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BackgroundThe objective of the study was to identify any changes in primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) in England by analysing procedural numbers, clinical characteristics and patient outcomes during the COVID-19 pandemic.MethodsWe conducted a retrospective cohort study of patients who underwent PCI in England between January 2017 and April 2020 in the British Cardiovascular Intervention Society-National Institute of Cardiovascular Outcomes Research database. Analysis was restricted to 44 hospitals that reported contemporaneous activity on PCI. Only patients with primary PCI for STEMI were included in the analysis.ResultsA total of 34 127 patients with STEMI (primary PCI 33 938, facilitated PCI 108, rescue PCI 81) were included in the study. There was a decline in the number of procedures by 43% (n=497) in April 2020 compared with the average monthly procedures between 2017 and 2019 (n=865). For all patients, the median time from symptom to hospital showed increased after the lockdown (150 (99–270) vs 135 (89–250) min, p=0.004) and a longer door-to-balloon time after the lockdown (48 (21–112) vs 37 (16–94) min, p<0.001). The in-hospital mortality rate was 4.8% before the lockdown and 3.5% after the lockdown (p=0.12). Following adjustment for baseline characteristics, no differences were observed for in-hospital death (OR 0.87, 95% CI 0.45 to 1.68, p=0.67) and major adverse cardiovascular events (OR 0.71, 95% CI 0.39 to 1.32, p=0.28).ConclusionsFollowing the lockdown in England, we observed a decline in primary PCI procedures for STEMI and increases in overall symptom-to-hospital and door-to-balloon time for patients with STEMI. Restructuring health services during COVID-19 has not adversely influenced in-hospital outcomes.

In this trial, fractional flow reserve was used to assess the functional significance of coronary stenoses in patients with clinically stable coronary artery disease. The clinical outcomes were better when this technique was used to direct the use of coronary stenting. Percutaneous coronary intervention (PCI) improves the outcome in patients with acute coronary syndromes. 1 In contrast, for the treatment of patients with stable coronary artery disease, controversy persists regarding the extent of the benefit from PCI, as compared with the best available medical therapy, as an initial management strategy. 2 – 5 The potential benefit of revascularization depends on the presence and extent of myocardial ischemia. 6 – 8 Performing PCI on nonischemic stenoses is not beneficial 9 and is probably harmful. 10 Thus, careful selection of ischemia-inducing stenoses is essential for deriving the greatest benefit from revascularization in patients with stable coronary artery disease. Fractional flow . . .

Correspondence to Professor Nick Curzen, Coronary & Structural Heart Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK; nick.curzen@uhs.nhs.uk Ghobrial et al describe the impact that one coronary angiogram-derived physiology system, virtual fractional flow reserve (vFFR), has on diagnosis and decision-making of cardiologists when assessing patients undergoing diagnostic angiography for either chronic coronary syndrome or non-ST elevation (NSTE) myocardial infarction (MI), when compared with angiography alone.1 In 320 patients, the availability of vFFR data led to a significant reduction in the number of vessels considered to have important disease and changed the management in 22% of cases when compared with their classification using angiography alone. Reassuringly, the degree of reclassification of vessels with significant disease and overall change in management reported in VIRTU4 are remarkably similar to the results of RIPCORD (Does routine pressure wire assessment influence management strategy at coronary angiography for diagnosis of chest pain?),2 on which this methodology was based, and several other studies that employed intracoronary pressure wire assessment of all coronary arteries of a size consistent with revascularisation and compared outcomes with angiographic assessment alone.3 The vFFR results certainly therefore raise the possibility that such profound alterations in diagnosis and management could be harnessed in routine clinical practice to aid more accurate treatment for individual patients undergoing coronary angiography. Specifically, the evidence base from observational and randomised trials unequivocally demonstrates that FFRCT significantly reduces both the number of ICA and the proportion of ICA that shows no significant coronary disease.6 Furthermore, as confidence in this technology grows, Heart Team consensus will allow for patients to undergo CABG surgery based on FFRCT results without the need for ICA. [...]in the near future, the majority of patients who undergo ICA will be those with known coronary disease very likely to require PCI: those with unobstructed coronary arteries, mild disease and surgical disease will be detected and managed based on non-invasive testing and, where appropriate, Heart Team discussion. [...]in randomised trials, the value of having routine and comprehensive information on coronary physiology at the time of ICA has consistently turned out to be lower than would be predicted from data derived from initial observational testing.

Anemia is common in patients undergoing percutaneous coronary intervention (PCI), and current guidelines fail to offer recommendations for its management. This review aims to examine the relation between baseline anemia and mortality, major adverse cardiovascular events (MACE), and major bleeding in patients undergoing PCI. We searched MEDLINE and EMBASE for studies that evaluated mortality and adverse outcomes in anemic and nonanemic patients who underwent PCI. Data were collected on study design, participant characteristics, definition of anemia, follow-up, and adverse outcomes. Random effects meta-analysis of risk ratios was performed using inverse variance method. A total of 44 studies were included in the review with 230,795 participants. The prevalence of baseline anemia was 26,514 of 170,914 (16%). There was an elevated risk of mortality and MACE with anemia compared with no anemia-pooled risk ratio (RR) 2.39 (2.02 to 2.83), p <0.001 and RR 1.51 (1.34 to 1.71), p <0.001, respectively. The risk of myocardial infarction and bleeding with anemia compared with no anemia was elevated, pooled RR 1.33 (1.07 to 1.65), p = 0.01 and RR 1.97 (1.03 to 3.77), p <0.001, respectively. The risk of mortality per unit incremental decrease in hemoglobin (g/dl) was RR 1.19 (1.09 to 1.30), p <0.001 and the risk of mortality, MACE, and reinfarction per 1 unit incremental decrease in hematocrit (%) was RR 1.07 (1.05 to 1.10), p = 0.04, RR 1.09 (1.08 to 1.10) and RR 1.06 (1.03 to 1.10), respectively. The prevalence of anemia in contemporary cohorts of patients undergoing PCI is significant and is associated with significant increases in postprocedural mortality, MACE, reinfarction, and bleeding. The optimal strategy for the management of anemia in such patients remains uncertain.

Complex high-risk and indicated revascularization using percutaneous coronary intervention (CHIP-PCI) is an emerging concept that is poorly studied. To define temporal changes in CHIP-PCI volumes, and the relationship between operator CHIP-PCI volume and patient outcomes. Data were analyzed on all CHIP-PCI procedures undertaken for stable angina in England and Wales between 2007 and 2014. Operator volume data was available for 2012-14. CHIP-PCI was defined by patient characteristics (age ≥80years, left ventricular (LV) ejection fraction <30%, previous CABG, or chronic renal failure) and/or by procedural characteristics (left main PCI, chronic total occlusion PCI, LV support, use of rotational atherectomy or laser atherectomy). CHIP-PCI as a percentage of total PCI increased from 28.1% in 2007 to 36.2% in 2014 (P < .001). Between 2012 and 2014, a total of 30,268 CHIP-PCI cases were performed. Total operator volume varied from 1 to 580 cases with median total operator volume of 29 cases. Higher operator volumes were associated with a greater degree of patient comorbidity and increasing procedural complexity. After adjustment for baseline difference, in-hospital major bleeding (P < .001 for trend), access site complications (P < .001) and coronary perforation (P = .002) were associated with increasing operator CHIP-PCI volumes. However, the frequency of in-hospital death (P = .394) and 12-month mortality (P = .638) were similar across the volume quartiles. Higher volumes quartiles were associated with a greater likelihood of same day discharge (P < .001). CHIP-PCI cases are an increasingly large population in contemporary PCI practice. Higher operator volumes were not associated with improved 12-month survival. Data were analyzed on all complex high-risk and indicated revascularization using percutaneous coronary intervention (CHIP-PCI) procedures in England and Wales between 2007 and 2014. CHIP-PCI as a percentage of total PCI increased from 28.1% in 2007 to 36.2% in 2014 (P < .001). Median total operator volume was 29 cases with higher volumes associated with more patient comorbidity and increasing procedural complexity. In-hospital major bleeding (P < .001 for trend), access site complications (P < .001) and coronary perforation (P = .002) all associated with increasing operator CHIP-PCI volumes. However, trends for in-hospital death (P = .394), and 12-month mortality (P = .638) were similar across the volume quartiles.

ObjectiveThere are concerns that healthcare and outcomes of black, Asian and minority ethnic (BAME) communities are disproportionately impacted by the COVID-19 pandemic. We investigated admission rates, treatment and mortality of BAME with acute myocardial infarction (AMI) during COVID-19.MethodsUsing multisource national healthcare records, patients hospitalised with AMI in England during 1 February–27 May 2020 were included in the COVID-19 group, whereas patients admitted during the same period in the previous three consecutive years were included in a pre-COVID-19 group. Multilevel hierarchical regression analyses were used to quantify the changes in-hospital and 7-day mortality in BAME compared with whites.ResultsOf 73 746 patients, higher proportions of BAME patients (16.7% vs 10.1%) were hospitalised with AMI during the COVID-19 period compared with pre-COVID-19. BAME patients admitted during the COVID-19 period were younger, male and likely to present with ST-elevation acute myocardial infarction. COVID-19 BAME group admitted with non-ST-elevation acute myocardial infarction less frequently received coronary angiography (86.1% vs 90.0%, p<0.001) and had a longer median delay to reperfusion (4.1 hours vs 3.7 hours, p<0.001) compared with whites. BAME had higher in-hospital (OR 1.68, 95% CI 1.27 to 2.28) and 7-day mortality (OR 1.81 95% CI 1.31 to 2.19) during COVID-19 compared with pre-COVID-19 period.ConclusionIn this multisource linked cohort study, compared with whites, BAME patients had proportionally higher hospitalisation rates with AMI, less frequently received guidelines indicated care and had higher early mortality during COVID-19 period compared with pre-COVID-19 period. There is a need to develop clinical pathways to achieve equity in the management of these vulnerable populations.

BackgroundCardiogenic shock (CS) complicating acute myocardial infarction (AMI) carries high mortality. Early revascularisation improves survival, but the effect of structured multidisciplinary care on outcomes remains underexplored.Methods and resultsACT-SHOCK is a service evaluation at a UK tertiary cardiac centre. Between May 2023 and May 2024, 82 patients with AMI-related CS requiring emergent percutaneous coronary intervention (PCI) were identified using protocolised physiological criteria and managed by an Advanced Cardiogenic-Shock Team (ACT). The ACT comprised interventional cardiologists, intensivists, anaesthetists, critical care staff and cardiac physiologists, coordinating PCI and ongoing care. Outcomes were compared with 83 historical controls from the year preceding ACT roll-out, who received standard care without ACT activation. Primary endpoints were 30-day and 1-year all-cause mortality; secondary outcomes included predictors of 30-day mortality.Within the ACT cohort, elevated lactate, critical care admission, invasive ventilation, out-of-hospital cardiac arrest and Society for Cardiovascular Angiography and Interventions (SCAI) Shock Stage E at first medical contact predicted 1-year mortality. Adjusted analyses showed ACT management was associated with lower 1-year mortality compared with standard care (HR 0.53, 95% CI 0.30 to 0.92; p=0.026). Although 30-day mortality was lower in the ACT group, this did not reach statistical significance (HR 0.71, 95% CI 0.39 to 1.29; p=0.26). Escalation from coronary care to critical care during the recovery phase occurred more promptly in the ACT group (9.7% vs 2.4%, p=0.09). At 24 hours, a smaller proportion of ACT patients remained in SCAI stages D/E compared with standard care (42% vs 48%; p=0.003).ConclusionsImplementation of physiological criteria to identify CS and activation of a multidisciplinary ACT in a UK tertiary centre was associated with earlier detection and improved 1-year survival in AMI-related CS. These pilot data support further study across multiple UK centres to inform national policy and standardise care pathways.

ObjectiveWe evaluated the clinical safety and performance of the ultrathin strut biodegradable polymer-coated Supraflex Cruz (Sahajanand Medical TechnologiesLtd., Surat, India) sirolimus-eluting stent (SES) in an all-comer patient population requiring coronary stent implantation.Study designThe study was a prospective, observational, multicentre, single-arm registry.Study settingsThe study was conducted at 19 NHS Hospitals across the UK, from March 2020 to September 2021.Study participantsA total of 1904 patients with symptomatic coronary artery disease (age ≥18 years) who underwent percutaneous coronary intervention with at least one Supraflex Cruz SES were enrolled.Primary and secondary outcomes measureThe primary endpoint was target lesion failure (TLF), a composite of cardiac death, target vessel myocardial infarction (TV-MI) and clinically indicated target lesion revascularisation (CI-TLR), at 12 months. Safety endpoints were stent thrombosis, all-cause death and any MI. Prespecified subgroups analysis included patients with diabetes mellitus, bifurcation lesion, type B2/C lesion defined as per ACC/AHA (American College of Cardiology/American Heart Association) lesion classification and long coronary lesions (>20 mm).ResultsA total of 2973 Supraflex Cruz SES were implanted in 1835 patients (mean age: 65.20±11.03 years). Of these, 404 patients had diabetes mellitus (491 lesions), 271 had bifurcation lesions (293 lesions), 1541 had type B2/C lesions (1832 lesions) and 985 had long coronary lesions (>20 mm, 1139 lesions). Among the overall population, device success was achieved in 98.2% of lesions. TLF occurred in 12 (0.7%) patients (0.3% cardiac death, 0.2% TV-MI, 0.2% CI-TLR) at 30 days and in 43 (2.3%) patients (0.8% cardiac death, 0.8% TV-MI, 0.8% CI-TLR) at 12 months follow-up. The rate of definite stent thrombosis was 0.3% in the overall population at 12 months. The incidence of TLF and stent thrombosis was 6.2% and 1% in the diabetic, 1.8% and none in bifurcation lesion, 2.5% and 0.3% in type B2/C lesion, and 2.7% and 0.3% in long coronary lesions (>20 mm) subgroups, respectively. at 12 months follow-up.ConclusionThe S-FLEX UK-II registry confirms the clinical safety and performance of the ultrathin Supraflex Cruz SES in an all-comer population with complex coronary artery disease, demonstrating low rates of TLF and stent thrombosis.Trial registration numberISRCTN39751665 (https://doi.org/10.1186/ISRCTN39751665)

ObjectiveTo estimate the population prevalence and treatable burden of severe aortic stenosis (AS) in the UK.MethodsWe adapted a contemporary model of the population profile of symptomatic and asymptomatic severe AS in Europe and North America to estimate the number of people aged ≥55 years in the UK who might benefit from surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI).ResultsWith a point prevalence of 1.48%, we estimate that 291 448 men and women aged ≥55 years in the UK had severe AS in 2019. Of these, 68.3% (199 059, 95% CI 1 77 201 to 221 355 people) would have been symptomatic and, therefore, more readily treated according to their surgical risk profile; the remaining 31.7% of cases (92 389, 95% CI 70 093 to 144 247) being asymptomatic. Based on historical patterns of intervention, 58.4% (116 251, 95% CI 106 895 to 1 25 606) of the 199 059 symptomatic cases would qualify for SAVR, with 7208 (95% CI 7091 to 7234) being assessed as being in a high, preoperative surgical risk category. Among the remaining 41.6% (82 809, 95% CI 73 453 to 92 164) of cases potentially unsuitable for SAVR, an estimated 61.7% (51 093, 95% CI 34 780 to 67 655) might be suitable for TAVI. We estimate that 172 859 out of 291 448 prevalent cases of severe AS (59.3%) will subsequently die within 5 years without proactive management.ConclusionsThese data suggest a high burden of severe AS in the UK requiring surgical or transcatheter intervention that challenges the ongoing capacity of the National Health Service to meet the needs of those affected.

Abstract Aims Limited data exist on the impact of COVID-19 on national changes in cardiac procedure activity, including patient characteristics and clinical outcomes before and during the COVID-19 pandemic. Methods and results All major cardiac procedures (n = 374 899) performed between 1 January and 31 May for the years 2018, 2019, and 2020 were analysed, stratified by procedure type and time-period (pre-COVID: January–May 2018 and 2019 and January–February 2020 and COVID: March–May 2020). Multivariable logistic regression was performed to examine the odds ratio (OR) of 30-day mortality for procedures performed in the COVID period. Overall, there was a deficit of 45 501 procedures during the COVID period compared to the monthly averages (March–May) in 2018–2019. Cardiac catheterization and device implantations were the most affected in terms of numbers (n = 19 637 and n = 10 453), whereas surgical procedures such as mitral valve replacement, other valve replacement/repair, atrioseptal defect/ventriculoseptal defect repair, and coronary artery bypass grafting were the most affected as a relative percentage difference (Δ) to previous years’ averages. Transcatheter aortic valve replacement was the least affected (Δ −10.6%). No difference in 30-day mortality was observed between pre-COVID and COVID time-periods for all cardiac procedures except cardiac catheterization [OR 1.25 95% confidence interval (CI) 1.07–1.47, P = 0.006] and cardiac device implantation (OR 1.35 95% CI 1.15–1.58, P < 0.001). Conclusion Cardiac procedural activity has significantly declined across England during the COVID-19 pandemic, with a deficit in excess of 45 000 procedures, without an increase in risk of mortality for most cardiac procedures performed during the pandemic. Major restructuring of cardiac services is necessary to deal with this deficit, which would inevitably impact long-term morbidity and mortality.