Mortality benefit of coronary angioplasty vs. conservative strategy in patients with prior coronary artery bypass surgery presenting with non-ST elevation myocardial infarction

Background

Patients with prior coronary artery bypass graft (CABG) surgery have been excluded or under-represented in many of the trials of percutaneous coronary intervention (PCI) vs. conservative strategy in the management of patients presenting with non-ST elevation myocardial infarction (NSTEMI). Therefore, limited data supports the use of PCI in this context. Given the higher risk profile of these patients, clinicians may default to a conservative strategy given the lack of evidence of benefit of PCI. Our institution consists of one PCI and one non-PCI acute site and serves a population of 500 000 including a uniquely high proportion of the elderly with a high follow up rate and an ideal, interesting population to study with many patients offered a conservative strategy.

Methodology

Patients who presented over a 5 year period from Jan 2012 to Dec 2017 with NSTEMI and prior CABG were identified from Myocardial Ischaemia National Audit Project (MINAP) returns. Hospital records were reviewed to exclude patients with type 2 MI and ST elevation MI. We identified patients who were managed conservatively or with PCI and assessed outcomes at the end pf December 2019, giving a follow up range of 2–7 years. The primary outcome was all cause death or myocardial infarction. Secondary outcome measures included readmission at 30 days and 1 year, angina, need for revascularisation.

Results

206 patients were identified (mean age 77.7y, 26% female) of whom 107 were managed medically and 99 underwent angiography. 74 (36%) of patients were admitted to the non-interventional site, of which 27 patients underwent angiography. Overall, 48 (23%) went on to have PCI (only 7% of patients from the non-PCI site). 29 patients had PCI to the native coronaries, 16 to a bypass graft and the remainder to both. Age and clinical frailty score (CFS) was significantly higher in patients managed conservatively. The primary end point occurred in a high proportion of patients (124, 74.6%) consisting of 28 MI and 96 deaths during the follow up period. Age at presentation, clinical frailty score (CFS), presence of heart failure and absence of statin use were were significantly associated with the primary outcome. There was a significant difference in the primary outcome in patients managed conservatively (113/158; 72%) compared to those who had PCI (11/48; 23%), P<0.001.

Conclusion

PCI in NSTEMI patients with prior CABG is significantly associated with improved survival and less myocardial infarction compared to a conservative strategy in this retrospective audit of our patient population, but PCI patients are younger and less frail, which, in themselves, could suggest treatment bias and might confer a survival benefit. PCI rates varied significantly when patients were assessed in non-interventional acute site compared to a PCI site which has important implications for service provision. A large-scale randomised control trial is warranted to guide best practice.

Funding Acknowledgement

Type of funding source: None

Leptospirosis presenting as severe cardiogenic shock: A case report

Background

Leptospirosis is a rare infectious illness caused by the Spirochaete Leptospira. It has a wide-varying spectrum of presentation. We present a rare case of severe cardiogenic shock secondary to leptospirosis, in the absence of its common clinical features.

Case presentation

A 36-year-old woman presented to our unit with severe cardiogenic shock and subsequent multi-organ failure. Her clinical course was characterised by ongoing pyrexia of unknown origin with concurrent cardiac failure. She was initially managed with broad-spectrum antibiotics and inotropes. Percutaneous cardiac biopsy excluded major causes of myocarditis. On day 21 after presentation, she was found to be IgM-positive for leptospirosis.

Conclusions

This is a rare case of severe cardiogenic shock secondary to leptospirosis infection. The case also highlights the importance of obtaining a thorough social history when assessing a patient with an unusual presentation, as clues can often be missed.

Provision, organization and models of heart valve clinics within The United Kingdom

BACKGROUND

Specialist clinics are recommended for the assessment and follow-up of patients with heart valve disease. We sought to identify the current provision of specialist valve clinics in UK.

METHODS

A database of all UK National Health Service hospitals was created. An online survey was distributed to each hospital to examine the model of heart valve clinic, patient population, provision of advanced imaging modalities and biochemical markers and provision of patient information services.

RESULTS

Valve clinics were run in 48/228 (21%) hospitals, in 27/45 (60%) tertiary centres and 21/183 (11%) district hospitals. The survey was completed by 34 (71%). A consultant cardiologist ran the clinic in 19 (56%), a cardiac sonographer in 8 (24%), a nurse specialist in 3 (9%) and a hybrid model was used in 4 (12%). Patients with native valve disease were seen in 32 (94%), after heart valve surgery in 19 (56%), pre-/post-transcatheter valve intervention in 10 (29%) and with Marfan syndrome in 9(26%). Stress echocardiography, cardiac magnetic resonance imaging, computed tomography and positron emission tomography were available in 21 (62%), 19 (56%), 22 (65%) and 6 (18%) hospitals, respectively.

CONCLUSION

There is an underprovision of specialist heart valve clinics within the UK, and there is a 5-fold difference between cardiac centres and district general hospitals.