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).

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)

Giant asymptomatic pericardial cyst.

Pericardial cysts are rare. We provide high-quality imagery demonstrating a giant cyst using plain radiography, ultrasound and magnetic resonance imaging (MRI).

Clinical outcomes after percutaneous coronary intervention involving very long segments of drug-eluting stent implantation: single-center experience.

BACKGROUND: Data on effectiveness and safety following the implantation of very long segments of drug-eluting stents (DES) are lacking. AIM: To describe our experience of consecutive patients undergoing implantation of very long segments of DES (> 50 mm) in de novo coronary lesions. METHODS: We evaluated major in-hospital complications, target lesion revascularization (TLR) rates and long-term outcomes in 88 consecutive patients (91 procedures) who underwent a single-vessel intervention with implantation of > 50 mm of overlapping DES to de novo lesions between October 2002 and October 2007. An additional 14 patients with long segments of in-stent restenosis, 10 receiving both DES and bare-metal stents for long-segment disease and 1 with long-segment disease in a saphenous vein graft were excluded from the study. Baseline clinical data, procedural outcomes and completed follow up were collected prospectively. RESULTS: Follow up was 100% complete up to April 30, 2008. The mean follow up was 26.5 months (6-60 months). The mean stent length was 70.6 mm (51-135 mm) and the average number of stents per vessel was 2.7 (2-5 stents). Acute complications included 1 case of acute stent thrombosis which was treated successfully, 1 case of aortic root dissection, and 1 case of retroperitoneal hemorrhage. The rate of non-Q-wave myocardial infarction (CKMB > 3 times normal) was 8%. During follow up, the rate of TLR was 6.5%. Five patients died, 4 of them due to noncardiac conditions. One death was attributed to possible late stent thrombosis (18 months) occurring suddenly 2 days post keloid repair. Two patients had definite very late stent thrombosis at 14 and 17 months. CONCLUSION: In our experience, the use of very long segments of DES is effective in treating diffuse de novo coronary artery lesions. However, longer-term follow up is necessary and more data are required to determine the optimum duration of dual antiplatelet therapy.

The whole nine yards: multiple cardiac surgical and percutaneous interventions in a patient during 30 years of care.

A 38-year-old man underwent coronary artery bypass graft surgery for angina pectoris following myocardial infarction. During the following 28 years, he required two repeat coronary artery bypass graft surgical procedures, nine percutaneous coronary interventions and 17 coronary angiograms. His treatment included saphenous vein, left internal mammary artery and gastroepiploic artery grafting, percutaneous transluminal coronary angioplasty and intragraft thrombolytic therapy, directional coronary atherectomy, cutting balloon angioplasty, intracoronary stenting with bare-metal and drug-eluting stents, treatment for in-stent restenosis, stenting of the left main and circumflex coronary arteries and saphenous vein graft as well as intracoronary pressure wire diagnostics. In addition to his statin therapy, antiplatelets and angiotensin-converting enzyme inhibitors, he also underwent biventricular automatic implantable cardioverter-defibrillator implantation and atrioventricular node radiofrequency ablation for his impaired left ventricular function, ventricular tachycardia and rapid atrial fibrillation. The present unusual case represents almost 'the whole nine yards' of treatment that has become available to patients with coronary artery disease during the past 30 years of technological development.

Late outcomes after drug-eluting stent implantation in "real-world" clinical practice.

BACKGROUND: We report the late outcomes in 411 consecutive patients undergoing drug-eluting stent (DES) implantation by a single operator between 2003-2006. METHODS: Prospective registry with continuous follow up. Patients with stable angina (SA) or acute coronary syndrome (ACS) received DES for long lesions, small vessels, chronic total occlusion, bifurcation, aorto-ostial, left main, post atherectomy or saphenous vein graft lesions, multivessel/multilesion single-vessel (V) disease, in-stent restenosis (ISR) or diabetes. RESULTS: Age range: 34-86 years. One hundred sixty-six (40.3%) had ACS, 98.3% hypercholesterolemia and 14.6% diabetes. Two hundred sixty-one (63.5%) had percutaneous coronary intervention (PCI) to 1V and 150 (36.5%) to >1V. Six hundred seven V were treated. Two hundred fifty-nine patients (63%) had multilesion PCI, and 109 (26.5%) 1V multilesion PCI. Two hundred ninety-three (71.3%) patients had long lesions and 224 had Vs < 2.75 mm diameter. 75.5% of lesions were Type B2/C. 1-8 stents were implanted/patient. Eight hundred twenty-two of 883 stents were DES. One hundred eight patients received > or = 1 stent of < or = 2.5 mm diameter and 246 patients received stents greater than or equal to 20 mm long. Twenty-five patients developed late complications. ISR occurred in 23, 3.5-38 months after DES implantation. Three had sudden late DES thrombosis (LST). One-third also had ISR. Twenty of twenty-five required PCI, 1 CABG and 4 medical treatment. Subsequently, 3 of the 20 required further PCI for recurrent ISR and 1 CABG. 9 patients died during 1-5-year follow up. CONCLUSIONS: In "real-world" patients at increased risk of ISR after bare-metal stenting (BMS), "off-label" DES implantation has a low incidence of late complications. The most common is ISR which presents later than after BMS. Acute LST is serious but unusual and may be accompanied by ISR.

Clinical implications of QRS duration and QT peak prolongation in patients with suspected coronary disease referred for elective cardiac catheterization.

BACKGROUND: The electrocardiogram (ECG) remains a simple, universally available, and prognostically powerful investigation in heart failure, and acute coronary syndromes. We sought to assess the prognostic utility of clinical, angiographic, and simple ECG parameters in a large cohort of patients undergoing elective cardiac catheterization (CC) for known or suspected coronary artery disease. METHODS: Consecutive consenting patients undergoing CC for coronary disease were enrolled at a single tertiary center. Patient data, drug therapy, catheter reports, and ECG recordings were prospectively recorded in a validated electronic archive. The primary outcome measure was death or nonfatal myocardial infarction (MI) over 1 year or until percutaneous or cardiac surgical intervention. Independent prognostic markers were identified using the Cox proportional hazard model. RESULTS: A total of 682 individuals were recruited of whom 17(2.5%) died or suffered a nonfatal MI in 1 year. In multivariate analysis QRS duration (ms) (HR 1.03 95% CI 1.01-1.05, P = 0.003), extent of coronary disease (HR 2.01 95% CI 1.24-3.58, P = 0.006), and prolonged corrected QT peak interval in lead I (HR 1.02 95% CI 1.00-1.03, P = 0.044) were independently associated with death or nonfatal MI. Receiver-operator characteristic (ROC) analysis for the multivariate model against the primary end point yielded an area under the curve of 0.759 (95% CI 0.660-0.858), P < 0.001. CONCLUSIONS: QRS duration and QT peak are independently associated with increased risk of death or nonfatal MI in stable patients attending for coronary angiography.

QT peak prolongation is not associated with left ventricular hypertrophy in teenage professional football players.

OBJECTIVE: QT peak prolongation is associated with left ventricular hypertrophy (LVH) in patients with hypertension. This study tests the hypothesis that QT peak prolongation correlates with LV mass index in apparently healthy young football players. METHODS: QT peak and other ECG criteria for LVH were assessed in 117 male professional footballers (mean age 16.4 years +/- SD 0.76). Their left ventricular mass index (LVMI) was assessed by transthoracic echocardiography. Heart rate-corrected QT peak (QTpc) interval was measured in lead I using Bazett's formula. Spearman (2-tailed) test and UNIANOVA was used to assess if there were correlations between QT peak and the various echocardiographic and ECG indices of LVH. RESULTS: Echocardiographic LVH, defined as LVMI > or = 134 g/m(2), was seen in 79 (70.5%) subjects. ECG-defined LVH was present in 54 (50 %) players by Sokolow-Lyon criteria, in 19 (16 %) players by Romhilt Score, in 5 (4 %) players by Cornell voltage criteria, and in 7 (6 %) players by Cornell product >2436 mm ms. There was no correlation between QT peak (QTpc) and LVMI on echocardiography (Spearman r = 0.058, 2-tailed P = 0.54). In addition, there was no relation between LVH and QTpc of lead I using any of the following ECG criteria: Sokolow-Lyon (P = 0.6), Romhilt (P = 0.3), Cornell voltage (P = 0.8), or Cornell product (P = 0.6). CONCLUSION: QT peak interval, which is associated with pathological LVH in hypertensive patients and is a measure of risk of cardiac death, does not correlate with LVH characterized by myocyte hypertrophy in young apparently healthy professional footballers.

Percutaneous coronary intervention for chronic total occlusions: improved survival for patients with successful revascularization compared to a failed procedure.

BACKGROUND: There are limited data on the impact of successful chronic total occlusion (CTO) revascularization by percutaneous coronary intervention (PCI) on survival. We performed a retrospective study comparing the survival between patients with a successful and a failed CTO revascularization by PCI. METHODS: Between January 1, 2000 and June 30, 2004, 543 of 5803 (9.4%) patients underwent PCI for a CTO at our center. A CTO was defined as an occlusion of the artery present for at least 3 months with Thrombolysis in Myocardial Infarction flow grade 0 or 1. Patient records were linked to a national database to monitor all deaths during follow up. Propensity matching was used to balance out case mix differences. RESULTS: Technical success for CTO was 377 of 543 (69.4%). In-hospital mortality was 0.3% and 1.2% for the CTO success and CTO failure patients, respectively. During a mean (SD) follow up of 1.7 (0.5) years, the mortality rate was 2.5% in the CTO success patients and 7.3% in the CTO failure patients. The crude hazard ratio for death with CTO failure was 3.92 (95% confidence intervals 1.56-10.07; P = 0.004). The rates of coronary artery bypass were 3.2% vs. 21.7% (P < 0.001) for the CTO success and CTO failure patients, respectively. Our propensity matched 157 CTO success to CTO failure patients and the associated hazard ratio for death with CTO failure was 4.63 (95% confidence interval 1.01-12.61; P = 0.049). Multivariate analysis showed that CTO failure was an independent predictor of death. CONCLUSION: Patients with a successful revascularization of a CTO by PCI have an increased survival rate compared to patients with a failed CTO procedure.

Spectral analysis, death and coronary anatomy following cardiac catheterisation.

OBJECTIVE: To establish the associations and prognostic utility of angiographic, clinical and HRV parameters in a large cohort of patients undergoing diagnostic cardiac catheterisation (CC). METHODS: Patients undergoing CC as elective day cases were enrolled at a single tertiary center from September 2001 to January 2003. Patient data, serum biochemistry, current drug therapy, catheter reports and five minute high resolution electrocardiograph (ECG) recordings were prospectively recorded and validated in an electronic archive. ECG recordings were used to generate time domain (SDNN (standard deviation of NN intervals)) and spectral HRV parameters (low frequency (LF) and high frequency (HF) power). Significant associations between dichotomized HRV variables and covariates were investigated using binary logistic regression. The independent prognostic ability of clinical markers was evaluated using the Cox proportional hazard model. RESULTS: 841 consecutive consenting patients of mean age 61+/-10 years were recruited into the study with a mean follow-up period of 690+/-436 days. In multivariate analysis decreasing LF spectral power was independently associated with proximal right coronary stenosis OR (odds ratio)=1.65 (95% CI=1.16-2.36), P=0.006 and to all cause mortality OR=5.01 (95% CI=1.47-17.01), P=0.010. Increasing LF power was also independently associated with normal coronary angiograms in patients investigated suspected coronary disease without a confirmed prior history of a coronary ischaemic event OR=2.16 (95% CI=1.26-3.73), P=0.002. CONCLUSIONS: Reduced LF power independently predicts all cause mortality in a large cohort of patients receiving medical therapy after elective CC. LF power was also independently associated with >75% proximal RCA stenosis.