Jim McLenachan

Association of diabetes with increased all-cause mortality following primary percutaneous coronary intervention for ST-segment elevation myocardial infarction in the contemporary era

Background: We investigated the association between diabetes mellitus (DM) and all-cause mortality in a large cohort of consecutive patients treated with primary percutaneous coronary intervention (PPCI) in the contemporary era. Methods: We conducted a retrospective analysis of a single-centre registry of patients undergoing PPCI for ST-segment elevation myocardial infarction (STEMI) at a large regional PCI centre between 2005 and 2009. All-cause mortality in relation to patient and procedural characteristics was compared between patients with and without DM. Results: Of 2586 patients undergoing PPCI, 310 (12%) had DM. Patients with DM had a higher prevalence of multi-vessel coronary disease (p<0.001) and prior myocardial infarction (p<0.001). Patients with DM were less commonly admitted directly to the interventional centre (p=0.002). Symptom-to-balloon (p<0.001) and door-to-balloon time (p=0.002) were longer in patients with DM. Final infarct-related-artery TIMI-flow grade was lower in patients with DM (p=0.031). All-cause mortality at 30 days (p=0.0025) and 1 year (p<0.0001) was higher in patients with DM. DM was independently associated with increased mortality after multivariate adjustment for potential confounders. Conclusions: Mortality remains substantially higher in patients with DM following reperfusion for STEMI in comparison with those without diabetes, despite contemporary management with PPCI. Greater co-morbidity, delayed presentation, longer times-to-reperfusion, and less optimal reperfusion may contribute to adverse outcomes.

Double valve replacement for acute spontaneous left chordal rupture secondary to chronic aortic incompetence

A 54 years old male with undiagnosed chronic calcific degenerative aortic valve incompetence presented with acute left anterior chordae tendinae rupture resulting in severe left heart failure and cardiogenic shock. He was successfully treated with emergency double valve replacement using mechanical valves. The pathogenesis of acute rupture of the anterior chordae tendinae, without any evidence of infective endocarditis or ischemic heart disease seems to have been attrition of the subvalvular mitral apparatus by the chronic regurgitant jet of aortic incompetence with chronic volume overload. We review the literature with specific focus on the occurrence of this unusual event.

29 Bivalirudin in patients undergoing primary percutaneous coronary intervention for acute ST-elevation myocardial infarction: outcomes in a large real-world UK population

Background The HORIZONS-AMI trial demonstrated a significantly lower early and late mortality in patients undergoing primary PCI (PPCI) treated with bivalirudin compared to a Glycoprotein IIb/IIIa inhibitor (GPI) + heparin. However, concerns remain regarding the increased incidence of acute stent thrombosis (ST) with bivalirudin, the apparently worse outcomes in the absence of additional pre-procedural heparin, and the translation of trial results into a real-world population. We evaluated the outcomes of patients undergoing PPCI with bivalirudin in a large all-comers UK setting. Methods All patients who underwent PPCI in Leeds General Infirmary from 1 January 2009 to 31 December 2009 were prospectively entered into a dedicated registry. Demographic, procedural, and 30-day outcome data were obtained by abstraction from the ONS mortality database and BCIS PCI database, review of hospital notes, and telephone follow-up. Bivalirudin was administered as a bolus, high-dose intra-procedural infusion, and low-dose infusion for 4 h post-PCI. Additional heparin was not routinely given, but was favoured by some operators. Bail-out GPI was administered according to physician judgement. Primary endpoints were death, MACE (death, re-infarction, stroke, unplanned target vessel revascularisation (TVR)), and stent thrombosis (ST) (ARC definition definite/probable) at 30-days follow-up. Results 968 patients (age 63.5±13 years, 71.9% male, 13.2% diabetics) underwent PPCI. Bivalirudin was given in 882 patients (91.1%), and GPI + heparin in 85 (8.8%). Of bivalirudin-treated patients 100 (11.3%) also received heparin (29 pre-PCI and 80 during) while bail-out GPI was used in 91 (10.3%). Thirty-day outcomes are shown in Abstract 29 table 1. All-cause mortality was 5.2% in the bivalirudin treated patients. Acute ST occurred in 1.0%, a median of 2 h post-PCI, and within 6 h in 90%. Mortality in patients who suffered acute ST was 20%, compared to 80% following subacute ST. There was no difference in outcomes between bivalirudin treated patients who also received heparin compared to those who didn′t (death 7.0% vs 5.0%, p value: 0.80; MACE 14.0% vs 10.8%, p value: 0.32; acute ST 0% vs 1.2%, p: 0.61).Abstract 29 Table 1 Outcomes at 30 days All patients Bivalirudin GPI + heparin p value No. of patients 968 882 85 Death 52 (5.4%) 46 (5.2%) 6 (7.1%) 0.450 Cardiac death 45 (4.7%) 39 (4.4%) 6 (7.1%) 0.277 Re-infarction 16 (1.7%) 14 (1.6%) 2 (2.4%) 0.645 Unplanned TVR 12 (1.2%) 10 (1.1%) 2 (2.4%) 0.286 Stroke 56 (5.8%) 54 (6.1%) 2 (2.4%) 0.222 Death, re-infarction, stroke or TVR 110 (11.4%) 100 (11.3%) 10 (11.8%) 0.906 Acute stent thrombosis 10 (1.0%) 9 (1.0%) 1 (1.2%) 0.604 Subacute stent thrombosis 15 (1.6%) 13 (1.5%) 2 (2.4%) 0.386 Conclusion Routine use of bivalirudin in a large UK all-comers primary PCI population was associated with excellent 30-day outcomes, including all-cause and cardiac mortality. Acute stent thrombosis was infrequent, despite the absence of routine additional heparin.

128 Impact of diabetes on 30-day and 1-year mortality after primary percutaneous coronary intervention for acute myocardial infarction

Background The presence of diabetes mellitus (DM) is associated with increased mortality in patients with acute ST segment elevation myocardial infarction (STEMI) treated with fibrinolysis. Primary percutaneous coronary intervention (PPCI) confers improved outcomes compared to fibrinolysis in unselected patients and is now the reperfusion strategy of choice. However, the impact of DM on survival in the era of PPCI for STEMI remains unclear. Methods We carried out a retrospective analysis of a database of all patients undergoing PPCI for STEMI at the Yorkshire Heart Centre, Leeds General Infirmary (covering a regional population of ∼3.2 million). 30-day and 1-year mortality, demographic factors and procedural characteristics were compared between patients with and without a diagnosis of DM on presentation. Results Between September 2002 and September 2008, 1629 patients underwent PPCI for STEMI at our centre. 209 (12.8%) patients had a prior diagnosis of DM. Mortality at 30 days (8.4% vs 3.9%; p=0.0023) and 1 year (15.8% vs 6.8%; p<0.0001) was significantly higher in patients with DM (Abstract 128 Figure 1). Patients with DM were older (mean age 63.78 vs 61.16; p=0.006) and more often required circulatory support (8.6% vs 4.5%; p=0.014) than patients without DM. Triple vessel disease was more common in patients with DM (32.5% vs 19.6%; p=0.001). Drug eluting stents were deployed more frequently in patients with DM (32% vs 25%; p=0.03). Administration of heparin+abciximab (62.1% vs 61.2%) and bivalirudin (38.8% vs 37.9%) was similar in both groups. TIMI flow grade was similar in the two groups at baseline. However, final TIMI flow achieved was lower in patients with DM compared to patients without diabetes (mean 2.74 vs 2.85; p=0.001). ‘Symptom to balloon time’ (Median time (minutes) (IQR): 244 (168–447) vs 211 (153–350); p=0.006) and ‘door to balloon time’ (107 (62–165) vs 85 (52–129); p=0.0003) were significantly longer in patients with DM. Abstract 128 Figure 1 Conclusions Survival remains substantially impaired in patients with DM undergoing contemporary reperfusion with PPCI for STEMI. Increased age, more advanced coronary disease and greater requirement for circulatory support may contribute to poorer outcomes, but the influence of DM on timing of presentation and reperfusion requires further investigation. Abstract 128 Figure 1. Kaplan Meier curves showing 1-year mortality post PPCI.