Abstract Background National Institute of Clinical Excellence (NICE) guidelines recommend consideration of Chest X-rays (CXRs) in patients presenting with chest pain to exclude non-cardiac causes of chest pains. However, patients with ST-segment elevation myocardial infarction (STEMI) have a clear diagnosis, rendering the rationale for routine CXRs in this cohort of patients unclear. However, this remains a common practice across the health service. Methods We performed a retrospective study use of CXRs in consecutive patients admitted with STEMI undergoing primary percutaneous coronary intervention in a single UK tertiary cardiac center. We aimed to investigate if CXRs added clinical and diagnostic value by comparing routine vs. clinically indicated use. Results A total of 122 patients (Mean Age 63±12, 87% Male) were admitted with STEMI during the study period and 114/122 (93.4%) patients received at least one CXR during their in-patient stay. All but 2/114 were portable thus resource-intensive. Of these, 75/114 (65.8%) were routine while 39/114 (34.2%) were clinically indicated. Although CXRs were performed in almost all the patients, only 56/114 (49.1%) of patients had the findings of CXRs documented in the clinical records. The diagnostic efficacy for CXR abnormalities was significantly higher in the clinically indicated CXR group (76.9%) rather than the routine CXR group (2.7%) (p=<0.001). The therapeutic efficacy was 53.8% for clinically indicated CXRs, whereas the routine CXRs had a therapeutic efficacy of 1.3% (p=<0.001). There was a significant association between CXR findings and whether the CXR requested was routine or not (χ2(1)=70.07, p<0.001) and also management changes (χ2(1)=45.43, p<0.001). Conclusions Routine CXR in patient admitted with STEMI are often unnecessary and may add very little clinical value. On the other hand, selective post-procedural CXRs have a significantly higher diagnostic and therapeutic yield. Our study questions the rationale behind routine CXRs in the care of patients with STEMIs. Funding Acknowledgement Type of funding sources: None. Table 1

Background. Although rare, external compression of the left main coronary artery (LMCA) by a pulmonary arterial aneurysm (PAA) as a consequence of pulmonary arterial hypertension causing stable angina pectoris is well described. However, acute myocardial infarction is extremely rare, particularly with a full array of electrocardiographic, biochemical, and echocardiographic features, as in this scenario. Case. In this case, a 62-year-old man with a past history of severe fibrotic lung disease was hospitalised with chest pain. The patient had dynamic anterolateral ischaemic changes on electrocardiography and serially elevated high-sensitivity troponin I. Transthoracic echocardiography revealed impaired left ventricular ejection fraction with anterolateral hypokinesis. Coronary angiography with intracoronary imaging revealed external compression of the LMCA. Computer tomography (CT) scans confirmed new PAA, compared to previous scans. The patient was successfully treated by percutaneous coronary stent implantation. Conclusion. Progressive dilatation of the pulmonary artery due to pulmonary arterial hypertension can result in acute MI secondary to external compression of the LMCA. Clinicians should be mindful of acute coronary syndromes in patients with long-standing pulmonary hypertension presenting with chest pain.

Abstract Funding Acknowledgements Type of funding sources: None. Background Covid-19 pandemic has had a profound impact on healthcare service delivery. Acute cardiovascular care however remains a priority despite the pandemic. Patients presenting with non-ST elevation MI (NSTEMI) have been poorly characterised during the pandemic. Methods We conducted a retrospective study of patients diagnosed with NSTEMI during the peak of the pandemic between April-May 2020 at our tertiary centre in the UK. Data was collected from electronic patient clinical records including time from admission to angiography, length of stay, mortality, prescription of secondary prevention pharmacotherapy and referral to cardiac rehabilitation. We compared this data to the same time period in 2019. Results As can be seen from Table 1, in 2020, the mean age, median time to angiography and length of stay were all significantly lower than the control period of 2019. Prescription of secondary prevention medication (Aspirin, P2Y12 inhibitor, Beta-blocker, Statin and ACEi/ARB) and referral to cardiac rehabilitation also improved in 2020, however neither was statistically significant. During the 2020 period, 1 patient died due to late presentation NSTEMI and multi-organ failure. There were 3 deaths in 2019: complications following coronary bypass surgery, upper GI bleed and a subarachnoid haemorrhage. Conclusion Our results show that the mean age of the patients presenting with NSTEMI during the peak of Covid-19 pandemic was younger suggesting that elderly patients failed to present. Compared to 2019, there was significant improvement in patient treatment times with a significantly shorter stay in hospital, probably as a result of the reduction in elective activity allowing un-restrained access to the catheter labs. We also saw improvement in prescription for secondary prevention and referral to cardiac rehabilitation services during this time suggesting that there may have been improved focus on these aspects of care again. Table 120192020p-valueAge (years)71.2 ± 12.265.0 ± 12.1p < 0.01Number of NSTEMI patients5659p = NSNumber of NSTEMI patients undergoing angiography5053p = NSMedian time to angiography (hours)68.614p < 0.01Median length of stay (days)5 (IQR 2:8)2 (IQR 1:4)p < 0.01Referral to cardiac rehabilitation77.4%84.5%p = NSPrescription of secondary prevention medication69.8%72.4%p = NSTable 1- Comparison of NSTEMI patients in 2019 and 2020Abstract Figure. Box and whisker plot for hospital stay

Background Coronary artery perforation (CAP) is a life-threatening complication of percutaneous coronary intervention (PCI). This study aims to identify CAP predictors using contemporary data. Methods Retrospective cohort study on all PCIs performed at the Queen Elizabeth Hospital, Birmingham between January 2010 and October 2020. Patient demographics, comorbidities, modified Ellis perforation class and perforation treatments were collected. The CAP population was split into two cohorts (1 and 2), representing the first and second 5-year period in the decade. Results During a 10-year period, 9,504 PCI procedures were performed with CAP occurring in 66 cases. According to the Ellis criteria, 4.5% of CAPs were type I, 13.6% type II, 45,5% type III, and 34.8% type V. Definitive management included balloon inflation only in 27%, covered stents 20%, conservative 20%, balloon inflation with heparin reversal 12%, coronary coils 12%, heparin reversal 4.5%, emergency surgery 3%, coil and covered stent 1.5%. Overall mortality within the total perforation cohort was 14%. Emergency pericardiocentesis was required in 13 patients; in this group mortality was 46%.The difference in trends is illustrated in the table 1. Conclusion The data demonstrates increased incidence of CAP and mortality in the second half of the decade. This may be explained by an increase in CTO, rotablation and IVUS use (surrogates for complex PCI) and an older population with more comorbidities. Cardiac tamponade was associated with a higher mortality in those with CAP. Conflict of Interest none

Previous studies of the incidence and severity of mitral regurgitation (MR) following acute myocardial infarction (MI) were limited by the study population (ST-elevation MI only), by diagnostic methods (lack of multiparametric quantification), or by the time-frame of study (late assessment post-MI). The true incidence of ischaemic MR (IMR) immediately following type 1 MI [non-ST-elevation (NSTEMI) and ST-elevation (STEMI)] patients in the modern era of universal early revascularisation remains unclear. Since even mild IMR confers a poor prognosis, factors which promote or protect against the development of MR require further evaluation. To determine the incidence, clinical and angiographic characteristics of patients with IMR following type 1 MI treated with PCI. This was a single-centre study of 1000 consecutive, prospectively recruited patients admitted to the Queen Elizabeth Hospital Birmingham with type 1 MI who underwent PCI. Early inpatient transthoracic echocardiography (TTE) was performed by accredited echocardiographers using standard multiparametric quantification. MR was observed in 294/1000 patients (29.4%) post-MI, graded as mild (76%), moderate (21%) and severe (3%). Median time from symptom onset to PCI was 1 day (IQR 0–4) and to TTE 2 days (IQR 1–3). Compared to patients without MR (MR-), those with MR (MR+) were older (73±12 years vs 66±13 years; p<0.001), male (75% vs 64%; p<0.001) and more likely to have a history of hypertension (HTN) (63% vs 55%; p=0.0117), heart failure (HF) (3.4% vs 1.1%; p=0.0140) and previous MI (28% vs 20%; p<0.005). MR+ patients more frequently presented with HF (8.5% vs 4.2%; p=0.0075), lower LV ejection fraction (LVEF) (50±14% vs 55±11%; p<0.001) and higher peak high sensitivity troponin T (765ng/L, IQR 170–3032 vs 400ng/L, IQR 51–1966; p<0.0001). MR+ patients were more likely to have severe disease in the left circumflex (LCx) (50% vs 33%; p<0.0001) or right coronary artery (RCA) (51% vs 43%; p=0.0135). Incidence of severe disease in the left main stem and left anterior descending artery (LAD) did not significantly differ between the two groups. Incidence of MR was equal (29%) amongst STEMI (126/431) and NSTEMI (168/569) patients. While the time to revascularisation did not affect the prevalence of MR following STEMI (linear regression analysis of door-to-balloon time in MR+ and MR- patients p=0.843), NSTEMI patients were more likely to develop MR if revascularisation was delayed (linear regression analysis of symptom onset to PCI time MR+ vs MR- p=0.061). Almost 1/3 of patients with type 1 MI undergoing revascularisation have MR evident on pre-discharge TTE. Factors promoting MR include older age, male sex, HTN, HF, larger non-LAD territory infarct, and depressed LVEF. The incidence of MR following STEMIs and NSTEMIs is equal. Earlier revascularisation is unlikely to reduce MR in STEMI patients but may improve MR prevalence following NSTEMI. Type of funding source: None

Abstract Background Ischaemic mitral regurgitation (IMR) confers a poor prognosis. Transcatheter intervention may improve survival but benefit is likely to depend on severity of IMR relative to LV remodelling following myocardial infarction (MI). In theory, those with “discordant” IMR (significant regurgitant volume without severe LV dilatation or impairment), are expected to benefit most from mitral intervention. While subcategorization may help to inform treatment, there are no data on post-MI patients in this respect. Purpose To determine the incidence of discordant & concordant IMR categorised on echocardiography post-MI and impact on outcomes. Methods 1000 consecutive patients admitted to our hospital with myocardial infarction who underwent coronary angioplasty were included. Early inpatient TTE was performed by accredited echocardiographers using standard multiparametric quantification. Using TTE parameters, 4 subgroups were identified (figure) according to the degree of MR relative to LV remodelling. Thresholds were based on European guidelines (± 2SD from normal) and median value among survivors for vena contracta (VC): – LVEF: 52% (♂), 54% (♀) – Indexed LV end diastolic volume (LVEDVi): 74ml/m2 (♂), 61ml/m2 (♀) – Effective regurgitant orifice area (EROA) ≥0.2cm2 – Regurgitant volume (RVol) ≥30ml – VC ≥0.5cm Results MR was seen in 294/1000 patients (29.4%) with a severity of mild (76%), moderate (21%) and severe (3%). Concordant and discordant IMR were each seen in 16/294 (5%) of IMR patients post-MI. After a mean follow up of 3.2 years, IMR patients had a 3% rate of heart failure (HF) within 1 year and 19% mortality. Non-survivors had significantly worse IMR (PISA 0.65±0.25cm vs 0.54±0.19cm; p=0.033; VC 0.63±0.25cm vs 0.49±0.18cm; p=0.014), worse LV function (LVEF 44±17% vs 51±13%; p<0.001), larger LV (LVEDVi 67±23ml/m2 vs 60±22ml/m2; p=0.032) and larger indexed LA volume (LAVi) (44±22ml vs 35±15ml; p<0.001). Those with concordant IMR had the worst survival (50%) although almost 1 in 5 of those with discordant MR died within the follow up period (19%). Using multivariable Cox regression, significant predictors of mortality included LVEF (p<0.001; HR 0.96, 0.94–0.98) and LAVi (p<0.001; HR 1.02, 1.01–1.03) but not LVEDVi. Conclusion 1) Significant predictors of mortality in IMR include LA dilatation and decline in LVEF, but not LV dilatation. 2) Although discordant severe IMR is uncommon following MI, mortality if left untreated remains high. Attention should be paid to early selection of this cohort for intervention. Funding Acknowledgement Type of funding source: None

Abstract Background National Institute of Clinical Excellence guideline (NICE, CG95) recommends CTCA as a 1st line diagnostic test for evaluation of ambulatory patients with suspected stable angina based on its high sensitivity and low cost. This has led to increasing demand for CTCA across the National Health Service (NHS) in order to comply with the NICE recommendation. Purpose We studied the utility and effectiveness of CTCA in the evaluation of ambulatory patients with suspected stable angina attending rapid access chest pain clinic (RACPC) in a large tertiary hospital in the UK. Methods The study included consecutive patients attending RACPC over a pre-specified period of 6-months who were suspected of having stable angina and hence, referred for CTCA. The data were collected on demographics, CTCA results including incidental finding and downstream investigations. All patients had a minimum of 12-months follow up for clinical outcomes. Results A total of 170 patients were referred for CTCA (mean age = 56.8 years, male = 53.5%) out of the 388 consecutive patients who were reviewed in the RACPC during the 6-month period. CTCA was non-diagnostic in 48/170 (28.2%) cases (Breathing artefact 35%, Severe Coronary Calcification 31%, Elevated heart rate/Ectopy 30%) while 63/170 (37.1%) of patients had incidental extra-cardiac findings. Amongst patients with incidental findings, 17/63 (27.0%) underwent further investigations. A total of 54/170 (31.7%) of patients were recommended to have downstream cardiac investigations such as a stress test (DSE/MRI/MPS) (23/170, 15.8%) while 31/170 (18.2%) were referred for invasive coronary angiography. Revascularisation procedures (PCI n=7.6%, CABG n=4.7%) were required in 21/170 (12.4%) patients. Based on 2017 NHS tariffs, overall average cost-per-patient with the initial CTCA approach was £122.11 excluding downstream investigations and £548.43 including the cost of downstream cardiac investigations. Incidental Findings after CTCA Conclusions Our study suggests that a CTCA based approach is associated with non-diagnostic information in at least 1:4 patients and incidental extracardiac findings in 1:3 patients. Further downstream cardiac investigations are required in around 1:3 patients after a CTCA carried out for evaluation suspected stable angina. The NICE recommendation is based on the low initial cost of CTCA and high sensitivity, however, taking in to account the additional cost of downstream investigations, the average cost per patient of this approach is significantly (4.5 times) higher. Acknowledgement/Funding None

Background The role of glycoprotein IIb/IIIa inhibitors (GPI) in primary PCI (PPCI) remains uncertain. We aim to compare patient outcomes between routine and selective GPI usage strategies. Methods All consecutive PPCIs in England between January 2009 and April 2015 were prospectively recorded in the BCIS database. The cohort was divided into routine and selective GPI usage groups based on the responsible consultant’s (RC) strategy. The primary endpoint was all-cause mortality, which was compared using Cox regression analyses. Results We assessed 110327 PPCIs. Routine compared to selective GPI usage (defined as GPI used in ≥75% and≤25% PPCIs performed by RC, respectively) was associated with significantly decreased Kaplan-Meier estimated rates for all-cause mortality at one year of 9.7% vs 11.0% (p Conclusion A strategy of routine GPI usage in patients undergoing PPCI was associated with lower all-cause mortality as compared to selective GPI usage.

Background: Poor quality cardiopulmonary resuscitation (CPR) predicts adverse outcome. During invasive cardiac procedures automated-CPR (A-CPR) may help maintain effective resuscitation. The use of A-CPR following in-hospital cardiac arrest (IHCA) remains poorly described.Aims & methods: Firstly, we aimed to assess the efficiency of healthcare staff using A-CPR in a cardiac arrest scenario at baseline, following re-training and over time (Scenario-based training). Secondly, we studied our clinical experience of A-CPR at our institution over a 2-year period, with particular emphasis on the details of invasive cardiac procedures performed, problems encountered, resuscitation rates and in-hospital outcome (AutoPulse-CPR Registry).Results: Scenario-based training: Forty healthcare professionals were assessed. At baseline, time-to-position device was slow (mean 59 (+/- 24) s (range 15-96 s)), with the majority (57%) unable to mode-switch. Following re-training time-to-position reduced (28 (+/- 9) s, p < 0.01 vs baseline) with 95% able to mode-switch. This improvement was maintained over time. AutoPulse-CPR Registry: 285 patients suffered IHCA, 25 received A-CPR. Survival to hospital discharge following conventional CPR was 28/260 (11%) and 7/25 (28%) following A-CPR. A-CPR supported invasive procedures in 9 patients, 2 of whom had A-CPR dependant circulation during transfer to the catheter lab.Conclusion: A-CPR may provide excellent haemodynamic support and facilitate simultaneous invasive cardiac procedures. A significant learning curve exists when integrating A-CPR into clinical practice. Further studies are required to better define the role and effectiveness of A-CPR following IHCA. (C) 2014 Elsevier Ireland Ltd. All rights reserved.

Introduction A simple provisional side-branch stenting strategy is favoured over a more complex approach in the majority of bifurcation lesions. In the subset of lesions that require a two-stent strategy the optimal treatment remains controversial. The Crush-T stent technique is advocated to minimise the risk of side-branch restenosis by ensuring complete circumferential stent coverage. Long-term follow-up outcome data for this technique are not available. Aim To determine procedural outcomes and rates of 1, 2 and 3-year major adverse cardiac events (MACE) in a consecutive series of 100 bifurcation lesions treated with paclitaxel-eluting stents using the Crush technique at University Hospital Birmingham. Methods In a prospective registry data were recorded for 100 cases treated between May 2003 and July 2005. Clinical follow-up was by telephone contact or hospital visit. Myocardial infarction (MI) during follow-up was defined according to European Society of Cardiology/American College of Cardiology definitions. Standard definitions of target lesion revascularisation (TLR) and target vessel revascularisation (TVR) were used. MACE was defined as any cardiac death, TVR or MI. The Academic Research Consortium definitions of stent thrombosis were used. Complete follow-up data are available for all patients at 3 years. Results The mean age was 62 ± 11 years (range 37–86) with 75% males, 15% patients with diabetes and 53% presenting with an acute coronary syndrome. Paclitaxel-eluting stents were used in all cases and exclusively in 96%. A glycoprotein IIb/IIIa inhibitor was used in all cases. The site of bifurcation was 81% left anterior descending/distal, 12% circumflex artery/obtuse marginal, 6% distal left main stem and 1% right posterior descending artery/atrioventricular continuation. 93% were true bifurcations (⩾50% stenosis in main vessel and side branch). Technical success was 98% due to two failed attempts to deliver a side branch stent. A final kissing balloon dilatation was attempted in 68 patients and was successful in 51. Inpatient MACE was due to four non-Q wave MI. Symptom-driven TLR was 8% comprising seven repeat PCI procedures and one bypass. In univariate analyses the absence of a final kissing inflation was a significant predictor of TVR and TLR (p 365 days). There was no significant correlation between the site of bifurcation, gender, diabetes or mode of presentation and any outcome variable. Conclusion The long-term outcome of Crush stenting using paclitaxel-eluting stents in true bifurcation lesions was acceptable and comparable to long-term outcomes of provisional T stenting. Revascularisation rates were low when compared with published data. Failure to perform kissing balloon inflation successfully is a drawback of this technique. The absence of a final kissing inflation predicts TLR but does not increase the risk of cardiac death, stent thrombosis or MI at 3 years.

Objective: To evaluate the pattern of right ventricular (RV) functional recovery and its relation with left ventricular (LV) function and interventricular septal (IVS) motion in low risk patients after acute myocardial infarction (AMI).Design and setting: Multicentre clinical trial carried out in 47 Italian coronary care units.Patients: 500 patients from the GISSI (Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico) -3 echo substudy, who underwent serial echocardiograms 24-48 hours after symptom onset and at discharge, six weeks, and six months after AMI.Results: Tricuspid annular plane systolic excursion (TAPSE) increased significantly during follow up (mean (SD) 1.79 (0.46) cm at 24-48 hours to 1.92 (0.46) cm at six months, p , 0.001) and the increase was already significant at discharge (1.88 (0.47) cm, p , 0.001).LV ejection fraction (LVEF) was the best correlate of TAPSE at 24-48 hours (r = 0.15, p = 0.001).TAPSE increased significantly in patients both with reduced (, 45%) and with preserved (> 45%) LVEF, but the magnitude of increase was higher in patients with lower initial LVEF (p = 0.001).Improvement in IVS wall motion score index (IVS-WMSI) was the only independent predictor of TAPSE changes during follow up (r = 20.12,p = 0.007).Conclusions: In low risk patients after AMI, RV function recovered throughout six months of follow up and was already significant at discharge.TAPSE was significantly related to LVEF at 24-48 hours.The magnitude of RV functional recovery was higher in patients with lower initial LVEF.RV functional recovery is best related to IVS-WMSI improvement, suggesting that IVS motion has an important role in RV functional improvement in this setting.

AIMSTo test whether measuring hyperaemic changes in pulse wave velocity (PWV) could be used as a new method of assessing endothelial function for use in clinical practice.METHODS AND RESULTSFlow-mediated changes in vascular tone may be used to assess endothelial function and may be induced by distal hyperaemia, while endothelium-mediated changes in vascular tone can influence PWV. These three known principles were combined to provide and test a novel method of measuring endothelial function by the acute effects of distal hyperaemia on upper and lower limb PWV (measured by a recently developed method). Flow-mediated changes in upper and lower limb PWV were compared in 17 healthy subjects and seven patients with stable chronic heart failure (CHF), as a condition where endothelial function is impaired but endothelium-independent dilator responses are retained. Corroborative measurements of PWV and brachial artery diameter responses to endothelium-dependent and -independent pharmacological stimuli were performed in a further eight healthy subjects. Flow-mediated reduction of PWV (by 14% with no change in blood pressure) was found in normal subjects but was almost abolished in patients with CHF. PWV responses appear to be inversely related to and relatively greater than brachial artery diameter responses.CONCLUSIONThe method may offer potential advantages of practical use and sensitivity over conduit artery diameter responses to measure endothelial dysfunction.