Treatment and outcomes of patients with chronic lung disease and acute myocardial infarction: Insights from the nationwide AMIS plus registry

BACKGROUND

Limited data are available on patients with chronic lung disease (CLD) presenting with acute myocardial infarction (AMI). We aimed to analyse baseline characteristics, treatment and outcome of those patients enrolled in the Swiss nationwide prospective AMIS Plus registry.

METHODS

All AMI patients enrolled between January 2002 and December 2021 with data on CLD, as defined in the Charlson Comorbidity Index, were included. The primary endpoints were in-hospital mortality and major adverse cardiac and cerebrovascular events (MACCE), defined as all-cause death, reinfarction and cerebrovascular events. Baseline characteristics, in-hospital treatments and outcomes were analysed using descriptive statistics and logistic regression.

RESULTS

Among 53,680 AMI patients enrolled during this time, 5.8% had CLD. Compared with patients without CLD, CLD patients presented more frequently with non-ST-elevation myocardial infarction (MI) and type 2 MI (12.8% vs. 6.5%, p < 0.001). With respect to treatment, CLD patients were less likely to receive P2Y12 inhibitors (p < 0.001) and less likely to undergo percutaneous coronary interventions (68.7% vs. 82.5%; p < 0.001). In-hospital mortality declined in AMI patients with CLD over time (from 12% in 2002 to 7.3% in 2021). Multivariable regression analysis showed that CLD was an independent predictor for MACCE (adjusted OR was 1.28 [95% CI 1.07-1.52], p = 0.006).

CONCLUSION

Patients with CLD and AMI were less likely to receive evidence-based pharmacologic treatments, coronary revascularization and had a higher incidence of MACCE during their hospital stay compared to those without CLD. Over 20 years, in-hospital mortality was significantly reduced in AMI patients, especially in those with CLD.

Sex differences in acute coronary syndromes: a never ending same old story or sign for improvement

Introduction

We previously described sex differences in baseline characteristics, interventional therapy and mortality in patients admitted for acute coronary syndromes (ASC) in Swiss hospitals and enrolled in the AMIS Plus registry between 1997 and 2006 (1). This present analysis aimed to reassess whether anything changed over the last 15 years.

Method

All AMIS Plus patients enrolled between 2007 and 2021 were included. Baseline characteristics, therapy and outcome were analysed according to sex and age groups. Multivariate analyses were performed to assess independent predictors of in-hospital mortality.

Results

Among 42,471 patients, 10,825 (25.5%) were women. Women were still older (71.6±12.6y vs. 64.2±12.6y for men), had more comorbidities (Charlson Comorbidity Index&gt;1: 26.5% vs. 21.7%), were less likely to receive drug therapy (e.g., P2Y12 inhibitors 83.3% vs. 89.2% or statins 73.0% vs. 78.5%) and underwent percutaneous coronary intervention (PCI) less frequently (OR 0.77; 95% CI 0.73–0.83). These findings paralleled our observations for the period 1997–2006. However, the increase in PCI use over the years, particularly in women, led to a marked decrease in differences between men and women with respect to revascularization, from 16.6% in 2006 down to 2.0% in 2020. Unadjusted in-hospital mortality was higher in women (OR 1.55; 95% CI 1.41–1.70), but this significance disappeared after adjustment for baseline differences (OR 1.07; (95% CI 0.96–1.20)). However, in women under the age of 50 years, crude mortality (3.1% versus 1.6%) was significantly higher than in same-aged men; adjusted OR 1.78 (95% CI 0.99–3.20).

Conclusions

Sex differences in the baseline characteristics of ACS patients and the use of evidence-based drugs persisted but the sex gap in PCI access slowly but surely diminished. Female sex per se was not an independent predictor of in-hospital mortality in the overall population but it showed a strong trend among patients younger than 50 years of age.

Funding Acknowledgement

Type of funding sources: None.

Treatment and outcome of patients with acute myocardial infarction and chronic lung disease: insights from the nationwide AMIS Plus registry

Introduction

Little is known about patients with acute myocardial infarction (AMI) and chronic lung disease (CLD). The aim of our study was to analyze risk factors, treatment, and outcome of AMI patients with CLD over the last 20 years using the nationwide AMIS Plus registry.

Methods

All AMI patients enrolled in the AMIS Plus registry with data on CLD between January 2002 and December 2021 were included. Chronic lung disease was determined according to the definition used in the Charlson Comorbidity Index. Data on baseline characteristics, regular medication, immediate therapy within 24 hours, in-hospital interventions and treatments, in-hospital outcome, complications and discharge medication were analyzed using descriptive statistics and logistic regression.

Results

Among 53,680 AMI patients, 5.8% had a CLD. The CLD group included 26.6% female and 73.4% male patients. Gender distribution was similar in patients with and without CLD. Patients with CLD were significantly older (71.2 vs. 65.8 y; p&lt;0.001), more frequently diagnosed with NSTEMI, had more comorbidities and were less frequently never smokers (17.4% vs. 35.3%; p&lt;0.001) compared to patients without CLD. In addition, CLD patients were less likely to receive aspirin, P2Y12 inhibitors, beta-blockers, ACE inhibitors and statins (all p&lt;0.001), and were also less likely to undergo percutaneous coronary interventions (68.7% vs. 82.5%; p&lt;0.001). Median length of stay was 2 days longer for CLD patients. Patients with CLD had more major adverse cardiac and cerebrovascular events in-hospital (10.3% vs. 5.9%; p&lt;0.001) and higher crude in-hospital mortality (8.3% vs. 4.7%; p&lt;0.001). However, multivariable regression analysis showed that CLD was not an independent predictor for in-hospital mortality (OR 1.19 (95% CI 0.98–1.45), p=0.081).

Conclusion

Patients with CLD were less likely to receive evidence-based medicine and had a worse in-hospital outcome compared to those without CLD. However, after adjustment, CLD was not an independent predictor of in-hospital mortality.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): AstraZeneca AG, Biotronik (Schweiz) AG

Acute myocardial infarction and work inability: insights from the AMIS Plus registry

Introduction

The impact of acute myocardial infarction (AMI) on the ability to pursue professional life is not well defined. Using a nationwide database, we aimed to describe the ability to return to work after AMI in Switzerland and identify factors associated therewith.

Methods

AMI patients of working-age enrolled in the AMIS Plus registry between 01/2006 and 09/2020 with data on self-reported work status before and 12 months after AMI were included. Using the Kruskal-Wallis rank sum test or Fisher's exact test we compared patient characteristics between those who did not reduce work hours, those who reduced, and those no longer working 12 months after the AMI.

Results

Of 4315 AMI patients (median (IQR) age 54 (49, 59)), 3204 (74.3%) did not reduce work, 592 (13.7%) reduced and 519 (12.0%) stopped working. Patients not reducing were youngest (median age (IQR)): 54y (49y, 58y), those who reduced: 56y (51y, 60y), those who stopped: 56y (51y, 61y), p&lt;0.001) and more often men (no reduction: 90%, reduced: 80%, stopped: 82%, p&lt;0.001). Patients who reduced showed worst cardiac function at AMI reflected in the highest rates of Killip class&gt;2 (no reduction: 1.8%, reduced: 5.2%, stopped: 3.3%, p&lt;0.001) and resuscitation before admission (no reduction: 4.1%, reduced: 6.9%, stopped: 4.0%, p=0.008). Patients who stopped work had the most comorbidities such as past AMI (no reduction: 8.6%, reduced: 10%, stopped: 13%, p=0.003), hypertension (no reduction: 45%, reduced: 50%, stopped: 54%, p&lt;0.001), diabetes (no reduction: 10%, reduced: 13%, stopped: 16%, p&lt;0.001) and cerebrovascular disease (no reduction: 0.8%, reduced: 1.2%, stopped: 2.3%, p=0.007). There was no significant difference for rehabilitation participation during follow up (no reduction: 84%, reduced: 86%, stopped: 84%, n.s. for all group comparisons). Multivariable regression showed that the reduction group had a higher proportion of women (OR 2.30; 95% CI 1.80–2.93 p&lt;0.001) and were more likely to have a Killip class &gt;2 at admission (OR 2.58; 95% CI 1.54–4.31 p&lt;0.001) as compared to the no reduction group whereas the comparison between no reduction and work stop identified comorbidities (past MI (OR 1.46; 95% CI 1.07–1.94 p=0.016), diabetes (OR 1.59; 95% CI 1.21–2.09 p=0.001), cerebrovascular disease (OR 2.53; 95% CI 1.22–5.25 p=0.013)) and being female (OR 1.98; 95% CI 1.51–2.58 p&lt;0.001) as major predictors for work stop.

Conclusion

Our data showed that 1:7 had reduced and 1:8 stopped professional activity 1 year after AMI. Younger age, being male and lower rates of comorbidities such as a past AMI, hypertension, diabetes and cerebrovascular disease were important factors associated with returning to work after AMI. Work reduction was significantly related with worse cardiac function whereas work stop was more related with comorbidities.

Funding Acknowledgement

Type of funding sources: None.

Multimodality imaging in the evaluation of left ventricle myocardial deformation determined by edema and scar in acute myocarditis

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

acute myocarditis (aMY) is characterized by the presence of edema and myocardial scar detected by cardiovascular magnetic resonance (CMR). 

Aim of our study is to investigate the diagnostic value of two-dimensional (2D) speckle tracking echocardiography and Cardiovascular Magnetic Resonance (CMR) feature tracking (FT) in detecting edema and myocardial scar in aMY.

METHODS

all consecutive patients with clinically suspected aMY were enrolled in our study. Inclusion criteria were: 1) new ECG abnormalities 2) myocardial cytolysis markers and 3) absence of angiographically detectable coronary artery disease. Exclusion criteria included poor cine image quality caused by respiratory motion and arrhythmia. All patients underwent transthoracic echocardiography and cardiac function was evaluated by a comprehensive assessment of LV function, including 2D speckle-tracking echocardiography (2D STE). CMR was performed in all patients in a 3T scanner. Extension of edema and myocardial scar were respectively evaluated on T2 mapping and on Late Gadolinium Enhancement sequences considering numbers of segments involved according to 17-segment model (AHA). FT analysis of the left ventricle (LV) was performed using the Tissue Tracking Module to obtain LV strain data.

RESULTS

52 patients were included in the study, mean age was 36± 17 years, three patients were female (6%). Mean LVEF was 56,2 ± 7,2 % and mean end diastolic volume index (EDVi) was 62,52 ± 19,02 ml/m2. 10 patients (19,2%) had impaired EF with mean values of 44,6 ± 6,15%. aMY was confirmed in all patients with the presence of myocardial edema and subepicardial late gadolinium enhancement (LGE).  Inferior segments were involved in 28 patients (53,8%), lateral segment in 19 patients (36,5%), septal segments in 7 patients (13,5%)  and anterior segments in 15 patients (28,8%). 2D STE LV GLS was -16.41± 5,47% while CMR-FT LV GLS was -19,07 ± 4,65%, showing a good agreement between the two methods (r = 0,5; p &lt; 0,001). The univariate analysis showed a significant correlation between 2D STE LV GLS and CMR-FT LV GLS with the extension of myocardial edema assessed by CMR (r= 0,43; p= 0,002 and r = 0.47; p = 0,002 respectively). The univariate analysis did not show a significant correlation between 2D STE LV and the extension of myocardial scar assessed by CMR (r= 0.2; p= 0.155) while a significant correlation was found between CMR-FT LV GLS and myocardial scar (r = 0.4; p = 0.01).

CONCLUSIONS

in patients with aMY, good correlation was found between CMR-FT and 2D STE in the evaluation of GLS. 2D STE LV GLS and CMR-FT LV GLS proved to have a good correlation with the extension of myocardial edema, while only CMR-FT LV GLS proved to be associated with myocardial scar extension.

Right-ventricular involvement in acute myocarditis assessed by cardiac magnetic resonance feature tracking

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

the prevalence of right ventricular (RV) involvement in acute myocarditis (aMY) has been poorly investigated. Actually, RV evaluation may be difficult in echocardiography and scar detection as well as the presence of edema in cardiovascular magnetic resonance (CMR) may be challenging due to small RV wall thickness. We sought to examine the incremental diagnostic value of CMR feature tracking (FT) in RV strain-analysis for patients with aMY.

METHODS

all consecutive patients with clinically suspected aMY were enrolled in our study. Inclusion criteria were: 1) new ECG abnormalities 2) myocardial cytolysis markers and 3) absence of angiographically detectable coronary artery disease. Exclusion criteria included poor cine image quality caused by respiratory motion and arrhythmias. All patients underwent transthoracic echocardiography (TTE) and CMR within hospitalization on a 3T scan. CMR protocol included current standard Lake Louise criteria (LLC) for myocarditis and T2 weighted images. The definite diagnosis was made when 2 or more Lake Louise criteria were fulfilled. FT analysis of the left ventricle (LV) and RV was performed using the Tissue Tracking Module to obtain LV and RV global longitudinal (RV-GLS) strain data. 20 sex and aged matched individuals who underwent to CMR for suspected cardiac disease, which was not confirmed thereafter, were considered as control population.

RESULTS

52 patients were included in the study, mean age was 36 ± 17 years, three patients were female (6%). Mean LV ejection fraction (EF) was 56,2 ± 7,2 and mean end-diastolic volume indexed (EDVi) was 62,52 ± 19,02 ml/mq. 10 patients (19%) had impaired EF with mean values of 44,6 ± 6,1%. All patients have normal RV function evaluated in TTE considering tricuspid annular plane systolic excursion (TAPSE) (22,7 ± 2,4mm). No kinetic abnormalities were reported. All patients underwent CMR within 3 ± 1 days. Normal RV-EF, normal volumes and no RV kinetic abnormalities were reported in all cases also in CMR examination. aMY was confirmed in all patients with the presence of myocardial oedema and subepicardial late gadolinium enhancement (LGE).  Inferior segments were involved in 28 patients (54%), lateral segments in 19 patients (37%), septal segments in 7 patients (13%) and anterior segments in 15 patients (29%).  RV-GLS was -21,5 ± 5,6% which was not significantly different from control population (-23,01 ± 3,63; p value= 0,201). Globally, 34 patients (65%) had an aMY involving inferior and lateral segments. In this subgroup, RV-GLS was significantly lower compared to other aMY (-19,8 ± 5,7 vs -23,9  ± 4,6 p value = 0,047) and compared to control population (-19,8 ± 5,7 vs -23,01 ± 3,6 p value= 0,032).

CONCLUSIONS

Despite normal RV function detected in both TTE and CMR, patients with infero-lateral aMY have lower values of RV longitudinal strain. CMR-FT RV strain analysis has proven to be a useful tool in detecting subclinical RV involvement in patients with aMY. Abstract Figure. CMR Right Ventricle GLS

Additional value of CMR feature tracking parameters for the evaluation of the risk of complex ventricular arrhythmias and sudden cardiac death in patients with Mitral Valve Prolapse

Funding Acknowledgements

Type of funding sources: None.

Background

Mitral valve prolapse (MVP) with mitro-annular disjunction (MAD) has been associated with complex ventricular arrhythmias (c-VA) and sudden cardiac death (SCD) but risk stratification in this subset of patients remains insufficiently characterized. The aim of this study was to investigate the association between deformation parameters assessed by feature tracking (FT) cardiac magnetic resonance (CMR) in patients with MVP and MAD (MVP-MAD) and c-VA and/or SCD.

Methods

We included 23 patients (47 ± 13 years; 43 % males) with MVP-MAD, of whom 17 (74 %) presented with c-VA and 6 (26%) with SCD, as well as 20 age- and sex-matched controls (50 ± 18 years; 57% males). All patients underwent CMR with assessment of MAD length, late gadolinium enhancement (LGE), extracellular volume (ECV), global and regional longitudinal (LS), and circumferential strain (CS). RATIO-CS was defined as the ratio between regional CS in the basal inferolateral and mid-inferolateral walls (fig.1).

Results

In MVP-MAD patients, non-ischemic LGE of the LV inferior and inferolateral wall was observed in 21 patients (50%). As compared to controls, MVP-MAD patients showed lower global LS (-18.7 ±4.1 vs -24.7 ± 5.7 p &lt; 0.001), higher native T1 relaxation time and ECV of the left ventricle (LV) inferolateral wall (1104 ± 63ms vs 1083 ± 66ms p &lt; 0.029 and 0.31 ± 0.03 vs 0.27 ± 0.04 p 0.003), lower CS and LS of the LV mid and inferolateral segments (p &lt; 0.005).

Logistic univariate regression analysis showed an increased risk of c-VA in case of LGE presence (OR: 9.52 [2.28-39.7] p = 0.002), a high number of LV segments with LGE (OR: 1.78 [1.21-2.63] p = 0.004), GLS (OR: 1.58 [1.21-2.07] p &lt; 0.001), decreased inferolateral mid ventricular wall CS (OR: 1.41 [1.16-1.72] p &lt; 0.001), decreased basal and mid-ventricular inferolateral wall LS (OR: 1.11 [1.00-1.23] p = 0.047 and OR: 1.62 [1.22-2.13] p &lt; 0.001 respectively), increased native T1 times (OR: 1.01 [1.00-1.02] p = 0.039), increased ECV of the basal infero-lateral wall  (OR: 4.93e + 07 [1.22-1.98e + 15] p = 0.047) and decreased RATIO-CS (OR: 7.48 [1.87-30.00] p = 0.005) (table 1). In multivariate analysis the presence of a lower LS in the basal inferolateral wall remained an independent predictor of c-VA (OR: 1.62 [1.22-2.13.00] p = 0.0007) and RATIO-CS remained an independent predictor of SCD (OR: 7.73 [1.78-33.60] p = 0.006).

Conclusion

Lower inferolateral LS and RATIO CS are respectively associated with c-VA and SCD in MVP-MAD patients.  FT may provide additional value for risk stratification on top of standard CMR parameters in this subset of patients. Abstract Figure. fig.1  Abstract table 1

Long-term trends in treatment and outcomes of patients with diabetes and acute coronary syndromes: insights from the nationwide AMIS plus registry

Background

Although impressive advances in the treatment of patients with acute coronary syndromes (ACS) have been achieved over the last decades, morbidity and mortality of patients with diabetes and ACS remain substantial. This study aimed at investigating long-term trends in treatment and outcomes of patients with diabetes and ACS, using data from a large, prospective, nation-wide database.

Methods

Patients with ST segment elevation myocardial infarction (STEMI) or non-ST segment elevation myocardial infarction (NSTEMI) enrolled in the prospective AMIS Plus registry between 01/2003 and 12/2018 and available data on diabetes diagnosis were included in the analysis. Major adverse cardiovascular events (MACE), a composite of all-cause death, non-fatal myocardial infarction, and cerebrovascular events were assessed for each 3-year period.

Results

Out of 49'413 ACS patients, 10'200 (20.6%) had diabetes (29.4% women). In diabetic patients, the percentage of women decreased from 32.3% in 2002–2004 to 25.9% in 2017–2019 (p&lt;0.001). Diabetic patients were older (p&lt;0.001), more frequently women (p&lt;0.001), and had a higher body mass index (p&lt;0.001). They less often underwent percutaneous coronary intervention (p&lt;0.001) and were more frequently treated by coronary artery bypass grafting (p&lt;0.001). Over the 18-year period, the percentage of diabetic patients undergoing PCI or CABG increased (p&lt;0.001). While treatment with glycoprotein IIb/IIIa inhibitors, low-molecular weight heparin, and beta blockers decreased over time, administration of aspirin, P2Y12 inhibitors, lipid-lowering drugs, and unfractionated heparin increased. Rates of MACE were 9.5% and 5.2% in diabetic and non-diabetic patients (p&lt;0.001). Rates of mortality (7.7% versus 4.1%, p&lt;0.001), recurrent myocardial infarction (1.5% versus 0.9%, p&lt;0.001), and cerebrovascular events (1.2% versus 0.6%, p&lt;0.001) were higher in diabetic as compared with non-diabetic patients, with highest rates of MACE, mortality, and myocardial infarction observed in diabetic women. Rates of MACE decreased from 11.8% in 2002–2004 to 7.5% in 2017–2019 in diabetic patients (p for trend &lt;0.001). While rates of mortality (9.4% to 5.9%, p for trend =0.001) and rates of recurrent myocardial infarction (3.4% to 0.9%, p for trend &lt;0.001) decreased over time, rates of cerebrovascular events remained stable (p for trend =0.34). Trends were the same in diabetic women and men.

Conclusions

Rates of MACE significantly decreased over the 18-year period in both diabetic women and men, with highest rates observed in diabetic women. Despite the observed improvements, rates of MACE remained 50% higher in diabetic as compared with non-diabetic patients. These findings emphasize that advanced strategies particularly targeting the vulnerable high-risk diabetic patient population are warranted to further improve quality of care in ACS.

Funding Acknowledgement

Type of funding sources: None.

Achievement of guideline recommended LDL-C goals in patients with acute myocardial infarction (AMI) in Switzerland

Background

In 2016 and subsequently again in 2019 the ESC/EAS Guidelines for the Management of Dyslipidaemia established a more intensive reduction of LDL cholesterol (LDL-C) treatment recommendations. We aim to characterize patients with acute myocardial infarction (AMI) with regards to achievement of recommended LDL-C goals and their current lipid lowering therapy.

Methods

We retrospectively analysed patients with AMI admitted to Swiss hospitals between 2016 and 2020. Patients were classified as “very high risk” due to prior atherosclerotic cardiovascular disease (ACSVD) events including at least one of the following: Myocardial infarction (MI), stroke, peripheral arterial disease (PAD) and type 2 diabetes mellitus with target organ damage. The remaining patients were classified as “other risk”. LDL-C treatment recommendation goals for the “very high risk” population were set to 1.8mmol/L (2016 ESC/EAS Guidelines) or 1.4mmol/L (2019 ESC/EAS Guidelines) and for the “other risk” population to 2.6mmol/L or 1.8mmol/L. To identify differences between the two groups the Mann-Whitney test was used and for differences within a group the Kruskal-Wallis test. In-hospital outcomes were summarised as major adverse cardiac and cerebrovascular events (MACCE).

Results

Among 7114 patients included, 18.4% were categorized as “very high risk” and 81.6% as “other risk” (p&lt;0.001). In general, the “very high risk” patients were older (69.2y vs. 63.6y, p&lt;0.001), more likely to be men (78.8% vs. 75.3%, p=0.007), had poorer in-hospital outcomes (6.0% vs. 3.4%, p&lt;0.001) and were more often on lipid lowering treatment (statin/ezetimibe/combination) (LLT) prior to admission (64.8% vs 14.0%, p&lt;0.001). The overall LDL-C median for the “very high risk” population was significantly lower than for the “other risk” population (2.4mmol/L vs. 3.5mmol/L, p&lt;0.001). In addition, median (IQR) LDL-C increased in the “other risk” group over the years from 3.5mmol/L (2.7; 4.2) in 2016 to 3.7mmol/L (3.1; 4.4) in 2020. In contrast, no change in LDL-C was observed in the patients at higher risk (Fig. 1).

Patients in the “other risk” group were more likely to miss the recommended LDL-C goals (2016 Guidelines: 80.0% vs. 75.4%, 2019 Guidelines: 94.2% vs. 89.1%). Patients without LLT prior to admission had a higher chance of not reaching the recommendations compared to patients with LLT prior to admission (without LLT: 2016: 85.3% vs. 91.0%, 2019: 96.1% vs. 96.6%), (with LLT: 2016: 50.8% vs. 66.8%, 2019: 83.2% vs.85.2%) (Fig. 2).

Conclusion

Median LDL-C levels have tended to increase in recent years in patients with very high CV risk and AMI admitted to Swiss hospitals. Despite existing lipid lowering therapies only few patients met guideline recommended LDL-C goals. Our results indicate that clinical implementation of guidelines remains to be optimised with regards to achievement of LDL-C goals to reduce CV risk and improve outcomes.

Funding Acknowledgement

Type of funding sources: None. Figure 1. LDL-C developmentFigure 2. Recommended LDL-C goal achievement

The impact of the COVID-19 pandemic on the management and outcomes of STEMI patients in Switzerland

Introduction

The COVID-19 pandemic has placed unprecedented strain on healthcare systems around the world, with potential repercussions on the quality of care of patients with other diseases. From a cardiological perspective, there have been concerns that the pandemic may have impacted the management of the most acute cardiovascular conditions.

Purpose

We evaluated the impact of the COVID-19 pandemic on the management of ST-elevation myocardial infarction (STEMI) in Switzerland by assessing a range of quality-of-care metrics during the first year of the pandemic, as compared with the preceding year.

Methods

Data on STEMI patients hospitalised in Switzerland from 1st January 2019 to 31st December 2020 were obtained from the Acute Myocardial Infarction in Switzerland (AMIS) registry. Symptom-to-first-medical-contact (symptom-to-FMC) time, symptom-to-door time, and door-to-balloon (DTB) time were compared between 2020 and 2019 in an analysis by year and by month. Additionally, rates of in-hospital all-cause mortality and in-hospital major adverse cardiovascular events (MACE: all-cause mortality, MI, stroke) were compared.

Results

Data on 2192 STEMI patients were available. Compared with the preceding 12 months, the first year of the pandemic was not associated with a significant change in median symptom-to-FMC time (2020: 90 minutes vs 2019: 95 minutes, p=0.32) or median symptom-to-door time (2020: 145 min vs 2019: 157 min, p=0.51). In 2020, February (start of the pandemic) and March (start of national lockdown) were associated with increased DTB times as compared with the same months of 2019 (+7 minutes, +10 minutes, respectively). However, overall median door-to-balloon times remained stable (2020: 40 min vs 2019: 39 min, p=0.06). Furthermore, there was no significant difference in the proportion of patients undergoing percutaneous coronary intervention (2020: 95.6% vs 2019: 95.1%, p=0.54). Finally, there were no significant differences in median length of stay (2020: 4 days vs 2019: 157 min, p=0.51), in-hospital all-cause mortality (2020: 4.9% vs. 2019: 4.2%, p=0.41) or MACE (2020: 6.2% vs. 2019: 5.6%, p=0.52).

Conclusions

Although there are some limitations associated with the present study inherent to its retrospective observational design (for instance, a potentially important number of late comers may not have been included in the registry), the data suggest that despite the impact of COVID-19 on the healthcare system in Switzerland in 2020, STEMI management as defined by a range of quality-of-care metrics remained effective and efficient.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of intracoronary imaging-derived measures for non-infarct related vessel revascularization throughout 7 years among patients with ST-elevation myocardial infarction

Background

Underlying plaque characteristics that lead to future revascularization during long-term follow-up remain poorly understood.

Purpose

We aimed to explore intracoronary imaging-derived measures as assessed by intravascular ultrasound (IVUS) and optical coherence tomography (OCT) associated with non-infarct related vessel revascularization (non-TVR) arising from imaged segments during long-term (up to 7 years) follow-up among patients with ST-elevated myocardial infarction (STEMI).

Methods

A total of 94 STEMI patients enrolled into the IBIS-4 (Integrated Biomarker Imaging Study-4) study undergoing serial (baseline and 13 months) IVUS and OCT in 2 non-infarct-related coronary arteries under high-intensity statin therapy were analyzed in the present study. Patients were divided into 2 groups according to the occurrence of non-TVR within previously imaged vessel segments (non-TVR: n=14, no non-TVR: n=80).

Results

Baseline characteristics including LDL level were comparable between groups. At baseline, lesions with future non-TVR were associated with greater percent atheroma volume by IVUS (55.6±5.4% vs. 49.6±6.1%, P&lt;0.001), minimum lumen area by OCT (3.4±1.7 mm2 vs. 6.0±3.3 mm2, P=0.004), and a higher prevalence of fibroatheroma (60.0% vs. 20.1%, P=0.007) by OCT compared with those without. Among patients with serial imaging, lesions with non-TVR had a trend towards a less reduction of percent atheroma volume (−0.2±3.8% vs. −2.4±4.2%, P=0.083).

Conclusion

Greater plaque burden, smaller lumen area, and higher prevalence of OCT-detected fibroatheroma at baseline were associated with non-infarct related vessel revascularization. Lesions with non-TVR tend to have less-pronounced regression of coronary atheroma despite intensive statin therapy and achieved LDL levels.

Non-TVR 7 years after index PCI

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation

Heavy drinking habits are associated with worse in-hospital outcomes in patients with acute coronary syndrome

Introduction

The association between alcohol consumption and the occurrence of coronary heart disease is well described in literature. Data regarding the impact of regular alcohol consumption on in-hospital outcomes in the setting of acute coronary syndrome (ACS) are lacking.

Purpose

We aimed to evaluate the impact of self-reported alcohol consumption on in-hospital outcomes in patients with ACS.

Methods

Data derived from patients enrolled between 2007 and 2019 in the Acute Myocardial Infarction in Switzerland (AMIS) Plus registry were retrospectively analyzed. The primary endpoint was all-cause in-hospital mortality, while secondary endpoints were set as incidence of major adverse cardiac and cerebrovascular events (MACCEs). Outcomes comparisons according to quantity of daily alcohol intake were also performed.

Results

Records concerning alcohol consumption were available in 25707 patients; 5298 of them (21%) fulfilled the criteria of regular alcohol consumption. Daily alcohol intake was reported in 4059 (77%), of these patients (regular drinkers) with 2640 light drinkers (≤2 drinks/day) and 1419 heavy drinkers (&gt;2 drinks/day). Regular drinkers were predominantly male, younger, smokers, more comorbid and with a worse clinical presentation as compared to abstainers/occasional drinkers.

In-hospital mortality and MACCEs of heavy drinkers were significantly higher compared to light drinkers (5.4% vs. 3.3% and 7.0% vs. 4.4%, both p=0.001). When tested together with GRACE risk score parameters, heavy alcohol consumption was independently associated to in-hospital mortality (p=0.004).

Conclusions

Heavy alcohol consumption is an additional independent predictor of in-hospital mortality in patients presenting with ACS.

Figure 1. Study flowchart.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Swiss Heart Foundation

Quantitative flow ratio to predict non-target-vessel-related events at 5 years in STEMI patients undergoing angiography-guided revascularization

Background

In patients with ST-segment-elevation myocardial infarction (STEMI), angiography-based complete revascularization is associated with superior outcomes compared with culprit-lesion-only percutaneous coronary intervention (PCI). Quantitative Flow Ratio (QFR) is a novel, non-invasive, vasodilator-free method to assess the hemodynamic significance of coronary stenoses.

Purpose

To investigate the incremental value of QFR over angiography alone in the assessment of non-culprit lesions (NCL) in STEMI patients undergoing primary PCI.

Methods

In the randomized, multicenter COMFORTABLE AMI trial, STEMI patients underwent angiography-guided complete revascularization. QFR was determined in untreated non-target vessels by assessors blinded for clinical outcomes.

Results

Out of 1161 STEMI patients, 946 vessels in 617 patients could be analyzed by QFR. At 5-year follow-up, the rate of the primary endpoint cardiac death, non-target vessel myocardial infarction (non-TV-MI) and clinically indicated, non-target vessel revascularization (non-TVR) was significantly higher in patients with QFR ≤0.80 compared with QFR &gt;0.80 (62.9% vs. 12.7%, HR 7.20, 95% CI 4.46–11.62, p&lt;0.001), driven by higher rates of non-TV-MI (15.4% vs. 3.6%, HR 4.59, 95% CI 1.72–12.23, p=0.002) and non-TVR (58.6% vs. 7.7%, HR 10.99, 95% CI 6.39–18.91, p&lt;0.001). No significant differences for cardiac death were observed. Multivariate analysis identified QFR ≤0.80, MI SYNTAX score and left ventricular function as independent predictors of the primary endpoint. QFR ≤0.80 showed an accuracy of 86.1%, sensitivity of 23.2%, specificity of 97.5%, positive predictive value of 62.9% and negative predictive value of 87.5% for the prediction of the primary endpoint.

Conclusions

Our study results suggest incremental value of QFR over angiography-guided PCI for NCL among STEMI patients undergoing primary PCI.

Kaplan-Meier curves of primary endpoint

Funding Acknowledgement

Type of funding source: None

Delay between symptom onset and hospital admission in patients with ST-elevation myocardial infarction: different trends in men and women

Introduction

The aim of this study was to analyse whether prehospital delay in ST-elevation myocardial infarction (STEMI) has changed in men and women since 2002.

Methods

We used data from the AMIS Plus registry of patients who were admitted for STEMI between 2002 and 2019. Patients who were transferred from another hospital or were resuscitated before admission were excluded. Patient delay was defined as the difference between symptom onset and hospital admission time. Trends in delay according to gender were depicted by medians per year with a 95% confidence interval. Differences between men and women were tested using the Mann-Whitney test. To analyse the adjusted effect of gender on delay, multivariable quantile regression was applied including the interaction between gender and admission year as well as the covariates age, diabetes, pain at presentation and myocardial infarction (MI) history.

Results

Among the 15,154 patients included (74.5% men), the overall median (IQR) delay between 2002 and 2019 was 150 (84; 345) minutes for men and 180 (100; 415) for women. Women were older (71.3y vs. 62.8y, p&lt;0.001), had more often diabetes (20.0% vs. 16.9%, p&lt;0.001), but less often MI history (11.2% vs. 14.9%, p&lt;0.001) and less often pain at presentation (92.0% vs. 94.8%, p&lt;0.001).

The unadjusted median delay decreased over the admission years. The decreasing trend was stronger in women than men: the unadjusted difference in delay between men and women decreased from 60 min in 2002 (p=0.003) to 15 min in 2019 (p=0.155) (Fig 1). The multivariable model confirmed a significant interaction between gender and admission year (p=0.042) indicating that the decrease in delay was stronger for women (−3.1 min per year) than for men (−1.4 min per year) even after adjustment. The adjusted difference between men and women decreased from 27.4 min in 2002 to −1.6 min for women in 2019. Additional independent predictors of longer delay were the covariates age (+1.6 min per additional year, p&lt;0.001) and diabetes (+27.1 min, p&lt;0.001). Conversely, pain at admission (−46.3 min, p&lt;0.001) and MI history (−32.9 min, p&lt;0.001) predicted a shorter delay.

Conclusions

The difference in delay between symptom onset and hospital admission in STEMI patients between men and women steadily diminished from 2002 to 2019. This might indicate that the public and health professionals' awareness of STEMI in women has ameliorated over time.

Unadjusted delay according to gender

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): AMIS Plus Foundation

HEART VALVE DISEASESP1 SEX AND GENDER DIFFERENCES IN TAVI PATIENTS: FROM CLINICAL PRESENTATION TO PROCEDURAL OUTCOMES

Background

The epidemiological impact of aortic stenosis has recently grown, and indications to valvular treatment have changed substantially with the implementation in clinical practice of TAVI procedures. Significant differences according to patients’ sex are likely to be related to different biological features, but the undelrying mechanisms haven’t been verified yet.

Aims and Methods

We collected from the SwissTAVI Registry the available data about 373 subjects who where consecutively treated in Cardiocentro Ticino with a TAVI procedure over the last 10 years. We compared two subgroups of female (n = 161, age 83.5±5.4 yrs) and male (n = 212, age 82.3±5.9 yrs) patients in terms of severity indices of the disease (residual valve area and transvalvular gradients). The same parameters were measured after the procedure with a quantitative estimation of eventual post-procedural paravalvular leaks.

Results

As previously reported, female patients showed significantly higher transvalvular mean gradients at baseline (48.02±16.0 vs. 42.9±14.8 mmHg; P = 0.004) on smaller resudual valve areas (0.66±0.18 vs. 0.77±0.19 cm2; P &lt; 0.001). TAVI procedures were equally efficient in both sex, restoring similar valve areas and gradients, but paravalvular leaks were more frequent and significant in females (F vs. M no leak 44.5 vs. 55.3%, mild 47.7 vs. 42.7%, moderate 6.5 vs. 1.5%, severe 1.3 vs. 0.5%; overall P = 0.037).

Conclusions

Sex-related differences are only partially described and their substrate is not clear. Female patients are known to be more prone to bleedings and cerebrovascular accidents, but our data show that also paravalvular leaks could be more common and significant in comparison to males. A detailed analysis of the anatomy of the aortic outflow and of the valvular deterioration in aortic stenosis is required and is the aim of the second phase of this study. Understanding sex-related characteristics underlying these discrepancies can potentially improve TAVI technologies towards a further customization of prosthetic devices.

P641 Severe pulmonary steno-insufficiency due to metastatic carcinoid tumor in a 57 years old patient treated with MTPV implantation: first experience

Funding Acknowledgements

none

Background

Right side heart valve involvement is a well known phenomenon in metastatic carcinoid disease. In recent times bioprosthetic valves have been widely used for replacement of stenotic and regurgitant native heart valves. Melody Transcatheter Pulmonary Valve (MTPV, Medtronic, Minneapolis, MN, USA) has been approved for treatment of native pulmonary valves as well as failing biological prostheses and conduits. We present the first case to our knowledge of severe native pulmonary valve steno-insufficiency due to metastatic carcinoid syndrome treated with MTPV implantation.

Case report

A 57-year-old woman is known since 2007 for metastatic carcinoid syndrome treated with surgical resection followed by chemotherapy (tamoxifene, everolimus) and radiotherapy. For 2 years she has been known for tricuspid and pulmonary involvement, which aggravated progressively, leading to symptomatic right heart failure. She was therefore submitted for multimodality imaging evaluation (see picture) and right heart catheterization.

Transthoracic echocardiogram, cardiac MRI and right heart catheterization confirmed severe pulmonary valve steno-insufficiency. Cardiopulmonary exercise testing revealed a severe limitation of aerobic exercise capacity (VO2 max 14.4 ml/min/kg).

After heart team discussion it was decided to treat the patient in a 2 step approach, initially with implantation of a Melody valve in pulmonary position and subsequently with surgical repair of the tricuspid valve.

Pulmonary valve was treated by placement of a 39 x 25 mm ANDRA stent and subsequent implantation of a 22 mm Melody valve. Before stenting, coronary angiography with simultaneous balloon inflation in RVOT was performed to exclude coronary artery compression. During the procedure the patient developed hypotension, which was treated effectively with Octeotride.

Post-operative echocardiogram showed a significant reduction in pulmonary valve gradient and no significant residual regurgitation.

Conclusions

We treated effectively severe pulmonary steno-insufficiency due to metastatic carcinoid tumor with MTPV implantation. No complications occurred. Multimodality imaging is fundamental for patients selection and preoperative planning of prosthetic valve dimensions.

Abstract P641 Figure. Multimodality imaging of PV

463Temporal trends in latecomer ST-segment elevation myocardial infarction patients: Insights from the AMIS Plus Registry 1997–2017

Introduction

A relevant proportion of patients experiencing ST-segment elevation myocardial infarction (STEMI) has a late presentation after symptoms onset. Temporal trends deriving from a large real-word scenario for this subgroup of patients are lacking.

Purpose

The aim of the present study was to provide a comprehensive analysis of temporal trends in latecomer STEMI patients, with particular regard to implementation of evidence-based treatments in this population and major in-hospital outcomes.

Methods

All STEMI patients included in the AMIS Plus Registry from January 1997 to December 2017 were included and patient-related delay was assessed: 27 231 patients were available for the final analysis. STEMI patients were classified as early or latecomers according to patient-related delay (≤ or >12 hours, respectively).

Results

22 928 patients were earlycomers (84%) and 4303 patients were classified as latecomers (16%). Across the study period we observed a significant decrease in prevalence of late presentation from 22% to 12.3% (p<0.001, Figure 1). In latecomer STEMI patients there was a gradual uptake of evidence-based pharmacological treatments with an increase in discharge prescription of P2Y12 inhibitors from 6% to 90.7% (p<0.001). Similarly, a marked increase in percutaneous coronary intervention (PCI) rate was observed (12.1–86.6%; p<0.001). Across this 20-year period, in-hospital mortality was reduced to a third (to an absolute rate of 4.5%, p<0.001) and a significant reduction in prevalence of both cardiogenic shock (14.6–4.3%) and re-infarction (5.4–0.2%) during the index hospitalisation was observed (p<0.001 for both variables). Length of hospitalisation in acute care facilities significantly decreased from 10 (6,14) days to 4 (1,7) days (p<0.001). At multivariate analysis, PCI had a strong independent protective effect toward in-hospital mortality (odds ratio 0.3, 95% confidence interval 0.187 to 0.480).

Figure 1

Conclusion

The present study provides a comprehensive picture of temporal trends in late presentation in STEMI over the last 20 years in Switzerland. During the study period in latecomer STEMI population there was a gradual uptake of evidence-based pharmacological treatments and a marked increase in PCI rate. In-hospital mortality was reduced to a third (to an absolute rate of 4.5%) and this reduction seems to be mainly associated with the increasing implementation of PCI.

P4726Functional mitral regurgitation treated with percutaneous repair: a relative survival analysis of a national Swiss cohort

Introduction

Percutaneous treatment of functional mitral regurgitation (FMR) with MitraClip (MC) has led to discordant results in recent randomized clinical trials. We aimed at estimating excess mortality (EM) and to evaluate its predictors in a large Swiss FMR population treated with MC.

Methods

FMR patients enrolled in the MitraSwiss Registry (479 pts) with a mean age of 74.7±9.42 years were evaluated. We computed and plotted EM up to 5 years after implant using the Swiss 2008–20013 mortality tables, stratified by age and sex. A Poisson regression was used to model EM as a function of age, sex, pre-implant RV/RA gradient, calendar period (2011–2013; 2014–2015,2016–2017), ischemic vs non ischemic aetiology, acute procedural success and residual MR.

Results

Patient's survival at 1,2,3,4 and 5 years were respectively 0.84, 0.72, 0.59, 0.53 and 0.48. FMR patients treated with MC showed excess mortality of +13% (95% CI,10%-18%), +22% (95% CI,17%-28%), +34% (95% CI,27%-41%), +37% (95% CI,28%-46%) and +39% (95% CI,28%-50%) at each time point as compared to the Swiss population, with not differences over the entire follow up (p=0.481). Age group, sex, RV/RA gradient calendar period, ischemic vs non ischemic and residual MR were not associated with excess mortality while a clear association was recognized with acute procedural success (p=0.011).

Conclusions

In FMR patients treated with MC a persistent EM was observed at a 5 years follow up. Acute procedural success is the only determinant of EM with a 65% lower EM as compared to procedural failures.

P3625Cocaine consumption and acute coronary syndrome: an analysis from the Swiss registry AMIS Plus

Introduction

The aim of this study is to evaluate the cardiovascular impact of cocaine in a population of patients enrolled in the Swiss nationwide AMIS Plus registry with a focus on in-hospital outcomes.

Methods

We retrospectively analysed data of patients enrolled in the Swiss AMIS Plus registry from 2007 to 2018. Baseline and in-hospital data of patients with ACS and cocaine use were compared with the remaining AMIS population as well as to a sex and aged matched ACS patients (1:5 ratio, 540 patients) without history of cocaine consumption. Primary endpoints were death and major adverse cardiac and cardiovascular events (MACCE).

Results

A total of 20'981 patients had been included in the AMIS Plus registry for ACS in the study period, of them 110 (0.5%) were cocaine user.

As compared to the remaining AMIS population, cocaine abusers were significantly younger (46.4±10.8 vs 66.4±13.2 years; p<0.001), presented more frequently with out of hospital cardiac arrest (11.8% vs 4.7%, p<0.001) and STEMI (68,2% vs 54.7%, p=0.007). Apart from active smoke and family history, had a lower burden of CV risk factors. In hospital mortality (3.6% vs 4.4%; p=1) and MACCE (5.4% vs 5.5%; p=0.83) were comparable.

When compared to the age matched ACS population without history of cocaine consumption, cocaine abusers were more frequently smokers (87.6% vs 63.6%, p<0.001) but less frequently obese (10.4% vs 25.6%, p=0,001). Clinical presentation was comparable among the two groups, nonetheless cocaine abuse was associated with a higher incidence of death (3.7% vs 0.7%, p<0.05) and MACCE (5.6% vs 1.3%, p<0.05).

Conclusion

This analysis presents the largest series of cocaine associated ACS available in literature. Cocaine abuse increases by 5 the risk of mortality and by 4 the risk of MACCE as compared to an age matched ACS population. No differences where observed in outcomes when compared to a 20 years older population.

P2585Cardiac dysfunction after myocardial infarction: role of pro-inflammatory extracellular vesicles

Background

Myocardial infarction (MI) is associated with significant loss of cardiomyocytes (CM), which are replaced by a fibrotic scar. Necrotic CM release damage-associated proteins that stimulate innate immune pathways and macrophages (MΦ) tissue infiltration, which drives to the progression of inflammation and myocardial remodeling process. Both, loss of CM and inflammatory response are determinants of the long term ventricle remodeling and heart failure. Circulating inflammatory extracellular vesicles (EV) play a crucial role in the acute and chronic phases of MI, in terms of inflammatory progression. In this study we examined whether reducing the generation of inflammatory EV within few hours from the ischemic event may ameliorate cardiac outcome at short and long time-point in LAD rat model.

Methods

Before coronary artery ligation, rats were injected IP with a chemical inhibitor of neutral sphingomyelinase (nSMase) which is essential for the biogenesis and release of EVs. The number and size profile of plasma-derived EV was assessed by NTA analysis at baseline and 24hrs after MI. Multiple EV cytokine levels were simultaneously determined using enzyme-linked immunosorbent assay (ELISA)-based protein array technology. Heart global function was assessed by echocardiography and hemodynamic analysis performed at 7, 14 and 28 days after MI. Cytotoxic effects of circulating EV were evaluated ex-vivo in a Langedorff, system by measuring the level of cardiac troponin I (cTnI) in the perfusate. Mechanisms undergoing cytotoxic effects of EV derived from pro-inflammatory MΦ (MΦM1) were studied in vitro into primary rat neonatal CM.

Results

The induction of MI and the consequent inflammation, dramatically increase the number of circulating EV carrying inflammatory cytokines such as IL1α, ILβ and Rantes. Preventive inhibition nSMase significantly reduced the boost of inflammatory EV and cytokines in treated group as compared to control animals. The reduction of circulating EV post MI results in preserved LV ejection fraction at 7 and 28 days post-MI as compared to control group. Hemodynamic analysis confirmed functional recovery by displaying a higher velocity of LV relaxation and an improved contractility capacity in treated versus control group. The number of infiltrating CD68+ monocytes/macrophages in the infarct area was significantly reduced. Post-MI circulating EV induce cell death in adult CM when added to the perfusate of Langendorff, as assessed by the incresed level of cTnI into media. In vitro MΦM1-EV activated nuclear translocation of NF-kB. Specific inhibition of TLR4 receptor activity abrogated NF-kB translocation and reduced cell death. Indicating that the axis TRL4-NF-kB is essential in EV-mediated CM death.

Conclusions

Systemic inhibition of EV release during the acute phase of MI preserves heart function in an animal model of LAD. These findings suggest detrimental effects of exosomes in the acute phase of MI.

P4391Cardiovascular risk factor trends over two decades in patients presenting with acute myocardial infarction: a failure of smoking control, especially in women

Background

Hypertension, diabetes, dyslipidemia and smoking are established cardiovascular risk factors (CVRF). Little is known about the changes of risk factor profiles over time in patients presenting with acute myocardial infarction (AMI).

Purpose

To analyze the temporal trends of CVRF in patients presenting with AMI over the last 22 years in Switzerland.

Methods

We included data of all AMI patients enrolled between 1997 and 2018 in the Swiss nationwide AMIS Plus registry. The rates of hypertension, diabetes, dyslipidemia and smoking at presentation were descriptively analyzed dividing the data into 2-year periods. Trend analyses were performed using the CHI-square-test and ANOVA. A p-value of <0.005 was considered as statistically significant.

Results

A total of 57,995 patients were included in the analysis (73.6% male). The mean age was 66.0 years (males: 64.0 years, females 71.6 years) and did not differ over the study period. The mean CVRF rates over the study period were as follows: diabetes 20.5% (males: 19.4%, females: 23.6%), hypertension 60.2% (males: 57.0%, females: 69.0%), dyslipidemia 59.4% (males: 60.5%, females: 56.4%), and smoking 39.3% (males: 43.0%, females: 28.7%). While there was no significant change over time in the rates of diabetes for both genders, there were significant increases in the rates of hypertension and dyslipidemia for both males and females (p<0.001 for all comparisons). In terms of smoking, there was no significant trend for males while there was a significant increase in the rate of smoking for females (p<0.001). As a result, the gap in smoking rates between men and women decreased from 19.9% (45.3% vs. 25.4%) in 1997/98 to 7.9% (41.2% vs. 33.3%) in 2017/18.

Trends in the rate of smokers

Conclusions

Among patients presenting with AMI in Switzerland over two decades, the prevalence of hypertension and dyslipidemia increased in both men and women, while diabetes at presentation did not change over the years. We documented a failure of smoking control, with a lack of a reduction in the smoking prevalence among males and a striking increase among women.

Combined heart and kidney transplantation: long-term analysis of renal function and major adverse events at 20 years

BACKGROUND

Combined heart-kidney transplantation (HKTx) is an accepted therapeutic option for patients with end-stage heart disease associated with severely impaired renal function. We report our long-term follow-up with this combined procedure.

PATIENTS AND METHODS

Between April 1989 to November 2009, nine patients underwent combined simultaneous (HKTx) at our center. Seven patients were males (mean age 45.2 +/- 10.12 years); seven patients were on dialysis at the time of transplantation.

RESULTS

Surgical procedures were uneventful in all patients. One patient died in the intensive care unit 41 days after transplantation. During long-term follow-up, three patients died: one due to infection and multiorgan failure 148 months after HKTx, one due to a lung neoplasm after 6 years, and one, a cerebral stroke at 34 months after transplantation. Only one patient experience renal allograft failure secondary to hypertension and cyclosporine nephrotoxicity at 10 years after HKTx with the need for renal replacement therapy. Last estimated glomerular filtration rates of all other patients was 61.3 +/- 17.4 mL/min.

CONCLUSIONS

In selected patients, with coexisting end-stage cardiac and renal failure, combined HKTx with an allograft from the same donor proved to give satisfactory short- and long-term results, with a low incidence of both cardiac and renal allograft complications.

Is pretreatment with Beta-blockers beneficial in patients with acute coronary syndrome?

OBJECTIVES

The role of beta-blockers in the treatment of hypertension is discussed controversially and the data showing a clear benefit in acute coronary syndromes (ACS) were obtained in the thrombolysis era. The goal of this study was to analyze the role of pretreatment with beta-blockers in patients with ACS.

METHODS

Using data from the Acute Myocardial Infarction in Switzerland (AMIS Plus) registry, we analyzed outcomes of patients with beta-blocker pretreatment in whom they were continued during hospitalization (group A), those without beta-blocker pretreatment but with administration after admission (group B) and those who never received them (group C). Major adverse cardiac events defined as composed endpoint of re-infarction and stroke (during hospitalization) and/or in-hospital death were compared between the groups.

RESULTS

A total of 24,709 patients were included in the study (6,234 in group A, 12,344 in group B, 6,131 in group C). Patients of group B were younger compared to patients of group A and C (62.5, 67.6 and 68.4, respectively). In the multivariate analysis, odds ratio for major adverse cardiac events was 0.59 (CI 0.47-0.74) for group A and 0.66 (CI 0.55-0.83) for group B, while group C was taken as a reference.

CONCLUSIONS

beta-Blocker therapy is beneficial in ACS and they should be started in those who are not pretreated and continued in stable patients who had been on chronic beta-blocker therapy before.

[Thoracic epidural analgesia (TEA) in clinical practice: effects, technique, complications and suggestions during anticoagulant treatment]

The effects of thoracic peridural analgesia (TEA) on the neuroendocrine response to surgery are well known, but, at the present this technique is not widely used especially in Italy. The aim of this paper is to give information and suggestions on thoracic epidural analgesia in thoracic and cardiac surgery, and to discuss how anticoagulant therapy may interfere on this technique.

[Heart interventions in Switzerland 1996]

For the year 1996, as for the previous 11 years, a survey of cardiac invasive and surgical procedures in Switzerland was carried out by a standardised questionnaire. At the 25 Swiss centres (10 public non-university, 10 private and 5 university centres) a total of 12,183 coronary revascularisation procedures were performed, 60% by percutaneous transluminal coronary angioplasty (PTCA). Of all PTCAs, 88% were single vessel interventions. PTCA for ongoing infarction accounted for 6% of all PTCAs. The use of coronary stents has increased to 50% of all angioplasties. Other interventions like directional atherectomy and rotablations have lost ground (0.4%, 35 cases). Only 22 interventions (0.2%) with intracoronary laser devices were recorded. Among the new diagnostic tools, only coronary ultrasound (233 cases) and Flowire (147) have been used regularly. Percutaneous balloon valvuloplasties (60 cases) and catheter closure of congenital shunt defects (42 cases) remained rare. Procedure related mortality for PTCA was 0.6%, infarction occurred in 1.0% and emergency coronary artery bypass grafting (CABG) became necessary in 0.4%. The total number of CABGs (4,463) slightly decreased. Among the 2,677 non-coronary operations, 48% were performed for valve disease and 51% for congenital heart disease. Heart transplantation was performed in 41 patients (1%). Half of the interventional catheter procedures were performed at the 5 university centres whereas the majority of CABGs were carried out at private centres. Four centres performed diagnostic procedures, exclusively. In-house surgical stand-by for PTCA was available in 17 of the 21 interventional centres.