Acute coronary occlusion with vs. without ST-elevation: impact on procedural outcomes and long-term all-cause mortality.

BACKGROUND: Acute total occlusion (ATO) is diagnosed in a substantial proportion of patients with Non-ST-elevation myocardial infarction (NSTEMI). We compared procedural outcomes and long- term mortality in patients with ST-elevation myocardial infarction (STEMI) with NSTEMI with vs. without ATO. METHODS: We included patients with acute myocardial infarction undergoing invasive coronary angiography between 2004 and 2019 at our center. ATO was defined as TIMI 0-1 flow in the infarct-related artery or TIMI 2-3 flow with highly elevated peak troponin (>100-folds the upper reference limit). Association between presentation and long-term mortality was evaluated using multivariable adjusted Cox regression analysis. RESULTS: From 2269 acute myocardial infarction patients (mean age 66 ± 13.2 years, 74% male), 664 patients with STEMI and 1605 patients with NSTEMI (471 [29.3%] with ATO) were included. ATO(+)NSTEMI had higher frequency of cardiogenic shock and no-reflow than ATO(-)NSTEMI with similar rates compared to STEMI patients (cardiogenic shock: 2.76 vs. 0.27 vs. 2.86%, p < 0.0001, p = 1; no-reflow: 4.03 vs. 0.18 vs. 3.17%, p < 0.0001, p = 0.54). ATO(+)NSTEMI and STEMI were associated with 60% and 55% increased incident mortality, as compared to ATO(-)NSTEMI (ATO(+)NSTEMI: 1.60[1.27-2.02], p < 0.0001, STEMI: 1.55[1.24-1.94], p < 0.0001). Likewise, left ventricular ejection fraction (48.5 ± 12.7 vs. 49.1±11 vs. 50.6 ± 11.8%, p = 0.5, p = 0.018) and global longitudinal strain (-15.2±-5.74 vs. -15.5±-4.84 vs. -16.3±-5.30%, p = 0.48, p = 0.016) in ATO(+)NSTEMI were comparable to STEMI but significantly worse than in ATO(-)NSTEMI. CONCLUSION: NSTEMI patients with ATO have unfavorable procedural outcomes, resulting in increased long-term mortality, resembling STEMI. Our findings suggest that the occlusion perspective provides more appropriate classification of acute myocardial infarction than differentiation into STEMI vs. NSTEMI.

The degree of permanent pacemaker dependence and clinical outcomes following transcatheter aortic valve implantation: implications for procedural technique.

Aims: Conduction abnormalities necessitating permanent pacemaker (PPM) implantation remain the most frequent complication post-transcatheter aortic valve implantation (TAVI), yet reliance on PPM function varies. We evaluated the association of right-ventricular (RV)-stimulation rate post-TAVI with 1-year major adverse cardiovascular events (MACE) (all-cause mortality and heart failure hospitalization). Methods and results: This retrospective cohort study of patients undergoing TAVI in two high-volume centers included patients with existing PPM pre-TAVI or new PPM post-TAVI. There was a bimodal distribution of RV-stimulation rates stratifying patients into two groups of either low [≤10%: 1.0 (0.0, 3.6)] or high [>10%: 96.0 (54.0, 99.9)] RV-stimulation rate post-TAVI. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated comparing MACE in patients with high vs. low RV-stimulation rates post-TAVI. Of 4659 patients, 408 patients (8.6%) had an existing PPM pre-TAVI and 361 patients (7.7%) underwent PPM implantation post-TAVI. Mean age was 82.3 ± 8.1 years, 39% were women. A high RV-stimulation rate (>10%) development post-TAVI is associated with a two-fold increased risk for MACE [1.97 (1.20, 3.25), P = 0.008]. Valve implantation depth was an independent predictor of high RV-stimulation rate [odds ratio (95% CI): 1.58 (1.21, 2.06), P=<0.001] and itself associated with MACE [1.27 (1.00, 1.59), P = 0.047]. Conclusion: Greater RV-stimulation rates post-TAVI correlate with increased 1-year MACE in patients with new PPM post-TAVI or in those with existing PPM but low RV-stimulation rates pre-TAVI. A shallower valve implantation depth reduces the risk of greater RV-stimulation rates post-TAVI, correlating with improved patient outcomes. These data highlight the importance of a meticulous implant technique even in TAVI recipients with pre-existing PPMs.

Utilization of IVUS improves all-cause mortality in patients undergoing invasive coronary angiography.

Background and aims: Available data suggest that the use of IVUS for guidance of percutaneous coronary interventions (PCIs) improves the prognosis of patients undergoing complex interventions. We aimed to examine how the utilization of intravascular ultrasound (IVUS) affects patient survival irrespective of procedure complexity. Methods: The present analysis is based on the longitudinal ECAD registry of consecutive patients undergoing coronary angiography between 2004 and 2019. The incidence of death due to any cause was evaluated during a mean follow-up of 3.4 years. Cox regression analysis was used to determine the association of IVUS utilization with incident mortality. Results: Overall, data from 30,814 coronary angiography exams (mean age 64.9 ± 12.5 years, 70.3% male) were included, among which 4991 procedures (16.2%) were guided by IVUS. Utilization of IVUS was associated with a 35% reduction in mortality, independent of traditional risk factors (0.64(0.58-0.71), p < 0.0001). The effect of IVUS on mortality was equally present in patients undergoing IVUS-guided coronary interventions (0.75[0.67-0.84], p < 0.0001) as well as purely diagnostic coronary angiography exams (0.62[0.56-0.72], p < 0.0001). In patients without coronary intervention, IVUS utilization led to a higher frequency of aspirin (82.6% vs. 61.9% for IVUS vs. no IVUS, p < 0.0001) and statin therapy (74.9% vs. 62.5%, p < 0.0001). Conclusions: In a large longitudinal registry cohort of patients undergoing invasive coronary angiography, IVUS utilization was associated with lower long-term mortality. The beneficial role of IVUS utilization on survival was equally present for coronary interventions and diagnostic coronary angiograms. Our results support the use of intravascular imaging for decision making in interventional cardiology.

Treatment Patterns of Lipid-Lowering Therapy in Patients with Coronary Artery Disease Aged Above and Below 75 Years: A Retrospective Cross-Sectional Study of 1500 Patients in a Tertiary Care Referral Center in Germany.

INTRODUCTION: Lipid-lowering therapy of elderly patients with coronary artery disease (CAD) inherits a medical challenge, as these patients experience a higher absolute risk reduction but may be more prone to side effects. We aimed to evaluate the treatment patterns in lipid-lowering therapy, comparing CAD patients above versus below 75 years of age. METHODS: We retrospectively included patients with known CAD admitted to the West German Heart and Vascular Center. Low-density lipoprotein cholesterol (LDL-C) levels and intensity of statin therapy (based on dosage and type of statin) were assessed from all available hospital records. RESULTS: We included 1500 patients (mean age 68.4 ± 11.2 years, 75.7% male) from 813 referring treating primary care physicians in 98 cities of Germany in our analysis. A total of 982 patients were < 75 years of age, whereas 518 were ≥ 75 years of age. LDL-C levels did not differ between age groups (≥ 75: 96.0 ± 35.1 mg/dl; < 75: 98.9 ± 35.8 mg/dl, p = 0.13). Simvastatin was most frequently prescribed in both age groups (54.9% vs. 50.7% for age ≥ 75 vs. < 75 years, p = 0.16), followed by atorvastatin (31.6% vs. 33.3%, p = 0.53). Elderly patients received slightly lower statin doses as compared to patients < 75 years of age (28.8 ± 12.8 mg vs. 31.4 ± 13.7 mg, p = 0.0007). Interestingly, patients ≥ 75 years of age achieved LDL-C < 70 mg/dl slightly more frequently than younger patients (24.0% vs. 20.1%, p = 0.09), while only a minority had LDL-C < 55 mg/dl in both age groups. Excluding patients with myocardial infarction at presentation, creatine kinase levels were not relevantly different between age groups (131.9 ± 450.0 U/l vs. 127.5 ± 111.4 U/l, p = 0.78). CONCLUSION: Patients ≥ 75 years of age receive lower doses of statin therapy and reach slightly lower LDL-C levels. However, the majority of elderly patients miss current recommendations regarding LDL-C thresholds.

Disconcordance between ESC prevention guidelines and observed lipid profiles in patients with known coronary artery disease.

BACKGROUND: We aimed to describe whether updated low-density lipoprotein (LDL)-targets in patients with manifest coronary artery disease (CAD) led to a change in lipid profile over time. METHODS: We retrospectively included patients with manifest CAD from 2009-2010, 2012-2013, and 2015-2016 (n = 500 each). Lipid levels and medication at the different time-points as well as rate of accordance to guidelines (<100 for 2009-2010, <70 mg/dl for 2012-2013 and 2015-2016) were evaluated. RESULTS: Overall, 1500 subjects (mean age: 68.4 ±â€¯11.2 years, 75.8% male) from 813 attending primary care physicians were included. Mean LDL-level was 98.0 ±â€¯35.7 mg/dl, whereas 34.1% reached LDL-targets according to guidelines as applied at each time-point. Reduction of LDL-goals in 2011 lead to an initial decrease in LDL from 98.3 ±â€¯33.4 mg/dl in 2009-2010 to 93.9 ±â€¯36.3 mg/dl in 2012-2013 (p = 0.045). This effect was no longer present in 2015-2016 (101.6 ±â€¯36.6 mg/dl, p = 0.17). The rate of patients meeting recommended LDL-targets decreased over time (2009-2010: 56.6%, 2012-2013: 25.4%, 2015-2016: 20.2%, p < 0.0001 for trend). Likewise, the frequency of statin-intake decreased over time (93.6% in 2009-2010 to 83.7% in 2015-2016, p < 0.0001). While use of medium intensity statins was most frequent (69.4%), only 20.9% of patients with medium intensity statins reached LDL-targets according to guidelines. CONCLUSION: In a large clinical cohort of patients with known coronary artery disease, reduction of LDL-targets in ESC-guidelines in 2011 led to an initial decline in LDL-levels, while this effect was attenuated over time with the majority of patients missing treatment goals. Higher acceptance and compliance of statin therapy is warranted to utilize its effect in secondary prevention in CAD-patients.