Pitt Lim

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.

Long-term Survival in Patients Undergoing Percutaneous Interventions With or Without Intracoronary Pressure Wire Guidance or Intracoronary Ultrasonographic Imaging: A Large Cohort Study

IMPORTANCE Intracoronary pressure wire-derived measurements of fractional flow reserve (FFR) and intravascular ultrasonography (IVUS) provide functional and anatomical information that can be used to guide coronary stent implantation. Although these devices are widely used and recommended by guidelines, limited data exist about their effect on clinical end points. OBJECTIVE To determine the effect on long-term survival of using FFR and IVUS during percutaneous coronary intervention (PCI). DESIGN AND SETTING Cohort study based on the pan-London (United Kingdom) PCI registry. In total, 64,232 patients are included in this registry covering the London, England, area. PARTICIPANTS All patients (n = 41,688) who underwent elective or urgent PCI in National Health Service hospitals in London between January 1, 2004, and July 31, 2011, were included. Patients with ST-segment elevation myocardial infarction (n = 11,370) were excluded. INTERVENTIONS Patients underwent PCI guided by angiography (visual lesion assessment) alone, PCI guided by FFR, or IVUS-guided PCI. MAIN OUTCOMES AND MEASURES The primary end point was all-cause mortality at a median of 3.3 years. RESULTS Fractional flow reserve was used in 2767 patients (6.6%) and IVUS was used in 1831 patients (4.4%). No difference in mortality was observed between patients who underwent angiography-guided PCI compared with patients who underwent FFR-guided PCI (hazard ratio, 0.88; 95% CI, 0.67-1.16; P = .37). Patients who underwent IVUS had a slightly higher adjusted mortality (hazard ratio, 1.39; 95% CI, 1.09-1.78; P = .009) compared with patients who underwent angiography-guided PCI. However, this difference was no longer statistically significant in a propensity score-based analysis (hazard ratio, 1.33; 95% CI, 0.85-2.09; P = .25). The mean (SD) number of implanted stents was lower in the FFR group (1.1 [1.2] stents) compared with the IVUS group (1.6 [1.3]) and the angiography-guided group (1.7 [1.1]) (P < .001). CONCLUSIONS AND RELEVANCE In this large observational study, FFR-guided PCI and IVUS-guided PCI were not associated with improved long-term survival compared with standard angiography-guided PCI. The use of FFR was associated with the implantation of fewer stents.

Outcome of 1051 Octogenarian Patients With ST‐Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention: Observational Cohort From the London Heart Attack Group

Background ST‐segment elevation myocardial infarction is increasingly common in octogenarians, and optimal management in this cohort is uncertain. This study aimed to describe the outcomes of octogenarians with ST‐segment elevation myocardial infarction treated by primary percutaneous coronary intervention. Methods and Results We analyzed 10 249 consecutive patients with ST‐segment elevation myocardial infarction treated with primary percutaneous coronary intervention between 2005 and 2011 at 8 tertiary cardiac centers across London, United Kingdom. The primary end point was all‐cause mortality at a median follow‐up of 3 years. In total, 1051 patients (10.3%) were octogenarians, with an average age of 84.2 years, and the proportion increased over the study period (P=0.04). In‐hospital mortality (7.7% vs 2.4%, P<0.0001) and long‐term mortality (51.6% vs 12.8%, P<0.0001) were increased in octogenarians compared with patients aged <80 years, and age was an independent predictor of mortality in a fully adjusted model (hazard ratio 1.07, 95% CI 1.07–1.09, P<0.0001). Time‐stratified analysis revealed an increasingly elderly and more complex cohort over time. Nonetheless, long‐term mortality rates among octogenarians remained static over time, and this may be attributable to improved percutaneous coronary intervention techniques, including significantly higher rates of radial access and lower bleeding complications. Variables associated with bleeding complications were similar between octogenarian and younger cohorts. Conclusions In this large registry, octogenarians undergoing primary percutaneous coronary intervention had a higher rate of complications and mortality compared with a younger population. Over time, octogenarians undergoing primary percutaneous coronary intervention increased in number, age, and complexity. Nevertheless, in‐hospital outcomes were reasonable, and long‐term mortality rates were static.

Contemporary trends in cardiogenic shock: Incidence, intra-aortic balloon pump utilisation and outcomes from the London Heart Attack Group:

Background: Cardiogenic shock remains a major cause of morbidity and mortality in patients with ST-segment elevation myocardial infarction. We aimed to assess the current trends in cardiogenic shock management, looking specifically at the incidence, use of intra-aortic balloon pump therapy and outcomes in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. Methods and results: We undertook an observational cohort study of 21,210 ST-segment elevation myocardial infarction patients treated between 2005–2015 at the eight Heart Attack Centres in London, UK. Patients’ details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society percutaneous coronary intervention dataset. There were 1890 patients who presented with cardiogenic shock. The primary outcome was all-cause mortality at a median follow-up of 4.1 years (interquartile range: 2.2–5.8 years). Increasing rates of cardiogenic shock were seen over the course of the study with consistently high mortality rates of 45–70%. A total of 685 patients underwent intra-aortic balloon pump insertion during primary percutaneous coronary intervention for cardiogenic shock with decreasing rates over time. Those patients undergoing intra-aortic balloon pump therapy were younger, more likely to have poor left ventricular function and less likely to have had previous percutaneous coronary intervention compared to the control group. Procedural success rates were similar (86.0% vs 87.1%, p=0.292) although crude, in-hospital major adverse cardiac event rates were higher (43.8% vs 33.7%, p<0.0001) in patients undergoing intra-aortic balloon pump therapy. Kaplan-Meier analysis demonstrated significantly higher mortality rates in patients receiving intra-aortic balloon pump therapy (50.9% intra-aortic balloon pump vs 39.9% control, p<0.0001) during the follow-up period. After multivariate Cox analysis (hazard ratio 1.04, 95% confidence interval 0.62–1.89) and the use of propensity matching (hazard ratio: 1.29, 95% confidence interval: 0.68–1.45) intra-aortic balloon pump therapy was not associated with mortality. Conclusion: Cardiogenic shock treated by percutaneous coronary intervention is increasing in incidence and remains a condition associated with high mortality and limited treatment options. Intra-aortic balloon pump therapy was not associated with a long-term survival benefit in this cohort and may be associated with increased early morbidity.

An unusual cause of myocardial infarction

A 47 year old woman presented to a local hospital with chest pain, palpitations, sweating, nausea, and vomiting after a hot shower. Her electrocardiogram on admission showed intermittent broad complex ventricular tachycardia, and serial electrocardiograms showed ST elevation in the inferior limb leads. After being given thrombolytic treatment with tenecteplase, she was started on an amiodarone infusion. She was subsequently transferred to our tertiary cardiac centre for further management because of continuing chest pain and hypotension. On arrival she was found to be in cardiogenic shock, with severe lactic acidosis and pulmonary oedema requiring intubation, assisted ventilation, and inotropic support. She had extensive lower body and limb livedo reticularis. An emergency coronary angiogram was performed and this showed widely patent coronary arteries. A left ventricular angiogram showed severe left ventricular systolic dysfunction with generalised hypokinesia, which was relatively worse in the mid-segments than in the apical and basal left ventricular segments. She also had severe mitral valve regurgitation and high left ventricular diastolic filling pressure. An intra-aortic balloon pump was inserted for haemodynamic stabilisation. She had experienced a similar but less severe event three years before, when she presented with an inferior ST elevation myocardial infarction, which was treated with thrombolysis, and she was subsequently discharged after a normal coronary angiogram. The next day she was extubated and transferred from the cardiac intensive care unit to the coronary care unit. An abdominal ultrasound was requested because she had developed deranged liver function tests, with a predominantly hepatitic picture. The ultrasound showed a right adrenal mass (fig 1⇓). Fig 1 Abdominal ultrasound showing a mass adjacent to the upper pole of the right kidney

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.

TCT-28 Comparison Of Outcomes For Primary Percutaneous Coronary Intervention During Out Of Working Hours Versus In Working Hours: An Observational Cohort Study Of 11,461 Patients

Primary percutaneous coronary intervention (PPCI) is the treatment of choice for ST-elevation myocardial infarction (STEMI). The optimum delivery of this service requires an integrated, multi-disciplinary, consultant-led, protocol-driven approach. It is widely recognised that resources including

DRUG-ELUTING STENTS VERSUS BARE METAL STENTS IN PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION UNDERGOING PRIMARY PERCUTANEOUS CORONARY INTERVENTION

In primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI), the relative safety of drug-eluting stents (DES) versus bare metal stents (BMS) continues to be debated. Whilst DES use is associated with reduced target lesion revascularization rates, stent

CULPRIT VESSEL VERSUS MULTIVESSEL INTERVENTION FOR PRIMARY PERCUTANEOUS CORONARY INTERVENTION IN PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION WITHOUT CARDIOGENIC SHOCK: AN OBSERVATIONAL COHORT STUDY OF 9,377 PATIENTS

Current guidelines discourage percutaneous coronary intervention (PCI) of non-infarct-related arteries at the time of primary PCI in patients with ST-elevation myocardial infarction (STEMI) without cardiogenic shock. The optimal strategy for treating non-culprit disease is currently under debate.