Complete Revascularisation in Impella-Supported Infarct-Related Cardiogenic Shock Patients Is Associated With Improved Mortality

Background: Acute myocardial infarction-related cardiogenic shock (AMI-CS) still has high likelihood of in-hospital mortality. The only trial evidence currently available for the intra-aortic balloon pump showed no benefit of its routine use in AMI-CS. While a potential benefit of complete revascularisation has been suggested in urgent revascularisation, the CULPRIT-SHOCK trial demonstrated no benefit of multivessel compared to culprit-lesion only revascularisation in AMI-CS. However, mechanical circulatory support was only used in a minority of patients.Objectives: We hypothesised that more complete revascularisation facilitated by Impella support is related to lower mortality in AMI-CS patients.Methods: We analysed data from 202 consecutive Impella-treated AMI-CS patients at four European high-volume shock centres (age 66 ± 11 years, 83% male). Forty-seven percentage (n = 94) had cardiac arrest before Impella implantation. Revascularisation was categorised as incomplete if residual SYNTAX-score (rS) was >8.Results: Overall 30-day mortality was 47%. Mortality was higher when Impella was implanted post-PCI (Impella-post-PCI: 57%, Impella-pre-PCI: 38%, p = 0.0053) and if revascularisation was incomplete (rS ≤ 8: 37%, rS > 8: 56%, p = 0.0099). Patients with both pre-PCI Impella implantation and complete revascularisation had significantly lower mortality (33%) than those with incomplete revascularisation and implantation post PCI (72%, p < 0.001).Conclusions: Our retrospective analysis suggests that complete revascularisation supported by an Impella microaxial pump implanted prior to PCI is associated with lower mortality than incomplete revascularisation in patients with AMI-CS.

Outcome of patients with prior coronary bypass surgery admitted with an acute coronary syndrome

BackgroundPatients with prior coronary artery bypass graft surgery (CABG) are at increased risk for recurrent cardiovascular ischaemic events. Advances in management have improved prognosis of patients with acute coronary syndrome (ACS), yet it is not known whether similar trends exist in patients with prior CABG.AimExamine temporal trends in the prevalence, treatment and clinical outcomes of patients with prior CABG admitted with ACS.MethodsTime-dependent analysis of patients with or without prior CABG admitted with an ACS who enrolled in the ACS Israeli Surveys between 2000 and 2016. Surveys were divided into early (2000–2008) and late (2010–2016) time periods. Outcomes included 30 days major adverse cardiac events (30d MACE) (death, myocardial infarction, stroke, unstable angina, stent thrombosis, urgent revascularisation) and 1-year mortality.ResultsAmong 15 152 patients with ACS, 1506 (9.9%) had a prior CABG. Patients with prior CABG were older (69 vs 63 years), had more comorbidities and presented more with non-ST elevation-ACS (82% vs 51%). Between time periods, utilisation of antiplatelets, statins and percutaneous interventions significantly increased in both groups (p<0.001 for each). The rate of 30d MACE decreased in patients with (19.1%–12.4%, p=0.001) and without (17.4%–9.5%, p<0.001) prior CABG. However, 1-year mortality decreased only in patients without prior CABG (10.5% vs 7.4%, p<0.001) and remained unchanged in patients with prior CABG. Results were consistent after propensity matching.ConclusionsDespite an improvement in the management and prognosis of patients with ACS in the last decade, the rate of 1-year mortality of patients with prior CABG admitted with an ACS remained unchanged.

Guideline adherence and long-term clinical outcomes in patients with acute myocardial infarction: a Japanese Registry of Acute Myocardial Infarction Diagnosed by Universal Definition (J-MINUET) substudy

Background: The association between guideline adherence and long-term outcomes in patients with acute myocardial infarction in real-world clinical practice remains unclear. Methods: We investigated 3283 consecutive patients with acute myocardial infarction who were selected from a prospective, nation-wide, multicentre registry (J-MINUET) database covering 28 institutions in Japan between July 2012 and March 2014. Among the 2757 eligible patients, we evaluated the use of seven guideline-recommended therapies, including urgent revascularisation, door-to-balloon time of 90 minutes or less, and five discharge medications (P2Y12 inhibitors on aspirin, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, statins, lipid-lowering drugs). The primary endpoint was a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, cardiac failure and urgent revascularisation for unstable angina up to 3 years. Results: The overall median composite guideline adherence was 85.7%. Patients were divided into the following three groups: complete (100%) adherence group ( n=862); moderate adherence (75% to <100%) group ( n=911); and low adherence (0–75%) group ( n=984). The rate of adverse cardiovascular events was significantly lower in the complete adherence group than in the low and moderate adherence groups (log rank P<0.0001). Multivariate Cox regression analysis showed complete guideline adherence was also significantly associated with lower adverse cardiovascular events compared with low guideline adherence (hazard ratio 0.66; 95% confidence interval 0.52–0.85; P=0.001). Conclusion: The use of guideline-based therapies for patients with acute myocardial infarction in contemporary clinical practice was associated with significant decreases in adverse long-term clinical outcomes. Trial registration: UMIN Unique trial Number: UMIN000010037

Role of clopidogrel in addition to aspirin in the prevention of recurrent ischaemic events in acute coronary syndrome with ST-segment elevation

Background: Studies regarding the efficacy of Aspirin alone versus combination of Aspirin and Clopidogrel in patients with Unstable Angina are many. But, studies on the comparative role of Aspirin alone versus Aspirin plus Clopidogrel in the background of Acute Coronary Syndrome (ACS) with ST segment elevation myocardial infarction (STEMI) were very few, at the time of starting of this study. Keeping this in mind present study was conducted to compare the efficacy and safety of Aspirin alone with combination of aspirin plus Clopidogrel in prevention of events in Acute Coronary Syndrome with ST segment elevation myocardial infarction.Methods: Patients who are admitted to intensive coronary care unit within 12hrs after the onset of symptoms and whose diagnosis as ACS with ST segment elevation has been established were included in this study. Patients in group 1 received 325 mg of aspirin as loading dose, followed by 150 mg once daily. Patients in group 2 received a combination of aspirin and Clopidogrel 325 and 300 mg, respectively, as loading dose, followed by 150 mg of aspirin and 75 mg of Clopidogrel daily. All the patients received a fibrinolytic agent. Treatment response was weighed against the primary and secondary expected outcomes.Results: Addition of Clopidogrel to Aspirin resulted in significant reduction in severe ischaemia not requiring urgent revascularisation i.e.; 32% in Aspirin alone group versus 10% in Aspirin plus Clopidogrel group and recurrent angina with no ECG changes i.e.; 42% in aspirin alone group versus 20% in Aspirin plus Clopidogrel group. Similarly, there was an improvement in ejection fraction at the end of one month i.e.; 0.3% in Aspirin alone group versus 1.85% in Aspirin plus Clopidogrel group.Conclusions: This study demonstrates the benefit of adding Clopidogrel to Aspirin for myocardial infarction with ST-segment elevation. Treatment with a loading dose of 300mg of Clopidogrel followed by a daily dose of 75mg, in addition to aspirin, resulted in significant improvement in the secondary efficacy related outcomes in patients with acute coronary syndrome with ST-segment elevation.