BACKGROUND:Little correlation exists between the burden of ischemia and severity of angina in patients with stable coronary artery disease. This placebo-controlled, n-of-1 study investigated the relationship between ischemia, the collateral circulation, and symptoms in stable coronary artery disease. Additionally, it explored the association between progressive collateral recruitment and ischemic preconditioning. METHODS:Fifty-one participants with severe single-vessel coronary artery disease and angina were recruited. Antianginal medications were stopped, and daily angina symptoms were documented using a dedicated smartphone application (ORBITA [Objective Randomized Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina] app) for 14 days before undergoing invasive pressure wire studies and coronary flow reserve assessment. Each participant then underwent four 60-s episodes of low-pressure balloon occlusion across their coronary stenosis. Each episode was paired with an audiovisually identical placebo inflation in a randomized order. After each episode, participants scored pain intensity on a 10-point scale, and a placebo-controlled pain intensity score was calculated. Collateral flow index was calculated from simultaneous measures of aortic, right atrial, and distal coronary wedge pressure during balloon occlusion. Higher Pr values from Bayesian models indicate a greater likelihood of association. RESULTS:The mean (±SD) age of participants was 63±9 years, and 78% were men. The median (interquartile range) fractional flow reserve was 0.68 (0.57-0.79), the median instantaneous wave-free ratio was 0.80 (0.48-0.89), and the median coronary flow reserve was 1.42 (1.08-1.85). Daily angina frequency showed little correlation with severity of ischemia, as assessed by fractional flow reserve (Somers' D 0.124, Pr=0.057) or instantaneous wave-free ratio (Somers' D 0.056, Pr=0.150). However, there was strong evidence of an association between lower fractional flow reserve and instantaneous wave-free ratio values and greater collateral flow (Somers' D 0.302, Pr=0.998 and Somers' D 0.316, Pr=0.999, respectively). There was also strong evidence of an association between more collateralization (higher collateral flow index) and lower pain intensity scores (Somers' D 0.341, Pr=0.999). Finally, pain intensity scores and collateral flow index remained stable between sequential balloon occlusion episodes within individual patients, indicating little evidence of ischemic preconditioning. CONCLUSIONS:Coronary collateralization is associated with ischemic burden and may reduce the intensity of ischemic chest pain. This may explain the nonlinear relationship between stenosis, ischemia, and angina. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT04280575.

INTRODUCTION:Transcatheter aortic valve replacement (TAVR) is increasingly in demand for treating severe aortic stenosis in a variety of surgical risk profiles. This means increasing wait times and elevated morbidity and mortality on the waitlist. To address this, we developed the SWIFT TAVR algorithm to prioritize patients based on clinical risk and reduce wait times. METHODS:The SWIFT algorithm, implemented in Microsoft Excel, calculates a clinical risk score from three parameters: left ventricular ejection fraction (LVEF), peak aortic valve gradient, and syncope. Scores categorize patients into four prioritisation profiles: high (9-10 points), intermediate (4-8 points), low (2-3 points), and minimal (0-1 point). The study prospectively applied the SWIFT algorithm to patients in 2022 (SWIFT group) and retrospectively to a 2021 cohort (CONTROL group). Outcomes measured were wait times from consultation to procedure and major adverse cardiac events (MACE) while awaiting TAVR. RESULTS:A total of 228 patients were included (117 SWIFT, 111 CONTROL). There was no significant difference in baseline characteristics between groups (p > 0.05). Overall wait times were significantly shorter in the SWIFT group (21 vs 28 weeks, p < 0.001), particularly for high-risk patients (12 vs 31 weeks, p < 0.001). MACE rates were similar (9 % vs 10 %, p = 0.722). DISCUSSION:The SWIFT algorithm significantly reduced wait times, particularly for high-risk patients, without increasing MACE rates. This automated, risk-based prioritisation tool improves equity and efficiency in TAVR waitlist management and is globally applicable. Further randomized studies are warranted to validate these findings.

Background In stable coronary artery disease, 30% to 60% of patients remain symptomatic despite successful revascularization. Perhaps not all symptoms reported by a patient with myocardial ischemia are, in fact, angina. Objectives This study sought to determine whether independent symptom verification using a placebo-controlled ischemic stimulus could distinguish which patients achieve greatest symptom relief from percutaneous coronary intervention (PCI). Methods ORBITA-STAR was a multicenter, n-of-1, placebo-controlled study in patients undergoing single-vessel PCI for stable symptoms. Participants underwent 4 episodes (60 seconds each) of low-pressure balloon occlusion across their coronary stenosis, randomly paired with 4 episodes of placebo inflation. Following each episode, patients reported the similarity of the induced symptom in comparison with their usual symptom. The similarity score ranged from -10 (placebo replicated the symptom more than balloon occlusion) to +10 (balloon occlusion exactly replicated the symptom). The primary endpoint was the ability of the similarity score to predict symptom relief with PCI. Results Fifty-one patients were recruited, aged 62.9 +/- 8.6 years. The median fractional flow reserve was 0.68 (Q1-Q3: 0.57-0.79), and the instantaneous wave-free ratio was 0.80 (Q1-Q3: 0.48-0.89). The median similarity score was 3 (Q1-Q3: 0.875-5.25). The similarity score was a strong predictor of symptom improvement following PCI: a patient with an upper quartile similarity score of 5.25 was significantly more likely to have lower angina frequency at follow-up (OR: 8.01; 95% credible interval: 2.39-15.86) than a patient with a lower quartile similarity score of 0.875 (OR: 1.31; 95% credible interval: 0.71-1.99), Pr-(difference) >99.9%. Conclusions Similarity score powerfully predicted symptom improvement from PCI. These data lay the foundation for independent symptom mapping to target PCI to those patients most likely to benefit. (Systematic Trial of Angina Assessment Before Revascularization [ORBITA-STAR]; NCT04280575) (c) 2024 Published by Elsevier on behalf of the American College of Cardiology Foundation.

Aim: To determine the safety and feasibility of an early (12 h) waking and extubation protocol for out-of-hospital cardiac arrest (OHCA) patients receiving targeted temperature management (TTM). Methods: This was a single-centre, prospective, non-randomised, observational, safety and feasibility pilot study which included successfully resuscitated OHCA patients, of presumed cardiac cause. Inclusion criteria were: OHCA patients aged over 18 years with a return of spontaneous circulation, who were going to receive TTM33 (TTM at 33 degrees C for 24 h and prevention of hyperthermia for 72 h) as part of their post cardiac arrest care. Clinical stability was measured against physiological and neurological parameters as well as clinical assessment. Results: 50 consecutive patients were included (median age 65.5 years, 82% male) in the study. Four (8%) patients died within the first twelve hours and were excluded from the final cohort (n = 46). Twenty-three patients (46%) were considered clinically stable and suitable for early waking based on the intention to treat analysis; 12 patients were extubated early based on a variety of clinical factors (21.4 +/- 8.6 h) whilst continuing to receive TTM33 with a mean core temperature of 34.2 degrees C when extubated. Of these, five patients were discharged from the intensive care unit (ICU) <48 h after admission with a mean ICU length of stay 1.8 +/- 0.4 days. Twenty-eight patients (56%) were discharged from the ICU with a modified Rankin Score of 0-2. The overall intra-hospital mortality was 50% (n = 25). Conclusions: It is safe and feasible to wake selected comatose OHCA patients at 12 h, allowing for earlier positive neuro-prognostication and reduced ICU stay.

This study aimed to assess the impact of stent optimization by NC‐balloon postdilatation (PD) during primary‐PCI for STEMI with the use of coronary physiology and intracoronary imaging.

Objectives We sought to evaluate mortality predictors and the role of new-generation drug-eluting stents (NG-DES) in stent thrombosis (ST) management. Background No data are available regarding the outcome of patients with ST after interventional management that includes exclusively NG-DES. Methods Patients with definite ST of DES or BMS who underwent urgent/emergent angiography between 2015 and 2018 at our institution were considered for the study. After excluding patients who achieved TIMI-flow<2 after intervention or received an old-generation stent, 131 patients were included. Management classification was stent or non-stent treatment (medical management, thromboaspiration, balloon-angioplasty). Follow-up was performed to document all-cause death (ACD) and target-lesion-revascularization (TLR) that was used for censorship. Results Mode of presentation was STEMI in 88% and UA/NSTEMI in 12%. Type of ST was early, late, and very late in 11, 4, and 85%, respectively. Eighty four patients received stent and 47 non-stent treatment. After 926 +/- 34 days, 21 ACDs, 7 TLRs and no cases of definite, recurrent ST were observed. Univariate predictors of in-hospital mortality were LVEF and presentation with shock or cardiac arrest. For patients discharged alive, non-stent treatment (HR 4.2, p = .01), TIMI-2 flow (HR 7.4, p = .002) and GFR < 60 mL/min (HR 3.8, p = .01) were independent predictors of ACD. The stent-treatment group had significantly better ACD-free survival after discharge, both unadjusted (p = .022) and adjusted (p = .018). Conclusions After ST management, different predictors were observed for in-hospital mortality and mortality in patients discharged alive. The better outcome with NG-DES treatment is a novel observation, warranting further studies to elucidate if it is associated with stent-related or patient-related factors.

In STEMI patients undergoing primary PCI, optimal stent deployment is challenging due to factors like thrombus formation and vasoconstriction. In this setting stent post-dilatation with non-compliant (NC) balloons could optimise acute results, but carries a risk of distal embolization and

Mild therapeutic hypothermia (MTH 33°C) post out-of-hospital cardiac arrest (OHCA) is widely accepted as standard of care. However, uncertainty remains around the dose and therapy duration. OHCA patients are usually kept sedated±paralyzed and ventilated for the first 24-36 hours, which allows for targeted temperature management, but makes neurological prognostication challenging. The aim of this study is to investigate the feasibility and safety of assessing the unconscious OHCA patient after 12 hours for early waking/extubation while continuing to provide MTH for 24 hours, and fever prevention for 72 hours by using an intravenous temperature management (IVTM) system and established conscious MTH anti-shiver regimens. This is a single-center, prospective, non-randomized observational study that will compare the results of early awakening (at 12 hours) with historical controls. A total of 50 consecutive unconscious survivors of OHCA, treated with MTH, who meet the Therapeutic Hypothermia and eArly Waking (THAW) inclusion criteria will be enrolled. The patient will receive MTH by using IVTM. After 12 hours of MTH, patients will be assessed by using strict clinical criteria to determine suitability for early waking and extubation. Once awake and extubated, MTH will continue for 24 hours with skin counter-warming and anti-shiver regimen followed fever prevention up to 72 hours. All patients will have serial electroencephalogram (EEG), somatic sensory potential, and neuro-biomarkers performed on admission to intensive care unit, 6 and 12 hours, then every 24 hours until 72 hours. The study has been approved by the National Research Ethics Service, Health Research Authority.

The index of microcirculatory resistance (IMR) emerges as a valuable prognostic tool in ST elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronay intervention (PPCI). An IMR value more than 40 at the end of the procedure has been related with worse outcomes. In the

Contrast-induced acute kidney injury (CI-AKI) is a recognised complication during primary percutaneous coronary intervention (PPCI) that affects short and long term prognosis. Volume of contrast media used is a known predisposing factor for its development. The aim of this study was to determine the

Novel therapies capable of reducing myocardial infarct (MI) size when administered prior to reperfusion are required to prevent the onset of heart failure in ST-segment elevation myocardial infarction (STEMI) patients treated by primary percutaneous coronary intervention (PPCI). Experimental animal studies have demonstrated that mineralocorticoid receptor antagonist (MRA) therapy administered prior to reperfusion can reduce MI size, and MRA therapy prevents adverse left ventricular (LV) remodeling in post-MI patients with LV impairment. With these 2 benefits in mind, we hypothesize that initiating MRA therapy prior to PPCI, followed by 3 months of oral MRA therapy, will reduce MI size and prevent adverse LV remodeling in STEMI patients. The MINIMISE-STEMI trial is a prospective, randomized, double-blind, placebo-controlled trial that will recruit 150 STEMI patients from four centers in the United Kingdom. Patients will be randomized to receive either an intravenous bolus of MRA therapy (potassium canrenoate 200 mg) or matching placebo prior to PPCI, followed by oral spironolactone 50 mg once daily or matching placebo for 3 months. A cardiac magnetic resonance imaging scan will be performed within 1 week of PPCI and repeated at 3 months to assess MI size and LV remodeling. Enzymatic MI size will be estimated by the 48-hour area-under-the-curve serum cardiac enzymes. The primary endpoint of the study will be MI size on the 3-month cardiac magnetic resonance imaging scan. The MINIMISE STEMI trial will investigate whether early MRA therapy, initiated prior to reperfusion, can reduce MI size and prevent adverse post-MI LV remodeling.

INTRODUCTION:Trials demonstrate significant clinical benefit in patients receiving therapeutic hypothermia (TH) after cardiac arrest. However, incidence of mortality and morbidity remains high in this patient group. Rapid targeted brain hypothermia induction, together with prompt correction of the underlying cause may improve outcomes in these patients. This study investigates the efficacy of Rhinochill, an intranasal cooling device over Blanketrol, a surface cooling device in inducing TH in cardiac arrest patients within the cardiac catheter laboratory. METHODS:70 patients were randomized to TH induction with either Rhinochill or Blanketrol. Primary outcome measures were time to reach tympanic ≤34 °C from randomisation as a surrogate for brain temperature and oesophageal ≤34 °C from randomisation as a measurement of core body temperature. Secondary outcomes included first hour temperature drop, length of stay in intensive care unit, hospital stay, neurological recovery and all-cause mortality at hospital discharge. RESULTS:There was no difference in time to reach ≤34 °C between Rhinochill and Blanketrol (Tympanic ≤34 °C, 75 vs. 107 mins; p=0.101; Oesophageal ≤34 °C, 85 vs. 115 mins; p=0.151). Tympanic temperature dropped significantly with Rhinochill in the first hour (1.75 vs. 0.94 °C; p<0.001). No difference was detected in any other secondary outcome measures. Catheter laboratory-based TH induction resulted in a survival to hospital discharge of 67.1%. CONCLUSION:In this study, Rhinochill was not found to be more efficient than Blanketrol for TH induction, although there was a non-significant trend in favour of Rhinochill that potentially warrants further investigation with a larger trial.

Heerajnarain Bulluck, MBBS; Georg M. Fröhlich, MD; Shah Mohdnazri, MBBS; Reto A. Gamma, FRCP; John R. Davies, PhD; Gerald J. Clesham, MD; Jeremy W. Sayer, MD; Rajesh K. Aggarwal, MD; Kare H. Tang, FRCP; Paul A. Kelly, MD; Rohan Jagathesan, MD; Alamgir Kabir, PhD; Nicholas M. Robinson, MD; Alex Sirker, PhD; Anthony Mathur, PhD; Daniel J. Blackman, MD; Cono Ariti, MSc; Arvindra Krishnamurthy, MBBS; Steven K. White, MBBS; Pascal Meier, MD; James C. Moon, MD; John P. Greenwood, PhD; Derek J. Hausenloy, MDPhD Department of Cardiology, Heart Hospital (Bulluck, Sirker, White, Meier, Moon), London, United Kingdom; National Institute of Health Research (Bulluck, White, Moon, Hausenloy), University College London Hospitals Biomedical Research Centre, London, United Kingdom; Hatter Cardiovascular Institute (Bulluck, White, Hausenloy), Institute of Cardiovascular Science, London, United Kingdom; Department of Cardiology, Leeds General Infirmary (Fröhlich, Blackman, Krishnamurthy, Greenwood), Leeds, United Kingdom; Department of Cardiology, Essex Cardiothoracic Center (Fröhlich, Mohdnazri, Gamma, Davies, Clesham, Sayer, Aggarwal, Tang, Kelly, Jagathesan, Kabir, Robinson), Nethermayne, Basildon, United Kingdom; London Department of Cardiology, Chest Hospital (Mathur), London, United Kingdom; Nuffield Health Trust (Ariti), London, United Kingdom; London School of Hygiene and Tropical Medicine (Ariti), London, United Kingdom; Cardiovascular and Metabolic Disorders Program (Hausenloy), Duke-National University of Singapore, Singapore; National Heart Research Institute Singapore (Hausenloy), National Heart Centre Singapore, Singapore

Introduction Mortality following ST-elevation myocardial infarction has declined significantly with the advent of primary PCI (PPCI). Concurrent use of antiplatelet agents has further decreased complication rates and mortality; however, these agents confer an increased bleeding risk, an independent risk factor for mortality. This retrospective study assesses the effect of blood loss on short- and long-term mortality and its association with clinical characteristics in a real world population of patients undergoing PPCI at a tertiary referral centre in the UK. Methods All patients accepted for PPCI within the period of September 2009 to November 2011 were eligible for inclusion in the study. Patient data were obtained from our Cardiac Services Database System (Phillips CVIS) and mortality data were gathered from the Summary Care Record (SCR) database. Statistical comparisons of continuous variables were made by one-way ANOVA. Categorical variables were compared using the chi-squared test. A P value of < 0.05 was taken to indicate statistical significance. Results 1403 patients with recorded admission and discharge haemoglobin levels were included in this analysis. Characteristics and clinical outcomes were compared in three groups according to the degree of haemoglobin reduction (Table 1). Patients with a reduction in haemoglobin were more likely to be female, slightly older and have prior history of MI. Patients with a significant reduction in haemoglobin were more likely to have received abciximab. Thirty-day mortality was significantly higher in the group with a haemoglobin drop (Table 1) as was overall mortality (hazard ratio 1.8, 95% CI 1.2–2.5) during a mean follow-up period of 2.1 years (Figure 1). Abstract 32 Figure 1 Kaplan-Meier survival curves Abstract 32 Table 1 Clinical characteristics and outcomes No change in Hb, g/dl (n = 374) Hb reduction 0.1–1 g/dl (n = 517) Hb reduction >1 g/dl (n = 512) p-value Risk factorsMean Age (+/- SD)MaleHypertensionDiabetes MellitusPrevious MIPrevious CABG 64.4 +/- 14290 (77.5%)110 (29.4%)53 (14.2%)59 (15.8%)9 (2.4%) 63.1 +/- 13383 (74%)132 (25.5%)63 (12.2%)61 (11.8%)14 (2.7%) 67.5 +/- 13355 (69.3%)140 (27.3%)64 (12.5%)51 (10%)11 (2.1%) <0.0001*0.021*0.3700.6560.031*0.843 Procedure relatedRadialAbciximab use 113 (30.2%)114 (30.5%) 147 (28.4%)161 (31.1%) 130 (25.4%)208 (40.6%) 0.2630.0001* Clinical outcome30-day mortalityOverall mortality 15 (4%)36 (9.6%) 12 (2.3%)46 (8.9%) 42 (8.2%)79 (15.4%) <0.0001*0.0019* Conclusions Our retrospective analysis in a large cohort of patients confirms recent data suggesting an adverse association between a reduction in haemoglobin following PPCI and long-term mortality. Further work is required on strategies to reduce bleeding risk and hence improve clinical outcome following PPCI.

Introduction Tako-tsubo cardiomyopathy (TCM) is increasingly being recognised in patients admitted with suspected acute coronary syndrome, as access to angiography and echocardiography are much quicker than before. Typically, patients with TCM present to the primary PCI service (PPCI) with chest pain and ST elevation on their electrocardiogram mimicking ST elevation myocardial infarction (STEMI). However, there is no ‘real-world’ data about the prevalence of this condition in PPCI admissions for suspected STEMI. Therefore we aimed to analyse the prevalence of TCM in a high volume regional PPCI service in UK. Table 1 Echocardiographic features of TCM patients in our study (n=17) Severely impaired LV function 2 (11.8%) Moderately impaired LV 15 (88.2%) RV impairment 2 (11.8%) Mitral regurgitation (MR)- None 13 (76.5%) MR (mild) 3 (17.6%) MR (moderate) 1 (5.9%) LVOT peak velocity: <1 m/s 6 (35.3%) LVOT peak velocity: >1 m/s 9 (52.9%) LVOT peak velocity: >2 m/s 2 (11.8%) Apical Thrombus 1 (5.9%) Methods All patients admitted with suspected STEMI between Sept 2009 and Nov 2011 to our centre were included. After excluding those who underwent PPCI, We analysed the echocardiogram and/or left ventriculogram of those patients who did not undergo PPCI to identify patients with typical TCM features of apical akinesia with basal hyperkinesia. Their coronary angiograms were reviewed and the inclusion criteria to identify TCM was the absence of significant coronary disease with no artery having >50% stenosis. Results Of the 1875 patients admitted, 17 (0.9%) patients (0 m, 17 f) with the mean age of 70±10.7 years (range 56–94 years) were identified to have typical TCM features. The prevalence of TCM in female PPCI admission was 3.1% (17/560) (figure 1). The admission ECG showed ST elevation in 14 patients (82%) and three had LBBB (18%). In those who had positive hsTroponin (n=16, 94.1%), the mean level was 921±668 (median 778, range 110–2550). Two patients had cardiac arrest prior to hospital admission with successful resuscitation. Left ventricular function was severely impaired (EF≤30%) in 2 patients whilst all others had moderately impaired LV function (EF 31–50%) (table 1). Aspirin, β-blocker, Angiotensin converter enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) was given to 13 (76.5%), 13 (76.5%) and 15 (88.2%) patients respectively on their discharge. All the 15 patients who had repeat echocardiogram within 3 months of their index admission showed complete recovery of their LV function. During a mean follow up period of 22±7 months (median 21, range 8–36 months), there was no mortality. Figure 1 Flow chart to identify Tako-tsubo Cardiomyopathy patients in our study. Conclusions This first ‘real-world’ observational study of TCM in STEMI patients admitted for PPCI to a single centre showed an overall prevalence of 0.9% with 3% prevalence in female population. Although TCM is not benign during the acute episode, there is an excellent survival outcome if managed appropriately during the acute phase.

Aims Current national and international guidelines continue to recommend activation of the primary percutaneous coronary intervention (PPCI) pathway in patients presenting with chest pain and presumed new-onset left bundle branch block (LBBB). Previous research has suggested that a lower proportion of patients presenting with LBBB require emergency intervention. In this study we have compared baseline clinical characteristics, angiographic findings and subsequent outcome in patients with LBBB versus ST-elevation myocardial infarction (STEMI) referred to our tertiary centre for PPCI. Methods All patients accepted for PPCI within the period of September 2009 to November 2011 were included in the study. Patient data obtained from our Cardiac Services Database System (Phillips CVIS) were analysed and angiographic images reviewed on our Cardiac Image Database (McKesson Horizon). Mortality data were gathered from the Summary Care Record (SCR) database. Statistical comparisons of continuous variables were made by an unpaired t test. Categorical variables were compared using the χ2 test. A p value of <0.05 was considered to indicate statistical significance. Results During the study period, 1875 patients were referred for PPCI of whom 155 (8.3%) had LBBB. Compared with STEMI, patients with LBBB were significantly older, more likely to be female and have prior history of MI and CABG (table 1). Patients with LBBB had similar door-to-balloon (DTB) and call-to-balloon (CTB) times. PCI was performed in 40 (26%) patients with LBBB although an acutely occluded culprit vessel was found in only 19 (12.2%) patients (table 2). Furthermore, 85 (54.8%) patients had non-flow limiting coronary artery disease and of those with significant disease 12 (7.7%) patients required CABG (figure 1). Overall, an acute coronary syndrome (defined as ischaemic chest pain with positive troponin) was confirmed in only 67 (43.2%) of patients presenting with LBBB. 30-day mortality was similar between LBBB and STEMI patients (table 2). However, during a mean follow-up period of 2.1 years, overall mortality was significantly higher in the LBBB group compared to STEMI (HR 2.01, 95% CI 1.26 to 3.20) (figure 2). Conclusions Our study shows that, in contrast to STEMI, only a small proportion of patients presenting with chest pain and LBBB had an acutely occluded coronary artery. Although short-term mortality was similar between the two groups, long-term outcome was significantly worse in patients with LBBB. Further work is needed to identify those patients presenting with LBBB who are most likely to have an acute coronary occlusion, in order to facilitate the appropriate use of emergency coronary angiography and PPCI.