IntroductionCardiac troponin (cTn) concentrations above the manufacturer recommended upper limit of normal (ULN) are frequently seen in hospital patients without a clinical presentation consistent with type 1 myocardial infarction, and the significance of this is uncertain. The aim of this study was to assess the relationship between medium-term mortality and cTn concentration in a large consecutive hospital population, regardless of whether there was a clinical indication for performing the test. MethodThis prospective observational study included 20 000 consecutive in-hospital and outpatient patients who had a blood test for any reason at a large teaching hospital, and in whom a hs-cTnI assay was measured, regardless of the original clinical indication. Mortality was obtained via NHS Digital. ResultsA total of 20 000 patients were included in the analysis and 18 282 of these (91.4%) did not have a clinical indication for cardiac troponin I (cTnI) testing. Overall, 2825 (14.1%) patients died at a median of 809 days. The mortality was significantly higher if the cTnI concentration was above the ULN (45.3% vs 12.3% p<0.001 log rank). Multivariable Cox analysis demonstrated that the log(10) cTnI concentration was independently associated with mortality (HR 1.76 (95% CI 1.65 to 1.88)). Landmark analysis, excluding deaths within 30 days, showed the relationship between cTnI concentration and mortality persisted. ConclusionIn a large, unselected hospital population, in 91.4% of whom there was no clinical indication for testing, cTnI concentration was independently associated with medium-term cardiovascular and non-cardiovascular mortality in the statistical model tested.

103 Table 1 Percentage of inpatients with hs-cTn above the ULN (specialities with more than 100 patients) Abstract 103 Table 2 Frequency of hs-cTn elevation in outpatients with a coded co-morbidity Abstracts103 Table 2 Frequency of hs-cTn elevation in outpatients with a coded co-morbidity Abstracts Heart 2019;105(Suppl 6):A1–A193 A85 on S etem er 8, 2023 by gest. P rocted by coright. httpeart.bm jcom / H ert: frst pulished as 10.113artjnl-2019-B C S .00 on 26 M ay 219. D ow nladed fom throughout. These data were combined with the source location for the blood test, as well as the presence of coded comorbidity since the year 2000. Results There were 18171 patients left once patients discharged with a diagnosis of MI (122) and those suspected of MI (1707) by the clinical team were excluded. There were 4759 inpatients, 9280 outpatients and 4132 patients in the emergency department with 7.3%, 2.0% and 7.4% of these having an hs-cTn level above the manufacturer-provided ULN respectively. Table 1 demonstrates the prevalence of hs-cTn levels above the ULN in hospitalised patients by speciality. In terms of outpatients; cardiothoracic, renal and oncology/haematology patients were the most likely to have an hs-cTn above the ULN with 7.4%, 4.9% and 2.6% respectively above this level. There were 4265 (46%) outpatients in whom there was at least one coded co-morbidity present. These patients were more likely to have an hs-cTn above the ULN than those without a coded co-morbidity (2.8% versus 1.2%, P<0.0001). Table 2 demonstrates the prevalence of outpatients with an hs-cTn above the ULN by coded co-morbidity. Conclusion These data suggest that application of a manufacturer-derived 99th centile for hs-cTn assay to a hospital population may be flawed, particularly if any assumption is made that a result above this level may represent acute MI in patients without a classical history. Caution and a good understanding of the assay is imperative for accurate diagnosis and management of hospital patients with an apparently elevated level, but these results also raise interesting questions about what the levels actually indicate in patients in whom the suspicion f acute Mi is low. More data are required. Conflict of Interest Educational support from BAYER 104 HERITABILITY AND FAMILY-BASED GWAS ANALYSES OF THE CIRCULATING CERAMIDE, ENDOCANNABINOID, AND N-ACYL ETHANOLAMIDE LIPIDOME Kathryn McGurk*, Bernard Keavney, Anna Nicolaou. The University of Manchester; Faculty of Biology, Medicine and Health, University of Manchester 10.1136/heartjnl-2019-BCS.10

Background: Patients hospitalized with COVID-19 suffer thrombotic complications. Risk factors for poor outcomes are shared with coronary artery disease. Objectives: To investigate the efficacy of an acute coronary syndrome regimen in patients hospitalized with COVID-19 and coronary disease risk factors. Methods: A randomized controlled, open-label trial across acute hospitals (United Kingdom and Brazil) added aspirin, clopidogrel, low-dose rivaroxaban, atorvastatin, and omeprazole to standard care for 28 days. Primary efficacy and safety outcomes were 30-day mortality and bleeding. The key secondary outcome was a daily clinical status (at home, in hospital, on intensive therapy unit admission, or death). Results: Three hundred twenty patients from 9 centers were randomized. The trial terminated early due to low recruitment. At 30 days, there was no significant difference in mortality (intervention vs control, 11.5% vs 15%; unadjusted odds ratio [OR], 0.73; 95% CI, 0.38-1.41; p = .355). Significant bleeds were infrequent and were not signifi-cantly different between the arms (intervention vs control, 1.9% vs 1.9%; p > .999). Using a Bayesian Markov longitudinal ordinal model, it was 93% probable that intervention arm participants were more likely to transition to a better clinical state each day (OR, 1.46; 95% credible interval [CrI], 0.88-2.37; Pr [beta > 0], 93%; adjusted OR, 1.50; 95% CrI, 0.91-2.45; Pr [beta > 0], 95%) and median time to discharge to home was 2 days shorter (95% CrI, -4 to 0; 2% probability that it was worse). Conclusion: Acute coronary syndrome treatment regimen was associated with a reduction in the length of hospital stay without an excess in major bleeding. A larger trial is needed to evaluate mortality.

Introduction High sensitivity troponin (hs-cTn) concentrations above the manufacturer recommended upper limit of normal (ULN) are frequently seen in patients without a clinical presentation consistent with type 1 myocardial infarction. There is increasing evidence that these concentrations may act as a marker of prognosis in a range of conditions. However, previous studies have been limited because they have only included patients in whom the clinician has requested the test. The aim of this study was to assess the relationship between medium term mortality and hs-cTn concentration in a large consecutive hospital population undergoing a blood test, regardless of whether there was a clinical indication for performing the hs-cTn.Method: This single centre study included 20,000 consecutive patients undergoing a blood test for any reason, in whom hs-cTnI was added, regardless of the clinical indication (CHARIOT population). Mortality data up to 2.25 years was obtained via NHS Digital. The association between hs-cTnI concentration and one year mortality was evaluated using Kaplan-Meier plots (with log-rank test) and Cox proportional hazards analyses. After the cohort was considered as a whole, each of the clinical areas (inpatient (IPD), outpatient (OPD), emergency department (ED)) were considered separately. Furthermore, in the IPD and ED populations, a landmark analysis was performed excluding those patients who died within 30 days to assess whether any longer term relationship was driven by short term mortality. Results Overall, 2825 (14.1%) patients had died at 2.25 years. The mortality at 2.25 years was significantly higher if the hs-cTnI concentration was above the ULN (45.3% versus 12.3% p<0.001 (log rank) in the entire cohort (figure 1). Multivariable Cox regression analysis demonstrated that the log(10)hs-cTnI concentration was independently associated with 2.25 year mortality (hazard ratio (HR)1.69 (95%confidence interval (CI) 1.59 – 180)). This relationship was demonstrated for patients in each of the clinical areas (IPD HR 1.46 (95%CI 1.33 – 1.60), OPD HR 2.19 (95%CI 1.84 – 2.60), ED HR 1.87 (95%CI 1.68 – 2.07)). Further analysis by excluding those patients that died within 30 days demonstrated that the relationship between hs-cTnI concentration and mortality persisted and it was not driven by short term mortality. Conclusion In a large, unselected hospital population of both in- and out-patients, the majority of whom there was no clinical indication for testing, hs-cTnI concentration was independently associated with medium term mortality. These data suggest that hs-cTnI may have a role as a biomarker of future risk. Conflict of Interest All of the assays used in our studies were provided free of charge by beckman coulter

The emergence of vaccines, with clear evidence of their efficacy, has been key to tackling the coronavirus disease 2019 (COVID-19) pandemic. However, as these vaccines are rolled out to larger numbers of patients, rare complications are inevitable, and clinicians should be aware of this possibility. We present a case of a young man who presented with an anaphylactoid reaction a day after having the Pfizer-BioNTech COVID-19 vaccine with thrombotic occlusion of his left anterior descending (LAD) artery. Paramedics attended a 38-year-old man with a sudden onset widespread erythematous rash, dyspnea, and stridor 18 hours after receiving his first dose of the Pfizer-BioNTech COVID-19 vaccine. Past medical history was notable for asthma and eczema but no known allergies. He was treated with 500 μg of adrenaline intramuscularly with initial good response; however, he developed severe central chest pain. Serial electrocardiograms revealed evolving ST-segment elevation — initially inferiorly and then anteriorly (Figure, A). He was therefore transferred to hospital and underwent urgent coronary angiography which surprisingly showed severe thrombotic stenosis of the proximal LAD with distal embolization (Figure, B). Optical coherence tomography confirmed significant LAD thrombus (Figure, C; white arrows) but no evidence of underlying atherosclerotic plaque rupture and normal smooth vessel wall segments (Figure, C; interrupted blue arrows). Multiple thrombus aspiration runs were undertaken, and the patient was started on a glycoprotein 2b/3a inhibitor with improvement of the angiographic appearances. Transthoracic echocardiography showed an apical left ventricular thrombus. Subsequent angiography 2 days later was reassuring with reduced thrombotic burden and no features suggestive of plaque rupture (Figure, D and E). Given the absence of coronary stenosis from an atherosclerotic plaque, a coronary stent was not deployed. The patient was managed medically with dual-antiplatelet therapy and a direct oral anticoagulant. On further questioning, he denied any insect bites or taking any drugs, and had been fasting for 12 hours. Interestingly, his mast cell tryptase was normal (10.7 ng/mL) and no cocaine metabolites were seen on urinalysis. The patient had an uneventful recovery and an EpiPen issued before discharge. The adverse event was reported to the Medicine and Healthcare products Regulatory Agency of the Department of Health and Social Care in the United Kingdom. Importantly, the Pfizer-BioNTech COVID-19 vaccine has been shown to be safe and effective in protecting against severe disease.1Polack F.P. Thomas S.J. Kitchin N. et al.Safety and efficacy of the BNT162b2 mRNA COVID-19 vaccine.N Engl J Med. 2020; 383: 2603-2615Crossref PubMed Scopus (9742) Google Scholar,2Lopez Bernal J. Andrews N. Gower C. et al.Effectiveness of the Pfizer-BioNTech and Oxford-AstraZeneca vaccines on COVID-19 related symptoms, hospital admissions, and mortality in older adults in England: test negative case-control study.BMJ. 2021; 373: n1088Crossref PubMed Scopus (773) Google Scholar Severe adverse reactions are rare and for the vast majority anaphylaxis occurs within minutes of administration.3Shimabukuro T.T. Cole M. Su J.R. Reports of anaphylaxis after receipt of mRNA COVID-19 vaccines in the US — December 14, 2020–January 18, 2021.JAMA. 2021; 325: 1101-1102Crossref PubMed Scopus (310) Google Scholar,4Shimabukuro T. Nair N. Allergic reactions including anaphylaxis after receipt of the first dose of Pfizer-BioNTech COVID-19 vaccine.JAMA. 2021; 325: 780-781Crossref PubMed Scopus (226) Google Scholar We postulate that, in the absence of significant underlying atherosclerotic coronary artery disease, spontaneous LAD thrombosis resulted either from a delayed anaphylactoid reaction or a combination of the immune reaction and adrenaline administered. Indeed, adrenaline injection promotes platelet aggregation and thrombus formation by increasing the levels of thromboxane and sensitivity to thrombin.5Laustiola K. Kaukinen S. Seppälä E. Jokela T. Vapaatalo H. Adrenaline infusion evokes increased thromboxane B2 production by platelets in healthy men: the effect of beta-adrenoceptor blockade.Eur J Clin Invest. 1986; 16: 473-479Crossref PubMed Scopus (27) Google Scholar,6Wallén N.H. Goodall A.H. Li N. Hjemdahl P. Activation of haemostasis by exercise, mental stress and adrenaline: effects on platelet sensitivity to thrombin and thrombin generation.Clin Sci (Lond). 1999; 97: 27-35Crossref PubMed Scopus (104) Google Scholar Adrenaline injection can induce vasospasm with occlusion or near occlusion of the lumen,7Yasue H. Nakagawa H. Itoh T. Harada E. Mizuno Y. Coronary artery spasm — clinical features, diagnosis, pathogenesis, and treatment.J Cardiol. 2008; 51: 2-17Abstract Full Text Full Text PDF PubMed Scopus (315) Google Scholar the resultant blood stasis in the coronary circulation may also facilitate thrombogenesis. Although a previous case report of LAD thrombosis following Pfizer-BioNTech COVID-19 vaccination shares some features with this case, the patient was 86 years of age with cardiovascular risk factors and their reaction occurred within 30 minutes of vaccination and was not associated with an anaphylactoid-type pattern.8Tajstra M. Jaroszewicz J. Gąsior M. Acute coronary tree thrombosis after vaccination for COVID-19.J Am Coll Cardiol Interv. 2021; 14: e103-e104Crossref PubMed Scopus (35) Google Scholar Physicians should be aware of the possibility for late anaphylactoid reactions, including potential thrombotic coronary artery occlusion, following COVID-19 vaccination.

IntroductionValve-in-valve transcatheter aortic valve implantation (V-in-V TAVI) has become an increasingly popular alternative to re-do surgery for patients with failing aortic bioprosthetic valves. The Trifecta aortic valve replacement (AVR), designed for supra-annular insertion, consists of a titanium stent with externally mounted leaflets fashioned from bovine pericardium. Several studies have reported premature structural degeneration of the Trifecta valve. There are currently few data regarding the feasibility & efficacy of V-in-V TAVI within Trifecta bioprostheses.MethodsThis represents a retrospective review of prospectively collected data at our centre for TAVI procedures performed between January 1st 2015 and December 31st 2020 inclusive. In cases of V-in-V TAVI to treat a failing Trifecta valve, we collected demographic, procedural, echocardiographic and short-term follow-up data from electronic records systems for both this NHS Trust and primary care.ResultsOver a 6-year period, we performed 549 TAVI procedures, of which 51 (9.3%) were V-in-V cases. Of these 51, 15 (29%) were for patients with failing Trifecta valves (9 female, mean age 80.9 ± 5.6yrs;. predominant stenosis in 5 & transvalvular regurgitation in 10). Figures 1 & 2 demonstrate examples of prosthesis stenosis & prosthesis regurgitation treated by V-in-V TAVI. The median time from original AVR to V-in-V TAVI procedure was 59 months (IQR 36.5, range 16–93 months). All procedures were performed via the transfemoral route and 13/15 under conscious sedation. A balloon-expandable TAVI valve was used in 14 patients & a self-expanding valve in 1 patient. Post-procedural echocardiography revealed a mean aortic peak velocity 2.9 ± 0.4m/s & mean aortic gradient 19 ± 5mmHg. Paravalvular aortic regurgitation was absent in 7 cases, trivial in 6 & mild in 2 patients. In-hospital and 30-day mortality were 0%. There were three deaths during follow-up (36, 14 & 3 months post procedure), all of which were non-cardiac in nature.ConclusionV-in-V TAVI is a safe and feasible alternative to re-do surgical AVR for patients with a failing Trifecta aortic bioprosthesis. Unlike other bioprosthetic valves, the Trifecta valve cannot be fractured to enable a larger V-in-V TAVI valve to be implanted. Thus, longer term follow-up of such patients will allow a full understanding of the long-term haemodynamic and clinical outcomes in this patient cohort.Conflict of InterestNil

Introduction High sensitivity troponin (hs-cTn) concentrations above the manufacturer recommended upper limit of normal (ULN) are seen frequently in patients without a clinical presentation consistent with an acute coronary syndrome. There is increasing evidence that these concentrations may act as a marker of prognosis in a range of conditions. However, previous studies have been limited because they have only included patients in whom the clinician has requested the test. The aim of this study was to assess the relationship between one year mortality and hs-cTn concentration in a consecutive hospital population, regardless of whether there was a clinical indication for performing the test. Method This study included 20,000 consecutive patients that had hs-cTnI added onto their blood tests at a large teaching hospital, regardless of the clinical indication (CHARIOT population). One year mortality data was obtained by linkage with NHS Digital. The association between hs-cTnI concentration and one year mortality was evaluated using Kaplan-Meier plots and Cox proportional hazards analyses. After the cohort was considered as a whole, each of the clinical areas (inpatient (IPD), outpatient (OPD), emergency department (ED)) were considered separately. Results Overall, 1782 (8.9%) patients had died at one year. Multivariable Cox regression analysis showed that a hs-cTnI concentration above the ULN was independently associated with the hazard of mortality (HR 2.23; 95% CI 1.97 – 2.52). There was a progressive increase in mortality across the strata of hs-cTnI concentration (figure 1). Furthermore the log (10) hs-cTnI concentration was an independent predictor of the hazard of one year mortality (HR 1.77; 95% CI 1.64 – 1.91). The discriminative ability of hs-cTnI for one year mortality was good with an AUC of 0.75 (95%CI 0.73 – 0.76). Further, the log(10) hs-cTnI concentration was independently associated with mortality across all three locations and most strongly in the OPD cohort (IPD HR 1.49; 95% CI 1.33 – 1.67, OPD HR 2.44; 95% CI 1.95 – 3.04, ED HR 1.99; 95% CI 1.76 – 2.25). Conclusion In a large, unselected hospital population of both in- and out-patients, 18,282 (91.4%) of whom there was no clinical indication for testing, hs-cTnI concentration was independently associated with one year mortality. These data suggest that hs-cTnI may have a role as a biomarker of future risk. Conflict of Interest Beckman Coulter paid for all of the assays used in our studies but had no other role in the studies

Hypertension is prevalent, under and contributes to the development of potentially unstable coronary artery disease in healthy male endurance athletes. Recom-mendations for cardiovascular evaluation of master athletes should consider a low threshold for non-invasive exercise test-ing and ambulatory BP monitoring for for athletes with hypertension and even high-normal BP.

This was an observational study of the 1-year outcomes of the 20,000 patients included in the original CHARIOT study. The aim of the study was to assess the association between high sensitivity troponin I (hs-cTnI) concentration and 1 year mortality in this cohort. The original CHARIOT study included a consecutive cohort of in- and out-patients undergoing blood tests for any reason. Hs-cTnI concentrations were measured regardless of whether the clinician requested them. These results were nested and not revealed to the team unless requested for clinical reasons. One year mortality data was obtained from NHS Digital as originally planned. Overall, 1782 (8.9%) patients had died at 1 year. Multi-variable Cox regression analysis showed that a hs-cTnI concentration above the upper limit of normal was independently associated with the hazard of mortality (HR 2.23; 95% confidence intervals 1.97 to 2.52). Furthermore, the log (10) hs-cTnI concentration was independently associated with the hazard of 1 year mortality (HR 1.77; 95% confidence intervals 1.64 to 1.91). In conclusion, in a large, unselected hospital population of both in- and out-patients, in 18,282 (91.4%) of whom there was no clinical indication for testing, hs-cTnI concentration was associated with 1 year mortality. (C) 2021 Elsevier Inc. All rights reserved.

BACKGROUND:Atrial Fibrillation is the most common arrhythmia worldwide with a global age adjusted prevalence of 0.5% in 2010. Anticoagulation treatment using warfarin or direct oral anticoagulants is effective in reducing the risk of AF-related stroke by approximately two-thirds and can provide a 10% reduction in overall mortality. There has been increased interest in detecting AF due to its increased incidence and the possibility to prevent AF-related strokes. Inexpensive consumer devices which measure the ECG may have the potential to accurately detect AF but do not generally incorporate diagnostic algorithms. Machine learning algorithms have the potential to improve patient outcomes particularly where diagnoses are made from large volumes or complex patterns of data such as in AF.METHODS:We designed a novel AF detection algorithm using a de-correlated Lorenz plot of 60 consecutive RR intervals. In order to reduce the volume of data, the resulting images were compressed using a wavelet transformation (JPEG200 algorithm) and the compressed images were used as input data to a Support Vector Machine (SVM) classifier. We used the Massachusetts Institute of Technology (MIT)-Beth Israel Hospital (BIH) Atrial Fibrillation database and the MIT-BIH Arrhythmia database as training data and verified the algorithm performance using RR intervals collected using an inexpensive consumer heart rate monitor device (Polar-H7) in a case-control study.RESULTS:The SVM algorithm yielded excellent discrimination in the training data with a sensitivity of 99.2% and a specificity of 99.5% for AF. In the validation data, the SVM algorithm correctly identified AF in 79/79 cases; sensitivity 100% (95% CI 95.4%-100%) and non-AF in 328/336 cases; specificity 97.6% (95% CI 95.4%-99.0%).CONCLUSIONS:An inexpensive wearable heart rate monitor and machine learning algorithm can be used to detect AF with very high accuracy and has the capability to transmit ECG data which could be used to confirm AF. It could potentially be used for intermittent screening or continuously for prolonged periods to detect paroxysmal AF. Further work could lead to cost-effective and accurate estimation of AF burden and improved risk stratification in AF.

Background The use of high-sensitivity troponin (hs-cTn) is established in guideline-directed clinical practice to facilitate the diagnosis or exclusion of myocardial infarction (MI). The manufacturer provided 99th percentile for this assay is derived from a small population of relatively healthy individuals but is used as an “upper limit of normal” (ULN) in routine hospital practice. This raises the question: does this ULN actually represent the 99th centile of the distribution of the assay in an all comers hospital population, in most of whom there is no clinical suspicion of an MI? Methods Twenty thousand consecutive patients attending this large University Teaching Trust who had biochemistry tests for any clinical reason, either as in- or outpatient had an hs-cTn assay as part of this study. In those patients in whom hs-cTn was not requested by their supervising clinician, the result of the assay was nested, and never revealed to doctor or patient. Ethical approval for this method required special permission from the national Confidentiality Advisory Group following support from the British Cardiac Patients Association. The Beckman Coulter Access AccuTnI+3 assay was used throughout. These data were combined with the source location for the blood test, as well as the presence of coded co-morbidity since the year 2000. Results There were 18171 patients left once patients discharged with a diagnosis of MI (122) and those suspected of MI (1707) by the clinical team were excluded. There were 4759 inpatients, 9280 outpatients and 4132 patients in the emergency department with 7.3%, 2.0% and 7.4% of these having an hs-cTn level above the manufacturer-provided ULN respectively. Table 1 demonstrates the prevalence of hs-cTn levels above the ULN in hospitalised patients by speciality. In terms of outpatients; cardiothoracic, renal and oncology/haematology patients were the most likely to have an hs-cTn above the ULN with 7.4%, 4.9% and 2.6% respectively above this level. There were 4265 (46%) outpatients in whom there was at least one coded co-morbidity present. These patients were more likely to have an hs-cTn above the ULN than those without a coded co-morbidity (2.8% versus 1.2%, P<0.0001). Table 2 demonstrates the prevalence of outpatients with an hs-cTn above the ULN by coded co-morbidity. Conclusion These data suggest that application of a manufacturer-derived 99th centile for hs-cTn assay to a hospital population may be flawed, particularly if any assumption is made that a result above this level may represent acute MI in patients without a classical history. Caution and a good understanding of the assay is imperative for accurate diagnosis and management of hospital patients with an apparently elevated level, but these results also raise interesting questions about what the levels actually indicate in patients in whom the suspicion f acute Mi is low. More data are required. Conflict of Interest Educational support from BAYER

OBJECTIVE To determine the distribution, and specifically the true 99th centile, of high sensitivity cardiac troponin I (hs-cTnI) for a whole hospital population by applying the hs-cTnI assay currently used routinely at a large teaching hospital. DESIGN Prospective, observational cohort study. SETTING University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom, between 29 June 2017 and 24 August 2017. PARTICIPANTS 20 000 consecutive inpatients and outpatients undergoing blood tests for any clinical reason. Hs-cTnI concentrations were measured in all study participants and nested for analysis except when the supervising doctor had requested hs-cTnI for clinical reasons. MAIN OUTCOME MEASURES Distribution of hs-cTnI concentrations of all study participants and specifically the 99th centile. RESULTS The 99th centile of hs-cTnI for the whole population was 296 ng/L compared with the manufacturer's quoted level of 40 ng/L (currently used clinically as the upper limit of normal; ULN). Hs-cTnI concentrations were greater than 40 ng/L in one in 20 (5.4%, n=1080) of the total population. After excluding participants diagnosed as having acute myocardial infarction (n=122) and those in whom hs-cTnI was requested for clinical reasons (n=1707), the 99th centile was 189 ng/L for the remainder (n=18 171). The 99th centile was 563 ng/L for inpatients (n=4759) and 65 ng/L for outpatients (n=9280). Patients from the emergency department (n=3706) had a 99th centile of 215 ng/L, with 6.07% (n=225) greater than the recommended ULN. 39.02% (n=48) of all patients from the critical care units (n=123) and 14.16% (n=67) of all medical inpatients had an hs-cTnI concentration greater than the recommended ULN. CONCLUSIONS Of 20 000 consecutive patients undergoing a blood test for any clinical reason at our hospital, one in 20 had an hs-cTnI greater than the recommended ULN. These data highlight the need for clinical staff to interpret hs-cTnI concentrations carefully, particularly when applying the recommended ULN to diagnose acute myocardial infarction, in order to avoid misdiagnosis in the absence of an appropriate clinical presentation.

Objective: To define the 99th percentile of high sensitivity cardiac troponin I (hs-cTnI) concentration for a hospital population.

​To The Editor  We read with interest the article by Tavernier et al regarding screening for atrial fibrillation (AF) in hospitalised geriatric patients and the feasibility to identify a significant number of patients (over 10% more than routine care) with AF who may benefit from anticoagulation.1 A new diagnosis of AF could prompt more vigilant heart rate monitoring and potentially prevent tachycardia-related cardiomyopathy.2 The authors have not …

Objective: To compare outcomes following femoral artery (FA) and radial artery(RA) access for consecutive patients undergoing primary percutaneouscoronary intervention (PPCI) over a four-year observational period. Methodology: This cross sectional study was conducted at University HospitalSouthampton . All PPCI cases performed at our center over a four-year period (1April 2008 to 31 March 2012) were rewired. Patients more than 18 years of agewere included . Procedural decisions including access site, device selection, useof adjunctive pharmacotherapy and type of stent were at the operator discretion.Cardiologists delivering the PPCI service, three used RA access , while the otherthree used FA access and outcomes between these two groups was recorded. Alldata were analysed using SPSS statistical software, (Version 20.0, IBMCorporation, Armonk, NY, USA). Result: Our study included 961 patients (64±12 years, 76% males). There wasno significant difference in door-to-balloon times, radiation dose or in-hospitallength of stay between the RA and FA groups. In-hospital mortality rates werehigher in FA group vs. RA group (6.8% vs. 2.0%, p=0.009). However, followingthe exclusion of cardiogenic shock patients, the in-hospital mortality rates wereno different, 2.4% vs. 4.3%, (p=0.10). There was a higher rate of combinedvascular complications in the FA group (1.4% vs. 0%, p=0.05). RA access wasassociated with a higher screening time (minutes) 9 (3 to 15) vs. 7.5 (0.5 to 14.5)(p<0.0001) and access site failure 2.8% vs. 0.1% (p<0.0001). Conclusion: Our data demonstrates that in patients without cardiogenic shockundergoing PPCI, there is no significant difference in outcomes for FA versus RAaccess.

Purpose of the study Out-of-hospital cardiac arrest (OHCA) has a poor prognosis despite bystander resuscitation and rapid transfer to hospital. Optimal management of patients after arrival to hospital continues to be contentious, especially the timing of emergency coronary angiography±revascularisation. Robust predictors of inhospital outcome would be of clinical value for initial decision-making. Study design A retrospective analysis of consecutive patients who presented to a university hospital following OHCA over a 70-month period (2008–2013). Patients were identified from the emergency department electronic patient registration and coding system. For those patients who underwent emergency percutaneous coronary intervention, details were crosschecked with national databases. Results We identified 350 consecutive patients who were brought to our hospital following OHCA. Return of spontaneous circulation (ROSC) for >20 min was achieved either before arrival or inhospital in 196 individuals. From the 350 subjects, 114 (32.6%) survived to hospital discharge. When sustained ROSC was achieved, either before or inhospital, survival to discharge was 58.2% (114 of 196). Non-shockable rhythm, absence of bystander cardiopulmonary resuscitation, ‘downtime’ >15 min and initial pH ≤7.11 were predictors of inhospital death. 12% patients who underwent angiography in the presence of ST elevation had no acute coronary occlusion. 21% patients with acute coronary occlusion at angiography did not have ST elevation. Conclusions In our cohort of patients with OHCA, those who achieve ROSC had a survival-to-discharge rate of 58.2%. We identified four predictors of inhospital death, which are readily available at the time of patient presentation. Reliance on ST elevation to decide about coronary angiography and revascularisation may be flawed. More data are required.

In the Fractional flow reserve (FFR) versus angiography in guiding management to optimise outcomes in non-ST elevation myocardial infarction (FAMOUS) clinical trial, FFR was shown to significantly reduce coronary revascularisation, compared to visual interpretation of standard coronary angiography without FFR. We estimated the cost-effectiveness from a UK National Health Service perspective, based on the results of FAMOUS.

HomeCirculationVol. 131, No. 14Coronary Artery Rupture Caused by Stent Infection Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBCoronary Artery Rupture Caused by Stent InfectionA Rare Complication Apostolos Roubelakis, PhD, John Rawlins, MD, MRCP, Giedrius Baliulis, MD, Sally Olsen, BM, Simon Corbett, PhD, FRCP, Markku Kaarne, MD and Nick Curzen, PhD, FRCP Apostolos RoubelakisApostolos Roubelakis From Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK (A.R., J.R., G.B., S.O., S.C., M.K., N.C.); and Faculty of Medicine, University of Southampton, Southampton, UK (N.C.). Search for more papers by this author , John RawlinsJohn Rawlins From Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK (A.R., J.R., G.B., S.O., S.C., M.K., N.C.); and Faculty of Medicine, University of Southampton, Southampton, UK (N.C.). Search for more papers by this author , Giedrius BaliulisGiedrius Baliulis From Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK (A.R., J.R., G.B., S.O., S.C., M.K., N.C.); and Faculty of Medicine, University of Southampton, Southampton, UK (N.C.). Search for more papers by this author , Sally OlsenSally Olsen From Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK (A.R., J.R., G.B., S.O., S.C., M.K., N.C.); and Faculty of Medicine, University of Southampton, Southampton, UK (N.C.). Search for more papers by this author , Simon CorbettSimon Corbett From Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK (A.R., J.R., G.B., S.O., S.C., M.K., N.C.); and Faculty of Medicine, University of Southampton, Southampton, UK (N.C.). Search for more papers by this author , Markku KaarneMarkku Kaarne From Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK (A.R., J.R., G.B., S.O., S.C., M.K., N.C.); and Faculty of Medicine, University of Southampton, Southampton, UK (N.C.). Search for more papers by this author and Nick CurzenNick Curzen From Wessex Cardiothoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK (A.R., J.R., G.B., S.O., S.C., M.K., N.C.); and Faculty of Medicine, University of Southampton, Southampton, UK (N.C.). Search for more papers by this author Originally published7 Apr 2015https://doi.org/10.1161/CIRCULATIONAHA.114.014328Circulation. 2015;131:1302–1303A 62-year-old man with a history of hypertension was admitted with unstable angina. Three years earlier, he had presented with a non–ST-segment–elevation myocardial infarction and had undergone percutaneous coronary intervention with a paclitaxel-eluting stent (3.0×20 mm; Taxus, Boston Scientific, Boston, MA) to the proximal left anterior descending coronary artery (Figure 1A). His initial ECG was normal, and his biomarkers were not elevated. Eight hours into his admission, he became pyrexial and developed chest pain associated with transient anterior ST-segment elevation. Emergency coronary angiography demonstrated aneurysmal dilatation at the proximal edge of the previous stent (Figure 1B). Because he had normal flow (Thrombolysis in Myocardial Infarction grade 3), his pain had settled spontaneously, and there was no evidence of a left ventricular regional wall motion abnormality (Movie I in the online-only Data Supplement) on transthoracic echocardiography, the supervising cardiologist elected to treat him medically in the first instance, pending administration of antibiotics and discussion about coronary artery bypass graft surgery. He was treated with dual antiplatelet therapy and antibiotics. Multiple blood cultures subsequently grew Staphylococcus aureus (methicillin sensitive) sensitive to flucloxacillin.Download figureDownload PowerPointFigure 1. Series of angiographic stills. A, The drug-eluting stent in the proximal left anterior descending artery (box) after the initial percutaneous coronary angiography. B, Aneurysmal dilatation at the proximal stent edge (box) on this presentation. C, Rapid progression with rupture 12 hours later.A few hours later, having continued to have a high temperature, he developed further chest pain and ST-segment elevation with hypotension. An emergency echocardiogram demonstrated a pericardial effusion. Repeat emergency coronary angiography confirmed rupture of the left anterior descending artery aneurysm (Figure 1C), and he was transferred for emergency surgery. At surgery, the left anterior descending artery was exposed (Figure 2A), and the diseased area, including the stent, was resected (Figure 2B–2D). The left internal mammary artery was then grafted to the left anterior descending artery. Postoperative transthoracic echocardiography demonstrated anterior hypokinesia with mild left ventricular systolic impairment (Movie II in the online-only Data Supplement). Tissue cultures confirmed the presence of methicillin-sensitive S aureus sensitive to flucloxacillin. The patient recovered well and was discharged home once he completed a 6-week course of antibiotic treatment, which consisted of intravenous flucloxacillin 2 g every 4 hours and peros fucidic acid 500 mg 3 times a day.Download figureDownload PowerPointFigure 2. Operative images from surgeon’s view. A, The area of the infected left anterior descending artery (LAD; circle). B, The incised LAD exposing the stent (circle). C and D, Excised LAD specimen with the stent showing the lack of stent coverage.Percutaneous stent deployment is the commonest modality for coronary revascularization. Infective complications are rare. The first coronary stent infection was described in 1993,1 and since then, <30 cases have been reported.2 Most cases describe early infection, with onset between 2 days and 4 weeks after percutaneous coronary intervention.3 Late infection is rare, with 1 report of stent infection 3 years after intervention associated with stent fracture.2 These cases of stent infection share similar clinical features: fever usually accompanied with an episode of chest pain.4 Diagnosis of stent infection can be challenging. Clinical suspicion should be high in patients with previous intervention, unexplained fever, positive blood cultures, and chest pain. There is no single modality confirming diagnosis, but hematologic cultures, echocardiography, coronary angiography, computed tomography, and magnetic resonance imaging scanning can provide useful information.4 The natural history of stent infection is often catastrophic. Complications may include pericardial empyema, tamponade, coronary vessel perforation, ventricular rupture, and cardiac arrest, in addition to severe sepsis and multiorgan failure. Surgical intervention is usually required, but even after surgery, overall mortality can reach 25% to 50%.4DisclosuresNone.FootnotesThe online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.114.014328/-/DC1.Correspondence to Apostolos Roubelakis, PhD, Wessex Cardiac Centre, Southampton University Hospital, Tremona Rd, Southampton, SO16 6YD, UK. E-mail [email protected]References1. Günther HU, Strupp G, Volmar J, von Korn H, Bonzel T, Stegmann T.Coronary stent implantation: infection and abscess with fatal outcome [in German].Z Kardiol. 1993; 82:521–525.MedlineGoogle Scholar2. Del Trigo M, Jimenez-Quevedo P, Fernandez-Golfin C, Vaño E, Delgado-Bolton R, Alfonso F, Gonzalo N, Kallmeyer A, Montes L, Escribano N, Hernandez-Antolin R, Macaya C.Very late mycotic pseudoaneurysm associated with drug-eluting stent fracture.Circulation. 2012; 125:390–392. doi: 10.1161/CIRCULATIONAHA.111.051508.LinkGoogle Scholar3. Kaufmann BA, Kaiser C, Pfisterer ME, Bonetti PO.Coronary stent infection: a rare but severe complication of percutaneous coronary intervention.Swiss Med Wkly. 2005; 135:483–487. doi: 2005/33/smw-11142.MedlineGoogle Scholar4. Elieson M, Mixon T, Carpenter J.Coronary stent infections: a case report and literature review.Tex Heart Inst J. 2012; 39:884–889.MedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Suryawan I, Luke K, Agustianto R and Mulia E (2021) Coronary stent infection: a systematic review, Coronary Artery Disease, 10.1097/MCA.0000000000001098, 33:4, (318-326), Online publication date: 1-Jun-2022. Cho K, Sunwoo S, Hong Y, Koo J, Kim J, Baik S, Hyeon T and Kim D (2021) Soft Bioelectronics Based on Nanomaterials, Chemical Reviews, 10.1021/acs.chemrev.1c00531, 122:5, (5068-5143), Online publication date: 9-Mar-2022. Pisani A, Braham W and Borghese O (2021) Coronary stent infection: Are patients amenable to surgical treatment? A systematic review and narrative synthesis, International Journal of Cardiology, 10.1016/j.ijcard.2021.09.030, 344, (40-46), Online publication date: 1-Dec-2021. Ben Messaoud M, Bouchahda N, Mahjoub M, Hmida B, Dridi Z and Gamra H (2019) Case Report: Coronary artery stent infection with mycotic aneurysm secondary to tricuspid valve infective endocarditis, F1000Research, 10.12688/f1000research.19067.1, 8, (853) Reddy K.V. C, Sanzgiri P, Thanki F and Suratkal V (2019) Coronary stent infection: Interesting cases with varied presentation, Journal of Cardiology Cases, 10.1016/j.jccase.2018.08.004, 19:1, (5-8), Online publication date: 1-Jan-2019. Davidson L and Ricciardi M (2018) Coronary Artery Perforation Complicated by Pericardial Abscess Formation, Circulation: Cardiovascular Interventions, 11:2, Online publication date: 1-Feb-2018. Elder A, Ho K, Allman K, Lowe H, Amos D and Adams M (2017) What is This Image? 2017: Image 2 Result, Journal of Nuclear Cardiology, 10.1007/s12350-017-1019-4, 24:5, (1512-1514), Online publication date: 1-Oct-2017. Shafer K, Toma C and Galdys A (2017) A common pathogen in an uncommon site: coronary artery stent meticillin-resistant Staphylococcus aureus infection, JMM Case Reports, 10.1099/jmmcr.0.005110, 4:9, Online publication date: 25-Sep-2017. Lai C, Lin Y, Lee W and Chang W (2017) Coronary Stent Infection Presented as Recurrent Stent Thrombosis, Yonsei Medical Journal, 10.3349/ymj.2017.58.2.458, 58:2, (458), . April 7, 2015Vol 131, Issue 14 Advertisement Article InformationMetrics © 2015 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.114.014328PMID: 25847982 Originally publishedApril 7, 2015 PDF download Advertisement SubjectsCardiovascular SurgeryStentTreatment

An economic model was developed to compare the medical resource cost and health outcome effects of physiology-guided management with FFR compared with standard angiography-guided management in patients with non-ST elevation myocardial infarction based on participants British Heart Foundation FAMOUS-

BACKGROUND:The use of coronary angiography (CA) for diagnosis and management of chest pain (CP) has several flaws. The assessment of coronary artery disease using fractional flow reserve (FFR) is a well-validated technique for describing lesion-level ischemia and improves clinical outcome in the context of percutaneous coronary intervention. The impact of routine FFR at the time of diagnostic CA on patient management has not been determined.METHODS AND RESULTS:Two hundred patients with stable CP underwent CA for clinical indications. The supervising cardiologist (S.C.) made a management plan based on CA (optimal medical therapy alone, percutaneous coronary intervention, coronary artery bypass grafting, or more information required) and also recorded which stenoses were significant. An interventional cardiologist then measured FFR in all patent coronary arteries of stentable diameter (≥2.25 mm). S.C. was then asked to make a second management plan when FFR results were disclosed. Overall, after disclosure of FFR data, management plan based on CA alone was changed in 26% of patients, and the number and localization of functional stenoses changed in 32%. Specifically, of 72 cases in which optimal medical therapy was recommended after CA, 9 (13%) were actually referred for revascularization with FFR data. By contrast, of 89 cases in whom management plan was optimal medical therapy based on FFR, revascularization would have been recommended in 25 (28%) based on CA.CONCLUSIONS:Routine measurement of FFR at CA has important influence both on which coronary arteries have significant stenoses and on patient management. These findings could have important implications for clinical practice.CLINICAL TRIAL REGISTRATION URL:http://www.clinicaltrial.gov. Unique identifier: NCT01070771.