Complex High-Risk Percutaneous Coronary Intervention Types, Trends, and Outcomes in Nonsurgical Centres.

BACKGROUND: Limited data are available on complex high-risk percutaneous coronary intervention (CHiP) trends and outcomes in nonsurgical centres (NSCs), particularly in health care systems where most centres are NSCs. METHODS: Using data from a national registry, we studied the characteristics and outcomes of CHiP procedures performed for stable angina from 2006 to 2017 according to the presence or absence of on-site surgical cover. Multivariate regression analyses and propensity score matching were used to determine risks for in-hospital death, major bleeding, and major cardiovascular or cerebral events (MACCE). RESULTS: Out of 134,730 CHiP procedures, 42,433 (31.5%) were performed in NSCs, increasing from 12.5% in 2006 to 42% in 2017. Compared with surgical centres (SCs), patients who had a CHiP procedure undertaken in NSCs were, on average, 2.4 years older and had a greater prevalence of cardiovascular risks. Common CHiP procedures performed in NSCs included poor left ventricular function (41.6%), chronic renal failure (38.8%), and chronic total occlusion percutaneous coronary intervention (31.1%). NSC-based CHiP is associated with lower odds of mortality (adjusted odds ratio [aOR] 0.7, 95% confidence interval [CI] 0.5-0.8) and major bleeding (aOR 0.7, 95% CI 0.6-0.8). In both groups, MACCE odds were similar (aOR 1.0, 95% CI 0.9-1.1). CONCLUSIONS: CHiP numbers have steadily increased in NSCs. NSC patients were older and had a higher prevalence of cardiovascular risks than SC patients. Mortality and major bleeding odds were significantly lower in those cases undertaken in NSCs, although MACCE odds were not different between the groups.

Complex high-risk percutaneous coronary intervention types, trends, and outcomes according to vascular access site.

BACKGROUND: Radial access is associated with improved outcomes following percutaneous coronary intervention (PCI); however, its role in complex, high-risk percutaneous coronary intervention (CHiP) remains poorly studied. METHODS: We studied retrospectively all registered patients's records from the British Cardiovascular Intervention Society dataset and compared the baseline characteristics, trends and outcomes of CHiP procedures performed electively between January 2006 and December 2017 according to the access site. RESULTS: Out of 137,785 CHiP procedures, 61,825 (44.9%) were undertaken via transradial access (TRA). TRA use increased over time (14.6% in 2006 to 67% in 2017). The TRA patients were older, with a greater prevalence of previous stroke, hypertension, peripheral vascular disease, and smokers. TRA was used more frequently in most CHiP procedures (elderly (51.6%), chronic renal failure (52.6%), poor left ventricular (LV) function (47.6%), left main PCI (48.0%), treatment for severe vascular calcification (50.3%); although transfemoral access (TFA) was used more commonly in those with prior history of coronary artery bypass graft surgery, and PCI to a chronic total occlusion and LV support patients. Following adjustment for differences in clinical and procedural characteristics, TFA was independently associated with higher odds for mortality [adjusted odds ratio (aOR): 1.3 (1.1-1.7)], major bleeding [aOR: 2.9 (2.3-3.4)], and MACCE (following propensity score matching) [aOR: 1.2 (1.1-1.4)]. The same was found with multiple accesses: mortality [aOR: 2.1 (1.5-2.8)], major bleeding [aOR: 5.5 (4.3-6.9)], and MACCE [aOR: 1.4 (1.2-1.7)]. CONCLUSION: TRA has become the predominant access site for CHiP procedures and is associated with significantly lower mortality, major bleeding and MACCE odds than TFA.

Complex, high-risk percutaneous coronary intervention types, trends, and in-hospital outcomes among different age groups: An insight from a national registry.

BACKGROUND: Complex, high-risk percutaneous coronary intervention (PCI) (CHiP) is increasingly being undertaken in octogenarians. However, limited data exist on CHiP types, trends, and outcomes in the octogenarian. METHODS: This is a retrospective cohort study from a national registry dataset on CHiP undertaken in patients with stable angina in England and Wales (January 2006 and December 2017) according to three age groups (group 1 [G1]: < 65 years; group 2 [G2]: 65-79 years; and group 3 [G3]: ≥80 years). RESULTS: Of 424,290 elective PCI procedures, 138,831 (33.0%) were CHiP [G1: 46,832 (33.7%); G2: 59,544 (42.9%); G3: 32,455 (23.4%)]. Among CHiP types, chronic total occlusion (CTO) (49.2%), prior coronary artery bypass graft (CABG) (30.4%), and severe vascular calcification (21.8%) were common in G1; prior CABG (42.9%), CTO (32.9%), and severe vascular calcifications (27%) were common in G2; prior CABG (15.8%), severe vascular calcification (15.5%), and chronic renal failure (11.1%) were common CHiP among the octogenarians. The older age groups had higher adjusted odds (aOR) for adverse outcomes [G2: mortality, aOR 1.7, 95% confidence interval (CI): (1.3-2.3); major bleeding, aOR 1.3, 95% CI (1.1-1.5); MACCE, aOR 1.2, 95% CI (1.0-1.3); G3: mortality, aOR 2.6, 95%CI (1.9-3.6); major bleeding, aOR 1.4, 95% CI (1.1-1.7); MACCE, aOR 1.3, 95% CI (1.1-1.5)]. CONCLUSION: There were significant differences in the types of CHiP cases undertaken and clinical outcomes across age groups.

Ethnicity in Complex High-Risk but Indicated Percutaneous Coronary Intervention Types and Outcomes.

Complex High-risk but indicated Percutaneous coronary interventions (CHiPs) is increasingly common in contemporary practice. However, data on ethnic differences in CHiP types, outcomes, and trends in patients with stable angina are limited; this is pertinent given the population of Black, Asian, and other ethnic minorities (BAME) in Europe is increasing. We conducted a retrospective analysis of CHiP procedures undertaken in patients with stable angina using data obtained from the BCIS (British Cardiovascular Intervention Society) registry (2006 to 2017). CHiP cases were identified and categorized by ethnicity into White and BAME groups. We then performed multivariable regression analysis and propensity score matching to determine adjusted odds ratios (aORs) of in-hospital mortality, major bleeding, and major adverse cardiovascular and cerebral events (MACCEs) in BAME compared with Whites. Of 424,290 procedure records, 105,949 were CHiP (25.0%) (White 89,038 [84%], BAME 16,911 [16%]). BAME patients were younger (median 68.1 vs 70.6 years). Previous coronary artery bypass surgery (33.4% vs 38.3%), followed by chronic total occlusion percutaneous coronary intervention (31.9% vs 32%) were common CHiP variables in both groups. The third common variable was age 80 years and above (23.6%) in White patients and severe vascular calcifications in BAME patients (18.8%). BAME patients had higher rates of diabetes (41.1 vs 23.6%), hypertension (68 vs 66.5%), previous percutaneous coronary intervention (43.7 vs 37.6%), and previous myocardial infarction (44.9 vs 42.5%), (p <0.001 for all). Mortality (aOR 1.1, 95% confidence interval [CI] 0.8 to 1.5) and MACCE (aOR 1.0, 95% CI 0.8 to 1.1) odds were similar among the groups. Bleeding odds (aOR 0.7, 95% CI 0.6 to 0.9) were lower in BAME. In conclusion, CHiP procedures differed among the ethnic groups. BAME patients were younger and had worse cardiometabolic profiles. Similar odds of death and MACCE were seen in BAME compared with their White counterparts. Bleeding odds were 30% lower in the BAME group.

Sex differences in high-risk but indicated coronary interventions (CHiP): National report from British Cardiovascular Intervention Society Registry.

OBJECTIVE: To assess sex-based differences in clinical outcomes following complex and high-risk but indicated percutaneous coronary intervention (CHiP). BACKGROUND: CHiP is increasingly common in contemporary percutaneous coronary intervention (PCI) practice. Data on sex differences in the type of CHiP procedures undertaken or their associated clinical outcomes are limited. METHODS: Patients with stable coronary artery disease who underwent CHiP between January 1, 2006, and December 31, 2017, were included. All procedures were stratified by sex. Multivariate logistic regression analyses were performed to investigate the sex-specific adjusted odds ratios (aOR) of in-hospital outcomes. RESULTS: Out of 424,290 PCI procedures, 141,610 (33.37%) were CHiP procedures. Overall, 32,129 (23%) of CHiP were undertaken in females. Females were older than males (median: 74.8 vs. 69.1 years). Males had a higher prevalence of previous myocardial infarction (MI) (44.6% vs. 35.6%) and previous PCI (40% vs. 32.5%). The most common variable observed in female patients undergoing CHiP was age >80 (35.4%), followed by prior coronary artery bypass graft (CABG) (24.3%) and severe coronary calcification (22.6%). In contrast, the most common variable in male patients was prior CABG (36%), followed by chronic thrombus occlusion (CTO) PCI (34.4%) and severe coronary calcification (22%). Females had higher odds (aOR) for mortality (aOR: 1.78, 95% CI: [1.4, 2.2]), bleeding (aOR: 1.99, 95% CI: [1.72, 3.2]), and major adverse cardiovascular and cerebral events (aOR: 1.23, 95% CI: [1.09, 1.38]) compared to males. CONCLUSION: In this national analysis of CHiP procedures over 12 years, there were significant sex differences in the type of CHiP procedures undertaken, with females at increased odds for mortality and in-hospital adverse outcomes.

Trends of Sex Differences in Clinical Outcomes After Myocardial Infarction in the United States.

BACKGROUND: Female patients have been shown to experience worse clinical outcomes after acute myocardial infarction (AMI) compared with male patients. However, it is unclear what trend these differences followed over time. METHODS: Data from patients hospitalized with AMI between 2004 and 2015 in the National Inpatient Sample were retrospectively analyzed, stratified according to sex. Multivariable logistic regression analyses were performed to examine the adjusted odds ratios (aORs) of invasive management and in-hospital outcomes according to sex. The Mantel-Haenszel extension of the χ2 test was performed to examine the trend of management and in-hospital outcomes over the study period. RESULTS: Of 7,026,432 AMI hospitalizations, 39.7% (n = 2,789,494) were women. Overall, women were older (median: 77 vs 70 years), with a higher prevalence of risk factors such as diabetes, hypertension, and depression. Women were less likely to receive coronary angiography (aOR, 0.92; 95% confidence interval [CI], 0.91-0.93) and percutaneous coronary intervention (aOR, 0.82; 95% CI, 0.81-0.83) compared with men. Odds of all-cause mortality were higher in women (aOR, 1.03; 95% CI, 1.02-1.04; P < 0.001) and these rates have not narrowed over time (2004 vs 2015: aOR, 1.07 [95% CI, 1.04-1.09] vs 1.11 [95% CI, 1.07-1.15), with similar observations recorded for major adverse cardiovascular and cerebrovascular events. CONCLUSIONS: In this temporal analysis of AMI hospitalizations over 12 years, we showed lower receipt of invasive therapies and higher mortality rates in women, with no change in temporal trends. There needs to be a systematic and consistent effort toward exploring these disparities to identify strategies to mitigate them.

CONTEXTE: Il a été démontré que les femmes présentent de moins bons résultats cliniques après un infarctus aigu du myocarde (IAM) que les hommes. Cependant, la tendance de ces différences dans le temps n'est pas claire. MÉTHODOLOGIE: Les données de la National Inpatient Sample sur les patients hospitalisés pour un IAM entre 2004 et 2015 ont été analysées rétrospectivement, stratifiées selon le sexe. Des analyses de régression logistique multidimensionnelles ont été effectuées pour examiner les rapports de cotes ajustés (RCA) de la prise en charge par un traitement invasif et des résultats obtenus en milieu hospitalier en fonction du sexe. Le test du χ2 étendu de Mantel-Haenszel a été effectué pour examiner la tendance de la prise en charge et des résultats en milieu hospitalier au cours de la période d'étude. RÉSULTATS: Sur 7 026 432 patients hospitalisés pour un IAM, 39,7 % (n = 2 789 494) étaient des femmes. Dans l'ensemble, les femmes étaient plus âgées (âge médian : 77 vs 70 ans), avec une plus forte prévalence de facteurs de risque comme le diabète, l'hypertension et la dépression. Les femmes étaient moins susceptibles que les hommes de subir une coronarographie (RCA : 0,92; intervalle de confiance [IC] à 95 % : 0,91-0,93) et une intervention coronarienne percutanée (RCA : 0,82; IC à 95 % : 0,81-0,83). Les probabilités de mortalité toutes causes confondues étaient plus élevées chez les femmes (RCA : 1,03; IC à 95 % : 1,02-1,04; p < 0,001), et ces taux n'ont pas diminué avec le temps (2004 vs 2015 : RCA : 1,07 [IC à 95 % : 1,04-1,09] vs 1,11 [IC à 95 % : 1,07-1,15), des observations similaires étant consignées pour les événements cardiovasculaires et vasculaires cérébraux majeurs. CONCLUSIONS: Dans cette analyse temporelle des hospitalisations pour IAM sur 12 ans, nous avons montré que les femmes subissaient moins de traitements invasifs et présentaient des taux de mortalité plus élevés, sans changement dans les tendances temporelles. Il faut un effort systématique et cohérent pour explorer ces disparités afin de cibler des stratégies pour les atténuer.

Atrial fibrillation in the Middle East: unmapped, underdiagnosed, undertreated.

INTRODUCTION: Atrial fibrillation (AF) is the commonest persistent cardiac arrhythmia with an estimated incidence rate of between 1.5-2% and an important cause of strokes. Few epidemiological studies and clinical trials on the management of AF have been conducted outside Europe and North America. These gaps in our understanding of AF likely lead to sub-optimal management of patients with AF in the rest of the world. Areas covered: We discuss the epidemiology, treatment and clinical outcomes for AF in the Middle East after systematic review of published work for AF from the Middle East. We also discuss important clinical trials on AF conducted in the West in the same period to help contextualize our findings. Expert commentary: The few available Middle East studies suggest important epidemiological differences between Middle Eastern and Western AF populations. In particular, the Middle Eastern AF population is younger and have more co-morbidities than patients in the West. We find that significant numbers of moderate to high risk patients with AF are either undertreated or untreated placing them at increased risk of complications such as stroke. More studies in the Middle Eastern population are required to aid the development of region-specific clinical guidelines to improve patient care.

Anomalous origin of RCA from left coronary sinus presenting as PSVT and recurrent acute coronary syndromes.

Anomalous origin of the right coronary artery from the left sinus of Valsalva and coursing between the aorta and pulmonary artery is a rare congenital abnormality representing less than 3% of the congenital coronary anomalies. Patients can present with myocardial ischemia, arrhythmias, or sudden cardiac death (SCD). This diagnosis should be suspected in young patients without risk factors for coronary artery disease and the diagnosis can be confirmed easily by 64-slice MDCT angiography. Surgery is generally recommended in symptomatic patients whereas conservative management in asymptomatic patients. Incidence of SCD is rare after the age of 35 years and hence conservative treatment may be advised in asymptomatic patients over the age of 35 years.

Myocarditis and Rhabdomyolysis in a Healthy Young Man Caused by Salmonella Gastroenteritis.

Salmonella gastroenteritis is a common, self-limiting, foodborne disease and a rare cause of life-threatening complications especially in immunocompetent individuals. Moreover, bacterial infections of the GI tract have been rarely reported as a cause of serious complications like acute myocarditis and rhabdomyolysis. While viral infections are commonly associated with myocarditis, bacterial infections are infrequently seen with these conditions. Similarly, bacterial infections may lead to only 5% of adult rhabdomyolysis events whereas viral-induced myositis appears to be the commonest. A 28-year-old young male with no past medical problems presented with acute salmonella gastroenteritis that was complicated by myocardial injury (most likely myocarditis), rhabdomyolysis, acute renal failure, and shock. He made an uneventful complete recovery of all complications by early recognition of these rare complications and prompt institution of appropriate therapy.

Rapidly progressive atrioventricular block in a patient with sarcoidosis.

Cardiac sarcoidosis is a major cause of death in patients with systemic sarcoidosis. Cardiac manifestations are seen in 2.3% of the patients. Atrioventricular (AV) block is one of the common manifestations of cardiac sarcoidosis. Other presentations of cardiac involvement include congestive heart failure, ventricular arrhythmias, and sudden cardiac death. The presence of AV block in young patients should raise the suspicion of sarcoidosis. AV block may be the only manifestation and patients may not have clinical evidence of pulmonary involvement. Here we describe a young male presented with exercise induced AV block rapidly progressing to complete heart block with recurrent syncope needing urgent pacemaker implantation. Factors that suggested an infiltrative process included his young age, rapidly progressive conduction abnormalities in the ECG in the absence of coronary disease, and previous history of cutaneous sarcoidosis.