Ioanna Kosmidou

Infarct size, left ventricular function, and prognosis in women compared to men after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: results from an individual patient-level pooled analysis of 10 randomized trials

AimnStudies have reported less favourable outcomes in women compared with men after primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI). Whether sex-specific differences in the magnitude or prognostic impact of infarct size or post-infarction cardiac function explain this finding is unknown.nnnMethods and resultsnWe pooled patient-level data from 10 randomized primary PCI trials in which infarct size was measured within 1u2009month (median 4 days) by either cardiac magnetic resonance imaging or technetium-99m sestamibi single-photon emission computed tomography. We assessed the association between sex, infarct size, and left ventricular ejection fraction (LVEF) and the composite rate of death or heart failure (HF) hospitalization within 1 year. Of 2632 patients with STEMI undergoing primary PCI, 587 (22.3%) were women. Women were older than men and had a longer delay between symptom onset and reperfusion. Infarct size did not significantly differ between women and men, and women had higher LVEF. Nonetheless, women had a higher 1-year rate of death or HF hospitalization compared to men, and while infarct size was a strong independent predictor of 1-year death or HF hospitalization (Pu2009<u20090.0001), no interaction was present between sex and infarct size or LVEF on the risk of death or HF hospitalization.nnnConclusionsnIn this large-scale, individual patient-level pooled analysis of patients with STEMI undergoing primary PCI, women had a higher 1-year rate of death or HF hospitalization compared to men, a finding not explained by sex-specific differences in the magnitude or prognostic impact of infarct size or by differences in post-infarction cardiac function.

New-Onset Atrial Fibrillation After PCI or CABG for Left Main Disease: The EXCEL Trial

BACKGROUNDnThere is limited information on the incidence and prognostic impact of new-onset atrial fibrillation (NOAF) following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for left mainxa0coronary artery disease (LMCAD).nnnOBJECTIVESnThis study sought to determine the incidence of NOAF following PCI and CABG for LMCAD and its effect on 3-year cardiovascular outcomes.nnnMETHODSnIn the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, 1,905 patients with LMCAD and low or intermediate SYNTAX scores were randomized to PCI withxa0everolimus-eluting stents versus CABG. Outcomes were analyzed according to the development of NOAF duringxa0thexa0initial hospitalization following revascularization.nnnRESULTSnAmong 1,812 patients without atrial fibrillation on presentation, NOAF developed at a mean of 2.7 ± 2.5xa0days after revascularization in 162 patients (8.9%), including 161 of 893 (18.0%) CABG-treated patients and 1 of 919 (0.1%) PCI-treated patients (pxa0< 0.0001). Older age, greater body mass index, and reduced left ventricular ejection fraction were independent predictors of NOAF in patients undergoing CABG. Patients with versus without NOAF had a significantlyxa0longer duration of hospitalization, were more likely to be discharged on anticoagulant therapy, and had an increased 30-day rate of Thrombolysis In Myocardial Infarction major or minor bleeding (14.2% vs. 5.5%; pxa0< 0.0001). Byxa0multivariable analysis, NOAF after CABG was an independent predictor of 3-year stroke (6.6% vs. 2.4%; adjustedxa0hazard ratio [HR]: 4.19; 95% confidence interval [CI]: 1.74 to 10.11; pxa0=xa00.001), death (11.4% vs. 4.3%; adjustedxa0HR: 3.02; 95% CI: 1.60 to 5.70; pxa0=xa00.0006), and the primary composite endpoint of death, MI, or stroke (22.6% vs. 12.8%; adjusted HR: 2.13; 95% CI: 1.39 to 3.25; pxa0=xa00.0004).nnnCONCLUSIONSnIn patients with LMCAD undergoing revascularization in the EXCEL trial, NOAF was common after CABG but extremely rare after PCI. The development of NOAF was strongly associated with subsequent death and stroke in CABG-treated patients. Further studies are warranted to determine whether prophylactic strategies to prevent or treat atrial fibrillation may improve prognosis in patients with LMCAD who are undergoing CABG. (Evaluation of XIENCE Versusxa0Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization [EXCEL]; NCT01205776).

Incidence, Predictors, and Outcomes of High-Grade Atrioventricular Block in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention (from the HORIZONS-AMI Trial)

High-grade atrioventricular block (HAVB) is historically considered a marker of worse outcomes in patients with ST-segment elevation myocardial infarction (STEMI). However, the predictors and prognostic impact of HAVB in the primary percutaneous coronary intervention (PCI) era remain poorly understood. We sought to describe the characteristics and predictors of HAVB in patients undergoing primary PCI in STEMI and to assess the prognostic significance of HAVB in the contemporary reperfusion era. The present analysis includes 3,115 patients presenting with STEMI from the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trial who underwent primary PCI. Outcomes were examined according to the presence of HAVB on a presenting electrocardiogram, as interpreted by an independent electrocardiography core laboratory. HAVB (second-degree Mobitz II or third-degree atrioventricular block) was present at baseline in 46 patients (1.5%). Independent predictors of HAVB included increased age, diabetes mellitus, right coronary artery occlusion, sum of ST-segment deviation, and baseline Thrombolysis In Myocardial Infarction flow 0/1. Thrombolysis In Myocardial Infarction flow 3 was restored in 83.7% and 91.5% of patients with versus without baseline HAVB respectively (pxa0= 0.06). Mortality rate was significantly higher in patients with versus without HAVB at 30-day, 1-, and 3-year follow-ups (unadjusted hazard ratio [HR] 3.83, 95% CI 1.40 to 10.48; unadjusted HR 4.37, 95% CI 2.09 to 9.38 and unadjusted HR 2.78, 95% CI 1.31 to 5.91, respectively). After covariate adjustment, mortality rate was significantly higher in patients with HAVB at 1xa0year (adjusted HR 2.45, 95% CI 1.09 to 5.50, pxa0= 0.03) but not at 30xa0days (adjusted HR 1.70, 95% CI 0.58 to 5.01, pxa0= 0.33) or 3xa0years (adjusted HR 0.71 to 3.41, pxa0= 0.27). In conclusion, HAVB is a rare complication of STEMI but remains associated with increased mortality, even after primary PCI.

Correlation of Admission Heart Rate With Angiographic and Clinical Outcomes in Patients With Right Coronary Artery ST‐Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention: HORIZONS‐AMI (The Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) Trial

Background Bradycardia on presentation is frequently observed in patients with right coronary artery ST‐segment elevation myocardial infarction, but it is largely unknown whether it predicts poor angiographic or clinical outcomes in that patient population. We sought to determine the prognostic implications of admission heart rate (AHR) in patients with ST‐segment elevation myocardial infarction and a right coronary artery culprit lesion. Methods and Results We analyzed 1460 patients with ST‐segment elevation myocardial infarction and a right coronary artery culprit lesion enrolled in the randomized HORIZONS‐AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trial who underwent primary percutaneous coronary intervention. Patients presenting with high‐grade atrioventricular block were excluded. Outcomes were examined according to AHR range (AHR <60, 61–79, 80–99, and ≥100 beats per minute). Baseline and procedural characteristics did not vary significantly with AHR except for a more frequent history of diabetes mellitus, longer symptom‐to‐balloon time, more frequent cardiogenic shock, and less frequent restoration of thrombolysis in myocardial infarction 3 flow in patients with admission tachycardia (AHR >100 beats per minute). Angiographic analysis showed no significant association between AHR and lesion location or complexity. On multivariate analysis, admission bradycardia (AHR <60 beats per minute) was not associated with increased 1‐year mortality (hazard ratio 1.33; 95% CI 0.41–4.34, P=0.64) or major adverse cardiac events (hazard ratio 1.08; 95% CI 0.62–1.88, P=0.78), whereas admission tachycardia was a strong independent predictor of mortality (hazard ratio 5.02; 95% CI 1.95–12.88, P=0.0008) and major adverse cardiac events (hazard ratio 2.20; 95% CI 1.29–3.75, P=0.0004). Conclusions In patients with ST‐segment elevation myocardial infarction and a right coronary artery culprit lesion undergoing primary percutaneous coronary intervention, admission bradycardia was not associated with increased mortality or major adverse cardiac events at 1 year. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT00433966.

Arrhythmia Endpoints in Interventional Cardiovascular Trials: A Missed Opportunity?

Randomized clinical trials are the cornerstone of the collective process evaluating novel technologic and pharmacologic discoveries. The commercial availability of breakthrough therapies is conting...

Prognostic implications of Q waves at presentation in patients with ST‐segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: An analysis of the HORIZONS‐AMI study

Presence of Q waves on the presenting electrocardiogram (ECG) in patients with ST‐segment elevation myocardial infarction (STEMI) has been associated with worse prognosis; however, whether the prognostic value of Q waves is influenced by baseline characteristics and/or rapidity of revascularization based on the guideline‐based metric of door‐to‐balloon time remains unknown.

TCT-198 Worsening Atrioventricular Conduction After Hospital Discharge in Patients With STEMI Undergoing Primary PCI: The HORIZONS-AMI Trial

population presented with typical symptoms exponentially more than atypical symptoms (92 % vs 8 %). Contrary to our expectations, women presented with typical anginal symptoms 86% of the time, which was statistically significant. Women with typical symptoms received an ECG on average at 10 minutes while men at 7 minutes; where as females with atypical symptoms received an ECG at 16 minutes (p < .001). Women suffered from significant left ventricular dysfunction and increased length of stay compared to men (p < 0.0001).

TCT-2 Worse Outcomes in Women Compared to Men After Primary PCI in STEMI Are Not Explained by Infarct Size: A Collaborative Patient-Level Pooled Analysis of 10 Randomized Trials

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TCT-71 The NIREUS Randomized Trial: 1-Year Results of the BioNIR Ridaforolimus-Eluting Coronary Stent System (BioNIR) EUropean Angiography Study

The BioNIR stent (Medinol, Israel) is a thin strut (91 um) cobalt chromium drug-eluting stent, which uses the rapamycin analogue ridaforolimus and a novel durable elastomeric polymeric coating (CarboSil® 20 55D). The NIREUS trial compared BioNIR with the Resolute (Medtronic, USA) zotarolimus-

TCT-168 Worse Outcomes in Women Compared to Men After Primary PCI in STEMI Are Not Explained by Left Ventricular Morphology and Cardiac Function: A Collaborative Patient-Level Pooled Analysis from 9 Randomized Trials.

TCT-168 Worse Outcomes in Women Compared to Men After Primary PCI in STEMI Are Not Explained by Left Ventricular Morphology and Cardiac Function: A Collaborative Patient-Level Pooled Analysis from 9 Randomized Trials Bjorn Redfors, Ioanna Kosmidou, Rushad Dordi, Ulrich Schaefer, Holger Thiele, Manesh Patel, James Udelson, E. Magnus Ohman, Ingo Eitel, Christopher Granger, Akiko Maehara, Ajay Kirtane, Philippe Généreux, Paul Jenkins, Ori Ben-Yehuda, Gregg Stone CRF, New York, New York, United States; Columbia University Medical Center and Cardiovascular Research Foundation, NY, New York, United States; Columbia University Medical Center; Asklepios Klinik St. Georg; Medizinische Klinik II (Kardiologie, Angiologie, Intensivmedizin), Lübeck, Germany; Duke University Medical Center, Durham, North Carolina, United States; Tufts Medical Center, Boston, Massachusetts, United States; Duke University Medical Center, Durham, North Carolina, United States; University Heart Center Lübeck, Lübeck, Germany; Duke University Medical Center, Durham, North Carolina, United States; Cardiovascular Research Foundation, New York, New York, United States; NewYork-Presbyterian Hospital/ Columbia University Medical Center, New York, New York, United States; Columbia University Medical Center/Hôpital du Sacré-Coeur de Montréal, New York, New York, United States; Loyola; Cardiovascular Research Foundation, New York, New York, United States; Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, United States