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Regional heart attack services have improved clinical outcomes following ST-segment elevation myocardial infarction (STEMI) by facilitating early reperfusion by primary percutaneous coronary intervention (PCI). Early discharge after primary PCI is welcomed by patients and increases efficiency of health care.This study aimed to assess the safety and feasibility of a novel early hospital discharge pathway for low-risk STEMI patients.Between March 2020 and June 2021, 600 patients who were deemed at low risk for early major adverse cardiovascular events (MACE) were selected for inclusion in the pathway and were successfully discharged in 48 hours. Patients were reviewed by a structured telephone follow-up at 48 hours after discharge by a cardiac rehabilitation nurse and underwent a virtual follow-up at 2, 6, and 8 weeks and at 3 months.The median length of hospital stay was 24.6 hours (interquartile range [IQR]: 22.7-30.0 hours) (prepathway median: 65.9 hours [IQR: 48.1-120.2 hours]). After discharge, all patients were contacted, with none lost to follow-up. During median follow-up of 271 days (IQR: 88-318 days), there were 2 deaths (0.33%), both caused by coronavirus disease 2019 (30 days after discharge), with 0% cardiovascular mortality and MACE rates of 1.2%. This finding compared favorably with a historical group of 700 patients meeting pathway criteria who remained in the hospital for48 hours (48-hour control group) (mortality, 0.7%; MACE, 1.9%) both in unadjusted and propensity-matched analyses.Selected low-risk patients can be discharged safely following successful primary PCI by using a pathway that is supported by a structured, multidisciplinary virtual follow-up schedule.

Background Coronavirus disease-2019 (COVID-19) is thought to predispose patients to thrombotic disease. To date there are few reports of ST-segment elevation myocardial infarction (STEMI) caused by type 1 myocardial infarction in patients with COVID-19. Objectives The aim of this study was to describe the demographic, angiographic, and procedural characteristics alongside clinical outcomes of consecutive cases of COVID-19–positive patients with STEMI compared with COVID-19–negative patients. Methods This was a single-center, observational study of 115 consecutive patients admitted with confirmed STEMI treated with primary percutaneous coronary intervention at Barts Heart Centre between March 1, 2020, and May 20, 2020. Results Patients with STEMI presenting with concurrent COVID-19 infection had higher levels of troponin T and lower lymphocyte count, but elevated D-dimer and C-reactive protein. There were significantly higher rates of multivessel thrombosis, stent thrombosis, higher modified thrombus grade post first device with consequently higher use of glycoprotein IIb/IIIa inhibitors and thrombus aspiration. Myocardial blush grade and left ventricular function were significantly lower in patients with COVID-19 with STEMI. Higher doses of heparin to achieve therapeutic activated clotting times were also noted. Importantly, patients with STEMI presenting with COVID-19 infection had a longer in-patient admission and higher rates of intensive care admission. Conclusions In patients presenting with STEMI and concurrent COVID-19 infection, there is a strong signal toward higher thrombus burden and poorer outcomes. This supports the need for establishing COVID-19 status in all STEMI cases. Further work is required to understand the mechanism of increased thrombosis and the benefit of aggressive antithrombotic therapy in selected cases., Central Illustration

Heart and circulatory diseases affect more than seven million people in the UK. Non-invasive cardiac imaging is a critical element of contemporary cardiology practice. Progressive improvements in technology over the last 20 years have increased diagnostic accuracy in all modalities and led to the incorporation of non-invasive imaging into many standard cardiac clinical care pathways. Cardiac imaging tests are requested by a variety of healthcare practitioners and performed in a range of settings from the most advanced hospitals to local health centres. Imaging is used to detect the presence and consequences of cardiovascular disease, as well as to monitor the response to therapies. The previous UK national imaging strategy statement which brought together all of the non-invasive imaging modalities was published in 2010. The purpose of this document is to collate contemporary standards developed by the modality-specific professional organisations which make up the British Cardiovascular Society Imaging Council, bringing together common and essential recommendations. The development process has been inclusive and iterative. Imaging societies (representing both cardiology and radiology) reviewed and agreed on the initial structure. The final document therefore represents a position, which has been generated inclusively, presents rigorous standards, is applicable to clinical practice and deliverable. This document will be of value to a variety of healthcare professionals including imaging departments, the National Health Service or other organisations, regulatory bodies, commissioners and other purchasers of services, and service users, i.e., patients, and their relatives.

Unprotected left main coronary artery disease (ULMD) is associated with an adverse prognosis (1,2). It was demonstrated almost a quarter of a century ago that patients with ULMD derive long-term prognostic benefit from coronary artery bypass graft surgery (CABG) compared with conservative treatment (3). The advent of coronary artery stenting quickly saw percutaneous coronary intervention (PCI) overtake CABG as the most commonly performed myocardial revascularisation procedure in patients with coronary artery disease as a whole (4). Only recently, however, has PCI been considered a genuine alternative to CABG for patients who have ULMD. This change in perspective arose due to improvements in balloon and stent technologies which facilitated complex PCI, pioneering PCI operators who brought ULMD PCI into mainstream clinical practice, and increasing evidence that PCI achieves favourable clinical outcomes in patients with ULMD.

Regional myocardial ischaemia is commonly expressed as exertional angina in patients with stable coronary artery disease (CAD). It also associates with prognosis, risk tending to increase with the severity of ischaemia. The validity of myocardial ischaemia as a surrogate for adverse clinical outcomes, however, has not been well established. Thus, in cohort studies, ischaemia testing has failed to influence rates of myocardial infarction and coronary death. Moreover, in clinical studies, pharmacological and interventional treatments that are effective in correcting ischaemia have rarely been shown to reduce cardiovascular (CV) risk. This contrasts with statins and other anti-inflammatory drugs that have no direct effect on ischaemia but improve CV outcomes by modifying the atherothrombotic disease process. Despite this, and with little evidence of patient benefit, stress testing is commonly used during the follow-up of patients with stable CAD when the demonstration of ischaemic change may be seen as a target for treatment, independently of symptomatic status. Substitution of a symptom-driven management strategy has the potential to reduce rates of non-invasive stress testing, unnecessary downstream revascularisation procedures and use of valuable resources in patients with stable CAD without adverse consequences for CV risk.

Acute kidney injury (AKI) is a frequent complication of cardiac surgery and usually occurs in patients with preexisting chronic kidney disease (CKD). Remote ischemic preconditioning (RIPC) may mitigate the renal ischemia-reperfusion injury associated with cardiac surgery and may be a preventive strategy for postsurgical AKI. We undertook a randomized controlled trial of RIPC to prevent AKI in 86 patients with CKD (estimated glomerular filtration rate under 60 ml/min per 1.73 m(2)) undergoing coronary artery bypass graft (CABG) surgery. Forty-three patients each were randomized to receive standard care with or without RIPC consisting of three 5-minute cycles of forearm ischemia followed by reperfusion. The primary end point was the development of AKI defined as an increase in serum creatinine concentration over 0.3 mg/dl within 48 h of surgery. Secondary end points included a comparison between the study and control groups of several serum biomarkers of renal injury including cystatin-C, neutrophil gelatinase-associated lipocalin (NGAL), and interleukin-18 (IL-18), and urinary biomarkers including NGAL, IL-18, and kidney injury molecule-1 measured at 6, 12, and 24 h after CABG, and the 72-h serum troponin T concentration area under the curve as a marker of myocardial injury. Clinical and operative characteristics were similar between the preconditioned and control groups. AKI developed in 12 patients in both groups within 48 h of CABG. There were no significant differences between the two groups in the concentrations of any of the serum or urinary biomarkers of renal or cardiac injury after CABG. Thus, RIPC induced by forearm ischemia-reperfusion had no effect on the frequency of AKI after CABG in patients with CKD.

BACKGROUND: The association between intraoperative cardiovascular changes and perioperative myocardial injury has chiefly focused on hypotension during noncardiac surgery. However, the relative influence of blood pressure and heart rate (HR) remains unclear. We investigated both individual and codependent relationships among intraoperative HR, systolic blood pressure (SBP), and myocardial injury after noncardiac surgery (MINS). METHODS: Secondary analysis of the Vascular Events in Noncardiac Surgery Cohort Evaluation (VISION) study, a prospective international cohort study of noncardiac surgical patients. Multivariable logistic regression analysis tested for associations between intraoperative HR and/or SBP and MINS, defined by an elevated serum troponin T adjudicated as due to an ischemic etiology, within 30 days after surgery. Predefined thresholds for intraoperative HR and SBP were: maximum HR >100 beats or minimum HR 160 mm Hg or minimum SBP 100 bpm was associated with MINS (odds ratio [OR], 1.27 [1.07–1.50]; P < .01), myocardial infarction (OR, 1.34 [1.05–1.70]; P = .02), and mortality (OR, 2.65 [2.06–3.41]; P < .01). Minimum SBP 160 mm Hg was associated with MINS (OR, 1.16 [1.01–1.34]; P = .04) and myocardial infarction (OR, 1.34 [1.09–1.64]; P = .01) but, paradoxically, reduced mortality (OR, 0.76 [0.58–0.99]; P = .04). Minimum HR 100 bpm was more strongly associated with MINS (OR, 1.42 [1.15–1.76]; P < .01) compared with minimum SBP

OBJECTIVES: Diabetes mellitus (DM) and renal impairment (RI) are both independent predictors of mortality after coronary artery bypass graft surgery (CABG). The two conditions often coexist, yet the impact on long-term prognosis after CABG of each factor relative to the other and the two in combination is uncertain. METHODS: We undertook a prospective cohort study of 4869 patients who underwent CABG between 2003 and 2007. The cohort was divided into four groups according to preoperative diabetic status and renal function: patients without either DM or RI (reference group), patients with DM alone, patients with RI alone and patients with both DM and RI. Clinical outcomes were compared between groups. Patients receiving renal replacement therapy were excluded. The primary outcome was 5-year all-cause mortality. RESULTS: The crude 5-year all-cause mortality rate was 9.0% for patients in the reference group, 11.1% for patients with DM alone, 20.3% for patients with RI alone and 28.5% for patients with both DM and RI (P< 0.0001). Five-year survival adjusted for potential confounding factors was significantly worse for patients with DM (hazard ratio (HR) 1.30; 95% confidence interval (CI) 1.06–1.59), patients with RI (HR 1.32; 95% CI 1.08–1.61) and patients with both DM and RI (HR 2.04; 95% CI 1.65–2.53) when compared with patients with neither condition. CONCLUSIONS: Preoperative DM and RI were important predictors of 5-year mortality after CABG. Patients with RI alone had a higher mortality rate than patients with DM alone, but this difference was largely accounted for by age and other comorbidities. The combination of DM and RI doubled the 5-year mortality rate after CABG independently of potential confounding factors.

Aims Myocardial revascularization by either coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI) carries the risk of serious complications. Observational data suggest that outcomes may be improved by experienced operators, but there are few studies that have analysed the relationship between mortality and primary operator grade. The aim of this study was to investigate the effect of operator grade (trainee vs. consultant) upon outcomes of revascularization procedures. Methods and results This was an observational study at a tertiary cardiology centre with accredited training programmes, between 2003 and 2011. A total of 22 697 consecutive patients undergoing either CABG or PCI were included. Associations between operator grade and mortality were assessed by hazard ratios, estimated by Cox regression analyses; 6689 patients underwent CABG, whereas 16 008 underwent PCI. Trainees performed 1968 (29.4%) CABG procedures and 8502 (53.1%) PCI procedures. The proportion of procedures performed by trainees declined over time for both CABG (30.2% in 2003 vs. 26.0% in 2010) and for PCI (58.1% in 2003 vs. 44.5% in 2010). In the unadjusted Cox analysis, consultant operator grade was associated with an increased 5-year mortality after both CABG [HR: 1.26 (95% CI: 1.07–1.47)] and PCI procedures [HR: 1.34 (95% CI: 1.22–1.47)] compared with a trainee operator. However, following multiple adjustment, consultant grade was no longer associated with mortality after either procedure [CABG: HR: 1.02 (95% CI: 0.87–1.20), PCI: HR: 1.08 (95% CI: 0.98–1.20)]. Conclusion There was no observed detrimental effect on patient outcomes arising from procedures undertaken by trainees working in a structured training environment compared with consultants.

ObjectivesThe electronic health record (EHR) is underused in the hospital setting. The aim of this service evaluation study was to respond to National Health Service (NHS) Digital’s ambition for a paperless NHS by capturing routinely collected cardiac outpatient data in the EHR to populate summary patient reports and provide a resource for audit and research.DesignA PowerForm template was developed within the Cerner EHR, for real-time entry of routine clinical data by clinicians attending a cardiac outpatient clinic. Data captured within the PowerForm automatically populated a SmartTemplate to generate a view-only report that was immediately available for the patient and for electronic transmission to the referring general practitioner (GP).ResultsDuring the first 8 months, the PowerForm template was used in 61% (360/594) of consecutive outpatient referrals increasing from 42% to 77% during the course of the study. Structured patient reports were available for immediate sharing with the referring GP using Cerner Health Information Exchange technology while electronic transmission was successfully developed in a substudy of 64 cases, with direct delivery by the NHS Data Transfer Service in 29 cases and NHS mail in the remainder. In feedback, the report’s immediate availability was considered very or extremely important by >80% of the patients and GPs who were surveyed. Both groups reported preference of the patient report to the conventional typed letter. Deidentified template data for all 360 patients were successfully captured within the Trust system, confirming availability of these routinely collected outpatient data for audit and research.ConclusionElectronic template development tailored to the requirements of a specialist outpatient clinic facilitates capture of routinely collected data within the Cerner EHR. These data can be made available for audit and research. They can also be used to enhance communication by populating structured reports for immediate delivery to patients and GPs.

Aims: To determine the clinical utility of 24 hour Holter monitoring by measuring the frequency of candidate arrhythmias recorded during the investigation of palpitations and altered consciousness. Methods: Of 9,729 Holter recordings, reports were available in 8,973 (92.2%) performed in the 7394 patients who comprise the study group. The mean age of the study group was 66 ± 19 years and 56.4% were women. Results: The most common indications were altered consciousness (41.7%) and palpitations (36.2%). Among patients with palpitations and sinus rhythm (n=2688), recordings were normal in 2247 (83.6%). Abnormalities included paroxysmal atrial fibrillation (PAF, 6.6%), narrow complex tachycardia (NCT, 2.8%) nonsustained or sustained ventricular tachycardia (NSVT/VT, 2.6%). Among patients with altered consciousness (n=3075), recordings were normal in 2589 (84.2%). Abnormalities included PAF (9.5%), NCT (2.6%), NSV/VT (0.2%), pause >2.8s (2.2%) and high degree AV block (1.3%). The diagnostic yield of Holter monitoring was particularly low in patients aged ≤50 years, of whom 93.1% had palpitations and 95.3% had altered consciousness had normal recordings. Conclusions: The diagnostic utility of Holter monitoring in patients being investigated for palpitations and altered consciousness is very limited, particularly in young patients for whom alternative diagnostic methods should be considered.

To compare long-term clinical outcomes in patients with ST-elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PPCI) using radial and femoral arterial access.The present study was an observational cohort study of patients with STEMI treated consecutively with PPCI between 2004 and 2011 at a single centre. The primary end point was all-cause mortality at a median follow-up of 3 years.Among 2727 patients, 1600 (58.7%) underwent PPCI via the femoral route. The femoral group was older (64.7 vs. 61.7 years; P 0.0001), and had higher rates of diabetes (18.6% vs. 16.0%; P 0.0001), previous PCI (11.2 vs. 7.8%; P = 0.004), previous myocardial infarction (15.3 vs. 8.3%; P 0.0001) and cardiogenic shock (9.8 vs. 1.3%; P 0.0001). Bleeding complications were more frequent in the femoral group (4.7 vs. 1.2%; P 0.0001). The 5-year death rate was significantly higher in the femoral group than in the radial group (10.4 vs. 3.0%; P 0.0001). After adjustment for confounding variables, bleeding complications [heart rate 2.07 (95% confidence interval 1.05-4.08)] and femoral access [heart rate 1.60 (95% confidence interval 1.02-2.53)] were independent predictors of all-cause mortality. After stratification using the propensity score, excess long-term mortality in patients treated via the femoral approach was predominantly in patients with a high baseline risk of death.Patients undergoing PPCI via the femoral route are at a higher risk of adverse short-term and long-term outcomes than patients undergoing PPCI via the radial route. Patients with a high baseline risk may benefit most from radial access, and future outcome studies should focus on the most at-risk patients.

The development of percutaneous procedures to diagnose and treat coronary artery disease has transformed the lives of many patients. Patients with limiting symptoms can now often be returned to full activity by percutaneous coronary intervention (PCI), with a low risk of procedure related cardiac events. PCI has obvious advantages over coronary artery bypass grafting, and, because increasingly complex disease can be treated in patients with previously prohibitive comorbidity, the demand for both diagnostic and interventional procedures increases every year.1 In percutaneous coronary procedures a sheath with a haemostatic valve is introduced into a peripheral artery under local anaesthetic. Preshaped catheters are passed through the sheath to the ostium of the relevant coronary artery, thus allowing the delivery of radiography contrast medium, angioplasty wires, balloons, and stents. After completion of the procedure, the catheter and sheath are removed and haemostasis is achieved by manual compression, an arterial closure device, or direct repair. The femoral artery has traditionally been the preferred access site for coronary procedures, but this approach has several limitations. It is relatively contraindicated in the presence of severe peripheral vascular disease and in patients receiving anticoagulation treatment. A period of post-procedure recumbency is needed to avoid disruption of the arterial puncture site. This may be poorly tolerated by patients with left ventricular dys-function, lung disease, or back and hip pain. Despite bed rest, the rate of complications at the femoral access site (haematoma, pseudoaneurysm, arteriovenous fistula, or need for blood transfusion or surgical arterial repair) is 2-8% after transfemoral PCI.2 3 These factors together affect patients' satisfaction, morbidity, length of hospital stay, and costs and have driven the development of alternative vascular access for coronary procedures. In this review we summarise the literature on transradial coronary procedures and discuss the potential clinical implications and technical considerations of …

The benefit of the routine application of aspiration thrombectomy in primary percutaneous coronary intervention (PPCI) is now well established. The optimal management of patients who have "failed" thrombectomy characterized by a large residual thrombus burden after repeated mechanical thrombectomy, however, is not known. We report a case of failed aspiration thrombectomy in a 66-year-old woman who was admitted to our institution with chest pain associated with inferior ST segment elevation. Coronary angiography showed a thrombotic occlusion of the right coronary artery. Aspiration thrombectomy did little to reduce thrombus load and so the patient was treated with intracoronary tenecteplase. Repeat coronary angiography 18 hr later revealed marked thrombus resolution with thrombolysis in myocardial infarction (TIMI) grade 3 anterograde flow and patency of the infarct-related artery was maintained at 2-month follow up. This case demonstrates the potential for intracoronary thrombolytic therapy as a treatment option for the management of patients following failed thrombectomy in PPCI.

Several studies have examined the relationship between age and clinical outcomes in patients with ST-elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PPCI). The majority of studies have concentrated on describing elderly patients and there has been less focus on the profile and outcome of young patients suffering from STEMI. The aim of this study was to describe the clinical profile and outcomes of young patients compared with an older cohort and to establish what risk factors were associated with young patients having PPCI for STEMI.This was an observational cohort study of 3618 patients with STEMI treated by PPCI at a regional heart attack centre in London between January 2004 and September 2012. Clinical characteristics and outcomes in (young) patients aged ≤ 45 years were compared with those in (older) patients aged45 years. The primary and main secondary outcomes were all-cause mortality and major adverse cardiovascular event rates, respectively, at a median follow-up of 3.0 (interquartile range 1.2-4.6) years.Of the 3618 patients, 367 (10.1%) were aged ≤ 45 years and 3251 (89.9%) were aged45 years. The proportion of patients aged ≤ 45 years increased from 8.5% to 11.5% (p=0.04) during the study period. Compared with older patients, those aged ≤ 45 years were more likely to be male, smokers, of South Asian ethnicity and to have a family history of premature coronary artery disease. Young patients were less likely to have a history of hypertension, hypercholesterolaemia, diabetes mellitus, previous myocardial infarction, myocardial revascularisation, or to have left ventricular systolic impairment or renal impairment. Over the follow-up period, mortality (2.7% vs. 7.6%; p0.0001) and major adverse cardiovascular event rates (7.0% vs. 13.5%; p0.0001) were significantly lower in patients aged ≤ 45 years compared with older patients. After adjustment for potential confounding factors, young age remained a predictor of reduced all cause mortality when compared with older patients (hazard ratio 0.12 (95% confidence interval 0.04-0.38)), including after incorporation of a propensity score (hazard ratio: 0.14 (95% confidence interval 0.04-0.36)).In this cohort of patients with STEMI treated by PPCI there was an increasing incidence of young patients aged ≤ 45 years throughout the study period. These patients were more often male, smokers and of South Asian ethnicity. Outcomes in younger patients was good. Focusing preventative strategies on smokers and high risk ethnic groups may help reduce the incidence of premature coronary artery disease.

Aim: This study presents an interim safety and feasibility analysis of the REGENERATE-IHD randomized controlled trial, which is examining the safety and efficacy of three different delivery routes of bone marrow-derived stem cells (BMSCs) in patients with ischemic heart failure. Methods & results: The first 58 patients recruited to the REGENERATE-IHD study are included in this interim analysis (pilot). Symptomatic patients with ischemic heart failure were randomized to receive subcutaneous granulocyte colony-stimulating factor or saline injections only; or subcutaneous granulocyte colony-stimulating factor injections followed by intracoronary or intramyocardial injections of BMSCs or serum (control). No significant differences were found in terms of safety and feasibility between the different delivery routes, with no significant difference in procedural complications or major adverse cardiac events. There was a signal towards improved heart failure symptoms in the patients treated with intramyocardial injection of mobilized BMSCs. Conclusion: Peripheral mobilization of BMSCs with or without subsequent direct myocardial delivery appears safe and feasible in patients with chronic ischemic heart failure.

Background: There is no clear consensus as to the correct screening procedure to identify patients undergoing cardiac surgery and who are at greatest risk of stroke because of the presence of significant carotid artery stenosis. Such screening is important because some patients benefit from combined carotid and cardiac surgery and, regardless of this, the information gained puts the cardiac surgeon in a position to provide an accurate assessment of surgical risk. Our objective was to examine current clinical practice of carotid artery investigation prior to urgent cardiac surgery and to review this illustrative practice in the context of the world literature. Hypothesis: The study aimed to establish that current typical practice for screening cardiac surgical patients for carotid artery disease is illogical according to the evidence in the world literature. Methods: The study consisted of a retrospective assessment of all patients undergoing urgent cardiac surgery and a Medline-derived literature review, and included all patients undergoing urgent cardiac surgery at a tertiary cardiothoracic center between January 1 and December 31, 1997. Results: Of 529 patients undergoing urgent cardiac surgery, 44 (8%) were screened preoperatively by duplex Doppler ultrasonography for carotid disease. The indications for screening were asymptomatic carotid bruit in 24 patients, history of stroke or transient ischemic attack (TIA) in 12 patients, and neither stroke, TIA, or bruit in 7 patients. The tests were requested either by the attending cardiologists or by the cardiac surgeon to whom they were referred. One patient had already been diagnosed as having carotid artery disease in the past. Thirteen patients underwent additional carotid investigations. Eleven patients were demonstrated to have internal carotid artery stenosis ≥ 60% and 3 patients underwent combined cardiac and carotid surgery. Review of the literature revealed the following groups to be at increased risk of future stroke unrelated to surgery, and of postoperative stroke: those with a history of stroke or TIA, those with carotid bruits, and, of importance, all patients with significant carotid stenosis. Recent data suggest that symptomatic patients and the elderly are at greatest risk. Conclusions: Only 8% of patients undergoing urgent cardiac surgery in a 1-year period were screened for carotid artery disease. We suggest that screening should definitely be performed in all patients with a history of stroke or TIA, all patients with a bruit, and all patients aged > 65 years. The literature suggests, however, that significant reductions in stroke rate could be achieved by screening the whole cardiac surgical population, although there is a paucity of data that are specifically pertinent to this patient subgroup. Further data are therefore required for the construction of a scientifically valid and medicolegally sound policy.

Cardiologists in the UK use clinical practice guidelines from the National Institute for Health and Care Excellence (NICE) and from the European Society of Cardiology (ESC) to aid clinical decision-making. This review compares their recommendations regarding stable angina. NICE's diagnostic algorithm changed clinical practice in the UK, with most cardiologists moving from the exercise ECG towards newer, more accurate imaging modalities such as CT and MRI for diagnostic testing in patients with a low or medium probability of coronary artery disease (CAD), and directly to invasive coronary angiography in patients with a high probability of CAD. ESC guidelines are based around stress imaging for most patient groups. Both guidelines stress the importance of optimal medical therapy for patients with stable angina. NICE recommends coronary artery bypass graft surgery to improve prognosis for patients with left main stem and/or proximal 3-vessel disease, whereas the ESC also includes proximal left anterior descending artery disease among its indications for revascularisation to improve prognosis, particularly if there is evidence of myocardial ischaemia. The relation between disease complexity and 5-year clinical outcomes after revascularisation in patients with left main stem and/or 3-vessel CAD has been integrated into ESC guidance through the use of the SYNTAX score to aid treatment selection in this group of patients. Patients with stable angina who have disease involving the proximal left anterior descending artery are less likely to undergo myocardial revascularisation if they are managed according to NICE's guidance compared with the ESC's guidance.

Two advantages of transradial coronary procedures are an increased potential for same-day discharge and better resource management. This study assessed the impact of a dedicated "radial lounge" (1) on the rate of same-day discharge after elective percutaneous coronary intervention (PCI) and coronary angiography and (2) on bed utilization.We compared our unit's rates of same-day discharge in patients who underwent elective PCI or coronary angiography in the year before and in the year after the opening of a dedicated radial lounge for elective patients.In its first year of operation, 439 patients who underwent PCI and 1,109 patients who underwent angiography were managed in the radial lounge. Among these patients, the rate of same-day discharge was 84.7% after PCI and 97.0% after angiography. Requirement for overnight admission was significantly more common after femoral access compared with radial access for both angiography (4.1% vs 2.8%, P.05) and PCI (20.3% vs 14.2%, P.01). The unit's overall rate of same-day discharge increased from 2.3% to 51.2% after elective PCI (P.0005) and from 72.7% to 84.9% after elective angiography (P.005). An estimated 595 bed days were saved through reduced overnight admissions in elective patients.Our unit's overall rates of same-day discharge after elective PCI and coronary angiography increased dramatically in the year after the opening of a dedicated radial lounge. This was directly attributable to the high rates of same-day discharge in radial lounge patients. The radial lounge impacted favorably on in-patient bed capacity.

We report the first case of primary percutaneous coronary intervention (PPCI) in a patient with a single coronary artery arising from the right aortic sinus. With the increasing availability of PPCI, more patients with coronary artery anomalies will undergo this procedure. This report highlights both the feasibility and safety of PPCI in patients with even the rarest of coronary artery anomalies.

Commentary on: Stergiopoulos K, Boden WE, Hartigan P, et al. Percutaneous coronary intervention outcomes in patients with stable obstructive coronary artery disease and myocardial ischaemia: a collaborative meta-analysis of contemporary randomized clinical trials. JAMA Intern Med 2014;174:232–40.[OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] In patients with stable coronary artery disease (CAD), the presence of myocardial ischaemia is associated with increased cardiac event rates. Percutaneous coronary intervention (PCI) achieves greater short-term reductions in myocardial ischaemia and angina than medical therapy. In contrast to patients with acute coronary syndromes, however, PCI has not been shown to reduce the likelihood of myocardial infarction (MI) or death in stable patients. The aim of this meta-analysis was to clarify the effect of PCI on clinical outcomes when restricted to patients who have demonstrable myocardial ischaemia. This was a meta-analysis of randomised controlled trials (RCTs) published between 1970 and November 2012 which compared medical therapy plus PCI with medical therapy alone in stable patients who had evidence of myocardial ischaemia. Included trials required stent use in at least 50% of patients … [1]: {openurl}?query=rft.jtitle%253DJAMA%2BIntern%2BMed%26rft.volume%253D174%26rft.spage%253D232%26rft_id%253Dinfo%253Adoi%252F10.1001%252Fjamainternmed.2013.12855%26rft_id%253Dinfo%253Apmid%252F24296791%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1001/jamainternmed.2013.12855&link_type=DOI [3]: /lookup/external-ref?access_num=24296791&link_type=MED&atom=%2Febmed%2F19%2F5%2F171.atom [4]: /lookup/external-ref?access_num=000333049200017&link_type=ISI

Aims: To determine the clinical utility of 24 hour Holter monitoring by measuring the frequency of candidate arrhythmias recorded during the investigation of palpitations and altered consciousness. Methods: Of 9,729 Holter recordings, reports were available in 8,973 (92.2%) performed in the 7394 patients who comprise the study group. The mean age of the study group was 66 ± 19 years and 56.4% were women. Results: The most common indications were altered consciousness (41.7%) and palpitations (36.2%). Among patients with palpitations and sinus rhythm (n=2688), recordings were normal in 2247 (83.6%). Abnormalities included paroxysmal atrial fibrillation (PAF, 6.6%), narrow complex tachycardia (NCT, 2.8%) nonsustained or sustained ventricular tachycardia (NSVT/VT, 2.6%). Among patients with altered consciousness (n=3075), recordings were normal in 2589 (84.2%). Abnormalities included PAF (9.5%), NCT (2.6%), NSV/VT (0.2%), pause >2.8s (2.2%) and high degree AV block (1.3%). The diagnostic yield of Holter monitoring was particularly low in patients aged ≤50 years, of whom 93.1% had palpitations and 95.3% had altered consciousness had normal recordings. Conclusions: The diagnostic utility of Holter monitoring in patients being investigated for palpitations and altered consciousness is very limited, particularly in young patients for whom alternative diagnostic methods should be considered.

Patients with endocarditis who present after embolism from a large, mobile vegetation pose a clinical dilemma: should they be managed with early surgery with the aim of preventing further emboli, or should a medical strategy be employed that avoids the morbidity and mortality associated with surgery but which risks further emboli? The management of such a patient is discussed in the context of the published literature regarding embolic risk in endocarditis.

Anemia is an important determinant of heart failure and death after ST elevation myocardial infarction (STEMI). The frequency of anemia and its impact on these outcomes across the range of acute coronary syndromes (ACS), however, have not been defined.This is a cohort study of 2310 patients with ACS stratified by quartiles of admission hemoglobin concentration [Hb]): Q1,12.5 g/dL; Q2, 12.5-13.6 g/dL; Q3, 13.7-14.7 g/dL; Q4,14.7 g/dL.There were 29.7% of women and 23.2% of men who were anemic. Rates of STEMI increased across [Hb] quartile groups from 25.0% (Q1) to 35.5% (Q4) as rates of unstable angina decreased from 52.0% (Q1) to 40.7% (Q4) (P.0005). Despite this, rates of left ventricular failure (LVF) were inversely related to [Hb] in all diagnostic groups, patients with unstable angina (Q1, 14.2%; Q4, 4.4%; P.0005) showing a similar trend to patients with non-STEMI (Q1, 26.8%; Q4, 10.4%; P.0005) and STEMI (Q1, 33.8%; Q4, 20.6%; P.0005). The age-adjusted odds of LVF in Q4 compared with Q1 were 0.64 (95% confidence interval, 0.45-0.90). Inhospital cardiac mortality was 3.0% and was not influenced by [Hb].Anemia is a common comorbidity in patients presenting with ACS, and it is a powerful independent determinant of LVF. The association with LVF occurs not only in STEMI but also in less severe diagnostic groups.

Non-ST segment elevation (NSTE) acute coronary syndromes (ACS) account for the majority of coronary care unit admissions. Registry data from the UK reveal that six months after such an admission there is a 12.2% rate of death or non-fatal myocardial infarction (MI), and a 30% rate of death, MI, refractory angina or readmission to hospital for unstable angina. 1 The pathophysiology of these syndromes is increasingly understood and is associated with improved targeting of medical therapy. 2,3 Risk stratification is the foundation of the current strategy for early coronary angiography and revascularisation (either percutaneous or surgical) in patients with ACS, with the aim of detecting those known to be at higher risk of further events, including death, MI or readmission with further unstable symptoms. Markers of high risk have been discussed in an earlier article in this section. In brief, the invasive cardiologist expects to be offered three categories of patients with NSTE ACS who should be referred for inpatient angiography and revascularisation because of their risk of further early events: 1 Patients with ongoing pain or ECG changes. 2 Patients with elevated troponin (Tn) levels (for example, (TnT) >0.05 ng/ml). 3 Patients with ST depression on admission ECG. What is the evidence that offering angiography and then revascularisation to patients in one of these high risk clinical categories provides them with a better outcome? Several trials can be used to address this question. From the viewpoint of modern interventional cardiology, they may be divided into two groups: historical and contemporary. The relevance of the historical trials is dubious because they are so far away from modern clinical practice in terms of intervention (stents and drug-coated stents) and adjunctive pharmacological therapy (clopidogrel, glycoprotein (GP) IIb/IIIa inhibitors, statins, angiotensinconverting enzyme inhibitors). Even the contemporary studies provide only some indication of the potential benefit of the newer therapies available.

The natural history of contractile left ventricular diverticulum in the adult is not known. Serial left ventricular angiography in an adult revealed that a left ventricular diverticulum did not increase in size over a 13-year period, suggesting that the clinical course may be benign.