Krishna Rathod

Culprit Vessel Versus Multivessel Intervention at the Time of Primary Percutaneous Coronary Intervention in Patients With ST-Segment–Elevation Myocardial Infarction and Multivessel Disease: Real-World Analysis of 3984 Patients in London

Background—It is estimated that up to two thirds of patients presenting with ST-segment–elevation myocardial infarction have multivessel disease. The optimal strategy for treating nonculprit disease is currently under debate. This study provides a real-world analysis comparing a strategy of culprit-vessel intervention (CVI) versus multivessel intervention at the time of primary percutaneous coronary intervention in patients with ST-segment–elevation myocardial infarction. Methods and Results—We compared CVI versus multivessel intervention in 3984 patients with multivessel disease undergoing primary percutaneous coronary intervention between 2004 and 2011 at all 8 tertiary cardiac centers in London. Multivariable-adjusted models were built to determine independent predictors for in-hospital major adverse cardiovascular events (MACEs) and all-cause mortality at 1 year. To reduce confounding and bias, propensity score methods were used. CVI was associated with reduced in-hospital MACE (4.6% versus 7.2%; P=0.010) and mortality at 1 year (7.4% versus 10.1%; P=0.031). CVI was an independent predictor for reduced in-hospital MACE (odds ratio, 0.49; 95% confidence interval [CI], 0.32–0.75; P<0.001) and survival at 1 year (hazard ratio, 0.65; 95% CI, 0.47–0.91; P=0.011) in the complete cohort; and in 2821 patients in propensity-matched cohort (in-hospital MACE: odds ratio, 0.49; 95% CI, 0.32–0.76; P=0.002; and 1-year survival: hazard ratio, 0.64; 95% CI, 0.45–0.90; P=0.010). Inverse probability treatment weighted analyses also confirmed CVI as an independent predictor for reduced in-hospital MACE (odds ratio, 0.38; 95% CI, 0.15–0.96; P=0.040) and survival at 1 year (hazard ratio, 0.44; 95% CI, 0.21–0.93; P=0.033). Conclusions—In this observational analysis of patients with ST-segment–elevation myocardial infarction undergoing primary percutaneous coronary intervention, CVI was associated with increased survival at 1 year. Acknowledging the limitations with observational analyses, our findings support current recommended practice guidelines.

Radial versus femoral access is associated with reduced complications and mortality in patients with non-ST-segment-elevation myocardial infarction: an observational cohort study of 10,095 patients.

Background—Compared with transfemoral access, transradial access (TRA) for percutaneous coronary intervention is associated with reduced risk of bleeding and vascular complications. Studies suggest that TRA may reduce mortality in patients with ST-segment–elevation myocardial infarction. However, there are few data on the effect of TRA on mortality, specifically, in patients with non–ST-segment–elevation myocardial infarction. Methods and Results—We analyzed 10 095 consecutive patients with non–ST-segment–elevation myocardial infarction treated with percutaneous coronary intervention between 2005 and 2011 in all 8 tertiary cardiac centers in London, United Kingdom. TRA was a predictor for reduced bleeding (odds ratio=0.21; 95% confidence interval [CI]: 0.08–0.57; P=0.002), access-site complications (odds ratio=0.47; 95% CI: 0.23–0.95; P=0.034), and 1-year mortality (hazard ratio [HR]=0.72; 95% CI: 0.54–0.94; P=0.017). Between 2005 and 2007, TRA did not appear to reduce mortality at 1 year (HR=0.81; 95% CI: 0.51–1.28; P=0.376), whereas between 2008 and 2011, TRA conferred survival benefit at 1 year (HR=0.65; 95% CI: 0.46–0.92; P=0.015). The mortality benefit with TRA at 1 year was not seen at the low-volume centers (HR=0.80; 95% CI: 0.47–1.38; P=0.428) but specifically seen in the high volume radial centers (HR=0.70; 95% CI: 0.51–0.97; P=0.031). In propensity-matched analyses, TRA remained a predictor for survival at 1 year (HR=0.60; 95% CI: 0.42–0.85; P=0.005). Instrumental variable analysis demonstrated that TRA conferred mortality benefit at 1-year with an absolute mortality reduction of 5.8% (P=0.039). Conclusions—In this analysis of patients with non–ST-segment–elevation myocardial infarction, TRA appears to be a predictor for survival. Furthermore, the evolving learning curve, experience, and expertise may be important factors contributing to the prognostic benefit conferred with TRA.

35 Successful recanalisation of chronic total occlusions is associated with increased long term survival

Introduction Chronic total occlusion (CTO) remains a challenging lesion subset. Despite advances in equipment and expertise, many CTO patients may not be offered PCI as physicians perceive procedural success may be lower, and the anatomy is stable. The aim of this study was to investigate the impact of procedural success on mortality following CTO-PCI in a large cohort of patients in the drug eluting stent era. Methods 6122 consecutive patients underwent elective PCI at a single centre (October 2003–May 2010), 836 (13.7%) for CTO. Demographic and procedural data were collected at the time of intervention (Abstract 35 table 1). In-hospital MACE (myocardial infarction, urgent revascularisation, stroke or death) was documented at discharge. All cause mortality data was obtained from the Office of National Statistics via the BCIS/CCAD national audit out to 4 years (mean 2.9±1.6) and stratified according to successful or unsuccessful CTO recanalisation.Abstract 35 Table 1 Successful (n=572) Unsuccessful (n=264) p value Age 62.4±0.47 63.7±0.69 0.1 Male 433 (75.7%) 209 (79.2%) 0.3 Diabetes 151 (26.9%) 74 (28.6%) 0.6 Hypertension 320 (63.8%) 160 (66.6%) 0.5 Hypercholesterolaemia 281 (56.0%) 147 (61.2%) 0.2 Previous MI 174 (31.7%) 94 (36.4%) 0.2 Radial access 123 (21.5%) 47 (17.8%) 0.3 Femoral access 416 (72.7%) 193 (73.1%) 0.6 Dual site access (bilateral femoral or radial + femoral) 23 (4.0%) 18 (6.8%) 0.5 Results 572 (68.4%) CTO procedures were successful. Coronary stents were implanted in 96.9% (mean 2.3±0.1 stents per patient, 70% drug eluting). Prior revascularisation was more frequent among patients with unsuccessful CTO-PCI than successful; prior CABG 16.5% unsuccessful vs 7.4% successful, (p<0.0001), PCI 36.0% vs 21.2%, (p<0.0001). Baseline characteristics were otherwise similar (Abstract 35 table 1). Intra-procedural complications (coronary dissection, perforation, access site (dissection, haematoma) were more frequent in unsuccessful cases (19% (52) vs 4.1% (20) (p<0.0001) but did not have an impact on in-hospital MACE (2% vs 1.8%, p=0.6). All cause mortality was 8% (21) in the unsuccessful group and 3% (17) in the successful group out to 4 years, (Abstract 35 figure 1). Mortality following successful CTO-PCI was similar to that of the non-CTO elective PCI group (5.1%, p=NS).Abstract 35 Figure 1 All cause mortality after PCI for elective patients. Conclusion A successful angiographic outcome following CTO-PCI is associated with a survival advantage out to 4 years following intervention. These data suggest that the adoption of new techniques and technologies to improve procedural success may improve prognosis.

Radial primary percutaneous coronary intervention is independently associated with decreased long-term mortality in high-risk ST-elevation myocardial infarction patients.

AIM To compare long-term clinical outcomes in patients with ST-elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PPCI) using radial and femoral arterial access. METHODS AND RESULTS The present study was an observational cohort study of patients with STEMI treated consecutively with PPCI between 2004 and 2011 at a single centre. The primary end point was all-cause mortality at a median follow-up of 3 years.Among 2727 patients, 1600 (58.7%) underwent PPCI via the femoral route. The femoral group was older (64.7 vs. 61.7 years; P < 0.0001), and had higher rates of diabetes (18.6% vs. 16.0%; P < 0.0001), previous PCI (11.2 vs. 7.8%; P = 0.004), previous myocardial infarction (15.3 vs. 8.3%; P < 0.0001) and cardiogenic shock (9.8 vs. 1.3%; P < 0.0001). Bleeding complications were more frequent in the femoral group (4.7 vs. 1.2%; P < 0.0001). The 5-year death rate was significantly higher in the femoral group than in the radial group (10.4 vs. 3.0%; P < 0.0001). After adjustment for confounding variables, bleeding complications [heart rate 2.07 (95% confidence interval 1.05-4.08)] and femoral access [heart rate 1.60 (95% confidence interval 1.02-2.53)] were independent predictors of all-cause mortality. After stratification using the propensity score, excess long-term mortality in patients treated via the femoral approach was predominantly in patients with a high baseline risk of death. CONCLUSION Patients undergoing PPCI via the femoral route are at a higher risk of adverse short-term and long-term outcomes than patients undergoing PPCI via the radial route. Patients with a high baseline risk may benefit most from radial access, and future outcome studies should focus on the most at-risk patients.

Glycoprotein IIb/IIIa inhibitors use and outcome after percutaneous coronary intervention for non-ST elevation myocardial infarction.

Aims. We investigate the effect of glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors on long-term outcomes following percutaneous coronary intervention (PCI) after non-ST elevation myocardial infarction (NSTEMI). Meta-analyses indicate that these agents are associated with improved short-term outcomes. However, many trials were undertaken before the routine use of P2Y12 inhibitors. Recent studies yield conflicting results and registry data have suggested that GP IIb/IIIa inhibitors may cause more bleeding than what trials indicate. Methods and Results. This retrospective observational study involves 3047 patients receiving dual-antiplatelet therapy who underwent PCI for NSTEMI. Primary outcome was all-cause mortality. Major adverse cardiac events (MACE) were a secondary outcome. Mean follow-up was 4.6 years. Patients treated with GP IIb/IIIa inhibitors were younger with fewer comorbidities. Although the unadjusted Kaplan-Meier analysis suggested that GP IIb/IIIa inhibitor use was associated with improved outcomes, multivariate analysis (including propensity scoring) showed no benefit for either survival (P = 0.136) or MACE (P = 0.614). GP IIb/IIIa inhibitor use was associated with an increased risk of major bleeding (P = 0.021). Conclusion. Although GP IIb/IIIa inhibitor use appeared to improve outcomes after PCI for NSTEMI, patients who received GP IIb/IIIa inhibitors tended to be at lower risk. After multivariate adjustment we observed no improvement in MACE or survival and an increased risk of major bleeding.

Randomised, double-blind, placebo-controlled study investigating the effects of inorganic nitrate on vascular function, platelet reactivity and restenosis in stable angina: protocol of the NITRATE-OCT study

Introduction The mainstay treatment for reducing the symptoms of angina and long-term risk of heart attacks in patients with heart disease is stent implantation in the diseased coronary artery. While this procedure has revolutionised treatment, the incidence of secondary events remains a concern. These repeat events are thought to be due, in part, to continued enhanced platelet reactivity, endothelial dysfunction and ultimately restenosis of the stented artery. In this study, we will investigate whether a once a day inorganic nitrate administration might favourably modulate platelet reactivity and endothelial function leading to a decrease in restenosis. Methods and design NITRATE-OCT is a double-blind, randomised, single-centre, placebo-controlled phase II trial that will enrol 246 patients with stable angina due to have elective percutaneous coronary intervention procedure with stent implantation. Patients will be randomised to receive 6 months of a once a day dose of either nitrate-rich beetroot juice or nitrate-deplete beetroot juice (placebo) starting up to 1 week before their procedure. The primary outcome is reduction of in-stent late loss assessed by quantitative coronary angiography and optical coherence tomography at 6 months. The study is powered to detect a 0.22±0.55 mm reduction in late loss in the treatment group compared with the placebo group. Secondary end points include change from baseline assessment of endothelial function measured using flow-mediated dilation at 6 months, target vessel revascularisation (TVR), restenosis rate (diameter>50%) and in-segment late loss at 6 months, markers of inflammation and platelet reactivity and major adverse cardiac events (ie, myocardial infarction, death, cerebrovascular accident, TVR) at 12 and 24 months. Ethics and dissemination The study was approved by the Local Ethics Committee (15/LO/0555). Trial results will be published according to the CONSORT statement and will be presented at conferences and reported in peer-reviewed journals. Trial registration numbers NCT02529189 and ISRCTN17373946, Pre-results.

Time-Trend Analyses of Bleeding and Mortality After Primary Percutaneous Coronary Intervention During Out of Working Hours Versus In-Working Hours An Observational Study of 11 466 Patients

Background—Primary percutaneous coronary intervention (PPCI) is the treatment of choice for ST-segment–elevation myocardial infarction. Resources are limited during out of working hours (OWH). Whether PPCI outside working hours is associated with worse outcomes and whether outcomes have improved over time are unknown. Methods and Results—We analyzed 11 466 patients undergoing PPCI between 2004 and 2011 at all 8 tertiary cardiac centers in London, United Kingdom. We defined working hours as 9 AM to 5 PM (Monday to Friday). We analyzed in-hospital bleeding and all-cause mortality ⩽3 years, comparing OWH versus in-working hours. A total of 7494 patients (65.3%) were treated during OWH. Multivariable analyses demonstrated that PPCI during OWH was not a predictor for bleeding (odds ratio, 1.47; 95% confidence interval [CI], 0.97–2.24; P=0.071) or 3-year mortality (hazard ratio, 1.11; 95% CI, 0.94–1.32; P=0.20). This was confirmed in propensity-matched analyses. Time-stratified analyses demonstrated that PPCI during OWH was a predictor for bleeding (odds ratio, 2.00; 95% CI, 1.06–3.80; P=0.034) and 3-year mortality during 2005 to 2008 (hazard ratio, 1.23; 95% CI, 1.00–1.50; P=0.050), but this association was lost during 2009 to 2011. During 2005 to 2008, transradial access was predominantly used during in-working hours and PPCI during OWH was predictive of reduced transradial access use (odds ratio, 0.83; 95% CI, 0.71–0.98; P=0.033), but this association was lost during 2009 to 2011. Conclusions—In this study of unselected patients with ST-segment–elevation myocardial infarction, PPCI during OWH versus in-working hours had comparable bleeding and mortality. Time-stratified analyses demonstrated a reduction in adjusted bleeding and mortality during OWH over time. This may reflect the improved service provision, but the increased adoption of transradial access during OWH may also be contributory.

16 Acute stent thrombosis resulting in ST elevation myocardial infarction (STEMI) is associated with worse clinical outcomes than STEMI due to native coronary thrombosis

Background Stent thrombosis (ST) is a recognised cause of ST Elevation Myocardial infarction (STEMI) in patients with previous percutaneous coronary interventions (PCI). The incidence is increasing and to date outcomes are not well characterised, though there is a suggestion that there is a worse clinical outcome. We therefore sought to compare STEMI caused by ST vs de novo coronary thrombosis to evaluate procedural risk and clinical outcome. Methods Clinical information was analysed from a prospective database on 2421 patients who underwent Primary PCI following STEMI between October 2003 and May 2010 at a London centre. Information was entered at the time of procedure, diagnosis of stent thrombosis made at the time by primary operator and outcome assessed by all-cause mortality information provided by the Office of National Statistics via the BCIS CCAD national audit. Results Stent thrombosis (ST) accounted for 7.4% (180/2421) of all STEMIs with a frequency that has increased over time (5.4% in 2005 to 9.8% 2009). ST occurred early (0–30 days) in 36% (65/180), late (30 days–1 year) in 22% (40/180) and very late (>1 year) in 42% (75/180) of pts. Drug-eluting stents (DES) accounted for 48% of ST overall and 70% over the past 3 years. Proposed mechanisms included premature discontinuation of anti-platelets (11%), under-deployment of previous stent insertion (22%) and underlying prothrombotic conditions (eg, SLE) (6%). Pts with ST compared to native artery occlusion had higher rates of previous MI (53.9% vs 11%, p<0.0001) and incidence of multi-vessel disease (59.8% vs 51.7%, p=0.04 There was no difference in age, diabetes or cardiogenic shock. See Abstract 16 table 1. Infarct size based on peak enzyme markers was similar (2.5 vs 2.2, p=0.45). In patients with ST, angiographic success (postprocedural Thrombolysis In Myocardial Infarction grade III flow) was worse than in patients with de novo STEMI (87.2% vs 93.7%, p=0.02). Pts with STEMI due to ST had higher in-hospital MACE (11% vs 3%, p=0.0001), MACE at 30 days (19% vs 6%, p<0.0001), this persisted up to 3 years (41% vs 12%, p<0.0001). See Abstract 16 figure 1. MACE was driven by higher rates of MI (7% vs 2%, p<0.0001), TVR (14% vs 3%, p<0.0001) and death (18% vs 6%, p=0.0001). After adjusting for comorbidities, stent thrombosis was an independent predictor of long-term adverse outcome (OR=2.1, 95% CI=1.3 to 2.8, p<0.001).Abstract 16 Table 1 AST (n=180) No AST (n=2241) Significance (p value) Age 63.9±18 62.9±4 0.406 Multi-vessel disease 101 (59.76%) 1011 (51.74%) 0.045 Previous MI 96 (53.93%) 246 (10.96%) <0.0001 Previous CABG 9 (5.06%) 60 (2.67%) 0.020 Diabetes mellitus 46 (25.84%) 407 (18.14%) 0.061 Hypertension 101 (56.74%) 975 (43.45%) 0.002 Hypercholesterolaemia 108 (60.67%) 768 (34.30%) <0.0001 Cardiogenic shock 108 (60.67%) 768 (34.30%) <0.0001Abstract 16 Figure 1 Conclusion Primary PCI for treatment of ST is less effective, and these patients are at increased risk for in-hospital and long-term mortality compared with patients undergoing primary PCI due to de novo STEMI.

19 Treatment of multivessel coronary artery disease in primary PCI for ST elevation myocardial infarction: culprit only revascularisation is associated with higher mace rates

Background Multi-vessel disease occurs in 40%–65% of patients undergoing Primary PCI for STEMI and is associated with adverse prognosis. Contemporary guidelines recommend treating the infarct related artery alone (culprit) during the urgent procedure. There is limited data comparing outcomes of complete with infarct-related artery (IRA)-only revascularisation in primary PCI for STEMI with few studies including the option of later date elective procedures for the other lesions (staged revascularisation). We therefore sought to clarify the outcome of patients with multi-vessel disease undergoing primary PCI dependent on management strategy. Methods Clinical information was analysed from a prospective data base on 2131 STEMI patients who underwent Primary PCI between January 2004 and May 2010 at a London centre. Patients with previous CABG were excluded. Information was entered at the time of procedure and outcome assessed by all-cause mortality information provided by the Office of National Statistics via the BCIS/CCAD national audit. Patients were split into three different treatment groups: culprit vessel angioplasty-only (COR group); staged revascularisation (SR group) and simultaneous treatment of non-IRA (CR group). The primary end point used was major adverse cardiac events (MACE), defined as death, myocardial infarction (MI), stroke and target vessel revascularisation (TVR). Results There were 963 (45%) consecutive patients with STEMI and multivessel CAD undergoing primary angioplasty. There were similar baseline characteristics between the 3 groups, aside from cardiogenic shock, which was significantly higher in the complete revascularisation group. See Abstract 19 table 1. At 30-days of follow-up, 23/263 (9%) patients in the CR group experienced at least one major adverse cardiac event (MACE), 1 (1%) in the SR group and 35 (5%) in the COR group, p=0.01. This trend continued up to 1-year of follow-up with the lowest rates of events in the SR group. However after 3 years MACE rates are significantly increased in the COR group (24%) but were similar in the CR (18%) and SR (17%) groups. See Abstract figure 1. MACE rates were driven mainly by death in the CR with high rates of TVR in the COR and SR groups. See Abstract figure 2.Abstract 19 Table 1 COR N=638 SR N=100 CR N=263 Significance Age 64.77 61.46 64.32 0.144 Gender (female) 156 (23.7%) 13 (13.0%) 74 (27.9%) 0.0114 Ethnicity (Caucasian) 441 (67.0%) 79 (79.0%) 185 (69.8%) 0.0511 Previous MI 109 (16.6%) 11 (11.0%) 36 (13.6%) 0.2414 Previous CABG 15 (2.3%) 2 (2.0%) 3 (1.1%) 0.5231 Previous PCI 83 (12.6%) 5 (5.0%) 23 (8.7%) 0.031 Diabetes Mellitus 129 (19.6%) 16 (16.0%) 55 (20.8%) 0.5932 Hypertension 312 (48.1%) 40 (40.0%) 91 (41.2%) 0.1205 Hypercholestrolaemia 269 (41.5%) 37 (37.0%) 92 (41.6%) 0.7751 GPIIb/IIIa Inhibitor 572 (87.7%) 93 (93.0%) 231 (89.5%) 0.1724 Cardiogenic Shock 29 (4.7%) 2 (2.0%) 31 (12.26%) p<0.0001Abstract 19 Figure 1 Comparison of MACE between multivessel disease.Abstract 19 Figure 2 Breakdown of MACE at 5 years. Conclusions Culprit vessel-only angioplasty was associated with the highest rate of long-term MACE compared with multivessel treatment. Patients scheduled for staged revascularisation experienced a similar rate of MACE to patients undergoing complete simultaneous treatment of non-IRA.

Eptifibatide is associated with significant cost savings and similar clinical outcomes to abciximab when used during primary percutaneous coronary intervention for ST-elevation myocardial infarction: An observational cohort study of 3863 patients.

Introduction Glycoprotein IIb/IIIa inhibitors are recommended by guidelines in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. There are few studies directly comparing these agents. The aim of this study was to assess whether eptifibatide is a safe and cost-effective alternative to abciximab in the treatment of primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Methods This was an observational cohort study of 3863 patients who received a GPIIb/IIIa inhibitor whilst undergoing primary percutaneous coronary intervention from 2007 to 2014. Patients who did not receive a GPIIb/IIIa inhibitor were excluded. Time to first major adverse cardiac event defined as death, non-fatal myocardial infarction, stroke or target vessel revascularization, and total hospital costs were compared between the groups. Results In all, 1741 patients received abciximab with 2122 receiving eptifibatide. Patients who received eptifibatide had higher rates of previous MI/percutaneous coronary intervention and were more likely to undergo a procedure from the radial route. Unadjusted Kaplan–Meier analysis revealed no significant difference in the 1-year event rates between patients given eptifibatide versus abciximab (p = 0.201). Age-adjusted Cox analysis demonstrated no difference in 1-year outcome between abciximab and eptifibatide (hazard ratio: 0.83; 95% confidence interval: 0.73–1.39), which persisted after multivariate adjustment (hazard ratio: 0.92; 95% confidence interval: 0.79–1.56) including the incorporation of a propensity score (hazard ratio: 0.88; 95% confidence interval: 0.71–1.44). Eptifbatide was associated with significant cost savings being 87% cheaper overall compared to abciximab (on average £650 cheaper per patient and saving approximately £950,000). Conclusion This observational data suggest that eptifibatide is associated with similar outcomes and significant cost savings compared to abciximab when used in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.