.73, 95% CI 0.62-0.87) was more severe. In LMICs, but not HICs, in-hospital mortality increased for STEMI (RR 1.22, 95% CI 1.10-1.37) and heart failure (RR 1.08, 95% CI 1.04-1.12). The magnitude of decline in hospitalisations for CV diseases did not differ between the first and second wave.

CONCLUSIONS

There was substantial global collateral CV damage during the COVID-19 pandemic with disparity in severity by country income classification.

Sphincterotomy and the treatment of detrusor-sphincter dyssynergia: current status, future prospects

STUDY DESIGN

Literature review of current treatment options for detrusor-sphincter dyssynergia (DSD) in spinal cord injury.

OBJECTIVES

To review the outcomes and complications associated with external sphincterotomy and to summarise the results and complications of alternative treatment options for detrusor-sphincter dyssynergia in spinal cord injury. In addition, we propose a potential alternative future drug treatment for external sphincter dyssynergia based upon recent research on the neuropharmacology of the external urethral sphincter.

SETTING

The National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK.

METHODS

Medline search from 1966 to 2002 using the words 'external sphincterotomy', 'detrusor-sphincter dyssynergia' and 'neurogenic bladder combined with surgery'.

RESULTS

While external sphincterotomy is an effective treatment for DSD, a significant number of men following this procedure continue to have high intrarenal pressures, recurrent urinary infection or troublesome autonomic dysreflexia and a worryingly high proportion demonstrate persistently raised leak point pressures, putting them at subsequent risk of renal damage. Alternative treatments for external sphincter dyssynergia include urethral stents and balloon dilatation, both of which are effective. However, over the long term stents can undergo encrustation and there remains a definite risk of stent migration necessitating stent removal or replacement. Balloon dilatation of the external sphincter is associated with a risk of subsequent stricture formation. Intraurethral Botulinum A toxin seems to be effective though there have been no large randomised studies comparing it against placebo. However, it is not a durable treatment option and it has not found a common place in the treatment of DSD. There is now a considerable amount of experimental data from both animal and human studies to suggest that nitric oxide (NO) is an important physiological inhibitory neurotransmitter in the urethral sphincter, mediating relaxation of the external urethral sphincter. The potential role of sphincter NO augmentation for treatment of DSD is discussed.

CONCLUSION

External sphincterotomy remains the mainstay of treatment for urodynamically significant detrusor-sphincter dyssynergia, but in recent years a number of effective, alternative treatment options have become available. While at present there is no effective systemic drug treatment, recent research into external sphincter neuropharmacology suggests that systemic or topical augmentation of external sphincter NO may provide an effective method for lowering sphincter pressure.

Association Between Type 2 Diabetes and All-Cause Hospitalization and Mortality in the UK General Heart Failure Population: Stratification by Diabetic Glycemic Control and Medication Intensification

OBJECTIVES

This study sought to investigate in the general heart failure (HF) population, whether the associations between type 2 diabetes (T2D) and risk of hospitalization and death, are modified by changing glycemic or drug treatment intensity.

BACKGROUND

In the general HF population, T2D confers a higher risk of poor outcomes, but whether this risk is modified by the diabetes status is unknown.

METHODS

A nested case-control study in an incident HF database cohort (2002 to 2014) compared patients with T2D with those without for risk of all-cause first hospitalization and death. T2D was stratified by categories of glycosylated hemoglobin (HbA_1c) or drug treatments measured 6 months before hospitalization and 1 year before death and compared with the HF group without T2D.

RESULTS

In HF, T2D was associated with risk of first hospitalization (adjusted odds ratio [aOR]: 1.29; 95% confidence interval [CI]: 1.24 to 1.34) and mortality (aOR: 1.24; 95% CI: 1.29 to 1.40). Stratification of T2D by HbA_1c levels, compared with the reference HF group without T2D, showed U-shaped associations with both outcomes. Highest risk categories were HbA_1c >9.5% (hospitalization, aOR: 1.75; 95% CI: 1.52 to 2.02; mortality, aOR: 1.30; 95% CI: 1.24 to 1.47) and <5.5% (hospitalization, aOR: 1.42; 95% CI: 1.12 to 1.80; mortality, aOR: 1.29; 95% CI: 1.10 to 1.51, respectively). T2D group with change in HbA_1c of >1% decrease was associated with hospitalization (aOR: 1.33; 95% CI: 1.18 to 1.49) and mortality (aOR: 1.36; 95% CI: 1.24 to 1.48). T2D drug group associations with hospitalization were no medication (aOR: 1.12; 95% CI: 1.04 to 1.19), oral antihyperglycemic only (aOR: 1.34; 95% CI: 1.27 to 1.41), oral antihyperglycemic+insulin (aOR: 1.36; 95% CI: 1.21 to 1.52), and insulin only (aOR: 1.61; 95% CI: 1.43 to 1.81); and with mortality for the same drug groups were 1.31 (95% CI: 1.23 to 1.39), 1.16 (95% CI: 1.11 to 1.22), 1.19 (95% CI: 1.06 to 1.34), and 1.43 (95% CI: 1.31 to 1.57), respectively. The T2D group with reduced drug treatments were associated with hospitalization (aOR: 2.13; 95% CI: 1.68 to 2.69) and mortality (aOR: 2.09; 95% CI: 1.81 to 2.41).

CONCLUSIONS

In the general HF population, T2D stratified by glycemic control and drug treatments showed differential risk associations. Routine measures of dynamic diabetes status provide important prognostic indication of poor outcomes in HF.

Gender impact on prognosis of acute coronary syndrome patients treated with drug-eluting stents

Women have a higher risk of adverse outcomes after percutaneous coronary intervention (PCI) than men. However, in acute coronary syndrome (ACS), long-term outcomes after contemporary PCI with drug-eluting stent (DES) have not been fully investigated. We aimed to test the impact of gender on outcomes in patients with ACS after PCI with DES. We analyzed all patients with ACS from the prospective NOBORI-2 trial who underwent PCI with a Nobori DES from 2008 through 2009 in 125 centers worldwide. End points of the study were target lesion failure, cardiac death, myocardial infarction (MI), and clinically driven target lesion revascularization, and major adverse cardiac events (composite of cardiac death, MI, and target vessel revascularization) at 1 year and yearly up to 5 years. There were 1,640 patients with ACS, 1,268 men (77%) and 372 women (23%). Compared to men, women were 5 years older and more frequently had co-morbidities such as diabetes mellitus and hypertension. There were no gender differences for cardiac death (1.3% vs 2.7%), MI (2.1% vs 3.2%), or target lesion revascularization (2.6% vs 3.8%) at 1 year after the procedure for men and women, respectively. The trend was the same at 2 years (cardiac death 2.0% vs 2.3%, MI 2.5% vs 3.5%, target lesion revascularization 3.2% vs 4.6%). Target lesion failure rates were 4.5% and 5.9% at 1 year and 5.7% and 7.3% at 2 years in men and women, respectively (p = NS). Multivariate analysis, which included age, hypertension, diabetes mellitus, and number of diseased vessels, showed that gender was not a predictor for outcome. There were no differences in bleeding or stent thrombosis rates. Relief from anginal symptoms was similar. The same rate of adherence to dual antiplatelet therapy was observed and reached 73% at 1 year and 31% at 2 years after the ACS event and PCI. In conclusion, although women had worse baseline characteristics, no differences in outcomes were observed between men and women treated for ACS with contemporary DES.

Clinical outcomes of the proximal optimisation technique (POT) in bifurcation stenting

BACKGROUND

Optimal deployment of coronary stents in a bifurcation lesion remains a matter of debate.

AIMS

We sought to capture the daily practice of bifurcation stenting by means of a worldwide registry and to investigate how post-implantation deployment techniques influence clinical outcomes.

METHODS

Data from the e-ULTIMASTER registry were used to perform an analysis of 4,395 patients undergoing percutaneous coronary intervention for bifurcation lesions. Inverse probability of treatment weights (IPTW) propensity score methodology was used to adjust for any baseline differences. The primary outcome of interest was target lesion failure (TLF) at one year (follow-up rate 96.2%).

RESULTS

The global one-year TLF rate was low (5.1%). The proximal optimisation technique (POT) was used in 33.9% of cases and was associated with a reduction in the adjusted TLF rate (4.0% [95% confidence interval: 3.0-5.1%] vs 6.0% [5.1-6.9%], p<0.01) due to a reduction of all components of this composite endpoint, except for cardiac death. Stent thrombosis was also positively impacted (0.4% [0.04-0.7%] vs 1.3% [0.8-1.7%], p<0.01). POT benefit was uniform across subgroups. Conversely, the use of the kissing balloon technique (36.5%) did not influence the adjusted TLF rate.

CONCLUSIONS

Despite a low one-year failure rate in this large bifurcation stenting cohort, POT was associated with a further reduction in the event rate and a uniform benefit across subgroups, suggesting systematic use of this deployment technique regardless of the bifurcation anatomy and stenting technique.

Racial differences in management and outcomes of acute myocardial infarction during COVID-19 pandemic

OBJECTIVE

There are concerns that healthcare and outcomes of black, Asian and minority ethnic (BAME) communities are disproportionately impacted by the COVID-19 pandemic. We investigated admission rates, treatment and mortality of BAME with acute myocardial infarction (AMI) during COVID-19.

METHODS

Using multisource national healthcare records, patients hospitalised with AMI in England during 1 February-27 May 2020 were included in the COVID-19 group, whereas patients admitted during the same period in the previous three consecutive years were included in a pre-COVID-19 group. Multilevel hierarchical regression analyses were used to quantify the changes in-hospital and 7-day mortality in BAME compared with whites.

RESULTS

Of 73 746 patients, higher proportions of BAME patients (16.7% vs 10.1%) were hospitalised with AMI during the COVID-19 period compared with pre-COVID-19. BAME patients admitted during the COVID-19 period were younger, male and likely to present with ST-elevation acute myocardial infarction. COVID-19 BAME group admitted with non-ST-elevation acute myocardial infarction less frequently received coronary angiography (86.1% vs 90.0%, p<0.001) and had a longer median delay to reperfusion (4.1 hours vs 3.7 hours, p<0.001) compared with whites. BAME had higher in-hospital (OR 1.68, 95% CI 1.27 to 2.28) and 7-day mortality (OR 1.81 95% CI 1.31 to 2.19) during COVID-19 compared with pre-COVID-19 period.

CONCLUSION

In this multisource linked cohort study, compared with whites, BAME patients had proportionally higher hospitalisation rates with AMI, less frequently received guidelines indicated care and had higher early mortality during COVID-19 period compared with pre-COVID-19 period. There is a need to develop clinical pathways to achieve equity in the management of these vulnerable populations.

Incidence and mechanisms of longitudinal stent deformation associated with Biomatrix, Resolute, Element, and Xience stents: Angiographic and case-by-case review of 1,800 PCIs

BACKGROUND

There is conflicting evidence regarding the incidence of longitudinal stent deformation (LSD) in contemporary practice.

METHODS AND RESULTS

To assess the incidence and mechanism of LSD across commonly used DES platforms, we performed a case-by-case review of 1,800 PCI cases involving 450 consecutive procedures using Biomatrix Flex, Resolute Integrity, Promus Element, and Xience V stents, respectively, between January 2009 and December 2011. LSD was detected in a higher proportion with Promus Element [15 (3.1%)] compared with other platforms (Xience V [4 (0.9%)], Biomatrix [3 (0.7%)], Resolute [3 (0.7%)]; P = 0.002). LSD was characterized as guide catheter/guide extension induced, or as impact from secondary devices such as postdilatation balloons or IVUS catheters. The incidence of guide catheter/guide extension LSD was similar across platforms; (Promus Element [5 (1.1%)], Xience V [4 (0.9%)], Biomatrix [3 (0.7%)], Resolute [3 (0.7%)]; P = 0.85). Secondary device LSD occurred exclusively with Promus Element (9/450 cases [2%] (P < 0.0001). Re-entering the deformed stent was more difficult in cases of secondary device LSD (6/9 compared with 0/12 treated cases; P < 0.001). Univariate predictors of LSD were previous CABG, culprit vessel, ostial involvement, and lesion tortuosity. Multivariate predictors of LSD were the Promus Element stent (OR 5.53 CI[1.54-19.85]), Guideliner use (OR 22.09 CI[4.73-103]), postdilation balloons (OR 5.47 CI[1.31-22.81]) and number of stents deployed (OR 2.06 CI[1.45-2.9].

CONCLUSION

LSD is more common than previously reported. LSD by a guide catheter/guide extension occurred equally with all platforms, however, LSD associated with secondary devices only occurred with the Element stent. These findings have important implications regarding current and future stent designs.

Timing and Causes of Unplanned Readmissions After Percutaneous Coronary Intervention: Insights From the Nationwide Readmission Database

OBJECTIVES

The aim of this study was to describe the rates and causes of unplanned readmissions at different time periods following percutaneous coronary intervention (PCI).

BACKGROUND

The rates and causes of readmission at different time periods after PCI remain incompletely elucidated.

METHODS

Patients undergoing PCI between 2010 and 2014 in the U.S. Nationwide Readmission Database were evaluated for the rates, causes, predictors, and costs of unplanned readmission between 0 and 7 days, 8 and 30 days, 31 and 90 days, and 91 and 180 days after index discharge.

RESULTS

This analysis included 2,412,000 patients; 2.5% were readmitted between 0 and 7 days, 7.6% between 8 and 30 days, 8.9% between 31 and 90 days, and 8.0% between 91 and 180 days (cumulative rates 2.5%, 9.9%, 18.0%, and 24.8%, respectively). The majority of readmissions during each time period were due to noncardiac causes (53.1% to 59.6%). Nonspecific chest pain was the most common identifiable noncardiac cause for readmission during each time period (14.2% to 22.7% of noncardiac readmissions). Coronary artery disease including angina was the most common cardiac cause for readmission during each time period (37.4% to 39.3% of cardiac readmissions). The second most common cardiac cause for readmission was acute myocardial infarction between 0 and 7 days (27.6% of cardiac readmissions) and heart failure during all subsequent time periods (22.2% to 23.7% of cardiac readmissions).

CONCLUSIONS

Approximately 25% of patients following PCI have unplanned readmissions within 6 months. Causes of readmission depend on the timing at which they are assessed, with noncardiovascular causes becoming more important at longer time points.

Not all pacemakers are created equal: MRI conditional pacemaker and lead technology

Due to expanding clinical indications and an aging society there has been an increase in the use of implantable pacemakers. At the same time, due to increased diagnostic yield over other imaging modalities and the absence of ionizing radiation, there has been a surge in demand for magnetic resonance imaging (MRI) assessment, of both cardiac and noncardiac conditions. Patients with an implantable device have a 50-75% chance of having a clinical indication for MRI during the lifetime of their device. The presence of an implantable cardiac device has been seen as a relative contraindication to MRI assessment, limiting the prognostic and diagnostic utility of MRI in many patients with these devices. The introduction of MRI conditional pacemakers will enable more patients to undergo routine MRI assessment without risk of morbidity or device malfunction. This review gives a general overview of the principles and current evidence for the use of MRI conditional implantable cardiac devices. Furthermore, we appraise the differences between those pacemakers currently released to market.

Endothelial progenitor cells: Exploring the pleiotropic effects of statins

Statins have become a cornerstone of risk modification for ischaemic heart disease patients. A number of studies have shown that they are effective and safe. However studies have observed an early benefit in terms of a reduction in recurrent infarct and or death after a myocardial infarction, prior to any significant change in lipid profile. Therefore, pleiotropic mechanisms, other than lowering lipid profile alone, must account for this effect. One such proposed pleiotropic mechanism is the ability of statins to augment both number and function of endothelial progenitor cells. The ability to augment repair and maintenance of a functioning endothelium may have profound beneficial effect on vascular repair and potentially a positive impact on clinical outcomes in patients with cardiovascular disease. The following literature review will discuss issues surrounding endothelial progenitor cell (EPC) identification, role in vascular repair, factors affecting EPC numbers, the role of statins in current medical practice and their effects on EPC number.

Use of the sheathless guide catheter during routine transradial percutaneous coronary intervention: a feasibility study

OBJECTIVE

The aim of this study is to investigate the feasibility of using a 6.5 Fr sheathless guide catheter as a default system in transradial (TRA) percutaneous coronary intervention (PCI).

BACKGROUND

TRA PCI has been shown to reduce mortality rates through a reduction in access site related bleeding complications compared with procedures performed though a femoral approach. Complications associated with the TRA route increase with the size of sheath used. These complications may be reduced by the use of a sheathless guide catheter system (Asahi Intecc, Japan) that is 1-2 Fr sizes smaller in diameter than the corresponding introducer sheath.

METHODS

We performed PCI in 100 consecutive cases using 6.5 Fr sheathless guides to determine the procedural success, rates of symptomatic radial spasm and radial occlusion.

RESULTS

Procedural success using the 6.5 Fr sheathless guide catheter system was 100% with no cases requiring conversion to a conventional guide and catheter system. There were no procedural complications recorded associated with the use of the catheter. Adjunctive devices used in this cohort included IVUS, stent delivery catheters, distal protection devices, and simple thrombectomy catheters. The rate of radial spasm was 5% and the rate of radial occlusion at 2 months was 2%.

CONCLUSION

Use of the 6.5 Fr sheathless guide catheter system, which has an outer diameter <5 Fr sheath, as the default system in routine PCI is feasible with a high rate of procedural success via the radial artery.