Objectives Approximately 5-10% of patients presenting for percutaneous coronary intervention (PCI) have concurrent atrial fibrillation (AF). To what extent AF portends adverse long-term outcomes in these patients remains to be defined. Methods We analysed data from the multicentre Melbourne Interventional Group Registry from 2014-2018. Patients were identified as being in AF or sinus rhythm (SR) at the commencement of PCI. The primary endpoint was long-term mortality, obtained via linkage with the National Death Index. Results 13,286 procedures were included, with 800 (6.0%) patients in AF and 12,486 (94.0%) in SR. Compared to SR, patients with AF were older (72.9 +/- 10.9 vs 64.1 +/- 12.0 p<0.001) and more likely to have comorbidities including diabetes mellitus (31.3% vs 25.0% p<0.001), hypertension (74.4% vs 65.1% p<0.001) and moderate to severe left ventricular systolic dysfunction (36.6% vs 19.5% p<0.001). Atrial fibrillation was associated with an increased risk of in-hospital mortality (11.0% vs 2.5% p<0.001) and MACE (composite of all-cause mortality, myocardial infarction, or target vessel revascularisation) (11.9% vs 4.2% p<0.001). Inhospital major bleeding was more common in the AF group (3.1% vs 1.0% p<0.001). On Cox proportional hazards modelling, AF was an independent predictor of long-term mortality (adjusted HR 1.38 95% CI 1.11-1.72 p<0.004) at a mean follow-up of 2.3 +/- 1.5 years. Conclusions Preprocedural AF is common among patients presenting for PCI. Preprocedural AF is associated with high-rates of comorbid illnesses and portends higher risk of short- and long-term outcomes including mortality underscoring the need for careful evaluation of its risks prior to PCI.

BACKGROUND:Primary percutaneous coronary intervention (PCI) for patients with ST-elevation myocardial infarction (STEMI) is recommended within 90 min of first medical contact. Those without pre-hospital notification (PN) are less likely to meet reperfusion targets and are an understudied subset of the STEMI population. METHODS:An observational cohort study from a multicentre PCI registry of consecutive patients undergoing primary PCI for STEMI between 2012 and 2017. Exclusion criteria included out-of-hospital cardiac arrest, prior thrombolysis, symptom onset >12 h prior, and cardiogenic shock. RESULTS:2519 patients were included: 1392 (55.3%) without PN (no-PN group) and 1127 (44.7%) with PN (PN group). Those without PN had longer median DTBT (78 min vs 51 min, p < 0.001) and STBT (206 min vs 161 min, p < 0.001), with only 55% meeting DTBT targets out-of-hours in the no-PN group. No-PN patients had lower rates of AHA/ACC type B2/C lesions, GP IIb/IIIa use, aspiration thrombectomy and had smaller stent diameter (all p ≤ 0.003), suggesting smaller areas of ischemic myocardium. There were no significant differences in 30-day MACE (no-PN 5.6% vs PN 6.5%, p = 0.36) or long-term National Death Index linked mortality (no-PN 6.2% vs PN 7.9%, p = 0.09). Lack of PN did not independently predict long-term mortality. CONCLUSION:Despite comparably excellent outcomes overall, those without PN had longer ischemic times and were less likely to meet DTBT targets, especially after hours. Ischemic times may be a better evaluation of PN networks than hard clinical outcomes, and efficient systems of care tailored to the individual health service are essential to ensure timely reperfusion of patients with STEMI.

Objectives To evaluate the effect of age in an all-comers population undergoing percutaneous coronary intervention (PCI). Background Age is an important consideration in determining appropriateness for invasive cardiac assessment and perceived clinical outcomes. Methods We analysed data from 29,012 consecutive patients undergoing PCI in the Melbourne Interventional Group (MIG) registry between 2005 and 2017. 25,730 patients <80 year old (78% male, mean age 62 +/- 10 years; non-elderly cohort) were compared to 3,282 patients >= 80 year old (61% male, mean age 84 +/- 3 years; elderly cohort). Results The elderly cohort had greater prevalence of hypertension, diabetes and previous myocardial infarction (all p<0.001). Elderly patients were more likely to present with acute coronary syndromes, left ventricular ejection fraction <45% and chronic kidney disease (p<0.0001). In-hospital, 30-day and long-term all-cause mortality (over a median of 3.6 and 5.1 years for elderly and non-elderly cohorts, respectively) were higher in the elderly cohort (5.2% vs. 1.9%; 6.4% vs. 2.2%; and 43% vs. 14% respectively, all p<0.0001). In multivariate Cox regression analysis, estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m(2) (HR 3.8, 95% CI: 3.4-4.3), cardiogenic shock (HR 3.0, 95% CI: 2.6-3.4), ejection fraction <30% (HR 2.5, 95% CI: 2.1-2.9); and age >= 80 years (HR 2.8, 95% CI: 2.6-3.1) were independent predictors of long-term all-cause mortality (all p<0.0001). Conclusion The elderly cohort is a high-risk group of patients with increasing age being associated with poorer long-term mortality. Age, thus, should be an important consideration when individualising treatment in elderly patients.

OBJECTIVES:We aimed to assess the outcomes of cardiogenic shock (CS) complicating acute coronary syndromes (ACS). BACKGROUND:CS remains the leading cause of mortality in patients presenting with ACS despite advances in care. METHODS:We studied 13,184 patients undergoing percutaneous coronary intervention (PCI) for all subtypes of ACS enrolled prospectively in a large multicentre Australian registry (Melbourne Interventional Group registry) from 2005 to 2013. All-cause mortality was obtained via linkage to the National Death Index. Patients were divided into those with and those without CS. RESULTS:Compared to the non-CS group (n = 12,548, 95.2%), the CS group (n = 636, 4.8%) had a higher proportion of out-of-hospital cardiac arrest (OHCA) (31.1 vs. 2.2%) and ST-elevation myocardial infarction (STEMI) presentation (89 vs. 34%), both p < .01. Patients in the CS group had higher rates of in-hospital (40.4 vs. 1.2%) and 30-day (41 vs. 1.7%) mortality compared to the non-CS group. Long-term mortality over a median follow-up of 4.2 years was higher in the CS group (50.6 vs. 13.8%), p < .001. Trends of in-hospital and 30-day mortality rates of CS complicating ACS were relatively stable from 2005 to 2013. Predictors of long-term NDI-linked mortality within the CS group include severe left ventricular systolic dysfunction (HR 3.0), glomerular filtration rate (GFR) <30 (HR 2.56), GFR 30-59 (HR 1.94), OHCA (HR 1.46), diabetes (HR 1.44), and age (HR 1.02), all p < .05. CONCLUSIONS:Rates of CS-related mortality complicating ACS have remained very high and steady over nearly a decade despite progress in STEMI systems of care, PCI techniques, and medical therapy.

Objectives To assess the clinical outcomes of patients presenting with ST-elevation myocardial infarction (STEMI) secondary to stent thrombosis (ST) compared to those presenting with STEMI secondary to a de novo culprit lesion and treated by percutaneous coronary intervention (PCI). Background ST is an infrequent but serious complication of PCI with substantial associated morbidity and mortality, however with limited data. Methods We studied consecutive patients who underwent PCI for STEMI from 2005 to 2013 enrolled prospectively in the Melbourne Interventional Group registry. Patients were divided into two groups: the ST group comprised patients where the STEMI was due to ST and the de novo group formed the remainder of the STEMI cohort and all patients were treated by PCI. The primary endpoint was 30-day all-cause mortality. Results Compared to the de novo group (n = 3,835), the ST group (n = 128; 3.2% of STEMI) had higher rates of diabetes, hypertension and dyslipidemia, established cardiovascular diseases, myocardial infarction, and peripheral vascular disease, all p < .01. Within the ST group, very-late ST was the most common form of ST, followed by late and early ST (64, 19, and 17%, respectively). There was no significant difference in the primary outcome between the ST group and the de novo group (4.7 vs. 7.1%, p = .29). On multivariate analysis, ST was not an independent predictor of 30-day mortality (odds ratio: 0.62, 95% confidence interval: 0.07-1.09, p = .068). Conclusion The short-term prognosis of patients with STEMI secondary to ST who were treated by PCI was comparable to that of patients with STEMI due to de novo lesions.

Background There is a long-held belief in the association between the full moon and extremes of human behaviour and adverse health consequences. Small-scale studies are conflicting; however, most suggest no clear association between lunar phase and occurrence of acute coronary syndromes. Aims To evaluate the impact of the lunar phase, and in particular, the full moon phase, on the incidence and outcomes among ST-elevation myocardial infarction (STEMI) cases undergoing percutaneous coronary intervention (PCI). Methods We conducted a multi-centre retrospective study from the Melbourne Interventional Group registry, including 7570 STEMI cases from six tertiary centres over a 12-year study period in Victoria, Australia, and performed statistical analysis using Stata software. Primary outcomes studied were the incidence of STEMI, the occurrence of major adverse cardiac and cerebrovascular events and mortality at 1 and 5 years in cases of STEMI undergoing primary or rescue percutaneous coronary intervention during the full moon between 2005 and 2017 in Victoria, Australia. Results This study demonstrated neither significant difference in STEMI incidence (P = 0.61) nor of major adverse cardiovascular events across all lunar phases. Subgroup analysis confirmed no difference in outcomes during the full moon compared to a composite of other lunar phases.Kaplan-Meier survival estimates showed similar 30-day outcomes across lunar phases (P = 0.35) and when comparing full moon to a composite of other lunar phases (P = 0.45). Similarly, there was no significant difference in survival at 1 and 5 years between lunar phases (P = 0.68) or compared to the full moon phase (P = 0.51). Conclusions This study showed no significant difference in the incidence or cardiovascular outcomes and survival in patients with STEMI undergoing primary or rescue percutaneous coronary intervention during the lunar phases.

International guidelines recommend that all patients presenting with STEMI receive aspirin and a P2Y12 inhibitor as early as possible. However, the safety and efficacy of pre-treatment with dual anti-platelet therapy before angiography is a matter of ongoing debate. Consecutive patients from the

hypertension, and previous myocardial infarction were comparable between groups. Totally occluded culprit arteries (48.8% vs 83%; p<0.001) and multivessel disease (23.8% vs 39.4%; p<0.001) were more rarely identified during PPCI in direct stenting group. There were no difference in rates of stent thrombosis (1.2% vs 0.8%; p1⁄40. 631) and repeat myocardial infarction (1.2% vs 1.2%; p1⁄40.973). The rates of failed PCI (4.4% vs 12,4%; p1⁄40.001), death (4% vs 8.9%; p1⁄40.024), MACE (4.8% vs 10.4%; p1⁄40.016), and angiographic noreflow (2% vs 11.6%; p<0.001) were significantly lower in the direct stenting group. After multivariate adjustment, predilation remained an independent predictor of no-reflow [odds ratio (OR) 3.9; 95% confidence interval (CI) 1.4-10.4; p1⁄40.007] along with totally occluded culprit arteries (OR 13; 95% CI 1.7-98.5; p1⁄40.013) and blood glucose level (OR 1.13; 95% CI 1.05-1,21; p1⁄40.002).

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

Objective: To determine whether introduction of high-sensitivity cardiac troponin I (hscTn-I) assays affected management of patients presenting with suspected acute coronary syndrome (ACS) to the emergency department (ED) of a tertiary referral hospital.Design, patients and setting: A retrospective analysis of all patients presenting to the Geelong Hospital ED with suspected ACS from 23 April 2010 to 22 April 2013 2 years before and 1 year after the changeover to hscTn-I assays on 23 April 2012.Main outcome measures: Hospital admission rates, time spent in the ED, rates of coronary angiography, rates of percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABGS), rates of discharge with a diagnosis of ACS, and rates of inhospital mortality.Results: 12360 consecutive patients presented with suspected ACS during the study period; 1897 were admitted to Geelong Hospital in the 2 years before and 944 in the 1 year after the changeover to hscTn-I assays. Comparing the two patient groups, there was no statistically significant difference in all-hospital admission rates (95% CI for the difference, - 3.1% to 0.3%; P = 0.10) or proportion of patients subsequently discharged with a diagnosis of ACS (95% CI for the difference, - 2.3% to 5.4%; P= 0.43). After the changeover, the median time patients spent in the ED was 11.5% shorter (3.85h v 4.35h; 95% Cl for the difference, - 0.59 to - 0.43; P< 0.001) and the proportion of admitted patients undergoing coronary angiography was higher (53.4% v 45.2%; 95% CI for the difference, 4.3 to 12.0 percentage points; P< 0.001), but there was no statistically significant rise in the proportion of patients who had invasive treatment (PCI and/or CABGS) (95% CI for the difference, - 0.4% to 6.3%; P= 0.08). Inhospital mortality rates from ACS did not change significantly (95% CI for the difference, - 1.5% to 0.8%; P= 0.43).Conclusion: The introduction of hscTn-I assays appeared to be associated with more rapid diagnosis, resulting in less time spent in the ED, without a change in hospital admission rates. A higher proportion of patients had coronary angiographies after the changeover, but:there was no significant change in rates of invasive treatment or inhospital mortality.

To evaluate the impact of chronic kidney disease on the survival of patients – 80 years of age undergoing percutaneous coronary intervention (PCI) in the long term.273 subjects who underwent PCI between January 2010 and January 2016 were divided into four categories: (1) stable angina (SA) and creatinine clearance – 30 (n = 24); (2) patients with SA and CrCl <30 (n = 70); (3) patients with acute coronary syndrome (ACS) and CrCl – 30 (n = 51); (4) patients with ACS and ICC <30 (n = 128). Mortality curves were evaluated using the Kaplan-Meier method and differences between groups were compared by log-rank statistic. Multivariate analysis was performed using the Cox proportional hazards method. The 4 groups were compared and the survival between the groups was evaluated.Octogenarian patients with CrCl <30 with SA and ACS have lower long-term survival (p < 0.0001).CKD has a worse long-term prognosis for patients undergoing PCI.

The goal of this paper is to generalize most of the moment formulae obtained in [12]. More precisely, we consider a general point process μ, and show that the quantities relevant to our problem are the so-called Papangelou intensities. When the Papangelou intensities of μ are well-defined, we show some general formulae to recover the moment of order n of the stochastic integral of the point process. We will use these extended results to introduce a divergence operator and study a random transformation of the point process.

Background: Uncertainty remains as to whether females benefit as much as males from percutaneous coronary intervention (PCI) in the setting of an acute coronary syndrome (ACS).Methods: We compared 802 women with 2151 men presenting with ACS, undergoing PCI from April 2004 to October 2006 from the Melbourne Interventional Group registry. Clinical characteristics, in-hospital, 30-day and 1-year outcomes were compared.Results: Women were older (69.6 +/- 11.6 vs. 62.17 +/- 12.3 years, p < 0.001), and had more diabetes (27.1% vs. 19.6%, p < 0.001) and hypertension (70.3% vs. 53.9%, p < 0.001) than men. Women were less likely to present with ST-elevation myocardial infarction (30.5% vs. 37.9%, p < 0.001). Bleeding (3.6% vs. 0.8%, p < 0.001) was higher among women. Thirty-day mortality (4.7 vs. 2.4%, p < 0.001) and MACE (10.1 vs. 6.4%, p < 0.001) were higher in women. Gender was an independent predictor of overall MACE at 30 days (OR 1.45, 95% CI 1.04-2.02, p=0.03) but not death. At 12 months, there were no significant differences in mortality (6.4% vs. 4.8%, p=0.09), myocardial infarction (5.5% vs. 5.0%, p=0.64), target vessel revascularization (7.9% vs. 7.0%, p=0.42) and MACE (16.3% vs. 14%, p=0.13) between women and men.Conclusions: There is an early hazard amongst women undergoing PCI for ACS, but not at 12 months. These data suggest that gender should not affect the decision to offer PCI but further gender specific studies are warranted. (C) 2010 Elsevier Ireland Ltd. All rights reserved.

Results: Significant baseline differences between the rescue PCI and PPCI groups included age (60.4 vs. 62.9, p=0.02), current smoking status (45.0% vs. 35.0%, p=0.01), ejection fraction (46.6% vs. 49.5%, p=0.03), STEMI-to-balloon-time (7.9 vs. 4.6 hours, [and door-to-balloon-time] both p<0.001), and Killip class IV (9.9% vs. 5.2%, p=0.02). Peri-procedural glycoprotein IIb/IIIa-inhibitor use was less in rescue patients (48.8% vs. 74.9%, p<0.001), but use of anti-thrombins or clopidogrel preloading was similar. The incidence of pre-PCI Thrombolysis in Myocardial Infarction (TIMI) 3 flow was higher among rescue (42.6% vs. 19.5%, p<0.0001) than PPCI patients, however, post-PCI TIMI 3 flow was similar in the two groups (89.1% vs. 91.5%, p=0.27). No significant differences were observed in any of the shortor long-term clinical endpoints between rescue PCIs and PPCIs including in-hospital bleeding complications (4.9% vs. 3.5%, p=0.34), 30-day mortality (6.2% vs. 6.0%, p=0.94), and overall major adverse cardiovascular events (MACE) (11.7% vs. 10.1%, p=0.52), and 12-month mortality (9.0% vs. 8.0%, p=0.67), and MACE (18.0% vs. 18.1%, p=0.99).

Background: Rescue PCI reduces death, re-infarction, stroke and heart failure 6 months post-myocardial infarction compared to medical therapy. We investigated short- and long-term clinical outcomes between STEMI patients treated with rescue PCI or PPCI in a large multi-centre Australian PCI registry.

Background: Peri-procedural administration of GPIIb/IIIa in STEMI patients undergoing PPCI improves outcomes compared with placebo.

Background: Clopidogrel loading prior to PCI improves short-term clinical outcomes in elective PCI and non-ST elevation acute coronary syndromes, and reduces ischaemic endpoints at 30 days in patients with STEMI treated with fibrinolysis. We aimed to assess the effects of clopidogrel pre-treatment in STEMI patients treated with PCI in a large contemporary multi-centre Australian registry.

Background: Adjuvant GPIIb/IIIa and clopidogrel have shown benefit in STEMI. It is unclear whether there is additional benefit from periprocedural GPIIb/IIIa (PP-GPIIb/IIIa) in STEMI patients undergoing PPCI who have had clopidogrel pre-treatment.

Background: The glycoprotein IIb/IIIa inhibitor, eptifibatide, was recently introduced into Australia as adjunctive therapy in percutaneous coronary intervention (PCI) (excluding acute ST elevation myocardial infarction (STEMI)). We aimed to prospectively monitor its initial pattern of use, efficacy and safety.