Jim Christie

Early treatment with captopril after acute myocardial infarction.

OBJECTIVES--To determine the effects of early treatment with captopril on haemodynamic function, neuroendocrine biochemistry, left ventricular structure, clinical outcome, and exercise capacity over one year from acute myocardial infarction. DESIGN--Randomised, double blind, placebo controlled comparison of captopril and placebo. SETTING--Coronary care units and cardiology departments of two university teaching hospitals in Glasgow. PATIENTS--99 haemodynamically stable patients with acute myocardial infarction, selected on clinical grounds as being at risk of late ventricular dilatation. INTERVENTION--Captopril or identical placebo started between six and 24 hours after start of symptoms and continued for 12 months. Target maintenance dose was 25 mg three times a day. MAIN OUTCOME MEASURES--(a) Acute haemodynamic effects of treatment; (b) neuroendocrine biochemistry from admission to two months; and (c) change in echocardiographic measures of left ventricular size, clinical outcome, and exercise capacity after 12 months of treatment with a separate analysis of the effects of one month of treatment withdrawal on left ventricular volumes. RESULTS--Captopril caused acute reductions in mean (SEM) pulmonary artery pressure (2.48 (0.69) mm Hg) and systemic vascular resistance (260 (103)) dyn.s.cm-5). Over the first 10 hours captopril reduced mean arterial pressure by 12.1 (2.4) mm Hg compared with 3.8 (1.9) mm Hg in the placebo group. No patient had to be withdrawn from the captopril group because of hypotension. From day 1 onwards systolic and diastolic arterial pressures in the captopril treated group were slightly but not significantly lower than on placebo. There was no difference in the incidence of ventricular or supraventricular arrhythmia with treatment. Captopril prevented the day 3 peak in angiotensin II that occurred in the placebo group (peak concentration (interquartile range): 10.1 (4.8-19.4) pg/ml v 16.8 (4.3-46.3) pg/ml)) but had no effect on atrial natriuretic factor, arginine vasopressin, or catecholamines. Plasma atrial natriuretic factor remained above normal in both groups at two months after infarction. After one year left ventricular volume indices had increased less on captopril than on placebo: left ventricular end systolic volume index 5.4 ml/m2 v 14.7 ml/m2 (95% confidence interval (95% CI) of difference -14.6 to -3.9; p = 0.0011); left ventricular end diastolic volume index 8.4 ml/m2 v 19.0 ml/m2 (95% CI of difference, -17.0 to -4.2; p = 0.0016). Withdrawal of captopril for one month did not affect ventricular volumes. There was no difference in exercise capacity. CONCLUSIONS--Captopril started between six and 24 hours after acute myocardial infarction is not associated with significant hypotension. It suppresses activation of the renin angiotensin system but has no effect on plasma concentrations of other neurohormones. Atrial natriuretic factor remains raised at two months after myocardial infarction. Captopril significantly decreases left ventricular dilatation. This effect is not lost after one month of treatment withdrawal and is thus due to an alteration of left ventricular structure and not to a short lived haemodynamic action of captopril. Long-term treatment with captopril does not result in improved aerobic exercise capacity after acute myocardial infarction.

Do radionuclide and echocardiographic techniques give a universal cut off value for left ventricular ejection fraction that can be used to select patients for treatment with ACE inhibitors after myocardial infarction

OBJECTIVE--To determine whether echocardiography and radionuclide angiography give comparable results when the left ventricular ejection fraction is measured early after myocardial infarction and thus whether, irrespective of the method used, a single value for the ejection fraction could be used as a guide for starting treatment with an angiotensin converting enzyme inhibitor. DESIGN--Prospective comparison of measurement of left ventricular ejection fraction by echocardiography and radionuclide angiography. SETTING--Coronary care units of two university teaching hospitals in Glasgow. PATIENTS--99 patients studied within 36 hours of acute myocardial infarction. OUTCOME MEASURES--Left ventricular ejection fraction assessed by echocardiography and radionuclide angiography. RESULTS--70 (77%) of the 99 patients had ejection fraction measured by both echocardiographic and radionuclide techniques, 30 in centre 1 and 40 in centre 2. In centre 1 the mean difference (SD) in ejection fraction (radionuclide angiography--echocardiography) was -8 (10%); 95% CI -12 to -4%. In centre 2 the mean difference was -14 (11%); 95% CI -17 to -11%. If patients had been treated with an ACE inhibitor on the basis of a radionuclide ejection fraction of < 40% then 93% in centre 1 (28 of 30) and 98% in centre 2 (39 of 40) would have been treated. This compares with 63% (19 of 30) and 50% (20 of 40), respectively if echocardiography had been used as a guide. CONCLUSION--Measurement of ejection fraction is highly dependent on the method used and it is therefore impossible to quote a universally applicable figure for left ventricular ejection fraction below which an ACE inhibitor should be used after myocardial infarction.

Long-term outcome of low-risk patients attending a rapid-assessment chest pain clinic

Objective: To examine the long-term outcome of patients evaluated in a rapid assessment chest pain clinic (RACPC): are “low-risk” patients safely reassured? Design: Retrospective cohort study. Setting: Staff grade-led RACPC in an urban teaching hospital. Participants: 3378 patients (51% male), attending the RACPC between April 1996 and February 2000. Main outcome measures: Death, coronary mortality, morbidity and revascularisation over a median follow-up of 6 years. Coronary standardised mortality ratio (SMR). Results: 2036 (60.3%) patients were categorised as “low risk”, 957 (28.3%) as having “stable coronary artery disease” and 214 (6.3%) as being an “acute coronary syndrome”. During the study, 3.6% of patients in the low risk category, 11.9% in the stable coronary artery disease category and 24.6% in the acute coronary syndrome category died from coronary artery disease or had a myocardial infarction. 5.5%, 18.2% and 18.4%, respectively, died from any cause. Compared to the local population (coronary SMR  = 100), our “low risk/non-coronary chest pain” cohort had a coronary SMR of 51 (95% CI 31 to 83), the “stable coronary artery disease” cohort 240 (187 to 308) and the “acute coronary syndrome” cohort 780 (509 to 1196). Conclusion: The RACPC was effective at triaging patients with chest pain. Patients identified as at “low risk” were unlikely to have an adverse coronary outcome and were appropriately reassured.

21 Influence of fractional flow reserve measurement on treatment-decisions in patients with recent acute non-ST elevation myocardial infarction

Introduction Non-ST elevation acute myocardial infarction (NSTEMI) is the most common form of acute coronary syndrome and has a relatively poor prognosis. Visual interpretation of the coronary angiogram is the standard approach to guide treatment decisions in patients with recent acute NSTEMI. The aim of our study was to determine whether measurement of coronary pressure derived fractional flow reserve (FFR), compared to coronary angiography alone, might influence treatment decisions. Setting The cardiac catheterisation laboratory in a regional heart centre in the UK. Definitions The clinical indication for FFR measurement was the presence of an intermediate coronary stenosis (50%–75% of the reference vessel diameter) which resulted in diagnostic and treatment uncertainty. FFR measurement was used to provide functional information on lesion severity and an FFR <0.80 was taken to represent a flow-limiting stenosis. Methods The study involved three accredited interventional cardiologists and a study coordinator. The cardiologists separately reviewed the coronary angiograms and together with the clinical history, made a decision for medical therapy, PCI, CABG/MDT, or deferred management. The FFR results were then disclosed and the initial management decision was reviewed in light of the FFR result and changed as appropriate. Results Of 1621 acute NSTEMI patients (January 2009–March 2010) in our hospital, 100 (6.2%) had FFR recorded. The treatment decisions for each cardiologist were: medical therapy 7%, 10%, 1%; PCI 64%, 70%, 60%; CABG/MDT 13%, 12%, 15%; deferred management 16%, 8%, 24%). The proportion of patients allocated to each treatment group differed between the 2nd and 3rd Cardiologist (p=0.02). Following FFR disclosure, each cardiologist changed his/her treatment decision in 58%, 50% and 62% of patients (p<0.05). Of the new decisions made following FFR disclosure, the proportion of patients allocated to medical therapy increased by 26%, 19% and 29%, whereas the proportion of patients allocated to deferred management or multi-vessel PCI decreased by 16%, 8%, 24% and by 5%, 7% and 5%, respectively (all p<0.05). The number of patients in whom the treatment decisions made by each cardiologist independently conformed (and so represented a consensus in at least 2 of the 3 decisions) increased from 74% to 92% as a result of FFR disclosure (p<0.001). Conclusion In our hospital about 1 in 20 NSTEMI had a coronary pressure wire study because of diagnostic uncertainty based on coronary angiography alone. In NSTEMI patients selected for FFR measurement, the FFR resulted in a change in management in at least half of the patients. FFR use increased the proportion of patients in whom treatment decisions conformed suggesting FFR use may also help to reduce the variation in treatment decisions using angiography alone. These results support further studies of the clinical utility and prognostic implications of FFR measurement in patients with NSTEMI.

TCT-231 The Glasgow Trans-radial Rotablation Registry – A Retrospective Analysis of High-speed Rotational Atherectomy

TCT-231 The Glasgow Trans-radial Rotablation Registry – A Retrospective Analysis of High-speed Rotational Atherectomy Alice Jackson, Kieran Docherty, Jim Christie, Mitchell Lindsay, Keith Oldroyd, Stuart Watkins, Aadil Shaukat, Colin Berry, Keith Robertson, Richard Good, Mark Petrie, Stuart Hood, Andrew Davie, Hany Eteiba, Margaret McEntegart, John Paul Rocchiccioli Herzund Diabeteszentrum NRW, Ruhr-Universität Bochum; Department of Cardiology and Angiology, Center of Internal Medicine, Klinikum Ernst von Bergmann, Potsdam, Germany, Glasgow, United Kingdom; Penn State University; Golden Jubilee National Hospital Scotland; West of Scotland Regional Heart and Lung Centre, Glasgow, United Kingdom; Golden Jubilee National Hospital, Glasgow, United Kingdom; Gri, Glasgow, United Kingdom; Golden Jubilee National Hospital, Glasgow, United Kingdom; NHS, Glasgow, United Kingdom; Golden Jubilee National Hospital, Glasgow, United Kingdom; Unknown, glasgow, United Kingdom; University of Minnesota; Unknown, Glasgow, United Kingdom; Golden Jubilee National Hospital, Clydebank, United Kingdom; Golden Jubilee National Hospital, Glasgow, United Kingdom; Golden Jubilee National Hospital, Glasgow, United Kingdom

20 A Minap-Like e-registry for the First Time in NHS Scotland? A Proof-of-Concept Report from the Pilot Project

Background The Myocardial Ischaemia National Audit Project (MINAP) provides data on national standards of care for patients with myocardial infarction (MI) in England and Wales but not in Scotland. In the West of Scotland (WoS), electronic patient records are being implemented in place of paper records. We aimed to record-link hospital patient episodes using the new e-systems in order to develop a secondary care e-registry for hospitalised patients with an acute coronary syndrome (ACS), including suspected STEMI, NSTEMI or unstable angina (UA). Methods The systems are (1) Trakcare Patient Admin System with extracts data based on ICD-10 diagnosis codes, (2) SCI-Gateway e-referrals for invasive cardiovascular procedures, (3) a hospital-level integrated patient record including cardiac catheter laboratory data (CATHI), (4) the WoS NHS Safe Haven for healthcare data including hospitalisation and mortality. We implemented a pilot study with data extraction for 1 Oct – 31 Dec 2013 for all admissions with an ICD-10 diagnosis of angina (I200-I209), MI (I210-I229), Other Ischaemic Heart Disease (IHD) (I240-I249), and heart failure (I50). The project involved identification of the NHS referral pathways, case e-record linkage, and quality assurance. Results The regional ACS network involves 7 acute hospitals in WoS (population 2.2 million) including the Golden Jubilee National Hospital, a regional hub for invasive cardiology. During the 3-month pilot, 930 unique patients had 1090 admissions involving 969 distinct spells (i.e. index admission and early out-patient re-admission for angiography). Of these spells, the final diagnosis was IHD in 775 (80%) patients, including 164 (16.9%) with STEMI, 287 (29.6%) with NSTEMI, 26 (2.7%) with unstable angina, 249 (25.7%) with stable angina, 5 with other IHD (0.5%), 43 (4.4%) with ‘other chest pain’ and 194 with a non-IHD final diagnosis (20%) (e.g. pericarditis). The pathways were mapped in 100% of the patients including 25.8% admitted directly to the invasive centre, 5.6% via local A&E to the invasive centre, 22.3% via the local hospital followed by in-patient transfer to the invasive centre, 8.9% discharged from the local hospital then readmitted to the invasive centre for planned early out-patient angiography, 4.6% within the local hospital only (no transfer), and 32.8% directly admitted on an elective basis to the invasive centre (non-acute). The mean duration of stay was similar for patients with a diagnosis of STEMI (5.2 days) or NSTEMI (4.6 days), but less for patients with UA (2.2 days) and more for other IHD diagnosis (9.1 days). Data on health outcomes will be presented at the conference. Conclusions For the first time, the pilot e-Registry has generated MINAP-like data in NHS Scotland. Information on admissions with or without a final ACS diagnosis is collected. NHS Scotland has emerging potential to contribute to MINAP.