Omar Farouque

Clinical characteristics and early mortality of patients undergoing coronary artery bypass grafting compared to percutaneous coronary intervention: Insights from the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) and the Melbourne Interventional Group (MIG) Registries

OBJECTIVES Controversy continues over the optimal revascularisation strategy for patients with multi-vessel coronary artery disease. Clinical characteristics, risk profile, and mortality of patients undergoing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are thought to differ but there are limited contemporary comparative data. METHODS We compared clinical characteristics, in-hospital and 30-day mortality of 3841 consecutive patients undergoing isolated CABG and 4417 undergoing PCI. Independent predictors of 30-day mortality were determined by multiple logistic regression analysis. RESULTS CABG patients were older (p<0.01). The CABG group had a higher incidence of diabetes, heart failure, left ventricular ejection fraction <45%, multi-vessel coronary artery, peripheral vascular and cerebro-vascular disease (all p<0.01). Patients undergoing PCI had a higher incidence of recent myocardial infarction (MI) as the indication for revascularisation (p<0.01). In-hospital and 30-day mortality was 1.8% and 1.7% in the CABG group, and 1.4% and 1.8% in the PCI group, respectively. Independent predictors of 30-day mortality after CABG were age (odds ratio 1.1 per year, 95% confidence interval 1.0-1.1), cardiogenic shock (4.10, 1.7-10.5) and previous CABG (6.6, 2.4-17.7). Predictors after PCI were diabetes (2.7, 1.4-5.1), female gender (3.0, 1.6-5.5), renal failure (3.2, 1.2-8.0), MI<24h (4.0, 2.2-7.6), left main intervention (5.4, 1.0-27.7), heart failure (6.0, 2.6-14.0) and cardiogenic shock (11.7, 5.4-25.2). CONCLUSIONS In contemporary clinical practice, CABG is preferred in patients with multi-vessel coronary and associated non-coronary vascular disease, while PCI is the dominant strategy for acute MI. Despite this, in-hospital and 30-day mortality rates were similar. Predictors of early mortality after CABG differ to those of PCI.

Survival in patients with myocardial infarction complicated by out-of-hospital cardiac arrest undergoing emergency percutaneous coronary intervention

OBJECTIVES We sought to evaluate the clinical outcomes of patients with myocardial infarction (MI) complicated by out-of-hospital cardiac arrest (OHCA) undergoing percutaneous coronary intervention (PCI). BACKGROUND Controversy remains regarding the benefit of early PCI in patients with MI complicated by OHCA. METHODS We analyzed the outcomes of 88 consecutive patients presenting with MI complicated by OHCA compared to 5101 patients with MI without OHCA who underwent PCI from the Melbourne Interventional Group registry between 2004 and 2009. RESULTS Patients with OHCA had a higher proportion of ST-elevation MI presentations (90.9% vs. 50%, p<0.01) and were more likely to be to be in cardiogenic shock (38.6% vs. 4.6%, p<0.01). Procedural success was similar in the two groups (95.5% OHCA vs. 96.5% non-OHCA MI cohort, p=0.65). In-hospital, 30-day, and 1-year survival in the OHCA cohort versus the non-OHCA MI cohort were 62.5% vs. 97.2% (p<0.01), 61.4% vs. 96.5% (p<0.01), and 60.2% vs. 94.2% (p<0.01), respectively. Within the OHCA cohort, presentation with cardiogenic shock (OR 7.2, 95% CI: 2.7-18.8; p<0.01) was strongly associated with in-hospital mortality. Importantly, 1-year survival of patients discharged alive from hospital was similar between the two groups (96% vs. 97% p=0.8). CONCLUSION Patients with MI complicated by OHCA remain a high-risk group associated with high mortality. However, high procedural success rates similar to non-OHCA patients can be attained. Survival rates better than previously reported were observed with an emergent PCI approach, with 1-year survival comparable to a non-OHCA cohort if patients survive to hospital discharge.

Contemporary outcomes in women undergoing percutaneous coronary intervention for acute coronary syndromes

BACKGROUND Uncertainty remains as to whether females benefit as much as males from percutaneous coronary intervention (PCI) in the setting of an acute coronary syndrome (ACS). METHODS We compared 802 women with 2151 men presenting with ACS, undergoing PCI from April 2004 to October 2006 from the Melbourne Interventional Group registry. Clinical characteristics, in-hospital, 30-day and 1-year outcomes were compared. RESULTS Women were older (69.6 ± 11.6 vs. 62.17 ± 12.3 years, p<0.001), and had more diabetes (27.1% vs. 19.6%, p<0.001) and hypertension (70.3% vs. 53.9%, p<0.001) than men. Women were less likely to present with ST-elevation myocardial infarction (30.5% vs. 37.9%, p<0.001). Bleeding (3.6% vs. 0.8%, p<0.001) was higher among women. Thirty-day mortality (4.7 vs. 2.4%, p<0.001) and MACE (10.1 vs. 6.4%, p<0.001) were higher in women. Gender was an independent predictor of overall MACE at 30 days (OR 1.45, 95% CI 1.04-2.02, p=0.03) but not death. At 12 months, there were no significant differences in mortality (6.4% vs. 4.8%, p=0.09), myocardial infarction (5.5% vs. 5.0%, p=0.64), target vessel revascularization (7.9% vs. 7.0%, p=0.42) and MACE (16.3% vs. 14%, p=0.13) between women and men. CONCLUSIONS There is an early hazard amongst women undergoing PCI for ACS, but not at 12 months. These data suggest that gender should not affect the decision to offer PCI but further gender specific studies are warranted.

Are drug-eluting stents indicated in large coronary arteries? Insights from a multi-centre percutaneous coronary intervention registry

BACKGROUND Restenosis rates are low in large coronary vessels >/=3.5 mm after bare-metal stent (BMS) implantation. The benefit of drug-eluting stents (DES) in large vessels is not established. OBJECTIVE We aim to assess clinical outcomes after deployment of BMS compared to DES in patients with large coronary vessels >/=3.5 mm. METHODS We analysed 672 consecutive patients undergoing percutaneous coronary interventions with >/=3.5 mm stent implantation in native coronary artery de-novo lesions from the Melbourne Interventional Group (MIG) registry. Baseline characteristics, 30-day and 12-month outcomes of patients receiving BMS were compared to DES. Multivariate analysis was performed to identify predictors of major adverse cardiac events [MACE, consisting of death, myocardial infarction (MI) and target vessel revascularisation (TVR)]. RESULTS Of the 672 PCIs performed in 844 lesions, DES was implanted in 39.5% (n=333) and BMS in 60.5% (n=511) of lesions. Patients who received DES compared to BMS were older, more likely to be diabetic, had left ventricular dysfunction <45% or complex lesions. Significantly fewer patients who presented with ST-elevation MI received DES compared to BMS. There were no significant differences in 12-month mortality (0.5 vs. 2.9%, p=0.07), TVR (3.6 vs. 4.8%, p=0.54), MI (6.3 vs. 3.4%, p=0.15), stent thrombosis (0.9 vs. 1.0%, p=0.88), or MACE (9.4 vs. 9.4%, p=0.90) in patients who received DES vs. BMS. Stent length >/=20 mm was the only independent predictor of 12-month MACE (Odds Ratio 2.07, 95% CI 1.14-3.76, p=0.02). CONCLUSION In this registry, BMS implantation in large native coronary vessels >/=3.5 mm was associated with a low risk of MACE and repeat revascularization at 12 months that was comparable to DES.

Retinal microvascular structure and function in patients with risk factors of atherosclerosis and coronary artery disease

OBJECTIVE Retinal microvascular signs are markers of cardiovascular disease risk. There are limited data, on relationships between retinal microvascular signs and retinal microvascular endothelial function. We sought to determine the relationship of retinal vascular signs with retinal microvascular endothelial function in patients with or at high risk of coronary artery disease. METHODS Participants with atherosclerosis risk factors and coronary disease (n=258; mean age 57±11 years) were recruited to have static and dynamic retinal vascular assessment. Retinal arteriolar dilatation in response to flicker light (FI-RAD) was measured using the Digital Vessel Analyser and expressed as percentage increase over baseline diameter. Static retinal photographs were acquired utilising a digital fundus camera for measurement of central retinal artery and vein equivalent (CRAE and CRVE), arteriovenous nicking (AVN) and focal arteriolar narrowing (FAN). RESULTS Intra-class correlation coefficient was 0.82 for flicker-light induced retinal arteriolar dilatation. There were modest associations in retinal vascular measurements between eyes. For each 10 μm decrease in retinal arteriolar diameter, the absolute increase in FI-RAD was 0.28% (95% CI 0.11, 0.45; p=0.002) independent of age, gender and atherosclerosis risk factors. AVN and FAN were associated with attenuated FI-RAD (β=-0.67%; 95% CI -1.20, -0.15; p=0.012) and (β=-0.83%; 95% CI -1.44, -0.23; p=0.007) respectively after adjustment for age and gender. CONCLUSION Assessment of retinal microvascular endothelial function is reproducible and correlated with retinal microvascular structure and signs, independent of atherosclerosis risk factors. Assessment of retinal vascular structure and function may provide insights into atherosclerotic disease.

Clopidogrel, Prasugrel or Ticagrelor in Patients with Acute Coronary Syndromes undergoing Percutaneous Coronary Intervention.

Guidelines recommend prasugrel or ticagrelor instead of clopidogrel in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary interventions (PCI).

Long-term survival of elderly patients undergoing percutaneous coronary intervention for myocardial infarction complicated by cardiogenic shock

BACKGROUND The long-term benefit of early percutaneous coronary intervention (PCI) for cardiogenic shock (CS) in elderly patients remains unclear. We sought to assess the long-term survival of elderly patients (age ≥ 75 years) with myocardial infarction (MI) complicated by CS undergoing PCI. METHODS We analyzed baseline characteristics, early outcomes, and long-term survival in 421 consecutive patients presenting with MI and CS who underwent PCI from the Melbourne Interventional Group registry from 2004 to 2011. Mean follow-up of patients who survived to hospital discharge was 3.0 ± 1.8 years. RESULTS Of the 421 consecutive patients, 122 patients were elderly (≥ 75 years) and 299 patients were younger (< 75 years). The elderly cohort had significantly more females, peripheral and cerebrovascular disease, renal impairment, heart failure (HF) and prior MI (all p < 0.05). Procedural success was lower in the elderly (83% vs. 92%, p < 0.01). Long-term mortality was significantly higher in the elderly (p < 0.01), driven by high in-hospital mortality (48% vs. 36%, p < 0.05). However, in a landmark analysis of hospital survivors in the elderly group, long-term mortality rates stabilized, approximating younger patients with CS (p = 0.22). Unsuccessful procedure, renal impairment, HF and diabetes mellitus were independent predictors of long-term mortality. However, age ≥ 75 was not a significant predictor (HR 1.2; 95% CI 0.9-1.7; p = 0.2). CONCLUSIONS Elderly patients with MI and CS have lower procedural success and higher in-hospital mortality compared to younger patients. However, comparable long-term survival can be achieved, especially in patients who survive to hospital discharge with the selective use of early revascularization.

Appropriate use of echocardiography in an Australian regional centre

The 2011 Appropriate Use Criteria (AUC) were developed by the American Society of Echocardiography (ASE) to provide guidance for referring physicians in response to growing concerns about unnecessary transthoracic echocardiogram (TTE) requests. When applied in multiple centres overseas, the rate of inappropriate referrals was as high as 22%.

Bacterial Mural Endocarditis. A Case Series

Mural endocarditis represents a rare subset of intracardiac infections, with potentially life threatening sequelae. Clinically alike, with many shared aetiologies, substrates and risk factors such as valvular endocarditis, it can be difficult to differentiate without the use of sophisticated cardiovascular imaging techniques. Despite high rates of complications, there are no definite strategies for management. Herein we present three interesting cases of left ventricular mural endocarditis, without valvular involvement, due to staphylococcus aureus.

SMARTphone-based, early cardiac REHABilitation in patients with acute coronary syndromes [SMART-REHAB Trial]: a randomized controlled trial protocol

BackgroundThere are well-documented treatment gaps in secondary prevention of coronary heart disease and no clear guidelines to assist early physical activity after acute coronary syndromes (ACS). Smartphone technology may provide an innovative platform to close these gaps. This paper describes the study design of a randomized controlled trial assessing whether a smartphone-based secondary prevention program can facilitate early physical activity and improve cardiovascular health in patients with ACS.MethodsWe have developed a multi-faceted, patient-centred smartphone-based secondary prevention program emphasizing early physical activity with a graduated walking program initiated on discharge from ACS admission. The program incorporates; physical activity tracking through the smartphone’s accelerometer with interactive feedback and goal setting; a dynamic dashboard to review and optimize cardiovascular risk factors; educational messages delivered twice weekly; a photographic food diary; pharmacotherapy review; and support through a short message service. The primary endpoint of the trial is change in exercise capacity, as measured by the change in six-minute walk test distance at 8-weeks when compared to baseline. Secondary endpoints include improvements in cardiovascular risk factor status, psychological well-being and quality of life, medication adherence, uptake of cardiac rehabilitation and re-hospitalizations.DiscussionThis randomized controlled trial will use a smartphone-phone based secondary prevention program to emphasize early physical activity post-ACS. It will provide evidence regarding the feasibility and utility of this innovative platform in closing the treatment gaps in secondary prevention.Trial registrationThe trial was retrospectively registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) on April 4, 2016. The registration number is ACTRN12616000426482.