The ability of contemporary cardiologists to judge the ischemic impact of a coronary lesion visually

BACKGROUND: Landmark trials showed that invasive pressure measurement (Fractional Flow Reserve, FFR) was a better guide to coronary stenting than visual assessment. However, present-day interventionists have benefited from extensive research and personal experience of mapping anatomy to hemodynamics. AIMS: To determine if visual assessment of the angiogram performs as well as invasive measurement of coronary physiology. METHODS: 25 interventional cardiologists independently visually assessed the single vessel coronary disease of 200 randomized participants in The Objective Randomized Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina trial (ORBITA). They gave a visual prediction of the FFR and Instantaneous Wave-free Ratio (iFR), denoted vFFR and viFR respectively. Each judged each lesion on 2 occasions, so that every lesion had 50 vFFR, and 50 viFR assessments. The group consensus visual estimates (vFFR-group and viFR-group) and individual cardiologists' visual estimates (vFFR-individual and viFR-individual) were tested alongside invasively measured FFR and iFR for their ability to predict the placebo-controlled reduction in stress echo ischemia with stenting. RESULTS: Placebo-controlled ischemia improvement with stenting was predicted by vFFR-group (p < 0.0001) and viFR-group (p < 0.0001), vFFR-individual (p < 0.0001) and viFR-individual (p < 0.0001). There were no significant differences between the predictive performance of the group visual estimates and their invasive counterparts: p = 0.53 for vFFR vs FFR and p = 0.56 for viFR vs iFR. CONCLUSION: Visual assessment of the angiogram by contemporary experts, provides significant additional information on the amount of ischaemia which can be relieved by placebo-controlled stenting in single vessel coronary artery disease.

The ability of contemporary cardiologists to judge the ischemic impact of a coronary lesion visually.

BACKGROUND: Landmark trials showed that invasive pressure measurement (Fractional Flow Reserve, FFR) was a better guide to coronary stenting than visual assessment. However, present-day interventionists have benefited from extensive research and personal experience of mapping anatomy to hemodynamics. AIMS: To determine if visual assessment of the angiogram performs as well as invasive measurement of coronary physiology. METHODS: 25 interventional cardiologists independently visually assessed the single vessel coronary disease of 200 randomized participants in The Objective Randomized Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina trial (ORBITA). They gave a visual prediction of the FFR and Instantaneous Wave-free Ratio (iFR), denoted vFFR and viFR respectively. Each judged each lesion on 2 occasions, so that every lesion had 50 vFFR, and 50 viFR assessments. The group consensus visual estimates (vFFR-group and viFR-group) and individual cardiologists' visual estimates (vFFR-individual and viFR-individual) were tested alongside invasively measured FFR and iFR for their ability to predict the placebo-controlled reduction in stress echo ischemia with stenting. RESULTS: Placebo-controlled ischemia improvement with stenting was predicted by vFFR-group (p < 0.0001) and viFR-group (p < 0.0001), vFFR-individual (p < 0.0001) and viFR-individual (p < 0.0001). There were no significant differences between the predictive performance of the group visual estimates and their invasive counterparts: p = 0.53 for vFFR vs FFR and p = 0.56 for viFR vs iFR. CONCLUSION: Visual assessment of the angiogram by contemporary experts, provides significant additional information on the amount of ischaemia which can be relieved by placebo-controlled stenting in single vessel coronary artery disease.

Safety, Feasibility and Economic Analysis of Same Day Discharge Following Elective Percutaneous Coronary Intervention.

Background: Advances in percutaneous coronary intervention (PCI) has made the possibility of facilitating same day discharge (SDD) of patients undergoing intervention. We sought to investigate the feasibility, safety and economic impact of such a service. Methods: We retrospectively collected data on all patients undergoing outpatient PCI at our institution over a 12-month period. We included in-hospital and 30-day major adverse cardiac events (MACE), vascular complications, acute kidney injury and any re-hospitalisations. We analysed the cost effectiveness of SDD compared to overnight admission post PCI and staged PCI following diagnostic angiography. Results: A total of 147 patients undergoing PCI with 129 patients deemed suitable for SDD (88%). Mean age was 65.7 years. Most patients had type C lesions (60.3%); including 4 chronic total occlusions (CTOs). At 30-day follow-up there were no MACE events (0%). There were 10 (7.8%) re-hospitalisations of which majority (70%) were non cardiac presentations. We also included cost analysis for an elective PCI with SDD, which equated to $2090 per patient (total of $269 610 for cohort). Elective PCI with an overnight admission was $4440 per patient (total of $572 760 for cohort), an additional $2350 per patient (total $303 150). Total cost of an angiogram followed by a staged PCI with an overnight stay was $4700 per patient (total $606 300). Conclusion: SDD is safe and feasible in the majority of patients that have elective coronary angiography that require PCI. SDD leads to a significant reduction in total cost and hospital stay of patients undergoing elective PCI.

Survival in Patients With Suspected Myocardial Infarction With Nonobstructive Coronary Arteries: A Comprehensive Systematic Review and Meta-Analysis From the MINOCA Global Collaboration.

BACKGROUND: Suspected myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA) occurs in ≈5% to 10% of patients with MI referred for coronary angiography. The prognosis of these patients may differ to those with MI and obstructive coronary artery disease (MI-CAD) and those without a MI (patients without known history of MI [No-MI]). The primary objective of this study is to evaluate the 12-month all-cause mortality of patients with MINOCA. METHODS: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the terms "MI," "nonobstructive," "angiography," and "prognosis" were searched in PubMed and Embase databases from inception to December 2018, including original, English language MINOCA studies with >100 consecutive patients. Publications with a heterogeneous cohort, unreported coronary stenosis, or exclusively focusing on MINOCA-mimicking conditions, were excluded. Unpublished data were obtained from the MINOCA Global Collaboration. Data were pooled and analyzed using Paule-Mandel, Hartung, Knapp, Sidik & Jonkman, or restricted maximum-likelihood random-effects meta-analysis methodology. Heterogeneity was assessed using Cochran's Q and I2 statistics. The primary outcome was 12-month all-cause mortality in patients with MINOCA, with secondary comparisons to MI-CAD and No-MI. RESULTS: The 23 eligible studies yielded 55 369 suspected MINOCA, 485 382 MI-CAD, and 33 074 No-MI. Pooled meta-analysis of 14 MINOCA studies accounting for 30 733 patients revealed an unadjusted 12-month all-cause mortality rate of 3.4% (95% CI, 2.6%-4.2%) and reinfarction (n=27 605; 10 studies) in 2.6% (95% CI, 1.7%-3.5%). MINOCA had a lower 12-month all-cause mortality than those with MI-CAD (3.3% [95% CI, 2.5%-4.1%] versus 5.6% [95% CI, 4.1%-7.0%]; odds ratio, 0.60 [95% CI, 0.52-0.70], P<0.001). In contrast, there was a statistically nonsignificant trend towards increased 12-month all-cause mortality in patients with MINOCA (2.6% [95% CI, 0%-5.9%]) compared with No-MI (0.7% [95% CI, 0.1%-1.3%]; odds ratio, 3.71 [95% CI, 0.58-23.61], P=0.09). CONCLUSIONS: In the largest contemporary MINOCA meta-analysis to date, patients with suspected MINOCA had a favorable prognosis compared with MI-CAD, but statistically nonsignificant trend toward worse outcomes compared to those with No-MI. Registration: URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42020145356.

Sub-acute cardiac magnetic resonance to predict irreversible reduction in left ventricular ejection fraction after ST-segment elevation myocardial infarction: A DANAMI-3 sub-study.

AIMS: To predict irreversible reduction in left ventricular ejection fraction (LVEF) during admission for ST-segment elevation myocardial infarction (STEMI) using cardiac magnetic resonance (CMR) in addition to classical clinical parameters. Irreversible reduction in LVEF is an important prognostic factor after STEMI which necessitates medical therapy and implantation of prophylactic implantable cardioverter defibrillator (ICD). METHODS AND RESULTS: A post-hoc analysis of DANAMI-3 trial program (Third DANish Study of Optimal Acute Treatment of Patients With ST-elevation Myocardial Infarction) which recruited 649 patients who had CMR performed during index hospitalization and after 3 months. Patients were divided into two groups according to CMR-LVEF at 3 months: Group 1 with LVEF≤35% and Group 2 with LVEF>35%. Group 1 included 15 patients (2.3%) while Group 2 included 634 patients (97.7%). A multivariate analysis showed that: Killip class >1 (OR 7.39; CI:1.47-36.21, P = 0.01), symptom onset-to-wire ≥6 h (OR 7.19; CI 1.07-50.91, P = 0.04), LVEF≤35% using index echocardiography (OR 7.11; CI: 1.27-47.43, P = 0.03), and infarct size ≥40% of LV on index CMR (OR 42.62; CI:7.83-328.29, P < 0.001) independently correlated with a final LVEF≤35%. Clinical models consisted of these parameters could identify 7 out of 15 patients in Group 1 with 100% positive predictive value. CONCLUSION: Together with other clinical measurements, the assessment of infarct size using late Gadolinium enhancement by CMR during hospitalization is a strong predictor of irreversible reduction in CMR_LVEF ≤35. That could potentially, after validation with future research, aids the selection and treatment of high-risk patients after STEMI, including implantation of prophylactic ICD during index hospitalization.

The validity of the diagnosis of heart failure (I50.0-I50.9) in the Danish National Patient Register.

INTRODUCTION: National discharge registers are important and cost-effective data sources for administrative and research purposes, but their value depends much on the validity of the registered data. The objective of this study was to assess the validity of heart failure (HF) diagnoses (ICD10: I50.0-I50.9) in the Danish National Patient Register (DNPR). METHODS: We reviewed medical records from a random sample of 500 patients with either a primary or a secondary discharge diagnosis of HF registered in the DNPR from any department in Northern Denmark in 2007. We noted symptoms, objective signs, diagnostic imaging and biomarkers and used the European Society of Cardiology definition of HF to categorise patients into definite, probable or non-verified HF. RESULTS: We classified 305 patients as having definite HF and 113 patients as having probable HF. The remaining cases were classified as non-verified HF. Thus, the positive predictive value (PPV) for definite and probable HF was 83.6% (95% confidence interval (CI): 80.1-86.7%).
The PPV increased to 88.0% (95% CI: 84.4-91.0%) when we restricted analyses to primary diagnoses and to 95.2% (95% CI: 89.2-98.4%) when we restricted analyses to HF diagnoses established at cardiology units. CONCLUSIONS: The HF diagnoses (I50.0-I50.9) in the DNPR should be used with caution if validation is not possible. However, restricting analyses to patients registered with a primary diagnosis of HF or patients discharged from cardiology units may be a useful alternative in population-based studies. FUNDING: none. TRIAL REGISTRATION: not relevant.

Long-term prognosis of patients with non-ST-segment elevation myocardial infarction according to coronary arteries atherosclerosis extent on coronary angiography: a historical cohort study.

BACKGROUND: Patients with non-ST-segment elevation myocardial infarction (NSTEMI) without obstructive coronary artery disease (CAD) are often managed differently than those with obstructive CAD, therefore we aimed in this study to examine the long-term prognosis of patients with NSTEMI according to the degree of CAD on coronary angiography (CAG). METHODS: We examined 8.889 consecutive patients admitted for first time NSTEMI during 2000-2011, to whom CAG was performed. Patients were classified by CAG into: 0-vessel disease (0VD), diffuse atherosclerosis (DA) (0% < stenosis <50%), 1-vessel disease (1VD), 2VD, and 3VD with stenosis ≥50%. Follow-up period: 13 years (median 4.5). RESULTS: One-year mortality for NSTEMI patients with 0VD was 3.7%, DA 5.7%, 1VD 2.5%, 2VD 4.8%, and 3VD 11.5%. Non-diabetic 0VD patients had higher risk of mortality than 1VD patients (HR:1.59; 95% CI:1.21-2.02; P < 0.001), while those with diabetes mellitus (DM) had not significantly different risk. In addition 0VD group had higher risk of heart failure (HF) (HR 1.61; 95% CI: 1.39-1.88; P < 0.001), and lower risk of recurrent MI (HR:0.55; 95% CI:0.39-0.77; P < 0.001) compared with 1VD. For patients with DA; mortality and HF risks were higher than 1VD and not different than 2VD, while recurrent MI risk was not different than 1VD and lower than 2VD. Finally, the DA group had higher risk of mortality if they had DM, higher risk of recurrent MI, and not different risk of HF and stroke compared with the 0VD group patients. CONCLUSION: Patients with NSTEMI and non-obstructive CAD (both normal coronaries and diffuse atherosclerosis) have a comparable prognosis to patients with one- or two-vessel disease. Patients with diffuse atherosclerosis have worse prognosis than those with angiographically normal coronary arteries.

Unrecognised myocardial infarction in patients with schizophrenia.

OBJECTIVE: Schizophrenia is associated with a reduction of the lifespan by 20 years, with type II diabetes and cardiovascular disease contributing the most to the increased mortality. Unrecognised or silent myocardial infarction (MI) occurs in ~30% of the population, but the rates of unrecognised MI in patients with schizophrenia have only been sparsely investigated. METHOD: Electrocardiograms (ECG) from three psychiatric hospitals in Denmark were manually interpreted for signs of previous MI. Subsequently, ECGs were linked to the National Patient Registry in order to determine whether patients had a diagnosis consistent with previous MI. RESULTS: A total of 937 ECGs were interpreted, 538 men (57.4%) and 399 women (42.6%). Mean age at the time of ECG acquisition was 40.6 years (95% CI: 39.7-41.5, range: 15.9-94.6). We identified 32 patients with positive ECG signs of MIs. Only two of these patients had a diagnosis of MI in the National Patient Registry. An additional number of eight patients had a diagnosis of MI in the Danish National Patient Registry, but with no ECG signs of previous MI. This means that 30 out of 40 (75%) MIs were unrecognised. Only increasing age was associated with unrecognised MI in a stepwise multiple logistic regression model compared with patients with no history of MI, OR: 1.03 per year of age, 95% CI: 1.00-1.06, p=0.021. CONCLUSION: Unrecognised MI is common among patients with schizophrenia and may contribute to the increased mortality found in this patient group.

Incidence and outcome of first myocardial infarction according to gender and age in Denmark over a 35-year period (1978-2012).

AIMS: To examine temporal changes in incidence and 1-year mortality of first myocardial infarction (MI) in different age groups for both genders in Denmark over a 35-year period (1978-2012). METHODS AND RESULTS: Patients aged 30 years or older admitted with first MI in Denmark from 1978 to 2012 were included (n = 316 790). Overall, first MI incidence per 100 000 person-years (/105 p.y.) decreased significantly from 500 to 297/105 p.y. for males and from 229 to 156/105 p.y. for females. The decline was greatest among men aged 70-79 from 1460 to 643/105 p.y. (-56%). The majority of age groups also experienced declining incidence. However, men aged 30-39 and ≥90 years as well as females aged 30-49 and ≥90 years had increasing incidence during the study period. Moreover, the incidence decreased from 1978 to 1996 among males aged 40-49 and females aged 50-59 years, but increased in the remainder of the study period. One-year case-fatality declined significantly from 50 to 9% of MI male patients, and from 53 to 15% of MI female patients when comparing 1978 to 2012. Statistical analysis with Poisson models demonstrated that the mortality rate increased with age and decreased with time and indicated no significant difference between genders. CONCLUSIONS: During the period from 1978 to 2012, there was a significant decline in MI incidence among most age groups for both genders; however, an incidence increase was observed in men under 50 and women under 60 years, and ≥90 years for both genders. One-year case-fatality decreased constantly during the study period.

A third troponin T blood sample is not cost-effective in patients with suspected non-ST segment elevation acute coronary syndrome.

BACKGROUND: The diagnosis of acute myocardial infarction requires troponin assessment in at least two blood samples 6-9 hours apart, with an optional third sample 12-24 hours after admission if suspicion is high. Yet, in many institutions, this third sample is routinely drawn. This study aimed to evaluate cost-effectiveness of this third sample of troponin. METHODS: A total of 534 patients with possible Non ST-Elevation Acute Coronary Syndrome (NSTE-ACS) were included. Blood samples for cardiac TroponinT (cTnT) were obtained on arrival, after 6-9 hours, and 12-24 hours after admission. The costs of cTnT analysis, and hospital stay were calculated. RESULTS: Of the 534 patients, 124 had at least one elevated cTnT value. Among these, four patients (3.2%) had cTnT values increased only in the third sample. Based on their risk profile and/or ECG changes, these four patients were eligible for referral to coronary angiography even before the result of the third sample became available. The number of patients whose length of stay was extended solely because of the third sample was 275. Incremental cost of the third blood sample: [534 patients × Euro (EUR) 12 per cTnT analysis] + [275 patients × 0.5 day × EUR 1,550] = EUR 219,533. Approximately 1400 patients with suspected NSTE-ACS are admitted to our department each year. Thus, the total cost per year is: (1,400/534) × EUR 219,533 = EUR 575,555. CONCLUSION: A third troponin sample adds no vital information regarding patients' treatment or investigations plan. On the contrary, it may lead to an unnecessary extension of the admission period and increased costs.