Safety of intravenous cangrelor infusion during percutaneous coronary intervention in a real-world cohort of non-pretreated NSTEACS patients

Background and purpose

Since publication of latest ESC guidelines in 2020, pretreatment with an oral P2Y12 receptor inhibitor (P2Y12i) is no longer systematically recommended in patients with non-ST elevation acute coronary syndrome (NSTEACS) [1]. Therefore, from now on, NSTEACS patients will arrive to the cathlab to a larger extent without having a loading dose of an oral P2Y12i administered. Cangrelor, a potent intravenous P2Y12i, is an emerging option that provides a rapid onset of platelet inhibition, but it has not been widely used yet [2]. We aimed to evaluate safety of cangrelor real-world use in NSTEACS patients who had not received an oral P2Y12i before percutaneous coronary intervention (PCI).

Methods

Development of periprocedural thrombotic complications, ischaemic and bleeding events at 30 days was retrospectively evaluated in a cohort of non-pretreated NSTEACS patients referred to PCI. Comparison among those who underwent intravenous infusion of cangrelor and those who received a loading dose of an oral P2Y12i (ticagrelor, prasugrel or clopidogrel) at the moment of PCI was performed.

Results

Between January and December of 2020, 155 non-pretreated NSTEACS patients were referred to our cathlab; of whom, 89 underwent PCI and were included in the analysis (18.0% with unstable angina, 82.0% with NSTEMI). Mean age was 66.0±14.3 years, 21 (23.6%) were female and the mean GRACE risk score was 112±34. PCI was performed ad-hoc (immediately after diagnostic catheterization) in 81 patients (91.0%), whereas 15 patients (16.9%) required PCI to be done in more than two times. Procedure was performed exclusively by radial or cubital artery access in 78 patients (87.6%). Regarding antiplatelet drug administration, cangrelor was used in 14 patients (15.7%), prasugrel in 35 (39.3%), ticagrelor in 29 (32.6%) and clopidogrel in 11 (12.4%). No significant differences were found among patients in terms of development of ischaemic events at 30 days (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke or stent thrombosis) or periprocedural thrombotic events (no-reflow, bailout use of anti-IIb/IIIb or intraprocedural stent thrombosis). The use of cangrelor did not raise the incidence of bleeding events at 30 days (7.1% vs. 15.1%, p=0.682) [Table 1]. Cangrelor tended to be more frequently used in high-risk NSTEMI patients (20.8% vs. 12.9%, p=0.357) and in case of complex PCI (26.3% vs. 7.8%, p=0.018) [Figure 1]. After controlling by both variables, cangrelor did not significantly increase the risk of bleeding or ischaemic events at 30 days either.

Conclusions

Intravenous infusion of cangrelor during PCI in non-pretreated NSTEACS patients shows no differences in terms of thrombotic or bleeding events in comparison to the administration of a loading dose of an oral P2Y12i. Our results also suggest that cangrelor could be a safe option in patients with high thrombus burden who require complex PCI.

Funding Acknowledgement

Type of funding sources: None.

Time to coronary angiography in a real-life cohort of NSTEACS patients: are guidelines too optimistic?

Background and purpose

In 2020, new recommendations against routine use of pretreatment in NSTEACS have been established, especially if an early invasive strategy (within first 24 hours) is planned [1]. These recommendations are mainly based on evidence from clinical trials that have included short intervals of time to coronary angiography (CA) [2,3]. However, this timing seems hard to achieve in daily clinical practice, above all, when high-risk NSTEACS patients are now advised for an early invasive strategy. We aimed to assess the feasibility of these recommendations in real-world clinical practice.

Methods

We performed a retrospective analysis of a real-life cohort of NSTEACS patients referred to CA in a tertiary-level hospital between January and December 2020.

Results

We analysed 347 consecutive NSTEACS patients referred to CA (21.7% unstable angina, 78.3% NSTEMI). Percutaneous coronary intervention was performed in 60.5% and the radial or cubital artery access were exclusively used in 86.7%. Median time from hospital admission to CA was 39.4 hours (IQR: 20.7–67.0 hours) and 31.4% patients had the CA performed within first 24 hours (Figure 1). Main differences regarding clinical and risk-related variables among those patients who underwent CA before and after first 24 hours are shown in Table 1. More patients with NSTEMI and dynamic changes in ECG tended to be referred earlier to CA, while those with impaired renal function were more likely to receive a delayed strategy. There were 282 patients (82.7%) who met the high-risk criteria from current ESC guidelines on NSTEACS (GRACE risk score >140, ST transient elevation or depression in ECG, raise of cardiac troponin levels above the 99th percentile of the upper reference limit, cardiogenic shock or cardiac arrest at presentation); of whom, only 95 (33.7%) were referred to CA in the first 24 hours. No differences were found according to patients being admitted to PCI or non-PCI centres (32.1% vs. 30.9% had the CA performed within first 24 hours, p=0.81) or receiving pretreatment with a P2Y12 receptor inhibitor or not (31.7% vs. 31.0% of the CA ≤24 hours group; p=0.87).

Conclusion

Evidence from this real-life registry shows that median time from admission to CA is far from current recommendations for high-risk NSTEACS patients. This might represent an important limitation at the moment of translating guidelines to daily clinical practice, especially those who presume patients to have a CA performed within first 24 hours.

Funding Acknowledgement

Type of funding sources: None.

HFA-ICOS cardiovascular toxicity risk score validation in CARDIOTOX registry

Background

Cancer therapy-related cardiovascular toxicity (CTox) is a growing medical problem and baseline cardiovascular (CV) risk assessment is recommended in all patients scheduled to receive potentially cardiotoxic cancer therapy. Based on literature review, the Heart Failure Association (HFA) Cardio-Oncology working group and the International Cardio-Oncology Society (ICOS) proposed a risk score to predict CTox but, it has not been validated.

Purpose

To validate the HFA-ICOS anthracycline risk assessment score in the CARDIOTOX registry cohort (NCT02039622).

Methods

The CARDIOTOX registry is a prospective multicenter study aiming at identifying factors related with CTox and assessing the utility of clinical, biochemical, and echo parameters for the early detection of CV disease during and after cancer therapy. A total of 1324 adult patients were prospectively included from April 2012 to October 2017. Data was collected at baseline, 3 weeks and 3, 6, 12, 18 and 24 months after initiation of treatment. Clinical follow-up was extended until January 2020. All patients receiving anthracycline chemotherapy were stratified according to HFA-ICOS risk score and Kaplan-Meier survival curves were analyzed to estimate the risk of all-cause mortality and anthracycline chemotherapy-related CV complications defined by HFA-ICOS risk score (left ventricular dysfunction (LVD), heart failure (HF) and arrhythmias).

Results

A total of 1066 patients were included in the analysis. Baseline characteristics are summarized in table 1. 571 patients (53.6%) meet low, 333 (31.2%) medium, 152 (14.3%) high and 10 (0.9%) very-high HFA-ICOS CTox risk criteria. 197 patients (18.4%) died of any cause during follow-up. CV death occurred in 4 patients (2%), all caused by HF. Any degree of CTox was identified in 519 (48.7%) patients during the 110 months follow-up (73 (6.8%) developed clinical HF/HF hospitalization, 29 (2.7%) asymptomatic LVEF <50%; 27 (2.5%) clinically relevant arrhythmias and 390 (36.6%) an asymptomatic increase in cardiac biomarkers or a relative decrease in GLS>15%). Figures 1A and 1B showed the cumulative mortality rate and CTox rate during follow-up. CTox and all-cause mortality rates increased significantly according to the estimated baseline HFA-ICOS score.

Conclusions

HFA-ICOS risk score categorizes patients according to their risk of developing anthracycline chemotherapy-related CTox, showing a good ability to predict both all-cause mortality and CTox.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Instituto de Salud Carlos III (PI13/00559).

Atrial imaging and cardiac rhythm in cryptogenic embolic stroke: a preliminary analysis of the ARIES study

Funding Acknowledgements

Type of funding sources: None.

Background

Cryptogenic stroke is frequently related to cardioembolic source previously unknown. We aim to analyze atrial fibrillation (AF), parafibrilatory status (para-AF) and echocardiographic signs of atrial dysfunction in patients (p) with cryptogenic stroke.

Methods

Consecutive p with cryptogenic stroke were prospectively enrolled in the on-going study ARIES (Atrial Imaging and cardiac Rhythm In Embolic Stroke). Cardiologic work-up includes external wearable 2-lead ECG monitoring system for 30 days (non-AF, AF, para-AF defined as >3000 atrial ectopic beats/day or >2 "micro-AF" episodes (fibrillatory burst <30 s)/day) and advanced left atrial echocardiography (signs of atrial dysfunction as strain during three phases -reservoir, conduit, and contractile-). The first monitoring was started before hospital discharge, p without AF in the first monitoring and without extremely disabling neurologic sequelae underwent a further 30 days monitoring. We describe stroke recurrence at 90 days follow-up, and we compare echocardiographic signs of atrial dysfunction according to rhythm study.

Results

78 p completed follow-up (72±12 yo, 53% females). AF was diagnosed in 27 (34%) p: 22/78 (28%) in the first monitoring and 5/43 (12%) in the second one. para-AF was diagnosed in 22/51 (43%) non-AF p. Other arrhythmias: sustained (>30 s) focal atrial tachycardia documented in 4/51 (8%) non-AF p, AVNRT in 1/51 (2%) non-AF p, advanced AV block in 1/78 (1%) p. Worse left atrial mechanical properties were demonstrated in p with para-AF compared to non-AF p (reservoir strain 22.2±9.8 vs 32.8±12, p=0.004; conduit strain -9.6±4.8 vs -14.4±9, p=0.008; contractile strain 12.6±4.8 vs 17.9±7.8, p=0.025), without significative differences compared to AF p. There were three stroke recurrences (3.8%), 2/3 in para-AF p.

Conclusion

In this preliminary analysis, patients with cryptogenic stroke presented AF in 34% and para-AF in 28%. Para-AF patients show significative atrial dysfunction in echocardiography and more stroke recurrences. A longer follow-up is required to confirm these findings.

Diagnostic value of post-return of spontaneous circulation electrocardiogram for selection of candidates for primary percutaneous coronary intervention after out-of-hospital cardiac arrest

Background

Once return of spontaneous circulation (ROSC) is achieved in cardiac arrest (CA) patients (pts), guidelines recommend immediate acquisition of a 12-lead electrocardiogram (ECG) in order to try to identify those with underlying ischemic heart disease that would benefit from an emergent coronary angiography. Nevertheless, post-ROSC ECG findings may be influenced by factors such as drugs used during CPR (e.g., adrenaline) or metabolic state of pts (e.g., lactic acidosis) and therefore its diagnostic value for identification acute coronary lesions has not yet been established.

Objectives

To describe the correlation between post-ROSC ECG findings and acute coronary angiography lesions in out-of-hospital CA (OHCA) pts.

Methods

Retrospective analysis from a prospective database of pts admitted consecutively to the acute cardiac care unit of a tertiary care hospital from September 2006 to April 2019. Post-ROSC ECG of OHCA pts who underwent emergent coronary angiography were blindly and separately classified by 2 cardiologists as follows 1) ST-s elevation, 2) ST-s depression, 3) LBBB, 4) T wave changes/unespecific and 5) normal ECG. If discordant diagnosis, a senior cardiologist made a third and separate analysis. Additionally, coronary lesions were considered to be acute in presence of thrombi or unstable plaque (with or without complete occlusion).

Results

From 412 pts, 211 had an available and interpretable post-ROSC ECG and underwent emergent coronary angiography. Mean age 60±13 years, male sex 183 (86.7%). Correlation between ECG findings and acute coronary lesions are shown in table 1. Pts with ST-s elevation had an underlying acute coronary lesion in 55.2%. Moreover ST-s elevation had a positive predictive value of 84% and sensitivity of 58.8% for identifying acute coronary lesions. Other post-ROSC ECG findings did not significantly associate acute coronary lesions, in fact LBBB had a high negative predictive value for acute lesions.

Conclusion

Among post-ROSC ECG findings, ST-s elevation is significantly associated with acute coronary lesions and when identified, an invasive strategy should be considered as established by current practice guidelines. On the contrary, LBBB rarely associates acute coronary lesions at least in OHCA scenario and when its “new onset” is not specified.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): University Hospital La Paz (Madrid) ECG findings and acute coronary lesions

Arrythmic storm in patients with and without an implantable cardioverter defibrillator

Introduction

Available data on arrhythmic storm (AS) is frequently obtained from retrospective observational series of patients who carry an implantable cardioverter defibrillator (ICD). Therefore, this selection bias limits the evidence regarding mortality and prognosis of patients with AS who do not have an ICD.

Purpose

Describe and compare the epidemiological and clinical characteristics, treatment, and outcomes of patients with and without an ICD, admitted for AS in the Acute Coronary Care Unit.

Methods

Between 2006 and 2020, 187 episodes of AS in 165 patients were identified in two third level hospitals. There were 71 patients without ICD and 116 patients with ICD. Clinical characteristics, treatment and outcome were analysed.

Results

Baseline characteristics are depicted in Figure 1. Risk profile of ICD carriers was worse (they were older, more frequently smokers, had more often hypertension, dyslipidemia, chronic kidney disease and thyroid disturbances, and had worse NYHA class). Known ejection fraction was also worse.

AS aetiology was also different. Myocardial infarction was present only in non ICD carriers (56.3% vs 0, p<0.001) and was the most frequent cause of AS in this group. Ion disturbances were also more common among ICD carriers (60.3% vs 33.6%, p<0.001), but it was the most frequent aetiology of AS in non ICD carriers. Heart failure or cardiogenic shock (36.6% vs 26.7%, p=0.154), infection (7% vs 13.8%, p=0.156) and bradycardia with acquired long QT syndrome (11.3% vs 9.5%, p=0.695) were similar in both groups. There were two episodes of myocarditis among non ICD carriers.

The predominant arrythmia was also different. Ventricular fibrillation was more common in non ICD carriers (43.7% vs 4.3%) while monomorphic ventricular tachycardia was more frequent in ICD carriers (38.8% vs 83.6%, p<0.001).

Non ICD carriers had worse levels of pH (7.30 vs 7.42, p<0.001) and lactate (4.4mmol/L vs 2.0mmol/L, p>0.001) and required inotropic and vasopressor drugs more frequently due to haemodynamic instability (57.7% vs 10.3%, p<0.001), mechanical support with intra-aortic balloon pump (40.8% vs 1.7%, p<0.001), ECMO (8.5% vs 0%, p<0.001), and other mechanical assist devices (5.6% vs 0%, p=0.010), and oral intubation (71.8% vs 17.2%, p<0.001).

Pharmacologic treatment is described in Figure 2.

Non ICD carriers required more frequently percutaneous coronary intervention (59.2% vs 4.3%, p<0.001) and less frequently ventricular ablation (28.2 vs 46.6%, p=0.013). Therapeutic hypothermia was used only in non ICD patients due to out of hospital cardiac arrest (33.8% vs 0%, p<0.001).

In-hospital mortality was higher in non ICD carriers (28.2% vs 11.2%, p=0.003).

Conclusion

Despite a worse cardiovascular profile in ICD carriers, AS is associated with a worse haemodynamic situation and mortality in non ICD carriers, due to different aetiology of the AS and to the absence of protection against sustained arrythmias.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Beca para la Formaciόn e Investigaciόn en Cuidados Críticos Cardiolόgicos concedida por la Asociaciόn de Cardiopatía Isquémica y Cuidados Críticos Cardiolόgicosde la SEC Figure 1. Baseline CharacteristicsFigure 2. Pharmacological treatment

Association between mean arterial pressure and neurological outcome in survivors of a cardiac arrest undergoing targeted temperature management

Background

Besides targeted temperature management (TTM), no other therapeutic strategy has shown to improve neurological outcome in cardiac arrest patients. Recently, it has been suggested that higher levels of mean arterial blood pressure (>90 mmHg) may have a protective neurological effect in this population, yet data is scarce.

Objective

To describe the association between neurological outcomes and MAP during TTM.

Methods

Retrospective study of a prospective database including survivors of a cardiac arrest undergoing TTM and admitted to the acute cardiac care of a tertiary university hospital from September 2007 to July 2020. MAP was recorded from arrival and hourly during TTM. Neurological outcome was graded 3 months after initial event using the Pittsburgh Cerebral Performance Category (CPC) scale and patients were divided classified as follows: Group A patients with CPC of 1 to 2 (good neurological outcome), and group B, with CPC 3 to 5 (poor neurological outcome or death). As CPC 5 comprises patients who have died but whose cause of death may not be related to their neurological condition, we sort to control this potential source of bias, by including a variable of “severe neurological injury”, which includes patients with CPC 3–4 and those CPC 5 who died due to WLST due to poor neurological prognosis/brain death.

Results

A total pf 431 patients were analysed. Baseline and cardiac arrest characteristics are depicted in Table 1. Patients in group B had a higher proportion of non-witnessed cardiac arrest, out-of-hospital cardiac arrest, non-shockable rhythm, and longer time before ROSC. The relation between MAP and neurological outcome is shown in Table 2. The were no differences of MAP in day 1 and 3 between groups. MAP was statistically higher in Group A during day 2 or rewarming phase. Mean MAP during day 1 and 2; and during day 1, 2 and 3 was also significantly higher in group A. However, when same analysis was performed under the variable “severe neurological injury” no statistically significant differences were observed.

Conclusion

There is no association between MAP and neurological outcomes, when true “severe neurological injury” is analysed. Therefore, and until further data is obtained, following actual practical guidelines or avoiding hypotension seems to be the goal in this population, as higher MAP may also have deleterious effects.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): University Hospital La Paz

Arrythmic storm in patients with and without a myocardial infarction

Introduction

Available data on arrhythmic storm (AS) is frequently obtained from retrospective observational series of patients who carry an implantable cardioverter defibrillator or who undergo ablation, and typically, patients with ST-elevation myocardial infarction (STEMI) as the cause of the AS are excluded. Therefore, this selection bias limits the evidence regarding mortality and prognosis of patients with AS due to STEMI.

Purpose

Describe and compare the epidemiological and clinical characteristics, treatment, and outcomes of patients admitted for AS in the Acute Coronary Care Unit due to STEMI and other causes.

Methods

Between 2006 and 2020, 187 episodes of AS in 165 patients were identified in two third level hospitals. There were 40 patients with STEMI and 147 patients with other causes of AS. Clinical characteristics, treatment and outcome were analysed.

Results

Baseline characteristics are depicted in Figure 1. Risk profile of patients without STEMI was worse (they were older, had more often hypertension, and thyroid disturbances, and had worse NYHA class). Patients with STEMI were more frequently smokers. Ejection fraction was higher among STEMI patients.

Predisposing features for AS (apart from myocardial ischemia) were also different. Ion disturbances were more common among STEMI patients (37.4% vs 67.5%, p=0.001). Heart failure or cardiogenic shock (27.9% vs 40.0%, p=0.140), infection (12.2% vs 7.5%, p=0.399) and bradycardia with acquired long QT syndrome (10.2% vs 10.0%, p=0.695) were similar in both groups. There were two episodes of myocarditis in patients without STEMI.

The predominant arrythmia was also different. Ventricular fibrillation was more common in STEMI patients (4.8% vs 72.5%) while monomorphic ventricular tachycardia was more frequent patients without STEMI (80.3% vs 7.5%, p<0.001).

STEMI patients had worse levels of pH (7.40 vs 7.25, p<0.001) and lactate (2.25mmol/L vs 5.56mmol/L, p>0.001) and required inotropics and vasopressors more frequently due to haemodynamic instability (15.0% vs 77.5%, p<0.001), mechanical support with intra-aortic balloon pump (5.4 vs 57.5%, p<0.001), ECMO (2.0% vs 7.5%, p=0.082), and other mechanical assist devices (0 vs 10.0%, p<0.001), and oral intubation (23.8% vs 90.0%, p<0.001).

Pharmacologic treatment is described in Figure 2.

Obviously, STEMI patients required more often percutaneous coronary intervention (8.2% vs 87.5%, p<0.001) and less frequently ventricular ablation (50.3% vs 0, p<0.001). Therapeutic hypothermia was more commonly used in STEMI patients due to out of hospital cardiac arrest (2.0% vs 52.5%, p<0.001).

In-hospital mortality was higher in STEMI patients (11.6% vs 42.5%, p<0.001).

Conclusion

Despite a worse cardiovascular profile in patients without STEMI, AS is associated with a worse haemodynamic situation and mortality in STEMI patients.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Beca para la Formaciόn e Investigaciόn en Cuidados Críticos Cardiolόgicos concedida por la Asociaciόn de Cardiopatía Isquémica y Cuidados Críticos Cardiolόgicosde la SEC Figure 1. Baseline CharacteristicsFigure 2. Pharmacological treatment

Are there mortality differences between men and women in all types of intracranial hemorrhages: subarachnoid, intraparenchymal and subdural? An analysis of the Spanish population

Objectives

There are 3 types of intracranial hemorrhage (ICH): 1) subarachnoid hemorrhage (SAH), CIE10:I60; 2) intraparenchymal hemorrhage (IPH), I61 and 3) subdural hemorrhage (SDH) I62. Epidemiological data on this field are scarce in Mediterranean countries. Our goal was to determine whether the relationship of ICH mortality with gender and age was different for the 3 types of HIC.

Methods

Data were retrospectively obtained from the Spanish National Institute of Statistics. Deaths/100.000 population of SAH, IPH and SDH were assessed for the entire Spanish population since 2008 to 2017 (n=46,527,039). Year 2017 was the last available for analysis. Incidence was analyzed for men and women and for age strata (<1 years of age, 2–10, 11–20, 21–30, 31–40, 41–50, 51–60, 61–70, 71–80; >80).

Results

In order to fit in the abstract space, only data of 2017 are presented, although years 2008 to 2017 were also analyzed and results were similar. Mortality/100,000 of IPH stayed very low under 40 years of age and then grew exponentially in both, men and women, and was significantly higher for men for all age strata. Mortality of SDH was much lower but behaved in a similar way: exponential growth since 40s and lower incidence in women. SAH behaved differently: it started to be significant since 20 years of age and there were no gender differences.

Conclusion

Mortality of intraparenchymal and subdural hemorrhage increases exponentially since 40 years of age and is lower in women. On the contrary, mortality of subarachnoid hemorrhage increases earlier and there are no gender differences.

Death/100.000 intracranial hemorrhage

Funding Acknowledgement

Type of funding source: None

P4756Stroke and bleeding in low, intermediate and high risk patients with atrial fibrillation treated with edoxaban: Results of the ETNA-AF Europe registry

Background

Edoxaban, a direct FXa inhibitor, has been proven non-inferior in efficacy and safer compared to warfarin in the ENGAGE AF-TIMI 48 trial. In routine care, the safety of edoxaban has not been formally established. ETNA-AF-Europe is a multinational, multi-centre, post-authorisation, observational study (NCT02944019) conducted in 825 sites in 10 European countries. Here 13,980 edoxaban-treated patients with AF were enrolled between November 2016 and February 2018, and will be followed-up for 4 years.

Methods

7,672 patients (73.4±9.26 years, 57.5% male) enrolled in the ETNA-AF Europe registry completed the one-year follow-up and were stratified into low-, intermediate- and high-risk for stroke and bleeding using the CHA2DS2-VASc and HASBLED score, respectively. We here analysed the occurrence of stroke, bleeding, intracranial haemorrhage and mortality in such categories.

Results

The mean CHA2DS2-VASc score at baseline was 3.1±1.38 and the mean HAS-BLED score was 2.5±1.1. Not surprisingly, patients at higher risk were older, had a lower body weight, more comorbidities, and a lower creatinine clearance. A higher proportion of patients at high risk received the reduced 30 mg edoxaban dose. Overall, the yearly event rates of stroke, intracranial haemorrhage, major bleeding and death were low. However, these rates increased consistently in patients with higher stroke and bleeding risks. Residual stroke risk on anticoagulation was comparable to the risk of major bleeding (Table 1).

Outcomes by stroke and bleeding risk CHA2DS2-VASc: mean 3.1±1.38 HAS-BLED: mean 2.5±1.1 All patients Low risk (0, 1 if female) Intermediate risk (1, 2 if female) High risk (≥2, 3 if female) Low risk (0, 1) Intermediate risk (2, 3) High risk (≥4) Patients, N 233 1,133 6,304 1,224 4,932 1,516 7,672 First occurrence of outcomes, n (%/year)   All-cause mortality 2 (0.92%) 12 (1.11%) 242 (4.09%) 14 (1.21%) 161 (3.47%) 82 (5.78%) 257 (3.56%)   Intracranial haemorrhage 0 (0.00%) 1 (0.09%) 19 (0.32%) 2 (0.17%) 10 (0.22%) 8 (0.56%) 20 (0.28%)   Major bleeding 0 (0.00%) 6 (0.56%) 62 (1.05%) 2 (0.17%) 43 (0.93%) 23 (1.63%) 68 (0.95%)   Stroke/SEE 0 (0.00%) 4 (0.37%) 59 (1.00%) 3 (0.26%) 41 (0.89%) 19 (1.34%) 63 (0.88%) SEE, systemic embolic event.

Conclusions

In this unselected cohort of patients with AF anticoagulated with edoxaban, high CHA2DS2-VASc and HAS-BLED scores were associated with higher risks of stroke, bleeding and death. Indirectly compared with the expected rates in non-anticoagulated patients, our data underpin the value of anticoagulants such as edoxaban in patients at high risk of stroke and bleeding.

Acknowledgement/Funding

The ETNA-AF Registry was funded by Daiichi Sankyo Europe GmbH, Munich, Germany.

Early coronary angioplasty for acute myocardial infarction complicated by cardiogenic shock: have novel therapies led to better results?

Patients with acute myocardial infarction (MI) and cardiogenic shock constitute a very high risk subset despite an aggressive management. The objective of this study was to evaluate if the results of early coronary angioplasty in patients with acute myocardial infarction and cardiogenic shock have changed over the last years, and to address which role the recent adjuvant therapies have played in this evolution. From 1991 to April 1999, 94 patients with acute MI and cardiogenic shock were treated with coronary angioplasty within the first 12 hours from the onset of symptoms. Temporal changes of the utilization of adjuvant therapies and operators experience were studied over these years, as well as their impact on the angiographic results and in-hospital outcome. Over the years, a progressive and significant increase on the use of coronary stents and c7E3Fab was observed, as well as an increased number of primary angioplasties performed per month. The proportion of patients treated with intraaortic balloon pump did not changed significantly over the years. An angiographic successful result (< 50% residual stenosis and TIMI flow 2 or 3) and a final TIMI grade 3 flow were obtained in 76 (80.9%) and 61 (64.9%) patients, respectively. The angiographic success rate progressively increased over the years, from 72.3% in patients treated before 1994 to 94.1% in those admitted in 1998Eth 1999 (p for trend 0.0409). The proportion of patients with a final TIMI grade 3 flow also grew progressively over the years: from 36.4% before 1994 to 76.5% after 1997 (p for trend 0. 0209). The overall in-hospital mortality rate was 63.8% (60 patients), and there was no significant change in mortality rate over the years. Therefore, apart from the growing operators experience, we have observed an incremental change in the use of coronary stents and c7E3 Fab (abciximab) in patients with acute myocardial infarction and cardiogenic shock treated with early coronary angioplasty. All these factors have led to an improvement in the angiographic results, although this change has not meant a significant reduction of mortality.