José Ps Henriques

Prognostic Impact of Chronic Total Occlusions: A Report From SCAAR (Swedish Coronary Angiography and Angioplasty Registry)

OBJECTIVESnThe aim of this study was to determine the prognostic impact of chronic total occlusion (CTO) on long-term mortality in a large prospective cohort.nnnBACKGROUNDnCTO is present in many patients with coronary artery disease and is difficult to treat with percutaneous coronary intervention.nnnMETHODSnThe study population consisted of all consecutive patients who underwent coronary angiography in Sweden between January 1, 2005 and January 1, 2012, who were registered in SCAAR (Swedish Coronary Angiography and Angioplasty Registry). The patient population was heterogeneous with regard to indication for angiography (stable angina, ST-segment elevation myocardial infarction [STEMI], unstable angina or non-STEMI, and other) and treatment options. The long-term mortality rates of patients with and without CTO were compared by using shared frailty Cox proportional hazards regression adjusted for confounders. Tests were conducted for interactions between CTO and several pre-specified characteristics: indication for angiography and percutaneous coronary intervention (stable angina, STEMI, unstable angina or non-STEMI, and other), severity of coronary artery disease (1-, 2-, and 3-vessel and/or left main coronary artery disease), age, sex, and diabetes.nnnRESULTSnDuring the study period, 14,441 patients with CTO and 75,431 patients without CTO were registered in SCAAR. CTO was associated with higher mortality (hazard ratio: 1.29; 95% confidence interval: 1.22 to 1.37; pxa0< 0.001). In subgroup analyses, the risk attributable to CTO was lowest in patients with stable angina and highest in those with STEMI. In addition, CTO was associated with highest risk in patients under 60 years of age and with lowest risk in octogenarians. There was no interaction between CTO and either diabetes or sex, suggesting an equally adverse effect inxa0both groups.nnnCONCLUSIONSnIn this large prospective observational study of patients with coronary artery disease, CTO was associated with increased mortality. This association was most prominent in younger patients and in those with acute coronary syndromes.

Long term effects of epoetin alfa in patients with ST- elevation myocardial infarction.

PurposeThe HEBE III trial showed that epoetin alfa administration in patients with a first ST-elevation myocardial infarction (STEMI) did not improve left ventricular function at 6xa0weeks after primary percutaneous coronary intervention (PCI). The long term effects of erythropoiesis- stimulating agents on cardiovascular morbidity and mortality are unknown, therefore we evaluated clinical events at 1xa0year after PCI.MethodsA total of 529 patients with a first STEMI and successful primary PCI were randomized to standard optimal medical treatment (Nu2009=u2009266) or an additional bolus of 60,000xa0IU epoetin alfa administered intravenously (Nu2009=u2009263) within 3xa0h after PCI. Analyses were performed by intention to treat.ResultsAt 1xa0year after STEMI, 485 patients had complete follow-up. The rate of the composite end point of all-cause mortality, re-infarction, target vessel revascularization, stroke and/or heart failure was 6.4xa0% (Nu2009=u200915) in the epoetin alfa group and 9.6xa0% (Nu2009=u200924) in the control group (pu2009=u20090.18). Thromboembolic events were present in 1.3xa0% (Nu2009=u20093) of patients in the epoetin alfa group and 2.4xa0% (Nu2009=u20096) in the control group. There was no evidence of benefit from epoetin alfa administration in subgroups of patients.ConclusionsAdministration of a single bolus of epoetin alfa in patients with STEMI does not result in a reduction of cardiovascular events at 1xa0year after primary PCI. There was a comparable incidence of thromboembolic complications in both treatment groups, suggesting that epoetin alfa administration is safe at long term.

Guideline-defined futility or patient-reported outcomes to assess treatment success after TAVI: what to use? Results from a prospective cohort study with long-term follow-up

Objective Transcatheter aortic valve implantation (TAVI) provides a significant symptom relief and mortality reduction in most patients; however, a substantial group of patients does not experience the same beneficial results according to physician-determined outcomes. Methods Single-centre prospective design; the population comprises all consecutive patients undergoing TAVI in 2012–2017. TAVI futility was defined as the combined endpoint of either no symptomatic improvement or mortality at 1u2009year. We actively gathered telephone follow-up using a predefined questionnaire. Results Guideline defined TAVI futility was present in 212/741 patients. Multivariate regression showed lower albumin and non-transfemoral approach to be predictive for futility. In addition to these, chronic obstructive pulmonary disease, lower estimated glomerular filtration rate, atrial fibrillation, low-flow–low-gradient aortic stenosis and lower Body Mass Index were predictive for 1-year mortality. Patients who showed symptomatic benefit estimated the percentage in which their symptoms were remedied higher than patients who did not (80% vs 60%, p<0.001). Guideline-defined TAVI futility occurs frequently, contrasting with patient-reported outcome measures (PROMs). The vast majority in both groups would again choose for TAVI treatment. Conclusion Lower albumin and non-transfemoral access route were predictors for guideline-defined TAVI futility, defined as mortality within 1u2009year or no objective symptomatic improvement in New York Heart Association class. Futility according to this definition occurred frequently in this study, contrasting with much more positive PROMs. The majority of patients would undergo a TAVI again, underlining the patients’ experienced value of TAVI and putting the definition of TAVI futility further on debate. In the near future, less-strict criteria for TAVI futility, that is, using a shorter warranted life expectancy and incorporating patients’ perceived outcomes, should be used.

Premedication to reduce anxiety in patients undergoing coronary angiography and percutaneous coronary intervention

Aims In this study, we examined the effects of the routinely administration of benzodiazepines on reducing periprocedural anxiety versus no premedication. Methods In this open label study, we enrolled 1683 patients undergoing diagnostic coronary angiograms (CAG) or percutaneous coronary interventions (PCI). Randomisation was simulated by systematically allocating patients in monthly rotational periods to lorazepam 1 u2009mg/sl, oxazepam 10 u2009mg/po, diazepam 5 u2009mg/po, midazolam 7.5 u2009mg/po or no premedication. Anxiety was measured at four different time points using the one-item Visual Analogue Scale for Anxiety (VAS score) ranging from 0 to 10. The primary outcome was the difference in anxiety reduction (ΔVAS, preprocedure to postprocedure), between the different premedication strategies versus no premedication. Results Anxiety reduction was larger in patients premedicated with lorazepam (ΔVAS=−2.0, SE=1.6, P=0.007) or diazepam (ΔVAS=−2.0, SE=1.5, p=0.003) compared with patients without any premedication (ΔVAS=−1.4, SE=1.2). The use of midazolam or oxazepam did not lead to a significant reduction in anxiety compared with patients who did not receive premedication. Additionally, a high number of patients treated with midazolam (N=39, 19.8%) developed side effects. Conclusions In this study, the use of lorazepam or diazepam was associated with a significant, but modest anxiety reduction in patients undergoing CAG or PCI. This study does not support the standard use of oxazepam or midazolam as premedication to reduce anxiety.

SERUM LACTATE INCREASE DURING HOSPITALIZATION AFTER TEMPORARY CIRCULATORY SUPPORT WITH THE IMPELLA LP5.0 IS AN INDEPENDENT PREDICTOR OF 30-DAY MORTALITY FOR PATIENTS WITH ACUTE LEFT VENTRICULAR CARDIOGENIC SHOCK

Acute primary left heart failure (HF) or post-cardiotomy cardiogenic shock is associated with a high mortality rate and remains a therapeutic challenge even after mechanical support. In this study with the Impella LP5.0 we evaluated the relationship between serum lactate changes during