Care processes and outcomes for patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) remain heterogeneous. A “patient pathway” framework—defined as the sequence of clinically relevant events from symptom onset through diagnosis, reperfusion, and early recovery—can help identify real-world points of failure and opportunities for system-level improvement. In this narrative review, we contrast an “ideal” STEMI pathway with the pathways commonly observed in routine practice for patients treated with primary PCI, and we contextualize deviations from best practice from patient, clinician, health service, and societal perspectives. From the patient's perspective, the priority is rapid symptom recognition and seeking care; however, delays are frequent, particularly in individuals with mild, atypical, or non-classical presentations, prolonging total ischemic time and increasing myocardial injury. Clinicians aim to diagnose STEMI promptly and initiate evidence-based therapy and reperfusion without delay, yet diagnostic uncertainty and competing differentials can contribute to missed or late diagnoses. Health systems seek to provide timely, efficient, and cost-effective emergency revascularization, but performance is influenced by pre-hospital logistics, triage, catheterization laboratory availability, and inter-hospital transfer processes. At the societal level, STEMI imposes substantial mortality, morbidity, and economic burden through premature death and disability. We synthesize evidence on delays to revascularization, misdiagnosis, populations at risk for atypical presentation, and pragmatic interventions to improve care. We conclude that pathway-based analyses offer a structured approach to defining desirable STEMI care trajectories and to reducing missed opportunities for better outcomes.

BACKGROUND:Long-term outcomes following percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) might be changing because of improved techniques and better medical therapy. This final prespecified analysis of the Fractional Flow Reserve (FFR) versus Angiography for Multivessel Evaluation (FAME) 3 trial aimed to reassess their comparative effectiveness at 5 years. METHODS:FAME 3 was a multicentre, randomised trial comparing FFR-guided PCI using current-generation zotarolimus-eluting stents versus CABG in patients with three-vessel coronary artery disease not involving the left main coronary artery. 48 hospitals in Europe, USA and Canada, Australia, and Asia participated in the trial. Patients (aged ≥21 years with no cardiogenic shock, no recent ST segment elevation myocardial infarction, no severe left ventricular dysfunction, and no previous CABG) were randomly assigned to either PCI or CABG using a web-based system. At 1 year, FFR-guided PCI did not meet the prespecified threshold for non-inferiority for the outcome of death, stroke, myocardial infarction, or repeat revascularisation versus CABG. The primary endpoint for this intention-to-treat analysis was the 5-year incidence of the prespecified composite outcome of death, stroke, or myocardial infarction. The trial was registered at ClinicalTrials.gov, NCT02100722, and is completed; this is the final report. FINDINGS:Between Aug 25, 2014 and Nov 28, 2019, 757 of 1500 participants were assigned to PCI and 743 to CABG. 5-year follow-up was achieved in 724 (96%) patients assigned to PCI and 696 (94%) assigned to CABG. At 5 years, there was no significant difference in the composite of death, stroke, or myocardial infarction between the two groups, with 119 (16%) events in the PCI group and 101 (14%) in the CABG group (hazard ratio 1·16 [95% CI 0·89-1·52]; p=0·27). There were no differences in the rates of death (53 [7%] vs 51 [7%]; 0·99 [0·67-1·46]) or stroke (14 [2%] vs 21 [3%], 0·65 [0·33-1·28]), but myocardial infarction was higher in the PCI group than in the CABG group (60 [8%] vs 38 [5%], 1·57 [1·04-2·36]), as was repeat revascularisation (112 [16%] vs 55 [8%], 2·02 [1·46-2·79]). INTERPRETATION:At the 5-year follow-up, there was no significant difference in a composite outcome of death, stroke, or myocardial infarction after FFR-guided PCI versus CABG, although myocardial infarction and repeat revascularisation were higher with PCI. These results provide contemporary evidence to allow improved shared decision making between physicians and patients. FUNDING:Medtronic and Abbott Vascular.

BACKGROUND:In ST-segment elevation myocardial infarction (STEMI), complete revascularization with percutaneous coronary intervention (PCI) reduces major cardiovascular events compared with culprit-lesion-only PCI. Whether age influences these results remains unknown. METHODS:COMPLETE was a multinational, randomized trial evaluating a strategy of staged complete revascularization, consisting of angiography-guided PCI of all suitable nonculprit lesions, versus a strategy of culprit-lesion-only PCI. In this prespecified subgroup analysis, treatment effect according to age (≥65 years vs <65 years) was determined for the first coprimary outcome of cardiovascular (CV) death or new myocardial infarction (MI) and the second coprimary outcome of CV death, new MI, or ischemia-driven revascularization (IDR). Median follow-up was 35.8 months (interquartile range [IQR]: 27.6-44.3 months). RESULTS:Of 4,041 patients randomized in COMPLETE, 1,613 were aged ≥ 65 years (39.9%). Higher event rates were observed for both coprimary outcomes in patients aged ≥ 65 years comparted with those aged < 65 years (11.2% vs 7.9%, HR 1.49, 95% CI 1.22-1.83; 14.4% vs 11.8%, HR 1.28, 95% CI 1.07-1.52, respectively). Complete revascularization reduced the first coprimary outcome in patients ≥ 65 years (9.7% vs 12.5%, HR 0.77; 95% CI, 0.58-1.04) and < 65 years (6.7% vs 9.1%, HR 0.72; 95% CI, 0.54-0.96)(interaction P = .74). The second coprimary outcome was reduced in those ≥ 65 years (HR 0.56, 95% CI, 0.43-0.74) and < 65 years (HR 0.48, 95% CI, 0.37-0.61 (interaction P = .37). A sensitivity analysis was performed with consistent results demonstrated using a 75-year threshold (albeit attenuated). CONCLUSIONS:In patients with STEMI and multivessel CAD, complete revascularization compared with culprit-lesion-only PCI reduced major cardiovascular events regardless of patient age and could be considered as a revascularization strategy in older adults.

BACKGROUND: Previous studies comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with multivessel coronary disease not involving the left main have shown significantly lower rates of death, myocardial infarction (MI), or stroke after CABG. These studies did not routinely use current-generation drug-eluting stents or fractional flow reserve (FFR) to guide PCI. METHODS: FAME 3 (Fractional Flow Reserve versus Angiography for Multivessel Evaluation) is an investigator-initiated, multicenter, international, randomized trial involving patients with 3-vessel coronary artery disease (not involving the left main coronary artery) in 48 centers worldwide. Patients were randomly assigned to receive FFR-guided PCI using zotarolimus drug-eluting stents or CABG. The prespecified key secondary end point of the trial reported here is the 3-year incidence of the composite of death, MI, or stroke. RESULTS: A total of 1500 patients were randomized to FFR-guided PCI or CABG. Follow-up was achieved in >96% of patients in both groups. There was no difference in the incidence of the composite of death, MI, or stroke after FFR-guided PCI compared with CABG (12.0% versus 9.2%; hazard ratio [HR], 1.3 [95% CI, 0.98–1.83]; P =0.07). The rates of death (4.1% versus 3.9%; HR, 1.0 [95% CI, 0.6–1.7]; P =0.88) and stroke (1.6% versus 2.0%; HR, 0.8 [95% CI, 0.4–1.7]; P =0.56) were not different. MI occurred more frequently after PCI (7.0% versus 4.2%; HR, 1.7 [95% CI, 1.1–2.7]; P =0.02). CONCLUSIONS: At 3-year follow-up, there was no difference in the incidence of the composite of death, MI, or stroke after FFR-guided PCI with current-generation drug-eluting stents compared with CABG. There was a higher incidence of MI after PCI compared with CABG, with no difference in death or stroke. These results provide contemporary data to allow improved shared decision-making between physicians and patients with 3-vessel coronary artery disease. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02100722.

Background Out of hospital cardiac arrest (OOHCA) due to acute myocardial infarction (MI) is a leading cause of sudden cardiac death. Survival-to-discharge rates for OOHCA are reported to be as low as 10%, however there is limited UK data on survival beyond 30 days. Limited studies, of OOHCA survivors post MI who survive to discharge, report a longer-term survival of 78-92%. We sought to report contemporary data from a single UK tertiary centre. Methods All patients undergoing percutaneous coronary intervention (PCI) at our institution are prospectively entered into a national registry (British Cardiovascular Intervention Society audit). A retrospective review of consecutive patients undergoing PCI following OOHCA and acute MI between 1/3/2015 and 1/3/2021 at Wythenshawe Hospital. Electronic patient records were accessed for baseline demographic, clinical, procedural and follow-up data. Exclusion criteria included non-shockable rhythm, in-hospital cardiac arrest. Patients who survived to discharge were included in the primary outcome analysis which was 1-year survival. In-hospital mortality was a secondary outcome. Results Of 282 records, 157 patients survived to discharge and were included (62±12 years, 82% male) with median length of stay 7 (3-17) days. Comorbidities included prior MI (12%), diabetes (10%), chronic obstructive airways disease (9%) and prior stroke (2%). Clinical presentation was predominantly ventricular fibrillation (93%) and ST-elevation MI (77%) with a significant proportion of cardiogenic shock (52%), intubation (23%) and mechanical support (13%). Intervention was attempted in most patients (99%); left anterior descending (53%), right coronary artery (31%), circumflex (27%) and left main (4%). Revascularization rates were high (98%) and included stent implantation (91%), drug coated balloon (10.1%), balloon angioplasty only (3.2%), surgical (2.5%) and hybrid (2%). In hospital mortality was 35.1%. Survival status at 1 year was available in all patients. Of patients who survived to discharge, 1-year survival was 96.8%. Conclusions Consistent with previous literature, we observed high inpatient mortality rates in acute MI presenting with OOHCA. However, in patients who survived to discharge 1-year survival was favourable. Further work is required to corroborate our contemporary single UK tertiary centre findings and to explore prognostic mortality factors. Conflict of Interest None

More than 300 000 procedures are performed in cardiac catheter laboratories in the UK each year. The variety and complexity of percutaneous cardiovascular procedures have both increased substantially since the early days of invasive cardiology, when it was largely focused on elective coronary angiography and single chamber (right ventricular) permanent pacemaker implantation. Modern-day invasive cardiology encompasses primary percutaneous coronary intervention, cardiac resynchronisation therapy, complex arrhythmia ablation and structural heart interventions. These procedures all carry the risk of cardiac arrest. We have developed evidence-based guidelines for the management of cardiac arrest in adult patients in the catheter laboratory. The guidelines include recommendations which were developed by collaboration between nine professional and patient societies that are involved in promoting high-quality care for patients with cardiovascular conditions. We present a set of protocols which use the skills of the whole catheter laboratory team and which are aimed at achieving the best possible outcomes for patients who suffer a cardiac arrest in this setting. We identified six roles and developed a treatment algorithm which should be adopted during cardiac arrest in the catheter laboratory. We recommend that all catheter laboratory staff undergo regular training for these emergency situations which they will inevitably face.

Objective and Background Dual antiplatelet therapy is standard of care in patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI), however debate remains regarding the optimal P2Y12 receptor antagonist to combine with aspirin. Methods We performed a retrospective analysis of all PCI procedures for ACS recorded in the British Cardiovascular Intervention Society database between 2007 and 2014 treated with aspirin and either clopidogrel, prasugrel or ticagrelor. The primary outcome measure was 30-day all-cause mortality, with secondary outcomes of mortality at 1 and 5 years. Odds ratios (OR) for mortality were determined from multivariable logistic regression. We used multiple imputations to address missing values and reduce inherent bias from complete case-only analysis. Difference in outcome amongst patients receiving different P2Y12 inhibitors was evaluated by Kaplan-Meier survival curves and log-rank testing. All statistical analysis, including calculation of marginal effects, was performed using SPSS version 21 and R software version 2.13.1. Results Among 382,361 eligible patients with 2 million person-years of observation, 6.8% (n=26,000) of patients had ticagrelor, 8.0% (n=30,590) had prasugrel and 85.2% (n=325,771) were treated with clopidogrel for ACS. Mean age of participants was 62.8±4.3 years; 77.1% of patients were males and 31.6% had diabetes. The proportion of people undergoing intervention for stable angina was largest and comprised of 164,797 participants, followed by NSTEMI [157,532 participants] with only a small proportion of patients undergoing intervention for a STEMI [60,032 participants]. ACS patients treated with clopidogrel were slightly older and had a higher percentage of people who had renal failure, but a lower proportion in this group were treated for a STEMI. This reflects on the increasing provision for PCI for STEMI during years when prasugrel and ticagrelor were introduced as options. Crude mortality rates for ACS were 34.7, 31.6 and 30.9 deaths per 1000-person-years for patients receiving clopidogrel, prasugrel, and ticagrelor, respectively. In age-sex unadjusted multinomial logistic regression analysis, use of ticagrelor or prasugrel rather than clopidogrel led to respective reductions in 1-year mortality of 64% [OR 0.34, 95% CI (0.32–0.36)], and 27% (OR 0.73 (0.69–0.77), p<0.0001). Using clopidogrel as the reference, the age-sex adjusted 1-year mortality rate was 63% [(OR 0.37 (0.34–0.40)] and 57% [(OR 0.43 (0.40–0.45), p<0.0001)] lower with ticagrelor and prasugrel, respectively in ST-elevation myocardial infarction (STEMI) patients and 80% [(OR 0.20 (0.18–0.23), p<0.0001)] and 36% [(OR 0.43 (0.40–0.45), p<0.0001)] lower in non-STEMI patients. Furthermore, using marginal effects, we demonstrate that while the probability of mortality increases with increasing age and BMI, it is lower across all ages and BMIs for patients on ticagrelor compared to patients on prasugrel. Figure 1 demonstrates the cumulative incidence for all-cause mortality stratified by antiplatelets. Conclusions This very large, real-world dataset of patients presenting with ACS demonstrates a significant net clinical benefit favouring the use of ticagrelor and prasugrel over clopidogrel in ACS patients for DAPT. This analysis concurs with the data from the landmark TRITON and PLATO RCTs, suggesting these agents should be considered as the standard of care in the management of ACS.

BACKGROUND:Patients with three-vessel coronary artery disease have been found to have better outcomes with coronary-artery bypass grafting (CABG) than with percutaneous coronary intervention (PCI), but studies in which PCI is guided by measurement of fractional flow reserve (FFR) have been lacking.METHODS:In this multicenter, international, noninferiority trial, patients with three-vessel coronary artery disease were randomly assigned to undergo CABG or FFR-guided PCI with current-generation zotarolimus-eluting stents. The primary end point was the occurrence within 1 year of a major adverse cardiac or cerebrovascular event, defined as death from any cause, myocardial infarction, stroke, or repeat revascularization. Noninferiority of FFR-guided PCI to CABG was prespecified as an upper boundary of less than 1.65 for the 95% confidence interval of the hazard ratio. Secondary end points included a composite of death, myocardial infarction, or stroke; safety was also assessed.RESULTS:A total of 1500 patients underwent randomization at 48 centers. Patients assigned to undergo PCI received a mean (±SD) of 3.7±1.9 stents, and those assigned to undergo CABG received 3.4±1.0 distal anastomoses. The 1-year incidence of the composite primary end point was 10.6% among patients randomly assigned to undergo FFR-guided PCI and 6.9% among those assigned to undergo CABG (hazard ratio, 1.5; 95% confidence interval [CI], 1.1 to 2.2), findings that were not consistent with noninferiority of FFR-guided PCI (P = 0.35 for noninferiority). The incidence of death, myocardial infarction, or stroke was 7.3% in the FFR-guided PCI group and 5.2% in the CABG group (hazard ratio, 1.4; 95% CI, 0.9 to 2.1). The incidences of major bleeding, arrhythmia, and acute kidney injury were higher in the CABG group than in the FFR-guided PCI group.CONCLUSIONS:In patients with three-vessel coronary artery disease, FFR-guided PCI was not found to be noninferior to CABG with respect to the incidence of a composite of death, myocardial infarction, stroke, or repeat revascularization at 1 year. (Funded by Medtronic and Abbott Vascular; FAME 3 ClinicalTrials.gov number, NCT02100722.).

OBJECTIVES The purpose of this study was to identify where ultrasmall superparamagnetic particles of iron oxide (USPIO) locate to in myocardium, develop a methodology that differentiates active macrophage uptake of USPIO from passive tissue distribution; and investigate myocardial inflammation in cardiovascular diseases. BACKGROUND Myocardial inflammation is hypothesized to be a key pathophysiological mechanism of heart failure (HF), but human evidence is limited, partly because evaluation is challenging. USPIO-magnetic resonance imaging (MRI) potentially allows specific identification of myocardial inflammation but it remains unclear what the USPIO-MRI signal represents. METHODS Histological validation was performed using a murine acute myocardial infarction (MI) model. A multiparametric, multi-time-point MRI methodology was developed, which was applied in patients with acute MI (n = 12), chronic ischemic cardiomyopathy (n = 7), myocarditis (n = 6), dilated cardiomyopathy (n = 5), and chronic sarcoidosis (n = 5). RESULTS USPIO were identified in myocardial macrophages and myocardial interstitium. R1 time-course reflected passive interstitial distribution whereas multi-time-point R2* was also sensitive to active macrophage uptake. R2*/R1 ratio provided a quantitative measurement of myocardial macrophage infiltration. R2* behavior and R2*/R1 ratio were higher in infarcted (p = 0.001) and remote (p = 0.033) myocardium in acute MI and in chronic ischemic cardiomyopathy (infarct: p = 0.008; remote p = 0.010), and were borderline higher in DCM (p = 0.096), in comparison to healthy controls, but were no different in myocarditis or sarcoidosis. An R2*/R1 threshold of 25 had a sensitivity and specificity of 90% and 83%, respectively, for detecting active USPIO uptake. CONCLUSIONS USPIO are phagocytized by cardiac macrophages but are also passively present in myocardial interstitium. A multiparametric multi-time-point MRI methodology specifically identifies active myocardial macrophage infiltration. Persistent active macrophage infiltration is present in infarcted and remote myocardium in chronic ischemic cardiomyopathy, providing a substrate for HF. (C) 2021 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation.

Introduction Spontaneous coronary artery dissection (SCAD) is recognised as an infrequent presentation of acute coronary syndromes (ACS). Using a large comprehensive UK ACS registry, we examined the incidence, demographic profile and long-term survival of ACS patients with SCAD. Methods We compared ACS patients with SCAD versus without SCAD admitted to hospitals in the UK (England) between 2000 and 2014 from the Algorithm for Co-morbidity, Associations, Length of stay and Mortality (ACALM) registry (n=33, 163). ACALM uses a big data approach collecting ICD-10 and OPCS-4 coding systems to identify patient data. Primary outcome was all-cause mortality over a 14-year time period. Adjustment was performed using a Cox-regression model. Results In our cohort, 182 patients (0.54%) were diagnosed with SCAD as the cause for ACS. Compared to patients without SCAD, patients with SCAD were younger, more commonly female and less likely to have traditional risk factors for ACS or significant comorbid conditions (Table 1). Revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery was uncommon with SCAD (11.0%, 2.7% respectively) compared to ACS patients without SCAD (50.7%, 10.6% respectively). All-cause mortality was significantly better in SCAD patients compared to non-SCAD ACS patients (10.4% vs. 32.1%, p=0.003). Kaplan-Meier curve comparing 5-year survival is shown below (figure 1). After adjusting for age, gender, ethnic group and the top causes of morbidity and mortality in the UK, patients with SCAD presenting as ACS demonstrate improved survival compared to ACS patients without SCAD (OR 1.89; 95% C.I 1.20–2.96). Conclusion Accepting the potential of under reporting by clinicians in routine clinical practice, a minority of ACS patients in this large UK registry present with SCAD. These patients are commonly younger females without traditional risk factors for ACS. To our knowledge, this is the first study to demonstrate improved long-term survival over a 14-year period with SCAD. Additionally, our analysis suggests conservative therapy is safe in this patient population. Further studies are required to explore non-traditional risk factors, predictors of SCAD and best treatment strategy for these patients. Conflict of Interest Nil

Background: Ventricular fibrillation (VF) during reperfusion in ST-elevation myocardial infarction (STEMI) is an infrequent event, however it contributes to increased in-hospital mortality.Dispersion of ventricular repolarization is known to contribute to ventricular vulnerability during acute ischemia.Prolongation of Tpeak-Tend interval was proposed as a ventricular repolarization dispersion marker, however its value for prediction of reperfusion VF has not been studied.We aimed to assess whether Tpeak-Tend early in the course of STEMI is associated with reperfusion VF.Methods: Consecutive STEMI patients admitted to a tertiary care hospital for primary PCI during 2007-2012 (n=3274) were retrospectively assessed for the presence of VF during reperfusion.Pre-PCI ECGs recorded in 40 patients who developed reperfusion VF (rVF group; age 67±12 years, 67% male) were compared with pre-PCI ECGs from 402 consecutive patients admitted for primary PCI during 2007 and not suffered from reperfusion arrhythmias (No-rVF; age 66±13 years; 80% male) group.ECGs were exported from digital archive and automatically processed in order to calculate Tpeak-Tend interval on a per-lead basis.The global Tpeak-Tend was calculated between the earliest Tpeak and the latest Tend in any lead.Tpeak-Tend interval was tested for association with reperfusion VF using logistic regression analysis adjusted for significant clinical covariates.Results: The leftward shift of Tpeak towards QRS onset in ischemic leads resulted in Tpeak-Tend prolongation.Global Tpeak-Tend in rVF group was higher than in No-rVF group (142±24 vs 129±28 ms; p=0.005).The optimal cut-off for global Tpeak-Tend for VF prediction was 131 ms (Sp=73%; Se= 58%).Global Tpeak-Tend >130 ms predicted reperfusion VF (OR=3.60;95% CI 1.76-7.40;p=0.001) and remained a significant predictor of reperfusion VF after adjustment for age, gender, smoking, myocardial infarction localization and QRS duration (OR=4.23;95% CI 1.89-9.43;p<0.001).Conclusion: Tpeak-Tend interval before PCI in STEMI was an independent predictor of reperfusion VF in a single-center study.Our findings warrants further research aimed at prospective validation of Tpeak-Tend as a marker of periprocedural arrhythmic risk.

Introduction Percutaneous Coronary Intervention (PCI) has changed the management of acute coronary syndrome (ACS). However, the role of PCI in patients with previous coronary artery bypass grafting (CABG) is widely debated. Lack of clear guidelines leads to subjective assessments based on clinician preferences. We sought to investigate if PCI affected all-cause mortality in ACS patients with previous CABG. Methods Completely anonymous information on patients with ACS with a background of previous CABG presenting to three multi-ethnic general hospitals in the North West of England, United Kingdom in the period 2000–2012 was obtained. Patients were traced using the ACALM (Algorithm for Comorbidities, Associations, Length of stay and Mortality) study protocol using ICD-10 and OPCS-4 coding systems. Information on demographics, co-morbidities and procedures were available for all patients. Predictors of mortality and survival analyses were performed using SPSS version 20.0. Results Out of 12,227 patients with ACS, 1172 (19.0%) cases had previous CAVBG. Of these 83 (7.1%) patients underwent PCI. Multi-nominal logistic regression, accounting for differences in age and co-morbidities, revealed that PCI conferred a 7.96 times improvement in mortality (2.36–26.83 95% CI) compared to not having PCI. Conclusions We have shown that PCI confers significantly improved all-cause mortality in the management of ACS in patients with previous CABG. This highlights the need for clinicians to conscientiously think about the individual benefits and risks of PCI for every patient.

Introduction Studies have shown that one in four psychiatric patients also suffer from a cardiovascular co-morbidity, and in recent years the links between cardiovascular disease and psychiatric conditions have been on the rise. We decided to investigate the prevalence of psychiatric co-morbidities and tendencies in patients with NIHF over a 14 year period. Methods We compiled an anonymous database of adult patients diagnosed with NIHF across 7 hospitals in the North of England, UK, during 01/01/2000 to 31/03/2013. We analysed the data for prevalence of psychiatric co-morbidities such as; anxiety disorder, schizophrenia, depression etc. and for tendencies such as substance abuse and suicide attempts. We traced our patients with the ACALM (Algorithm for Co-morbidities, Associations, Length of Stay and Mortality) study protocol, which uses ICD-10 and OPCS-4 codes to allocate patients for statistical analysis using SPSS Version 20.0. Results Between the years 2000–2013, 929,552 patients were admitted, 958 (0.1%) of which had NIHF. The majority of our patients where male (68%), had a mean age of 54.9 years ± 13.9 years, and had a Caucasian background (77%). Of these 958 patients, 8.1% (n = 78) had a psychiatric co-morbidity; depression and schizophrenia where most prevalent. Depression however, seems to more prevalent in dilated cardiomyopathy (DCM) as opposed to hypertrophic cardiomyopathy (HCM). 10.3% (n = 99) suffered from substance abuse, made up mainly by alcohol and tobacco abuse. 2 of our patients (0.2%) where admitted following suicide attempts. Conclusion It remains debatable whether these psychiatric conditions and tendencies represent a causative or correlative link. Studies exists to lend evidence to both claims. We did however find a steady increase in tobacco and alcohol abuse, and the diagnosis of depression in relation to our cohort during our 14-year period. We found that almost one in ten (8.14%) patients with NIHF suffer from psychiatric co-morbidity and that one in ten (10.33%) abuse some form of substance alongside their cardiac condition. Thus, a holistic approach to patients with NIHF should be adopted, and this approach would fall short if it did not explore patient’s use of recreational drugs, suicidal intent and psychiatric wellbeing.

Introduction Ischaemic heart disease is the leading cause of mortality worldwide. The development of surgical and percutaneous interventions has improved survival rates, but the influence of sociodemographic factors on outcomes following MI and their potential use as predictors of such outcomes, are increasingly recognised. Conclusive studies show associations between marriage and lower incidences of IHD in addition to better survival prospects for married individuals suffering MI. There is however, a conflicting evidence base and a lack of literature considering the influence of marital status on LOS, which has been observed to be highly variable in MI patients. Objectives From a large patient database, we aimed to investigate the impact of marital status on the prevalence, LOS and crude mortality of MI patients admitted in Northern England, UK. Methods We compared marital status variations and associated LOS and mortality data by one way anova and cox regression respectively, using anonymous information on MI patients obtained from hospitals in North England between 1st January 2000 and 31st March 2013. This data was analysed according to the ACALM (Algorithm for Comorbidities, Associations, Length of stay and Mortality) study protocol, which uses ICD-10 and OPCS-4 codes to trace patients and demographics. P values <0.05 were taken as statistically significant. Results Amongst 929552 patient admissions recorded during the study period there were 25287 cases involving a new diagnosis of MI. Mean age of MI patients was 66.6 years, 64.2% of the cohort were male and 80.3% were Caucasian. 38.2% of MI patients died and mean LOS was 7.0 days. Crude mortality was highest among widowed patients (62.9%). Logistic regression accounting for age, sex and gender showed that married (OR 0.863), widowed (OR 0.959) and unmarried patients (OR 0.973) had statistically lower mortality rates when compared to single people. LOS was statistically shorter for married patients (2.12 days shorter), and unmarried patients (2.66 days shorter) compared to a mean LOS of 8.2days recorded amongst single patients. Conversely, mean LOS was 1.82 days longer for widowed patients. Conclusion Marital status has a clinically important impact on LOS and mortality of MI patients. In particular, single patients show higher mortality rates and longer LOS compared to married patients. It is reasonable to suggest that these results may be due to reduced social support at home and this should be taken into account when considering the holistic care of patients with MI.

Background Atrial Fibrillation (AF) and Heart Failure (HF) frequently co-exist conferring considerable morbidity and mortality, yet current treatment options remain limited. Recent meta-analyses of patients with concomitant AF and HF have suggested no prognostic benefit of beta-blockers or digoxin, creating a paradox whereby those most in need have the fewest therapeutic choices. We sought to investigate the association between HF and AF and their impact on mortality from a large 14-year naturalistic follow-up study. Methods Anonymous data of adult patients aged ≥18 with all types of HF and AF admitted to several hospitals in the North of England between 2000 and 2013 was obtained and processed using the ACALM (Algorithm for Co-morbidity, Associations, Length of stay and Mortality) study protocol. ACALM uses the ICD-10 and OPCS-4 coding systems to identify patients and the methodology has been published widely. Analyses were performed comparing mortality between patients with HF, AF and combined HF and AF at baseline and their development during follow-up. Results At baseline, of 929,552 adult patients 29,164 (3.1%) had AF, 19,474 (2.1%) had HF, and 5,728 (0.6%) had both HF and AF. Of those with AF at baseline, 1,647 (5.6%) developed HF during follow-up, and of those with HF at baseline, 824 (4.2%) developed AF during follow-up. Demographics and crude mortality rates are shown; see Table. Patients with combined AF and HF at baseline had increased mortality than patients with AF or HF alone. Patients with AF at baseline that developed HF, and patients with HF at baseline that developed AF, experienced a greater mortality compared to those with combined HF and AF at baseline; see Figure. Conclusion Concomitant AF and HF is associated with substantial mortality and risk of death, irrespective of which disease develops first. In light of limited current treatment for these patients, future therapies to specifically target the combined HF and AF group are required.