Safety and effectiveness of glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: insights from the SPUM-ACS study

AIMS

Data on Glycoprotein IIb/IIIa inhibitors (GPI) use in real world ACS patients following the introduction of potent P2Y12 inhibitors and newer generation stents are scant. Here, we aimed to assess the utilization, effectiveness, and safety of GPI in a large prospective multi-centre cohort of contemporary ACS patients.

METHODS AND RESULTS

SPUM-ACS prospectively recruited patients presenting with ACS between 2009 and 2017. The primary endpoint of the present study was major adverse cardiovascular events (MACE), a composite of all-cause death, non-fatal myocardial infarction (MI) and non-fatal stroke at one year. Secondary endpoints were defined as any bleeding events, BARC 3-5 bleeding, and net adverse cardiovascular events (NACE). A total of 4395 ACS patients were included in the analysis. GPI-treated patients had more total coronary artery occlusion (56% vs 35%, p<0.001) and thrombus (60% vs 35%, p<0.001) at angiography. Among the propensity score matched (PSM) population (1992 patients equally split into two groups), GPI-treated patients showed lower risk of MACE (PSM adjusted HR 0.70, 95% CI 0.49-0.99), but a higher risk of any (PSM adj HR 1.46, 95% CI 1.06-1.99) and major bleedings (PSM adj HR 1.73, 95% CI 1.09-2.76), resulting in a neutral effect on NACE (PSM adj HR 0.87, 95% CI 0.65-1.17). These results remained consistent across all subgroups.

CONCLUSION

In patients with ACS undergoing PCI and receiving potent P2Y12 inhibitors, we observed a reduced risk of MACE and an increased risk of major bleedings at 1 year in patients treated with GPI. Although the routine use of GPI is currently not recommended, they might be considered in selected patients following a personalized balancing between ischaemic and bleeding risks.

Prognosis Impact and Prediction of Trans-Radial Access Failure in Patients With STEMI, A Nationwide Observational Study

Trans-radial access (TRA) is the primary arterial approach for percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI). However, occasionally, a crossover to trans-femoral access is necessary because of unsuccessful TRA. The impact of failed TRA on the prognosis in STEMI patients and the utility of predictive models for TRA failure remains uncertain. Data from the Hungarian Myocardial Infarction Registry (January 2014 to December 2020) were analyzed. Primary endpoints were 1-year mortality and major adverse cardiovascular events. Propensity score matching was employed to create a balanced cohort for comparing successful and failed TRA. The impact of unsuccessful TRA on prognosis was evaluated using Cox regression analysis. Machine learning techniques were applied to predict TRA failure. The performance and the clinical applicability of the novel and previous prediction models were comprehensively evaluated. Of 76,625 registered patients, 34,293 (69.8 ± 13.4 years, male/female: 21,893/12,400) underwent TRA (33,573) or failed TRA (720) PCI for STEMI. After propensity score matching, in the unsuccessful TRA group, the risk of mortality (34.3% vs 22.5%, hazard ratio 1.6, 95% confidence interval 1.3 to 2.0, p <0.001) and major adverse cardiovascular events (37.4% vs 26.8%, hazard ratio 1.5, 95% confidence interval 1.3 to 1.8, p <0.001) were significantly higher. Door-to-balloon time did not differ significantly (p = 0.835). In predictive analysis, Regularized Discriminant Analysis emerged as the most promising model, surpassing previous prediction models (area under the curve: 0.66, sensitivity: 0.32, specificity: 0.86). Nevertheless, Global Registry of Acute Coronary Events (GRACE) 2.0 score demonstrated a remarkable performance (area under the curve: 0.65, sensitivity: 0.51, specificity: 0.73). This study underscores the pivotal role of successful TRA in enhancing outcomes in STEMI cases, advocating for its prioritization. The inability to conclude interventions through this approach is linked to a poorer prognosis, even in risk-adjusted analyses. Our findings indicate that prediction models utilizing clinical parameters do not outperform the established GRACE 2.0 algorithm, questioning their utility. In conclusion, the results emphasize the significance of TRA success and the continued relevance of the GRACE score in clinical decision-making to optimize patient outcomes.

Evaluation of Ultrathin Strut Biodegradable Polymer-Coated Sirolimus-Eluting Stents in an All-Comers Patient Population: 1-Year Results of the S-FLEX Slovakia Registry

BACKGROUND

Supraflex (Sahajanand Medical Technologies Limited, Surat, India) is a new-generation, biodegradable polymer-coated sirolimus-eluting stent (SES) designed on an ultrathin (60 µm) cobalt-chromium platform with a flexible 'S-link.' The S-FLEX Slovakia registry aimed to assess the safety and effectiveness of Supraflex SES in an all-comers population, with a subgroup of diabetic patients.

METHODS

This was a prospective, observational, multi-center, post-market registry conducted between February 2018 and May 2019. All consecutive patients with symptomatic coronary artery disease scheduled for percutaneous coronary intervention with Supraflex SES were enrolled. The primary endpoint was target lesion failure (TLF), defined as a composite of cardiac death, target vessel myocardial infarction (TV-MI), or clinically indicated target lesion revascularization (CI-TLR) by percutaneous or surgical methods at 1-year follow-up. Stent thrombosis was a safety endpoint.

RESULTS

A total of 413 patients was assessed (145 diabetics and 268 nondiabetics). At 1-year follow-up, the primary endpoint of TLF occurred in 5.1% patients, comprised of 3.9% cardiac deaths, 0.5% TV-MI, and 0.7% CI-TLR. Overall stent thrombosis occurred in 0.5% patients at 1-year follow-up. In the subgroup analysis, TLF occurred in 6.2% diabetics and 4.5% nondiabetics (P =.433) and comprised 4.8% and 3.4% cardiac deaths (P =.447), 0.7% and 0.4% TV-MI (P =.653), and 0.7%, and 0.7% CI-TLR (P =.952) in diabetics and non-diabetics, respectively. Overall stent thrombosis occurred in 0.7% diabetic and 0.4% non-diabetic patient (P =.659).

CONCLUSION

This registry demonstrates favourable clinical outcomes after the implantation of the ultrathin biodegradable polymer coated Supraflex SES in an all-comers population, with event rates that were similar in diabetic and nondiabetic patients.

Evaluation of the effectiveness and safety of a novel substrate-based radiofrequency ablation for persistent atrial fibrillation: a prospective, randomised, parallel-controlled, single-blinded study protocol

INTRODUCTION

Pulmonary vein isolation (PVI) is the cornerstone of radiofrequency (RF) ablation for atrial fibrillation (AF). However, a single ablation strategy does not always achieve the desired therapeutic effect in all patients with persistent AF, and individualised strategies are required for different clinical characteristics.

METHODS AND ANALYSIS

This study aimed to determine the optimal catheter ablation strategy for persistent AF by comparing the efficacy of PVI and BCXL (BC: big circles encircling pulmonary vein isolation; XL: unfixed number of lines based on the left atrial substrate). The BCXL-AF study (clinical trial no. ChiCTR2200067081) was designed as a prospective, randomised, parallel-controlled, single-blinded clinical trial. Overall, 400 patients with persistent AF were randomised in a 1:1 ratio into PVI-only and BCXL-individualised ablation groups. Patients randomised to the individualised ablation group will be further categorised into risk strata according to their clinical condition using the actual ablation method determined by the strata. Seven postoperative visits were conducted from discharge to 24 months of age. The primary observation endpoint will be the incidence of atrial tachyarrhythmia (including AF, atrial flutter and atrial tachycardia with a duration of ≥30 s) without using antiarrhythmic drugs after a blank period of 3 months following a single ablation procedure. The BCXL-AF study will assess an optimal approach for persistent AF RF ablation and evaluate the effectiveness of individualised RF ablation strategies in reducing the recurrence rate of AF.

ETHICS AND DISSEMINATION

The study protocol was reviewed, and ethical approval was obtained from the Army Medical University Human Ethics Committee (approval number: 2022-484-01). All the participants provided written informed consent. This study was conducted according to the principles of the Declaration of Helsinki and its amendments. The results of this study will be disseminated through manuscript publication and conference presentations.

TRIAL REGISTRATION NUMBER

ChiCTR2200067081.

Successful Primary PCI in Stanford Type A Aortic Dissection Complicated by Inferior ST-Elevation Myocardial Infarction: A Case in a Facility with No Surgical Backup

Mortality of type A aortic dissection (TAAD) complicated with coronary malperfusion syndrome is very high even when emergency surgery is performed. Several reports suggested that primary percutaneous coronary intervention (PPCI) followed by immediate corrective surgery may reduce mortality. In many countries, immediate transfer to an aortic surgery center may not be possible. We report a case of TAAD complicated by coronary malperfusion successfully treated with PPCI followed by elective corrective surgery. A 48-year-old man was referred to emergency department with acute inferior ST-elevation myocardial infarction (STEMI) and underwent PPCI. During the procedure, we realized that the cause of STEMI was TAAD. We decided to continue because the patient experienced seizures and bradycardia. Subsequently, echocardiography and computed tomography confirmed the dissection. The patient was discharged and referred to the National Cardiovascular Center where he underwent successful elective surgery. In this patient, immediate revascularization was lifesaving and served as a bridging procedure before surgical correction.

Randomised controlled trial of early magnetically controlled capsule endoscopy for the prevention of gastrointestinal bleeding in patients at high bleeding risk scheduled for percutaneous coronary intervention: MACE-GPS study protocol

INTRODUCTION

Limited data are available regarding the decision-making process for preventing gastrointestinal bleeding in patients at high risk of bleeding scheduled for percutaneous coronary intervention (HBPCI), especially due to the lack of a simple, accurate and sensitive methods for gastrointestinal injury detection. This randomised trial aims to assess the effects of early magnetically controlled capsule endoscopy (MCE) in patients with HBPCI for the prevention of gastrointestinal bleeding compared with conventional management.

METHODS AND ANALYSIS

The Magnetic-Assisted Capsule Endoscopy Gastrointestinal bleeding Protection Strategy (MACE-GPS) is a multicentre, open-label, randomised controlled trial. Patients admitted for HBPCI will be randomised and placed into two study groups. In the early MCE group, 1228 patients will undergo MCE following admission to the hospital. If necessary, these patients may further undergo a multidisciplinary approach to determine treatment based on the MCE findings. A total of 1228 patients in the control group will undergo conventional treatment based on the attending cardiologist's interpretation of their clinical presentations. The primary end point is the incidence of gastrointestinal bleeding within 12 months of enrolment.

ETHICS AND DISSEMINATION

The MACE-GPS trial has been approved by the ethics committees of all participating sites. Participant recruitment began in April 2023 and will be completed in April 2025, and the 1-year follow-up will be completed in April 2026. The study results will be disseminated through conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ChiCTR2300070025.

Comparative treatment outcomes of a single long stent vs. overlapped short stents in acute myocardial infarction

Objectives

There is no consensus regarding the optimal choice between single long stent (SLS) and overlapped double short stents (DSS) in patients with acute myocardial infarction (AMI). Therefore, we aimed to compare treatment outcomes among patients with AMI treated with these two different stenting methods.

Methods

In total, 537 patients with AMI from a single tertiary center were categorized into two groups: (1) those who received an SLS (stent length ≥38 mm) (n = 254; 47.3%) and (2) those who received overlapped DSS (individual stent lengths <38 mm) (n = 283; 52.7%). The primary outcome was the incidence of major adverse cardiac and cerebrovascular events (MACCEs) within 1 year.

Results

The mean age of participants was 65.4 years, and 75.0% were male. Patients receiving an SLS had a higher rate of serum creatinine level ≥1.5 mg/dl (16.3% vs. 8.9%, p = 0.009) but a lower rate of hypertension (46.8% vs. 55.8%, p = 0.038), lesser total stent length (38.26 ± 1.31 vs. 45.20 ± 9.25 mm, p < 0.001), total procedure time (41.40 ± 15.74 vs. 53.31 ± 21.75 min, p < 0.001) and total contrast volume (134.13 ± 30.72 vs. 160.57 ± 39.77 ml, p < 0.001) than in those receiving DSS. One-year MACCEs were comparable between the two groups before [hazard ratio (HR), 1.33; 95% confidence interval (CI), 0.80-2.24] and after adjusting for covariates (HR, 1.21; 95% CI, 0.67-2.19).

Conclusions

Stenting with an SLS demonstrated similar outcomes compared to those achieved when using stenting with overlapped DSS in patients with AMI. Therefore, if the deliverability is acceptable, stenting with an SLS appears to be a safe and effective strategy for AMI treatment.

Effect of preinitiated glucose-insulin-potassium strategy for patients with undergoing planned percutaneous coronary intervention: a systematic review and meta-analysis

OBJECTIVES

Whether the glucose-insulin-potassium (GIK) should be used as an adjuvant therapy for ischaemic myocardial disease remains controversial nowadays reperfusion era. This meta-analysis aimed to assess the effects of preinitiated GIK for patients undergoing planned percutaneous coronary intervention (PCI).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Web of science, MEDLINE, Embase, Cochrane Library and ClinicalTrials.gov were searched through 27 November 2022.

ELIGIBILITY CRITERIA

Only randomised controlled trials involving participants preinitiated with GIK or placebo before planned PCI were included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers used standardised methods to search, screen and code included trials. Risk of bias was assessed with the Cochrane tool. Pooled analysis was conducted using random or effects models according to the heterogeneity. Subgroup analyses were carried out for dosage of GIK and if with ongoing myocardial ischaemia.

RESULTS

13 randomised controlled trials (RCTs) including 3754 participants were evaluated. We found patients preconditioned with GIK before PCI showed a significant increase in Thrombolysis in Myocardial Infarction 3 flow events after angioplasty (OR 1.59, 95% CI 1.03 to 2.46, p=0.04), also revealed improved in-hospital left ventricular ejection fraction (weighed mean difference, WMD 1.62, 95% CI 0.21 to 3.03, p=0.02) and myocardial salvage index (WMD 0.09, 95% CI 0.01 to 0.16, p=0.03). Nevertheless, no benefit was observed in all-cause mortality neither on 30-day (OR 0.81, 95% CI 0.59 to 1.11, p=0.18) nor 6 months (OR 1.02, 95% CI 0.42 to 2.46, p=0.97). Furthermore, GIK intervention was associated with higher occurrences of complications such as phlebitis (OR 10.13, 95% CI 1.74 to 59.00, p=0.01) and hypoglycaemia (OR 10.43, 95% CI 1.32 to 82.29, p=0.03), but not hyperkalaemia (OR 9.36, 95% CI 0.50 to 175.27, p=0.13), liquid overload (OR 1.02, 95% CI 0.25 to 4.13, p=0.98) or in-hospital heart failure (OR 0.42, 95% CI 0.06 to 2.96, p=0.39).

CONCLUSIONS

Our study shows preconditioning GIK exhibits myocardial reperfusion and cardiac function benefits for patients planning to receive PCI intervention, while also some complications such as phlebitis and hypoglycaemia accompany.

PROSPERO REGISTRATION NUMBER

CRD42022326334.

Assessment of silent brain injury in patients undergoing elective percutaneous coronary intervention due to chronic total occlusion

Objective: Silent brain infarcts (SBI) are thromboembolic complications associated with cardiac surgery, diagnostic angiography, and percutaneous interventions. Serum neuron-specific enolase (NSE) is the proven biomarker for measuring neuronal damage. This study aimed to evaluate the incidence of SBI, defined as elevated NSE after coronary chronic total occlusion (CTO) intervention and elective coronary stenting. Design: The study population consisted of two patient groups: the CTO group included consecutive patients with coronary CTO intervention, and the control group consisted of patients who underwent elective coronary intervention. NSE blood levels were measured before and 12-18 h after the procedure. NSE blood levels of >20 ng/mL were considered SBI. Results: A total of 108 patients were included in the study. Of these, 55 (50.9%) had SBI after the procedure. The SBI rate was 59.7% in the CTO group and 39.1% in the control group. Patients with SBI were more likely to have diabetes mellitus, hyperlipidemia, higher HbA1c, higher total stent length, and longer procedural time. Multivariate logistic regression analysis showed that CTO procedure (odds ratio [OR]: 3.129; 95% confidence interval [CI]: 1.246-7.858; p < 0.015) and diabetes mellitus (OR: 2.93; 95% CI: 1.185-7.291; p < 0.020) are independent predictors of SBI. Conclusion: Our data suggest that SBI occurs more frequently after CTO intervention than after non-CTO intervention. Intervention complexity and patient clinical characteristics may explain the increased incidence.

Design and rationale of the ATTRACTIVE trial: a randomised trial of intrAThrombus Thrombolysis versus aspiRAtion thrombeCTomy during prImary percutaneous coronary interVEntion in ST-segment elevation myocardial infarction patients with high thrombus burden

INTRODUCTION

ST-segment elevation myocardial infarction (STEMI) with high thrombus burden is associated with a poor prognosis. Manual aspiration thrombectomy reduces coronary vessel distal embolisation, improves microvascular perfusion and reduces cardiovascular deaths, but it promotes more strokes and transient ischaemic attacks in the subgroup with high thrombus burden. Intrathrombus thrombolysis (ie, the local delivery of thrombolytics into the coronary thrombus) is a recently proposed treatment approach that theoretically reduces thrombus volume and the risk of microvascular dysfunction. However, the safety and efficacy of intrathrombus thrombolysis lack sufficient clinical evidence.

METHODS AND ANALYSIS

The intrAThrombus Thrombolysis versus aspiRAtion thrombeCTomy during prImary percutaneous coronary interVEntion trial is a multicentre, prospective, open-label, randomised controlled trial with the blinded assessment of outcomes. A total of 2500 STEMI patients with high thrombus burden who undergo primary percutaneous coronary intervention will be randomised 1:1 to intrathrombus thrombolysis with a pierced balloon or upfront routine manual aspiration thrombectomy. The primary outcome will be the composite of cardiovascular death, recurrent myocardial infarction, cardiogenic shock, heart failure readmission, stent thrombosis and target-vessel revascularisation up to 180 days.

ETHICS AND DISSEMINATION

The trial was approved by Ethics Committees of China-Japan Friendship Hospital (2022-KY-013) and all other participating study centres. The results of this trial will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05554588.

Technically Challenging Percutaneous Interventions of Chronic Total Occlusions Are Associated with Enhanced Platelet Activation

Percutaneous coronary intervention (PCI) is a frequently performed treatment option for recanalization in patients with chronic total occlusion (CTO). As CTO-PCIs are often complicated and challenging for interventionalists, the stressful and damaging nature of the procedure can be remarkable, thus platelets can be easily activated. Our aim was to investigate the effect of CTO-PCI on platelet activation and the expression of selected circulating microRNAs (miR) of platelet and endothelium origin after CTO-PCI. In this study, 50 subjects after CTO-PCI were enrolled. Blood samples were obtained before PCI, at 2 days and 3-6 months after the procedure to measure the degree of platelet activation and the level of plasma miR-223, miR-181b, and miR-126. Patients were divided based on the characteristics of the intervention. Patients with higher Japanese CTO scores and longer duration of PCI showed significantly elevated platelet P-selectin positivity (p = 0.004 and p = 0.013, respectively) 2 days after the procedure compared to pre-PCI and increased concentration of soluble P-selectin 3-6 months after the intervention (higher Japanese CTO score: p = 0.028 and longer duration of PCI: p = 0.023) compared to baseline values. Shorter total stent length caused a significantly lower miR-181b expression at 3-6 months after the intervention (p = 0.031), while no difference was observed in miR-223 and miR-126. One stent thrombosis occurred during the follow-up period. Although these technically challenging CTO-PCIs may cause enhanced platelet activation right after the intervention and long-term endothelial cell dysfunction, these interventions are not associated with more adverse clinical events.

Prevention of Contrast-induced Nephropathy in Patients Undergoing Percutaneous Coronary Intervention

Contrast-induced nephropathy (CIN) or contrast-induced acute kidney injury has varying definitions, but in general, increased serum creatinine level by ≥ 0.3 mg/dL (26.5 µmol/L) or 1.5x of baseline value or urine output <0.5 mL/kg/h within 1-7 days after contrast media (CM) administration can be considered as CIN. CIN is one of the most common complications and is associated with increased mortality in patients undergoing percutaneous coronary intervention (PCI). Thus, risk stratification for CIN should be made and preventive strategies should be employed in which the intensity of the approach must be tailored to patient's risk profile. In all patients, adequate hydration is required, nephrotoxic medications should be discontinued, and pre-procedural high-intensity statin is recommended. In patients with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, IV hydration should be started 12 hours pre-procedure up until 12-24 hours after the procedure. Remote ischemic preconditioning may be performed pre-procedurally. Radial first approach for vascular access is recommended. During the procedure, low or iso-osmolar CM should be used and its volume should be limited to eGFR x 3.7. In patients at high risk for CIN, additional contrast-sparing strategies may be applied, such as using a contrast reduction system, 5 Fr catheter with no sideholes, CM dilution, limiting test injection, confirming placement using guidewire, use of stent enhancing imaging technology, using metallic/software roadmap to guide PCI, use of IVUS or dextran-based OCT, and coronary aspiration. A more advanced hydration technique based on central venous pressure, left ventricular end-diastolic pressure, or using furosemide-matched hydration, might be considered.

Everolimus-Eluting Stents or Bypass Surgery for Multivessel Disease in Diabetics: The BEST Extended Follow-Up Study

BACKGROUND

Diabetes mellitus is associated with more complex coronary artery diseases. Coronary artery bypass grafting (CABG) is a preferred revascularization strategy over percutaneous coronary intervention (PCI) in diabetics with multivessel coronary artery disease (MVD).

OBJECTIVES

This study sought to examine the different prognostic effects of revascularization strategies according to the diabetes status from the randomized BEST (Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease) trial.

METHODS

Patients (n = 880) with MVD were randomly assigned to undergo PCI with an everolimus-eluting stent vs CABG stratified by diabetics (n = 363) and nondiabetics (n = 517). The primary endpoint was the composite of death, myocardial infarction, or target vessel revascularization during a median follow-up of 11.8 years (IQR: 10.6-12.5 years).

RESULTS

In diabetics, the primary endpoint rate was significantly higher in the PCI group than in the CABG group (43% and 32%; HR: 1.53; 95% CI: 1.12-2.08; P = 0.008). However, in nondiabetics, no significant difference was found between the groups (PCI group, 29%; CABG group, 29%; HR: 0.97; 95% CI: 0.67-1.39; P = 0.86; Pinteraction= 0.009). Irrespective of the presence of diabetes, no significant between-group differences were found in the rate of a safety composite of death, myocardial infarction, or stroke and mortality rate. However, the rate of any repeat revascularization was significantly higher in the PCI group than in the CABG group.

CONCLUSIONS

In diabetics with MVD, CABG was associated with better clinical outcomes than PCI. However, the mortality rate was similar between PCI and CABG irrespective of diabetes status during an extended follow-up. (Ten-Year Outcomes of Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease [BEST Extended], NCT05125367; Randomized Comparison of Coronary Artery Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients With Multivessel Coronary Artery Disease [BEST], NCT00997828).

Ten-year clinical outcomes from a randomized trial comparing new-generation everolimus-eluting stent versus first-generation Sirolimus-eluting stent: Results from the RESET extended study

BACKGROUND

New-generation drug-eluting stents (DES) achieved technological innovations and reported clinical advantages as compared with first-generation DES in clinical trials with 3-5 years follow-up. However, detailed clinical outcome data in very long-term follow-up is still scarce.

OBJECTIVES

To evaluate 10-year clinical outcomes after first- and new-generation DES implantation.

METHODS

In this extende follow-up study of the RESET, which is a largest randomized trial comparing everolimus-eluting stent (EES) with Sirolimus-eluting stent (SES), the study population consisted of 2892 patients from 84 centers. The primary efficacy and safety endpoints were target lesion revascularization (TLR) and a composite of death or myocardial infarction (MI), respectively. Complete 10-year follow-up was achieved in 87.9% of patients.

RESULTS

Cumulative 10-year incidences of TLR and non-TLR were not significantly different between EES and SES (13.9% vs. 15.7%, Log-rank p = 0.20, and 33.4% vs. 31.3%, Log-rank p = 0.30). The cumulative 10-year incidence of death/MI was also not significantly different between the groups (32.5% vs. 34.4%, Log-rank p = 0.18). Cumulative 10-year incidence of definite stent thrombosis was numerically lower in EES than in SES (1.0% vs. 1.7%, Log-rank p = 0.16). The lower risk of EES relative to SES was significant for a composite endpoint of target lesion failure (TLF: 19.6% vs. 24.9%, Log-rank p = 0.001) and target vessel failure (TVF: 26.7% vs. 31.4%, Log-rank p = 0.006).

CONCLUSION

During 10-year of follow-up, the risks for primary efficacy and safety endpoints were not significantly different between new-generation EES and first-generation SES, although EES compared with SES was associated with a lower risk for composite endpoints such as TLF and TVF.

Assessing lead curtains' impact on radiation protection in coronary interventions

The objective of this investigation is to assess the impact of supplementary lead curtains on the reduction of radiation dose exposure to operators during coronary interventional procedures. Seven standard positions during coronary angiography (foot, right foot, head, left foot, left lateral, left head, and right lateral) were simulated on a standard anthropomorphic phantom with radial artery access. Measurements were taken at two different heights, 125 cm and 155 cm, and dosimeters were used to measured surface incident dose rates for the first and second operators, both with and without additional lead curtains at various positions. Each position was measured 20 times, and arithmetic means were computed. At-test was utilised to compare dose rates with and without supplementary lead curtains, as well as dose rates with additional lead curtains at varying heights. The finding indicate that the dose rates of the first operator with supplementary lead curtains were not significantly lower compared to those without, except for the 125 cm head and left foot positions and the 155 cm head position with the additional lead curtain edge 10 cm below the umbilical level (tumbilical= 0.9, 0.4, 0.5,P> 0.05). The dose rates of the second operator with additional lead curtains were significantly lower than those without, with statistically significant differences (P< 0.05). The arithmetic mean dose rates for the first and second operators at each position were lowest when the upper edge of the additional lead curtain was situated 10 cm above the umbilical level. Employing supplementary lead curtains during coronary interventions effectively reduces radiation doses received by operators. The protective effect is enhanced when the additional lead curtain is closer to the irradiation field. Hence, it is recommended that additional curtains be employed judiciously, while ensuring that clinical procedures are not impeded, in order to effectively mitigate the radiation exposure of operators.

Quality of Life in Patients With Unstable Angina Before and After Percutaneous Coronary Intervention: A Single-Center Pilot Study Using the European Quality of Life 5-Dimension 5-Level (EQ-5D-5L) Questionnaire

Background Unstable angina (UA) has a negative impact on patients' quality of life. Percutaneous coronary intervention (PCI) is a commonly recommended treatment that exhibits positive therapeutic effects and enhances quality of life. This study aimed to compare the alterations in quality of life and related factors before and after PCI in UA patients. Methods A longitudinal follow-up study was conducted on 48 patients with UA before and one month after undergoing PCI. The European Quality of Life (EuroQol) 5-Dimension 5-Level (EQ-5D-5L) scale was utilized to measure the quality of life of patients. Results The study revealed a significant improvement in the quality of life score after one month of coronary artery intervention compared to the pre-intervention stage: the quality of life score before the intervention was 0.73 ± 0.32, whereas it increased to 0.89 ± 0.20 after one month (p<0.001). Sex, occupation, and troponin T were associated with changes in quality of life one month after the coronary artery intervention. Conclusion The pilot study demonstrated a notable enhancement in the quality of life among patients with UA following coronary intervention. Additionally, sex, occupation, and troponin T were identified as factors associated with this improvement.

Feasibility and safety of Post-Urgent PCI Same-DaY discharge (PUSDY Trial) in China: protocol for a multicentre randomised controlled trial

INTRODUCTION

In the Chinese healthcare system, where there is overcrowding in hospitals, especially in tertiary care centres, adoption of same-day discharge (SDD) post-percutaneous coronary intervention (PCI) could potentially lead to significant savings of healthcare resources and costs. This study is a non-inferiority trial examining whether post-PCI SDD is feasible in China. The primary hypothesis is that patient outcomes in post-urgent PCI SDD patients are non-inferior to regular discharge patients.

METHODS AND ANALYSIS

Post-Urgent PCI Same-DaY is an investigator-initiated multicentre randomised unblinded clinical non-inferiority trial, with 1:1 centralised randomisation to the SDD or usual care (UC) group. Based on sample size calculations, 1296 patients from at least three hospitals, with mild to moderate myocardial infarction, will be included, and acute coronary syndrome patients will be excluded. All patients will receive UC while patients assigned to the SDD group will be discharged on the same day or within 12 hours post-PCI. The primary outcome is major adverse cardiovascular and cerebrovascular events 30 days after discharge. The secondary outcomes are all-cause mortality, bleeding and access site complications. The outcome rates will be compared between groups with the absolute risk difference with a 95% CI.

ETHICS AND DISSEMINATION

The study protocol V.2.0 has been approved on 21 January 2022 by the Ethics Committee of Beijing Anzhen Hospital, Capital Medical University (approval number: 2021 KLSD No. 23). The outcomes of this study will be disseminated through a peer-reviewed journal and presented at international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR 2200057065; China Clinical Trial Registration.

Outcome monitoring and risk stratification after cardiac procedure in neonates, infants, children and young adults born with congenital heart disease: protocol for a multicentre prospective cohort study (Children OMACp)

INTRODUCTION

Congenital heart disease (CHD) represents the most common birth defect, affecting from 0.4% to 1.2% of children born in developed countries. The survival of these patients has increased significantly, but CHD remains one of the major causes of neonatal and childhood death. The aetiology of CHD is complex, with some evidence of both genetic and environmental causes. However, there is still lack of knowledge regarding modifiable risk factors and molecular and genetic mechanisms underlying the development of CHD. This study aims to develop a prospective cohort of patients undergoing cardiac procedures that will bring together routinely collected clinical data and biological samples from patients and their biological mothers, in order to investigate risk factors and predictors of postoperative-outcomes, as well as better understanding the effect of the surgical intervention on the early and long-term outcomes.

METHODS AND ANALYSIS

Children OMACp (OMACp, outcome monitoring after cardiac procedure in congenital heart disease) is a multicentre, prospective cohort study recruiting children with CHD undergoing a cardiac procedure. The study aims to recruit 3000 participants over 5 years (2019-2024) across multiple UK sites. Routine clinical data will be collected, as well as participant questionnaires collecting sociodemographic, NHS resource use and quality of life data. Biological samples (blood, urine and surgical waste tissue from patients, and blood and urine samples from biological mothers) will be collected where consent has been obtained. Follow-up outcome and questionnaire data will be collected for 5 years.

ETHICS AND DISSEMINATION

The study was approved by the London-Brent Research Ethics Committee on 30 July 2019 (19/SW/0113). Participants (or their parent/guardian if under 16 years of age) must provide informed consent prior to being recruited into the study. Mothers who wish to take part must also provide informed consent prior to being recruited. The study is sponsored by University Hospitals Bristol and Weston Foundation Trust and is managed by the University of Bristol. Children OMACp is adopted onto the National Institute for Health Research Clinical Research Network portfolio. Findings will be disseminated through peer-reviewed publications, presentation at conference, meetings and through patient organisations and newsletters.

TRIAL REGISTRATION NUMBER

ISRCTN17650644.

Alirocumab effect on preventing periprocedural ischaemic events in coronary heart disease patients undergoing coronary stenting (APPEASE trial): study protocol of a multicentre, open-label, randomised controlled trial

INTRODUCTION

Percutaneous coronary intervention (PCI)-related myocardial infarction (type 4a MI) and major periprocedural myocardial injury have been demonstrated leading to poor prognosis of patients with coronary heart disease (CHD) undergoing elective PCI and still remain high occurrence even after the therapy of dual antiplatelet agents and statins. Proprotein convertase subtilisin/kexin type 9 inhibitor alirocumab has been shown to be effectively in reducing the risk of acute MI (AMI). However, the effect of alirocumab on preventing PCI-related MI or major periprocedural myocardial injury in patients with CHD undergoing elective PCI remains uncertain.

METHODS AND ANALYSIS

Alirocumab effect on Preventing Periprocedural ischaemic Events in coronary heart diseAse patients undergoing coronary StEnting trial is a multicentre, open-label, randomised controlled trial aiming to determine whether alirocumab could reduce the incidence of type 4a MI or major periprocedural myocardial injury in patients with CHD undergoing elective PCI. In total, 422 non-AMI CHD patients planned to undergo elective PCI will be randomly assigned to receive standard pharmacotherapy of CHD (control group) or additional use of subcutaneous alirocumab 75 mg 1 day before procedure (alirocumab group). The primary outcome is type 4a MI or major periprocedural myocardial injury defined as high-sensitivity cardiac troponin elevating above 5×99 th percentile upper reference limit in 48 hours after PCI. Patients will continue receiving standard pharmacotherapy or additional biweekly subcutaneous alirocumab 75 mg for 3 months according to the initial randomisation group. We will follow up for 3 months and record all the major adverse cardiovascular events (MACEs). Incidence of PCI-related MI or major periprocedural myocardial injury, and MACE in 3 months after PCI will be compared between control group and alirocumab group.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Medical Ethics Committee of the Third Affiliated Hospital of Sun Yat-sen University with approval number: (2022)02-140-01. The results of this study will be reported through peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

ChiCTR2200063191.

Risk factors associated with contrast-associated acute kidney injury in ST-segment elevation myocardial infarction patients: a systematic review and meta-analysis

OBJECTIVE

The objective of this systematic review and meta-analysis was to evaluate the risk factors for contrast-associated acute kidney injury (CA-AKI) in ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

We searched the databases of PubMed, Embase and Ovid, up to February 2022, for observational studies that investigated the association between risk factors and CA-AKI.

RESULTS

A total of 21 studies were included in the meta-analysis. Of the total 22 015 participants, 2728 developed CA-AKI. Pooled incidence was 11.91% (95% CI 9.69%, 14.14%). Patients with CA-AKI were more likely to be older, female, also had comorbidities (hypertension, diabetes, previous heart failure). Smoking (OR: 0.60; 95% CI 0.52, 0.69) and family history of CAD (coronary artery disease) (OR: 0.76; 95% CI 0.60, 0.95) were associated with lower risk of CA-AKI. Left anterior descending (LAD) artery occlusion (OR: 1.39; 95% CI 1.21, 1.59), left main disease (OR: 4.62; 95% CI 2.24, 9.53) and multivessel coronary disease (OR: 1.33; 95% CI 1.11, 1.60) were risk factors for CA-AKI. Contrast volume (weighted mean difference: 20.40; 95% CI 11.02, 29.79) was associated with increased risk in patients receiving iso-osmolar or low-osmolar non-ionic contrast.

CONCLUSIONS

In addition to the known risk factors, LAD artery infarction, left main disease and multivessel disease are risk factors for CA-AKI. The unexpected favourable association between smoking, as well as family history of CAD, and CA-AKI requires further investigation.

PROSPERO REGISTRATION NUMBER

CRD42021289868.

Factors Affecting Radial Artery Occlusion After Right Transradial Artery Catheterization for Coronary Intervention and Procedures

Objective

To determine the factors influencing proximal radial artery occlusion (PRAO) right radial artery after coronary intervention.

Methods

This is a single-center prospective observational study. A total of 460 patients were selected to undergo coronary angiography (CAG) or percutaneous coronary intervention (PCI) via the proximal transradial approach (PTRA) or distal transradial approach (DTRA). The 6F sheath tube were received by all patients. Radial artery ultrasound was performed 1 day before procedure and 1-4 days after procedure. Patients were divided into the PRAO group (42 cases) and the non-PRAO group (418 cases). General clinical data and preoperative radial artery ultrasound indexes of the two groups were compared to analyze related factors leading to PRAO.

Results

The total incidence of PRAO was 9.1%, including 3.8% for DTAR and 12.7% for PTRA. The PRAO rate of DTRA was significantly lower than that of PTRA (p < 0.05). Female, low body weight, low body mass index (BMI) and CAG patients were more likely to develop PRAO after procedure (p < 0.05). The internal diameter and cross-sectional area of the distal radial artery and proximal radial artery were smaller in the PRAO group than in the non-PRAO group, and the differences were statistically significant (p < 0.05). Multifactorial model analysis showed that the puncture approach, radial artery diameter and procedure type were predictive factors of PRAO, and the receiver operating characteristic curve showed a good predictive value.

Conclusion

A larger radial artery diameter and DTRA may reduce the incidence of PRAO. Preoperative radial artery ultrasound can guide the clinical selection of appropriate arterial sheath and puncture approach.

Cystatin C as a Predictor of Major Adverse Cardiovascular Event in Patients with Acute Myocardial Infarction Without Cardiogenic Shock and Renal Impairment After Coronary Intervention

Purpose

To prove that cystatin C is a predictor of major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI), either with ST-segment Elevation (AMI-EST) or without ST-segment elevation (AMI-NEST), without cardiogenic shock or renal impairment.

Patient and Methods

This was an observational cohort study. Samples were obtained from AMI patients who underwent PCI between February 2022 and March 2022 at the Intensive Cardiovascular Care Unit. Cystatin C levels were measured before PCI. MACE were observed within 6 months. Comparisons between normally distributed continuous data were performed using the t-test; Mann-Whitney test was used for non-normally distributed data. Categorical data were compared using the chi-squared test. The cut-off point of cystatin C levels to predict MACE was analyzed using Receiver Operating Characteristics (ROC).

Results

The participants were 40 AMI patients, consisting of 32 patients (80%) with AMI-EST and eight patients (20%) diagnosed with AMI-NEST, who were evaluated for the occurrence of MACE within 6 months after PCI. Ten patients (25%) developed MACE during follow-up [(MACE (+)], and the rest were in the MACE (-) group. Cystatin C levels were significantly higher in the MACE (+) group (p=0.021). ROC analysis revealed a cystatin C level of 1.21 mg/dL; cystatin C > 1.21 is associated with MACE risk, showing a significant relationship with the odds ratio value reaching 26.00, with 95% CI (3.99-169.24).

Conclusion

Cystatin C level is an independent predictor of MACE in patients with AMI without cardiogenic shock or renal impairment after PCI.

Efficacy of Intravascular Ultrasound-Based 3D Wiring Using the Tip Detection Method for CTO Intervention

To perform intravascular ultrasound (IVUS)-based real-time 3-dimensional wiring in chronic total occlusion percutaneous coronary intervention, we devised a tip detection method and developed AnteOwl WR (AO)-IVUS, which is an upgraded version of Navifocus WR (Navi)-IVUS with an added pull back transducer system. We compared the procedural outcomes of AO-IVUS-based 3-dimensional wiring using the tip detection method (n = 30) and Navi-IVUS-based conventional wiring (n = 17) in chronic total occlusion percutaneous coronary intervention. The success rate of IVUS-guided wiring was markedly improved in the AO-IVUS group compared with the Navi-IVUS group (93% vs 59% of cases, respectively; P = 0.007). In cases of successful IVUS-guided wiring, the IVUS-guided wiring time was markedly improved in the AO-IVUS group compared with the Navi-IVUS group (9 ± 8 minutes vs 24 ± 26 minutes, respectively; P = 0.001). There were 2 successful cases of tip detection-antegrade dissection and re-entry in the AO-IVUS group.

Rationale and Design of the Rivaroxaban Post-Transradial Access for the Prevention of Radial Artery Occlusion Trial (CAPITAL-RAPTOR)

INTRODUCTION

Transradial access (TRA) has rapidly emerged as the preferred vascular access site for coronary angiography and percutaneous coronary intervention. Radial artery occlusion (RAO) remains as an important complication of TRA as it precludes future ipsilateral transradial procedures. While intraprocedural anticoagulation has been studied extensively, the definitive role of postprocedural anticoagulation has not yet been established.

METHODS AND ANALYSIS

The Rivaroxaban Post-Transradial Access for the Prevention of Radial Artery Occlusion trial is a multicentre, prospective, randomised, open-label, blinded-endpoint design study investigating the efficacy and safety of rivaroxaban to reduce the incidence of RAO. Eligible patients will undergo randomisation to receive either rivaroxaban 15 mg once daily for 7 days or to no additional postprocedural anticoagulation. Doppler ultrasound to assess radial artery patency will be performed at 30 days.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Ottawa Health Science Network Research Ethics Board (approval number 20180319-01H). The study results will be disseminated via conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT03630055.

Spontaneous Coronary Artery Dissection in Young Patients: A Case Series and Review of Current Management Algorithm

Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized non-atherosclerotic cause of acute coronary syndrome. Common risk factors for SCAD are coronary atherosclerosis, female gender, peripartum period, systemic inflammatory conditions, and connective tissue disorders. It manifests as myocardial ischemia and infarction, arrhythmia, and sudden cardiac death. We present a case series of two young men and one young female with SCAD who had chest pain and were diagnosed with SCAD-associated ST-elevation myocardial infarction. Its diagnosis requires a high degree of clinical suspicion and its management is guided by the patient's clinical condition and the characteristics of the lesions.

Sudden cardiac death caused by a right coronary artery aneurysm complicated with acute myocardial infarction: a case report

Coronary aneurysms are defined as coronary artery ectasia (CAE) more than 1.5 times the normal adjacent segment diameter or the maximum coronary artery diameter. Although most CAE patients are asymptomatic, some patients present with acute coronary syndrome (ACS), such as angina pectoris, myocardial infarction (MI), and even sudden cardiac death. Sudden death due to coronary artery dilatation is very rare. However, we report a case of a patient with aneurysm-like dilatation of both the left and right coronary arteries, with acute inferior ST segment elevation myocardial infarction and sudden death due to third-degree atrioventricular block. After cardiopulmonary resuscitation, the patient underwent emergency coronary intervention. After thrombus aspiration and intracoronary thrombolysis in the right coronary artery, the atrioventricular block returned to normal on the fifth day of hospitalization. Following anticoagulant therapy, coronary angiography was repeated and showed that the thrombus had disappeared. The patient is recovering well after active rescue at the time of writing.

Estimating the cost-effectiveness and return on investment of the Victorian Cardiac Outcomes Registry in Australia: a minimum threshold analysis

OBJECTIVES

We sought to establish the minimum level of clinical benefit attributable to the Victorian Cardiac Outcomes Registry (VCOR) for the registry to be cost-effective.

DESIGN

A modelled cost-effectiveness study of VCOR was conducted from the Australian healthcare system and societal perspectives.

SETTING

Observed deaths and costs attributed to coronary heart disease (CHD) over a 5-year period (2014-2018) were compared with deaths and costs arising from a hypothetical situation which assumed that VCOR did not exist. Data from the Australian Bureau of Statistics and published sources were used to construct a decision analytic life table model to simulate the follow-up of Victorians aged ≥25 years for 5 years, or until death. The assumed contribution of VCOR to the proportional change in CHD mortality trend observed over the study period was varied to quantify the minimum level of clinical benefits required for the registry to be cost-effective. The marginal costs of VCOR operation and years of life saved (YoLS) were estimated.

PRIMARY OUTCOME MEASURES

The return on investment (ROI) ratio and the incremental cost-effectiveness ratio (ICER).

RESULTS

The minimum proportional change in CHD mortality attributed to VCOR required for the registry to be considered cost-effective was 0.125%. Assuming this clinical benefit, a net return of $A4.30 for every dollar invested in VCOR was estimated (ROI ratio over 5 years: 4.3 (95% CI 3.6 to 5.0)). The ICER estimated for VCOR was $A49 616 (95% CI $A42 228 to $A59 608) per YoLS. Sensitivity analyses found that the model was sensitive to the time horizon assumed and the extent of registry contribution to CHD mortality trends.

CONCLUSIONS

VCOR is likely cost-effective and represents a sound investment for the Victorian healthcare system. Our evaluation highlights the value of clinical quality registries in Australia.

One-year major adverse cardiovascular events among same-day discharged patients after primary percutaneous coronary intervention at a tertiary care cardiac centre in Karachi, Pakistan: a prospective observational study

OBJECTIVE

Knowledge regarding the short-term outcomes after same-day discharge (SDD) post primary percutaneous coronary intervention (PCI) is lacking. In this study, we evaluated 1-year major adverse cardiovascular events (MACE) among SDD patients after primary PCI.

DESIGN

1-year follow-up analysis of a subset of patients from an existing prospective cohort study.

SETTING

Tertiary care cardiac hospital in Karachi, Pakistan.

PARTICIPANTS

Consecutive patients, from August 2019 to July 2020, with ST segment elevation myocardial infarction who had undergone primary PCI with SDD (within 24 hours) after the procedure by the treating physician and with at least one successful follow-up up to 1 year.

OUTCOME MEASURE

Cumulative MACE during follow-up at the intervals of 1 week, 1 month, 6 months and 1 year.

RESULTS

489 patients were included, with a gender distribution of 83.2% (407) male patients and a mean age of 54.58±10.85 years. Overall MACE rate during the mean follow-up duration of 326.98±76.71 days was 10.8% (53), out of which 26.4% (14/53) events occurred within 6 months of discharge and the remaining 73.6% (39/53) occurred between 6 months and 1 year. MACE was significantly higher among patients with a Zwolle Risk Score (ZRS) ≥4 at baseline, with an incidence rate of 21.9% (16/73) vs 8.9% (37/416; p=0.001) in patients with ZRS≤3 (relative risk 2.88 (95% CI 1.5 to 5.5)).

CONCLUSION

A significant burden of short-term MACE was identified among SDD patients after primary PCI; most of these events occurred after 6 months of SDD, mainly among patients with ZRS≥4. A systematic risk assessment based on risk stratification modalities such ZRS could be a viable option for SDD patients with primary PCI.

Evolving Diagnostic and Management Advances in Coronary Heart Disease

Despite considerable improvement in diagnostic modalities and therapeutic options over the last few decades, the global burden of ischemic heart disease is steadily rising, remaining a major cause of death worldwide. Thus, new strategies are needed to lessen cardiovascular events. Researchers in different areas such as biotechnology and tissue engineering have developed novel therapeutic strategies such as stem cells, nanotechnology, and robotic surgery, among others (3D printing and drugs). In addition, advances in bioengineering have led to the emergence of new diagnostic and prognostic techniques, such as quantitative flow ratio (QFR), and biomarkers for atherosclerosis. In this review, we explore novel diagnostic invasive and noninvasive modalities that allow a more detailed characterization of coronary disease. We delve into new technological revascularization procedures and pharmacological agents that target several residual cardiovascular risks, including inflammatory, thrombotic, and metabolic pathways.

Learning Curve of Perclose ProGlide Utilization During Percutaneous Coronary Intervention

OBJECTIVE

This study aimed to investigate the learning curve (LC) of Perclose ProGlide (Chicago, IL: Abbott Laboratories) utilization for percutaneous coronary intervention (PCI) for the first time.

METHODS

The study was conducted in a prospective manner and the final sample of the study was determined as 80 patients. Patients' characteristics, diameter of common femoral artery (CFA), distance from skin to CFA, degree of calcification (<50% or ≥50%), procedure-related parameters, complications, and success of procedures were recorded. Patients were equally divided into four groups and groups were compared according to patient demographic properties, procedure-related parameters, complications, and success.

RESULTS

The mean age and mean BMI of the study population were 55.5 years and 27.5 kg/m², respectively. The mean procedure time was 144.8 minutes (min) in group 1, 138.9 min in group 2, 122.2 min in group 3, and 101.1 min in group 4, and the difference was statistically shorter in favor of group 3 and group 4 (p=0.023). Moreover, mean fluoroscopy time significantly decreased after 20 cases (p=0.030). Hospitalization period was significantly shortened following 40 procedures (p=0.031). Complications were detected in five patients in group 1, four patients in group 2, and one patient in group 4 (p=0.044). Success was significantly higher in group 3 and group 4 in comparison to group 1 and group 2 (p=0.040).

CONCLUSION

This study showed that procedure time and hospitalization time significantly decreased after 40 cases and fluoroscopy time significantly decreased after 20 cases. Moreover, after 40 procedures, the success of Perclose ProGlide utilization during PCI significantly increased and complications of the procedure significantly decreased.

Development and validation of dynamic models to predict postdischarge mortality risk in patients with acute myocardial infarction: results from China Acute Myocardial Infarction Registry

OBJECTIVES

The risk of adverse events and prognostic factors are changing in different time phases after acute myocardial infarction (AMI). The incidence of adverse events is considerable in the early period after AMI hospitalisation. Therefore, dynamic risk prediction is needed to guide postdischarge management of AMI. This study aimed to develop a dynamic risk prediction instrument for patients following AMI.

DESIGN

A retrospective analysis of a prospective cohort.

SETTING

108 hospitals in China.

PARTICIPANTS

A total of 23 887 patients after AMI in the China Acute Myocardial Infarction Registry were included in this analysis.

PRIMARY OUTCOME MEASURES

All-cause mortality.

RESULTS

In multivariable analyses, age, prior stroke, heart rate, Killip class, left ventricular ejection fraction (LVEF), in-hospital percutaneous coronary intervention (PCI), recurrent myocardial ischaemia, recurrent myocardial infarction, heart failure (HF) during hospitalisation, antiplatelet therapy and statins at discharge were independently associated with 30-day mortality. Variables related to mortality between 30 days and 2 years included age, prior renal dysfunction, history of HF, AMI classification, heart rate, Killip class, haemoglobin, LVEF, in-hospital PCI, HF during hospitalisation, HF worsening within 30 days after discharge, antiplatelet therapy, β blocker and statin use within 30 days after discharge. The inclusion of adverse events and medications significantly improved the predictive performance of models without these indexes (likelihood ratio test p<0.0001). These two sets of predictors were used to establish dynamic prognostic nomograms for predicting mortality in patients with AMI. The C indexes of 30-day and 2-year prognostic nomograms were 0.85 (95% CI 0.83-0.88) and 0.83 (95% CI 0.81-0.84) in derivation cohort, and 0.79 (95% CI 0.71-0.86) and 0.81 (95% CI 0.79-0.84) in validation cohort, with satisfactory calibration.

CONCLUSIONS

We established dynamic risk prediction models incorporating adverse event and medications. The nomograms may be useful instruments to help prospective risk assessment and management of AMI.

TRIAL REGISTRATION NUMBER

NCT01874691.

Methods for assessing guideline adherence for invasive procedures in the care of chronic coronary artery disease: a scoping review

OBJECTIVES

In the care of coronary artery disease (CAD), evidence questions the adequate application of guidelines for cardiovascular procedures, particularly coronary angiographies (CA) and myocardial revascularisation. This review aims to examine how care providers' guideline adherence for CA and myocardial revascularisation in the care of chronic CAD was assessed in the literature.

DESIGN

Scoping review.

DATA SOURCES

PubMed and EMBASE were searched through in June 2021 (rerun in September 2022).

ELIGIBILITY CRITERIA

We included studies assessing care providers' adherence to evidence-based guidelines for CA or myocardial revascularisation in the care of chronic CAD. Studies had to list the evaluation of guideline adherence as study objective, describe the evaluation methods used and report the underlying guidelines and recommendations.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers used standardised forms to extract study characteristics, methodological aspects such as data sources and variables, definitions of guideline adherence and quantification methods and the extent of guideline adherence. To elucidate the measurement of guideline adherence, the main steps were described.

RESULTS

Twelve studies (311 869 participants) were included, which evaluated guideline adherence by (1) defining guideline adherence, (2) specifying the study population, (3) assigning (classes of) recommendations and (4) quantifying adherence. Thereby, primarily secondary data were used. Studies differed in their definitions of guideline adherence, where six studies each considered only recommendation class I/grade A/strong recommendations as adherent or additionally recommendation classes IIa/IIb. Furthermore, some of the studies reported a priori definitions and allocation rules for the assignment of recommendation classes. Guideline adherence results ranged from 10% for percutaneous coronary intervention with prior heart team discussion to 98% for coronary artery bypass grafting.

CONCLUSION

Due to remarkable inconsistencies in the assessment, a cautious interpretation of the guideline adherence results is required. Future efforts should endeavour to establish a consistent understanding of the concept of guideline adherence.

Serial quantitative angiographic study of target lumen enlargement after drug-coated balloon angioplasty for native coronary artery disease

BACKGROUND

Target lumen enlargement (TLE) or "late lumen enlargement" is often encountered after percutaneous coronary intervention (PCI) with drug-coated balloons (DCB). To date, the prognosis of coronary arterial lesions with or without TLE has not been clearly elucidated.

AIMS

This study aimed to assess the long-term prognosis of coronary arterial lesions with or without TLE observed within 1 year (early TLE) after DCB angioplasty using serial quantitative angiographic follow-up.

METHODS

One hundred and ninety-three consecutive patients (de novo coronary arterial lesions, 251) who underwent follow-up angiography within 1 year after DCB angioplasty (early follow-up, median: 6 months) were retrospectively evaluated. Of these, 97 patients (125 lesions) also underwent angiography more than 1 year after DCB angioplasty (late follow-up, median: 37 months). TLE was defined as an increase in minimal lumen diameter (MLD) after PCI at each follow-up.

RESULTS

Early TLE was detected in 142 lesions (56.6%). Of these, 76 lesions were also evaluated at late follow-up. TLE persisted even at late follow-up in 67 of the 76 lesions (88.2%). An increase in MLD in early TLE (+) lesions was observed in the period between post-PCI and early follow-up (1.84 ± 0.06 vs. 2.12 ± 0.07 mm, p < 0.001) but not between early and late follow-up (2.12 ± 0.07 vs. 2.16 ± 0.07 mm, p = 0.74). In contrast, 49 of 109 lesions without early TLE were evaluated at late follow-up, of which 28 lesions (57.1%) showed TLE at late follow-up. The MLD of early TLE (-) lesions (n = 49) significantly increased from early (1.63 ± 0.061 mm) to late follow-up (1.84 ± 0.06 mm) (p < 0.001). No aneurysms were found in any of these cases.

CONCLUSION

Early TLE was observed in more than half of the lesions, with the majority remaining at late follow-up. Alternatively, half of the lesions without early TLE showed late TLE, occurring biphasically after DCB angioplasty.

Effects of sacubitril/valsartan on cardiac reverse remodeling and cardiac resynchronization in patients with acute myocardial infarction

Introduction

In 2014, the PARADIGM-HF trial (Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) has shown that sacubitril/valsartan can reduce the risk of hospitalization and death from cardiovascular causes more effectively than enalapril (an ACEI) in heart failure patients with reduced ejection fraction (HFrEF). Similarly, the PARADIGM-HF trial (Comparison of Sacubitril-Valsartan vs. Enalapril on Effect on NT-proBNP in Patients Stabilized from an Acute Heart Failure Episode) came to similar conclusions and extended the PARADIGM-HF trial results in 2019. Since then, numerous new studies have provided further insight in HFrEF, sacubitril/valsartan can reduce N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, increase left ventricular ejection fraction (LVEF), reverse ventricular remodeling, and reduce other non-fatal manifestations of clinical deterioration as compared to ACEI/ARB. However, few trials have compared the effects of these drugs in patients shortly after AMI. Therefore, it is necessary to further explore the clinical efficacy and safety of sacubitril/valsartan vs. valsartan in patients with AMI.

Methods

We conducted an open-label, prospective, randomized controlled trial to determine the superiority in ameliorating ventricular remodeling and preventing of heart failure in patients with AMI after percutaneous coronary intervention (PCI), 148 patients were randomly assigned (85 to sacubitril/valsartan and 63 to valsartan).

Results

LAV, LVDV, and LVSV were all decreased in the sacubitril/valsartan group when compared with before treatment, but there was no difference between the sacubitril/valsartan group and the valsartan group. In addition, compared with before treatment in the sacubitril/valsartan group, the heart global work index (GWI) and the global work efficiency (GWE) increased, while the heart global wasted work (GWW) decreased. Patients in the sacubitril/valsartan group have similar MACE and adverse side effects to those in the valsartan group.

Conclusion

Sacubitril/valsartan has the same performance as valsartan in inhibiting ventricular remodeling and preventing heart failure after PCI in patients with AMI, and its clinical application is safe. It provides a clinical foundation for the application of sacubitril/valsartan in patients with AMI.

Abatement of potent P2Y12 antagonist-based dual antiplatelet therapy after coronary intervention: A network meta-analysis of randomized controlled trials

Introduction

Dual antiplatelet therapy (DAPT) including prasugrel or ticagrelor is recommended in patients with acute coronary syndromes (ACS) treated with coronary intervention (PCI). Acknowledging the importance of bleeding, multiple trials tested abatement schemes including uniform or guided de-escalation from the potent P2Y12 inhibitor (P2Y12-De) or P2Y12 inhibitor monotherapy (P2Y12-Mo) with heterogeneous results. We aimed to perform a systematic review and network meta-analysis of the impact of DAPT abatement strategies in patients with PCI.

Methods

Electronic databases were searched for relevant randomized clinical studies evaluating clinical outcomes of patients after PCI. The rate of adverse events was evaluated using a frequentist network metanalysis. The random-effects model was used to combine risk estimates across trials and risk ratio (RR) with 95% confidence intervals (95% CIs) served as summary statistics. The primary endpoints of interest were the rate of major cardiac adverse events (MACE, defined as the composite of cardiovascular mortality, myocardial infarction and stroke) and bleeding.

Results

Ten studies were identified randomizing 42511 patients. 6359 switched to the P2Y12-De and 13062 switched to the P2Y12-Mo. The risk of MACE, reflected a 24% reduction in the P2Y12-De and a 14% in the P2Y12-Mo in comparison with the DAPT strategy using potent P2Y12 inhibitors (RR: 0.76 [0.62, 0.94], and RR: 0.86 [0.75, 0.99], p < 0.05 both). A 35% risk reduction of major bleeding was seen with monotherapy (RR: 0.65 [0.46, 0.91],) contrasting the de-escalation trials where this effect was not significant (RR: 0.84 [0.57, 1.22]). All bleeding and minor bleeding events were reduced with both strategies. Indirect P2Y12-Mo versus P2Y12-De comparisons exhibited them as similar alternatives without significant differences.

Conclusion

Our analysis suggests that both P2Y12-De and P2Y12-Mo reduce ischemic events and bleeding among PCI-treated ACS patients. Ischemic benefit was more expressed with P2Y12-De, however, reduction of major bleeding was only significant with P2Y12-Mo strategy.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021258502, identifier CRD42021258502.

Heartwatch: an Irish cardiovascular secondary prevention programme in primary care, a secondary analysis of patient outcomes

OBJECTIVES

To investigate patient follow-up data from Heartwatch: Ireland's secondary prevention programme for cardiovascular disease delivered in general practice.

DESIGN

Retrospective descriptive study based on secondary analysis of routinely collected data from Heartwatch.

SETTING

Heartwatch targeted 20% of general practices in Ireland and recruited 475 general practitioners across 325 practices.

PARTICIPANTS

The patient population included people with a history of acute myocardial infarction, percutaneous transluminal coronary angioplasty or a coronary artery bypass graft. Over 16 000 patients entered the programme however, to assess the long-term progress of patients, we identified a cohort of 5700 patients with at least 8 years in the programme.

INTERVENTIONS

A standard protocol for continuing care of patients for the secondary prevention of cardiovascular disease was administered by general practices. The programme was designed using WHO and European Society of Cardiology guidelines on secondary prevention.

OUTCOME MEASURES

A Continuing Care (CCare) score out of eight was the primary outcome measure used. It was calculated based on programme targets for well-known cardiovascular risk factors: exercise, systolic blood pressure, LDL cholesterol, optimally controlled glucose, smoking status, and pharmacological treatment.

RESULTS

After 1 year, 37% of the 8-year cohort had achieved a CCare score >5 increasing to 44% after year 8. Patient sex was predictive of better scores; male patients had almost a half-point advantage (0.432, 99% CI: 0.335 to 0.509). Patients who enrolled earlier following their qualifying event and patients with more frequent visits were also more likely to achieve higher CCare scores.

CONCLUSIONS

Overall, patients are not likely to meet all targets set by secondary prevention guidelines, however, supporting patient self-management may impact on this. Early enrolment after a cardiac event and frequent structured care visits should be priorities in the design and implementation of similar programmes. Ongoing evaluation of them is necessary to improve outcomes.

How Coronary Perforation Looks at Optical Coherence Tomography Imaging

In this case, review of OCT images after successful closure of a coronary perforation (CP) showed that the initial CP was visible as an abrupt interruption of the intimal tissue and the presence of a crater with blood reaching the external layers of vessel wall. CP was probably caused by overstretch of the vessel wall in an intramural segment of the left anterior descending coronary artery. CP is a possible complication of PTCA that is rarely documented with intracoronary imaging due to its rapid and dramatic evolution. We report the unique images of how an initial CP appears at OCT.

Cognitive changes associated with cerebral emboli during coronary intervention

OBJECTIVE

To investigate factors influencing the frequency and type of microembolic signals (MES) detected using transcranial Doppler (TCD) in patients undergoing elective coronary intervention, and to correlate MES with silent stroke detected using magnetic resonance imaging (MRI) and cognitive dysfunction.

METHODS

The subset study of a randomized clinical trial was conducted on 70 patients (58 males; mean age 59.9 ± 8.4 years) who underwent bilateral TCD monitoring of middle cerebral arteries (MCAs) during elective coronary interventions. Neurologic examination and brain MRI were performed prior to, and 24 h post‑intervention. Cognitive function tests were performed prior to, and on day 30 post‑intervention.

RESULTS

The incidence of detected MES was 94.3 %. Eighteen (25.7 %) patients had new clinically asymptomatic ischemic lesions on MRI. The number of solid MES negatively correlated with changes in revised Addenbrooke's Cognitive Examination test (ACE-R) and, the number of solid MES and combinations of solid and gaseous MES negatively correlated with changes in Mini Mental‑State Examination (MMSE) conducted on day 30 after the intervention (p < 0.05 in all cases).

CONCLUSION

Cardiac catheterization was associated with a high risk of cerebral embolism in our patients. A higher number of solid MES and combinations of solid and gaseous MES was associated with the deterioration in cognitive tests (Tab. 5, Fig. 3, Ref. 30).

Two-Year clinical outcomes after coronary bifurcation stenting in older patients from Korea and Italy

Background

Older patients who treated by percutaneous coronary intervention (PCI) are at a higher risk of adverse cardiac outcomes. We sought to investigate the clinical impact of bifurcation PCI in older patients from Korea and Italy.

Methods

We selected 5,537 patients who underwent bifurcation PCI from the BIFURCAT (comBined Insights from the Unified RAIN and COBIS bifurcAtion regisTries) database. The primary outcome was a composite of target vessel myocardial infarction, clinically driven target lesion revascularization, and stent thrombosis at two years.

Results

In patients aged ≥75 years, the mean age was 80.1 ± 4.0 years, 65.2% were men, and 33.7% had diabetes. Older patients more frequently presented with chronic kidney disease (CKD), severe coronary calcification, and left main coronary artery disease (LMCA). During a median follow-up of 2.1 years, older patients showed similar adverse clinical outcomes compared to younger patients (the primary outcome, 5.7% vs. 4.5%; p = 0.21). Advanced age was not an independent predictor of the primary outcome (p = 0.93) in overall patients. Both CKD and LMCA were independent predictors regardless of age group.

Conclusions

Older patients (≥75 years) showed similar clinical outcomes to those of younger patients after bifurcation PCI. Advanced age alone should not deter physicians from performing complex PCIs for bifurcation disease.

Effect of a standardised heart team protocol versus a guideline-based protocol on revascularisation decision stability in stable complex coronary artery disease: rationale and design of a randomised trial of cardiology specialists using historic cases

INTRODUCTION

A multidisciplinary heart team approach has been recommended by revascularisation guidelines, but how to organise and implement the heart team in a standardised way has not been validated. Inter-team and intra-team decision instability existed in the guideline-based heart team protocol, and our standardised heart team protocol based on a mixed method study may improve decision stability. The objective of this study is to evaluate the effect of the standardised heart team protocol versus the guideline-based protocol on decision-making stability in stable complex coronary artery disease (CAD).

METHODS AND ANALYSIS

Eighty-four eligible interventional cardiologists, cardiac surgeons or non-interventional cardiologists from 26 hospitals in China have been enrolled. They will be randomised to a standardised heart team protocol group or a guideline-based protocol group to make revascularisation decisions for 480 historic cases (from a prospective registry) with stable complex CAD. In the standardised group, we will establish 12 heart teams based on an evidence-based protocol, including specialist selection, specialist training, team composition, team training and a standardised meeting process. In the guideline-based group, we will organise 12 heart teams according to the guideline principles, including team composition and standardised meeting process. The primary outcome is the overall percent agreement in revascularisation decisions between heart teams within a group. To demonstrate the clinical implication of decision-making stability, we will further explore the association between decision stability and 1-year clinical outcomes.

ETHICS AND DISSEMINATION

The study was approved by the Institutional Review Board (IRB) of Fuwai Hospital (No. 2019-1303). All participants have provided informed consent and all patients included as historic cases provided written informed consent at the time of entry to the prospective registry. The results of this trial will be disseminated through manuscript publication and national/international conferences, and reported in the trial registry entry.

TRIAL REGISTRATION NUMBER

NCT05039567.

Retrograde approach for rewiring a jailed side branch during double kissing crush stenting

Double kissing crush (DK crush) is one of the preferred strategies for bifurcation stenting due to the lower risk of target vessel failure but can be difficult to perform. Difficulty in wiring the jailed side branch after stenting the main vessel is not uncommon. The retrograde crossing can provide a solution in selected cases when antegrade rewiring of a jailed side branch fails during DK crush (or other bifurcation stenting techniques).

Cost-effectiveness of follow-up invasive coronary angiography after percutaneous coronary stenting: a real-world observational cohort study in Japan

OBJECTIVES

Follow-up invasive coronary angiography (FUICA) after percutaneous coronary intervention (PCI) has been shown to increase the rate of early coronary revascularisation without reducing the incidence of subsequent myocardial infarction or death. However, no studies have evaluated the cost-effectiveness of FUICA in patients after coronary stenting. Therefore, this study aimed to evaluate the cost-effectiveness of FUICA after PCI.

DESIGN

Retrospective observational cohort study.

SETTING

497 hospitals.

PARTICIPANTS AND INTERVENTIONS

Overall, 558 patients who underwent coronary artery stenting between April 2014 and March 2015 were matched and included in the invasive angiographic follow-up (AF) group (n=279), in which patients underwent FUICA 6-12 months after PCI, or in the clinical follow-up alone group (CF; n=279) using propensity scores.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint was the composite outcome of death, myocardial infarction, urgent coronary revascularisation, stroke or hospitalisation for the heart failure. The secondary endpoints included all-cause death, non-fatal myocardial infarction, urgent revascularisation, coronary artery bypass grafting, stroke, hospitalisation for the heart failure and any coronary revascularisation after a minimum of 6 months of follow-up.

RESULTS

Costs were calculated as direct medical expenses based on medical fee billing information. The cumulative 3-year incidence of the primary endpoint was 5.3% in the AF group and 4.7% in the CF group (HR 1.02; 95% CI 0.47 to 2.20; p=0.98). The total incremental cost at the 3-year endpoint in the AF group was US$1874 higher than that in the CF group (US$8947±US$5684 vs US$7073±US$6360; p≤0.001).

CONCLUSIONS

FUICA increased the costs but did not improve clinical benefits. Thus, FUICA is not economically more attractive than CF alone.

TRIAL REGISTRATION NUMBER

UMIN000039768.

A clinical trial for computed tomography myocardial perfusion based non-invasive index of microcirculatory resistance (MPBIMR): rationale and trial design

INTRODUCTION

Accurate and rapid assessment of the coronary microcirculation has become an important medical challenge. However, reliable and non-invasive quantitative methods to diagnose coronary microvascular disease (CMVD), select treatments for coronary artery disease (CAD), and therefore improve coronary microcirculation are lacking. Current detection methods have limitations. Therefore, we will assess whether a new detection method, the non-invasive index of microcirculatory resistance (IMR), based on computed tomography (CT) perfusion and hydrodynamics (CT-IMR), can effectively evaluate the function of coronary microvessels.

METHODS

We will conduct a multicenter, randomized, open-label study, including a Phase I single-center and Phase II multicenter trial, to assess the accuracy of the non-invasive CT-IMR coronary measurement of microcirculation function. The study will enroll 295 patients who will undergo coronary CT angiography (CCTA), dynamic CT-myocardial perfusion imaging (CT-MPI), invasive coronary angiography (ICA), and invasive IMR. This study will identify the key influencing factors when calculating myocardial microcirculation perfusion and develop an accurate three-dimensional coronary reconstruction method and a non-invasive coronary IMR calculation method based on computational fluid dynamics (CFD). This will facilitate the development of a non-invasive system to detect and measure coronary microcirculation.

CONCLUSION

The clinical trial for computed tomography myocardial perfusion based non-invasive index of microcirculatory resistance (MPBIMR) will establish the key influencing factors when calculating myocardial microcirculation perfusion and create a non-invasive CT-IMR calculation method based on CFD. This method may diagnose patients with simple coronary microvascular lesions and those with coronary microvascular lesions combined with coronary vascular lesions.

Distal Transradial Access For Cardiac Catheterization in Patients Undergoing Hemodialysis

OBJECTIVES

Although a distal radial artery (DRA) approach has recently been used in patients undergoing cardiac catheterization, no studies have so far investigated the safety and feasibility of DRA in patients undergoing hemodialysis (HD). We aimed to investigate the incidence of conventional radial artery (CRA) occlusion and puncture site complications after DRA puncture in patients undergoing HD.

METHODS

We retrospectively analyzed the data of 117 consecutive patients with HD who underwent coronary angiography or percutaneous coronary intervention via a DRA approach at our institution from September 2017 to December 2019. The primary endpoint was the incidence of CRA occlusion after DRA puncture, as assessed via vascular ultrasonography. Secondary endpoints included difficulty achieving hemostasis, DRA occlusion, aneurysm, arteriovenous shunt, and acute ischemia.

RESULTS

The DRA puncture was successful in 106 patients (success rate: 90.5%). Because 21 patients lacked postprocedural vascular ultrasonography data, the primary endpoint was evaluated in 85 patients. CRA occlusion occurred in three patients (3.5%) following DRA puncture. DRA occlusion and aneurysm occurred in five patients (5.9%) and one patient (1.2%), respectively.

CONCLUSIONS

Catheterization through DRA is feasible in patients undergoing HD, with a clinically acceptable incidence of CRA and complications.

Predictors of long-term symptom burden and quality of life in patients hospitalised with chest pain: a prospective observational study

OBJECTIVE

To describe the magnitude and predictors of symptom burden (SB) and quality of life (QoL) 3 months after hospital admission for acute chest pain.

DESIGN

Prospective observational study.

SETTING

Single centre, outpatient follow-up.

PARTICIPANTS

1506 patients.

OUTCOMES

Scores reported for general health (RAND-12), angina-related health (Seattle Angina Questionnaire 7 (SAQ-7)) and dyspnoea (Rose Dyspnea Scale) 3 months after hospital admission for chest pain.

METHODS

A total of 1506 patients received questionnaires assessing general health (RAND-12), angina-related health (SAQ-7) and dyspnoea (Rose Dyspnea Scale) 3 months after discharge. Univariable and multivariable regression models identified predictors of SB and QoL scores. A mediator analysis identified factors mediating the effect of an unstable angina pectoris (UAP) diagnosis.

RESULTS

774 (52%) responded. Discharge diagnoses were non-ST elevation myocardial infarction (NSTEMI) (14.2%), UAP (17.1%), non-coronary cardiac disease (6.6%), non-cardiac disease (6.3%) and non-cardiac chest pain (NCCP) (55.6%). NSTEMI had the most favourable, and UAP patients the least favourable SAQ-7 scores (median SAQ7-summary; 88 vs 75, p<0.001). NCCP patients reported persisting chest pain in 50% and dyspnoea in 33% of cases. After adjusting for confounders, revascularisation predicted better QoL scores, while UAP, current smoking and hypertension predicted worse outcome. NSTEMI and UAP patients who were revascularised reported higher scores (p<0.05) in SAQ-7-QL, SAQ7-PL, SAQ7-summary (NSTEMI) and all SAQ-7 domains (UAP). Revascularisation altered the unstandardised beta value (>±10%) of an UAP diagnosis for all SAQ-7 and RAND-12 outcomes.

CONCLUSIONS

Patients with NSTEMI reported the most favourable outcome 3 months after hospitalisation for chest pain. Patients with other diseases, in particular UAP patients, reported lower scores. Revascularised NSTEMI and UAP patients reported higher QoL scores compared with patients receiving conservative treatment. Revascularisation mediated all outcomes in UAP patients.

TRIAL REGISTRATION NUMBER

NCT02620202.

Prognostic and diagnostic accuracy of intracoronary electrocardiogram recorded during percutaneous coronary intervention: a meta-analysis

OBJECTIVE

Intracoronary ECG (IC-ECG) recording has been shown to be sensitive and reliable for detecting myocardial viability and local myocardial ischaemia in some studies. But IC-ECG is neither widely used during percutaneous coronary intervention (PCI) nor recommended in guidelines. This up-to-date meta-analysis of published studies was conducted to evaluate the prognostic and diagnostic accuracy of IC-ECG recorded during PCI.

METHODS

Relevant studies were identified by searches of MEDLINE until 19 June 2021. Observational and diagnostic studies which reported the prognostic or diagnostic accuracy of IC-ECG were included. Data were extracted independently by two authors. Summary estimates of clinical outcomes were obtained using a random effects model. Summary diagnostic accuracy was obtained by using a Bayesian bivariate random effects model.

RESULTS

Of the 12 included studies, 7 studies reported the clinical outcomes (821 patients) and 6 studies reported the diagnostic accuracy (485 patients) of IC-ECG. The pooled ORs with 95% CIs of ST-segment elevation recorded by IC-ECG were 4.65 (1.69 to 12.77), 5.08 (1.10 to 23.44), 4.53 (0.79 to 25.90) and 1.83 (0.93 to 3.62) for major adverse cardiac events, myocardial infarction, cardiac death and revascularisation, respectively. The weighted mean difference were 6.49 (95% CIs 3.84 to 9.14) for ejection fraction when ST-segment resolution was recorded, and 0.86 (95% CIs -8.55 to 10.26) when ST-segment elevation was recorded. The pooled sensitivity and specificity of ST-segment elevation were 0.78 (95% credibility intervals 0.64 to 0.89) and 0.87 (95% credibility intervals 0.75 to 0.94), respectively.

CONCLUSIONS

These findings provide quantitative data supporting that IC-ECG had promising diagnostic ability for local myocardial injury, and could predict clinical outcomes.