Robotic Assisted Percutaneous Coronary Intervention: Initial Australian Experience

BACKGROUND & AIM

Robotic-assisted percutaneous coronary intervention (R-PCI) has been increasingly performed overseas. Initial observations have demonstrated its clinical efficacy and safety with additional potential benefits of more accurate lesion assessment and stent deployment, with reduced radiation exposure to operators and patients. However, data from randomised controlled trials or clinical experience from Australia are lacking.

METHODS

This was a single-centre experience of all patients undergoing R-PCI as part of the run-in phase for an upcoming randomised clinical trial (ACTRN12623000480684). All R-PCI procedures were performed using the CorPath GRX robot (Corindus Vascular Robotics, Waltham, Massachusetts, USA). Key inclusion criteria included patients with obstructive coronary disease requiring percutaneous coronary intervention. Major exclusion criteria included ST-elevation myocardial infarction, cardiogenic shock or lesions deemed unsuitable for R-PCI by the operator. Clinical success was defined as residual stenosis <30% without in-hospital major adverse cardiovascular events (MACE). Technical success was defined as the completion of the R-PCI procedure without unplanned manual conversion. Procedural characteristics were compared between early (cases 1-3) and later (cases 4-21) cases.

RESULTS

Twenty-one (21) patients with a total of 24 lesions were analysed. The mean age of patients was 66.5 years, and 66% of cases were male. Radial access was used in 18 cases (86%). Most lesions were American Heart Association/American College of Cardiology class B2/C (66%). Clinical success was achieved in 100% with manual conversion required in four cases (19%). No procedural complications or in-hospital MACE occurred. Compared to the early cases, later cases had a statistically significantly shorter fluoroscopy time (44.0mins vs 25.2mins, p<0.007), dose area product (967.3 dGy.cm2 vs 361.0dGy.cm2, p=0.01) and air kerma (2484.3mGy vs 797.4mGy, p=0.009) with no difference in contrast usage (136.7mL vs 131.4mL, p=0.88).

CONCLUSIONS

We present the first clinical experience of R-PCI in Australia using the Corindus CorPath GRX robot. We achieved clinical success in all patients and technical success in the majority of cases with no procedural complications or in-hospital MACE. With increasing operator and staff experience, cases required shorter fluoroscopy time and less radiation exposure but similar contrast usage.

Management and outcomes with 5-year mortality of patients with mildly elevated high-sensitivity troponin T levels not meeting criteria for myocardial infarction

OBJECTIVES

To examine management and outcomes of patients presenting to EDs with symptoms suggestive of acute coronary syndrome, who have mild non-dynamically elevated high-sensitivity troponin T (HsTnT) levels, not meeting the fourth universal definition of myocardial infarction (MI) criteria (observation group).

METHODS

Consecutive patients presenting to the ED with symptoms suggestive of acute coronary syndrome at Liverpool Hospital, Sydney, Australia, those having ≥2 HsTnT levels after initial assessment were adjudicated according to the fourth universal definition of MI, as MI ruled-in, MI ruled-out, or myocardial injury in whom MI is neither ruled-in nor ruled-out (>1 level ≥15 ng/L, called observation group); follow-up was 5 years.

RESULTS

Of 2738 patients, 547 were in the observation group, of whom 62% were admitted to hospital, 52% to cardiac services, whereas 97% of MI ruled-in patients and 21% of MI ruled-out patients were admitted; P < 0.001. Non-invasive testing occurred in 42% of observation group patients (36% had echo-cardiography), and 16% had coronary angiography. Of observation group patients, MI rates were 1.5% during hospitalisation and 4% during the following year, similar to that in those with MI ruled-in, among those with MI ruled-out, the MI rate was 0.2%. The 1-year death rate was 13% among observation group patients and 11% MI ruled-in patients (P = 0.624), whereas at 5 years among observation group patients, type 1 MI and type 2 MI were 48%, 26% and 58%, respectively (P = 0.001).

CONCLUSION

Very few unselected consecutive patients attending ED, with minor stable HsTnT elevation, had MI, although most had chronic myocardial injury. Late mortality rates among observation group patients were higher than those with confirmed type 1 MI but lower than those with type 2 MI.

Ultrasound guidance for transfemoral access in coronary procedures: an individual participant-level data metaanalysis from the femoral ultrasound trialist collaboration

BACKGROUND

Randomised controlled trials of ultrasound (US)-guided transfemoral access (TFA) for coronary procedures have shown mixed results.

AIMS

We aimed to compare US-guided versus non-US-guided TFA from randomised data in an individual participant-level data (IPD) meta-analysis.

METHODS

We completed a systematic review and an IPD meta-analysis of all randomised controlled trials comparing US-guided versus non-US-guided TFA for coronary procedures. We performed a one-stage mixed-model meta-analysis using the intention-to-treat population from included trials. The primary outcome was a composite of major vascular complications or major bleeding within 30 days.

RESULTS

A total of 2,441 participants (1,208 US-guided, 1,233 non-US-guided) from 4 randomised clinical trials were included. The mean age was 65.5 years, 27.0% were female, and 34.5% underwent a percutaneous coronary intervention. The incidence of major vascular complications or major bleeding (34/1,208 [2.8%] vs 55/1,233 [4.5%]; odds ratio [OR] 0.61, 95% confidence interval [CI]: 0.39-0.94; p=0.026) was lower in the US-guided TFA group. In the prespecified subgroup of participants who received a vascular closure device, those randomised to US-guided TFA experienced a reduction in the primary outcome (2.1% vs 5.6%; OR 0.36, 95% CI: 0.19-0.69), while no benefit for US guidance was observed in the subgroup without vascular closure devices (4.1% vs 3.3%; OR 1.21, 95% CI: 0.65-2.26; interaction p=0.009).

CONCLUSIONS

In participants undergoing coronary procedures by TFA, US guidance decreased the composite outcome of major vascular complications or bleeding and may be especially helpful when using vascular closure devices.

Exploration of Cardiology Patient Hospital Presentations, Health Care Utilisation and Cardiovascular Risk Factors During the COVID-19 Pandemic

OBJECTIVES

COVID-19 and the lockdowns have affected health care provision internationally, including medical procedures and methods of consultation. We aimed to assess the impact of COVID-19 at two Australian hospitals, focussing on cardiovascular hospital admissions, the use of community resources and cardiovascular risk factor control through a mixed methods approach.

METHODS

Admissions data from the quaternary referral hospital were analysed, and 299 patients were interviewed from July 2020 to December 2021. With the admissions data, the number, complexity and mortality of cardiology hospital admissions, prior to the first COVID-19 lockdown (T0=February 2018-July 2019) were compared to after the introduction of COVID-19 lockdowns (T1=February 2020-July 2021). During interviews, we asked patients about hospital and community health resource use, and their control of cardiovascular risk factors from the first lockdown.

RESULTS

Admission data showed a reduction in hospital presentations (T0=138,099 vs T1=128,030) and cardiology admissions after the lockdown period began (T0=4,951 vs T1=4,390). After the COVID-19-related lockdowns began, there was an increased complexity of cardiology admissions (T0=18.7%, 95% CI 17.7%-19.9% vs T1=20.3%, 95% CI 19.1%-21.5%, chi-square test: 4,158.658, p<0.001) and in-hospital mortality (T0=2.3% of total cardiology admissions 95% CI 1.9%-2.8% vs T1=2.8%, 95% CI 2.3%-3.3%, chi-square test: 4,060.217, p<0.001). In addition, 27% of patients delayed presentation due to fears of COVID-19 while several patients reported reducing their general practitioner or pathology/imaging appointments (27% and 11% respectively). Overall, 19% reported more difficulty accessing medical care during the lockdown periods. Patients described changes in their cardiovascular risk factors, including 25% reporting reductions in physical activity.

CONCLUSION

We found a decrease in hospital presentations but with increased complexity after the introduction of COVID-19 lockdowns. Patients reported being fearful about presenting to hospital and experiencing difficulty in accessing community health services.

Text Messages to Improve Medication Adherence and Secondary Prevention After Acute Coronary Syndrome: The TEXTMEDS Randomized Clinical Trial

BACKGROUND

TEXTMEDS (Text Messages to Improve Medication Adherence and Secondary Prevention After Acute Coronary Syndrome) examined the effects of text message-delivered cardiac education and support on medication adherence after an acute coronary syndrome.

METHODS

TEXTMEDS was a single-blind, multicenter, randomized controlled trial of patients after acute coronary syndrome. The control group received usual care (secondary prevention as determined by the treating clinician); the intervention group also received multiple motivational and supportive weekly text messages on medications and healthy lifestyle with the opportunity for 2-way communication (text or telephone). The primary end point of self-reported medication adherence was the percentage of patients who were adherent, defined as >80% adherence to each of up to 5 indicated cardioprotective medications, at both 6 and 12 months.

RESULTS

A total of 1424 patients (mean age, 58 years [SD, 11]; 79% male) were randomized from 18 Australian public teaching hospitals. There was no significant difference in the primary end point of self-reported medication adherence between the intervention and control groups (relative risk, 0.93 [95% CI, 0.84-1.03]; P=0.15). There was no difference between intervention and control groups at 12 months in adherence to individual medications (aspirin, 96% vs 96%; β-blocker, 84% vs 84%; angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, 77% vs 80%; statin, 95% vs 95%; second antiplatelet, 84% vs 84% [all P>0.05]), systolic blood pressure (130 vs 129 mm Hg; P=0.26), low-density lipoprotein cholesterol (2.0 vs 1.9 mmol/L; P=0.34), smoking (P=0.59), or exercising regularly (71% vs 68%; P=0.52). There were small differences in lifestyle risk factors in favor of intervention on body mass index <25 kg/m² (21% vs 18%; P=0.01), eating ≥5 servings per day of vegetables (9% vs 5%; P=0.03), and eating ≥2 servings per day of fruit (44% vs 39%; P=0.01).

CONCLUSIONS

A text message-based program had no effect on medical adherence but small effects on lifestyle risk factors.

REGISTRATION

URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364448; Unique identifier: ANZCTR ACTRN12613000793718.

Pericardiocentesis over 3 years at a tertiary referral Australian hospital

Funding Acknowledgements

Type of funding sources: None.

Background

 Pericardiocentesis is a lifesaving intervention performed both percutaneously or surgically. We analysed 3 years of experience in a major tertiary hospital in Sydney Australia. 

Purpose

 To examine the indications, safety and delivery of a pericardiocentesis service at a major teaching hospital. 

Methods

 We retrospectively audited consecutive patients who underwent pericardiocentesis for  pericardial effusion[PE] at a major teaching hospital from February 2018 to December 2020. Eligible patients were identified from the electronic medical records with this coding diagnosis.

Results

89 patients identified with mean age 60.8 ± 18.9years and 58.4%(51/89) male. Follow-up to August 2021 showed 41.5% had died, with an index hospitalisation mortality of 19%(17/89). Malignancy was the most common aetiology 30.3%(27/89) and attributable cause of hospitalisation death in 29.4%. Alternate causes included pericarditis 14.6%, idiopathic 13.4%, percutaneous-coronary-intervention(PCI) 5.6%(6/89) and electrophysiology 4.5%(4/89) complications. Three patients had aortic dissection (3.3%) and two were fatal. Clinical tamponade was present in 66.2%(55/89), PE identification occurred via echocardiography(TTE) in 55% cases (49/89) and incidental CT-diagnosis in 20.2%. TTE findings: right atrial collapse 54%(47/87), right ventricular collapse 60.9%(53/87), fixed and dilated inferior vena cava 64.7%. Pericardiocentesis was performed by cardiology trainees in 90.5% cases, 64.5% with consultant supervision and during working hours in 57.3% of cases. Percutaneous drainage was successful in 96%(72/75) of cases and was performed in the coronary care unit (30.3%), catheterisation laboratory (23.5%), emergency department (19.1%) and ICU (11.2%). Subxiphoid approach in 70%(62/89) was the most common then trans-apical 15%(13/89), parasternal 3%(3/89) and surgical 16%(14/89). TTE confirmed drain position in 76%(54/71), fluoroscopy in 28.5%(6/21) and agitated saline in 38.9%(30/77). Haemo-serous fluid noted in 77%(67/87) with average initial fluid drainage 480 ± 326mls and mean drain removal time 54 ± 33hrs. 17%(15/89) required re-drainage with adenocarcinoma found in 33.3%(5/15). Background antiplatelet treatment in 30.6%(27/88) and of these 67%(18/27) were on dual antiplatelets. 33%(29/89) patients were anticoagulated and 31.3%(9/29) required reversal prior to drainage. Complications were rare, 4%(3/75) had right heart chamber perforation needing emergency surgery. Two were post complex PCI (one died during admission from multiorgan failure) and one with pericarditis . 

Conclusions

 Pericardiocentesis is a safe and effective procedure for tamponade treatment and largely guided by echocardiography in our experience. Complications are rare and prognosis depends on aetiology with malignancy the most common. Drainage is often successfully performed emergently where the patient is located. Tamponade resulting from procedural complications are rare in our cohort.

Right ventricular myocardial infarction: pathophysiology, clinical implications and management

Right ventricular myocardial infarction (RVMI) and right ventricular (RV) failure are complications from an acute occlusion of a dominant right coronary artery (RCA) or left anterior descending (LAD) artery. Although some patients have good long-term RV recovery, RVMI is associated with high rates of in-hospital morbidity and mortality driven by hemodynamic compromise, cardiogenic shock, and electrical complications. As such, it is important to identify specific clinical signs and symptoms, initiate resuscitation and commence reperfusion therapy with fibrinolytic therapy or percutaneous coronary intervention. This review will discuss RVMI pathophysiology, describe the current diagnostic measures, highlight current therapies, and explore future management options.

In Hospital Outcomes for High-Risk Percutaneous Coronary Intervention (PCI) in Patients Referred From a Rural Centre to Metropolitan Sites

BACKGROUND

Cardiac Society of Australia and New Zealand (CSANZ) guidelines recommend elective high-risk percutaneous coronary intervention (PCI) is not performed in sites greater than 1 hour from cardiac surgery.

METHODS

In hospital outcomes for all patients from Orange Health Service (OHS) from January 2017 to January 2020 who were transferred electively to tertiary centres in Sydney for high risk PCI were examined.

RESULTS

One hundred and fourteen (114) patients were identified, with 1,259 PCIs performed at OHS over the same period without transfer. The mean age of these 114 patients was 71 years, with 74.6% male. Receiving hospitals were Royal Prince Alfred Hospital, Sydney, NSW (66.7%), Concord Repatriation General Hospital, Concord, NSW (19.3%) and Strathfield Private Hospital, Strathfield, NSW (14%). The definition of high risk and indication for transfer included at least one of: moderate or greater calcification of the target lesion or proximal segment (34%), single or multiple target lesions that in aggregate jeopardised over 50% of remaining viable myocardium (27%), degenerated saphenous vein grafts (14.8%), chronic total occlusions (7.0%) and severe left ventricular (LV) impairment (3.9%). American Heart Society/American College of Cardiology (AHA/ACC) lesion types were A (1%), B1 (4.2%), B2 (40.2%), and C (54.6%). PCI was performed via the femoral route in 96.2%. The mean procedure duration was 72 minutes, mean combined fluoroscopy time was 19 minutes and mean radiation dose as defined by Reference Air Kerma was 1,630 mGy. Complications occurred in 13 patients and were: acute vessel dissection requiring stenting (4), perforation (2), acute vessel closure (4), puncture site related (1), and life-threatening arrhythmia (2). There were no cases of emergent coronary artery bypass graft (CABG) or death.

CONCLUSION

This contemporary cohort of high-risk patients transferred electively from a regional PCI centre to a tertiary cardiac unit underwent lengthy PCI procedures, with high radiation doses, and a modest rate of peri-procedural complications, but had otherwise excellent procedural and clinical outcomes.

The Learning Curves for Transradial and Ultrasound-Guided Arterial Access: An Analysis of the SURF Trial

INTRODUCTION

Historically, coronary angiography and percutaneous coronary intervention involved accessing the femoral artery via palpation. However, recently there has been a trend towards using a transradial approach and ultrasound guidance for arterial access. Studies have shown that these techniques respectively improve major bleeding rates and access outcomes. There have been no studies conducted that assess the time it takes to train operators to attain proficiency. This sub-analysis of the Standard versus Ultrasound-guided Radial and Femoral access in coronary angiography and intervention (SURF) trial aims to assess the number of procedures required to attain proficiency in ultrasound-guided transradial and transfemoral access.

METHODS

The SURF trial randomised 1,388 patients undergoing coronary angiography and/or percutaneous coronary intervention into standard or ultrasound-guidance and radial or femoral access in a 2×2 factorial design. Operators who participated in this trial were required to have performed at least 50 standard and 10 ultrasound-guided punctures for each of transradial and transfemoral access. Cases were then chronologically ordered and stratified into groups of five, from which the primary endpoint measured was a progression in mean access time and first-pass success rates.

RESULTS

Across all operators, there was a reduction in mean access time between procedures one to five and six to 10 with ultrasound-guided femoral punctures (60.5 secs-51.5 secs, p=0.029) and between procedures 11 to 15 and 16 to 20 ultrasound-guided radial punctures (74s to 62.5 secs, p=0.082). This trend was more obvious in trainees, with significant reductions in mean access time between procedures one to five and six to 10 from 73.5 to 53.5 seconds (p<0.001) for ultrasound-guided femoral access and from 99.5 seconds to 60 seconds (p=0.024) for ultrasound-guided radial access. There were no trends with standard transradial access.

CONCLUSION

The numbers required to attain competency in ultrasound-guided femoral and radial access are 15 and 25 punctures, respectively. Fifty (50) punctures appear adequate for proficiency in a standard transradial approach. These numbers are useful in incorporating into training program for advanced trainees and interventionalists.

Comparison of standard versus ultrasound guidance in radial and femoral access: a subanalysis of the randomised SURF trial

Background

Ultrasound (US) guidance in facilitating arterial access may reduce vascular complications and possible bleeding. There are still limited trials assessing real-time US guidance for coronary angiography. The SURF (Standard versus ultrasound-guided radial and femoral access in coronary angiography and intervention) trial showed no difference in primary outcome when the combined radial and femoral ultrasound analysis compared with standard (SD) technique, but significantly improved access efficiency and success rate.

Purpose

This subanalysis compared clinical and procedural outcomes of the individual radial and femoral access with US guidance versus standard technique.

Methods

Patients (n=1388) undergoing coronary angiography and percutaneous coronary intervention were randomised (1:1) into radial or femoral access, and (1:1) to SD or US guidance. The primary outcome was a composite of ACUITY (Acute Catheterisation and Urgent Intervention Triage strategY) major bleeding, MACE (death, stroke, myocardial infarction or urgent target lesion revascularisation) and vascular complications at 30 days. Secondary outcomes were access time, number of attempts, venepuncture, difficult accesses and first-pass success.

Results

Compared to standard, US guidance produced no difference in composite endpoint for both radial (1.4% vs 1.2%, p=0.78) and femoral (3.1% vs 3.8%, p=0.65) accesses. ACUITY major bleeding (radial: 0.9% US vs 0.6% SD, p=0.69; femoral: 1.9% US vs 2.3% SD, p=0.69), vascular complications (radial: 0.3% US vs 0.3% SD, p=0.98; femoral: 1.3% US vs 0.9% SD, p=0.63) and MACE (radial: 0.6% US vs 0.3% SD, p=0.59; femoral: 0.9% US vs 1.2% SD, p=0.78) were similar in the US and SD approaches, respectively. However, US guidance resulted in improved procedural outcomes for both accesses. Femoral access derived the most benefit from US, with reduced mean access time (73 sec vs 97 sec, p=0.006), attempts (1.35 vs 1.84, p≤0.0001), difficult accesses (1.8% vs 6.2%, p=0.004), venepuncture (5.8% vs 12.6%, p=0.002) and improved first-pass success (77.2% vs 58.8%, p≤0.0001). For radial, US reduced attempts (1.59 vs 1.97, p=0.0007), difficult accesses (6.9% vs 12.3%, p=0.02), venepuncture (2.5% vs 5.6%, p=0.04) and improved first-pass success (69.2% vs 60.7%, p=0.02). There was no difference in radial mean access time (111 sec vs 126 sec, p=0.18).

Conclusions

US guidance in radial and femoral access did not reduce primary outcome compared to standard technique. The use of US significantly improved the efficiency and success rate of arterial cannulation, with femoral access derived the most benefit.

Funding Acknowledgement

Type of funding source: None

Rural and Remote Cardiology During the COVID-19 Pandemic: Cardiac Society of Australia and New Zealand (CSANZ) Consensus Statement

THE CHALLENGES

Rural and remote Australians and New Zealanders have a higher rate of adverse outcomes due to acute myocardial infarction, driven by many factors. The prevalence of cardiovascular disease (CVD) is also higher in regional and remote populations, and people with known CVD have increased morbidity and mortality from coronavirus disease 2019 (COVID-19). In addition, COVID-19 is associated with serious cardiac manifestations, potentially placing additional demand on limited regional services at a time of diminished visiting metropolitan support with restricted travel. Inter-hospital transfer is currently challenging as receiving centres enact pandemic protocols, creating potential delays, and cardiovascular resources are diverted to increasing intensive care unit (ICU) and emergency department (ED) capacity. Regional and rural centres have limited staff resources, placing cardiac services at risk in the event of staff infection or quarantine during the pandemic.

MAIN RECOMMENDATIONS

Health districts, cardiologists and government agencies need to minimise impacts on the already vulnerable cardiovascular health of regional and remote Australians and New Zealanders throughout the COVID-19 pandemic. Changes in management should include.

COVID-19 and Acute Heart Failure: Screening the Critically Ill - A Position Statement of the Cardiac Society of Australia and New Zealand (CSANZ)

Up to one-third of COVID-19 patients admitted to intensive care develop an acute cardiomyopathy, which may represent myocarditis or stress cardiomyopathy. Further, while mortality in older patients with COVID-19 appears related to multi-organ failure complicating acute respiratory distress syndrome (ARDS), the cause of death in younger patients may be related to acute heart failure. Cardiac involvement needs to be considered early on in critically ill COVID-19 patients, and even after the acute respiratory phase is passing. This Statement presents a screening algorithm to better identify COVID-19 patients at risk for severe heart failure and circulatory collapse, while balancing the need to protect health care workers and preserve personal protective equipment (PPE). The significance of serum troponin levels and the role of telemetry and targeted transthoracic echocardiography (TTE) in patient investigation and management are addressed, as are fundamental considerations in the management of acute heart failure in COVID-19 patients.

Standard Versus Ultrasound-Guided Cannulation of the Femoral Artery in Patients Undergoing Invasive Procedures: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

It is unclear whether or not ultrasound-guided cannulation (UGC) of the femoral artery is superior to the standard approach (SA) in reducing vascular complications and improving access success.

OBJECTIVE

We sought to compare procedural and clinical outcomes of femoral UGC versus SA in patients undergoing percutaneous cardiovascular intervention (PCvI).

METHODS

We searched EMBASE, MEDLINE, Scopus and web sources for randomized trials comparing UGC versus SA. We estimated risk ratio (RR) and standardized mean differences (SMDs) with 95% confidence intervals (CIs) for categorical and continuous variables, respectively. Primary efficacy endpoint was the success rate at the first attempt, while secondary efficacy endpoints were access time and number of attempts. Primary safety endpoints were the rates of vascular complications, while secondary endpoints were major bleeding, as well as access site hematoma, venepuncture, pseudoaneurysms and retroperitoneal hematoma. This meta-analysis has been registered on Centre for Open Science (OSF) (osf.io/fy82e).

RESULTS

Seven trials were included, randomizing 3180 patients to UGC (n = 1564) or SA (n = 1616). Efficacy between UGC and SA was the main metric assessed in most of the trials, in which one third of the enrolled patients underwent interventional procedures. The success rate of the first attempt was significantly higher with UGC compared to SA, (82.0% vs. 58.7%; RR: 1.36; 95% CI: 1.17 to 1.57; p < 0.0001; I² = 88%). Time to access and number of attempts were significantly reduced with UGC compared to SA (SMD: -0.19; 95% CI: -0.28 to -0.10; p < 0.0001; I² = 22%) and (SMD: -0.40; 95% CI: -0.58 to -0.21; p < 0.0001; I² = 82%), respectively. Compared with SA, use of UGC was associated with a significant reduction in vascular complications (1.3% vs. 3.0%; RR: 0.48; CI 95%: 0.25 to 0.91; p = 0.02; I² = 0%) and access-site hematoma (1.2% vs. 3.3%; RR: 0.41; CI 95%: 0.20 to 0.83; p = 0.01; I² = 27%), but there were non-significant differences in major bleeding (0.7% vs. 1.4%; RR: 0.57; CI 95%: 0.24 to 1.32; p = 0.19; I² = 0%). Rates of venepuncture were lower with UGC (3.6% vs. 12.1%; RR: 0.32; CI 95%: 0.20 to 0.52; p < 0.00001; I² = 55%).

CONCLUSION

This study, which included all available data to date, demonstrated that, compared to a standard approach, ultrasound-guided cannulation of the femoral artery is associated with lower access-related complications and higher efficacy rates. These results could be of great clinical relevance especially in the femoral cannulation of high risk patients.

Revascularization Strategies in Patients With STEMI: Culprit-Only vs Multivessel Revascularization Using Percutaneous Coronary Intervention

BACKGROUND

Approximately 50% of patients undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) have multivessel coronary disease (MVD). Evidence on the best PCI approach for these patients is conflicting. The aim of this study is to examine Australian data from the CONCORDANCE registry to describe the practice and outcomes of patients receiving multivessel vs culprit-only PCI.

METHODS

Two cohorts were constructed from MVD-STEMI patients undergoing primary PCI at 41 hospitals between 2009 and 2015: culprit-only PCI (n = 587; 87%) and multivessel PCI (n = 82; 12%). Clinical characteristics were described, and the outcomes were all-cause mortality, heart failure, and myocardial reinfarction, in-hospital and at 6-month follow-up. The relative prevalence of each procedure over time was also described.

RESULTS

The patient cohorts were comparable in age, sex, and cardiovascular risk factors. Patients with higher Killip scores were more likely to receive multivessel PCI (P=.02). The multivessel group was significantly more likely to have in-hospital cardiogenic shock (P<.01), myocardial reinfarction (P=.02), cardiac arrest (P=.02), and stroke (P=.01). There was no difference in the incidence of ischemic events at 6 months, but the multivessel group had a lower rate of planned repeat revascularizations (12% vs 2%; P=.03). There was no difference in the relative frequency of multivessel vs culprit-only PCI during the observation period.

CONCLUSIONS

The relative frequency of multivessel vs culprit-only PCI has not changed from 2009-2015. Index complete revascularization for STEMI-MVD patients is more likely to be performed in those with worse presentations and is associated with worse in-hospital complications.

P2717Type-II MI and chronic myocardial injury rates, invasive management and 4 year mortality among consecutive patients undergoing high sensitivity troponin T testing in the emergency department

Background

In emergency departments (EDs), assessment of patients with suspected acute coronary syndromes (ACS) represents a major workload and high sensitivity troponin (HsTn) T and I levels are frequently measured. A minority of patients have final diagnosis of myocardial infarction (MI).

Methods and results

Among 2738 consecutive patients with suspected ACS presenting to ED at Liverpool Hospital, Australia, between March and June 2014, we determined the relative frequencies of 3 patient groups: type-I MI, type-II MI including chronic myocardial injury (CMI), and assessed the use of invasive and pharmacological therapies and 4-year outcomes. Adjudication of MI was according to the 4th universal definition of MI as follows: 1) type-I MI; 2) type-II MI (including acute myocardial injury), and 3) CMI. Of 995 patients (36%) median age 76 years [IQR 65–83]), with at least 2 HsTnT measurements and one >14ng/l, 727 (73%) had chronic myocardial injury, 171 (17%) had type-II MI; and 97 (9.7%) had type-I MI. Patients with type-I MI (mean age 63 years) were younger than those with type-II MI or chronic myocardial injury by 12 and 14 years respectively. The main triggering factors for type-II MI/acute injury included: sepsis (21.1%), acute heart failure (18.3%), tachyarrhythmia (16.9%), anaemia (8.6%) and a combination of factors (16%). In-hospital angiography (62% had PCI) rates were 95% for patients with type-I MI, 24% (7% PCI) for those with type-II MI and 3.4% for CMI. Mortality at 4 years was 55% for type-II MI, 44% for CMI and 18% for type-1 MI (P<0.001; Figure), though after Cox modelling adjusting for age, gender, renal function and COPD, compared to type 1 MI, type-II MI (hazard ratio 1.61 [95% CIs 0.90–2.86]; p=0.106) and CMI (hazard ratio 1.01 [95% CIs 0.59–1.74]; p=0.963) were not independently associated with increased late mortality, largely because patients with type 1 MI were a decade younger.

Conclusion

Among unselected patients undergoing HsTnT testing in EDs, type-II MI including acute myocardial injury was more common than type-I MI. Chronic myocardial injury, which occurred in 3 of 4 patients. While patients with type-II MI acute myocardial injury had higher late mortality rates than type-I MI, though after multivariable analyses mortality rates were not different.

P6443Late outcomes in patients undergoing PCI for ST elevation myocardial infarction with respect to diabetic status and completeness of revascularisation

Objectives

This paper examines the degree to which the poor prognosis of ST elevation myocardial infarction (STEMI) patients with diabetes mellitus (DM) can be attributed to incomplete revascularization (ICR).

Background

Cardiovascular disease is the most common cause of death for patients with DM; patients with DM often have complex coronary disease and ICR. In STEMI the relative impact of DM and ICR is uncertain as these two factors frequently co-exist, the potential for confounding is high.

Methods and results

Of 589 consecutive STEMI patients, 22% had DM, who compared to patients without DM were of similar age (59 years), were more often female, had more hypertension and dyslipidaemia, but less often were smokers. A residual SYNTAX Score (rSS) >8, which defined ICR, occurred in 33%. Late cardiac death [median 3.5 years] was 4% among those without DM and 12% in those with DM (p=0.002) (p<0.001), and was 3% among 396 with rSS≤8 and 12% in 193 patients with rSS>8 (p<0.001). Patients with both ICR and DM accounted for only 8% of the STEMI population but 30% of all cardiac deaths. At final follow up (3.5 years) cardiac death rates (see Figure) were 22% in patients with both DM and ICR; these were significantly higher than rates in patients with ICR but no-DM (9%, p=0.034), and those with DM and rSS≤8 (6%, p<0.019). Multivariable analysis for cardiac death found a HR for ICR of 2.89 (95% CI 1.31–6.37; p=0.009) and a HR for DM of 5.18 (95% CI 2.45–10.97, p<0.001).

Diabetes, cardiac death & rSS

Conclusions

While ICR in DM patients with STEMI predicts a significantly poorer outcome, the poor prognosis seen in patients with DM is not explained by the degree of ICR alone. Both ICR and DM contribute independently to the risk of cardiac death in STEMI patients.

P2708Clopidogrel versus ticagrelor on coronary microvascular and peripheral endothelial function after non-ST elevation acute coronary syndrome: a randomised trial

Background

Ticagrelor has been shown to reduce microvascular injury and improve peripheral endothelial function compared to clopidogrel in ST-elevation myocardial infarction and stable patients. However, comparable data is lacking in non-ST elevation acute coronary syndromes (NSTE-ACS).

Purpose

To investigate the effects of clopidogrel versus ticagrelor on coronary microvascular function and peripheral endothelial function in NSTE-ACS patients.

Methods

Patients hospitalised for NSTE-ACS were prospectively randomised 1:1 to clopidogrel (300mg loading then 75mg daily) or ticagrelor (180mg loading then 90mg twice-daily). Coronary microvascular function was assessed with index of microcirculatory resistance (IMR) in the infarct related artery (IRA) and non-IRA before and after percutaneous coronary intervention (PCI) using a standard pressure-temperature coronary wire. Peripheral endothelial function was assessed with flow-mediated vasodilation (FMD) of the brachial artery, performed on admission prior to antiplatelet loading and again before discharge, using a pneumatic cuff and 10MHz linear ultrasound transducer.

Results

A total of 40 patients were included for analysis (Figure 1). Median age was 53.5 (IQR 49.0–61.5) years, 35 (87.5%) were male, 11 (27.5%) had diabetes, 19 (47.5%) were smokers. Median peak troponin T was 527 (175–1006.5) ng/L, median GRACE score 91.5 (78.3–103.3) and median SYNTAX score 13 (6–20). Baseline characteristics were similar between both groups. There was no significant difference in the median baseline IMR between the 2 groups in both the IRA (clopidogrel 14.4 [IQR 12.2–18.6] vs ticagrelor 20.8 [11.3–27.4], p=0.22) and non-IRA (14.0 [11.0–22.0] vs 14.0 [10.0–29.5] respectively, p=0.74). 28 patients underwent PCI to the IRA (12 clopidogrel, 16 ticagrelor). There was no significant difference in the median post-PCI IMR between the 2 groups (19.5 [14.5–24.5] vs 29.0 [19.0–35.6] respectively, p=0.11). However, there was significant worsening of post-PCI compared with pre-PCI IMR (19.5 vs 15.0, p=0.049) in the clopidogrel group but not in the ticagrelor group (29.0 vs 25.4, p=0.47). FMD was performed in 23 patients (9 clopidogrel, 14 ticagrelor). Admission median %FMD (change in post-stimulus diameter as a percentage of the baseline diameter) was similar between the 2 groups (13.2% [10.1–17.6] vs 12.2% [10.2–15.8] respectively, p=0.41). There was a trend towards higher median pre-discharge %FMD in the ticagrelor group (12.8% [12.2–18.0]) compared to the clopidogrel group (10.4% [9.5–11.2], p=0.09). There was a trend towards lower pre-discharge %FMD compared to admission in the clopidogrel group (10.4% vs 13.2%, p=0.05) but not the ticagrelor group (12.8% vs 12.2%, p=0.43).

Figure 1

Conclusions

In our NSTE-ACS patients undergoing PCI, ticagrelor resulted in less disruption of coronary microvascular function and may also have beneficial effects on peripheral endothelial function compared to clopidogrel.

Acknowledgement/Funding

Dr. James Xu is funded by a post-graduate scholarship from the Australian Government Research Training Program (RTP)

Standard versus ultrasound-guided radial and femoral access in coronary angiography and intervention (SURF): a randomised controlled trial

AIMS

This study aimed to compare outcomes in unselected patients undergoing cardiac catheterisation via transradial versus transfemoral access and standard versus ultrasound-guided arterial access.

METHODS AND RESULTS

This was a prospective, randomised (radial vs. femoral and standard vs. ultrasound), 2x2 factorial trial of 1,388 patients undergoing coronary angiography and percutaneous coronary intervention. The primary outcome was a composite of ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) major bleeding, MACE (death, stroke, myocardial infarction or urgent target lesion revascularisation) and vascular complications at 30 days. Transradial access reduced the primary outcome (RR 0.37, 95% CI: 0.17-0.81; p=0.013), mostly driven by ACUITY major bleeding (RR 0.343, 95% CI: 0.123-0.959; p=0.041) when compared with the transfemoral approach. There was no difference in the primary outcome between standard and ultrasound guidance (p=0.76). Ultrasound guidance, however, reduced mean access time (93 sec vs. 111 sec; p=0.009), attempts (1.47 vs. 1.9; p<0.0001), difficult accesses (4.5% vs. 9.2%; p=0.0007), venepuncture (4.1% vs. 9.2%; p<0.0001) and improved first-pass success (73% vs. 59.7%; p<0.0001).

CONCLUSIONS

Transradial access significantly reduced the composite outcome compared to transfemoral access. Ultrasound guidance did not reduce the primary outcome compared to the standard technique, but significantly improved the efficiency and overall success rate of arterial access.