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ObjectivesThe clinical impact of SARS-CoV-2 has varied across countries with varying cardiovascular manifestations. We review the cardiac presentations, in-hospital outcomes and development of cardiovascular complications in the initial cohort of SARS-CoV-2 positive patients at Imperial College Healthcare National Health Service Trust, UK.MethodsWe retrospectively analysed 498 COVID-19 positive adult admissions to our institute from 7 March to 7 April 2020. Patient data were collected for baseline demographics, comorbidities and in-hospital outcomes, especially relating to cardiovascular intervention.ResultsMean age was 67.4±16.1 years and 62.2% (n=310) were male. 64.1% (n=319) of our cohort had underlying cardiovascular disease (CVD) with 53.4% (n=266) having hypertension. 43.2%(n=215) developed acute myocardial injury. Mortality was significantly increased in those patients with myocardial injury (47.4% vs 18.4%, p<0.001). Only four COVID-19 patients had invasive coronary angiography, two underwent percutaneous coronary intervention and one required a permanent pacemaker implantation. 7.0% (n=35) of patients had an inpatient echocardiogram. Acute myocardial injury (OR 2.39, 95% CI 1.31 to 4.40, p=0.005) and history of hypertension (OR 1.88, 95% CI 1.01 to 3.55, p=0.049) approximately doubled the odds of in-hospital mortality in patients admitted with COVID-19 after other variables had been controlled for.ConclusionHypertension, pre-existing CVD and acute myocardial injury were associated with increased in-hospital mortality in our cohort of COVID-19 patients. However, only a low number of patients required invasive cardiac intervention.

Objective To determine whether the instantaneous wave-free ratio (iFR) can detect improvement in stenosis significance after percutaneous coronary intervention (PCI) and compare this with fractional flow reserve (FFR) and whole cycle Pd/Pa. Design A prospective observational study was undertaken in elective patients scheduled for PCI with FFR ≤0.80. Intracoronary pressures were measured at rest and during adenosine-mediated vasodilatation, before and after PCI. iFR, Pd/Pa and FFR values were calculated using the validated fully automated algorithms. Setting Coronary catheter laboratories in two UK centres and one in the USA. Patients 120 coronary stenoses in 112 patients were assessed. The mean age was 63±10 years, while 84% were male; 39% smokers; 33% with diabetes. Mean diameter stenosis was 68±16% by quantitative coronary angiography. Results Pre-PCI, mean FFR was 0.66±0.14, mean iFR was 0.75±0.21 and mean Pd/Pa 0.83±0.16. PCI increased all indices significantly (FFR 0.89±0.07, p<0.001; iFR 0.94±0.05, p<0.001; Pd/Pa 0.96±0.04, p<0.001). The change in iFR after intervention (0.20±0.21) was similar to ΔFFR 0.22±0.15 (p=0.25). ΔFFR and ΔiFR were significantly larger than resting ΔPd/Pa (0.13±0.16, both p<0.001). Similar incremental changes occurred in patients with a higher prevalence of risk factors for microcirculatory disease such as diabetes and hypertension. Conclusions iFR and FFR detect the changes in coronary haemodynamics elicited by PCI. FFR and iFR have a significantly larger dynamic range than resting Pd/Pa. iFR might be used to objectively document improvement in coronary haemodynamics following PCI in a similar manner to FFR.

Symptomatic relief is the primary goal of percutaneous coronary intervention (PCI) in stable angina and is commonly observed clinically. However, there is no evidence from blinded, placebo-controlled randomised trials to show its efficacy. ORBITA is a blinded, multicentre randomised trial of PCI versus a placebo procedure for angina relief that was done at five study sites in the UK. We enrolled patients with severe (≥70%) single-vessel stenoses. After enrolment, patients received 6 weeks of medication optimisation. Patients then had pre-randomisation assessments with cardiopulmonary exercise testing, symptom questionnaires, and dobutamine stress echocardiography. Patients were randomised 1:1 to undergo PCI or a placebo procedure by use of an automated online randomisation tool. After 6 weeks of follow-up, the assessments done before randomisation were repeated at the final assessment. The primary endpoint was difference in exercise time increment between groups. All analyses were based on the intention-to-treat principle and the study population contained all participants who underwent randomisation. This study is registered with ClinicalTrials.gov, number NCT02062593. ORBITA enrolled 230 patients with ischaemic symptoms. After the medication optimisation phase and between Jan 6, 2014, and Aug 11, 2017, 200 patients underwent randomisation, with 105 patients assigned PCI and 95 assigned the placebo procedure. Lesions had mean area stenosis of 84·4% (SD 10·2), fractional flow reserve of 0·69 (0·16), and instantaneous wave-free ratio of 0·76 (0·22). There was no significant difference in the primary endpoint of exercise time increment between groups (PCI minus placebo 16·6 s, 95% CI −8·9 to 42·0, p=0·200). There were no deaths. Serious adverse events included four pressure-wire related complications in the placebo group, which required PCI, and five major bleeding events, including two in the PCI group and three in the placebo group. In patients with medically treated angina and severe coronary stenosis, PCI did not increase exercise time by more than the effect of a placebo procedure. The efficacy of invasive procedures can be assessed with a placebo control, as is standard for pharmacotherapy. NIHR Imperial Biomedical Research Centre, Foundation for Circulatory Health, Imperial College Healthcare Charity, Philips Volcano, NIHR Barts Biomedical Research Centre.

IntroductionRecent recommendations by national and international societies advocate the use of coronary computed tomography (CCT) as the first-line test for the assessment of low-risk patients with suspected stable angina. However limited real-life data exist regarding its relative clinical value versus stress echocardiography (SE)-guided management.We aimed to assess in a real-life setting the clinical value of stress echocardiography (SE)-guided versus CCT-guided management in patients presenting with stable chest pain and no prior history of coronary artery disease (CAD).MethodsWe compared the relative feasibility, efficacy and the proportion of patients undergoing downstream testing including revascularisation and their impact on outcome (mortality and myocardial infarction) when CCT versus SE were used as the first line test for the assessment of stable chest pain.Of the patients who underwent CCT (N=2192) or SE (N=2081) between October 2013 and October 2014 only those with suspected stable angina and without previous CAD were selected. The population was propensity-matched (total 1980 patients-990 patients each group) to account for differences in the baseline cardiovascular risk factors (Figure 1).Abstract 120 Figure 1Schematic diagram of study population selectionACS: Acute coronary syndrome, CAD: Coronary artery disease, CT: computed tomography, HOCM: Hypertrophic obstructive cardiomyopathy, LVEF: Left ventricular ejection fractionResultsThe baseline characteristics of the propensity-matched population are shown in Table 1. The mean age of the population was 59±13.2 years and 949 (47.9%) patients were male. Inconclusive tests were 6% versus 3% (p<0.005) in CCT versus SE. Severe (>70%) luminal stenosis on CCT and inducible ischemia on SE detected obstructive CAD by invasive coronary angiography in 63% versus 57% patients (p=0.33). Over the entire follow-up period (median 717 (IQR 93-1069) days) significantly more patients underwent invasive coronary angiography (21.5% versus 7.3%, p<0.005) and revascularisation (33.5% versus 3.5%, p<0.005) respectively in the CCT versus the SE group (Table 2). Following their initial assessment 336 (33.9%) patients in the CCT and 86 (8.7%) in the SE group underwent further functional testing (SE, stress cardiac MRI, exercise electrocardiography) (p<0.005). There was no difference in all-cause mortality (p=0.26) or death and myocardial infarction (p=0.16) between the two groups (Table 2, Figure 2).Abstract 120 Table 1Baseline demographic and clinical characteristics of patients undergoing coronary CTa versus stress echocardiography in the propensity-matched populations aCT: computed tomography, bIHD: Ischaemic heart diseaseAbstract 120 Table 2Incidence of invasive coronary angiography, revascularization death and major cardiac events in the propensity matched population aCT: Computed tomography, bPCI: Percutaneous coronary intervention, cCABG: Coronary artery bypass graftingAbstract 120 Figure 2Comparison of outcome (death and composite of myocardial infarction and death) following stress echocardiography versus coronary CT. CT: computed tomography, MI: Myocardial infarctionConclusionsSE when used for the assessment of patients with stable angina and no prior CAD resulted in more conclusive tests, similar detection of obstructive CAD, less overall invasive coronary angiography and revascularization and less subsequent functional tests compared with CCT. These findings suggest that SE may be considered an equally appropriate test compared to CCT in the assessment of low-risk patients with chest pain and no prior CAD.Conflict of InterestNone

Background: Elevated plasma homocysteine (Hcy) is a risk factor for coronary disease. The objective of this study was to investigate whether Hcy either alone or in high glucose conditions induces endothelin-1 (ET-1) synthesis via the production of reactive oxygen species (ROS). Methods: Bovine aortic endothelial cells were grown in high (25 mmol/l) and low (5 mmol/l) glucose medium. Results: In high glucose, Hcy caused a time-dependent increase in ET-1 release, which was greatest with 50 µmol/l Hcy at 24 h (p < 0.01). This effect was not seen in low glucose conditions. In high glucose and 50 µmol/l Hcy, ET-1 mRNA levels were maximal after 1 h (p < 0.05). Tissue factor mRNA levels were raised at 4 h (p < 0.05) and functional activity was raised at 6 h (p < 0.01). Intracellular ROS production was increased by 50 µmol/l Hcy after 24 h (p < 0.05) but only in high glucose. To investigate the role of mitochondrial metabolism in ROS production, cells were incubated with thenoyltrifluoroacetone (inhibitor of complex II) or carbonyl cyanide m-chlorophenylhydrazone (uncoupler of oxidative phosphorylation). Both compounds abolished the Hcy-induced increase in ROS production and ET-1 release. There was an alteration in intracellular glutathione (GSH) levels with Hcy treatment with more oxidised GSH present. Conclusion: The combined metabolic burden of Hcy and high glucose stimulates ET-1 synthesis in bovine aortic endothelial cells via a mechanism dependent on the production of mitochondrial ROS, but may not be generalisable to all types of endothelial cells.

The present paper aims at analyzing growth performance and structural transformations in respect of work-force in Indian economy during post-reforms period. A glaring finding of the study was that, between the time periods 2004-05 (61st round) and 2009-10 (66th round), there has been a decline in employment of females in the rural as well as urban areas, thereby calling for an urgent need to generate additional employment opportunities for females in the economy. Furthermore, the relative share of agriculture sector in total employment has been declining over time, but still majority of the population is employed in this low productivity sector. On the other hand, the share of manufacturing sector has remained, more or less, stagnant, while the share of services sector in total employment has been rapidly rising. However, for strengthening the economic base of our economy, secondary sector should have taken a perceptible lead over tertiary sector by laying more emphasis on agro-based and small scale industrialization, which will not only help in promoting industrial activities, but will also act as a catalyst for the shift of employment from low productive to high productive activities.

BackgroundPatients with ST-elevation myocardial infarction commonly have multi-vessel disease. After treating the culprit, the optimal strategy for residual disease is unknown. Large observational studies suggest deferring treatment of residual disease, but smaller randomised controlled trials (RCTs) suggest multi-vessel primary percutaneous coronary intervention (MV-PPCI) is safe. We examine if allocation bias of high-risk patients could explain conflicting results between observational studies and RCTs.MethodsA meta-analysis of registries comparing culprit-only PPCI to MV-PPCI was performed. A meta-regression was performed to determine if allocation bias of high-risk patients could explain differences in outcomes between therapies.Results47,717 patients (19 studies) were eligible. MV-PPCI had higher mortality than culprit-only PPCI (OR 1.59, 95% CI 1.12 to 2.24, p = 0.03). Higher risk patients were more likely to be allocated to MV-PPCI (OR 1.45, 95% CI 1.18 to 1.78, p = 0.0005). When this was accounted for, there was no difference in mortality (OR 0.99, 95% CI 0.69 to 1.41, p = 0.94).DiscussionClinicians preferentially allocate higher-risk patients to MV-PPCI at the time of STEMI. When this is accounted for, these large observational studies in ‘real world’ patients support the conclusion of the smaller RCTs in the field: MV-PPCI has equivalent mortality to a culprit-only approach.Abstract 97 Figure 1

The present analytical study based on regular time series data (for the period 196061 to 2008-09) aims at examining growth performance and causal linkage among wage rate and labour productivity in major sectors of India. The study has made use of a variety of econometric computations, such as successive and exponential growth rates; ADF and PP tests of stationarity; Johensen-Juselius technique for cointegration; VAR based Granger causality tests; etc. As per the main findings from the study, output per worker has grown, in general, at a faster pace than wage rate, thereby pointing towards the prevalence of labour exploitation in India. Tertiary-2 sector (comprising mainly of Banking & Insurance; Residential Buildings and Dwellings; Public Administration; and Other Services) was, however, the lone exception, wherein the growth rates' pattern was just the other way round. The analysis has provided an indication towards the presence of bi-directional causality between wage rate in primary sector and that in tertiary sector. Further, labour productivity in Tertiary-2 sector was detected to be Granger-caused by real wage rate in the short run. However, direction of causality was just the opposite in the long run. Thus as a secular policy measure, labour productivity needs to be enhanced (say, through provision of better health infrastructure, and increased skill formation activities via education and training programs), so as to ensure higher wage earnings of the work force. [PUBLICATION ABSTRACT]

Methods In 51 vessels intra-coronary pressure and flow velocity was measured distal to the stenosis at rest and during adenosine mediated hyperaemia. iFR, FFR, baseline and hyperaemic microvascular resistance were calculated using automated algorithms.