Temporal trends in referral patterns for invasive coronary angiography - a multicenter 10-year analysis.

AIM: To assess the temporal trends in the usage pattern of non-invasive testing before invasive coronary angiography (ICA) and its diagnostic yield in patients with suspected coronary artery disease (CAD). METHODS: Cross-sectional observational multicenter study of 4805 consecutive patients (60% male, mean age 66 ± 10 years) with suspected CAD undergoing elective ICA due to angina pectoris in two centers, from 2008 to 2017. The use of noninvasive testing and the proportion of patients with obstructive CAD (defined as the presence of at least one ≥50% stenosis on ICA) were assessed. RESULTS: There were 4038 (84%) patients referred for ICA with positive noninvasive test, mainly SPECT (38%, n = 1828) and exercise ECG (36%, n = 1731). Obstructive CAD was found in 54.5% (n = 2621) of the patients and 37.9% (n = 1822) underwent revascularization. The prevalence of obstructive CAD was higher in patients with vs. without previous noninvasive testing (55.8% vs. 48.1%, respectively, P < 0.001) and tended to decrease during the study period (P for trend <0.001). Both the presence of obstructive CAD and revascularization rate were higher in patients who underwent anatomical evaluation with CCTA compared with noninvasive functional tests (P = 0.001 and P = 0.018, respectively). The number of patients referred after exercise testing and SPECT decreased (p for trend 0.005 and 0.006, respectively) and after CCTA and stress CMR increased (both P for trend <0.001). The proportion of patients referred without previous testing remained stable. CONCLUSION: Nearly half of the patients undergoing ICA for suspected CAD did not have obstructive coronary lesions. This proportion tended to increase over the 10-year span of this study. Better clinical assessment tools and diagnostic pathways for stable CAD are warranted.

Mild troponin elevation in patients admitted to the emergency department with atrial fibrillation: 30-day post-discharge prognostic significance.

Patients with atrial fibrillation (AF) often undergo troponin (Tn) testing in the emergency department (ED), but the clinical significance of mildly elevated values remains unclear. We evaluated short-term 30-day post-discharge outcomes in AF patients according to troponin levels. Out of 2181 AF patients evaluated in the ED (June 2014 to June 2015), we included consecutive admitted patients. Patients were grouped into those with normal Tn values (≤ 0.05 ng/mL), mild elevations (> 0.05-0.5 ng/mL, 10× URL) and marked elevations (> 0.5 ng/mL). Outcomes included acute coronary syndrome (ACS), revascularization, all-cause mortality and combined end point; the secondary outcome was ischemic stroke. A total of 348 patients (90.9%) had Tn testing, which was associated with longer in-hospital stay (median 2.04 vs. 0.74 days in unmeasured Tn, p = 0.014); 37.1% did not have clinical suspicion of ACS. Mild Tn elevation occurred in 19.0% and 6.3% had markedly elevated values. Compared to normal values, mild elevations had higher absolute incidence, without statistical significance, of ACS (1.5 vs. 0.0%, p = 0.202), revascularization (1.5 vs. 0.0%, p = 0.202), all-cause mortality (12.1 vs. 6.9%, p = 0.200), combined end point (13.3 vs. 6.9%, p = 0.084) or ischemic stroke (4.5 vs. 2.3%, p = 0.394). Tn testing is routine in admitted AF patients, even without suspicion of ACS, and is associated with prolonged stay. Mild Tn elevation is associated with a nonsignificant trend toward higher adverse events. Larger-scale studies are needed to evaluate the cost-effectiveness of Tn testing for prognosis in admitted AF patients, as this prolongs stay and has unclear impact on patient management.

Impact of complete revascularization in patients with ST-elevation myocardial infarction: analysis of a 10-year all-comers prospective registry.

BACKGROUND: The benefit of complete revascularization (CR) during a primary percutaneous coronary intervention (PCI) in patients with multivessel disease (MVD) is still not clear. The aim of the present study was to evaluate the impact of CR in a nonselected population from an all-comers prospective registry of patients with ST-elevation myocardial infarction (STEMI) over a long period of time. METHODS AND RESULTS: Between 2004 and 2014, 671 noncardiogenic shock STEMI patients with MVD were included in the present study, of whom 522 were subjected to incomplete revascularization and 149 were subjected to CR. Patients in the CR group were younger [61 (SD 12) vs. 64 (SD 12.4) years old, P=0.001], more often subjected to femoral access (79.4 vs. 67.1%, P=0.002), and had a lower number of segments with lesion [2 (2.2) vs. 3 (3.4), P=0.001]. The CR group tended to have a lower 1-year major adverse cardiac event (MACE) rate (17.8 vs. 25.7%; P=0.05) that reached statistical significance at 2 years (19.4 vs. 28.5%, P=0.03). The rates of the individual endpoints were not different between groups. Independent predictors of 2-year MACE were age, femoral access, and previous PCI. Index CR was associated with lower MACE (hazard ratio 0.5, 0.36-0.79). MACE-free survival was higher in the CR group throughout the 2 years of follow-up. CONCLUSION: In patients with STEMI and MVD undergoing culprit lesion PCI, preventive PCI in noninfarct coronary arteries with significant stenosis was associated with a lower risk of MACE compared with incomplete revascularization in this all-comers prospective registry.

Applicability of the Zwolle risk score for safe early discharge after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction.

INTRODUCTION AND AIM: The optimal length of stay for patients with uncomplicated ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PPCI) is still undetermined. The Zwolle risk score (ZRS) is a simple tool designed to identify patients who can be safely discharged within 72 hours. The purpose of this study was to assess the applicability and performance of the ZRS in our population. METHODS: We studied 276 consecutive patients (mean age 62 ± 14 years, 75% male, 20% Killip class >1) admitted over a two-year period for STEMI and treated with PPCI. ZRS, length of stay, 30-day mortality and readmission were obtained for all patients. Low risk was defined as ZRS ≤ 3. RESULTS: The median ZRS was 3 (interquartile range [IQR] 1-4), with 171 patients (62%) being classified as low risk. Thirty-day mortality was 4.7% (13 patients). Compared to other patients, low-risk patients had shorter length of stay (median 5.0 [IQR 4-7] vs. 7.0 [5-13] days, p<0.001), and lower 30-day mortality (0 vs. 12.4%, p<0.001), yielding a negative predictive value of 100% (95% CI 97.0-100%) for the proposed cutoff. The ZRS showed excellent discriminative power (C-statistic: 0.937, 95% CI 0.906-0.968, p<0.001), and good calibration against the original cohort. CONCLUSIONS: The ZRS appears to perform well in identifying low-risk STEMI patients who could be safely discharged within 72 hours of admission. Using the ZRS in our population could result in a more rational use of in-patient resources.

A rare case of persistent troponin elevation in a patient with chronic heart failure.

We present the case of a woman diagnosed with hypertrophic cardiomyopathy who suffered a myocardial infarction when she was 28 years old, without coronary artery disease on coronary angiography. Two years later, she presented signs of heart failure and left ventricular systolic dysfunction with persistent troponin I elevation, followed by progressive worsening of ventricular dysfunction.

Diagnostic yield of current referral strategies for elective coronary angiography in suspected coronary artery disease-an analysis of the ACROSS registry.

INTRODUCTION AND OBJECTIVES: The purpose of this study was to assess the diagnostic yield of current referral strategies for elective invasive coronary angiography (ICA). METHODS: We performed a cross-sectional observational study of consecutive patients without known coronary artery disease (CAD) undergoing elective ICA due to chest pain symptoms. The proportion of patients with obstructive CAD (defined as the presence of at least one ≥50% stenosis on ICA) was determined according to the use of noninvasive testing. RESULTS: The study population consisted of 1892 individuals (60% male, mean age 64±11 years), of whom 1548 (82%) had a positive noninvasive test: exercise stress test (41%), stress myocardial perfusion imaging (36%), stress echocardiogram (3%) or coronary computed tomography angiography (3%). Referral without testing occurred in 18% of patients. The overall prevalence of obstructive CAD was 57%, higher among those with previous testing (58% vs. 51% without previous testing, p=0.026) and when anatomic rather than functional tests were used (81.3% vs. 57.1%, p=0.001). A positive test and conventional risk factors were all independent predictors of obstructive CAD, with adjusted odds ratios (95% confidence interval) of 1.34 (1.03-1.74) for noninvasive testing, 1.05 (1.04-1.06) for age, 3.48 (2.81-4.29) for male gender, 1.86 (1.32-2.62) for current smoking, 1.74 (1.38-2.20) for diabetes, 1.30 (1.04-1.62) for hypercholesterolemia, and 1.39 (1.08-1.80) for hypertension. CONCLUSIONS: More than 40% of patients without known CAD undergoing elective ICA did not have obstructive lesions, even though four out of five had a positive noninvasive test. These exams were relatively weak gatekeepers; functional tests were more often used but appeared to be outperformed by the anatomic test.