Diagnostic accuracy of instantaneous wave-free ratio at rest and during dobutamine provocation to assess myocardial bridging relevance

Background

Diastolic fractional flow reserve (d-FFR) during dobutamine provocation (DOB) was found to be a more reliable physiological index for the functional assessment of myocardial bridging (MB). However, d-FFR calculation is complicated and time-consuming, and therefore several authors have suggested the use of instantaneous wave-free ratio (iFR) to overcome these issues.

Purpose

The aim of our study was to assess diagnostic performance of d-FFR and iFR at rest and during DOB with exercise-induced myocardial ischemia as reference.

Methods

Twenty-four symptomatic patients (17 males, mean age 58±8 years) with MB and systolic compression ≥50% diameter stenosis on the left anterior descending (LAD) artery were included. Exercise stress-echocardiography test (SE), and both d-FFR and iFR in the distal segment of LAD at rest and peak DOB (30–50μg/kg/min), were performed in all patients. Optimal cut-off values and diagnostic performance of resting and hyperemic d-FFR and iFR were assessed using SE.

Results

Exercise-SE was positive for myocardial ischemia in 7/24 patients (29%). The area-under-the-receiver-operating-characteristic curve (ROC-AUC) for exercise-induced myocardial ischemia was 0.64 (95% CI: 0.400–0.885) for resting d-FFR, 0.62 (95% CI: 0.378–0.866) for resting iFR, 1.000 (95% CI: 0.999–1.000) for d-FFR at peak DOB, and 0.96 (95% CI: 0.895–1.000) for iFR at peak DOB. No significant difference in ROC-AUC was observed between d-FFR and iFR at peak DOB (p=0.243). The best cut-off value for both d-FFR and iFR at peak DOB was <0.76 with similar sensitivity and negative predictive values (100 vs. 100% for both), but lower specificity and positive predictive value for iFR in identifying MB associated with exercise-induced ischemia (94% vs. 82%; 88% vs. 70%, respectively). Compared with exercise-induced myocardial ischemia, the diagnostic accuracy of d-FFR and iFR at peak DOB was 96% (kappa=0.903, p<0.001) and 88% (kappa=0.731, p<0.001), respectively.

Conclusions

iFR during DOB provocation showed similar diagnostic accuracy as d-FFR to identify the functionally significant MB when compared with exercise-induced myocardial ischemia.

Funding Acknowledgement

Type of funding sources: None.

Cut-off value of coronary flow velocity reserve obtained by transthoracic Doppler echocardiography during intravenous infusion of dobutamine for diagnosis of functional significant myocardial bridging

Background

Recent studies showed that coronary flow velocity reserve (CFVR) measurement by transthoracic Doppler echocardiography (TTDE) during inotropic stimulation with dobutamine (DOB), in comparison to vasodilation with adenosine, provides more reliable functional evaluation of myocardial bridging (MB). However, the adequate cut-off value of CFVR during DOB for diagnosing functional significant MB has not been fully established.

Purpose

The purpose of the study was to evaluate the adequate cut-off value of TTDE- CFVR during DOB for diagnosis of functional significant MB.

Methods

This prospective study included 79 patients (54 males, mean age 55±10 years) with angiographic evidence of isolated MB on the left anterior descending artery (LAD) and systolic compression ≥50% diameter stenosis. Exercise stress-echocardiography test (ExSE) and TTDE-CFVR in the distal segment of LAD during DOB infusion (DOB: 10–40μg/kg/min) were performed in all patients. Percent diameter stenosis (DS) of MB at end-systole and end-diastole were analyzed using quantitative coronary angiography.

Results

Exercise-SE was positive for myocardial ischemia in 22/79 (28%). CFVR during peak DOB was significantly lower in SE-positive group in comparison to SE-negative group (1.94±0.16 vs. 2.78±0.53, p<0.001). ROC analysis identifies the optimal CFVR during peak DOB cut-off value <2.1 (AUC 0.985, 95% CI: 0.965–1.000, p<0.001), with a sensitivity of 96% and specificity of 95%, positive predictive value of 88%, and negative predictive value of 98%, for identifying functionally significant MB associated with stress-induced myocardial ischemia. The categorical agreement between TTDE-CFVR at peak DOB and ExSE was high (kappa value = 0.877, p<0.001). Multivariate logistic regression analysis showed that percent DS at end-diastole was the only independent predictor of ischemic CFVR value <2.1 (OR: 1.136, 95% CI: 1.045–1.235, p=0.003).

Conclusion

A cut-off value <2.1 of CFVR during DOB infusion obtained by TTDE may adequate discriminate functional significant MB that induce myocardial ischemia which is caused by an incomplete diastolic MB-decompression.

Funding Acknowledgement

Type of funding sources: None.

Relative impact of acute heart failure and acute kidney injury on short- and long-term prognosis of patients with STEMI treated with primary PCI

Background

Although both acute heart failure (AHF) and acute kidney injury (AKI) have been separately recognized as contributors to an increased mortality risk in patients with ST-segment elevation myocardial infarction (STEMI), their relative importance has not been extensively studied.

Purpose

Our aim was to investigate the relative impact of AHF and AKI on 30-day and 5-year mortality following primary PCI for STEMI.

Methods

8 054 patients referred to primary PCI during the years 2009–2019, and with the available repeated creatinine measurements, were analyzed. AKI was defined as ≥25% relative or ≥0.5 mg/dl absolute rise in creatinine from baseline, within 72 hours of intervention. Acute heart failure was defined as Killip class ≥2 on admission to hospital. Cox regression model was used to assess the effect of the interaction of AHF and AKI on mortality. Median follow-up was 5 years.

Results

The incidence of AKI was 9.9% (n=805) and of AHF 12.3% (n=1050). Concurrence of AHF and AKI was noted in 1.7% of the included patients (n=315). The combined presence of AHF and AKI significantly increased mortality both at 30 days (30.7%) and at 5 years (73.3%), as compared with AKI alone (8.2% at 30 days and 32.3% at 5 years) and AHF alone (13.0% and 53.0%). When adjusted for other significant predictors, such as age, prior stroke, hyperlipidemia, atrial fibrillation, ejection fraction, final TIMI flow in the culprit artery, the use of intra-aortic balloon pump and multivessel disease, both AKI and AHF were independently associated with mortality. The adjusted relative impact of AKI on mortality was stronger than that of AHF at 30 days (adjusted HR 3.5 and 2.2, respectively), whereas it was comparable at 5 years (adjusted HR 1.3 and 1.4, respectively). Furthermore, the combined presence of AHF on admission and the post-primary PCI development of AKI was associated with the highest magnitude of risk at both 30 days (HR 5.0, CI95% 3.0–8.3, p<0.001) and 5 years (HR 2.4, CI95% 1.83–3.16, p<0.001).

Conclusion

Acute kidney injury following primary PCI for STEMI was associated with a higher adjusted risk of short-term mortality when compared with acute heart failure, whereas their relative impact was comparable in the long-term.

Funding Acknowledgement

Type of funding sources: None.

A two year echocardiographic follow-up of patients with chronic total occlusion treated with percutaneous coronary intervention or receiving only medical therapy

Background

Percutaneous coronary intervention of chronic total occlusion (PCI CTO) can reduce angina and the need for bypass surgery, however, it is still not clear how it effects the myocardial function. Conventional echocardiography is subjective and experience-dependent while tissue Doppler imaging together with strain imaging provides a more objective assessment of myocardial contractility.

Purpose

Our aim was to access the effectiveness of percutaneous coronary intervention (PCI) along with optimal medical therapy (OMT) on myocardial function.

Methods

We compared two groups of patients. The first group of patients underwent PCI CTO with OMT while the second group of patients only received OMT (control group). The echocardiographic exam was performed before randomization and after 24 months of follow-up. Doppler time intervals- isovolumetric relaxation time (IVRT), isovolumetric contraction time (IVCT) and ejection time (ET) were measured from mitral inflow and left ventricular outflow Doppler tracings. Myocardial performance index (MPI) is equal to the sum of the IVRT and IVCT divided by the ET. Velocity of early mitral filling wave (E) was measured and divided by average peak early diastolic annular velocity (e'). Peak longitudinal strain was assessed in 17 left ventricular segments. Time intervals from start Q/R on electrocardiogram to peak negative strain during the cardiac cycle were assessed. Mechanical dispersion was defined as the standard deviation of this time interval from 17 left ventricular segments, reflecting myocardial contraction heterogeneity

Results

Comparing the groups at follow up, there was no significant change in ejection fraction (EF), diastolic function, and mechanical dispersion, however, there was improvement in GLS and MPI (Table 1).

Conclusion

Global longitudinal strain as a parameter of systolic function and Myocardial performance index as a parametar of global systolic and diastolic function are sensitive markers that can detect subtle improvement in myocardial function after recanalisation of CTO.

Funding Acknowledgement

Type of funding source: None

Prognostic impact of elevated baseline CRP levels in primary PCI-treated patients with residual cholesterol risk

Background

Recent large randomized studies have indicated the potential of anti-inflammatory therapies to reduce adverse cardiovascular events in patients with myocardial infarction, with the most pronounced benefit in patients with baseline elevated C-reactive protein (CRP).

Purpose

Our aim was to assess the association of CRP levels with 30-day and 1-year mortality in patients with acute myocardial infarction treated with primary PCI and with residual cholesterol risk.

Methods

The study included 1531 patients admitted for primary PCI, with the residual cholesterol risk, i.e. low-density lipoprotein cholesterol (LDL-C) levels of >1.80 mmol/l (70 mg/dl), from a prospectively kept electronic registry of a high-volume tertiary center, for whom in-hospital CRP measurements were available. Elevated CRP was defined as ≥5 mg/l (local laboratory cut off value), measured during index hospitalization. Cox regression models were constructed to assess the impact of elevated CRP on 30-day and 1-year mortality.

Results

72% of the included patients with LDL-C >1.80 mmol/l had elevated in-hospital CRP (n=1107). Compared with patients with CRP levels within reference limit, elevated CRP was associated with older age (62 vs. 60, p<0.001), higher rates of diabetes (25.8% vs. 18.5%, p=0.002), renal failure (6.4% vs. 2.1%, p<0.001) and Killip class >1 at presentation (22.5% vs. 12.3%, p<0.001), as well as lower EF (44% vs. 48%, p<0.001) and lower haemoglobin on admission (13.9 g/dl vs. 14.2 g/dl, p<0.001). Crude mortality rates were increased in patients with CRP ≥5mg/l at both 30 days (6.0% vs. 2.4%, p=0.003) and 1 year (13.2% vs. 6.3%, p<0.001) (Figure). After adjusting for the observed baseline differences, CRP ≥5mg/l remained an independent predictor of mortality at 1 year (HR 1.691, 95% CI: 1.050–2.724, p=0.03), but not at 30 days (HR 1.690, 95% CI: 0.859–3.324, p=0.13).

Conclusion

In primary PCI-treated patients with residual cholesterol risk, elevated in-hospital CRP was independently associated with 1-year mortality. Our findings may thus suggest a potential window of opportunity, for anti-inflammatory therapies to improve outcomes beyond the acute phase.

Figure 1

Funding Acknowledgement

Type of funding source: None

Characteristics, predictors and outcomes after unprotected left main stem primary percutaneous coronary intervention

Background

Reports about outcomes of patients undergoing primary percutaneous coronary intervention (PCI) for unprotected left main (ULM) coronary artery are limited. We aimed to investigate the characteristics, in-hospital and the long-term outcomes of these patients.

Methods

From a high-volume, single-centre, prospective registry, in a period from 2009–2019, we identified 111 pts (0.96%) who undergone primary PCI for ULM culprit lesion. The short- and the long-term outcomes in this subset was evaluated and compared to 9463 (82.5%) patients undergoing pPCI for lesions located in other segments (Non-LM group). Technical success was defined as final TIMI 3 flow in both, left main and distal vessels, anterior descending and circumflex artery, without significant residual stenosis (>20% following balloon angioplasty or stent implantation) and side branch compromise (residual stenosis >75%).

Results

Patients with ULM were older and more likely to present as Non-ST-elevation MI (77% vs. 93%; p<0.000) and in cardiogenic shock (40% vs. 2.2%; p<0.000), having less occlusive disease with TIMI 0–1 flow prior to PCI (44% vs. 78%; p<0.000) compared to Non-LM patients. Also, greater procedure complexity was observed with longer lesions >20mm (50% vs. 29%; p<0.000), more intraluminal thrombus (86% vs. 45%; p<0.000), greater number (1,48±0,9 vs. 1,28±0,7; p<0.01) and longer stents (30,5±15,8 vs. 27,4±14,3; p=0.028), more GP IIb/IIIa inhibitors (32% vs. 23%; p=0.022), intra-aortic counterpulsations (7% vs. 0.6%; p<0.000) and contrast media used (202±96 vs. 172±66; p<0.000) in ULM group. Despite obtaining comparable rates of final TIMI 3 flow in main branch (91.9% vs. 95.4%; p=0.084), patients with LMCA had significantly higher in-hospital (27% vs. 4.7%: p<0.000), and one-year all-cause mortality (41% vs. 11%: p<0.000), but for the remaining duration of clinical follow-up (available for 97.8% pts, median duration 51±37 months) survival rates were comparable between ULM and Non-LM pts (18% vs. 15%: p=0.506) (Figure 1).

Regression analysis showed that final TIMI 3 in main branch at 30 days (HR 0.05 [95% CI 0.005–0.604]; p=0.018), while peri-procedural cardiogenic shock (hazard ratio (HR) 8.3 [95% CI 2.5–28.1]; p=0.001), creatinine clearance <60 ml/min (HR 7.5 [95% CI 2.3–25.1]; p=0.001) and technical success (HR 0.16 [95% CI 0.45–0.57]; p=0.005) at 5 years, independently predicted mortality in ULM patients.

Conclusions

Despite performance of primary PCI, patients with MI due to ULM lesions are associated with worse in-hospital and one-year mortality but following that period mortality was comparable to control group. Suboptimal final coronary flow best predicted the 30 day, while peri-procedural cardiogenic shock, renal dysfunction at admission and suboptimal technical procedure result, predicted long-term mortality in these patients.

Figure 1

Funding Acknowledgement

Type of funding source: None

Time-dependent improvement in coronary flow reserve in collateral donor artery following successful recanalization of the Coronary Chronic Total Occlusion

Background

Coronary chronic total occlusion (CTO) is characterized by the presence of collateral blood vessels which can provide additional blood supply to CTO-artery dependent myocardium. Successful CTO recanalization is followed by significant decrease in collateral donor artery blood flow and collateral derecruitment.

Purpose

Study aim was to assess time-dependent changes in coronary flow reserve (CFR) in collateral donor artery after CTO recanalization and identify factors that influence these changes.

Methods

Our study enrolled 31 patients with CTO scheduled for percutaneous coronary intervention (PCI). Non-invasive CFR was measured before PCI in collateral donor artery, and 24h and 6 months post-PCI in CTO and collateral donor artery. Gated SPECT MIBI was performed before PCI, while quality of life was assessed by Seattle angina questionnaire (SAQ) pre-PCI, and 6 months after PCI.

Results

Collateral donor artery showed significant increase in CFR 24h after CTO recanalization compared to pre-PCI values (2.30±0.49 vs. 2.71±0.45, p=0.005), which remained unchanged after 6 months (2.68±0.24). Maximum baseline blood flow velocity of the collateral donor artery showed significant decrease measured 24h post-PCI compared to pre-PCI values (0.28±0.06 vs. 0.24±0.04m/s), and remained similar after 6-months. There was no significant difference in maximum hyperemic blood flow velocity pre-PCI, 24h and 6 months post-PCI. CFR change of the collateral donor artery 24h post-PCI compared to pre-PCI values showed inverse correlation with left ventricle ejection fraction (LVEF) measured on SPECT. CFR changes showed no correlation with the changes in quality of life assessed by SAQ post-PCI compared to pre-PCI.

Conclusions

Significant increase in CFR of the collateral donor artery was observed within 24h after successful recanalization of CTO artery, which maintained constant after the 6 months follow-up. This increase was largely driven by the significant reduction in the maximum baseline blood flow velocity within 24h after CTO recanalization compared to pre-PCI values. Our results suggest that possible benefit of CTO recanalization could be the improvement in physiology of the collateral donor artery.

Funding Acknowledgement

Type of funding source: None

Clinical characteristics and long-term mortality of patients with midrange ejection fraction undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction

Background

Previous studies associated midrange ejection fraction (mrEF) with impaired prognosis in patients with ST-elevation myocardial infarction (STEMI).

Purpose

Our aim was to assess clinical profile and short- and long-term mortality of patients with mrEF after STEMI treated with primary percutaneous coronary intervention (PCI).

Methods

This analysis included 8148 patients admitted for primary PCI during 2009–2019, from a high-volume tertiary center, for whom echocardiographic parameters obtained during index hospitalization were available. Midrange EF was defined as 40–49%. Adjusted Cox regression models were used to assess 30-day and 5-year mortality hazard of mrEF, with the reference category being preserved EF (>50%).

Results

mrEF was present in 29.8% (n=2 427), whereas low ejection fraction (EF<40%) was documented in 24.7% of patients (n=2 016). mrEF was associated with a higher baseline risk as compared with preserved EF patients, but lower when compared with EF<40%, in terms of prior MI (14.5% in mrEF vs. 9.9% in preserved EF vs. 24.2% in low EF, p<0.001), history of diabetes (26.5% vs. 21.2% vs. 30.0%, p<0.001), presence of Killip 2–4 on admission (15.7% vs. 6.9% vs. 26.5%, p<0.001) and median age (61 vs. 59 vs. 64 years, p<0.001). At 30 days, mortality was comparable in mrEF vs. preserved EF group, while it was significantly higher in the low EF group (2.7% vs. 1.6% vs. 9.4%, respectively, p<0.001). At 5 years, mrEF patients had higher crude mortality rate as compared with preserved EF, but lower in comparison with low EF (25.1% vs. 17.0% vs. 48.7%, p<0.001) (Figure). After adjusting for the observed baseline differences mrEF was independently associated with increased mortality at 5 years (HR 1.283, 95% CI: 1.093–1.505, p=0.002), but not at 30 days (HR 1.444, 95% CI: 0.961–2.171, p<0.001).

Conclusion

Patients with mrEF after primary PCI for STEMI have a distinct baseline clinical risk profile, as compared with patients with reduced (<40%) and preserved (≥50%) EF. Importantly, mrEF did not have a significant impact on short-term mortality following STEMI, but it did independently predict the risk of 5-year mortality.

Funding Acknowledgement

Type of funding source: None

Prognostic impact of gender and young age in patients with acute myocardial infarction undergoing primary PCI

Background

Previous studies showed higher unadjusted mortality rates in female patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI). However, after adjusting for differences in baseline characteristics, including age, female gender was not consistently associated with higher mortality.

Purpose

Our aim was to investigate the impact of gender on short- and long-term mortality in patients aged 18 to 55 years with AMI undergoing primary PCI.

Methods

We included 11 288 patients admitted for primary PCI during 2009–2019, from a prospectively kept, electronic registry of a high-volume tertiary center. Adjusted Cox regression models were used to assess 30-day and 5-year mortality hazard. Median follow up was 1 507 days.

Results

3 505 patients were younger than 55 years (31%). In this age group, 18.9% were female patients (n=661). Baseline characteristics were similar for females vs. males below the age of 55 years, including similar reperfusion times (338 min. vs. 341 min., p=0.8), with only exceptions being a higher rate of previous hypertension (64% vs. 58%, p=0.002) and stroke (3.6% vs. 2.2%, p=0.049), as well as lower ejection fraction (48% vs. 51%, p<0.001), in female patients. MINOCA (Myocardial Infarction with Nonobstructive Coronary Arteries) was more frequently present in female vs. male patients aged ≤55 years (10.1% vs. 5.0%, p<0.001). In the overall population, crude mortality was higher in female patients at 30 days (9.8% vs. 6.0%, p<0.001) and 5 years (38.4% vs. 30.2%, p<0.001). In younger patients (≤55 years), mortality rates were low and similar between the sexes at both 30 days (3.6% in females vs. 2.5% in males, p=0.136) and 5 years (14.5% vs. 13.4%, p=0.58). On the contrary, in patients aged >55 years, crude mortality was higher in female patients at both 30 days (11.3% vs. 7.9%, p<0.001) and 5 years (43.9% vs. 39.4%, p=0.02), albeit mainly driven by the differences in baseline characteristics between the sexes in this older age group (adjusted HR for female sex 1.220, CI95% 0.920–0.617, p=0.17, at 30 days; and adjusted HR 1.033, CI95% 0.908–0.175, p=0.62, at 5 years).

Conclusion

Differences in crude mortality rates between sexes in patients with AMI admitted for primary PCI appear to be mainly dependent on age, with similar rates of both short- and long-term mortality in younger patients (≤55 years). The observed excess in mortality in older (>55 years) female vs. male patients could be explained by the differences in baseline clinical characteristics.

Funding Acknowledgement

Type of funding source: None

Prognostic impact of atrial fibrillation in patients undergoing primary PCI with versus without left ventricular function impairment

Background

Atrial fibrillation (AF) and impaired left ventricular (LV) function have both been separately associated with increased risk of mortality following primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI).

Purpose

Our aim was to comparatively evaluate the impact of LV dysfunction and AF on the risk of mortality in primary PCI-treated patients.

Methods

This analysis included 8561 patients admitted for primary PCI during 2009–2019, from a prospectively kept, electronic registry of a high-volume tertiary center, from whom echocardiographic parameters were available. LV dysfunction was defined as EF<40%. Adjusted Cox regression models were used to assess 30-day and 1-year mortality hazard.

Results

AF was present in 3.2% (n=273), whereas 37% had LV dysfunction (n=3189). Crude mortality rates were increased in the presence of either AF or LV dysfunction, and were the highest in the group of patients having both AF and impaired LV function, at 30 days (1.8% in no AF and no LV dysfunction vs. 5.4% if AF only vs. 7.0% if EF<40% only vs. 14.9% if AF and LV dysfunction concurrently present, p<0.001) and at 3 years (10.5% if no AF and no LV dysfunction vs. 35.8% if AF only vs. 28.5% if EF<40% only vs. 60.3% if AF and LV dysfunction both present, p<0.001). After multivariable adjustment for other significant mortality predictors, including age, previous stroke, MI, diabetes, hyperlipidemia, anemia and Killip≥2, LV dysfunction alone and in combination with AF was an independent predictor of mortality at both 30 days (HR=2.2 and HR=2.5, respectively, p<0.001 for both) and at 3 years (HR=1.9 and HR=2.9, respectively, p<0.001 for both). However, presence of AF alone, in the absence of an impaired LV function, was not independently associated with mortality at 30 days (HR 1.34, CI 95% 0.58–3.1, p=0.48), but rather at 3 years (HR 1.74, CI 95% 1.91–2.54, p=0.004).

Conclusion

Atrial fibrillation is associated with long-term mortality in STEMI patients undergoing primary PCI, irrespective of the LV function. Conversely, short-term prognostic relevance of atrial fibrillation in STEMI is dependent on the presence of LV dysfunction.

Kaplan Meier curve_AF_LV dysfunction

Funding Acknowledgement

Type of funding source: None

Comparison of contrast induced nephropathy definitions and in-hospital mortality in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction

Background

Contrast induced nephropathy (CIN) has been associated with increased mortality in patients with acute myocardial infarction (AMI). However, different definitions of CIN have so far been used.

Purpose

We aimed to compare predictive accuracy of the 2 contemporary CIN definitions in patients with AMI undergoing primary percutaneous coronary intervention (PCI).

Method

From a high-volume, single-centre, prospective registry, in a period from 2009–2019, we identified 7987 pts who underwent primary PCI for AMI in whom creatinine measurements were available for analysis. CIN incidence was evaluated according to relative creatinine increases of ≥25% (CIN25) and ≥50% (CIN50) from baseline levels within 72 hours after intervention. The primary end point was in-hospital mortality.

Results

Overall, 1116 (13.9%), and 345 (4.3%) patients developed CIN25, CIN50, respectively. Crude in-hospital mortality rate was 3.9% (312 pts) in the overall population. Both definitions were independently associated with in-hospital mortality (CIN25 adjusted odds ratio (OR) 4.2, 95% CI 2.7–6.6; p<0.001, and CIN 50 adjusted OR 8.2, 95% CI 4.9–13.9; p<0.001). Comparison of ROC curves showed that only the addition of the CIN50 (and not CIN25) definition to the combined model of clinical predictors of in-hospital mortality, which included pre-intervention TIMI flow 0–1, cardiogenic shock on admission, baseline creatinine clearance, prior stroke, chronic occlusion of non-culprit artery, post-intervention TIMI flow 3, left ventricular ejection fraction and procedure time, improved prognostic accuracy of the model (Figure 1).

Conclusion

Only acute kidney injury according to the CIN50 definition, but not the CIN25 definition, offers additional prognostic information above and beyond the combination of baseline predictors of in-hospital mortality in patients with AMI undergoing primary PCI.

Figure 1

Funding Acknowledgement

Type of funding source: None

Impact of a CTO in a non-infarct-related artery on long-term mortality in patients undergoing primary PCI

Background

Previous studies showed increased mortality rates in patients with ST-elevation myocardial infarction (STEMI) and a chronic total occlusion (CTO) in a non-infarct-related artery, but long-term data are scarce.

Purpose

Our aim was to assess all-cause mortality during 5 years follow-up in patients with a remaining nonculprit CTO after being treated with primary PCI.

Methods

The study included 9504 patients admitted for primary PCI during 2009–2019, with available baseline angiography, from an electronic, prospective registry of a high-volume catheterization laboratory. Kaplan Meier cumulative mortality curves for non-culprit CTO vs. no CTO were compared with the log-rank test, with landmarks set at 30 days and then annually up to 5 years follow-up. Adjusted Cox regression models were constructed to assess 30-day and 5-year mortality risk of a non-culprit CTO. Median follow-up was 1507 days.

Results

Nonculprit CTO was present in 13.2% of patients (n=1253). Presence of a nonculprit CTO was associated with older age (64 vs. 61, p<0.001), more frequent history of cardiovascular disease including prior MI (33% vs. 14%, p<0.001), stroke (10.3% vs. 5.9%, p<0.001) and CABG (10.5% vs. 1.5%, p<0.001), higher rates of renal failure (10.7% vs. 4.8%, p<0.001), as well as more often Killip class 2–4 on admission (29% vs. 16%, p<0.001) and a lower ejection fraction (40% vs. 47%, p<0.001). Crude mortality rates were significantly increased in patients with a nonculprit CTO vs. no CTO, at both 30 days (15.7% vs. 5.6%, p<0.001) and 5 years (54.6% vs. 27.9%, p<0.001). After adjusting for the observed baseline differences, nonculprit CTO was still associated with an elevated mortality risk at both 30-days (HR 1.5, CI95% 1.1–1.9, p=0.007) and 5 years (HR 1.6, CI95% 1.4–1.9, p<0.001). Landmark analyses showed continuously increasing risk of mortality in the presence of a nonculprit CTO, as compared with primary PCI-treated patients with no CTO (30 days to 1 year 11.4% vs. 4.9%, p<0.001; 1st to 2nd year of follow-up 6.3% vs. 3.4%, p<0.001; 2nd to 3rd year 6.2% vs. 2.8%, p<0.001; 3rd to 4th year 7.4% vs. 3.0%, p<0.001; and 4th to 5th year 5.2% vs. 3.6%, p=0.1).

Conclusions

Presence of a nonculprit CTO is independently associated with 5-year mortality after primary PCI. Importantly, the mortality risk increases continuously with an average annual absolute difference of 3%, in patients with a nonculprit CTO vs. those with no CTO.

Nonculprit CTO vs. no CTO

Funding Acknowledgement

Type of funding source: None

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 >0.80 (62.9% vs. 12.7%, HR 7.20, 95% CI 4.46–11.62, p<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<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

Comparison of the FASTEST and the ZWOLLE risk scores for identification of very low-risk patients for all-cause mortality and MACE following primary PCI

Background

Prior studies suggest that low-risk ST-segment-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI) can be considered for early discharge in order to reduce healthcare costs and improve resource utilization. Novel, simple, the FASTEST score, demonstrated additional prognostic value over guideline recommended ZWOLLE score in a derivation cohort, but robust data about external validation are lacking.

Purpose

We aimed to compare overall predictive ability and discriminating power in identification of low-risk patients of novel FASTEST score compared to validated ZWOLLE score.

Methods

From a high-volume, single-center, prospective registry, in a period from 2009–2019, we included STEMI patients who underwent successful pPCI in whom both, FASTEST (1 point added for: femoral access, age>65, LVEF <50, TIMI <3, creatinine >1.5 mg/dl; left main disease; and Killip≥2) and ZWOLLE (age, anterior infarct, Killip class, TIMI flow, ischemia time, 3 vessel disease) scores were both calculated. Predictive ability of scores for in-hospital, 30 days and 1 year mortality and hospital MACE was tested using ROC analysis and comparing AUC. Also, event rate was compared between low-risk patients as classified by FASTEST (score=0) or ZWOLLE (score≤3).

Results

We included 5650 patients (age 60.8±11.4, male (71%), anterior STEMI (44%) and femoral approach (81%)). Overall, mortality rates were 2.1%, 3.1% and 8.1% for hospital, 30 days and one-year. As Low-risk subjects, ZWOLLE identified broader proportion of population compared to FASTEST (67% vs. 5.5%) mainly due to high prevalence of femoral approach (FASTEST low-risk 30% in radial approach subset), still, later had numerically lower mortality rates at hospital (0.7% vs. 0.3% (only 1 pt); p=0.62), 30 days (1.3% vs. 0.7%; p=0.39) and at one-year (4% vs. 2%; p=0.14). Both scores showed similar and very good predictive ability for in-hospital (AUC 0.81 vs. 0.81; p=0.66) and 30 days mortality (AUC 0.79 vs. 0.77; p=0.29), while at one-year, discrimination of crude mortality by FASTEST trended, but didn't reach statistical significance compared to ZWOLLE score, respectively (AUC 0.77 vs. 0.75; p=0.07). FASTEST showed better prediction for composite endpoint of in-hospital MACE - death, stroke, reinfarction and bleeding BARC class 3 or higher (AUC 0.71 vs. 0.67; p<0.000) (Figure 1).

Conclusion

Both the FASTEST and the ZWOLLE scores showed very good discriminating power for in-hospital, 30 day mortality and one-year mortality, yet the FASTEST score offered comparative advantage for prediction of in-hospital MACE and could be used to identify selected patients where an early hospital discharge can be considered.

ZWOLLE vs FASTEST ROC analisys

Funding Acknowledgement

Type of funding source: None

P278 Does recanalization of chronic total occlusion reflect on myocardial function?

Background

Percutaneous coronary intervention for chronic total occlusion (PCI CTO) is still high risk procedure and it is doubtful will it become standard of care. There is evidence that it can reduce angina but even silent ischemia represent ischemic burden that ultimately lead to left ventricle remodeling and electrical instability.

Purpose

Our aim was to access effectiveness of percutaneous coronary intervention (PCI) when added to optimal medical therapy (OMT) on myocardial function.

Methods

We compared two groups of pts. First patients with percutaneous coronary intervention of chronic total occlusion with optimal medical therapy and second group - patients with only optimal medical therapy (control group). Echocardiographic exam was performed before randomization and after 6 months of follow-up. Doppler intervals- isovolumetric relaxation time (IVRT), isovolumetric contraction time (IVCT) and ejection time (ET) were measured. MPI (Myocardial performance index) is equal to the sum of the IVRT and IVCT divided by the ET. Velocity of early mitral wave (E) was divided by average peak early diastolic annular velocity (e"). Peak longitudinal strain was assessed in 17 left ventricular segments. Time intervals from start Q/R on electrocardiogram to peak negative strain during the cardiac cycle were assessed. Mechanical dispersion was defined as the standard deviation of this time intervals from 17 segments, reflecting myocardial contraction heterogeneity.

Results

A total of 94 age matched CTO patients (48 in PCI + OMT group and 46 in OMT) were analyzed. Changes in ejection fraction (EF), diastolic function represented by E/e", global cardiac function represented by MPI, global longitudinal strain (GLS) and myocardial dispersion changes were compared between groups. At follow up between groups in there was no significant change in ejection fraction (EF), diastolic function, GLS and mechanical dispersion, but there was improvement in MPI.

Conclusion

Myocardial performance index is sensitive marker which can detect subtle improvement in global myocardial function after recanalization of chronic total occlusion..

Variable PCI + OMT (n = 46) OMT (n = 48) ΔOMT vs. ΔPCI + OMT p value baseline At 6month follow up P value baseline At 6month follow up P value EF (%) 55.69 ± 8.56 54.83 ± 8.44 0.10 50.22 ± 11.71 51.42 ± 10.45 0.06 0.71 MPI 0.676 ± 0.99 0.632 ± 0.96 <0.01* 0.593 ± 0.14 0.604 ± 0.12 0.22 <0.01* E/e" 13.10 ± 6.90 12.05 ± 5,08 <0.05* 14,12 ± 5.70 13.02 ± 5.62 <0.05* 0.23 GLS (%) -14,38 ± 3,38 -15,22 ± 3,68 <0.05* -13.33 ± 3.43 -13.29 ± 3.42 0.87 0.07 Mechanical dispersion (ms) 63.89 ± 26.22 57.35 ± 27.33 <0.01* 53.30 ± 21.68 50.00 ± 22.40 0.05 0.06 Δ- percentage changes between baseline and at 6 month follow up

P284 Patients with reduced systolic function benefit most from recanalisation of chronic total occlusion

Background

Percutaneous coronary intervention of chronic total coronary occlusion (PCI of CTO) is proved to reduce symptoms of angina and long term survival.

Purpose

This study aimed to assess systolic and diastolic left ventricular function with standard echocardiographic indices.

Methods

We analyzed total of 46 CTO patients (age 58 ± 9, 73% male). Measures were obtained with the transducer in the apical four-chamber view. Doppler time intervals were measured from mitral inflow and left ventricular outflow Doppler tracings by pulsed wave Doppler. The isovolumetric relaxation time (IVRT) was measured from closure of the aortic valve to opening of the mitral valve. The isovolumetric contraction time (IVCT) was measured from closure of the mitral valve to opening of the aortic valve. Ejection time (ET) was measured from the opening to the closure of the aortic valve on the LV outflow velocity profile. Myocardial performance index (MPI) is simple method for evaluation of overall cardiac function and is independent of heart rate and blood pressure. MPI was equal to the sum of the IVRT and IVCT divided by the ET. Velocity of early mitral filling wave (E) was measured and divided by average peak early diastolic annular velocity (e") which was measured as average value between septal and lateral side of the mitral annulus using Doppler tissue imaging. The E/e’ ratio was calculated to estimate the LV filling pressures

Results

Six months after PCI of CTO patients showed no change in ejection fraction (EF) (55.69 ± 8.56% vs. 54.83 ± 8.44%, p = 0.10). MPI was significantly decreased (0.676 ± 0.99 vs. 0.632 ± 0.96 p < 0.01), E/e" was significantly reduced, (13,10 ± 6.90 vs. 12.05 ± 5.1 p < 0.05), and when we analyzed only patients with baseline EF < 50% (n = 9) improvement of diastolic function (reduction of E/e") was even greater (22.53 ± 5.52 vs. 15.65 ± 4.8 p < 0.01).

Conclusion

PCI of CTO improves overall cardiac function, particularly diastolic function in patients with reduced ejection fraction.

P1508The Coronary Arteriogenesis with combined Heparin and Exercise therapy in chronic refractory Angina (CARHEXA) trial: a double-blind randomized placebo-controlled stress echocardiographic study

Background

Coronary collateral circulation exerts protective effects on myocardial ischemia due to coronary artery disease (CAD) and can be promoted by exercise (E) with heparin (H) co-administration. Whether this arteriogenetic effects is accompanied by functional improvement of left ventricle (LV) during stress remains unknown.

Purpose

To establish the stress-induced functional effects on LV regional and global function of 2-week cycle of H+E in patients with “no-option” CAD.

Methods

In a prospective, single-center, double-blind, randomized, parallel-group study we recruited 32 “no-option” patients (27 males; mean age of 61±8 years), with stable angina and CTO, refractory to OMT, not suitable for revascularization and with E-induced ischemia. All underwent 2-week cycle of E (2 E test per day, 5 days a week) and were pre-treated with i.v. 0.9% saline or unfractionated H (100 IU/kg up to maximum of 5.000IU, 10 min prior to E). Canadian Class Score (CCS) and 12-lead E-ECG for time-to-1 mm ST-segment depression were assessed at entry and after treatment. LV function was evaluated during treadmill exercise with conventional and advanced imaging indices: Wall Motion Score Index (WMSI); Ejection Fraction (EF); Force (systolic blood pressure/end-systolic volume); Global Longitudinal Strain (GLS).

Results

Post-treatment exercise-time and CCS improved in both groups. In H+E patients exercise-time improved from 369.8±107.8 sec to 475.3±114.6 sec (p=0.001) while in E patients improved from 384±152.7 sec to 464.8±134.1 sec (p=0.019). CCS score changed in H+E from 2.6±0.7 to 1.9±0.7 (p=0.000), and in E group from 2.4±0.7 to 2.1±0.9 (p=0.046). At peak exercise, H+E was different from E group for EF and GLS (see Table).

Effects of H+E on SE parameters H+E p P+E p *H+E vs P+E STRESS Time 0 vs Time 1 Time 0 vs Time 1 Time 0 Time 1 WMSI 1.377 vs 1.279 0.005 1.404 vs 1.376 0.290 0.626 0.255 EF (%) 60.9 vs 64.8 0.016 61.2 vs 57.8 0.284 0.943 0.016 Force (mmHg/mL) 6.36 vs 6.5 0.158 5.82 vs 4.68 0.209 0.760 0.098 GLS (%) −16.96 vs −18.50 0.001 −15.79 vs −15.60 0.380 0.325 0.027 SE = stress echocardiography; H+E = heparin+exercise; P+E = placebo+exercise; Time 0 = before randomization; Time 1 = after 2-week therapy cycle. *p values.

Conclusion

A 2-week, H+E cycle is associated with improvement in regional and global LV function during exercise, concordantly shown by conventional (WMSI, EF) and advanced (GLS) echocardiographic indices of LV function. This integrates and supplements the classical objective index based on ST-segment depression, unable to localize and quantify the functional consequences of therapy on myocardial ischemia.

P2710Anti-ischemic effect of 2-week cycle of heparin plus exercise-to-ischemia twice daily in patients with “no-option” angina: the CARHEXA trial

Background

Coronary collateral circulation (CCC) exerts protective effects on myocardial ischemia due to coronary artery disease (CAD), but the anti-ischemic, pro-CCC effects of exercise (E) with or without heparin (H) co-administration remain unclear.

Purpose

To establish the anti-ischemic functional efficacy of 2-week cycle of E-to-ischemia twice daily, with or without unfractionated i.v. H immediately before E, in patients with “no-option” CAD

Methods

In a prospective, single-center, parallel group study design we recruited 32 “no-option” patients (27 males; mean age of 61±8 years) with at least one chronically occluded coronary artery and stable angina, refractory to optimal medical management, not suitable for revascularization therapy and with E-induced ischemia. All underwent a 2-week cycle of E (2 E test per day, 5 days a week, for 2 weeks) and were randomized, with a double-blind design, to i.v. placebo (0.9% saline) versus unfractionated H (100 IU/kg up to a maximum of 5.000 IU iv, 10 min prior to E). Seattle stable angina questionnaire (SAQ), 12-lead E-ECG for time-to-ischemia (treadmill exercise testing), and MDCT angiography for CCC imaging (Rentrop score, from 0= absent to 3= full opacification of occluded vessel) were assessed at entry and re-assessed after treatment for symptomatic, ECG, and anatomic end-points respectively.

Results

In H+E group (n=16), time to 1 mm ST segment depression (ST-D) increased, and CCC improved, p<0.05. On the contrary, no difference was observed in E group (n=16) in the pre-specified end-points (p>0.05) (see table). Clinically important change of more 10 points in SAQ was observed regarding physical limitation, angina stability and disease perception in H+E patients, and in only angina frequency in E group.

The ECG and angiographic results Heparin + Exercise Placebo + Exercise Rentrop baseline 0.73±0.88 1.06±1.06 Rentrop 2-week 1.6±0.99* 1.19±1.05 Time to ST-D base (s) 269±64 273±176 Time to ST-D 2-week (s) 328±65* 306±151 *p<0.05.

Conclusion

A 2-week, 10 E test cycles are well tolerated and effective particularly with H in ameliorating symptoms, E-induced ischemia and CCC in “no-option” CAD patients with refractory angina.

P4619Comparison of the CRUSADE, ACUITY-HORIZONS, and ACTION bleeding risk scores for predicting in-hospital bleeding in acute myocardial infarction patients undergoing primary PCI

Background

Considering clinical importance of bleeding complications in patients with acute myocardial infarction (AMI), bleeding risk stratification is a key part of the management of these patients. CRUSADE, ACTION and ACUITY-HORIZONS bleeding risk scores are available for predicting in-hospital major bleeding events in patients with acute myocardial infarction.

Purpose

We aimed to evaluate performance of the three above mentioned risk scores for predicting in-hospital bleeding events defined according to The Bleeding Academic Research Consortium (BARC) criteria.

Methods

From a prospective electronic registry of a high-volume catheterization laboratory in a period from January 2009 to December 2017, a total of 6505 consecutive patients with acute myocardial infarction who underwent pPCI were included in analysis. Calibration and discrimination of the three risk models were evaluated by the Hosmer-Lemeshow (H-L) goodness-of-fit test and C-statistic, respectively.

Results

Overall there were 372 (5.7%) bleeding events out of which 117 (1.8%) fulfilled stage BARC 3 or higher bleeding criteria. All three scores showed good model calibration as assessed by the H-Ls test and very good discriminative power for BARC 3 of higher bleeding events detection as assessed by C-statistics (Table 1 & Figure 1):

Bleeding events stage BARC 3 or higher were statistically highly related with higher in-hospital mortality (13.7% vs. 3.5%; p<0.000).

Table 1 Risk score H-L H-L p AUC 95% CI p CRUSADE 11.46 0.177 0.761 0.750–0.771 vs. ACUITY = ns vs. ACTION <0.000 ACUITY-HORIZONS 10.47 0.236 0735 0.724–0.745 vs. ACTION = ns ACTION 5.74 0.677 0.701 0.698–0.712

Figure 1

Conclusions

All three evaluated scores showed very good discriminative capacity for predicting BARC 3 or higher bleeding events in patients undergoing pPCI for AMI.

P5481Predictors of mortality in patients with non-anterior ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

Background

Previous studies have indicated that patients with non-anterior ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) have a more favorable prognosis compared with anterior STEMI, especially in the short term.

Purpose

Our aim was to identify predictors of increased 30-day mortality in patients with non-anterior STEMI undergoing primary PCI.

Methods

This analysis included 8188 patients referred to primary PCI during 2009–2017, from a prospective electronic registry of a high-volume catheterization laboratory, for whom 30-day follow-up was available. Non-anterior infarction was defined as presence of ST-segment elevation in inferior and/or lateral ECG leads or true posterior MI. Multivariable Cox regression was used to assess the mortality risk at 30 days.

Results

59.4% (n=4863) of the included patients presented with a non-anterior STEMI. Mortality rate was significantly lower in patients with non-anterior vs. anterior STEMI (4.2% vs. 8.3%, p<0.001). Older age (> median of 61, HR 2.2, p=0.002), baseline renal failure (eGFR <60, HR 4.0, p<0.001), Killip class ≥2 (HR 3.8, p<0.001), previous stroke (HR 1.8, p=0.004), non-culprit chronic total occlusion (CTO, HR 2.0, p<0.001) and final TIMI flow grade <3 in the infarct-related artery (HR 3.1, p<0.001) were independently associated with an increased risk of 30-day mortality in non-anterior STEMI. The presence of at least one of these high-risk factors was noted in 61.2% of patients with non-anterior STEMI and was associated with a significantly higher risk of 30-day mortality (HR 18.2, p<0.001), similarly to the overall risk associated with anterior STEMI (HR 22.9, p<0.001), as compared with patients with non-anterior STEMI but without any of the here identified high-risk factors (Figure).

Figure 1

Conclusions

Crude mortality rate was significantly lower in patients with non-anterior vs. anterior STEMI. However, the majority of non-anterior STEMI patients had at least one of the high-risk factors (older age, previous CVI, baseline renal failure, Killip class ≥2, non-culprit CTO or final TIMI flow <3), which predisposed these patients to a similar increase in short-term mortality risk as in patients with anterior STEMI.

P950Synergistic impact of renal failure and left ventricular dysfunction on short- and long-term mortality in patients with STEMI undergoing primary PCI

Background

Impaired left ventricular function (LV) and renal failure (RF) have both been separately associated with increased risk of mortality in ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

Purpose

Our aim was to comparatively evaluate the relative impact of LV dysfunction and renal failure (RF) on the risk of mortality in primary PCI-treated STEMI patients.

Methods

5878 patients admitted for primary PCI during 2009–2015, from a prospectively kept, electronic registry of a high-volume catheterization laboratory, were included in the analysis. LV dysfunction was defined as EF<40%, and RF as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 according to Cockcroft-Gault formula. Adjusted Cox regression models were used to assess 30-day and 3-year mortality hazard, with patients with EF≥40% and normal renal function serving as the reference group.

Results

RF was documented in 17.1% (n=1006), whereas 36.5% had LV dysfunction (n=2141). LV dysfunction and RF were separately associated with increased crude mortality rates, whereas the concurrence of both resulted in the highest mortality rate at 30 days (0.7% if no RF and normal EF vs. 5.4% if RF alone vs. 3.9% if EF<40% alone vs. 12.6% if both RF and EF<40%; p<0.001), and at 3 years (5.7% if no RF and normal EF vs. 29.0% if RF alone vs. 19.0% if EF<40% alone vs. 47.4% if both RF and EF<40%; p<0.001). After multivariable adjustment for other significant mortality predictors, such as age, previous stroke, diabetes, hyperlipidemia, anemia and Killip≥2, RF and LV dysfunction were associated with a comparable increase in mortality risk at 30 days (HR=4.1 and HR=3.7, respectively, p<0.001 for both) and at 3 years (HR=2.8 and HR=2.7, respectively, p<0.001 for both). Importantly, the combined presence of RF and low EF was independently associated with a marked increase in both 30- day (HR=6.5, 95% CI 3.7–11.4, p<0.001), and 3-year mortality (HR=4.3, 95% CI 3.3–5.6, p<0.001).

Kaplan Meier cumulative mortality curves

Conclusion

Apart from each being independently associated with an increased risk of mortality, the concurrence of renal failure and LV dysfunction had a synergistic negative impact on the prognosis of primary PCI-treated STEMI patients

P953Comparison of the original and updated ACTION risk scores for predicting in-hospital and one-year mortality in patients with acute myocardial infarction undergoing primary PCI

Background

The Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry-Get With The Guidelines (GWTG) AMI mortality model and risk score (ACTION) were introduced in 2011 to predict in-hospital mortality. In 2016 score was updated to enable a more accurate assessment, but, up-to-date, external validation in direct comparison was not performed.

Purpose

We aimed to externally validate and compare the prognostic value of original and updated ACTION score for in-hospital and one-year mortality.

Method

From a prospective electronic registry of a high-volume catheterization laboratory in a period from January 2009 to December 2017, a total of 5615 consecutive patients who underwent pPCI were available for analysis. For each patient, original (O-) and updated (U-) ACTION scores were calculated using required clinical and angiographic characteristics. In-hospital and one-year mortality (follow-up available for 91%) were assessed. Calibration and discrimination of the three risk models were evaluated by the Hosmer-Lemeshow (H-L) goodness-of-fit test and C-statistic, respectively.

Results

Mortality rates for in-hospital and one-year mortality were 4.2% and 9.6%, respectively. Both scores showed good model calibration as assessed by the H-L test and very good discriminative power for in-hospital and one-year mortality as assessed by C-statistics (Table 1 & Figure 1).

Net reclassification index (NRI=1.06) showed that 48% of patients with in-hospital event and 58% without event, had their risk recalculated with U-ACTION with Integrated Discrimination Improvement slope 9.1% higher than in first model.

Table 1 Risk score H-L H-L p value AUC 95% CI p value AUC 95% CI Significant p value O-ACTION 9.4 0.3 0.829 0.819 to 0.839 p<0.0001 0.781 0.769 to 0.792 p<0.0001 U-ACTION 10.9 0.2 0.918 0.911 to 0.925 0.838 0.827 to 0.848

Figure 1

Conclusion

Updated ACTION score enables better prediction of in-hospital and one-year mortality in patients undergoing pPCI for acute myocardial infarction, thus it can be used preferentially over the original ACTION score for assessment of short and long-term mortality risks of this population.

P5011Impact of guideline-recommended medical therapy at discharge on long-term mortality in patients with or without left ventricular dysfunction after primary PCI for STEMI

Background

Clinical practice guidelines provide class I recommendation for the use of angiotensin-converting enzyme inhibitors (ACE-I) and beta-blockers in patients with prior myocardial infarction and left ventricular (LV) dysfunction, whereas their use in patients without LV dysfunction is considered to be a class IIa recommendation.

Purpose

Our aim was to comparatively assess the impact of ACE-I and/or beta-blockers on 3-year mortality in patients with or without impaired left ventricular (LV) function undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).

Methods

The analysis included 4425 patients admitted for primary PCI during 2009–2015 from a prospective, electronic registry of a high-volume tertiary center, who survived initial hospitalization, and for whom information on LV function and discharge medication were available. Patients were stratified according to LV systolic dysfunction, defined as LVEF <40%. Unadjusted and adjusted Cox regression models were created to investigate the impact of beta-blocker and/or ACE-I therapy on 3-year mortality.

Results

22.9% (n=1013) had LV dysfunction, 23.0% (n=1017) received either an ACE-I or a beta-blocker and 72.2% received both medications at discharge (n=3197). The concurrent use of both ACE-I and beta-blockers was not different in LVEF≥40% vs. LVEF<40% (72.4% vs. 71.7%, p=0.43). The use of at least one of the guideline-recommended medications was associated with a significantly lower 3-year mortality in both patients with LVEF≥40% (18.7% if neither was used, 11.2% if either a beta-blocker or an ACE-I were used and 9.4% if both were used, p=0.001), and LVEF<40% (55.4% if neither was used, 32.5% if either a beta-blocker or an ACE-I were used and 22.9% if both were used, p<0.001) (Figure). After adjusting for significant mortality predictors including older age, diabetes, hypertension, renal failure, previous stroke, Killip class ≥2 and non-culprit chronic total occlusion (CTO), the concurrent use of both a beta-blocker and an ACE-I remained independently associated with lower 3-year mortality in both patients with LVEF<40% (HR 0.30, p<0.001) and LVEF≥40% (HR=0.41, p=0.001). The use of a single agent was independently associated with lower mortality in patients with LVEF<40% (HR 0.45, p=0.002), but not in patients with LVEF≥40% (HR 0.61, p=0.07).

Conclusions

Guideline-recommended use of both a beta-blocker and an ACE-I in post-MI patients was associated with a lower 3-year mortality regardless of the LV function, whereas using only one of the two agents was associated with improved prognosis only in patients with LV dysfunction, but not in patients without LV impairment.

P849Comparison of long-term mortality risk assessed with recalculated (maximal) CADILLAC score vs. baseline (admission) CADILLAC score in STEMI patients undergoing primary PCI

Background

Since patients with STEMI have high rate of adverse events not only during hospital stay, but also during short and long-term follow–up, appropriate risk stratification is a key part of the management of these patients following hospital discharge. CADILLAC score was derived and subsequently validated as accurate clinical tool for identifying patients with heightened risk following index event.

Purpose

We aimed to compare predictive value of recalculated, maximal, (M-) CADILLAC score vs. baseline (B-) CADILLAC score for long-term mortality in hospital survivors.

Methods

From a prospective electronic registry of a high-volume catheterization laboratory in a period from January 2009 to December 2017, a total of 5387 consecutive patients STEMI who underwent primary PCI were included in analysis. For each patient B-CADILLAC score was calculated, and for survivors, we recalculated M-CADILLAC score, incorporating changes in three variable score individual contributors (worsening of Killip class, anemia development and renal function deterioration). As in original score derivation, patients with cardiogenic shock were excluded from analysis. Discrimination of the two risk models was evaluated by the C-statistic, Net reclassification index (NRI) and Integrated Discrimination Improvement (IDI) index.

Results

For 111 (2.1%) patients that died in-hospital, B-CADILLAC very well predicted the event (AUC 0.87, 95% CI 0.86–0.88; p<0.0001) (Figure 1A). For hospital survivors, both evaluated scores showed good discriminative ability for long-term mortality (11.7%) but recalculated M-CADILLAC score was statistically better predictor of long-term mortality, as assessed by C-statistics (Table 1 & Figure 1B):

NRI showed that 38% of patients were reclassified with M-CADILLAC with IDI slope 0.8% higher than in first model.

Table 1 4723 pts (follow-up=90% pts, 41±27 months) AUC 95% CI p B-CADILLAC 0.756 0.744–0.768 p=0.018 M-CADILLAC 0.776 0.754–0.779

Figure 1

Conclusions

Baseline CADILLAC score has very good predictive ability for in-hospital mortality, but recalculated, maximal CADILLAC score offers discriminative advantage in hospital survivors for prediction of long-term mortality in STEMI patients undergoing primary PCI.

P3125Five-year impact of immediate invasive strategy on clinical outcomes in patients with non-ST-segment elevation myocardial infarction: RIDDLE-NSTEMI study

Background

Most of the previous studies evaluated the impact of early versus delayed invasive intervention on clinical outcomes in patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) in one-year period.

Purpose

The aim of this study was to assess whether the immediate invasive intervention influences the occurrence of death and new myocardial infarction (MI), specifically in patients with non-ST segment MI (NSTEMI) in long-term follow-up.

Methods

In The Randomized Study of Immediate Versus Delayed Invasive Intervention in Patients With Non ST-segment Elevation Myocardial Infarction (RIDDLE-NSTEMI) 323 patients with NSTEMI were randomized to either immediate (median time to intervention was 1.4 hours) or delayed invasive strategy (61.0 hours). The incidence of primary outcome -death or new MI at 30 days was lower in patients assigned to the immediate (n=162) than in patients assigned to the delayed (n=161) invasive intervention group (4.3% vs. 13%, respectively; p=0.008). Long-term follow-up of 5 years was available for 96.90% of the patients.

Results

At 5 years, the immediate invasive intervention was associated with lower rate of death or new MI, compared with delayed invasive strategy (15.8% vs 32.9%, respectively; p=0.00). The observed benefit of the immediate intervention was mainly due to an increased early reinfarction risk with the delayed strategy (2.5% vs 9.9%, p=0.001) with similar new MI rates beyond 30 days (5.9% in the immediate and 10.7% in the delayed group, p=0.130). Five-year mortality was 12.0% in the immediate invasive intervention strategy group, and 18.1% in the delayed strategy group (p=0.135).

Conclusion

Immediate invasive intervention in the patients with NSTEMI significantly reduces the early risk of new MI. However, the timing of invasive intervention appears not to have significant impact on the clinical outcome beyond 30 days.

P845Comparison of the performance of the five validated risk scores in acute myocardial infarction patients undergoing primary PCI

Background

Several risk scores have been developed to predict mortality of patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (pPCI), with limited data on the comparative prognostic value of these models.

Purpose

We aimed to compare the prognostic value of five validated risk scores for in-hospital and one-year mortality of patients with AMI undergoing pPCI.

ume catheterization laboratory in a period from January 2009 to December 2017, a total of 3868 consecutive patients who underwent pPCI were available for analysis. For each patient, the Thrombolysis In Myocardial Infarction (TIMI), Controlled Abciximab and Device Investigation to Lower Late Angioplasty complications (CADILLAC), ACTION Registry-GWTG in-hospital mortality risk score (ACTION), Age, Creatinine, and Ejection Fraction (ACEF), and ZWOLLE risk scores were calculated using required clinical and angiographic characteristics. In-hospital and one-year mortality were assessed (follow-up available for 92% of pts). Calibration and discrimination of the three risk models were evaluated by the Hosmer-Lemeshow (H-L) goodness-of-fit test and C-statistic, respectively.

Results

Mortality rates for in-hospital and one-year mortality were 1.8% and 6.9% respectively. All five scores showed good model calibration as assessed by the H-L test and very good discriminative power for in-hospital and one-year mortality as assessed by C-statistics (Table 1 & Figure 1):

Table 1 Risk score H-L H-L p AUC in-hospital 95% CI Significant p AUC one-year 95% CI Significant p ZWOLLE 1.3 0.7 0.90 0.89–0.91 vs. CADILLAC <0.05 0.75 0.74–0.77 vs. TIMI <0.005 ACTION 13.1 0.1 0.87 0.86–0.88 vs. TIMI <0.005 0.79 0.77–0.80 CADILLAC 5.5 0.2 0.85 0.84–0.86 vs. TIMI <0.01 0.81 0.80–0.83 vs. ZWOLLE <0.000 vs. TIMI <0.000 ACEF 9.9 0.3 0.814 0.83–0.85 0.80 0.78–0.81 vs. ZWOLLE <0.000 vs. TIMI <0.05 TIMI 7.1 0.3 0.79 0.78–0.80 0.76 0.75–0.78

Figure 1

Conclusion

Risk stratification of patients with AMI undergoing pPCI using the ZWOLLE, ACTION, CADILLAC, ACEF or TIMI risk scores enables accurate identification of high-risk patients for in-hospital and one-year mortality in an all-comers population. Among evaluated scores, ZWOLLE model was better fitted for prediction of in-hospital mortality while CADILLAC and ACEF better predicted late events.