Data from previous studies of patients with heart failure and coronary artery disease suggest that those with higher resting heart rates (HRs) have worse cardiovascular outcomes. We sought to evaluate whether HR immediately before percutaneous coronary intervention (PCI) is an independent predictor for 30-day outcome. We analyzed the outcome of 3,720 patients who had HR recorded before PCI from the Melbourne Interventional Group registry. HR and outcomes were analyzed by quintiles, and secondarily by dichotomizing into <70 or >= 70 beats/min. Patients with cardiogenic shock, intra-aortic balloon pump or inotropic support, and out-of-hospital arrest were excluded. The mean +/- SD HR was 70.9 +/- 14.7 beats/min. HR by quintile was 55 +/- 5, 64 +/- 2, 70 +/- 1, 77 +/- 3, and 93 +/- 13 beats/min, respectively. Patients with higher HR were more likely to be women, current smokers, have higher systolic and diastolic blood pressure, atrial fibrillation, recent heart failure, lower ejection fraction, and ST-elevation myocardial infarction as the indication for the PCI (all p <= 0.002). However, rates of treated hypertension, multivessel disease, previous myocardial infarction, PCI, and coronary bypass surgery were lower (all p <= 0.004). Increased HR was associated with higher 30-day mortality (p for trend = 0.04), target vessel revascularization (p for trend = 0.003), and 30-day major adverse cardiac events (MACE) (p for trend = 0.004). In a multivariable analysis, HR was an independent predictor of 30-day MACE (OR 1.21 per quintile; 95% confidence interval (CI): 1.06 to 1.39, p = 0.004). When dichotomized into <70 or >= 70 beats/min, HR independently predicted both 30-day MACE (OR 1.59, 95% CI 1.08 to 2.36, p = 0.02) and 30-day mortality (OR 2.80, 95% CI 1.10 to 7.08, p = 0.03). In conclusion, HR immediately before PCI is an independent predictor of adverse 30-day cardiovascular outcomes. (C) 2018 Elsevier Inc. All rights reserved.

AIMS:Despite the guidelines, a "treatment gap" exists in the delivery of pharmacotherapy for secondary prevention. We aimed to analyze the trend in guideline-based medication usage following percutaneous coronary intervention (PCI) using the Melbourne Interventional Group (MIG) registry over a 6-year period (2005-2010).METHODS:The MIG registry prospectively collects demographical, clinical, and procedural characteristics of consecutive patients undergoing PCI. We assessed medication use (aspirin, clopidogrel, ACE inhibitors, angiotensin receptor blockers, beta-blockers, and lipid-lowering agents) at 30 days and 12 months in patients alive and able to provide the information.RESULTS:The cohort consists of 12,813 patients who underwent 14,787 consecutive interventional procedures. They comprised 76% males: 22% were elderly (≥75 years), 23% had diabetes, 2% had severe renal impairment, 2% had severe left ventricular dysfunction, 26% presented with STEMI, and 44% of patients received drug-eluting stent. Follow-up was complete for 97.8% of the cohort at 30 days (2.2% mortality) and 89.1% at 12 months (4% mortality). From 2005 to 2010, the percentage of patients taking all five classes of medications increased each year. In 2010 at 30 days, nearly 60% of patients took all five classes of medications, and by 12 months, 75% of patients were taking four or five classes of medications.CONCLUSION:In conclusion, while the increasing use of cardiovascular medicines in an "at-risk" Australian cohort is encouraging, a treatment gap appears to still exist.

With an aging population, fragility fractures including injuries to the proximal humerus continue to rise in the United States. The purpose of this study was to investigate recent trends in the incidence and treatment of proximal humerus fractures (PHFs) in a cross-sectional elderly population.Medicare data from 2005 to 2012 were queried to identify patients treated for PHF. Associated patient demographics, hospitalization data, treatment, and revision status were obtained. Statistical analyses were performed to identify significant trends in treatment.There were 259,506 PHFs recorded, with 79% occurring in female patients. In all age groups, nonoperative treatment of PHF was the most common method (67%). Within the surgical group, open reduction with internal fixation was most frequently used, and total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA) was the least common (11%). However, although the overall rate of surgical intervention remained constant, there was a significant increase in treatment with TSA from 3% in 2005 to 17% in 2012. In particular, RTSA represented 89% of all TSAs for PHF in 2011. All surgical treatment options demonstrated high 2-year survival rates without revision surgery (97%).Recent trends show that in the elderly population, nonoperative management remains the most common treatment for PHFs. Within the surgically treated cohort, there has been an increase in treatment with arthroplasty including RTSA, with a low rate of early revisions. There are excellent survival rates in all surgically treated PHFs, but long-term data will be required to fully evaluate the viability of these surgical options.

Anterior tension wiring using Kirschner wires (K-wires) is still considered the standard treatment for patella fractures, despite its high complication rate. The objective of this prospective clinical study was to evaluate intra- and perioperative complications as well as the clinical outcome of patients with patella fracture treated with a new developed bilateral, polyaxial, fixed-angle 2.7 mm patella plate.Between 2011 and 2014 all patients with a patella fracture were included in this prospective study and treated with a fixed-angle patella plate. Avulsion fractures of the inferior or superior pole of the patella were excluded. All fractures were classified according to the AO/OTA fracture classification. During a twelve-month follow up period all intra- and postoperative complications were recorded as well as the time until fracture healing. One year postoperatively the Lysholm Score, the pre- and postoperative Tegner Score, the Hospital for Special Surgery Knee Score (HSS), the Turba Score, the Oxford Knee Score, the Knee injury and Osteoarthritis Outcome Score (KOOS), the Bostman Score and the Iowa Knee Score were surveyed. Altogether, 20 patella fractures in 19 patients were included in this prospective study. The most frequent type of fracture, n = 10, was a simple transverse patella fracture (C1), followed by 7 comminuted patella fractures (C3) and 3 T-shaped patella fractures (C2).During the 12-month follow up period two patients treated with the patella plate had a complication. In one patient a superficial wound infection occurred, which was treated successfully with hardware removal and in one patient a fracture dislocation due to an implant failure occurred. X-rays demonstrated complete bony healing in all fractures on average 3.2 months postoperatively. All knee scores showed good to excellent clinical results one year postoperatively.The results of this first clinical study indicate that the fixed-angle patella plate is an effective and safe treatment option for patella fractures with a short operative learning curve. The treatment of communited patella fractures (C3) with a fixed-angle patella plate should be well-considered to avoid distending the indication and biomechanical properties.

Globally, cardiovascular disease remains a major cause of adverse outcomes in young individuals, unlike its decline in other age groups. This group is not well studied and has a unique risk profile with less traditional cardiovascular risk factors compared with older populations. Plaque rupture still remains the most common etiology of myocardial infarction, but unique syndromes such as plaque erosion, coronary microvascular dysfunction, spontaneous coronary artery dissection, and coronary spasm related to drug use are more prevalent in this age group. Such diversity of diagnosis and presentation, along with therapeutic implications, underscore the need to study the profile of myocardial infarction in young persons. We searched PubMed for articles published from 1980 to 218 using the terms acute myocardial infarction, young, plaque rupture, plaque erosion, spontaneous coronary artery dissection (SCAD), coronary vasospasm, variant or Prinzmetal angina, drug-induced myocardial infarction, myocarditis, coronary embolism, microvascular dysfunction, MINOCA, and myocardial infarction in pregnancy and reviewed all the published studies. With the data from this search, we aim to inform readers of the prevalence, risk factors, presentation, and management of acute myocardial infarction in young patients and elaborate on special subgroups with diagnostic and therapeutic challenges. We also outline a parsimonious method designed to simplify management of these complex patients.

We are reporting a case of 46 year-old man, smoker with strong family history of coronary artery disease, presenting with acute anterolateral ST elevation myocardial infarction (STEMI). Diagnostic angiography revealed thrombus at the distal left main, occluding the anterior descending and intermediate arteries. Thrombus aspiration was performed with successful return of flow in the left coronary system. Stenting was deferred due to absence of occlusive lesion. He was commenced on glycoprotein (GP) IIbIIIa inhibitor and received intra-aortic balloon pulsation for haemodynamic support. Follow-up angiography revealed good flow in left coronary artery with normal ventricular function and no significant disease. He remained event-free at one-year follow-up. This case demonstrated that in the absence of occlusive lesion, thrombus aspiration alone without angioplasty or stenting is safe and effective with good clinical outcome.

Introducción. Las vías clínicas son herramientas que facilitan la atención sistemática y multidisciplinaria del paciente. Son especialmente útiles en procesos frecuentes y con un curso clínico predecible, en los que encontramos una elevada variabilidad en su asistencia. El objetivo de este trabajo es presentar los resultados de la evaluación de la vía clínica de la tiroidectomía tras 5 meses de implantación.Entre octubre de 2001 y marzo de 2002 fueron intervenidos 44 pacientes por enfermedad tiroidea (35 tiroidectomías totales y nueve hemitiroidectomías). Los resultados se comparan con una serie obtenida de un muestreo aleatorio estratificado de 56 pacientes operados previamente a la implantación de la vía clínica. La vía contempla una estancia media de 2 días en la hemitiroidectomía, y de 3, en la tiroidectomía total. Se incorpora a la vía clínica un protocolo de tratamiento de reposición de calcio asociado con la tiroidectomía total. Se establecen como indicadores: la estancia hospitalaria, los efectos adversos y los resultados de la encuesta de satisfacción a los pacientes.La estancia media de los pacientes con hemitiroidectomía fue de 3,3 días antes de la implantación de la vía clínica y de 2,4 tras ésta, y la de los pacientes con tiroidectomía total fue de 4,3 días antes de la vía clínica y de 3,4 días después de ésta, con diferencias estadísticamente significativas en ambos procesos. No hubo diferencias en cuanto aefectos adversos antes o después de la implantación de la vía clínica. Al 93,2% de los pacientes le parecióadecuado el tiempo de ingreso en el hospital.La implantación de la vía clínica de la tiroidectomía ha conseguido disminuir la variabilidad clínica y, con ello, acortar la estancia hospitalaria, todo ello sin aumentar las complicaciones y con un alto grado de satisfacción de los pacientes.Clinical pathways facilitate systematic and multidisciplinary patient care.They are especially useful in common processes with a predictable course and wide clinical variability in their management. In this study we present the results of evaluation of the clinical pathway for thyroidectomy five months after it was introduced.Between October 2001 and March 2002, 44 patients underwent surgery for thyroid disease (35 thyroidectomies and 9 hemithyroidectomies). The results were compared with those of a series obtained from stratified random sampling of 56 patients who underwent surgery before the introduction of the clinical pathway. The clinical pathway envisions a postoperative length of hospital stay of 1 day for hemithyroidectomy and one of 2 days for total thyroidectomy. A protocol for calcium replacement therapy in patients undergoing total thyroidectomy was incorporated into the clinical pathway. Length of hospital stay, adverse effects, and the results of a patient satisfaction survey were evaluated.After introduction of the clinical pathway, the mean length of hospital stay showed a statistically significant decrease in both hemithyroidectomy (3.3 days vs 2.4 days) and total thyroidectomy (4.3 days vs 3.4 days). No differences were found in adverse effects before and after the introduction of the clinical pathway. A total of 93.2% of the patients considered that the length of time spent in hospital was adequate.The introduction of the clinical pathway for thyroidectomy reduced clinical variability and consequently length of hospital stay with no increase in the complication rate and a high degree of patient satisfaction.

BackgroundGuidelines for patients with ST-elevation myocardial infarction include a door-to-balloon time (DTBT) of 90min for primary percutaneous coronary intervention.AimThe aim of this study was to assess temporal trends (2006-2010) in DTBT and determine if a reduction in DTBT was associated with improved clinical outcomes.MethodsWe compared annual median DTBT in 1926 STEMI patients undergoing primary percutaneous coronary intervention from the Melbourne Interventional Group registry. ST-elevation myocardial infarction presenting >12h and rescue percutaneous coronary intervention was excluded. Major adverse cardiac events were analysed according to DTBT (dichotomised as 90min vs >90min). A multivariable analysis for predictors of mortality (including DTBT) was performed.ResultsBaseline demographics, clinical and procedural characteristics were similar in the STEMI cohort across the 5 years, apart from an increase in out-of-hospital cardiac arrest (3.6% in 2006 vs 9.4% in 2010, P < 0.0001) and cardiogenic shock (7.7-9.6%, P = 0.07). The median DTBT (interquartile range) was reduced from 95 (74-130) min in 2006 to 75 (51-100) min in 2010 (P < 0.01). In this period, the proportion of patients achieving a DTBT of 90min increased from 45% to 67% (P < 0.01). Lower mortality and major adverse cardiac event rates were observed with DTBT 90min (all P < 0.01). Multivariable analysis showed that a DTBT of 90min was associated with improved clinical outcomes at 12 months (odds ratio 0.48; 95% confidence interval 0.33-0.73, P < 0.01).ConclusionThere has been a decline in median DTBT in the Melbourne Interventional Group registry over 5 years. DTBT of 90min is associated with improved clinical outcomes at 12 months.

Background: Patients with rheumatoid arthritis (RA) have a higher prevalence of coronary disease and higher cardiovascular event rates than individuals without RA. We sought to evaluate whether RA is an independent predictor for cardiovascular outcomes following percutaneous coronary intervention (PCI). Methods: The outcomes of 279 patients with RA (68 ± 10 years; 43% female) enrolled in the Melbourne Interventional Group registry were compared to 13,385 patients without RA. In a secondary analysis, patients were propensity-matched by major predictors of outcome following PCI: age, gender, renal function (eGFR), diabetes and cardiogenic shock. Results: Patients with RA were more likely to be female and older, and to have a history of renal impairment, cerebrovascular disease, peripheral vascular disease, chronic lung disease, and obstructive sleep apnoea (all p ≤ 0.005). They were more likely to receive a bare-metal stent and to have no reflow post-PCI (all p ≤ 0.004). Re-admission rates were higher in the RA group at both 30 days and 12 months (p ≤ 0.04 for both), but there was no difference in in-hospital and 30-day mortality and MACE between the groups. However, there was a trend to increased mortality in patients with RA at 12 months (4.7% versus 7.2%, p = 0.053). When compared to a propensity-matched cohort, there was no difference in in-hospital, 30-day or 12-month MACE and mortality. Conclusions: Patients with RA undergoing PCI have similar in-hospital, 30-day and 12-month outcomes to patients without RA. These data suggest despite the perceived high-risk status of patients with RA, the presence of RA should not affect the decision to offer percutaneous revascularisation.

Aims: The aim of this study was to examine contemporary outcomes in diabetic patients undergoing percutaneous coronary intervention (PCI). Methods: Analysis was made of the Melbourne Interventional Group registry which has collected consecutive patient PCI data (2005–2011). We assessed all-cause mortality and major adverse cardiovascular events (MACE) at 30 days and 12 months; specifically focusing on diabetic versus non-diabetic patients according to single (SVD) versus multi-vessel (MVD) disease. Results: The cohort included 17,545 PCI patients of which 4307 (24.5%) were diabetic. Of the diabetic group, 70.8% were male with a mean age of 64.6 ± 11.9 years, and 23.2% required insulin. Compared to non-diabetics, diabetics had higher all-cause mortality at 30 days (OR 1.62, 95% CI: 1.3–2.0, p < 0.001) and 12 months (OR 1.7, 95% CI: 1.5–2.0, p < 0.001). Diabetics also had higher MACE at 30 days (OR 1.4, 95% CI: 1.3–2.0, p < 0.001) and 12 months (OR 1.4, 95% CI: 1.3–1.6, p < 0.001). Diabetics with MVD undergoing PCI had worse outcomes than diabetics with SVD and non-diabetics. No difference in mortality was found between diabetics and non-diabetics with SVD undergoing PCI. Conclusion: Diabetic patients with coronary artery disease undergoing PCI are a high-risk cohort. Diabetic patients with MVD undergoing PCI have the highest mortality and need careful assessment prior to proceeding with PCI.

To evaluate outcomes of patients undergoing rotational atherectomy (RA) in a multicenter percutaneous coronary intervention (PCI) registry. Background: RA remains an important technique for plaque modification in PCI, particularly with complex calcification. Methods: The study population consisted of consecutive patients undergoing PCI in nine major Australian hospitals, who were treated over an 8-year period (June 2004 to June 2012). Results: Of 16,577 PCI's, 1.0% of patients n = 167 (214 lesions) underwent RA. Patients undergoing RA were more likely to be older (71.0 +/- 69.7 vs. 64.4 +/- 11.9 years, P < 0.01), with greater incidence of diabetes (37.7% vs. 23.8%, P < 0.01) and renal impairment. There was no significant difference in procedural success (94.6% vs. 95.5%, P = 0.57), dissection (6.1% vs. 4.8%, P = 0.39), transient no reflow (4.4% vs. 2.8%, P = 0.23), or persistent no reflow (0% RA vs. 0.7% non-RA, P = 0.23). Those undergoing RA had a low but increased risk of death at 12 months (6.6 vs. 3.6%, P = 0.04). There was no significant difference in 12 month major adverse cardiovascular outcomes (MACE) between groups following adjustment for univariate predictors (OR 1.00, 95% CI; 0.93-1.08). Additionally, there was no significant difference in 30-day MACE (6.0% vs. 5.1%, P = 0.62) or 30-day mortality (2.4% vs. 1.8%, P = 0.54) between groups. Conclusions: In this large multicenter registry, RA continues to be used to treat complex lesions with low procedural complications and MACE rates. It is essential for interventional cardiologists to maintain skills in RA to enable effective percutaneous treatment of certain complex lesions. (C) 2015 Wiley Periodicals, Inc.

Whilst transradial PCI has been associated with improved outcomes in patients presenting with STEMI, procedural delays with this approach remain a concern. We investigated the impact of these delays on D2BT in primary STEMI PCI. The median D2BT for 899 patients undergoing primary STEMI PCI between July 2009 and November 2012 from a large Australian multicentre PCI registry was calculated. Patients undergoing rescue PCI and non-urgent PCI post-lysis were excluded. Post procedural complication rates including stroke, bleeding and vascular injury were determined in addition to 30-day MACE rates. Radial access was utilised in 6.7% of STEMI PCI procedures. Patients in the transradial cohort (60 patients) were younger (58.8 vs. 63.1 years p = 0.01), more likely to have received prasugrel (40.4% vs. 6.2% p < 0.001), low molecular weight heparin (28.3 vs. 5.5% p < 0.001) and less likely to be smokers (29.5% vs. 39.1% p = 0.01) than those in the transfemoral cohort (839 pts). There was no significant difference in median D2BT between transradial and transfemoral cohorts (71 min vs. 75 min p = 0.77). There were no vascular complications and one instance of non-access site bleeding requiring transfusion (1.6%) in the transradial cohort, compared with a 4.34% bleeding/vascular complication rate in the transfemoral cohort (p = 0.48). Thirty day MACE rates did not differ significantly (3.33% radial vs. 6.20% femoral p = 0.37). In this retrospective study, radial access did not prolong D2BT compared with femoral access. Radial access may offer both timely reperfusion and reduced vascular complication rates.

Background: Current international guidelines recommend assessment of bleeding risk in patients with acute coronary syndrome (ACS). The “Can Rapid risk stratification of Unstable angina patients Suppress ADverse Outcomes with Early implementation of the ACC/AHA guidelines” (CRUSADE) bleeding score predicts the likelihood of major bleeding in patients with ACS. We aimed to assess the ability of the CRUSADE score to predict in-hospital bleeding in a contemporary cohort of patients with ACS. Methods/results: We analysed outcomes in 2509 patients with ACS undergoing PCI between April 2008 and June 2010 in the Melbourne Interventional Group registry. For each patient we calculated their CRUSADE bleeding-risk score (using gender, creatinine clearance, heart rate, heart failure, peripheral vascular disease, diabetes mellitus, and systolic blood pressure; however, haematocrit was unavailable). Discrimination ability and calibration of the model was assessed using receiver operating characteristics (ROC) and Hosmer–Lemeshow (H–L) statistics, respectively. The mean CRUSADE score was 25 ± 12. The overall incidence of major bleeding was low: 80 of 2509 patients (3.2%). The incidence increased with higher score categories: 1–20: 2.19%; 21–30: 2.2%; 31–40: 5.76%; 41–50: 5.37%; >50: 6.85% (p-trend < 0.001). The discriminatory ability of the CRUSADE score to predict in-hospital bleeding post-PCI was moderate (ROC = 0.65; 95%CI: 0.59–0.71, p < 0.01), with good model calibration (H–L: – = 0.22). Conclusions: The CRUSADE score adequately predicts bleeding after PCI in this Australian cohort. Prediction may have been enhanced with the addition of haematocrit. The CRUSADE score may be useful in tailoring therapy such as vascular access site and adjuvant antithrombotics in patients with ACS undergoing PCI.

The Melbourne Interventional Group registry commenced in 2004 and currently includes 14,832 patients who have undergone 17,029 coronary interventional procedures in seven tertiary referral hospitals. We reflect on key lessons learned since the inception of the registry. These are ranked and will be addressed in detail:1.A multicentre registry with university affiliation allows cardiology trainees increased access to personnel, to critically appraise data and improve their exposure to research.2.Long-term follow-up beyond 12 months becomes too labour intensive for individual patient review; reliance is now placed on linkage to the National Death Index. Alternative avenues such as electronic linkage to hospital records will be discussed.3.Outcomes of patients following PCI are, in general, consistent with other international large scale PCI registries, although our annualised mortality rates are increasing, reflecting an ageing higher-risk population.4.In patients with multivessel disease, comparison of revascularisation technique with the ASCTS CABGS registry is challenged by an inability to match cohorts at baseline.5.Dual antiplatelet therapy is the cornerstone of therapy in PCI patients and rates of long-term use (≥12 months) continue to increase.6.Radial PCI is increasing and may represent a paradigm shift in access for coronary intervention.7.Funding for such a venture has and will continue to be challenging, particularly if standards of independence are to be maintained. The MIG registry remains a valuable vehicle for evaluation of current Australian coronary interventional practice. Future goals include expansion to regional hospitals and linkage to established international registries.

Background: Randomised controlled trials have shown an improvement in surrogate endpoints with aspiration thrombectomy (TA) compared to standard PCI. However, a benefit in clinical outcomes has yet to be demonstrated. Despite this, NHF gives TA class I recommendation. TA can be difficult and often at the expense of longer restoration of perfusion time. As such, there remains clinical equipoise as to the value of TA in primary PCI. Aim: To determine if there is a difference in procedural features and clinical outcomes in those patients treated with TA in Primary PCI in a large registry. Methods: We prospectively collected data from 2833 patients from the MIG registry in Australia who presented with STEMI (<24 hr) between July 2006 and November 2010. Multivariate analysis was performed to determine predictors of 12-month major adverse cardiac events (MACE). Results: There were more males, hypertensive patients and smokers in the TA group. Thrombectomy aspiration was more likely to be used with TIMI 0 flow. The lesions were more complex (B2/C), and longer with more “no-reflow”. There was less DES usage in the TA group. TIMI flow post procedure was not significantly different between the groups. No difference was seen in 30-day mortality.Tabled 11 year OutcomesThrombectomy Device, n = 425No Thrombectomy Device, n = 1975P valueDeath43 (10%)188 (9.5%)0.70Recurrent MI22 (5%)93 (4%)0.68TVR40 (9%)163 (8%)0.43MACE84 (20%)370 (19%)0.63 Open table in a new tab Conclusion: The use of TA in primary PCI did not improve in-hospital mortality or one year MACE outcomes.

Background: Major bleeding is an important and potentially preventable cause of morbidity and mortality in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS). We sought to analyse the incidence and prognostic impact of peri-procedural bleeding in a cohort of patients with ACS undergoing PCI. Methods: We analysed the outcomes of 10,816 patient procedures for ACS from the Melbourne Interventional Group registry. Major bleeding was defined as bleeding requiring transfusion and/or prolonging the hospital stay and/or causing a drop in haemoglobin >3.0 g/dl. Clinical outcomes were measured at 30 days, with independent predictors of mortality identified. Results: Major bleeding occurred in 296 (2.7%) patients. These patients were older (67 ± 13 vs. 64 ± 12 years), more frequently female (39% vs. 25%), with a higher prevalence of heart failure and chronic renal impairment (all p < 0.01). They presented more often with STEMI (61% vs. 42%), cardiogenic shock (20% vs. 4%) and out-of-hospital cardiac arrest (9% vs. 2%) (all p < 0.01). Patients with bleeding were more likely to receive glycoprotein-IIb/IIIa inhibitors, but had lower use of access via the radial artery (all p < 0.01). Major bleeding was associated with increased 30-day mortality rates (15% vs. 3%, p < 0.0001) and major adverse cardiac events (22% vs. 6%, p < 0.0001). Following adjustment for important patient and procedural characteristics, bleeding remained an independent predictor of mortality (odds ratio 2.1: 95%CI 1.3–3.3, p < 0.002) (Table 1, Table 2, Table 3, Table 4).Table 1Baseline characteristics.No Bleeding N = 10,520Bleeding N = 296P ValueAge (years)63.9 ± 1267.4 ± 13<0.001Males, n (%)7900 (75)183 (61)<0.001BMI (kg/m2)28.2 ± 726.9 ± 50.01Diabetes mellitus, n (%)2365 (23)70 (24)0.64Hypertension, n (%)6398 (61)194 (66)0.10Hypercholesterolaemia, n (%)6856 (65)172 (59)0.02Current or ex-smoker, n (%)7071 (68)185 (63)0.09Previous myocardial infarction, n (%)2402 (23)58 (20)0.19Peripheral vascular disease, n (%)659 (6)24 (8)0.20Preexisting heart failure (>2 weeks prior), n (%)363 (3)18 (6)0.02Heart failure prior to procedure, n (%)577 (5)40 (14)<0.001Stroke, n (%)649 (6)32 (11)0.001STEMI, n (%)4408 (42)182 (61)<0.001Cardiogenic shock, n (%)409 (4)60 (20)<0.001Out-of-hospital cardiac arrest, n (%)221 (2)27 (9)<0.001eGFR ≥ 60 mL/min/1.73 m2, n (%)7825 (77)190 (66)<0.001eGFR < 30 mL/min/1.73 m2, n (%)327 (3)17 (6)eGFR 30–59 mL/min/1.73 m2, n (%)2074 (20)83 (29)Abbreviations: BMI = body-mass index; STEMI = ST-elevation myocardial infarction; eGFR = estimated glomerular filtration rate; ACS = acute coronary syndrome. Open table in a new tab Table 2Procedural and lesion characteristics.No BleedingBleedingP ValueLeft main artery involvement, n (%)108 (1)2 (1)0.55Left anterior descending lesion, n (%)4291 (34)140 (39)0.04Proximal left anterior descending artery lesion, n (%)2048 (16)78 (22)0.01Multivessel disease, n (%)5734 (57)171 (59)0.43ACC/AHA B2&C lesions, n (%)6951 (55)235 (66)<0.001Drug-eluting stent use, n (%)5307 (42)123 (34)0.004Mean stent length (mm)19.1 ± 8.617.1 ± 5.30.60Mean stent diameter (mm)3.0 ± 0.53.0 ± 0.50.91Access SiteFemoral9932 (94)286 (97)0.009Radial550 (5)6 (2)Brachial37 (0.4)3 (1)Bivalirudin use, n (%)192 (2)2 (0.7)0.10Thrombolysis prior to procedureThrombolysis used <3 hrs prior to PCIThrombolysis used 3-12 hrs prior to PCIThrombolysis used >12 hrs prior to PCIGlycoprotein IIb/IIIa inhibitor use, n (%)4365 (42)189 (64)<0.001Pre-procedure TIMI 3 flow, n (%)Post-procedure TIMI 3 flow, n (%)11,988 (95)333 (93)0.06LVEF Peri-ProcedureLVEF >45%LVEF 30-45%LVEF <30%Abbreviations: TIMI = thrombolysis in myocardial infarction score; LVEF = left ventricular ejection fraction. Open table in a new tab Table 3In-hospital, 30-day outcomes, 12 month outcomes.No BleedingBleedingP ValueIn-hospital complicationsMortality, n (%)260 (2.5)42 (14)<0.001Peri-procedural MI, n (%)127 (1)8 (3)0.02Heart failure, n (%)430 (4)63 (21)<0.001Renal failure, n (%)138 (1.3)36 (12.2)<0.001Stroke, n (%)33 (0.3)6 (2)<0.001In-hospital MACE, n (%)466 (4.4)60 (20)<0.00130-day OutcomesMortality, n (%)311 (3)44 (15)<0.001Cardiac death, n (%)224 (72)26 (59)0.08Non-cardiac death, n (%)87 (28)18 (41)MI, n (%)229 (2.2)11 (4)0.08TVR, n (%)245 (2.3)21 (7)<0.001TLR, n (%)206 (2)20 (7)<0.001MACE, n (%)657 (6)65 (22)<0.001Abbreviations: MI = myocardial infarction; PCI = percutaneous coronary intervention; MACE = major adverse cardiac events; TVR = target vessel revascularisation. Open table in a new tab Table 4Multivariate predictors of 30 day mortality.VariableOR95% CIP ValueBleeding2.11.3–3.30.002aCompared to eGFR≥60mL/min/1.73m2. eGFR=estimated glomerular filtration rate, IABP=intra-aortic balloon pulsation.eGFR < 30 mL/min/1.73 m25.73.6–9.0<0.0001aCompared to eGFR≥60mL/min/1.73m2. eGFR=estimated glomerular filtration rate, IABP=intra-aortic balloon pulsation.eGFR 30–59 mL/min/1.73 m22.51.8–3.3<0.0001Out-of-hospital cardiac arrest7.04.6–10.6<0.0001Cardiogenic shock9.77.1–13.4<0.0001STEMI2.72.0–3.80.001Age1.031.02–1.04<0.001Diabetes mellitus2.01.5–2.70.0001Multivessel disease1.41.03–1.90.03Left main coronary involvement2.41.2–4.80.009Dyslipidaemia0.70.5–0.90.009DES use0.70.5–0.90.024LAD involvement1.51.1–1.90.005CHF prior2.31.6–3.2<0.001CVD1.81.2–2.70.004a Compared to eGFR ≥ 60 mL/min/1.73 m2.eGFR = estimated glomerular filtration rate, IABP = intra-aortic balloon pulsation. Open table in a new tab Abbreviations: BMI = body-mass index; STEMI = ST-elevation myocardial infarction; eGFR = estimated glomerular filtration rate; ACS = acute coronary syndrome. Abbreviations: TIMI = thrombolysis in myocardial infarction score; LVEF = left ventricular ejection fraction. Abbreviations: MI = myocardial infarction; PCI = percutaneous coronary intervention; MACE = major adverse cardiac events; TVR = target vessel revascularisation. Conclusion: Major bleeding is independently associated with poorer outcomes in patients with ACS undergoing PCI. Risk stratification and minimisation of bleeding risks may lead to improved outcomes.

Background: Aspirin, clopidogrel, angiotensin-converting-enzyme inhibitors (ACEi), angiotensin-receptor blockers (ARB), beta-blockers (BB) and statins are of proven benefit in many coronary artery disease subgroups and are guideline indicated. We aim to describe the use of these medications following PCI from 2005 to 2009. Methods: Patients undergoing PCI were prospectively enrolled between 1st January 2005 and 31st December 2009, representing 12,582 PCI procedures. Telephone follow-up or record review at 30 days and 12 months was completed for 99.5% and 91% of procedures respectively. We report the frequency of use of these medications at these time points. Results: Table 1 shows significantly increasing frequencies of use for all medications from 2005 to 2009 at both 30-day and 12-month follow-up.Table 1Total20052006200720082009p-trendAspirin (%)30 days97.295.696.797.198.298.8<0.00112 months92.491.091.592.894.595.9<0.001Clopidogrel (%)30 days94.489.994.696.396.396.0<0.00112 months62.857.663.664.164.471.1<0.001BB (%)30 days72.865.569.373.877.578.9<0.00112 months65.759.862.768.671.772.7<0.001ACEi/ARB (%)30 days77.975.677.479.379.379.10.00112 months77.074.476.978.280.277.20.002Statin (%)30 days93.691.593.394.194.895.7<0.00112 months92.091.091.292.594.093.9<0.001 Open table in a new tab Conclusion: Overall use of these medications at 30 days and 12 months was very good following PCI. The frequency of medication use across the years at follow-up post-PCI is increasing.

Background: Aspirin, clopidogrel, angiotensin-converting-enzyme inhibitors (ACEi), angiotensin-receptor blockers (ARB), beta-blockers (BB) and statins are of proven benefit in most coronary artery disease subgroups and are guideline indicated. We aim to describe the use of these medications following PCI from 2005 to 2009. Melbourne Interventional Group (MIG) is a multi-center PCI registry in Melbourne, Australia. Methods: Patients undergoing PCI were prospectively enrolled between 1 st January 2005 and 31 st December 2009, representing 12582 PCI procedures. Follow-up at 30 days and 12 months was completed for 99.5% & 91% of procedures respectively. We report the frequency of use of these medications at these time points. Results: Overall use of all 5 medications was high at both 30 days and 12 months. There was a steady increase in utilization of medication from 2005 to 2009 amongst all 5 medications, although the use of clopidogrel and BB increased the most. Utilization of all 5 medications from 30 days to 12 months was very good (see Table 1). Similar results were observed in the frequencies of total number of medications being taken, with very few patients reporting taking 0-3 medications at 30 days. At 12 months, 75.7% of patients were either taking 4 (37.6%) or 5 (38.1%) guideline-indicated medications. Table 1: Year Aspirin (%) Clopidogrel (%) BB (%) ACEi/ARB (%) Statin (%) 30 day 12 month 30 day 12 month 30 day 12 month 30 day 12 month 30 day 12 month 2005 95.6 91 89.9 57.6 65.5 59.8 75.6 74.4 91.5 91 2006 96.7 91.5 94.6 63.6 69.3 62.7 77.4 76.9 93.3 91.23 2007 97.1 92.8 96.3 64.1 73.8 68.6 79.3 78.2 94.1 92.5 2008 98.2 94.5 96.3 64.4 77.5 71.7 79.3 80.2 94.8 94 2009 98.8 95.9 96 71.1 78.9 72.7 79.1 77.2 95.7 93.9 Total 97.2 92.8 94.5 63.5 72.6 66.3 78.1 77.3 93.8 92.3 Conclusion: Overall use of these medications from 30 days through to 12 months was very good following PCI. The frequency of medication use across the years at follow-up post PCI is increasing

The aim was to examine timing, causes, and predictors of death during long-term follow-up after contemporary percutaneous coronary intervention (PCI) using a large multicenter Australian registry. The cohort consisted of 10,682 consecutive patients from the Melbourne Interventional Group registry undergoing PCI (February 2004 through November 2009). For the first time in Australia, long-term mortality rates of a PCI cohort were defined by linkage to the National Death Index database. The cohort (mean age 64 +/- 12 years) comprised 75% men, 24% diabetics, 59% with multivessel disease, 4.4% with renal failure, 25% with ST-elevation myocardial infarction (STEMI), 2.5% with cardiogenic shock, and 5.1% with heart failure. Drug-eluting stents (DES) were used in 43% of cases. Mean follow-up was 3.2 +/- 0.5 years. In-hospital, 30-day, 12-month, and long-term (3.2 +/- 0.5 years) mortalities were 1.6% (80% cardiac), 2.1% (79%), 3.9% (61%), and 8.2% (50%), respectively. Independent predictors of long-term mortality included age (hazard ratio 1.05, 95% confidence interval 1.04 to 1.06), cardiogenic shock (4.58, 3.60 to 5.83), renal failure (3.14, 2.58 to 3.82), previous heart failure (1.97, 1.60 to 2.41), STEMI (1.79, 1.47 to 2.18), peripheral vascular disease (1.72, 1.4 to 2.11), non-STEMI (1.58, 1.32 to 1.90), multivessel disease (1.47, 1.24 to 1.74), current smoking (1.39, 1.12 to 1.71), diabetes (1.36, 1.16 to 1.59), and cerebrovascular disease (1.33, 1.06 to 1.60, p < 0.01 for all comparisons). DES deployment appeared protective against late mortality (hazard ratio 0.85, 0.73 to 0.99, p = 0.04); however, after 30 days, there was no difference in mortality rates between those who received a bare metal stent and those who received a DES. In conclusion, different clinical variables such as renal and heart failure predicted long-term mortality after PCI, whereas DES use in this large registry was not associated with late mortality risk. Crown Copyright (C) 2011 Published by Elsevier Inc. All rights reserved. (Am.J Cardiol 2011;108:936-942)