Cardiac service provision in the United Kingdom.

Cardiac conditions account for at least half of acute medical admissions. The provision of a comprehensive and responsive cardiological service in the UK is therefore pivotal to the manner in which the NHS continues to modernise. This article reviews recent developments in cardiology, describes the current provision of cardiac services for the more commonly encountered conditions, and explores future developments that will impact on the care patients presenting with heart disease receive.

Percutaneous Intervention Before Coronary Artery Bypass Surgery Does Not Unfavorably Impact Survival: A Single-Center Propensity-Matched Analysis.

BACKGROUND: This retrospective propensity-matched study investigated the impact of prior percutaneous coronary intervention (PCI) on short-term and long-term survival after coronary artery bypass graft surgery (CABG). METHODS: A total of 4,634 patients underwent isolated first-time CABG between April 2004 and March 2014. Among these, 424 (9.2%) had PCI. Propensity score analysis yielded 1:1 risk-adjusted matched groups: PCI (330 patients) and non-PCI (330 patients). A Cox proportional hazards model was used among the matched groups to assess the impact of prior PCI among other variables. Kaplan-Meier survival curves were compared at 1, 2, 3, 5, 7, and 10 years using the log-rank test to assess differences in survival. RESULTS: In-hospital 30-day mortality was 1.1% (non-PCI) versus 0.9% (prior PCI; p = 0.66). Overall survival at 10 years was 77.5% (non-PCI) versus 82.71% (prior PCI; p = 0.4). Cox regression analysis identified European System for Cardiac Operative Risk Evaluation, nonsinus rhythm, age, pulmonary disease, and urgent surgery as risk factors for increased mortality. Prior PCI was not an independent predictor for mortality (hazard ratio, 0.55; 95% confidence interval, 0.25 to 1.18; p = 0.123). Overall survival in matched cohorts, non-PCI versus prior PCI, was 96.02% versus 97.13% (p = 0.08) at 1 year, 92.64% versus 96.36% (p = 0.08) at 3 years, 90.01% versus 93.47% (p = 0.02) at 5 years, 83.33% versus 90.37% (p = 0.01) at 7 years, and 73.56% versus 90.27% (p = 0.004) at 10 years. CONCLUSIONS: The survival in matched cohorts did not show adverse outcomes with prior PCI at 1, 3, 5, 7, and 10 years. Prior PCI does not adversely impact survival after CABG.

Structure and functioning of a multidisciplinary 'Heart Team' for patients with coronary artery disease: rationale and recommendations from a joint BCS/BCIS/SCTS working group.

The decision-making process in the management of patients with ischaemic heart disease has historically been the responsibility of the cardiologist and encompasses medical management, percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG). Currently, there is significant geographical variability in the PCI:CABG ratio. There are now emerging recommendations that this decision-making process should be carried out through a multidisciplinary approach, namely the Heart Team. This work was carried out on behalf of The British Cardiovascular Society (BCS), Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS) and British Cardiovascular Intervention Society (BCIS). This manuscript sets out the principles for the functioning of the Heart Team. This work has been approved by the Executive Committees of BCS/BCIS/SCTS.

Clinical outcomes after final kissing balloon inflation compared with no final kissing balloon inflation in bifurcation lesions treated with a dedicated coronary bifurcation stent.

OBJECTIVE: We evaluated differences in clinical outcomes between patients who underwent final kissing balloon inflation (FKBI) and patients who did not undergo FKBI in bifurcation treatment using the Tryton Side Branch Stent (Tryton Medical, Durham, North Carolina, USA). METHODS: Clinical outcomes were defined as target vessel failure (composite of cardiac death, any myocardial infarction and clinically indicated target vessel revascularisation), cardiac death, myocardial infarction (MI), clinically indicated target vessel revascularisation and stent thrombosis. Cumulative event rates were estimated using the Kaplan-Meier method. A multivariable logistic regression analysis was performed to evaluate which factors were potentially associated with FKBI performance. RESULTS: Follow-up data was available in 717 (96%) patients with a median follow-up of 190 days. Cardiac death at 1 year occurred more often in the no-FKBI group (1.7% vs 4.6%, respectively, p=0.017), although this difference was no longer observed after excluding patients presenting with ST segment elevation MI (1.6% vs 3.3%, p=0.133). No significant differences were observed concerning the other clinical outcomes. One-year target vessel failure rates were 10.1% in the no-FKBI group and 9.2% in the FKBI group (p=0.257). Multivariable logistic regression analysis identified renal dysfunction, ST segment elevation MI as percutaneous coronary intervention indication, narrow (<30°) bifurcation angle and certain stent platforms as being independently associated with unsuccessful FKBI. CONCLUSIONS: A lower cardiac death rate was observed in patients in whom FKBI was performed compared with a selection of patients in whom FKBI could not be performed, probably explained by an unbalance in the baseline risk profile of the patients. No differences were observed regarding the other clinical outcomes.

Six-month and one-year clinical outcomes after placement of a dedicated coronary bifurcation stent: a patient-level pooled analysis of eight registry studies.

AIMS: Smaller studies have previously shown promising results after Tryton Side Branch Stent™ (Tryton Medical, Durham, NC, USA) placement. However, these previous studies were limited by their small sample size and relatively short follow-up. We performed a patient-level pooled analysis to evaluate six-month and one year clinical outcomes of more than 900 patients who were enrolled in eight registries with the Tryton stent. METHODS AND RESULTS: Data from eight Tryton registries, including 905 patients with 929 bifurcation lesions, were pooled on a patient level to form one dataset. The primary outcome was six-month target vessel failure (TVF), defined as the composite of cardiac death, any myocardial infarction, and clinically indicated target vessel revascularisation. Procedural success was defined as successful stent placement and no in-hospital major adverse cardiac events. Multivariable analysis was performed to determine independent predictors for one-year TVF. Follow-up data were available in 97%. Procedural success was 95% and TVF rate was 6.5% at six months and 8.5% at one year. Stent thrombosis occurred in 0.5% of patients. Left main coronary artery bifurcation lesion (HR 6.46) and main branch reference vessel diameter <3.0 mm (HR 2.62) were independent predictors for TVF. CONCLUSIONS: In the real world setting of registries including more than 900 patients, the use of the Tryton stent is associated with procedural and mid-term clinical results that compare very favourably with historical studies. The primary endpoint of TVF was primarily determined by reference vessel diameter of the main branch and left main bifurcation lesion location.

Heart team discussion in managing patients with coronary artery disease: outcome and reproducibility.

Recent ESC/EACTS revascularization guidelines advocate a 'Heart Team' (HT) approach in the decision-making process when managing patients with coronary disease. We prospectively assessed HT decision-making in 150 patients analysing personnel attendance, data presented, the 'actioning' of the HT decision and, if not completed, then the reasons why. Additionally, 50 patients were specifically re-discussed after 1 year in order to assess consistency in decision-making. We have two HT meetings each week. At least one surgeon, interventional cardiologist and non-interventional cardiologist were present at all meetings. Data presented included patient demographics, symptoms, co-morbidities, coronary angiography, left ventricular function and other relevant investigations, e.g. echocardiograms. HT decisions included continued medical treatment (22%), percutaneous coronary intervention (PCI; 22%), coronary-artery bypass grafting (CABG; 34%) or further investigations such as pressure wire studies, dobutamine stress echo or cardiac magnetic resonance imaging (22%). These decisions were fully undertaken in 86% of patients. Reasons for aberration in the remaining 21 patients included patient refusal (CABG 29%, PCI 10%) and further co-morbidities (28%). On re-discussion of the same patient data (n = 50) a year later, 24% of decisions differed from the original HT recommendations reflecting the fact that, for certain coronary artery disease pattern, either CABG or PCI could be appropriate.

The Heart Failure Revascularisation Trial (HEART).

AIMS: Revascularization is frequently advocated to improve ventricular function and prognosis for patients with heart failure due to coronary artery disease, especially when there is evidence of extensive myocardial viability. METHODS AND RESULTS: Patients with heart failure, coronary artery disease, and a left ventricular (LV) ejection fraction < 35%, who had a substantial volume of viable myocardium with contractile dysfunction assessed by any standard imaging technique, were randomly assigned to a strategy of conservative management vs. angiography with the intent of percutaneous or surgical revascularization. Patients requiring revascularization for angina or too frail for surgery were excluded. Only 138 of the planned 800 patients were enrolled because of withdrawal of funding due to slow recruitment. Also, a larger trial (The Surgical Treatment for Ischemic Heart Failure Trial) addressing a similar question became available, which investigators were encouraged to join. Of 69 patients assigned to the invasive strategy, 6 refused angiography, 2 died as a result of the diagnostic procedure, 14 were considered unsuitable for revascularization, 2 refused surgery, and 45 had revascularization. After a median follow-up of 59 (inter-quartile range: 33-63) months, there were 51 (37%) deaths; 25 (37%) in those assigned to the conservative strategy, and 26 (38%) in those assigned to the invasive strategy, 13 (29%) of whom had been revascularized. CONCLUSION: A conservative management strategy may not be inferior to one of coronary arteriography with the intent to revascularize in patients with heart failure, LV systolic dysfunction, and extensive myocardial viability. However, this study was underpowered and, further, larger trials are required to settle this issue. Clinical trials Registration No: ISRCTN86284615.

Management of 'no-reflow' complicating reperfusion therapy.

No-reflow phenomenon, defined as inadequate myocardial perfusion of the adequately dilated target vessel without evidence of angiographic mechanical obstruction. It is a multifactorial, well-recognised, secondary phenomenon following reperfusion therapy such as thrombolysis or percutaneous coronary interventions (PCI). The pathophysiological mechanisms leading to the no-reflow state are incompletely understood. Embolization of the atheromatous material to the distal vasculature and intense arteriole vasospasm caused by microembolization of platelet-rich thrombi that release vasoactive agents resulting in microvascular obstructions are likely mechanisms. Current prophylaxis and management strategies are derived from limited clinical data. Intracoronary verapamil, adenosine and nitroprusside have been most frequently studied and administered for angiographic no-reflow during PCI for acute myocardial infarction or saphenous vein graft (SVG) lesions and have been shown to improve epicardial flow and microvascular perfusion. The use of distal embolic protection devices in SVG interventions also provide microvascular protection and improve clinical outcomes. However, by far the most important measures are prevention and anticipation during PCI as once no-reflow established, complete reversal of the situation may not be possible.

Cardiogenic shock complicating myocardial infarction and outcome following percutaneous coronary intervention.

Cardiogenic shock is the commonest cause of death in acute myocardial infarction (AMI). Although the syndrome of cardiogenic shock complicating AMI is common to all, the spectrum of underlying pathology is broad. While thrombolysis can be attempted with inotropic support or augmentation of blood pressure with an intra-aortic balloon pump, the greatest mortality benefit is seen after urgent coronary angiography and early revascularization. The long-term SHOCK Trial six-year follow-up results confirm durability of early revascularization over medical stabilization in shock patients. Indeed, cardiogenic shock is a catheter laboratory emergency. Percutaneous left ventricular assist devices may provide an advance in the management of patients with left ventricular dysfunction and cardiogenic shock.