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ObjectivesAs stipulated by the 2016 NICE Chest Pain of recent onset guidelines, Computed Tomography Coronary Angiography (CTCA) is the recommended first line investigation when stable angina cannot be excluded by clinical assessment alone (1). Non-invasive Computed Fractional Flow Reserve (CT-FFR; Heartflow) is a method which utilises CT data as a diagnostic tool in identification of patients that may benefit from coronary revascularisation (2). We aimed to evaluate the diagnostic utility of CT-FFR in a district general setting in predicting significant coronary disease, defined as a positive functional test or the need for revascularisation (percutaneous or coronary artery bypass grafting).Method:This was a single centre, retrospective study of patients who had CTCA with subsequent FFR analysis from July 2019 to February 2021 (n=106). Electronic records were used to determine subsequent downstream testing and revascularisation. Lesions were documented as concordant or discordant; the former indicating an FFR result that was in keeping with the reported anatomical severity and the latter indicated discrepant results. Due to the intermediate nature of CAD-RADS 3 results, CT-FFR findings could not be defined as either concordant or discordant. Positive and negative predictive values of both CTCA and CT-FFR in identifying significant coronary pathology were calculated.Results:106 patients underwent CTCA with FFR analysis. 15 were excluded from this study due to suboptimal image quality preventing reliable FFR results. The Positive Predictive Value (PPV) and Negative Predictive Value (NPV) for CTCA alone in predicting functionally significant coronary disease was 41.3% and 86.9%, respectively. When the CAD-RADS 3 cohort was eliminated, PPV increased to 71.4% and the NPV remained unchanged (86.9%). The combination of CTCA with FFR gives a Positive and Negative Predictive Value of 48.4% and 83.3%, respectively. With elimination of the CAD-RADS 3 group, PPV was 85.7% and NPV of 80%.Abstract 152 Figure 1Revascularisation in the discordant and concordant CT-FFR groupsAbstract 152 Figure 2Outcomes of FFR analysis in the CAD-RADS 3 cohortConclusionAs supported by previously published literature, the negative predictive value of both CTCA in isolation, and when combined with FFR remains consistently reliable. Our study demonstrated that the positive predictive value is less reliable for both tests and supports the notion that these tests tend to over-estimate the severity of coronary lesions. However, at the extremes of the CAD-RADS spectrum, PPV is a much more robust variable, as highlighted by the increase in this value when CAD-RADS 3 results are removed from the cohort. This reiterates the importance of not letting test results detract from robust clinical assessment and symptom correlation, particularly in the context of discordant or intermediate results.References1. National Institute for health and care excellence (NICE) guidance for the assessment and diagnosis of recent-onset chest pain of suspected cardiac origin (clinical guideline 95 (CG95)).2. Pijls NH, van Schaardenburgh P, Manoharan G, et al. Percutaneous coronary intervention of functionally non-significant stenosis: 5-year follow-up of the defer study. J Am Coll Cardiol. 2007;49:2105–2111.Conflict of Interestnone

IntroductionRevascularisation in patients with symptomatic stable coronary artery disease compared to optimal medical therapy remains controversial and practice is variable between clinicians. National guidance (NICE) recommends referral for revascularisation only if a patient is on maximal tolerated dose of two anti-anginal agents. ESC guidance however stipulates that in patients with chronic coronary syndrome, revascularisation should be an adjunct to optimal guideline directed medical therapy in those who remain symptomatic or whom revascularisation will improve prognosis.Our objective was to review local practice at our centre and evaluate whether patients referred for elective percutaneous coronary intervention (PCI) due to stable anginal symptoms are on optimal medical therapy (OMT) prior to attempted coronary revascularisation. MethodsPatients were retrospectively identified from the British Cardiovascular Intervention Society (BCIS) database and included if they attended for elective PCI over a 12 month period. Patients were excluded if they had PCI for an acute coronary syndrome. Baseline demographic data were collected, procedural details and details of anti-anginal therapy pre angiography.Results134 patients were included in this study, 108 (81%) were male and median age was 71 years. 17 (13%) patients had functional testing prior to PCI including stress echocardiography or stress CMR. Most patients had single vessel PCI (94%) (table 1). The majority of patients, 106 (79%) were on at least one first-line anti-anginal agent at baseline – defined as either a beta blocker, calcium- channel blocker or long-acting nitrate (table 2). 28 (21%) patients were not on any anti-anginal medication. 44 (33%) patients were on 3 anti-anginal agents and only 2 patients (1%) were on 4 agents at baseline. Following outpatient review, prior to planned PCI, only 21 patients (16%) had initiation of anti-anginal therapy or up-titration of existing therapy. In 10/21 patients a nitrate was added or increased and in 7/21 patients beta-blocker therapy was added or up-titrated.ConclusionsOur study demonstrates that the majority of patients referred for elective revascularisation in the context of stable angina and chronic coronary artery disease were established one or two anti-anginal agents hence failed medical therapy. Of note, 21% patients were not on any anti-anginal therapy prior to PCI. The question remains as to whether further up-titration prior to PCI changes outcomes or symptom severity and whether a guideline directed OMT strategy should be pursued prior to revascularisation in this patient subgroup.Abstract 226 Table 1Baseline patient characteristics n % cohort Male 108 81% Age (years) 40–60 34 25% 61–80 78 58% >80 22 16% PCI to LMS 5 4% PCI to LAD 62 46% PCI to RCA 53 40% PCI to LCx 19 14% LMS: Left main stem, LAD: Left Anterior Descending, RCA: Right Coronary artery, LCx: Left Circumflex arteryAbstract 226 Table 2Established anti-anginals at baseline n % cohort Beta blocker 79 59% Calcium channel blocker 53 40% Nitrate 49 37% Nicorandil 6 4% Ranolazine 1 1% Conflict of InterestNone

Hybrid coronary revascularisation (HCR), being a treatment path combining both coronary artery bypass grafting and percutaneous coronary intervention (PCI) approaches, offers the advantages of both methods in patients with multi-vessel coronary artery disease. Since available literature provides few studies comparing the need for repeat revascularisation (RR) after HCR in comparison to PCI, our review aimed at summarising the latest data on this topic from the last 5 years (2018-2023). The search was conducted within the PubMed and Embase databases, followed by application of inclusion and exclusion criteria and providing a summary of data and characteristics of eligible studies. On the basis of 7 records included in the final analysis, RR and/or follow-up target vessel revascularisation (TVR) were significantly less frequently required in the case of HCR than in PCI in 3 out of 7 records, whereas the remaining four provided no significant differences in analysed rates between the 2 therapeutic pathways. When it comes to lowering the necessity for follow-up TVR and/or RR in a fraction of instances, HCR demonstrates a significant advantage over PCI. The complexity of outcomes associated with these therapies is emphasised by the fact that no statistically significant differences were observed between the 2 methods in the remaining 4 records.

Background and Objectives: Surgical revascularisation of patients with atherosclerosis of the ascending aorta remains a challenge. Different surgical strategies have been described in coronary surgical patients to offer alternative revascularisation strategies other than the conventional surgical revascularisation in patients unsuitable for it. The aim of this study is to compare the real-world outcomes between two groups of patients who underwent off-pump surgery (left internal mammary artery graft to the left anterior descending artery) or a hybrid with a percutaneous revascularisation procedure at a later stage. Materials and Methods: This is a single-centre retrospective observational study. Between the years 2010 and 2021, 91/6863 patients (1.33%) were diagnosed with severe atherosclerosis of the ascending aorta. All the patients were treated with off-pump revascularisation (91 patients), and the cardiologist would decide at a later stage whether the rest of the vessels would be treated with percutaneous revascularisation (25 patients). Results: There was no statistical difference in the various preoperative characteristics, except for coronary artery left main disease (30.30% vs. 64%; p = 0.0043). The two groups had no statistical differences in the perioperative characteristics and postoperative complications. The 1-, 5-, and 10-year mortality rates in the two groups were 6.1% vs. 0%, 59% vs. 80%, and 93.9% vs. 100%, respectively (off-pump vs. hybrid with percutaneous revascularisation procedure, p = 0.1958). Conclusions: Both strategies have high long-term comparable mortality. The off-pump surgery and the HCR procedure at a later stage may be solutions for these high-risk patients, but the target treatment should be complete HCR revascularisation during the index hospitalization.

Aims/hypothesisAfter coronary artery bypass graft (CABG) surgery in individuals with type 2 diabetes, there remains a considerable residual cardiovascular risk. In the EMPA-REG OUTCOME® trial in participants with type 2 diabetes and established cardiovascular disease, empagliflozin reduced the risk of cardiovascular death by 38%, all-cause mortality by 32%, hospitalisation for heart failure by 35% and incident or worsening nephropathy by 39% vs placebo when given in addition to standard of care. The aim of this post hoc analysis of the EMPA-REG OUTCOME® trial was to determine the effects of the sodium glucose cotransporter 2 inhibitor empagliflozin on cardiovascular events and mortality in participants with type 2 diabetes and a self-reported history of CABG surgery.MethodsThe EMPA-REG OUTCOME® trial was a randomised, double-blind, placebo-controlled trial. Participants with type 2 diabetes and established cardiovascular disease were randomised 1:1:1 to receive placebo, empagliflozin 10 mg or empagliflozin 25 mg, once daily, in addition to standard of care. In subgroups by self-reported history of CABG (yes/no) at baseline, we assessed: cardiovascular death; all-cause mortality; hospitalisation for heart failure; and incident or worsening nephropathy (progression to macroalbuminuria, doubling of serum creatinine, initiation of renal replacement therapy or death due to renal disease). Differences in risk between empagliflozin and placebo were assessed using a Cox proportional hazards model.ResultsAt baseline, 25% (1175/4687) of participants who received empagliflozin and 24% (563/2333) of participants who received placebo had a history of CABG surgery. In participants with a history of CABG surgery, HRs (95% CI) with empagliflozin vs placebo were 0.52 (0.32, 0.84) for cardiovascular mortality, 0.57 (0.39, 0.83) for all-cause mortality, 0.50 (0.32, 0.77) for hospitalisation for heart failure and 0.65 (0.50, 0.84) for incident or worsening nephropathy. Results were consistent between participants with and without a history of CABG surgery (p > 0.05 for treatment by subgroup interactions).Conclusions/interpretationIn participants with type 2 diabetes and a self-reported history of CABG surgery, treatment with empagliflozin was associated with profound reductions in cardiovascular and all-cause mortality, hospitalisation for heart failure, and incident or worsening nephropathy. These data have important implications for the secondary prevention of cardiovascular events after CABG in individuals with type 2 diabetes.Trial registration:ClinicalTrials.gov NCT01131676

American College of Cardiology (ACC), American Heart Association (AHA) and Society for Cardiovascular Angiography and Interventions (SCAI) recently released the Clinical Practice Guidelines for myocardial revascularization [1]. The guidelines were the felt need of the fraternity and this single all-encompassing document, relegating the previous six guidelines on the subject to archives, is indeed welcome. However, the downgrading of coronary artery bypass surgery for stable multivessel coronary artery disease and its bracketing with percutaneous coronary interventions has caused a lot of anguish in the surgical fraternity. This document presents the official viewpoint of the Indian Association of Cardiovascular and Thoracic Surgeons on the matter.

Objective This study aims to investigate the safety and feasibility of using a deep learning algorithm to calculate computed tomography angiography–based fractional flow reserve (DL-FFRCT) as an alternative to invasive coronary angiography (ICA) in the selection of patients for coronary intervention. Materials and methods Patients ( N = 296) with symptomatic coronary artery disease identified by coronary computed tomography angiography (CTA) with stenosis over 50% were retrospectively enrolled from a single centre in this study. ICA-guided interventions were performed in patients at admission, and DL-FFRCT was conducted retrospectively. The influences on decision-making by using DL-FFRCT and the clinical outcome were compared to those of ICA-guided care for symptomatic CAD at the 2-year follow-up evaluation. Result Two hundred forty-three patients were evaluated. Up to 72% of diagnostic ICA studies could have been avoided by using a DL-FFRCT value > 0.8 as a cut-off for intervention. A similar major adverse cardiovascular event (MACE) rate was observed in patients who underwent revascularisation with a DL-FFRCT value ≤ 0.8 (2.9%) compared to that of ICA-guided interventions (3.3%) (stented lesions with ICA stenosis > 75%) ( p = 0.838). Conclusion DL-FFRCT can reduce the need for diagnostic coronary angiography when identifying patients suitable for coronary intervention. A low MACE rate was found in a 2-year follow-up investigation. Key Points • Seventy-two percent of diagnostic ICA studies could have been avoided by using a DL-FFRCT value > 0.8 as a cut-off for intervention. • Coronary artery stenting based on the diagnosis by using a 320-detector row CT scanner and a positive DL-FFRCT value could potentially be associated with a lower occurrence rate of major adverse cardiovascular events (2.9%) within the first 2 years. • A low event rate was found when intervention was performed in tandem lesions with haemodynamic significance based on DL-FFRCT < 0.8 as a cut-off value.

Objectives: To compare long term outcomes of the crush versus the T technique in bifurcation lesions. Design: 182 consecutive patients were identified who underwent percutaneous coronary interventions for bifurcation lesions with drug eluting stents between April 2002 and January 2004. Two techniques were used according to the operator’s discretion: crush (group C, n  =  121) or T (group T, n  =  61). Results: In-hospital outcome differed significantly between the two groups. Angiographic follow up was available for 142 (78%) patients. Groups C and T did not differ significantly regarding late loss (0.42 (0.39) mm v 0.34 (0.35) mm, p  =  0.52) and rate of restenosis (16.2% v 13.0%, p  =  0.80) in both the main and the side branch without final kissing balloon post-dilatation. However, when final kissing balloon post-dilatation was performed, group C had significantly lower late lumen loss (0.23 (0.21) mm v 0.37 (0.33) mm, p  =  0.02) and restenosis rate (8.6% v 26.5%, p  =  0.04) in the side branch. At one year’s clinical follow up, group C compared with group T had lower rates of target lesion revascularisation (14.0% v 31.1%, p  =  0.01) and target vessel revascularisation (16.5% v 32.8%, p  =  0.02). Conclusions: In non-selected bifurcation lesions treated with drug eluting stents, the restenosis rate remains relatively high in the side branch. Compared with the T stenting technique, crush stenting with kissing balloon post-dilatation is associated with a reduced rate of restenosis in the side branch.

Objective Deferred revascularisation based upon fractional flow reserve (FFR >0.80) is associated with a low incidence of target lesion failure (TLF). Whether deferred revascularisation is also as safe in diabetes mellitus (DM) patients is unknown. Methods All DM patients and the next consecutive Non-DM patients who underwent a FFR-assessment between 1/01/2010 and 31/12/2013 were included, and followed until 1/07/2015. Patients with lesions FFR >0.80 were analysed according to the presence vs. absence of DM, while patients who underwent index revascularisation in FFR-assessed or other lesions were excluded. The primary endpoint was the incidence of TLF; a composite of target lesion revascularisation (TLR) and target vessel myocardial infarction (TVMI). Results A total of 250 patients (122 DM, 128 non-DM) who underwent deferred revascularisation of all lesions (FFR >0.80) were compared. At a mean follow up of 39.8 ± 16.3 months, DM patients compared to non-DM had a higher TLF rate, 18.1 vs 7.5 %, logrank p ≤ 0.01, Cox regression-adjusted HR 3.65 (95 % CI 1.40–9.53, p < 0.01), which was largely driven by a higher incidence of TLR (17.2 vs. 7.5 %, HR 3.52, 95 % CI 1.34–9.30, p = 0.01), whilst a non-significant but numerically higher incidence of TVMI (6.1 vs. 2.0 %, HR 3.34, 95 % CI 0.64–17.30, p = 0.15) was observed. Conclusions This study, the largest to directly compare the clinical outcomes of FFR-guided deferred revascularisation in patients with and without DM, shows that DM patients are associated with a significantly higher TLF rate. Whether intravascular imaging, additional invasive haemodynamics or stringent risk factor modification may impact on this higher TLF rate remains unknown.

Acute mesenteric ischaemia (AMI) is a sudden onset of impaired bowel perfusion. Has a high mortality rate and is difficult to diagnose. Therapy involves endovascular, surgical, or a combination of both. Because of baseline differences, the comparison between endovascular and open surgical treatment is subject to selection bias. The aim of this study was to evaluate the results of treatment of AMI by open or endovascular approach in combination with laparotomy, and evaluation of treatment strategy in similar situations. Clinical data from 21 patients treated for AMI between 2018 and 2022 were retrospectively reviewed and compared. The primary endpoint of the study was in-hospital mortality. The secondary endpoint was the statistical evaluation of risk factors for mortality. All patients underwent acute endovascular revascularisation. Aspiration thromboembolectomy was performed in nine patients, stenting in seven, PTA in one and surgery in three. Endovascular therapy was unsuccessful for technical reasons in 3 patients. None of the monitored parameters reached statistical significance. The best results were achieved in the early diagnosis group. The overall mortality of acute mesenteric ischaemia in our cohort was 34.8%. Acute mesenteric ischaemia is a serious condition affecting mainly elderly patients with a high mortality rate, but the diagnosis of mesenteric ischaemia is not an automatic death sentence. To achieve the best therapeutic outcome, mesenteric ischaemia needs to be diagnosed and treated at an early stage. The best therapeutic outcomes are achieved in centres with 24-hour access to endovascular revascularisation and surgical therapy.