AIMS:There are limited data on aspirin (ASA) desensitization for patients with coronary disease. We present our experience with a rapid nurse-led oral desensitization regimen in patients with aspirin sensitivity undergoing coronary angiography.METHODS:This single-center retrospective observational study includes patients with a history of ASA sensitivity undergoing coronary angiography with intent to perform percutaneous coronary intervention (PCI).RESULTS:Between January 2012 and January 2017, 24 patients undergoing coronary angiography for stable coronary disease (7 cases) or acute coronary syndromes (non-ST-segment myocardial infarction [NSTEMI; 8 cases], STEMI [9 cases]) underwent aspirin desensitization having reported previous reactions to aspirin. At initial presentation, previous sensitivity reactions were reported as: mucocutaneous reactions in 17 patients (urticaria in 3 [13%], nonurticarial rash in 6 [25%], angio-oedema in 8 [33%]), respiratory sensitivity in 4 (17%), and systemic anaphylactoid reactions in 3 (13%). Seventeen (71%) patients underwent PCI. Desensitization was acutely successful in 22 (92%) patients and unsuccessful in 2 (8%) patients who both had a single short-lived episode of acute bronchospasm treated successfully with nebulized salbutamol. Fifteen successfully desensitized patients completed 12 months of aspirin; no patient had recurrent hypersensitivity reaction. Aspirin was stopped prior to 12 months in 7 patients (replaced by warfarin [1 case], no antiplatelet or single antiplatelet clinically indicated and clopidogrel chosen [4 cases], patient choice without evidence of recurrent hypersensitivity [1 case], and death due to cardiogenic shock following STEMI [1 case]).CONCLUSION:A rapid aspirin desensitization protocol is safe and effective across a broad spectrum of hypersensitivity reactions and clinical presentations.

There are limited data on aspirin desensitisation for patients with coronary disease.1 This study aimed to evaluate our single-centre experience with a rapid oral desensitisation regime in patients with aspirin sensitivity undergoing coronary angiography. Methods This single-centre retrospective observational study includes patients with self-reported hypersensitivity reactions to aspirin confirmed by clinical history who were planned to undergo coronary angiography with intent to perform percutaneous coronary intervention between Jan 2012 and Jan 2017. The aspirin desensitisation protocol is shown in table 1. All patients had blood pressure, oxygen saturation and peak flow measurements every 30 min during the dug administration and for 3 three hours after the final dose. Continuous ECG monitoring was not routinely performed unless clinically indicated. No patients received pre-treatment with steroids, antihistamines or antileukotrienes. The primary outcome was cessation of aspirin due to recurrent hypersensitivity reaction within 12 months. Results Twenty-four patients were included in the study including patients with both stable coronary disease (7 cases) and acute coronary syndromes (NSTEMI (8 cases), STEMI (9 cases)). Previous reactions reported were mucocutaneous reactions in 17 patients (urticaria in 3 (13%), non-urticarial rash in 6 (25%), angio-oedema in 8 (33%)), respiratory sensitivity in 4 patients (17%) and systemic anaphylactoid reactions in 3 patients (13%). Percutaneous coronary intervention (PCI) was performed in 17 patients (71%) and coronary artery bypass grafting in 1 patient (4.2%). Desensitisation was acutely successful in 22 patients (92%). Two cases were unsuccessful, both following primary PCI (previous true anaphylactoid reaction experienced bronchospasm requiring nebulised salbutamol (1 case), previous angio-oedema experienced an exacerbation of her poorly controlled asthma (but no angio-oedema) treated with nebulised salbutamol (1 case)). Both patients were discharged on single antiplatelet therapy (clopidogrel and prasugrel respectively). Fifteen successfully desensitised patients completed 12 months of aspirin; no patients suffered a recurrent hypersensitivity reaction. Aspirin was stopped prior to 12 months in seven patients (replaced by formal anticoagulation (1 case), no antiplatelet or only single antiplatelet clinically indicated and clopidogrel chosen (4 cases), patient choice without evidence of recurrent hypersensitivity (1 case), death due to cardiogenic shock following STEMI (1 case)). Conclusion Our rapid desensitisation protocol is significantly faster than the ADAPTED registry protocol (120 vs 330 min) and appears as effective across a wide range of clinical presentations and hypersensitivity reactions. Reference . Rossini R, et al. Results of the Multicenter ADAPTED Registry (Aspirin Desensitization in Patients with Coronary Artery Disease). Circ Cardiovasc Interv. 2017;10:e004368.

Background The PRAMI and CvLPRIT trials support preventive percutaneous coronary intervention (PCI) for multivessel coronary disease found during ST-segment elevation myocardial infarction (STEMI). We assess our real-world experience of the management of multivessel disease identified during primary PCI (PPCI) in a large UK regional centre. Patients and methods All STEMI patients who underwent culprit-only PPCI during the study period (August 2011 to August 2013) were retrospectively assessed for eligibility to each trial. The two resulting groups were designated as the ‘observational’ cohorts. Primary outcomes were then determined and compared with the culprit-only revascularisation cohorts from the respective published randomized controlled trials (RCTs). Results A total of 1143 consecutive cases were presented during the study period. Of these, 343 would have been suitable for inclusion to PRAMI and were included in the ‘observational PRAMI’ cohort; 196 patients were included in the ‘observational CvLPRIT’ cohort. The ‘observational PRAMI’ cohort experienced fewer primary outcome events (13.1 vs. 22.9%), cardiac deaths (0.6 vs. 4.3%) and nonfatal myocardial infarctions (3.5 vs. 8.7%) than the culprit-only PCI PRAMI cohort (n=231); there were significantly more diabetics (P=0.022) and anterior STEMI initial presentations in the culprit-only PCI PRAMI cohort. Primary outcomes were comparable to those of the preventive PCI PRAMI cohort. The ‘observational CvLPRIT’ cohort showed no significant difference in primary outcomes over 12 months (16.8 vs. 21.2%), but significantly lower all-cause mortality (2 vs. 6.9%) than the culprit-only PCI CvPLRIT cohort (n=146). The 30-day event rates were similar to the preventive PCI arm; the 12-month events were better than the nonpreventive, but not as good as the preventive RCT cohorts. Conclusion Outcomes from culprit-only primary PCI for multivessel disease in patients selected by the RCT criteria from an all-comers population representing real-life experience are better than those published in the two main RCTs. The RCTs may have selected a high-risk population for study exaggerating the benefits of preventive PCI.

Volume 4 of Continuing Cardiology Education focuses on the treatment of patients with coronary artery disease, CAD. All European cardiologists need to have a thorough knowledge of the issues that are discussed, since despite advances in our understanding of the prevention of CAD, patients suffering from its consequences increasingly seek help from cardiologists across all European countries and across all the subspecialty areas of cardiology. The authors of the articles are all practising clinicians working in an area with a particularly high prevalence of coronary artery disease, the North East of England. The regional cardiothoracic centre at The James Cook University Hospital in Middlesbrough serves a population of around 1.5 million people across Teesside, County Durham, North Yorkshire and Cumbria. The authors have drawn on their day to day experience of treating patients alongside the published literature to provide, for both the trainee in cardiology and the established specialist, a review and update of the essential knowledge needed to understand contemporary clinical practice. Where appropriate, the authors have referred to existing ESC guidelines. It must be remembered that not all the guideline recommendations can be based on firm evidence from randomized control trials or high quality observational research and there are unfortunately still a large number of recommendations based on only “expert opinion”. Where possible, we must work harder to reduce these sources of uncertainty with more research. It is also critical for us to be aware that when applying guidelines to individual cases, we need to know the strengths and weaknesses of the underlying evidence so that that guideline recommendations can be appropriately applied to a plan of care for an individual patient and not just follow a “one size fits all” approach. For trainees in cardiology, the knowledge required across this area of cardiology is set out in the ESC Core Curriculum for General Cardiology (see particularly chapters 2.8 and 2.9) and how the acquisition and application of this knowledge fits into overall training is set out in the Training Requirements for the Specialty of Cardiology from the UEMS 1, 2.Readers will be able to confirm their understanding of the material and gain EBAC CME credits by completion of the series of formative MCQs that have been prepared in conjunction with each of the articles. These MCQs have been modeled on the style of question used in the European Examination of General Cardiology, that is, there is a clinical stem, a single question followed by five possible answers with the need to select the single best answer. Further details about the EEGC are available at the UEMS-Cardiac Section website 3. Completion of the formative MCQs can be used as evidence of successful knowledge acquisition, for example, for ongoing specialist revalidation or for the European Diploma of General Cardiology 4. Coronary artery disease, CAD, is a common contributor to or bystander of cardiac arrhythmias. Dr Ruairidh Martin and Dr Matt Bates have provided a practical guide to the management of atrial fibrillation, AF, in patients with concomitant CAD, including an update on the rapidly evolving area of appropriate antithrombotic therapy in the context of AF and CAD. Dr Dewi Thomas and Dr Andrew Thornley have looked at the basic mechanisms underlying ventricular arrhythmia in the different presentations of CAD and given us and some practical guidance for treatments. Coronary artery disease can present to the practicing cardiologist in the stable phase or as an acute coronary syndrome. Dr Thandar Aye and Dr Richard Graham outline their approach to the assessment of prognosis in the patient with stable disease. They have provided insights into the evidence relating to the pros and cons of the commonly available imaging modalities used every day in our clinics. Dr Alex Brown and Dr David Austin have looked at the question of which antiplatelet therapy to use in CAD patients presenting with an acute coronary syndrome. This is a relatively evidence-rich area of clinical practice but nevertheless still throws up practical questions for day to day practice. In order to make balanced judgments of the best advice for individual patients, we need a thorough understanding of the strengths and weaknesses of the evidence base. Their comprehensive review of this important topic contains messages that we can take away and apply to our patients. Heart failure is an increasing problem with an increasingly aged population and CAD is a common cause. Dr Pamela Brown and Dr Jeet Thambyrajah have provided an evidence-based approach to the management of patients with both acute and chronic heart failure. Cardiology is a rapidly developing area for the established clinician and the developments have often been driven by quantum leaps in technology. Cardiac magnetic resonance imaging is underpinned by complex theories of subatomic physics and has the potential to redefine our traditional approaches to investigation and monitoring of cardiovascular disease. Dr Alexandra Thompson and Dr Neil Maredia have provided an up-to-date guide to what they call the “comprehensive IHD assessment” with a basic outline of their approach using the techniques of LV cine stacks, edema imaging, stress myocardial perfusion, rest myocardial perfusion, early and late Gadolinium enhancement. How and when to use these techniques and how to interpret the results will be a key part of the knowledge and skills of all practising cardiologists, not just cardiac imaging subspecialists. Another new development driven by improved technology in material science is transarterial aortic valve implantation, TAVI, where the engineering of the implant devices has permitted safe and effective percutaneous delivery. Dr Muzaffar Mahmood and Dr Douglas Muir have reviewed the vexing issue of how best to manage concomitant CAD when a patient undergoes TAVI. This is currently the best example of highly individualized decision-making based upon clinical judgment rather than an extensive evidence base and the most convincing need for a well-functioning local multidisciplinary team. Also venturing into the world of materials science is the consideration of stent design by Dr Mohammed Awan and Dr Paul Williams—what stents to use and when and why, and how to more critically appraise potential pitfalls in stent design. We hope that trainees and specialists find these reviews and updates valuable. We hope that the formative MCQs will be used to confirm the assimilation of the information presented. We have attempted in this issue to emphasize the importance to all cardiologists of knowledge across the spectrum of “sub-specialty areas”. In our experience, it is usually the case that patients do not confine their needs to a single area of cardiology and so the knowledge, skills, and behaviors needed for success in general cardiology will remain a basic requirement for all cardiologists well into the 21st century. Educational activities such as CCE will hopefully prosper and be widely available to help trainees and all practising cardiologists maintain their grounding in general cardiology. Dr Hall and Dr Wright have nothing to disclose.

ndrew G. C. Sutton, MA, MB, MRCP,* Philip G. Campbell, MB, MRCP,* ichard Graham, MB, MRCP,* Dallas J. A. Price, MB, MRCP,* Janine C. Gray, BSC(HONS), PHD,† ver D. Grech, MD, MRCP, FACC,* James A. Hall, MA, MD, FRCP,* lun A. Harcombe, MD, MRCP,* Robert A. Wright, MD, FRCP,* oger H. Smith, BSC(HONS), MB, FRCP,‡ Jerry J. Murphy, MB, BS, DM, FRCP,§ nanthaiah Shyam-Sundar, MB, BS, MD, DM, FRCP,‡ Michael J. Stewart, MD, FRCP,* drian Davies, BSC, MB, BS, FRCP,* Nicholas J. Linker, BSC, MD, FRCP, FESC,* ark A. de Belder, MA, MD, FRCP* iddlesbrough, Newcastle-upon-Tyne, Stockton-on-Tees, and Darlington, United Kingdom

Background The adoption of the transradial ( TR ) approach over the traditional transfemoral ( TF ) approach has been hampered by concerns of increased radiation exposure—a subject of considerable debate within the field. We performed a patient‐level, multi‐center analysis to definitively address the impact of TR access on radiation exposure. Methods and Results Overall, 10 centers were included from 6 countries—Canada (2 centers), United Kingdom (2), Germany (2), Sweden (2), Hungary (1), and The Netherlands (1). We compared the radiation exposure of TR versus TF access using measured dose‐area product ( DAP ). To account for local variations in equipment and exposure, standardized TR : TF DAP ratios were constructed per center with procedures separated by coronary angiography ( CA ) and percutaneous coronary intervention ( PCI ). Among 57 326 procedures, we demonstrated increased radiation exposure with the TR versus TF approach, particularly in the CA cohort across all centers (weighted‐average ratios: CA , 1.15; PCI , 1.05). However, this was mitigated by increasing TR experience in the PCI cohort across all centers ( r =−0.8; P =0.005). Over time, as a center transitioned to increasing TR experience ( r =0.9; P =0.001), a concomitant decrease in radiation exposure occurred ( r =−0.8; P =0.006). Ultimately, when a center's balance of TR to TF procedures approaches 50%, the resultant radiation exposure was equivalent. Conclusions The TR approach is associated with a modest increase in patient radiation exposure. However, this increase is eliminated when the TR and TF approaches are used with equal frequency—a guiding principle for centers adopting the TR approach.

A 30-year-old man was admitted with acute anterior ST-segment elevation myocardial infarction. He smoked 30 cigarettes a day with no history of recreational drug use. He was known to have attention deficit hyperactivity disorder (ADHD), which was being treated with methylphenidate. Clinical examination was normal. A coronary angiogram showed a critical obstruction to flow in the proximal left anterior descending artery associated with thrombolysis in myocardial infarction (TIMI) grade 1 flow (Fig. Panel A). The angiographic appearances were suggestive of spontaneous coronary artery dissection. The circumflex, intermediate and right coronary arteries were normal. In view of on-going ischemia, primary percutaneous coronary intervention (PPCI) was performed with deployment of a 3.5 × 28 mm drug eluting stent. TIMI grade 3 flow was restored with improved angiographic appearances (Fig. Panel B). Acute myocardial infarction was confirmed with highly sensitive Troponin I level of >50,000 ng/l (N < 17 ng/L). Dual antiplatelet therapy, statin, beta-blocker and ACE-I therapy was started. Methylphenidate was stopped. A transthoracic echocardiogram showed moderate left ventricular systolic impairment secondary to antero-apical akinesia. At 6-week follow-up the patient was well with normalisation of left ventricular systolic function. Fig. Panel BCoronary angiogram antero-posterior projection with 30° caudal angulation (AP, CAUD 30). View Large Image Figure Viewer Download Hi-res image

Background Strategies to reduce DTB (door-to-balloon) time have been previously described. However, there is no well-established data-monitoring system that can be used for prompt feedback. The aims of this study were to use statistical process control (SPC) methodology to measure current processes, to provide real-time feedback on the impact of a change in service delivery and to identify individual outliers for specific investigation.Methods A prospective study was conducted in a tertiary centre in North England. Data were collected for 841 consecutive STEMI patients from the local district undergoing PPCI. The impact on median DTB time after changes in protocols were prospectively determined.Results Median DTB times fell significantly as a result of changes in protocol. The upper control limit (UCL) decreased from 209 to 86 min and narrower control limits indicated improved performance. The main outliers included patients presenting to the Accident and Emergency department and patients who developed STEMI while being treated in non-cardiology wards for other reasons (18.3% of the study population).Conclusions SPC provides a statistically robust mechanism for assessing the effect of process redesign interventions, and in this context provides a clear visual representation of DTB times for individual patients. Identification of significant outliers allows investigation of any variation with a special cause. It allows a unit to identify when a system of service delivery, albeit stable, is inadequate and needs redesign and can monitor the impact of changes in protocol.

Objective To use funnel plots and cumulative funnel plots to compare in-hospital outcome data for operators undertaking percutaneous coronary interventions with predicted results derived from a validated risk score to allow for early detection of variation in performance. Design Analysis of prospectively collected data. Setting Tertiary centre NHS hospital in the north east of England. Participants Five cardiologists carrying out percutaneous coronary interventions between January 2003 and December 2006. Main outcome measures In-hospital major adverse cardiovascular and cerebrovascular events (in-hospital death, Q wave myocardial infarction, emergency coronary artery bypass graft surgery, and cerebrovascular accident) analysed against the logistic north west quality improvement programme predicted risk, for each operator. Results are displayed as funnel plots summarising overall performance for each operator and cumulative funnel plots for an individual operator’s performance on a case series basis. Results The funnel plots for 5198 patients undergoing percutaneous coronary interventions showed an average observed rate for major adverse cardiovascular and cerebrovascular events of 1.96% overall. This was below the predicted risk of 2.06% by the logistic north west quality improvement programme risk score. Rates of in-hospital major adverse cardiovascular and cerebrovascular events for all operators were within the 3σ upper control limit of 2.75% and 2σ upper warning limit of 2.49%. Conclusion The overall in-hospital major adverse cardiovascular and cerebrovascular events rates were under the predicted event rate. In-hospital rates after percutaneous coronary intervention procedure can be monitored successfully using funnel and cumulative funnel plots with 3σ control limits to display and publish each operator’s outcomes. The upper warning limit (2σ control limit) could be used for internal monitoring. The main advantage of these charts is their transparency, as they show observed and predicted events separately. By this approach individual operators can monitor their own performance, using the predicted risk for their patients but in a way that is compatible with benchmarking to colleagues, encapsulated by the funnel plot. This methodology is applicable regardless of variations in individual operator case volume and case mix.

The impact of chronic coronary obstructions on resting blood flow in stable cardiac patients and the response to percutaneous coronary intervention (PCI) using the TIMI frame count method has not been well documented. We studied the impact of coronary artery stenosis severity on the corrected TIMI frame count (cTFC) in chronically stenosed coronary arteries. We prospectively and quantitatively determined the impact of stenting on the cTFC during elective PCI. Methods: In substudy 1, analysis was performed to obtain the mean cTFC for arteries with <50% stenosis (Group A), 51–75% stenosis (Group B), 76–85% stenosis (Group C1), 86–95% stenosis (Group C2) and 96–99% stenosis (Group C3). In substudy 2, the cTFC and quantitative coronary angiography were performed pre‐ and post‐PCI. Results: In substudy 1, the cTFC increased exponentially beyond a diameter stenosis of 75% (P < 0.01). However there was no significant difference in the cTFC for coronary arteries with <75% stenosis. In substudy 2, the overall pre‐ and poststenting cTFC was 17.1 ± 11.7 and 7.8 ± 2.7 (P < 0.01) and the TFC index [calculated by dividing the mean cTFC for the relevant artery by the mean cTFC for the corresponding coronary artery in a previously derived control group in our laboratory] was 1.6 ± 1 and 0.7 ± 0.2 (P = < 0.01), respectively. Conclusion: We have demonstrated that there was a significant increase in the cTFC when the coronary artery stenosis was more than 75% reflecting significant flow abnormalities at this degree of stenosis in chronically diseased coronary arteries. Following stenting there is a significant improvement in the cTFC, which is better than the cTFC for arteries with normal flow, suggesting early hyperaemia. © 2007 Wiley‐Liss, Inc.

Cardiac catheterisation and angiography uses ionising radiation and therefore produces a radiation dose to the patient and to the operating staff. The dose to the patient can be measured using thermoluminescent dosemeters placed on the skin or by using a large-area detector attached to the x ray tube to measure the dose–area product (DAP) for the incident x ray beam (DAP meter). The DAP is particularly useful for assessing and comparing the radiation dose from screening procedures. It provides a more useful indication of the overall patient exposure than measurement of surface dose at particular locations. The dose measurement is used either as a surrogate for radiation risk or as a step in actually estimating the risk. Published factors allow conversion of the DAP to effective dose, a derived quantity in which doses to different organs or tissues are weighted according to their radiosensitivity and summed to give a risk-related dose quantity.1–5 UK legislation does not give dose limits for patients undergoing medical diagnostic exposures, but requires adherence to the “as low as reasonably practicable” principle, and comparison of doses with diagnostic reference levels for common procedures. Published data for patient exposure, absorbed dose, effective dose and risk of malignancy from the different specific diagnostic cardiac catheterisation procedures are incomplete, and there are no national diagnostic reference levels for individual procedures. We undertook this study with the aim of establishing local patient doses for six different diagnostic cardiac catheterisation procedures …

UNLABELLED:The intra-aortic balloon pump (IABP) is the most commonly used temporary cardiac assist device. The precise role and the mechanism of any benefit in high-risk patients undergoing percutaneous coronary intervention (PCI) have not been fully determined. We hypothesized that the use of an IABP following PCI in high-risk non-shocked patients would immediately increase coronary blood flow, tissue perfusion and hence preserve left ventricular function.METHODS:Predefined high-risk, but non-shocked, patients were randomized to either an IABP or no IABP following PCI. Angiography was performed pre-PCI, immediately post-PCI and 10 minutes after the completion of the procedure. TIMI flow grade (TFG), TIMI frame count (TFC) and myocardial blush grade (MBG) were measured. Echocardiographic wall motion index (WMI) was measured on days 1 and 30 following PCI.RESULTS:Of 33 patients, 17 received IABP and 16 did not. At final angiography, the TFG was 2.8 +/- 0.7 and 2.9 +/- 0.3 (p = 0.6), the TFC was 19.9 +/- 23 and 16.9 +/- 16.9 (p = 0.7), and the MBG was 2.5 +/- 0.9 and 2.5 +/- 0.7 (p = 0.9) in the IABP and the no-IABP arms. The WMI on day 1 was 1.7 +/- 0.4 and 1.7 +/- 0.4 (p = 0.7), and on day 30, it was 1.5 +/- 0.4 and 1.5 +/- 0.4 (p = 0.9). There was no difference in the total sum of ST-segment elevation prior to PCI (12.6 +/- 7.7 vs. 13.5 +/- 7.9; p = 0.8), nor in the summed ST change in subsequent electrocardiograms (ECGs) to 48 hours in both of the groups.CONCLUSION:Whether an IABP is of any benefit in non-shocked, but high-risk, patients undergoing PCI remains to be established, but any potential benefit does not appear to be associated with early improvement in coronary flow. Whether the insertion of an IABP improves coronary flow beyond 10 minutes is not known. However, the IABP did not significantly affect subsequent left ventricular wall motion index or ECG ST-segment resolution in this study.

BACKGROUND:Early (30 days) and midterm (6 months) clinical outcomes in trials comparing rescue angioplasty (rescue percutaneous coronary intervention [rPCI]) with conservative treatment of failed fibrinolysis complicating ST-segment elevation myocardial infarction have shown variable results. Whether early rPCI confers late (up to 3 years) clinical benefits is not known. METHODS:The MERLIN trial compared rPCI and a conservative strategy in patients with failed fibrinolysis complicating ST-segment elevation myocardial infarction. Three hundred seven patients with electrocardiographic evidence of failure to reperfuse at 60 minutes were included. Patients in cardiogenic shock were excluded. Thirty-day and 1-year results have been reported. Results of 3 years of follow-up are presented. RESULTS:Three-year mortality in the conservative arm and rPCI, respectively, was 16.9% versus 17.6% (P = .9, relative difference [RD] -0.8, 95% CI [-9.3 to 7.8]). Death rates were similar (3.9% vs 3.2%) between 1- and 3-year follow-up, respectively. The incidence of the composite secondary end point of death, reinfarction, stroke, unplanned revascularization, or heart failure was significantly higher in the conservative arm (64.3% vs 49%, P = .01, RD 15.3, 95% CI [4.2-26]). There was no significant difference in the rate of reinfarction (0.7% vs 0.7%) or heart failure (1.3% vs 2.7%) between 1 and 3 years between the conservative and rPCI arms, respectively. The incidence of subsequent unplanned revascularization at 3 years was significantly higher in the conservative arm (33.8% vs 14.4%, P < .01, RD 19.4, 95% CI [10-28.7]), most of which occurred within 1 year; the rates between 1 and 3 years were 3.9% in the conservative arm versus 2% in the rPCI arm. There was a trend toward fewer strokes in the conservative arm at 3 years (conservative arm 2.6% vs rPCI 6.5%, P = .1, RD -3.9%, 95% CI [-9.4 to 0.8]), with similar stroke rates (1.3% vs 1.3%) between 1- and 3-year follow-up. CONCLUSIONS:Rescue angioplasty did not confer a late survival advantage at 3 years. The composite end point occurred less often in the rPCI arm mainly because of fewer unplanned revascularization procedures in the early phase of follow-up. The highest risk of clinical events in patients with failed reperfusion is in the first year, beyond which the rate of clinical events is low.

The TIMI frame count (TFC) is a useful measure of coronary flow. To be widely applicable, the effect of different catheter sizes and the use of intracoronary glyceryl trinitrate (ICGTN) must be determined when films are acquired at lower acquisition rates (12.5 frames/s, f/s). Methods: We compared 6F versus 5F diagnostic catheters (n = 44), 6F versus 7F diagnostic catheters (n = 45) and 6F diagnostic versus 7F guide catheters (n = 44). In the nitrate angiography group (n = 141), coronary angiography was performed before and after 200 micrograms of ICGTN. In the nitrate percutaneous coronary intervention (PCI) group (n = 48), coronary angiography was performed before and after 200 micrograms of ICGTN after the completion of the elective PCI procedure. Results: The mean difference in the uncorrected TFC using 6F and 5F was 0.02 (95 % CI −0.5, 0.6; P = 0.9); using 6F and 7F diagnostic catheters it was 0.3 (95% CI −0.49, 1.1; p = 0.4); and using 6F diagnostic and 7F guide catheters it was 0.4 (95% CI −2.6, 3.4; P = 0.7) respectively. In the nitrate angiography group, the uncorrected TFC before and after ICGTN was 13.1±6.2 and 15±7.5 (equivalent to 31.4±14.9 and 36±2 at 30 f/s), with a mean difference of 1.9 (95% CI 1.3, 2.5; P = <0.0001). In the nitrate PCI group, the uncorrected TFC before and after ICGTN administration was 9.2±3.7 and 10.3±4.2 (equivalent to 22.6±9.6 and 25.2±11 at 30 f/s) respectively with a mean difference between the two injections of 1.2 (95% CI −0.4, 1.9; P = 0.003). Conclusion: We have demonstrated that the catheter sizes did not significantly affect the TFC when angiography was performed at 12.5f/s. The use of ICGTN significantly increased the TFC in both normal and diseased coronary arteries. This effect was also observed when ICGTN was administered into the culprit vessels after the completion of the elective PCI procedure. This effect must be considered when investigating the impact of specific treatments or drugs on coronary flow.