Sundeep Kalra

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.

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.

Fooled by the heart

A previously healthy 54-year-old man presented in February, 2009, with dyspnoea and syncope. The admission ECG showed anterolateral T-wave inversion, and the troponin-I concentration was raised (0∙20 μg/L). He was treated for an acute coronary syndrome. Echocardiography showed concentric left ventricular hypertrophy with inferoposterior hypokinesis, and mild systolic dysfunction. The right ventricle (RV) was slightly dilated with mild systolic dysfunction. Coronary angiography showed mild atheroma; he was managed medically. He presented again to his local hospital the day after discharge, with further syncope and dyspnoea. Repeat echocardiography showed progressive cardiac dysfunction with moderate RV dilatation and severe RV systolic dysfunction. He was transferred to our centre. Cardiac MRI showed several diff use cardiac masses involving all four cardiac chambers and encasing the coronary arteries and ascending aorta; intracardiac tumour, perhaps lymphoma, was thought possible (fi gure A). Percutaneous RV biopsy confi rmed a histological diagnosis of diff use large B-cell lymphoma. CT showed no extracardiac disease and a bone-marrow trephine sample was normal, which suggested a diagnosis of primary cardiac lymphoma. Chemotherapy was started 6 weeks after presentation. Rituximab, cyclophosphamide, vincristine, and prednisolone were used in the fi rst cycle because of concern about potential early cardiac toxicity of anthracyclines. He then received four cycles of rituximab, cyclophosphamide, full-dose doxorubicin, vincristine, and prednisolone. For the initial three cycles, he was treated as an inpatient with intensive cardiac monitoring because his fi rst two cycles were complicated by two ventricular fi brillation cardiac arrests, treated with external defi brillation. We planned to monitor response to chemotherapy with serial cardiac MRI, and therefore deferred implantation of an internal cardiac defi brillator (ICD); we discharged him home with an external cardiac defi brillator (LifeVest, Zoll Medical, Pittsburgh, PA, USA). Interval cardiac MRI, after the second cycle of chemotherapy and 4 months after completion, showed

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.

Inorganic Nitrite Selectively Dilates Epicardial Coronary Arteries

Inorganic nitrite (NO2−) as sodium nitrite or derived from dietary nitrate found in green leafy vegetables and beetroot has potential as a tolerance-free therapy in heart failure with preserved ejection fraction [(1)][1], including pulmonary hypertension-associated heart failure with preserved

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.