David Austin

Patient characteristics associated with self-presentation, treatment delay and survival following primary percutaneous coronary intervention

Background: Delayed arrival to a primary percutaneous coronary intervention (PPCI)-capable hospital following ST-elevation myocardial infarction (STEMI) is associated with poorer outcome. The influence of patient characteristics on delayed presentation during STEMI is unknown. Methods and results: This was a retrospective observational study. Patients presenting for PPCI from March 2008 to November 2011 in the north of England (Northumbria, Tyne and Wear) were included. The outcomes were self-presentation to a non-PPCI-capable hospital, symptom to first medical contact (STFMC) time, total ischaemic time and mortality during follow-up. STEMI patients included numbered 2297; 619 (26.9%) patients self-presented to a non-PPCI-capable hospital. STFMC of >30 min and total ischaemic time of >180 min was present in 1521 (70.7%) and 999 (44.9%) cases, respectively. Self-presentation was the strongest predictor of prolonged total ischaemic time (odds ratio, OR (95% confidence interval, CI): 5.05 (3.99–6.39)). Married patients (OR 1.38 (1.10–1.74)) and patients living closest to an Emergency Room self-presented more commonly (driving time (vs. ≤10 min) 11–20 min OR 0.66 (0.52–0.83), >20 minutes OR 0.46 (0.33–0.64). Unmarried females waited longest to call for help (OR vs. married males 1.89 (1.29–2.78) and experienced longer total ischaemic times (OR 1.51 (1.10–2.07)). Married patients had a borderline association with lower mortality (hazard ratio 0.75 (0.53–1.05), p=0.09). Conclusions: Unmarried female patients had the longest treatment delays. Married patients and those living closer to an Emergency Room self-present more frequently. Early and exclusive use of the ambulance service may reduce treatment delay and improve STEMI outcome.

IVUS and OCT guided primary percutaneous coronary intervention for spontaneous coronary artery dissection with bioresorbable vascular scaffolds

Spontaneous coronary artery dissection (SCAD) is an uncommon but important cause of acute coronary syndrome. The diagnosis of SCAD by an angiogram alone can be challenging and the increasing use of intracoronary imaging has proven an invaluable diagnostic adjunct in this regard. The appropriate initial management of SCAD has been a matter of significant debate. Owing to frequent spontaneous healing of coronary dissection and a higher risk of complications with percutaneous coronary intervention (PCI) in the setting of SCAD, a default approach of mechanical revascularization is not recommended. However in the presence of vessel occlusion and on-going myocardial infarction PCI is mandated. Bioresorbable vascular scaffolds (BVS) offer potential advantages over the conventional stents in the setting of SCAD. We describe a state-of-the-art approach to the acute treatment of SCAD causing STEMI, utilizing intravascular ultrasound (IVUS), optical coherence tomography (OCT) and BVS and discuss management strategies for the modern era.

Compression of Main Pulmonary Artery by Giant Saphenous Vein Graft Aneurysm

An aneurysm of a saphenous vein graft (SVGA) is a rare late complication of coronary artery bypass grafting (CABG). We present a case of a 75-year-old retired family physician who underwent CABG in 1984 and 1991. At the second procedure, all previous grafts were tied off and de novo aortocoronary reverse SVG grafts were placed to the posterior descending coronary artery, obtuse marginal artery (OM), and left anterior descending coronary artery (LAD). The patient represented 19 years after his second CABG with a non-ST elevation myocardial infarction, and recent history of exertional dyspnea. A chest roentgenogram (Fig 1) revealed a left hilar mass. Computed tomographic scan (Fig 2A) and reconstructed computed tomographic coronary angiogram (Fig 2B) show an SVG aneurysm, believed to have arisen from the OM graft (measuring 8 cm in diameter) compressing the main pulmonary artery (MPA). In view of the aneurysm size, relationship to the main pulmonary artery, and recent symptomatic status, surgical management was recommended. Standard invasive coronary angiography showed severe native disease, patent SVG to the right coronary artery, a recently occluded SVG to the LAD graft, and delineated the SVGA arising from the OM graft, which had little antegrade flow. At operation, femoral-femoral bypass was established, and a false SVGA was found arising from the distal anastamosis site of the OM graft. It shrunk immediately after cross clamping of the aorta demonstrated

1 Route of admission in stemi: do patients who present directly to a PCI-capable hospital differ from inter-hospital transfers?

Background Rapid delivery of reperfusion therapy with PPCI is the gold standard treatment in STEMI. Systems have been developed, such as direct admission to a PCI-capable hospital, to minimise the time from diagnosis to PPCI. Despite this, a significant minority of patients are initially admitted to non-PCI capable hospitals. The aim of this study was to determine whether patients differed in their characteristics, time to PPCI, and outcome by route of admission. Methods The study was performed in a single tertiary centre in North England. Data are collected routinely on all patients undergoing PPCI and include demographic, clinical and procedural variables. In-hospital MACCE (death, re-infarction or CVA) and mortality are collected providing relevant outcome measures. Baseline clinical variables by route of admission were compared and unadjusted in-hospital MACCE rates determined. One-year mortality by route of admission was calculated using the K-M product limit estimate. In-hospital and 1-year outcomes were analysed after adjustment for factors known to be predictors of early mortality following STEMI (models 1 and 3). To determine the relative importance of delays in treatment, call-to-balloon time was added (models 2 and 4). Logistic regression was used for the adjusted in-hospital outcomes, and Cox-proportional regression for adjusted 1-year mortality. Results 2268 patients were included in the analysis. 510 patients (22.5%) were treated with PPCI following transfer from a non-PCI capable centre. Analysis of baseline variables (Abstract 1 table 1) showed the transfer group were more likely to have an LAD occlusion treated, and previous MI. Despite shorter DTB times, the transfer group had a greater median CTB time (52 minutes longer) compared with direct admissions. Other baseline variables were statistically no different between groups. There were 110 in-hospital MACCE events, and 168 deaths within 1-year follow-up. The transfer group had significantly higher unadjusted in-hospital MACCE rates (2.4% absolute, 58% relative increase (Abstract 1 table 2)). At 1 year, the transfer group had significantly higher unadjusted mortality (2.7% absolute, 48% relative increase (Abstract 1 table 2)). After adjustment for relevant co-variates (models 1 and 3) route of admission remained a significant predictor of in-hospital and 1-year mortality. With the addition of call-to-balloon time, no significant difference in outcome was noted by route of admission for either in-hospital or 1-year events.Abstract 1 Table 1 Direct Transfer p Age (years±SD) 64.3 (12.7) 63.9 (12.4) 0.17 Male 1252 (71.2) 367 (72.0) 0.74 Diabetes 177 (10.1) 55 (10.8) 0.68 Previous MI 225 (12.6) 89 (17.3) 0.001 Treated vessel 0.001  LMS 24 (1.4) 13 (2.5)  LAD 630 (36.1) 218 (42.9)  LCx 249 (14.3) 83 (16.3)  RCA 812 (46.6) 188 (37.0)  Graft 28 (1.7) 5 (1.1) Cardiogenic shock 28 (1.7) 35 (6.9) 0.61 Smoking (ex/current) 1331 (75.7) 377 (73.9) 0.42 Call-to-balloon time 102 (82–135) 154 (107–235) <0.001 Door-to-balloon time 44 (29–76) 34 (24–50) <0.001Abstract 1 Table 2 Direct Transfer OR (±95% CI) p In-hospital MACCE 4.3% 6.7% 1.58 (1.04 to 2.39) 0.03 Adjusted in-hospital MACCE (model 1) 1.64 (1.00 to 2.28) 0.05 Adjusted in-hospital MACCE (model 2) 1.34 (0.79 to 2.29) 0.27 Direct Transfer HR (±95% CI) p 1-year mortality 7% 9.7% 1.48 (1.06 to 2.07) 0.02 Adjusted 1-year mortality (model 3) 1.41 (0.99 to 2.01) 0.05 Adjusted 1-year mortality (model 4) 1.29 (0.87 to 1.89) 0.20 Conclusion In this study, patients who presented directly had superior in-hospital and 1-year outcomes compared with those who required transfer from other hospitals. Adjustment for longer call-to-balloon times attenuated the finding of poorer outcomes in these patients, suggesting that delays in treatment are critical. Systems of care should be designed to avoid admission of STEMI patients to non-PCI hospitals, and facilitate more rapid transfer of patients where this has not been possible.

The impact of diabetes on the prognostic value of left ventricular function following percutaneous coronary intervention: Insights from the British Cardiovascular Intervention Society

To study the relationship between diabetes mellitus (DM) and left ventricular (LV) function on outcomes following percutaneous coronary intervention (PCI).

27 Use of rotational atherectomy in primary pci for st-elevation myocardial infarction- a single centre 10-year experience

Introduction Rotational atherectomy (RA) during primary PCI (PPCI) for STEMI is relatively contraindicated because of the perceived increased risk of no-reflow. However, RA PPCI may sometimes be required to restore flow in heavily calcified coronary arteries. Previously only very limited observational data has described the use of RA in PPCI. Aim We report the clinical and procedural characteristics, and in hospital outcomes, of 21 patients who underwent RA PPCI at our centre between 2006 and 2016, Methods A retrospective review of the PCI database and medical records. Results 21 patients (age 78(10) years (mean (SD)), 12 men) underwent RA during PPCI (0.4% of all PPCI). 3 patients had cardiogenic shock at presentation and 2 had out of hospital cardiac arrest. Hypertension (n=19), smoking history (n=18), hypercholesterolemia (n=16), diabetes (n=6) and chronic kidney disease (n=6 with eGFR<60) were frequently present. Aspirin was given to 20/21 patients and clopidogrel, ticagrelor and prasugrel to 10, 9 and 3 patients respectively. Heparin was used in all patients, glycoprotein (GP) IIBIIIA inhibitor in 10 and bivalirudin in 2. Radial access was used in 14 and femoral in 7. Initial TIMI flow grade was 0, 1, 2 and 3 in 11, 2, 1 and 7 patients respectively. The target vessel was the RCA in 14, Cx in 4, LMS in 2 and LAD in 1. All were severely calcified with visible thrombus in 13/21. The lesion length was 36(19) mm (range 12–72 mm). The vessel diameter was 2.5–2.99 mm in 5, 3–3.49 mm in 10 and 3.5–4.0 mm in 6. RA was used because of anticipated difficulty with conventional PCI in 7/21 and uncrossable/unexpandable lesions in 14/21. The number of burrs used was 1.33 (0.48) and the final burr was 1.25, 1.5, 1.75 and 2 mm in 4, 11, 4 and 1 patient respectively. The burr-to-artery ratio was <0.4 in 5 and 0.4–0.6 in 16. The final procedure was DES in 17, BMS in 3 and POBA followed by CABG in 1. A temporary pacemaker was used in 3 cases and intra-aortic balloon pump in 3 cases. There were no perforations, no tamponade and no vascular complications. The median(range) pain-to-PCI time was 180 min (114–544); door-to-PCI time 49 min (21–186, 14 patients <60 min) and procedure time was 119 min (66-175). Procedural difficulty caused door-to-PCI>60 min in 5/7 patients while medical/logistic reasons contributed in the other 2. 1 patient underwent CT scanning prior to PCI; 1 underwent an urgent MDT discussion before PCI. Final flow was TIMI 3 in 19/21 and TIMI 2 in 2/21 cases. The procedure was complicated by 1 event of distal embolization. There was 1 event of peri-procedural cerebral infarction. 20/21 patients survived to hospital discharge. Conclusions Our study suggests that RA PPCI can be performed safely in a small group of predominantly elderly, complex patients in whom conventional techniques are inadequate or unsuccessful. It is associated with a relatively long procedure time but we did not experience a marked increase in no-reflow.

97 Can pre-operative troponin levels predict post-operative mortality following non-cardiac surgery?

Introduction Despite advances in surgical and anaesthetic techniques, non-cardiac surgery still has a significant mortality. We hypothesised that pre-operative troponin levels might predict post-operative mortality. Methods Patients undergoing elective and urgent/emergency non-cardiac surgery excluding minor procedures were retrospectively assessed for known vascular disease (defined by diagnostic imaging or previous intervention rather than clinical assessment) and vascular risk factors including hypertension, treatment with lipid-modifying agents (irrespective of agent or dose) and chronic lung disease. Pre-operative high-sensitivity troponins and routine pre-operative bloods were recorded. Six- and twelve-month mortality data were collected; independent predictors of mortality and associations between pre-operative patient characteristics and pre-operative troponin were determined. Results 993 patients were assessed; 13% had an elevated pre-operative troponin with 3%>50 ng/L. 825 (83%) were elective patients; 8.6% had an elevated pre-operative troponin. Six-month mortality was 4.2% and 5.9% at twelve months. Elevated pre-operative troponin was associated with higher post-operative mortality; 2.5%, 12.5% and 25% for a troponin <17 ng/L, 17 – 49 ng/L and >50 ng/L respectively (figure?1). This trend was also evident at twelve months; 3.7%, 16.3% and 37% for the same troponin bands (figure 2). Lipid-modifying agents were independently associated with a lower rate of pre-operative troponin release (HR 0.446 (0.232 – 0.857) p=0.015). Impaired renal function (assessed as a continuous variable), emergency presentation and pre-operative troponin levels were independent predictors of six- and twelve-month mortality with emergency presentation the strongest predictor by hazard ratio (table 1). Age over 75 independently predicted twelve-month mortality only. Conclusion The role of pre-operative troponin monitoring and the prevalence of pre-operative troponin has not previously been established on an all-comer population. Pre-operative troponin level greater than 50 ng/L is an independent predictor of six and twelve-month mortality following non-cardiac surgery in an all-comers cohort although the mechanism of troponin release is not clear. The lower rate of troponin release associated with lipid-modifying medication has been seen in other studies (1). We hypothesise the known anti-inflammatory effects of statins may indicate a systemic inflammatory process responsible for the troponin release rather than unstable coronary disease. Further studies to assess this in the elective population may be useful to target pre-operative interventions. Reference Association between pre-operative statin use and major cardiovascular complications among patients undergoing non-cardiac surgery: the VISION study. ?Berwanger O, Le Manach Y, Suzumura EA, et al. Eur Heart J2016Jan 7;37(2):177?–?85Abstract 97 Table 1Abstract 97 Figure 1Abstract 97 Figure 2

Cardiac compression due to gastric volvulus: an unusual cause of chest pain

A 42-year-old man was admitted to coronary care for assessment with severe retrosternal chest pain. Echocardiography showed significant external compression of the left atrium. A subsequent CT scan revealed him to have a large hiatus hernia, with most of his stomach herniating into his thorax causing left atrial compression and gastric volvulus. He subsequently underwent successful emergency decompression of the gastric volvulus and repair of his hiatus hernia.

88 Routine Post-Operative Troponin Screening for Myocardial Injury after Noncardiac Surgery (MINS) Events – A Single Centre Experience

Introduction The VISION study demonstrated an association between 30-day mortality after surgery and raised post-operative troponin levels.1 Subsequently, diagnostic criteria for ‘ischaemic’ MINS were established excluding non-ischaemic aetiology.2 We evaluated our initial experiences with post-operative troponin monitoring, to look in-depth at patients who suffer MINS events. Methods Pre- and post-operative high-sensitive troponins were checked on all elective and emergency surgical patients over 45 years of age with an inpatient stay of more than 2 days between August 2014 and June 2015. A MINS event was defined as in the VISION (1) study as any positive post-operative troponin. Thirty-day mortality after surgery was determined via HES data. Notes, pathology reports and discharge letters were reviewed for evidence of sepsis, prolonged tachycardia, multi-organ failure or significant bleeding (Hb loss of >5 g/l and/or total Hb <8 g/dl). Events were classified as ‘non MINS’, ‘unexplained MINS’ or ‘secondary MINS’ due to one of these provoking factors. Cox regression analysis was performed to assess association between variables. Results 388 patients were studied. 196 were male with a mean age of 69 years (range 45–95). 132 (34%) were emergency admissions. 245 (63.1%) had normal post-operative troponins (i.e. non MINS), with 81 (20.9%), 49 (12.6%) and 13 (3.4%) recording troponin levels of 17–50, 51–1000 and more than 1000 respectively. 21 of the positive post-op values represented a downward trend from pre-op tests, with a further 17 positive pre-op values falling into the normal range post-operatively.Abstract 88 Table 1 Types of MINS and 30 day mortality Pathophysiology Emergency N = 132 (% of total MINS) Elective N = 256 (% of total MINS) All surgery N = 388 (% of total MINS) 30 day mortality N = 11 (% of total mortality) All MINS events 82 60 142 8 (72.7%) Unexplained MINS 31 (37.8%) 39 (65%) 70 (49.3%) 0 (0%) Secondary to Sepsis 41 (50%) 15 (25%) 56 (39.4%) 8 (72.7%) Secondary to Bleeding 9 (11%) 5 (8.3%) 14 (9.9%) 0 (0%) Secondary to Tachycardia 1 (1.2%) 1 (1.7%) 2 (1.4%) 0 (0%) No MINS event 50 196 246 3 (27.3%) All patients 132 256 388 11 The 30 day mortality rate was 2.8% compared to 1.9% in VISION. Of the 11 deaths, 10 (90.9%) were emergency admissions. Two (18.2%) deaths occurred in patients exhibiting a downward trend in troponin and 3 (27.3%) had a normal post-operative troponin (i.e. did not suffer a MINS event). Discussion A raised post-operative troponin was associated with poor prognosis as suggested in the VISION study (p = 0.022 HR 0.213 [0.057–0.803]). Sepsis was also associated with a poor prognosis (p < 0.001 HR 0.08 [0.021–0.305]) as is emergency admission for surgery (p = 0.004 HR 0.05 [CI 0.006–0.392]). However, there was no mortality from ‘ischaemic’ MINS events (unexplained events and events secondary to tachycardia and bleeding). Whether MINS events are a separate clinical entity related to unstable or significant coronary disease or a reflection of other poor prognostic factors remains unclear. Further studies assessing coronary anatomy may be useful in delineating this further. References Devereaux PJ, Chan MT, Alonso-Coello P, et al. Association between Post-operative Troponin Levels and 30-Day Mortality among Patients undergoing Noncardiac Surgery. JAMA. 2012;307(21) Myocardial Injury After Noncardiac Surgery. VISION Study Investigators. Anaesthesiology, 2014;120: 564-–78

30 Do PRAMI and CVLPRIT represent real-life experiences of culprit-only PPCI? - a single centre observational study

Introduction The RCTs, PRAMI1 and CVLPRIT,2 have suggested that preventative PCI for multi-vessel disease identified during PPCI improves outcomes with higher rates of cardiovascular events in the culprit-only cohorts. Methods 1143 consecutive STEMIs at our centre from August 2011–2013 were retrospectively assessed for eligibility to one or both trials. 343 patients would have been suitable for PRAMI and 196 for CVLPRIT; termed ‘observational’ cohorts. Outcomes were determined from clinic letters, procedure reports and regional blood result reporting with mortality outcomes compared to ONS data. Results Over 36 months, our observational PRAMI cohort experienced fewer combined primary outcomes (13.9% vs 22.9%), comparable to the preventative PRAMI (Figure 1A) arm with only 8.5% undergoing additional early planned revascularisation. Our observational CVLPRIT cohort experienced numerically fewer MACE primary outcomes over 12 months (16.8% vs 21.2% Figure 1B) with 30 day event rates comparable to the preventative PCI cohort, despite only 9.2% undergoing additional early planned revascularisation. Abstract 30 Figure 1 A – Primary outcomes from PRAMI (1) cohorts, B – Primary outcomes from CVLPRIT (2) cohorts. Original graphs reproduced with permission with observational cohort outcomes superimposed Conclusion Our all-comers culprit-only PCI cohorts have better outcomes than those seen in the published RCTs suggesting a high-risk population may have been selected for inclusion. Reference PRAMI trial. Wald DS, Morris JK, Wald NJ, et al. Randomized trial of preventive angioplasty in myocardial infarction. N Eng J Med. 2013, 369(12), 1115–1123 CVLPRIT trial. Gershlick AH. Khan JN, Kelly DJ, et al. Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial. J Am Coll Cardiol. 2015 Mar 17;65(10):963–972. Figure A was originally published in N Eng J Med, 369(12):1115–1123, D. S. Wald et al, Randomised Trial of Preventive Angioplasty in Myocardial Infarction, Copyright