Jeremy Sayer

Comparison of case fatality in south Asian and white patients after acute myocardial infarction: observational study

Abstract Objective: To compare mortality in south Asian (Indian, Pakistani, and Bangladeshi) and white patients in the six months after hospital admission for acute myocardial infarction. Design: Observational study. Setting: District general hospital in east London. Patients: 149 south Asian and 313 white patients aged <65 years admitted to the coronary care unit with acute myocardial infarction from 1 December 1988 to 31 December 1992. Main outcome measure: All cause mortality in the first six months after myocardial infarction. Results: The admission rate in the south Asians was estimated to be 2.04 times that in the white patients. Most aspects of treatment were similar in the two groups, except that a higher proportion of the south Asians received thrombolytic drugs (81.2% v 73.8%). After adjustment for age, sex, previous myocardial infarction, and treatment with thrombolysis or aspirin, or both, the south Asians had a poorer survival over the six months from myocardial infarction (hazard ratio 2.02 (95% confidence interval 1.14 to 3.56), P=0.018), but a substantially higher proportion were diabetic (38% v 11%, P<0.001), and additional adjustment for diabetes removed much of their excess risk (adjusted hazard ratio 1.26 (0.68 to 2.33), P=0.47). Conclusion: South Asian patients had a higher risk of admission with myocardial infarction and a higher risk of death over the ensuing six months than the white patients. The higher case fatality among the south Asians, largely attributable to diabetes, may contribute to the increased risk of death from coronary heart disease in south Asians living in Britain. Key messages This study shows that south Asians have high mortality in the first six months after a heart attack This may contribute to the high standardised mortality ratios for coronary disease in south Asians living in the Britain Diabetes may be an important contributor to this excess risk The high prevalence of diabetes and relatively poor prognosis after myocardial infarction in south Asian patients are important to consider in clinical management

Attenuation or absence of circadian and seasonal rhythms of acute myocardial infarction.

OBJECTIVES: To examine the circadian, seasonal, and weekly rhythms of acute myocardial infarction, and to identify subgroups in whom the rhythms are attenuated or absent to provide further information about the mechanisms of the rhythms and the processes responsible for triggering plaque events. DESIGN AND SETTING: Prospective, observational study in a general hospital. PATIENTS AND METHODS: 1225 consecutive patients admitted to a coronary care unit with acute myocardial infarction were studied. Admission rates were calculated according to the hour of the day (circadian rhythm), day of the week (weekly rhythm), and month of year (seasonal rhythm). The data were analysed for variations within the whole group and within subgroups. RESULTS: A weekly rhythm of acute myocardial infarction could not be demonstrated but there was a trend towards higher admission rates at the beginning of the week. However, the time of onset of symptoms showed significant circadian variation for the group as a whole, peaking in the morning (P = 0.006), against an otherwise fairly constant background rate. Subgroup analysis showed complete absence of the circadian rhythm in patients who were diabetic, South Asian, or taking beta blockers or aspirin on admission. Significant seasonal variation in admission rates was also demonstrated for the group as a whole with a winter peak and a summer trough (P = 0.009). Again, no seasonal rhythm could be demonstrated in patients who were diabetic, South Asian, or taking beta blockers or aspirin on admission. CONCLUSIONS: The absence of circadian and seasonal rhythms of acute myocardial infarction in almost identical subgroups suggests that common mechanisms are involved in driving these rhythms. The autonomic nervous system is a likely candidate because the rhythms were absent in patients taking beta blockers as well as in patients in whom derangement of autonomic function commonly occurs.

Circadian activity of the endogenous fibrinolytic system in stable coronary artery disease : effects of beta-adrenoreceptor blockers and angiotensin-converting enzyme inhibitors

OBJECTIVES To examine circadian changes in the sympathovagal balance, the activity of the renin-angiotensin system and hemostatic variables in patients with stable coronary artery disease, and the effects of beta-adrenoceptor blockade and angiotensin-converting enzyme inhibition. BACKGROUND Sympathovagal balance and key components of the fibrinolytic system show circadian variability. The effects of beta-adrenergic blocking agents and angiotensin-converting enzyme inhibitors on these autonomic and hemostatic rhythms are not well defined. METHODS Twenty patients with coronary artery disease underwent 24-h Holter monitoring for heart rate variability and blood sampling (6 hourly for 24 hours) after three consecutive treatment phases, (firstly with placebo, then bisoprolol, and finally quinapril). The effects on sympathovagal balance, hemostatic variables and the renin-angiotensin system activity were measured. RESULTS The fibrinolytic capacity showed marked circadian variation at the end of the placebo phase (p = 0.002), plasminogen activator inhibitor-1 (PAI-1) activity peaking at 06.00 AM when tissue plasminogen activator (tPA) activity was at its nadir. Sympathovagal balance showed a sharp increase at approximately the same time but plasma renin activity did not rise until later in the day. Inspection of the 24-h profiles suggested that bisoprolol reduced sympathovagal balance and the morning peak of PAI-1 activity and antigen, with a small increase in tPA activity, although these changes were not significant. Quinapril produced a substantial rise in renin (p = 0.01) but did not significantly affect either PAI-1 or tPA. Sympathovagal balance was unaffected by quinapril. CONCLUSIONS In patients with stable coronary artery disease, angiotensin-converting enzyme inhibition with quinapril does not affect either sympathovagal balance or the endogenous fibrinolytic system. Our data suggest that the sympathoadrenal system may modify fibrinolytic activity, judged by the response to beta-adrenoreceptor blockade with bisoprolol.

Investigation of coronary artery disease in diabetes: is screening of asymptomatic patients necessary?

Diabetes is a major risk factor for ischaemic heart disease; the relative risk increases at least twofold among diabetic men and even more so for women.1 Diabetes is associated with more extensive coronary artery disease and an increased risk of cardiac death.2 Even in the absence of frank diabetes, glucose intolerance has been associated with a heightened risk of coronary artery disease independent of age, blood pressure, and other risk factors.3 Moreover, patients with diabetes are more likely to sustain an acute myocardial infarction,4 and in these patients diabetes is a major independent predictor of morbidity and mortality.5 Because the prevalence of coronary artery disease is higher in diabetic than non-diabetic populations, the probability of disease in the diabetic patient with typical angina is also high. In most cases, this allows a confident clinical diagnosis to be made without the need for non-invasive testing. In many diabetic patients, however, angina is atypical, presenting the physician with a more difficult diagnostic task. It is clear that when chest pain is atypical the probability of coronary disease will be lower, but will remain appreciably higher in diabetic than non-diabetic patients with similar …

Early targeted brain COOLing in the cardiac CATHeterisation laboratory following cardiac arrest (COOLCATH).

INTRODUCTION Trials demonstrate significant clinical benefit in patients receiving therapeutic hypothermia (TH) after cardiac arrest. However, incidence of mortality and morbidity remains high in this patient group. Rapid targeted brain hypothermia induction, together with prompt correction of the underlying cause may improve outcomes in these patients. This study investigates the efficacy of Rhinochill, an intranasal cooling device over Blanketrol, a surface cooling device in inducing TH in cardiac arrest patients within the cardiac catheter laboratory. METHODS 70 patients were randomized to TH induction with either Rhinochill or Blanketrol. Primary outcome measures were time to reach tympanic ≤34 °C from randomisation as a surrogate for brain temperature and oesophageal ≤34 °C from randomisation as a measurement of core body temperature. Secondary outcomes included first hour temperature drop, length of stay in intensive care unit, hospital stay, neurological recovery and all-cause mortality at hospital discharge. RESULTS There was no difference in time to reach ≤34 °C between Rhinochill and Blanketrol (Tympanic ≤34 °C, 75 vs. 107 mins; p=0.101; Oesophageal ≤34 °C, 85 vs. 115 mins; p=0.151). Tympanic temperature dropped significantly with Rhinochill in the first hour (1.75 vs. 0.94 °C; p<0.001). No difference was detected in any other secondary outcome measures. Catheter laboratory-based TH induction resulted in a survival to hospital discharge of 67.1%. CONCLUSION In this study, Rhinochill was not found to be more efficient than Blanketrol for TH induction, although there was a non-significant trend in favour of Rhinochill that potentially warrants further investigation with a larger trial.

Rotational Atherectomy in a Patient with Acute ST-Elevation Myocardial Infarction and Cardiogenic Shock.

Rotational atherectomy (rotablation) of coronary artery is relatively contraindicated in high thrombotic state such as acute ST-elevation myocardial infarction (STEMI) because of the risk of platelet activation by the rotablator. We present a case where rotablation was necessary to recanalize the right coronary artery in a patient presenting with acute STEMI complicated by cardiogenic shock, after unsuccessful attempts with balloon catheters. He improved remarkably after the procedure and was discharged after 4 days.

32 The Impact of Haemoglobin Reduction on Short- and Long-Term Mortality Following Primary Percutaneous Coronary Intervention for St-Elevation Myocardial Infarction-analysis from a Real World Stemi Population

Introduction Mortality following ST-elevation myocardial infarction has declined significantly with the advent of primary PCI (PPCI). Concurrent use of antiplatelet agents has further decreased complication rates and mortality; however, these agents confer an increased bleeding risk, an independent risk factor for mortality. This retrospective study assesses the effect of blood loss on short- and long-term mortality and its association with clinical characteristics in a real world population of patients undergoing PPCI at a tertiary referral centre in the UK. Methods All patients accepted for PPCI within the period of September 2009 to November 2011 were eligible for inclusion in the study. Patient data were obtained from our Cardiac Services Database System (Phillips CVIS) and mortality data were gathered from the Summary Care Record (SCR) database. Statistical comparisons of continuous variables were made by one-way ANOVA. Categorical variables were compared using the chi-squared test. A P value of < 0.05 was taken to indicate statistical significance. Results 1403 patients with recorded admission and discharge haemoglobin levels were included in this analysis. Characteristics and clinical outcomes were compared in three groups according to the degree of haemoglobin reduction (Table 1). Patients with a reduction in haemoglobin were more likely to be female, slightly older and have prior history of MI. Patients with a significant reduction in haemoglobin were more likely to have received abciximab. Thirty-day mortality was significantly higher in the group with a haemoglobin drop (Table 1) as was overall mortality (hazard ratio 1.8, 95% CI 1.2–2.5) during a mean follow-up period of 2.1 years (Figure 1). Abstract 32 Figure 1 Kaplan-Meier survival curves Abstract 32 Table 1 Clinical characteristics and outcomes No change in Hb, g/dl (n = 374) Hb reduction 0.1–1 g/dl (n = 517) Hb reduction >1 g/dl (n = 512) p-value Risk factorsMean Age (+/- SD)MaleHypertensionDiabetes MellitusPrevious MIPrevious CABG 64.4 +/- 14290 (77.5%)110 (29.4%)53 (14.2%)59 (15.8%)9 (2.4%) 63.1 +/- 13383 (74%)132 (25.5%)63 (12.2%)61 (11.8%)14 (2.7%) 67.5 +/- 13355 (69.3%)140 (27.3%)64 (12.5%)51 (10%)11 (2.1%) <0.0001*0.021*0.3700.6560.031*0.843 Procedure relatedRadialAbciximab use 113 (30.2%)114 (30.5%) 147 (28.4%)161 (31.1%) 130 (25.4%)208 (40.6%) 0.2630.0001* Clinical outcome30-day mortalityOverall mortality 15 (4%)36 (9.6%) 12 (2.3%)46 (8.9%) 42 (8.2%)79 (15.4%) <0.0001*0.0019* Conclusions Our retrospective analysis in a large cohort of patients confirms recent data suggesting an adverse association between a reduction in haemoglobin following PPCI and long-term mortality. Further work is required on strategies to reduce bleeding risk and hence improve clinical outcome following PPCI.

158 TAKO-TSUBO CARDIOMYOPATHY IN PATIENTS ADMITTED FOR PRIMARY PERCUTANEOUS CORONARY INTERVENTION IN A HIGH VOLUME UK CENTRE

Introduction Tako-tsubo cardiomyopathy (TCM) is increasingly being recognised in patients admitted with suspected acute coronary syndrome, as access to angiography and echocardiography are much quicker than before. Typically, patients with TCM present to the primary PCI service (PPCI) with chest pain and ST elevation on their electrocardiogram mimicking ST elevation myocardial infarction (STEMI). However, there is no ‘real-world’ data about the prevalence of this condition in PPCI admissions for suspected STEMI. Therefore we aimed to analyse the prevalence of TCM in a high volume regional PPCI service in UK. Table 1 Echocardiographic features of TCM patients in our study (n=17) Severely impaired LV function 2 (11.8%) Moderately impaired LV 15 (88.2%) RV impairment 2 (11.8%) Mitral regurgitation (MR)- None 13 (76.5%) MR (mild) 3 (17.6%) MR (moderate) 1 (5.9%) LVOT peak velocity: <1 m/s 6 (35.3%) LVOT peak velocity: >1 m/s 9 (52.9%) LVOT peak velocity: >2 m/s 2 (11.8%) Apical Thrombus 1 (5.9%) Methods All patients admitted with suspected STEMI between Sept 2009 and Nov 2011 to our centre were included. After excluding those who underwent PPCI, We analysed the echocardiogram and/or left ventriculogram of those patients who did not undergo PPCI to identify patients with typical TCM features of apical akinesia with basal hyperkinesia. Their coronary angiograms were reviewed and the inclusion criteria to identify TCM was the absence of significant coronary disease with no artery having >50% stenosis. Results Of the 1875 patients admitted, 17 (0.9%) patients (0 m, 17 f) with the mean age of 70±10.7 years (range 56–94 years) were identified to have typical TCM features. The prevalence of TCM in female PPCI admission was 3.1% (17/560) (figure 1). The admission ECG showed ST elevation in 14 patients (82%) and three had LBBB (18%). In those who had positive hsTroponin (n=16, 94.1%), the mean level was 921±668 (median 778, range 110–2550). Two patients had cardiac arrest prior to hospital admission with successful resuscitation. Left ventricular function was severely impaired (EF≤30%) in 2 patients whilst all others had moderately impaired LV function (EF 31–50%) (table 1). Aspirin, β-blocker, Angiotensin converter enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) was given to 13 (76.5%), 13 (76.5%) and 15 (88.2%) patients respectively on their discharge. All the 15 patients who had repeat echocardiogram within 3 months of their index admission showed complete recovery of their LV function. During a mean follow up period of 22±7 months (median 21, range 8–36 months), there was no mortality. Figure 1 Flow chart to identify Tako-tsubo Cardiomyopathy patients in our study. Conclusions This first ‘real-world’ observational study of TCM in STEMI patients admitted for PPCI to a single centre showed an overall prevalence of 0.9% with 3% prevalence in female population. Although TCM is not benign during the acute episode, there is an excellent survival outcome if managed appropriately during the acute phase.

036 COMPARISON OF CLINICAL CHARACTERISTICS AND OUTCOMES IN PATIENTS WITH LEFT BUNDLE BRANCH BLOCK VERSUS ST ELEVATION MYOCARDIAL INFARCTION REFERRED FOR PRIMARY PCI

Aims Current national and international guidelines continue to recommend activation of the primary percutaneous coronary intervention (PPCI) pathway in patients presenting with chest pain and presumed new-onset left bundle branch block (LBBB). Previous research has suggested that a lower proportion of patients presenting with LBBB require emergency intervention. In this study we have compared baseline clinical characteristics, angiographic findings and subsequent outcome in patients with LBBB versus ST-elevation myocardial infarction (STEMI) referred to our tertiary centre for PPCI. Table 1 Clinical characteristics Risk factor LBBB (n=155) STEMI (n=1720) p Value Mean age (±SD) 70.35±11.9 64.95±14.0 <0.0001 Male 87 (56.1%) 1228 (71.4%) <0.0001 Hypertension 70 (45.2%) 668 (38.8%) 0.127 Hypercholesterolaemia 52 (33.5%) 512 (29.8%) 0.327 Diabetes mellitus 26 (16.8%) 201 (11.7%) 0.063 Previous MI 36 (23.2%) 205 (11.9%) <0.0001 Previous CABG 10 (6.5%) 44 (2.6%) 0.005 Methods All patients accepted for PPCI within the period of September 2009 to November 2011 were included in the study. Patient data obtained from our Cardiac Services Database System (Phillips CVIS) were analysed and angiographic images reviewed on our Cardiac Image Database (McKesson Horizon). Mortality data were gathered from the Summary Care Record (SCR) database. Statistical comparisons of continuous variables were made by an unpaired t test. Categorical variables were compared using the χ2 test. A p value of <0.05 was considered to indicate statistical significance. Results During the study period, 1875 patients were referred for PPCI of whom 155 (8.3%) had LBBB. Compared with STEMI, patients with LBBB were significantly older, more likely to be female and have prior history of MI and CABG (table 1). Patients with LBBB had similar door-to-balloon (DTB) and call-to-balloon (CTB) times. PCI was performed in 40 (26%) patients with LBBB although an acutely occluded culprit vessel was found in only 19 (12.2%) patients (table 2). Furthermore, 85 (54.8%) patients had non-flow limiting coronary artery disease and of those with significant disease 12 (7.7%) patients required CABG (figure 1). Overall, an acute coronary syndrome (defined as ischaemic chest pain with positive troponin) was confirmed in only 67 (43.2%) of patients presenting with LBBB. 30-day mortality was similar between LBBB and STEMI patients (table 2). However, during a mean follow-up period of 2.1 years, overall mortality was significantly higher in the LBBB group compared to STEMI (HR 2.01, 95% CI 1.26 to 3.20) (figure 2). Conclusions Our study shows that, in contrast to STEMI, only a small proportion of patients presenting with chest pain and LBBB had an acutely occluded coronary artery. Although short-term mortality was similar between the two groups, long-term outcome was significantly worse in patients with LBBB. Further work is needed to identify those patients presenting with LBBB who are most likely to have an acute coronary occlusion, in order to facilitate the appropriate use of emergency coronary angiography and PPCI. Table 2 Clinical outcomes Outcome LBBB (n=155) STEMI (n=1720) p Value Door-to-balloon time (min±SD) 40±17 37±25 0.710 Call-to-balloon time (min±SD) 128±36 120±47 0.263 Acute coronary occlusion 19 (12.2%) 1096 (63%) <0.0001 PCI performed 40 (26%) 1430 (83%) <0.0001 30-day mortality (all) 8 (5.2%) 120 (6.9%) 0.391 30-day mortality (PCI) 3/40 (7.5%) 94/1430 (6.6%) 0.825 30-day mortality (no PCI) 5/115 (4.3%) 26/290 (8.9%) 0.115 Overall mortality 32 (27.8%) 240 (13.9%) 0.023 Figure 1 Clinical outcome in patients with LBBB. Figure 2 Kaplan-Meier comparison of survival curves.

30 Comparison of bivalirudin vs abciximab vs “unfractionated heparin only” for primary percutaneous coronary intervention in a high-volume centre

Introduction Primary percutaneous coronary intervention (PPCI) has been established as a standard therapy for ST elevation myocardial infarction (STEMI). In addition to thrombectomy and unfractionated heparin (UFH), thrombus burden in STEMI may require use of more potent antithrombotic agents. Bivalirudin is shown to be superior to abciximab in reducing the net adverse clinical events and major bleeding in STEMI in the HORIZONS-AMI trial (Stone et al NEJM, 2008). We aimed to carry out a “real world” comparison of different anti-thrombotic regimes in patients undergoing PPCI in our unit. Methods Our PPCI service started in September 2009 and we included all patients undergoing PPCI between September 2009 and September 2010. Prospectively entered data were obtained from our dedicated cardiac service database system (Philips CVIS). Mortality data were obtained from the summary care record (SCR) database. We used Fisher′s exact test to compare clinical outcomes between the groups. Results Of the 998 patients admitted with suspected STEMI to our unit during the study period, 776 (77.8%) underwent PPCI. After excluding patients who had both bivalirudin and abciximab during their procedure (n=15), we divided the others (n=761) into 3 groups according to the anti-thrombotic regime used (Grp 1- Abciximab+UFH, Grp 2- Bivairudin+UFH and Grp 3- “UFH only”). Patient demographics and procedural information are given in Abstract 30 table 1. Continuous data are presented as mean± SD. Clinical outcomes are shown in Abstract 30 table 2. In-hospital and 30-day mortality did not differ between patients who had bivalirudin vs abciximab (5.6% vs 3.8%, p=0.35 and 6.8% vs 5.2% p=0.53 respectively). Both acute and 30 day stent thrombosis rates were also similar in the two groups (0.6% vs none, p=0.3, 0.6% vs 0.9%, p=1.0 respectively). Even though the bleeding risk was higher in the abciximab group when compared with bivalirudin, this was not significant (5.8% vs 3.1%, p=0.27). There was also no difference in the outcomes between the bivalirudin and “UFH only” groups for mortality, stent thromboses (acute and 30-day) and major bleeding. The abciximab group had significantly higher major bleeding rates than the “UFH only” group (5.8% vs 2.4%, p=0.04); all other outcomes were similar.Abstract 30 Table 1 Abciximab + UFH (n=346) Bivalirudin + UFH (n=162) UFH only (n=253) Age in yrs (range) 64±14.1 (25–99) 65±13.0 (31–94) 67±13.2 (30–96) Male (%) 77.7 72.2 66.8 Diabetes (%) 12.4 6.2 11.5 Pre-procedure cardiogenic shock (%) 7.8 6.2 4.7 Drug eluting stent (at least one) (%) 56.1 56.8 53.8 No of stents 1.4±0.9 1.4±0.8 1.4±0.9 Single vessel PCI (%) 91.3 87 89.3 Three vessel PCI (%) 1.4 1.9 2 Radial procedure (%) 28 26.5 31.2Abstract 30 Table 2 % Abciximab + UFH (n=346) Bivalirudin + UFH (n=162) UFH only (n=253) In-hospital Mortality (including cardiogenic shock) 3.8 5.6 5.1 30 day Mortality (including cardiogenic shock) 5.2 6.8 7.1 30 day Mortality (excluding cardiogenic shock) 3.5 4.9 5.5 Stent Thrombosis (within 30 days) 0.9 0.6 1.2 Acute stent Thrombosis (24 h) ≤ 0 0.6 0.4 Major bleed requiring blood transfusion (non CABG related) 5.8 3.1 2.4 Access related bleed requiring transfusion (includes IABP related) 3.8 1.9 1.2 Conclusion These “real-world” data do not show any significant difference in the clinical outcome for patients who had bivalirudin or abciximab. There was no advantage seen with the more expensive agent (abciximab) in keeping with previous trial data. Therefore bivalirudin should be considered as a non-inferior alternative to abciximab. This would have considerable economic benefits in the present situation. The “UFH only” group had similar outcomes to both bivalirudin and abciximab, which suggests that this may be a viable alternative in its own right. However, our study is clearly limited by not being randomised and those patients treated with UFH alone may have been a lower risk group.