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Background: De-escalation from potent platelet P2Y12 inhibitors to clopidogrel is common. Despite having a clinical rationale, non-bleeding-related de-escalation when a lateral change between potent agents is an option may put patients at increased ischemic risk. We set out to define the scope of P2Y12 inhibitor de-escalation in a large clinical registry and evaluate the potential impact of non-bleeding-related de-escalation on clinical outcomes., Methods: : A retrospective cohort study was performed on consecutive patients in the Ca rdiovascular P ercutaneous I ntervention T ri al (CAPITAL) registry to identify those who underwent a switch in therapy within 1 year of percutaneous coronary intervention. The de-escalations were categorized as bleeding-related or non-bleeding-related. The primary outcome was major adverse cardiovascular events, a composite of death, myocardial infarction, and stroke. Secondary outcomes included individual components of major adverse cardiovascular events and a safety endpoint of thrombolysis in myocardial infarction bleeding., Results: Of 1854 patients, 209 (11.3%) underwent de-escalation: 24.9% of cases were bleeding-related, 37.8% were non-bleeding-related, and 37.3% were for unknown reasons. All patients with non-bleeding-related de-escalation were switched from ticagrelor to clopidogrel. The primary outcome occurred in 14 (6.7%) patients, of which 50% underwent non-bleeding-related de-escalation ( P  = 0.430). Among those with non-bleeding-related de-escalation, 7.6% were hospitalized for myocardial infarction, compared to 1.9% and 3.8% among those with a bleeding-related and unknown rationale, respectively ( P  = 0.293)., Conclusions: De-escalation, particularly non-bleeding-related de-escalation, of P2Y12 inhibitors is common. A substantial proportion of such de-escalation may be avoidable. Given the potential risk of ischemic complications, strategies should be considered to encourage both the upfront use of potent P2Y12 inhibitors and alternative strategies to de-escalation., (© 2021 The Authors.)

Background: Management of ST-elevated myocardial infarction (STEMI) necessitates rapid reperfusion. Delays prolong myocardial ischemia and increase the risk of complications, including death. The COVID-19 pandemic may have impacted STEMI management. We evaluated the relative volume of hospitalizations and clinical time intervals within a regional STEMI system., Methods: 494 patients with STEMI were grouped into pre-lockdown, lockdown and re-opening cohorts. Clinical, temporal and outcome data were collected and compared between groups for both urban and rural patients, receiving primary percutaneous coronary intervention (PCI) and pharmacoinvasive revascularization, respectively. Data was compared to a 10-year historical comparator., Results: During pre-lockdown there was 238 cases versus 193 in lockdown; a 19.0% reduction in volume. When lockdown was compared to the median caseload from a 10-year historical cohort, a 19.8% reduction was observed. For patients treated with primary PCI during lockdown, median symptom-to-balloon time increased by 44-minutes [217 (IQR 157-387) vs. 261 (160-659) minutes; p=0.03]; driven by an increase in median symptom-to-door time of 41-minutes [136 (IQR 80-267) vs. 177 (IQR 90-569) minutes; p<0.01]. Only patients transferred from non-PCI facilities demonstrated an increase in door-to-reperfusion time [116 (IQR 93-150) vs. 139 (IQR 100-199) minutes; p<0.01]. More patients had left ventricular dysfunction during the lockdown [35% vs. 44%; p=0.04], but there was no difference in mortality., Conclusion: During the COVID-19 lockdown, fewer patients presented with STEMI. Time-to-reperfusion was significantly prolonged and appeared driven predominantly by patient-level and transfer delays. Public education and systems-level changes will be integral to STEMI care during the second wave of COVID-19., (© 2020 Published by Elsevier Inc. on behalf of the Canadian Cardiovascular Society.)

Background: Cardiogenic shock (CS) is associated with high mortality. We report on a "Shock Team" approach of combined interdisciplinary expertise for decision making, expedited assessment, and treatment., Methods: We reviewed 100 patients admitted in CS over 52 months. Patients managed under a Code Shock Team protocol (n = 64, treatment) from 2016 to 2019 were compared with standard care (n = 36, control) from 2015 to 2016. The cohort was predominantly male (78% treatment, 67% control) with a median age of 55 years (interquartile range [IQR], 43-64) for treatment vs 64 years (IQR, 48-69) for control ( P = 0.01). New heart failure was more common in the treatment group: 61% vs 36%, P = 0.02. Acute myocardial infarction comprised 13% of patients in CS. There were no significant differences between treatment and control in markers of clinical acuity, including median left ventricular ejection fraction (18% vs 20%), prevalence of moderate-severe right ventricular dysfunction (64% vs 56%), median peak serum lactate (5.3 vs 4.7 mmol/L), acute kidney injury (70% vs 75%), or acute liver injury (50% vs 31%). Inotropes, dialysis, and invasive ventilation were required in 92%, 33%, and 66% of patients, respectively. Temporary mechanical circulatory support was used in 45% of treatment and 28% of control patients ( P = 0.08). There were no significant differences in median hospital length of stay (17.5 days), 30-day survival (71%), or survival to hospital discharge (66%). Over 240 days (IQR, 14,847) of median follow-up, survival was 67% for treatment vs 42% for control (hazard ratio, 0.53; 95% confidence interval, 0.28-0.99; P = 0.03)., Conclusion: A multidisciplinary Code Shock Team approach for CS is feasible and may be associated with improved long-term survival., (Crown Copyright © 2020 Published by Elsevier Inc. on behalf of the Canadian Cardiovascular Society.)