Intravascular lithotripsy for severe coronary calcification: a systematic review.

INTRODUCTION: Coronary artery calcification remains a challenge in percutaneous coronary interventions, due to the higher risk of suboptimal result with subsequent poor clinical outcomes. Intravascular lithotripsy is a novel way of treating severe coronary calcification as it has the ability to modify calcium both circumferentially as well as transmurally, facilitating stent expansion and apposition. We conducted a systematic overview of the published literature on intravascular lithotripsy (IVL) assessing the efficacy and feasibility of IVL in treating severe coronary calcification. EVIDENCE ACQUISITION: Of the retrieved publications, 62 met our inclusion criteria and were included. A total of 1389 patients (1414 lesions) with significant coronary calcification or under-expanded stents underwent IVL. EVIDENCE SYNTHESIS: The mean age was 72.03 years (74.7% male). There was a significant improvement in acute and sustained vessel patency, with mean minimal lumen diameter of 2.78±0.46 mm, resulting in acute gain of 1.72±0.51 mm. The acute procedural success rate was 78.2 to 100% with in-hospital complication rate of 5.6 to 7.0%. The majority of the studies reported 30-day MACE, which was between 2.2 to 7.8%. CONCLUSIONS: The recent studies have highlighted that the use of IVL with adjuvant intracoronary imaging has revolutionized the way of treating heavily calcified, non-dilatable coronary lesions and is likely to succeed the conventional ways of treating these complex lesions. We need further studies to gauge the long-term efficacy and safety of IVL against techniques currently available for calcium modification including conventional balloons, cutting or scoring balloons, rotational atherectomy and laser atherectomy.

Interactions Between Atrial Fibrillation and Natriuretic Peptide in Predicting Heart Failure Hospitalization or Cardiovascular Death.

Background Natriuretic peptides are routinely quantified to diagnose heart failure (HF). Their concentrations are also elevated in atrial fibrillation (AF). To clarify their value in predicting future cardiovascular events, we measured natriuretic peptides in unselected patients with cardiovascular conditions and related their concentrations to AF and HF status and outcomes. Methods and Results Consecutive patients with cardiovascular conditions presenting to a large teaching hospital underwent clinical assessment, 7-day ECG monitoring, and echocardiography to diagnose AF and HF. NT-proBNP (N-terminal pro-B-type natriuretic peptide) was centrally quantified. Based on a literature review, four NT-proBNP groups were defined (<300, 300-999, 1000-1999, and ≥2000 pg/mL). Clinical characteristics and NT-proBNP concentrations were related to HF hospitalization or cardiovascular death. Follow-up data were available in 1616 of 1621 patients (99.7%) and analysis performed at 2.5 years (median age, 70 [interquartile range, 60-78] years; 40% women). HF hospitalization or cardiovascular death increased from 36 of 488 (3.2/100 person-years) in patients with neither AF nor HF, to 55 of 354 (7.1/100 person-years) in patients with AF only, 92 of 369 (12.1/100 person-years) in patients with HF only, and 128 of 405 (17.7/100 person-years) in patients with AF plus HF (P<0.001). Higher NT-proBNP concentrations predicted the outcome in patients with AF only (C-statistic, 0.82; 95% CI, 0.77-0.86; P <0.001) and in other phenotype groups (C-statistic in AF plus HF, 0.66; [95% CI, 0.61-0.70]; P <0.001). Conclusions Elevated NT-proBNP concentrations predict future HF events in patients with AF irrespective of the presence of HF, encouraging routine quantification of NT-proBNP in the assessment of patients with AF.

Rapid transformation of the medical on-call rotas to deal with the COVID-19 pandemic: a case study.

At Sandwell and West Birmingham Hospitals Trust, an emergency rota was put into place in anticipation of the COVID-19 pandemic. Key changes included re-deploying non-general medical (GIM) consultants on to the GIM on-call rota and re-deploying junior doctors on to medical rotas, and introducing a COVID-19 induction training programme to support these redeployments. Results from a survey showed 100% of consultants felt the rotas were resilient, with 96% of consultants stating they felt the rotas were well-staffed and 77% stating that they observed no drop in quality of care. Here we outline how these changes were made and present quantitative and qualitative feedback, with the aim of informing other trusts carrying out similar urgent reconfigurations in the future, or seeking to apply the lessons learnt to their non-emergency rotas.

The EXCEL Trial: The Interventionalists' Perspective.

Left main stem (LMS) disease is identified in up to 5% of diagnostic angiography cases, and is associated with significant morbidity and mortality due to the proportion of myocardium it subtends. In the past 10 years, there has been a significant change in the way we contemplate treating lesions in the LMS due to evolving experience and evidence in percutaneous coronary intervention (PCI) strategies and technologies. This has been reflected in recent changes in European and International guidance on managing patients with this lesion subset. Here, the authors provide an overview of the current literature regarding the management of LMS disease using PCI in light of new developments and emerging concepts in this field, specifically looking at the recent EXCEL trial.

ECG changes in hospitalised patients with COVID-19 infection.

The coronavirus disease 2019 (COVID-19) commonly involves the respiratory system but increasingly cardiovascular involvement is recognised. We assessed electrocardiogram (ECG) abnormalities in patients with COVID-19. We performed retrospective analysis of the hospital's COVID-19 database from April to May 2020. Any ECG abnormality was defined as: 1) new sinus bradycardia; 2) new/worsening bundle-branch block; 3) new/worsening heart block; 4) new ventricular or atrial bigeminy/trigeminy; 5) new-onset atrial fibrillation (AF)/atrial flutter or ventricular tachycardia (VT); and 6) new-onset ischaemic changes. Patients with and without any ECG change were compared. There were 455 patients included of whom 59 patients (12.8%) met criteria for any ECG abnormality. Patients were older (any ECG abnormality 77.8 ± 12 years vs. no ECG abnormality 67.4 ± 18.2 years, p<0.001) and more likely to die in-hospital (any ECG abnormality 44.1% vs. no ECG abnormality 27.8%, p=0.011). Coxproportional hazard analysis demonstrated any ECG abnormality (hazard ratio [HR] 1.97, 95% confidence interval [CI] 1.12 to 3.47, p=0.019), age (HR 1.03, 95%CI 1.01 to 1.05, p=0.0009), raised high sensitivity troponin I (HR 2.22, 95%CI 1.27 to 3.90, p=0.006) and low estimated glomerular filtration rate (eGFR) (HR 1.73, 95%CI 1.04 to 2.88, p=0.036) were independent predictors of in-hospital mortality. In conclusion, any new ECG abnormality is a significant predictor of in-hospital mortality.

The additive prognostic value of coronary calcium score (CCS) to single photon emission computed tomography myocardial perfusion imaging (SPECT-MPI)-real world data from a single center.

AIMS: Single-photon emission computed tomography myocardial perfusion imaging [SPECT-MPI] is a functional test for coronary ischemia. We aimed to assess the additive prognostic value of coronary calcium score (CCS) to SPECT-MPI in stable patients. METHODS: This study is a retrospective analysis of 655 patients who underwent SPECT-MPI with CCS (2012 to 2017). Receiver operator characteristic (ROC) identified CCS cutoff value for all-cause mortality: CCS+ if > cutoff value and MPI+ if ≥ 5% total perfusion defect (TPD). Patients were divided into 1 MPI-/CCS-; 2 MPI+/CCS-; 3 MPI-/CCS+; 4 MPI+/CCS+ and compared. Cox proportional hazard analysis identified predictors of mortality. RESULTS: CCS cutoff for all-cause mortality was > 216 (C statistic 0.756, P < 0.0001). In MPI+ groups, mean TPD was similar (13.4% and 13.1% respectively) but mortality was higher in the CCS+ (12.5% vs. 4.8%, P = 0.22) as was the severe LV systolic dysfunction (8.0% vs. 0%, P = 0.095). In MPI- groups, mean TPD was similar (0.7% and 0.9% respectively) but all-cause mortality was higher in the CCS+ (10.7% vs. 1.6%, P < 0.0001) as was severe LVSD (2.9 % vs. 0.3% P = 0.016). Age, smoking, renal impairment ,and CCS > 216 were independent predictors of mortality. CONCLUSIONS: Patients with raised CCS on SPECT-MPI have increased mortality and poor LV function despite a negative MPI.

Rotablation in the Very Elderly - Safer than We Think?

BACKGROUND/PURPOSE: Calcified coronary artery stenosis remains a challenge for Percutaneous Coronary Intervention (PCI). Calcium modification is facilitated by rotablation and is used in 1-3% of cases. Data on rotablation in patients ≥80 years is limited and perceived to be high risk. We compared PCI with rotablation and outcomes between patients ≥80 years and those <80 years. METHODS/MATERIALS: Retrospective analysis was performed of consecutive patients who underwent rotablation and PCI from 3 United Kingdom (UK) PCI Centres (2014-2017). In-hospital outcomes (composite of stroke, myocardial infarction, death, emergency coronary artery bypass graft surgery, vascular damage, coronary perforation, advanced AV-block, bleeding and renal impairment) and 30 day mortality risk score was compared between groups. RESULTS: 213 patients were included. 33.3% (n = 71) were ≥80 years. Baseline and angiographic characteristics were similar in the two groups. Older patients were more likely to present with acute coronary syndrome (ACS) (≥80 years 53.5% vs. 33.8% in <80 years, p = 0.006) and had increased hospital stay (≥80 years 2.8 days (±6.0) vs. 1.3 days (±1.9) <80 years, p = 0.009). Majority of PCI were performed through radial access (≥80 years 91.5% vs. 88.0% <80 years, p = 0.43). In-hospital composite outcomes were similar between the groups (≥80 years 5.6% vs. 4.9% <80 years, p = 1.0). The 30-day mortality risk score demonstrated a higher average risk of 2.5% in ≥80 years versus under 1% risk in <80 years (p < 0.001). CONCLUSION: This study demonstrates that outcomes after rotablation in the very elderly are similar to younger patients despite being high risk and presenting with ACS.

General medicine consultant of the week model shortens hospital length of stay and improves the patient journey.

BACKGROUND AND AIMS: The consultant of the week (COW) model of inpatient care means the consultants' primary focus is to deliver ward-based care daily. At Sandwell and West Birmingham Hospitals NHS Trust, a COW model has been successfully used for cardiology and stroke services. This has improved continuity of care and developed a 7-day working week. Our aim was to extend this model to all general medical consultants who manage inpatients. METHODS: We introduced the COW model to the unselected general medical take. Restructuring of consultant job plans allowed daily ward presence, 5 days per week. Outcome measures included length of stay (LOS) and accuracy of expected date of discharge (EDD). RESULTS: LOS over a 12-month period improved from an average of 9.17 days to 6.61 days. The number of EDD changes reduced, from a previous average of 3.0 changes to 1.8 changes. Consultant feedback showed there was an improvement in collaboration between teams, improved training of junior doctors and higher job satisfaction. CONCLUSIONS: Improved 5-day consultant presence is associated with reduced LOS. Learning points included the delay in implementation due to the complexity of consultant job planning. We plan to extend COW to 7-days for all general medical wards.

A detailed analysis of patients included in the Summary Hospital-level Mortality Indicator (SHMI) for myocardial infarction (MI)-all is not what it seems?

BACKGROUND: The Summary Hospital-level Mortality Indicator (SHMI) for Myocardial Infarction (MI) is the ratio of the observed to the expected number of deaths due to MI. We aimed to assess (1) the accuracy of MI as a diagnosis in the SHMI for MI and (2) the healthcare received by patients with type 1 MI included in the SHMI for MI. METHODS: Retrospective review of patients included in SHMI for MI from April 2017 to March 2018. The diagnosis of MI was divided into type 1, type 2 and non-MI. For patients with type 1 MI who underwent intervention, we applied the prognostic Toronto Risk Score (TRS) and classified into group 0: score <13 (mortality risk 0%-4%, lowest risk), group 1: score 13-16 (mortality risk 6%-19.6%), group 2: score 17-19 (mortality risk 27.4%-47.6%) and group 3: score ≥20 (mortality risk 58%-92%). For patients with type 1 MI who underwent conservative management, we reviewed appropriateness of conservative management. RESULTS: SHMI for MI was 96 (41/42.83) falling to 65.4 with the inclusion of only type 1 MI (28 patients, 28/42.83). About 41.5% (n=17) underwent intervention of whom three were in the lowest risk TRS (group 0) and all received appropriate healthcare. Conservative management was appropriate for the 26.8% (n=11) treated medically, the most common reason was severe cognitive dysfunction. CONCLUSIONS: We have demonstrated that SHMI for MI can be inaccurate due to the inclusion of type 2 MI or non-MI. Grouping patients into intervention versus conservative management helps in assessment of healthcare.

Detection of unknown atrial fibrillation by prolonged ECG monitoring in an all-comer patient cohort and association with clinical and Holter variables.

OBJECTIVES: Prolonged ECG monitoring is clinically useful to detect unknown atrial fibrillation (AF) in stroke survivors. The diagnostic yield of prolonged ECG monitoring in other patient populations is less well characterised. We therefore studied the diagnostic yield of prolonged Holter ECG monitoring for AF in an unselected patient cohort referred from primary care or seen in a teaching hospital. METHODS: We analysed consecutive 7-day ECG recordings in unselected patients referred from different medical specialities and assessed AF detection rates by indication, age and comorbidities. RESULTS: Seven-day Holter ECGs (median monitoring 127.5 hours, IQR 116 to 152) were recorded in 476 patients (mean age 54.6 (SD 17.0) years, 55.9% female) without previously known AF, requested to evaluate palpitations (n=241), syncope (n=99), stroke or transient ischaemic attack (n=75), dizziness (n=29) or episodic chest pain (n=32). AF was newly detected in 42/476 (8.8%) patients. Oral anticoagulation was initiated in 40/42 (95.2%) patients with newly detected AF. Multivariate logistic regression, adjusted for age, sex and monitoring duration found four clinical parameters to be associated with newly detected AF: hypertension OR=2.54, (1.08 to 8.61) (adjusted OR (95% CI)), p=0.034; previous stroke or TIA OR=4.14 (1.81 to 13.01), p=0.001; left-sided valvular heart disease OR=5.07 (2.48 to 18.70), p<0.001 and palpitations OR=2.86, (1.33 to 10.44), p=0.015. CONCLUSIONS: Open multispeciality access to prolonged ECG monitoring, for example, as part of integrated, cross-sector AF care, can accelerate diagnosis of AF and increase adequate use of oral anticoagulation, especially in older and symptomatic patients with comorbidities.

Impact of Mon2 monocyte-platelet aggregates on human coronary artery disease.

BACKGROUND: Monocyte-platelet aggregates (MPAs) form when Mon1, Mon2 or Mon3 monocyte subsets adhere to platelets. They are pathophysiologically linked to coronary artery disease (CAD). However, their individual roles in the occurrence of diffuse CAD remain unknown. MATERIALS AND METHODS: Peripheral blood from 50 patients with diffuse CAD, 40 patients with focal CAD and 50 age-matched patients with normal coronary arteries was analysed by flow cytometry to quantify MPAs associated with individual monocyte subsets. Cutaneous forearm microcirculation was assessed using laser Doppler flowmetry at rest and after iontophoresis of acetylcholine (endothelium-dependent vasodilation) and sodium nitroprusside (endothelium-independent vasodilation) at 100 µA for 60 seconds. Patients with CAD had repeat assessment at 6 and 12 months. RESULTS: Baseline counts of MPAs with Mon2 subset (CD14++CD16+CC2+ monocytes) were significantly higher in patients with diffuse CAD compared to focal CAD (P = .001) and patients without CAD (P = .006). On multivariate regression, MPAs with Mon2 independently predicted diffuse CAD (odds ratio 1.10, 95% confidence interval 1.02-1.19, P = .01) and correlated negatively with endothelium-dependent microvascular vasodilation (r = -.37, P = .008), an association which persisted after adjustment for covariates. Longitudinal observation confirmed the persistence of an inverse relationship between MPAs with Mon2 and endothelium-dependent microvascular function. CONCLUSION: Monocyte-platelet aggregates with Mon2 are increased in patients with diffuse CAD and therefore could represent an important contributor to accelerated coronary atherosclerotic progression by a mechanism involving microvascular endothelial dysfunction.

Current Understanding of Atherogenesis.

Scientific understanding of atherogenesis is constantly developing. From Virchow's observations 160 years ago we now recognize the endothelial response to injury as inflammatory, involved in all stages of atherosclerosis. Endothelial activation may cause reversible injury or dysfunction, or lead to irreparable damage. Indeed, early atherosclerosis is reversible. The introduction of genome-wide association testing has furthered the identification of potentially important genetic variants that help explain the heritability of coronary artery disease as well as spontaneous cases of severe coronary artery disease in patients with otherwise minimal risk factors. However, the mechanisms by which many of the newer variants exert their influence remain unknown.

Epidemiology and pathogenesis of diffuse obstructive coronary artery disease: the role of arterial stiffness, shear stress, monocyte subsets and circulating microparticles.

Despite falling age-adjusted mortality rates coronary artery disease (CAD) remains the leading cause of death worldwide. Advanced diffuse CAD is becoming an important entity of modern cardiology as more patients with historical revascularisation no longer have suitable anatomy for additional procedures. Advances in the treatment of diffuse obstructive CAD are hampered by a poor understanding of its development. Although the likelihood of developing clinically significant (obstructive) CAD is linked to traditional risk factors, the morphology of obstructive CAD among individuals is highly variable - some patients have diffuse stenotic disease, while others have a focal stenosis. This is challenging to explain in mechanistic terms as vascular endothelium is equally exposed to injury stimulants. Patients with diffuse disease are at high risk of adverse outcomes, particularly if unsuitable for revascularisation. We searched multiple electronic databases (MEDLINE, EMBASE and the Cochrane Database) and reviewed the epidemiology, pathogenesis and prognosis relating to advanced diffuse CAD with particular focus on the role of endothelial shear stress, large artery stiffness, monocyte subsets and circulating microparticles. Key messages Although traditional CAD risk factors correlate strongly with disease severity, significant individual variation in disease morphology exists. Advanced, diffuse CAD is difficult to treat effectively and can significantly impair quality of life and increases mortality. The pathophysiology associated with the progression of CAD is the result of complex maladaptive interaction between the endothelium, cells of the immune system and patterns of blood flow.

Symptom-to-door times in patients presenting with ST elevation myocardial infarction--do ethnic or gender differences exist?

BACKGROUND: Studies have shown higher in-hospital mortality for female patients and ethnic minorities admitted to hospital with acute ST elevation myocardial infarction (STEMI). Pre-hospital delay is thought to be associated with increased in-hospital mortality. AIM: To assess the impact of gender and ethnicity on symptom-to-door time (STDT) in patients presenting with STEMI. DESIGN: Retrospective survey of consecutive patients receiving primary percutaneous coronary intervention between January 2008 and January 2013. A multivariate model was used to adjust for confounders. MAIN OUTCOME MEASURE: Influence of gender and ethnicity on STDT. RESULTS: We analysed 1020 patients (75% male, 263 South Asians, 38 Afro Caribbeans and 719 White Europeans.) There was a trend towards longer unadjusted median STDT in women compared with men (132 min vs. 113 min P = 0.07) which disappeared after correction for age and ethnicity (P = 0.15). There was no gender difference in hospital mortality after correction for age (odds ratio 0.69, 95% confidence interval 0.40-1.18, P = 0.17). On linear regression analysis South Asians showed a trend towards longer STDT than other ethnic groups (P = 0.08) however after adjustment for diabetes there was no association between South Asian ethnicity and hospital mortality. CONCLUSIONS: Neither female gender nor ethnicity were shown to be associated with significant pre-hospital delay.

Lessons from primary PCI practice for the next decade.

Primary percutaneous coronary intervention (PPCI) is the reperfusion treatment of choice for acute ST-elevation myocardial infarction with studies having demonstrated improved outcomes with PPCI over thrombolysis. Its use has increased substantially over the last decade, overtaking thrombolytic therapy in many countries. This has been paralleled with advances in adjunctive technology and pharmacological therapy to further improve outcome, but challenges remain for PPCI practitioners. The evidence behind PPCI is reviewed at every stage of the patient's journey.

Progressive breathlessness in an Afro Caribbean hypertensive subject.

The sensitivity and specificity of structural assessment of the heart by echocardiography in black hypertensive patients presenting with symptoms of heart failure is often incomplete. Cardiovascular magnetic resonance, mainly by virtue of its ability to characterize myocardial tissue composition, may be of value in differentiating some of the common pathologies noninvasively. We present an illustrative case of hypertrophic cardiomyopathy in a British Afro Caribbean hypertensive patient where at least some features of familial amyloidosis were present on screening echocardiography. Cardiovascular magnetic resonance examination of this case established not only the usefulness of this technique, but also highlighted the importance of recognizing the variations and departure from the usual which one associates with hypertrophic cardiomyopathy, so as to arrive at the final diagnosis.

Eosinophil count predicts mortality following percutaneous coronary intervention.

INTRODUCTION: Several inflammatory markers have been shown to be independent predictors for both the development of clinically significant atherosclerosis and for adverse outcome in patients with symptomatic coronary artery disease (CAD). We investigated the prognostic role of eosinophil count in low to intermediate risk patients with CAD. METHODS: We studied 909 patients admitted for elective or urgent percutaneous coronary intervention (PCI) from April 2002 to December 2004, and measured pre-procedural total and differential white blood cell (WBC) counts. Inter-tertile WBC differences in short (6months) and long term (up to 74months) mortality were analysed after adjusting for differences in baseline characteristics. RESULTS: Over a median period of 54months (inter-quartile range 47-65), a total of 138 deaths (15.2%) occurred, of which 24 were in the first 6months of follow-up. Cox regression analysis showed that high pre-procedural eosinophil count (top tertile) was associated with improved outcome within the first 6months (OR=0.23 [0.06-0.84]; p=0.03) but after this period there was an increased risk of mortality (OR=2.21, [1.26-3.88]; p=0.006). CONCLUSIONS: Eosinophil count is a novel biomarker for risk stratification of CAD patients, which was associated initially with reduced mortality, but after 6months with increased mortality.

Posterior myocardial infarction: are we failing to diagnose this?

INTRODUCTION: Isolated posterior ST-elevation myocardial infarction (STEMI) accounts for up to 7% of STEMIs. The diagnosis is suggested by indirect anterior-lead ECG changes. Confirmation requires presence of ST-elevation in posterior-leads (V7-V9). We investigated the ability of hospital doctors and paramedics to diagnose posterior STEMI (PMI). METHODS: Doctors in the emergency department and acute medical unit at two teaching hospitals and West Midlands Ambulance Service Paramedics were asked to interpret a 12-lead ECG illustrating ST-depression and dominant R-wave in V1-V2 in the context of cardiac chest pain, and identify PMI as a potential diagnosis. Their ability to identify PMI was compared with their ability to diagnose anterolateral STEMI on a 12-lead ECG. We assessed whether doctors knew that posterior-leads were required to confirm PMI and whether doctors and nurses could position posterior-leads. RESULTS: 44 of the 117 doctors (38%) identified PMI as a potential diagnosis. PMI was identified by 73% of registrars, 30% of senior house-officers and 18% of house-officers. 50% of doctors who identified potential PMI knew that posterior-leads were required to confirm the diagnosis. 20% of doctors correctly positioned these and 19% knew the diagnostic criteria for PMI (ST-elevation ≥1 mm in V7-V9). 13 of the 60 nurses (22%) in the emergency department and acute medical unit correctly positioned posterior-leads. Five of the 50 (10%) paramedics identified PMI as a potential diagnosis. Doctors and paramedics were significantly better at diagnosing anterolateral STEMI than PMI. CONCLUSIONS: A significant proportion of doctors and paramedics were unable to diagnose PMI. Hence, the majority of PMIs may be being missed. Routine use of posterior-leads in the standard assessment of patients with chest pain may identify up to an additional 7% of STEMIs, allowing prompt reperfusion therapy, which would reduce morbidity and mortality.