Primary percutaneous coronary intervention in nonagenarians: is it worthwhile?

BACKGROUND: Previous studies have demonstrated the feasibility of primary percutaneous coronary intervention (PPCI) in carefully selected nonagenarians. Although current guidelines recommend immediate revascularization in patients with ST elevation myocardial infarction (STEMI) it remains unclear whether PPCI reduces mortality in nonagenarians. The objective of this study is to compare mortality in nonagenarians presenting via the PPCI pathway who undergo coronary intervention, versus those who are managed medically. METHODS AND RESULTS: A total of 111 consecutive nonagenarians who presented to our tertiary center via the PPCI pathway between July 2013 and December 2018 with myocardial infarction were included. Clinical and angiographic details were collected alongside data on all-cause mortality. The final diagnosis was STEMI in 98 (88.3%) and NSTEMI in 13 (11.7%). PPCI was performed in 42 (37.8%), while 69 (62.2%) were medically managed. A significant number of the medically managed cohort had atrial fibrillation (23.2% vs 2.4% p = 0.003) and presented with a completed infarct (43.5% vs 4.8% p = 0.001). Other baseline and clinical variables were well matched in both groups. There was a trend towards increased 30-day mortality in the medically managed group (40.6% vs 23.8% p = 0.07). Kaplan Meier survival analysis demonstrated a significant difference in survival by 3 years (48.1% vs 21.7% p = 0.01). This was the case even when those with completed infarcts were excluded (44.3% vs 14.6%, p = 0.01). CONCLUSION: In this series of selected nonagenarians presenting with acute myocardial infarction, those undergoing PPCI appeared to have a lower mortality compared to those managed medically.

Long-term outcomes of left atrial appendage occlusion in high-risk atrial fibrillation patients: 4-year follow up data.

Long-term follow-up data of left atrial appendage (LAA) occlusion in patients with atrial fibrillation (AF) are sparse. To address these data gaps, we analysed the 4-year outcomes of AF patients following LAA occlusion. The was a retrospective cohort study of high-risk patients with AF who underwent successful implantation of the Amulet device at our center between 2014 and 2017. Study endpoints were the rate of stroke, major bleeding and all-cause mortality. We included 71 patients (35.2% females) with a median age of 78 (IQR 73-82) years. Over a median follow-up period of 46 (IQR 19-56) months, the annual rate of ischemic stroke was 1.06 events/100 patient-years (95% CI 0-2.35), hemorrhagic stroke was 1.06 events/100 patient-years (95% CI 0-2.35) and major extracranial bleeding that required unplanned hospital admission was 1.84 events/100 patient-years (95% CI 0.25-3.43). A total of 28 (39.4%) patients died during this period with an annual mortality rate of 10.29 events/100 patient-years (95% CI 7.25-13.32). Our experience suggests that LAA occlusion using the Amulet device appears to be associated with a low risk of ischemic stroke in high-risk AF patients who are deemed unsuitable for oral anticoagulation; however, these patients have a high rate of mortality over the medium to long-term follow-up, and an ongoing significant risk of bleeding and thrombotic events.

Unfractionated heparin versus bivalirudin in primary percutaneous coronary intervention (HEAT-PPCI): an open-label, single centre, randomised controlled trial.

BACKGROUND: Bivalirudin, with selective use of glycoprotein (GP) IIb/IIIa inhibitor agents, is an accepted standard of care in primary percutaneous coronary intervention (PPCI). We aimed to compare antithrombotic therapy with bivalirudin or unfractionated heparin during this procedure. METHODS: In our open-label, randomised controlled trial, we enrolled consecutive adults scheduled for angiography in the context of a PPCI presentation at Liverpool Heart and Chest Hospital (Liverpool, UK) with a strategy of delayed consent. Before angiography, we randomly allocated patients (1:1; stratified by age [<75 years vs ≥75 years] and presence of cardiogenic shock [yes vs no]) to heparin (70 U/kg) or bivalirudin (bolus 0·75 mg/kg; infusion 1·75 mg/kg per h). Patients were followed up for 28 days. The primary efficacy outcome was a composite of all-cause mortality, cerebrovascular accident, reinfarction, or unplanned target lesion revascularisation. The primary safety outcome was incidence of major bleeding (type 3-5 as per Bleeding Academic Research Consortium definitions). This study is registered with ClinicalTrials.gov, number NCT01519518. FINDINGS: Between Feb 7, 2012, and Nov 20, 2013, 1829 of 1917 patients undergoing emergency angiography at our centre (representing 97% of trial-naive presentations) were randomly allocated treatment, with 1812 included in the final analyses. 751 (83%) of 905 patients in the bivalirudin group and 740 (82%) of 907 patients in the heparin group had a percutaneous coronary intervention. The rate of GP IIb/IIIa inhibitor use was much the same between groups (122 patients [13%] in the bivalirudin group and 140 patients [15%] in the heparin group). The primary efficacy outcome occurred in 79 (8·7%) of 905 patients in the bivalirudin group and 52 (5·7%) of 907 patients in the heparin group (absolute risk difference 3·0%; relative risk [RR] 1·52, 95% CI 1·09-2·13, p=0·01). The primary safety outcome occurred in 32 (3·5%) of 905 patients in the bivalirudin group and 28 (3·1%) of 907 patients in the heparin group (0·4%; 1·15, 0·70-1·89, p=0·59). INTERPRETATION: Compared with bivalirudin, heparin reduces the incidence of major adverse ischaemic events in the setting of PPCI, with no increase in bleeding complications. Systematic use of heparin rather than bivalirudin would reduce drug costs substantially. FUNDING: Liverpool Heart and Chest Hospital, UK National Institute of Health Research, The Medicines Company, AstraZeneca, The Bentley Drivers Club (UK).

Concurrent percutaneous left atrial appendage occlusion and catheter ablation for atrial fibrillation: State-of-the-art review.

Stroke prevention and symptom control are two integral pillars in atrial fibrillation (AF) management. Percutaneous left atrial appendage occlusion (LAAO) is effective at reducing stroke risk in high-risk patients with AF who cannot tolerate oral anticoagulant therapy, whilst catheter ablation is effective at reducing AF burden and improving quality-of-life in patients who remain symptomatic despite medical therapy. If both procedures are indicated in an individual patient, they have traditionally been performed on separate occasions, due to long cumulative procedural times, itself associated with thromboembolic risk. Recently, with the advancement of procedural techniques, the concept of concurrent LAAO and AF catheter ablation has gained traction. This review summarises the evidence for and against concurrent LAAO and AF catheter ablation, discussing procedural considerations, including procedural sequencing and post-procedural antithrombotic therapy, safety and efficacy outcomes, and future directions in the field.

Percutaneous left atrial appendage occlusion following successful treatment of large bi-atrial thrombi in a patient with atrial fibrillation: a case report.

Background: Atrial fibrillation (AF) is a well-established risk factor for intracardiac thrombosis. Left atrial appendage occlusion (LAAO) is emerging as a viable alternative to oral anticoagulation (OAC) for high-risk AF patients who are contraindicated to long-term OAC. Case summary: A 74-year-old man with a history of permanent AF and subdural haemorrhage on warfarin therapy was referred to our facility for further management. Cardiac CT imaging revealed large bi-atrial thrombi for which apixaban therapy was initiated. Serial imaging over nine months showed gradual shrinkage and then resolution of the thrombi. In line with the patient's preference to avoid life-long OAC, he received LAAO using an Amplatzer™ Amulet™ device. Follow-up transoesophageal echocardiography showed a well-seated device with no leak and no thrombus. Discussion: We discussed the key issues surrounding management of bi-atrial thrombi and the decision to perform LAAO in these circumstances, relying on shared decision making and multi-disciplinary team input.

Myocardial rupture and left ventricular pseudoaneurysm due to late STEMI presentation during the COVID-19 pandemic lockdown: a classical case report.

BACKGROUND: Left ventricular (LV) pseudoaneurysm is a serious and rare complication of myocardial infarction (MI). It occurs when an injured myocardial wall ruptures and is contained by overlying adherent pericardium or scar tissue, most commonly it develops in patients with late presentation of MI and delayed revascularization. CASE SUMMARY: A 64-year-old man presented to the emergency department with intermittent central chest pain radiating to back and neck and increasing on deep inspiration, which was considered to be of musculoskeletal origin for a week, but worsened despite medications. Electrocardiography showed features of ST-elevation MI; a circumflex artery occlusion was found on coronary angiogram and angioplasty was performed. Cardiovascular magnetic resonance (CMR) revealed features of healed lateral wall rupture with adherent parietal pericardium and the patient was managed conservatively. Two months later the patient returned with severe chest pain; echocardiogram and cardiac computed tomography showed significant interval progression of the pseudoaneurysm. Aneurysmectomy was performed, after which the patient recovered and had none of the previous symptoms since. Follow-up CMR study revealed improvement of LV systolic function. DISCUSSION: A rare case of post-infarction LV pseudoaneurysm was reported. Multimodality imaging helped to detect and to differentiate this complication from the true aneurysm and to follow it up and plan the treatment. Conservative treatment was not effective in this case as the pseudoaneurysm progressed; aneurysmectomy helped to improve LV systolic function.

A direct comparison of decision rules for early discharge of suspected acute coronary syndromes in the era of high sensitivity troponin.

BACKGROUND: We tested the hypothesis that a single high sensitivity troponin at limits of detection (LOD HSTnT) (<5 ng/l) combined with a presentation non-ischaemic electrocardiogram is superior to low-risk Global Registry of Acute Coronary Events (GRACE) (<75), Thrombolysis in Myocardial Infarction (TIMI) (≤1) and History, ECG, Age, Risk factors and Troponin (HEART) score (≤3) as an aid to early, safe discharge for suspected acute coronary syndrome. METHODS: In a prospective cohort study, risk scores were computed in consecutive patients with suspected acute coronary syndrome presenting to the Emergency Room of a large English hospital. Adjudication of myocardial infarction, as per third universal definition, involved a two-physician, blinded, independent review of all biomarker positive chest pain re-presentations to any national hospital. The primary and secondary outcome was a composite of type 1 myocardial infarction, unplanned coronary revascularisation and all cause death (MACE) at six weeks and one year. RESULTS: Of 3054 consecutive presentations with chest pain 1642 had suspected acute coronary syndrome (52% male, median age 59 years, 14% diabetic, 20% previous myocardial infarction). Median time from chest pain to presentation was 9.7 h. Re-presentations occurred in eight hospitals with 100% follow-up achieved. Two hundred and eleven (12.9%) and 279 (17%) were adjudicated to suffer MACE at six weeks and one year respectively. Only HEART ≤3 (negative predictive value MACE 99.4%, sensitivity 97.6%, %discharge 53.4) and LOD HSTnT strategy (negative predictive value MACE 99.8%, sensitivity 99.5%, %discharge 36.9) achieved pre-specified negative predictive value of >99% for MACE at six weeks. For type 1 myocardial infarction alone the negative predictive values at six weeks and one year were identical, for both HEART ≤3 and LOD HSTnT at 99.8% and 99.5% respectively. CONCLUSION: HEART ≤3 or LOD HSTnT strategy rules out short and medium term myocardial infarction with ≥99.5% certainty, and short-term MACE with >99% certainty, allowing for early discharge of 53.4% and 36.9% respectively of suspected acute coronary syndrome. Adoption of either strategy has the potential to greatly reduce Emergency Room pressures and minimise follow-up investigations. Very early presenters (<3 h), due to limited numbers, are excluded from these conclusions.

Outcome of left atrial appendage occlusion in high-risk patients.

OBJECTIVE: Percutaneous left atrial appendage (LAA) occlusion can be an interventional alternative to oral anticoagulation for stroke prevention in patients with atrial fibrillation. METHODS: We delivered LAA occlusion therapy using a standardised approach to patient referral, multidisciplinary team assessment, implant criteria, imaging and follow-up. We analysed patient characteristics, efficacy and safety of the implant procedure, and 12-month outcomes. RESULTS: Of 143 referrals from October 2014 to December 2016, 83 patients (age 76±8years, 32.5% female, mean CHAD2S2-VASc score 4 ±1) were offered LAA occlusion. Eighty (95.3%) had previous major bleeding (intracranial in 59%). LAA occluder implantation with an Amulet device was successful in 82 (98.8%), with periprocedural major adverse events occurring in 5 (6.0%) patients (2 device embolisations including 1 death, 2 major bleeds). Cardiac imaging in 75 (94%) patients 2months following implant showed device-related thrombus in 1 case (1.3%) and minor (<5mm) device leaks in 13 (17.1%). Over a median 12-month follow-up, 3 (3.8%) ischaemic strokes, 2 (2.5%) haemorrhagic strokes and 5 (6.3%) major extracranial bleeds occurred. All-cause mortality was 10%, with most deaths (7, 87.5%) due to non-cardiovascular causes. CONCLUSIONS: LAA occlusion may be a reasonable option for stroke prevention inhigh-risk patients with atrial fibrillation ineligible for anticoagulation. However, procedural complication rates are not insignificant, and patients remain at risk of serious adverse events and death even after successful implant.

The effects of initiation or continuation of statin therapy on cholesterol level and all-cause mortality after the diagnosis of left ventricular systolic dysfunction.

BACKGROUND: Statins (3-hydroxy-3-methyl-glutaryl coenzyme A reductase inhibitors) are known to reduce mortality and cardiac events in patients with coronary artery disease who have not progressed to left ventricular systolic dysfunction (LVSD) and/or heart failure (HF). This study investigated the effect of changes in statin therapy and cholesterol level on mortality in patients with LVSD. METHODS: Data from consecutive patients with LVSD enrolled in a single local hospital HF management program were analyzed. Patients were grouped according to changes in statin treatment within 4 months after their initial visit: groups NS (no statin), IS (initiation of statin), CS (continuation of statin), and SS (statin stopped). RESULTS: Nine hundred patients were followed for a median of 36 (28-43) months (range, 16-66 months). The 2-year mortality was 16.7%. Groups IS and CS had lower 2-year mortality than groups NS and SS (11.0% and 11.9% vs 22.0% and 34.8%, respectively; P < .001). This was independent of age, sex, severity of LVSD, HF medications, New York Heart Association functional class, and baseline cholesterol. The effect was mainly observed in patients with coronary artery disease. In 734 patients who had completed 1-year follow-up on stable HF treatment, neither baseline cholesterol nor change over 1 year predicted outcome. CONCLUSION: Initiation and maintenance of treatment with statins is associated with better survival in patients with LVSD. This could not be explained by other measured variables.

The cholesterol paradox in heart failure.

Heart failure (HF) is a common and serious condition that is usually due to coronary artery disease (CAD). Hypercholesterolemia is a major risk factor for CAD but, paradoxically, patients with advanced HF often have low cholesterol, which is associated with a poor prognosis. Cholesterol lowering with statins reduces morbidity and mortality in patients with CAD who do not have HF and might also have improved outcome in patients with HF had they not been excluded from the reported trials. The results of large trials such as the Controlled Rosuvastatin Multinational Study in Heart Failure (CORONA) and the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico-Insufficienza Cardiaca (GISSI-HF) study addressing the effects of rosuvastatin in HF are keenly awaited. In addition to cholesterol lowering, statins have other biologic effects that might be responsible for some of their favorable effects. This article examines this cholesterol paradox and possible mechanisms.

Fighting against sudden death: a single or multidisciplinary approach.

There are many causes of sudden death ranging from accidents and suicide to vascular events and arrhythmias. Most sudden deaths will occur in people who have not been diagnosed with a serious heart condition but at a very low annual rate. Many of these events are probably vascular and might be prevented by reducing the risk of developing coronary disease. Only a minority of sudden deaths occur in people with established cardiac disease, but in patients with major structural heart disease, the annual rate is high. The causes of sudden death are many in this clinical setting also, but dominated by ventricular arrhythmias and vascular events. There is good evidence that conventional treatments for heart failure, including ACE inhibitors, beta-blockers, aldosterone antagonists and cardiac resynchronization devices reduce the risk of sudden death. Evidence that statins, aspirin or revascularisation are safe or effective in patients with heart failure is currently lacking. Implantable defibrillators confer a small but definite additional survival advantage by treating arrhythmias that have not been prevented.

Clinical trials update from the European Society of Cardiology Heart Failure meeting and the American College of Cardiology: darbepoetin alfa study, ECHOS, and ASCOT-BPLA.

This article provides information and a commentary on landmark trials presented at the European Society of Cardiology Heart Failure meeting held in June 2005, relevant to the pathophysiology, prevention and treatment of heart failure. All reports should be considered as preliminary data, as analyses may change in the final publication. The erythropoiesis stimulating protein, darbepoetin alfa, increased haemoglobin levels, improved quality of life and showed a trend for improved exercise duration in anaemic patients with symptomatic chronic heart failure. In the ECHOS study, the selective dopamine agonist nolomirole (CHF1035) showed no benefit in heart failure patients. Preliminary results of the ASCOT-BPLA study, which were reported at the American College of Cardiology meeting in March 2005, showed that in hypertensive patients, treatment with a calcium antagonist plus an ACE inhibitor was more effective at reducing cardiovascular outcomes than atenolol plus a diuretic.

Clinical trials update from the American College of Cardiology meeting: CARE-HF and the remission of heart failure, Women's Health Study, TNT, COMPASS-HF, VERITAS, CANPAP, PEECH and PREMIER.

This article provides information and a commentary on landmark trials presented at the American College of Cardiology meeting held in March 2005, relevant to the pathophysiology, prevention and treatment of heart failure. All reports should be considered as preliminary data, as analyses may change in the final publication. CARE-HF showed that Cardiac Re-synchronisation Therapy, administered in addition to expert pharmacological management, reduced all cause mortality and CV hospitalisation in patients with moderate or severe heart failure and cardiac dyssynchrony. The Women's Health Study showed no benefit of vitamin E supplementation or aspirin in the primary prevention of CV disease. The TNT study showed that reducing LDL cholesterol to levels lower than currently recommended, produced a 22% reduction in the incidence of major cardiovascular events. In COMPASS, an implantable device that continuously monitors intra-cardiac pressures was shown to be safe and to improve care in patients with chronic heart failure. Tezosentan failed to show benefit in patients with acute heart failure in the VERITAS study. The CANPAP study failed to show a benefit of continuous positive airway pressure on mortality and heart transplantation in heart failure patients with central sleep apnoea. EECP therapy improved exercise capacity but had no effect on peak VO2 in heart failure patients in the PEECH study. In the PREMIER study the matrix metalloproteinase inhibitor PG-116800 failed to prevent LV remodelling following myocardial infarction.

Clinical trials update from the American Heart Association meeting: ACORN-CSD, primary care trial of chronic disease management, PEACE, CREATE, SHIELD, A-HeFT, GEMINI, vitamin E meta-analysis, ESCAPE, CARP, and SCD-HeFT cost-effectiveness study.

This article provides information and a commentary on landmark trials presented at the American Heart Association meeting held in November 2004, relevant to the pathophysiology, prevention, and treatment of heart failure. An open trial of the ACORN Cardiac Support Device (CSD) showed encouraging preliminary results in patients with severe heart failure. The PEACE (Prevention of Events with Angiotensin-Converting Enzyme inhibition) study supports data from previous studies showing that ACE inhibitors reduce vascular events in patients at increased risk. The CREATE (clinical trial of metabolic modulation in acute MI treatment evaluation) study of patients with acute myocardial infarction (MI) showed no mortality benefit of a glucose/insulin/potassium regimen, but treatment with reviparin reduced the incidence of death, MI, or stroke. Azimilide was not associated with a significant reduction in shocks, but reduced the shocks or episodes of markedly symptomatic ventricular tachycardia terminated by pacing in the SHIELD (Shock Inhibition Evaluation with Azimilide) study. The addition of isosorbide dinitrate plus hydralazine to standard therapy improved survival in black heart failure patients in the A-HeFT (African-American Heart Failure Trial) study. In an investigation of hypertensive patients with diabetes, carvedilol had fewer adverse effects on diabetic control than metoprolol. A meta-analysis of high-dose vitamin E supplementation suggested an association with increased mortality. The ESCAPE (Evaluation Study of CHF and Pulmonary Artery Catheterisation Effectiveness) study showed no benefit of pulmonary artery catheterisation over clinical management in patients with severe heart failure. Routine prophylactic coronary revascularisation for stable coronary disease prior to major vascular surgery showed no benefit in the CARP (Coronary Artery Revascularization Prophylaxis) study. Analysis of data from SCD-HeFT supports the cost-effectiveness of ICDs in heart failure, although overall cost implications may be prohibitive.

Clinical trials update from the American Heart Association meeting: Omega-3 fatty acids and arrhythmia risk in patients with an implantable defibrillator, ACTIV in CHF, VALIANT, the Hanover autologous bone marrow transplantation study, SPORTIF V, ORBIT and PAD and DEFINITE.

The American Heart Association meeting reported the results of several clinical trials of particular interest to those who care for patients with heart failure. Omega-3 fatty acids were associated with a trend to increased recurrence of ventricular arrhythmias but not mortality in patients with an implantable debrillator. The ACTIV in CHF study provides more evidence of a therapeutic role for arginine vasopressin antagonists in the treatment of heart failure. The VALIANT study provides further evidence to suggest that a combination of angiotensin receptor antagonist and ACE inhibitor does not reduce mortality but may reduce morbidity in post-MI patients with heart failure or major LV systolic dysfunction. A study of autologous bone marrow cell transplantation into myocardial scar give gave encouraging results. SPORTIF V showed ximelagation to be as effective as warfarin but with improved safety. ORBIT and PAD showed public access defibrillators saved lives but questioned their cost effectiveness. DEFINITE supported a role for ICDs in patients with non-ischemic cardiomyopathy, although cost-effectiveness remains in doubt.

How should I treat a spontaneously reperfused acute STEMI that involves the left main stem and proximal LAD?

BACKGROUND: A 41-year-old female with 90 minutes of severe chest pain and ST-elevation in leads V1-V2 underwent emergency coronary angiography with a view to primary angioplasty. INVESTIGATIONS: Physical examination, electrocardiography, coronary angiography. DIAGNOSIS: ST-segment elevation anterior myocardial infarction. MANAGEMENT: Coronary angiography, antiplatelet and antithrombotic therapy, statin, angiotensin-converting enzyme inhibitor, beta blocker, IVUS and percutaneous coronary intervention (PCI)

Predictors of short term mortality in heart failure - insights from the Euro Heart Failure survey.

OBJECTIVE: To identify factors associated with short term mortality in hospitalised patients with heart failure. BACKGROUND: Hospitalisation is frequent in patients with heart failure and is associated with a high mortality. METHODS: The Euro Heart Failure survey collected data from patients with suspected heart failure. We searched this data for predictors of short term mortality. RESULTS: Of 10,701 patients, 1404 (13%) died within 12 weeks of admission. On univariate analysis, increasing age, hyponatraemia, renal impairment, hyperkalaemia, anaemia, severe mitral regurgitation, severe LV systolic dysfunction(LVSD), increasing QRS and female sex carried adverse prognosis. ACEI, beta-blockers, nitrates, anti-thrombotic and lipid lowering drugs were associated with a better prognosis. On multivariable analysis the following provided independent prognostic information: increasing age (OR per SD=1.5, 95% CI 1.4-1.6), severe LVSD (1.8, 1.5-2.1), serum creatinine (1.2, 1.2-1.3), sodium (0.9, 0.8-0.9), Hb (0.9, 0.8-0.9) and treatment with ACEI (0.5, 0.5-0.6), beta-blockers (0.7, 0.6-0.8), statins (0.6, 0.5-0.7), calcium channel blockers (0.7, 0.6-0.8), warfarin (0.5, 0.4-0.6), heparin (1.7, 1.4-1.9), anti-platelet drugs (0.6, 0.5-0.6) and need for inotropes (5.5, 4.6-6.6). A simple risk score (range 0-11) identified cohorts with a 12 week mortality ranging from 2% to 44%. CONCLUSIONS: Simple and readily available clinical variables and a risk score based on medical history and routine tests that all patients admitted with heart failure have, can identify patients with good, intermediate and high short term mortality.