Background: Lower socioeconomic status (SES) has been associated with increased mortality from coronary heart disease. This excess risk, relative to affluent patients, may be due to a combination of more adverse cardiovascular-risk factors, inequalities in access to cardiac investigations, longer waiting times for cardiac revascularisation and lower use of secondary prevention drugs. We sought to investigate whether socio-economic status influenced long-term all-cause mortality after PCI in a large metropolitan city (London), which serves a population of 11 million people with a mixed social background over a 10-year period. Methods: We conducted an observational cohort study of 123,780 consecutive PCI procedures from the Pan-London (United Kingdom) PCI registry. This data set is collected prospectively and includes all patients treated between January 2005 and December 2015. The database includes PCI performed for stable angina and ACS (ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina). Patient socio-economic status was defined by the English Index of Multiple Deprivation (IMD) score, according to residential postcode. Patients were analysed by quintile of IMD score (Q1, least deprived; Q5, most deprived). Median follow-up was 3.7 (IQR: 2.0–5.1) years and the primary outcome was all-cause mortality. Results: The mean age of the patients was 64.3 ± 12.1 years and 25.2% were female. A total of 22.4% of patients were diabetic and 27.3% had a history of previous myocardial infarction. The rates of long-term all-cause mortality increased progressively across quintiles of IMD score, with patients in Q5 showing significantly higher long-term mortality rates compared with patients in Q1 (p = 0.0044). This persisted following the inclusion of a propensity score in the proportional hazard model as a covariate (HR for Q5 compared to Q1: 1.15 [95% CI: 1.10–1.42]). Conclusions: This study has demonstrated that low SES is an independent predictor of adverse clinical outcomes following PCI in the large, diverse metropolitan city of London. There clearly are inequalities in cardio-vascular risk factors, time to access to medical treatment/PCI, access to complex imaging and devices during PCI, access to secondary prevention after PCI, and even race differences. Hence, attention to reducing the burden of cardiovascular risk factors and improving primary prevention, particularly in patients with lower SES, is required.

BACKGROUND Outcome following ST-segment elevation myocardial infarction (STEMI) is thought to be worse in women than in age-matched men. We assessed whether such differences occur in the UK Pan-London dataset and if age, and particularly menopause, influences upon outcome. METHODS We undertook an observational cohort study of 26,799 STEMI patients (20,633 men, 6,166 women) between 2005-2015 at 8 centres across London, UK. Patient details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society (BCIS) PCI dataset. Primary outcome was all-cause mortality at a median follow-up of 4.1 years (IQR: 2.2-5.8 years). RESULTS Kaplan-Meier analysis demonstrated a higher mortality rate in women versus men (15.6% men vs. 25.3% women, P<0.0001). Univariate Cox analysis revealed that female sex was a predictor of all-cause mortality (HR: 1.69 95% CI: 1.59-1.82). However, after multivariate adjustment, this effect of female sex diminished (HR: 1.05 95% CI: 0.90-1.25). In a sub-group analysis, we compared the sexes separated by age into the ≤55 and the >55 year olds. Age-stratified Cox analysis revealed that female sex was a univariate predictor of all-cause mortality (HR: 1.60 95% CI: 1.25-2.05) in the ≤55 group and in the >55 group (HR: 1.38 95% CI: 1.28-1.47). However, after regression adjustment incorporating the propensity score into a proportional hazard model as a covariate, whilst female sex was not a significant predictor of all-cause mortality in the ≤55 group it was a predictor in the >55 group. Moreover, whilst age did not influence outcome in <55 group, this effect in the >55 group was correlated with age. CONCLUSIONS Overall women have a worse all-cause mortality following primary PCI for STEMI compared to men. However, this effect was driven predominantly by women >55 years of age since after adjusting for co-morbidities the risk in younger women did not differ significantly from that in men. These observations support the view that as women advance past the menopausal years their risk of further events following revascularization increases substantially and we suggest that routine assessment of hormonal status may improve clinical decision-making and ultimately outcome for women post-PCI.

Background and aims: In patients with ST-segment elevation myocardial infarction (STEMI), mortality is directly related to time to reperfusion with guidelines recommending patients be delivered directly to centres for primary percutaneous coronary intervention (PCI). The aim of this study was to describe the impact of inter-hospital transfer on reperfusion time and to assess whether or not treatment delays influenced clinical outcomes in comparison with direct admission to a primary PCI centre in a large regional network. Method and results: We undertook an observational cohort study of patients with STEMI treated with primary PCI between 2005 and 2015 in London, UK. Patient details were recorded at the time of the procedure in databases using the British Cardiovascular Intervention Society PCI dataset. The primary end-point was all-cause mortality at a median of 4.1 years (interquartile range: 2.2-5.8 years). Secondary outcomes were in-hospital major adverse cardiac events. Of 25,315 patients, 17,560 (69.4%) were admitted directly to a primary PCI centre and 7755 (31.6%) were transferred from a non-primary PCI centre. Patients in the direct admission group were older and more likely to have left ventricular impairment compared with the inter-hospital transfer group. Median time from call for help to reperfusion in transferred patients was 52 minutes longer compared with patients admitted directly (p <0.001). However, call to first hospital admission was similar. Kaplan-Meier analysis demonstrated significantly lower mortality rates in patients who were transferred directed to a primary PCI centre compared with patients who were transferred from a non-PCI centre (17.4% direct vs. 18.7% transfer, p=0.017). Furthermore, after propensity matching, direct admission for primary PCI was still a predictor of all-cause mortality (hazard ratio: 0.89, 95% confidence interval: 0.64-0.95). Conclusions: In this large registry of over 25,000 STEMI patients treated by primary PCI survival was better in patients admitted directly to a cardiac centre versus patients transferred for primary PCI, most likely due to longer call to balloon times in patient transferred from other hospitals.

Background Limited information exists regarding procedural success and clinical outcomes in patients with previous coronary artery bypass grafting (CABG) undergoing percutaneous coronary intervention ( PCI ). We sought to compare outcomes in patients undergoing PCI with or without CABG . Methods and Results This was an observational cohort study of 123 780 consecutive PCI procedures from the Pan‐London ( UK ) PCI registry from 2005 to 2015. The primary end point was all‐cause mortality at a median follow‐up of 3.0 years (interquartile range, 1.2–4.6 years). A total of 12 641(10.2%) patients had a history of previous CABG , of whom 29.3% (n=3703) underwent PCI to native vessels and 70.7% (n=8938) to bypass grafts. There were significant differences in the demographic, clinical, and procedural characteristics of these groups. The risk of mortality during follow‐up was significantly higher in patients with prior CABG (23.2%; P =0.0005) compared with patients with no prior CABG (12.1%) and was seen for patients who underwent either native vessel (20.1%) or bypass graft PCI (24.2%; P <0.0001). However, after adjustment for baseline characteristics, there was no significant difference in outcomes seen between the groups when PCI was performed in native vessels in patients with previous CABG (hazard ratio [HR],1.02; 95% CI, 0.77–1.34; P =0.89), but a significantly higher mortality was seen among patients with PCI to bypass grafts (HR,1.33; 95% CI, 1.03–1.71; P =0.026). This was seen after multivariate adjustment and propensity matching. Conclusions Patients with prior CABG were older with greater comorbidities and more complex procedural characteristics, but after adjustment for these differences, the clinical outcomes were similar to the patients undergoing PCI without prior CABG . In these patients, native‐vessel PCI was associated with better outcomes compared with the treatment of vein grafts.

HomeCirculation: Cardiovascular InterventionsVol. 13, No. 7Effect of the COVID-19 Pandemic on ST-Segment–Elevation Myocardial Infarction Presentations and In-Hospital Outcomes Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBEffect of the COVID-19 Pandemic on ST-Segment–Elevation Myocardial Infarction Presentations and In-Hospital Outcomes Simon J. Wilson, Michelle J. Connolly, Ziyad Elghamry, Claudia Cosgrove, Sami Firoozi, Pitt Lim, Rajan Sharma and James C. Spratt Simon J. WilsonSimon J. Wilson Correspondence to: Simon J. Wilson, MBCHB, Cardiovascular Department, St. George's Hospitals and University Foundation NHS Trust, London, United Kingdom. Email E-mail Address: [email protected] https://orcid.org/0000-0002-1999-5103 Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. , Michelle J. ConnollyMichelle J. Connolly Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. , Ziyad ElghamryZiyad Elghamry Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. , Claudia CosgroveClaudia Cosgrove Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. , Sami FirooziSami Firoozi Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. , Pitt LimPitt Lim Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. , Rajan SharmaRajan Sharma Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. and James C. SprattJames C. Spratt Department of Cardiology, St. George's University Foundation Hospitals NHS Trust, London, United Kingdom. Originally published30 Jun 2020https://doi.org/10.1161/CIRCINTERVENTIONS.120.009438Circulation: Cardiovascular Interventions. 2020;13:e009438Preliminary reports suggest there has been a marked reduction in the number of patients presenting with acute ST-segment–elevation myocardial infarction (STEMI) during the coronavirus disease 2019 (COVID-19) pandemic.1–3 However, the available data are limited. Moreover, it remains to be determined what effect COVID-19 has had on STEMI in-hospital outcomes. Here we report changes in presentation and prognostic markers in patients admitted to our institution with STEMI following the outbreak of COVID-19.Index admission data were collected on all patients referred for primary percutaneous coronary intervention (PPCI) to our tertiary cardiac center between February 19 and April 14 for the past 4 consecutive years. The COVID-19 era was defined as March 18, 2020, onward, corresponding to the introduction of restrictions of movement and a public health drive to combat rising cases in the United Kingdom. Poisson regression modeling was used to estimate the impact of COVID-19 on weekly number of PPCI referrals, cardiac catherization laboratory (cath-lab) activations, and true STEMI numbers adjusting for calendar week and year. To further investigate the impact on in-hospital survival, the observed-to-predicted mortality ratio was determined using the US National Cardiovascular Data Registry risk calculator. Effect on time to call for help from symptom onset (early, <4 hours; delayed, 4–12 hours; late, >12 hours), in-hospital mortality, percentage of PPCI referrals resulting in cath-lab activation, and percentage of cath-lab activations resulting in STEMI diagnosis were assessed by the χ2 test. Mean difference in index admission echocardiogram-derived quantitatively determined left ventricular ejection fraction was examined by an unpaired t test. A two-sided P of <0.05 was considered statistically significant. All calculations were performed using the statistical package R (www.R-project.org). The study was conducted in accordance with local ethic guidelines with all procedures undertaken as part of standard care and informed consent provided. The data, analytical methods, and study materials will be made available upon reasonable request.Across the 8-week window, the total number of PPCI referrals, cath-lab activations, and STEMI presentations were 952, 441, and 388, respectively. Compared with before COVID-19, incidence rate ratios showed weekly PPCI referrals in the COVID-19 era decreased by a factor of 42.8% ([95% CI, 23.7%–57.6%]; P<0.001), cath-lab activations by 53.1% ([95% CI, 27.7%–70.1%]; P<0.001), and STEMI presentations by 51.4% ([95% CI, 23.6%–70.2%]; P=0.002; Figure [A]). Time to call for help was significantly longer in the COVID-19 era with more patients presenting either delayed or late (Figure [B]). The percentage of PPCI referrals triggering cath-lab activation (46.5% versus 41.5%; P=0.45) and cath-lab activations resulting in STEMI diagnosis (87.4% versus 92.6%; P=0.56) did not change.Download figureDownload PowerPointFigure. Impact of coronavirus disease 2019 (COVID-19) on ST-segment–elevation myocardial infarction (STEMI) presentations and in-hospital outcomes. Impact of COVID-19 on (A) weekly primary percutaneous coronary intervention (PPCI) referrals, coronary catheterization laboratory (cath-lab) activations, and STEMI numbers, (B) time from symptom onset to call for help for all cath-lab activations, (C) left ventricular ejection fraction in STEMI admissions (box, median and interquartile range; whiskers, minimum to maximum), and (D) in-hospital mortality in STEMI admissions.The left ventricular ejection fraction of STEMI patients was significantly lower in the COVID-19 era (43.7% versus 47.4%; P=0.02; Figure [C]) with data available in 97% and 94% of patients, respectively. There was a numerical increase in STEMI in-hospital mortality that did not reach significance (14.5% versus 11.0%; P=0.47; Figure [D]) while the observed-to-predicted mortality ratios remained comparable (1.69 versus 1.83). None of the STEMI patients who died tested positive for COVID-19, and baseline characteristics were similar before and during the outbreak (age, 64.8 versus 63.0 years; male, 78.1% versus 67.9%; diabetes mellitus, 18.6% versus 14.3%; creatinine, 94.3 versus 82.1 μmol/L; preprocedure cardiogenic shock, 18.6% versus 17.9%; and anterior infarct, 47.9% versus 57.1%; P>0.2 for all).Recent data from the United States have suggested a major decline in STEMI activations during the early phase of COVID-19.1 However, it is unclear whether this reflected a true reduction in STEMI presentations or a decrease in inappropriate referrals/cath-lab activations. Coincident with a rise in COVID-19 in the United Kingdom and the introduction of social distancing measures, we observed a fall of ≈50% in both cath-lab activations and STEMI admissions. Comparing the COVID-19 era to historic data, there was no change in the relative number of inappropriate PPCI referrals or false cath-lab activations. Thus, our data indicate the occurrence of a true decline in STEMI presentations with a similar fall in STEMI numbers reported in Europe.2Besides a reduction in STEMI admissions, we observed a striking change in presentation and prognostic indicators. Time to call for help lengthened considerably with more than a 3-fold increase in the number of patients presenting late. This is in line with evidence that falls in STEMI admission are being driven, at least in part, by behavior change.4 The impact of this delay to presentation is a major concern with STEMI patients admitted in the COVID-19 era found to have a significantly worse left ventricular ejection fraction than before the outbreak. This reduction in left ventricular ejection fraction will be likely to translate to increased future morbidity and mortality.5 Indeed, we observed a numerical increase in STEMI in-hospital mortality not explained by intercurrent COVID-19 illness or changes in baseline characteristics, although it should be emphasized the difference was nonsignificant.In conclusion, we have shown a substantial decline in STEMI presentations since the outbreak of COVID-19 and demonstrate for the first time an increase in markers of adverse prognosis. Our results indicate a high potential for major cardiac collateral damage during the COVID-19 pandemic and support measures to combat this where possible.Sources of FundingNone.DisclosuresNone.FootnotesFor Sources of Funding and Disclosures, see page 3.Correspondence to: Simon J. Wilson, MBCHB, Cardiovascular Department, St. George's Hospitals and University Foundation NHS Trust, London, United Kingdom. Email simonwilson3@nhs.netReferences1. Garcia S, Albaghdadi MS, Meraj PM, Schmidt C, Garberich R, Jaffer FA, Dixon S, Rade JJ, Tannenbaum M, Chambers J, et al. Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic.J Am Coll Cardiol. 2020; 75:2871–2872. doi: 10.1016/j.jacc.2020.04.011CrossrefMedlineGoogle Scholar2. Metzler B, Siostrzonek P, Binder RK, Bauer A, Reinstadler SJ. Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: the pandemic response causes cardiac collateral damage.Eur Heart J. 2020; 41:1852–1853. doi: 10.1093/eurheartj/ehaa314CrossrefMedlineGoogle Scholar3. Rodríguez-Leor O, Cid-Álvarezd B, Ojeda S, Martín-Moreiras J, Rumoroso JR, López-Palop R, Serrador A, Cequier A, Romaguera R, Cruz I, et al. Impact of the COVID-19 pandemic on interventional cardiology activity in Spain.REC Interv Cardiol. 2020; 2:82–89.Google Scholar4. Tam CF, Cheung KS, Lam S, Wong A, Yung A, Sze M, Lam YM, Chan C, Tsang TC, Tsui M, et al. Impact of coronavirus disease 2019 (COVID-19) outbreak on ST-segment-elevation myocardial infarctionare in Hong Kong, China.Circ Cardiovasc Qual Outcomes. 2020; 13:e006631. doi: 10.1161/CIRCOUTCOMES.120.006631LinkGoogle Scholar5. Burns RJ, Gibbons RJ, Yi Q, Roberts RS, Miller TD, Schaer GL, Anderson JL, Yusuf S; CORE Study Investigators. The relationships of left ventricular ejection fraction, end-systolic volume index and infarct size to six-month mortality after hospital discharge following myocardial infarction treated by thrombolysis.J Am Coll Cardiol. 2002; 39:30–36. doi: 10.1016/s0735-1097(01)01711-9CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Hernandez I, Yang L, Tang S, Cameron T, Guo J, Gabriel N, Essien U, Magnani J and Gellad W (2024) COVID-19 pandemic and trends in clinical outcomes and medication use for patients with established atrial fibrillation: A nationwide analysis of claims data, American Heart Journal Plus: Cardiology Research and Practice, 10.1016/j.ahjo.2024.100396, 42, (100396), Online publication date: 1-Jun-2024. 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July 2020Vol 13, Issue 7 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.120.009438PMID: 32600109 Originally publishedJune 30, 2020 Keywordshospital mortalitypandemicsprognosispublic healthstroke volumePDF download Advertisement SubjectsPercutaneous Coronary Intervention

Aims The public reporting of healthcare outcomes has a number of potential benefits; however, unintended consequences may limit its effectiveness as a quality improvement process. We aimed to assess whether the introduction of individual operator specific outcome reporting after percutaneous coronary intervention (PCI) in the UK was associated with a change in patient risk factor profiles, procedural management, or 30-day mortality outcomes in a large cohort of consecutive patients. Methods and results This was an observational cohort study of 123 780 consecutive PCI procedures from the Pan-London (UK) PCI registry, from January 2005 to December 2015. Outcomes were compared pre- (2005-11) and post- (2011-15) public reporting including the use of an interrupted time series analysis. Patients treated after public reporting was introduced were older and had more complex medical problems. Despite this, reported in-hospital major adverse cardiovascular and cerebrovascular events rates were significantly lower after the introduction of public reporting (2.3 vs. 2.7%, P < 0.0001). Interrupted time series analysis demonstrated evidence of a reduction in 30-day mortality rates after the introduction of public reporting, which was over and above the existing trend in mortality before the introduction of public outcome reporting (35% decrease relative risk 0.64, 95% confidence interval 0.55-0.77; P < 0.0001). Conclusion The introduction of public reporting has been associated with an improvement in outcomes after PCI in this data set, without evidence of risk-averse behaviour. However, the lower reported complication rates might suggest a change in operator behaviour and decision-making confirming the need for continued surveillance of the impact of public reporting on outcomes and operator behaviour.

Background Chronic total occlusions (CTO) are commonly encountered in patients undergoing coronary angiography; however, percutaneous coronary intervention (PCI) is infrequently performed owing to technical difficulty, the perceived risk of complications and a lack of randomized data. The aim of this study was to analyse the frequency and outcomes of CTO-PCI procedures in a large contemporary cohort of successive patients. Patients and methods We undertook an observational cohort study of 48234 patients with stable angina of which 5496 (11.4%) procedures were performed for CTOs between 2005 and 2015 at nine tertiary cardiac centres across London, UK. Outcome was assessed by in-hospital major adverse cardiac events and all-cause mortality at a median follow-up of 4.8 years (interquartile range: 2.2-6.4 years). Results Over time, there was an increase in the proportion of elective PCI procedures performed for CTOs, but no increase in the absolute number. Overall success rates increased over time (74.3% in 2005 to 81.5% in 2015; P=0.0003) despite an increase in case complexity (previous myocardial infarction, diabetes, renal failure, previous coronary artery bypass grafting, peripheral vascular disease and left ventricular impairment) that correlated with procedural advancements. Successful CTO PCI was associated with lower mortality [9.5%, 95% confidence interval (CI): 8.1-11.6 vs. 15.3%, 95% CI: 13.7-20.6, P<0.0001] that persisted after multivariate cox analysis (hazard ratio: 0.37, 95% CI: 0.25-0.62) and propensity matching (hazard ratio=0.36, 95% CI: 0.18-0.73, P=0.0005). Conclusion Successful procedures were associated with lower mortality suggesting that the greater uptake of CTO PCI may improve clinical outcomes in a wider population than are currently being offered therapy. Copyright (C) 2018 Wolters Kluwer Health, Inc. All rights reserved.

BACKGROUND A large proportion of patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI) present with multivessel disease (MVD). There is uncertainty in the role of complete coronary revascularization in this group of patients. OBJECTIVES The aim of this study was to investigate the outcomes of complete revascularization compared with culprit vessel-only intervention in a large contemporary cohort of patients undergoing percutaneous coronary intervention (PCI) for NSTEMI. METHODS The authors undertook an observational cohort study of 37,491 NSTEMI patients treated between 2005 and 2015 at the 8 heart attack centers in London. Clinical details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society (BCIS) PCI dataset. A total of 21,857 patients (58.3%) presented with NSTEMI and MVD. Primary outcome was all-cause mortality at a median follow-up of 4.1 years (interquartile range: 2.2 to 5.8 years). RESULTS A total of 11,737 (53.7%) patients underwent single-stage complete revascularization during PCI for NSTEMI, rates that significantly increased during the study period (p = 0.006). Those patients undergoing complete revascularization were older and more likely to be male, diabetic, have renal disease and a history of previous myocardial infarction/revascularization compared with the culprit-only revascularization group. Although crude, in-hospital major adverse cardiac event rates were similar (5.2% vs. 4.8%; p = 0.462) between the 2 groups. Kaplan-Meier analysis demonstrated significant differences in mortality rates between the 2 groups (22.5% complete revascularization vs. 25.9% culprit vessel intervention; p = 0.0005) during the follow-up period. After multivariate Cox analysis (hazard ratio: 0.90; 95% confidence interval: 0.85 to 0.97) and the use of propensity matching (hazard ratio: 0.89; 95% confidence interval: 0.76 to 0.98) complete revascularization was associated with reduced mortality. CONCLUSIONS In NSTEMI patients with MVD, despite higher initial (in-hospital) mortality rates, single-stage complete coronary revascularization appears to be superior to culprit-only vessel PCI in terms of long-term mortality rates. This supports the need for further randomized study to confirm these findings. (c) 2018 by the American College of Cardiology Foundation.

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

Objective: To establish the analytical performance of a heart fatty acid binding protein (HFABP) method suitable for routine clinical use and examine its role for the diagnosis of myocardial ischemia and myocardial infarction.Methods: Analyses of HFABP were performed on an Advia 2400 (Siemens Healthcare Diagnostics). Imprecision, limit of detection (LOD), limit of blank (LOB), and linearity were assessed using standard methods. Stability was assessed at 4 degrees C, -20 degrees C, and with 3 repeated freeze-thaw cycles. Clinical diagnostic performance was assessed using chest pain in patients, with a final diagnosis according to the universal definition of myocardial infarction with cardiac troponin I (cTnI) measured on the Siemens Advia Centaur (cTnI Ultra method, 99th percentile 50 ng/L, 10% CV 30 ng/L). Ischemia was detected using sampling pre- and postangioplasty.Results: LOD and analytical imprecision exceeded the manufacturer's specification (LOD 1.128 mu g/L, 20% CV 1.3 mu g/L, 10% CV 2.75 mu g/L). Clinical diagnostic efficiency was less than cTnI. Addition of HFABP to cTnI produced a modest increase in diagnostic sensitivity at a cost of significant loss of specificity.Conclusions: Although the test had excellent analytical performance, it did not contribute to the clinical diagnosis of patients with chest pain. HFABP appears to be a marker of myocardial infarction not myocardial ischemia.

Background— Primary percutaneous coronary intervention (PPCI) is the treatment of choice for ST-segment–elevation myocardial infarction. Resources are limited during out of working hours (OWH). Whether PPCI outside working hours is associated with worse outcomes and whether outcomes have improved over time are unknown. Methods and Results— We analyzed 11 466 patients undergoing PPCI between 2004 and 2011 at all 8 tertiary cardiac centers in London, United Kingdom. We defined working hours as 9 am to 5 pm (Monday to Friday). We analyzed in-hospital bleeding and all-cause mortality ≤3 years, comparing OWH versus in-working hours. A total of 7494 patients (65.3%) were treated during OWH. Multivariable analyses demonstrated that PPCI during OWH was not a predictor for bleeding (odds ratio, 1.47; 95% confidence interval [CI], 0.97–2.24; P =0.071) or 3-year mortality (hazard ratio, 1.11; 95% CI, 0.94–1.32; P =0.20). This was confirmed in propensity-matched analyses. Time-stratified analyses demonstrated that PPCI during OWH was a predictor for bleeding (odds ratio, 2.00; 95% CI, 1.06–3.80; P =0.034) and 3-year mortality during 2005 to 2008 (hazard ratio, 1.23; 95% CI, 1.00–1.50; P =0.050), but this association was lost during 2009 to 2011. During 2005 to 2008, transradial access was predominantly used during in-working hours and PPCI during OWH was predictive of reduced transradial access use (odds ratio, 0.83; 95% CI, 0.71–0.98; P =0.033), but this association was lost during 2009 to 2011. Conclusions— In this study of unselected patients with ST-segment–elevation myocardial infarction, PPCI during OWH versus in-working hours had comparable bleeding and mortality. Time-stratified analyses demonstrated a reduction in adjusted bleeding and mortality during OWH over time. This may reflect the improved service provision, but the increased adoption of transradial access during OWH may also be contributory.

OBJECTIVES This study aimed to assess the impact of thrombus aspiration on mortality in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention (PCI).BACKGROUND The clinical effect of routine intracoronary thrombus aspiration before primary PCI in patients with ST-segment elevation myocardial infarction is uncertain.METHODS We undertook an observational cohort study of 10,929 ST-segment elevation myocardial infarction patients from January 2005 to July 2011 at 8 centers across London, United Kingdom. Patients' details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society PCI dataset. Primary outcome was all-cause mortality at a median follow-up of 3.0 years (interquartile range: 1.2 to 4.6 years).RESULTS In our cohort, 3,572 patients (32.7%) underwent thrombus aspiration during primary PCI. Patients who had thrombus aspiration were younger, had lower rates of previous myocardial infarction but were more likely to have poor left ventricular function. Procedural success rates were higher (90.9% vs. 89.2%; p = 0.005) and in-hospital major adverse cardiac event rates were lower (4.4% vs. 5.5%; p = 0.012) in patients undergoing thrombus aspiration. However, Kaplan-Meier analysis demonstrated no significant difference in mortality rates between patients with and without thrombus aspiration (14.8% aspiration vs. 15.3% PCI only; p = 0.737) during the follow-up period. After multivariate Cox analysis (hazard ratio [HR]: 0.89, 95% confidence interval [CI]: 0.65 to 1.23) and the addition of propensity matching (HR: 0.85 95% CI: 0.60 to 1.20) thrombus aspiration was still not associated with decreased mortality.CONCLUSIONS In this cohort of nearly 11,000 patients, routine thrombus aspiration was not associated with a reduction in long-term mortality in patients undergoing primary PCI, although procedural success and in-hospital major adverse cardiac event rates were improved. (C) 2015 by the American College of Cardiology Foundation.

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

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

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

Background— It is estimated that up to two thirds of patients presenting with ST-segment–elevation myocardial infarction have multivessel disease. The optimal strategy for treating nonculprit disease is currently under debate. This study provides a real-world analysis comparing a strategy of culprit-vessel intervention (CVI) versus multivessel intervention at the time of primary percutaneous coronary intervention in patients with ST-segment–elevation myocardial infarction. Methods and Results— We compared CVI versus multivessel intervention in 3984 patients with multivessel disease undergoing primary percutaneous coronary intervention between 2004 and 2011 at all 8 tertiary cardiac centers in London. Multivariable-adjusted models were built to determine independent predictors for in-hospital major adverse cardiovascular events (MACEs) and all-cause mortality at 1 year. To reduce confounding and bias, propensity score methods were used. CVI was associated with reduced in-hospital MACE (4.6% versus 7.2%; P =0.010) and mortality at 1 year (7.4% versus 10.1%; P =0.031). CVI was an independent predictor for reduced in-hospital MACE (odds ratio, 0.49; 95% confidence interval [CI], 0.32–0.75; P <0.001) and survival at 1 year (hazard ratio, 0.65; 95% CI, 0.47–0.91; P =0.011) in the complete cohort; and in 2821 patients in propensity-matched cohort (in-hospital MACE: odds ratio, 0.49; 95% CI, 0.32–0.76; P =0.002; and 1-year survival: hazard ratio, 0.64; 95% CI, 0.45–0.90; P =0.010). Inverse probability treatment weighted analyses also confirmed CVI as an independent predictor for reduced in-hospital MACE (odds ratio, 0.38; 95% CI, 0.15–0.96; P =0.040) and survival at 1 year (hazard ratio, 0.44; 95% CI, 0.21–0.93; P =0.033). Conclusions— In this observational analysis of patients with ST-segment–elevation myocardial infarction undergoing primary percutaneous coronary intervention, CVI was associated with increased survival at 1 year. Acknowledging the limitations with observational analyses, our findings support current recommended practice guidelines.

Background-Compared with transfemoral access, transradial access (TRA) for percutaneous coronary intervention is associated with reduced risk of bleeding and vascular complications. Studies suggest that TRA may reduce mortality in patients with ST-segment-elevation myocardial infarction. However, there are few data on the effect of TRA on mortality, specifically, in patients with non-ST-segment-elevation myocardial infarction.Methods and Results-We analyzed 10 095 consecutive patients with non-ST-segment-elevation myocardial infarction treated with percutaneous coronary intervention between 2005 and 2011 in all 8 tertiary cardiac centers in London, United Kingdom. TRA was a predictor for reduced bleeding (odds ratio=0.21; 95% confidence interval [CI]: 0.08-0.57; P=0.002), access-site complications (odds ratio=0.47; 95% CI: 0.23-0.95; P=0.034), and 1-year mortality (hazard ratio [HR]=0.72; 95% CI: 0.54-0.94; P=0.017). Between 2005 and 2007, TRA did not appear to reduce mortality at 1 year (HR=0.81; 95% CI: 0.51-1.28; P=0.376), whereas between 2008 and 2011, TRA conferred survival benefit at 1 year (HR=0.65; 95% CI: 0.46-0.92; P=0.015). The mortality benefit with TRA at 1 year was not seen at the low-volume centers (HR=0.80; 95% CI: 0.47-1.38; P=0.428) but specifically seen in the high volume radial centers (HR=0.70; 95% CI: 0.51-0.97; P=0.031). In propensity-matched analyses, TRA remained a predictor for survival at 1 year (HR=0.60; 95% CI: 0.42-0.85; P=0.005). Instrumental variable analysis demonstrated that TRA conferred mortality benefit at 1-year with an absolute mortality reduction of 5.8% (P=0.039).Conclusions-In this analysis of patients with non-ST-segment-elevation myocardial infarction, TRA appears to be a predictor for survival. Furthermore, the evolving learning curve, experience, and expertise may be important factors contributing to the prognostic benefit conferred with TRA.