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Background: Suboptimal coronary reperfusion (no reflow) is common in acute coronary syndrome percutaneous coronary intervention (PCI) and is associated with poor outcomes. We aimed to develop and externally validate a clinical risk score for angiographic no reflow for use following angiography and before PCI., Methods: We developed and externally validated a logistic regression model for prediction of no reflow among adult patients undergoing PCI for acute coronary syndrome using data from the Melbourne Interventional Group PCI registry (2005-2020; development cohort) and the British Cardiovascular Interventional Society PCI registry (2006-2020; external validation cohort)., Results: A total of 30 561 patients (mean age, 64.1 years; 24% women) were included in the Melbourne Interventional Group development cohort and 440 256 patients (mean age, 64.9 years; 27% women) in the British Cardiovascular Interventional Society external validation cohort. The primary outcome (no reflow) occurred in 4.1% (1249 patients) and 9.4% (41 222 patients) of the development and validation cohorts, respectively. From 33 candidate predictor variables, 6 final variables were selected by an adaptive least absolute shrinkage and selection operator regression model for inclusion (cardiogenic shock, ST-segment-elevation myocardial infarction with symptom onset >195 minutes pre-PCI, estimated stent length ≥20 mm, vessel diameter <2.5 mm, pre-PCI Thrombolysis in Myocardial Infarction flow <3, and lesion location). Model discrimination was very good (development C statistic, 0.808; validation C statistic, 0.741) with excellent calibration. Patients with a score of ≥8 points had a 22% and 27% risk of no reflow in the development and validation cohorts, respectively., Conclusions: The no-reflow prediction in acute coronary syndrome risk score is a simple count-based scoring system based on 6 parameters available before PCI to predict the risk of no reflow. This score could be useful in guiding preventative treatment and future trials., Competing Interests: Disclosures None.

There is paucity of data examining long-term outcomes of premature coronary artery disease (CAD). We aimed to investigate the short- and long-term clinical outcomes of patients with premature CAD treated by percutaneous coronary intervention (PCI) compared to older cohorts. We analyzed data from 27,869 patients who underwent PCI from 2005-2017 enrolled in a multicenter PCI registry. Patients were divided into three age groups: young group (≤ 45 years), middle-age group (46-65 years) and older group (>65 years). There were higher rates of current smokers in the young (n = 1,711) compared to the middle-age (n = 12,830) and older groups (n = 13,328) (54.2% vs 34.6% vs 11%) and the young presented more frequently with acute coronary syndrome (ACS) (78% vs 66% vs 62%), all p <0.05. There were also greater rates of cardiogenic shock (CS), out-of-hospital cardiac arrest (OHCA) and ST-elevation myocardial infarction (STEMI) in the young, all p <0.05. The young cohort with STEMI had higher rates of in-hospital, 30-day death, and long-term mortality (3.8% vs 0.2%, 4.3% vs 0.2% and 8.6% vs 3.1%, all p <0.05, respectively) compared to the non-STEMI subgroup. There was a stepwise increase in long-term mortality from the young, to middle-age, to the older group (6.1% vs 9.9% vs 26.8%, p <0.001). Younger age was an independent predictor of lower long-term mortality (HR 0.66, 95% CI 0.52-0.84, p = 0.001). In conclusion, younger patients presenting with STEMI had worse prognosis compared to those presenting with non-STEMI. Despite higher risk presentations among young patients, their overall prognosis was favorable compared to older age groups., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To assess the clinical outcomes of patients presenting with ST-elevation myocardial infarction (STEMI) secondary to stent thrombosis (ST) compared to those presenting with STEMI secondary to a de novo culprit lesion and treated by percutaneous coronary intervention (PCI)., Background: ST is an infrequent but serious complication of PCI with substantial associated morbidity and mortality, however with limited data., Methods: We studied consecutive patients who underwent PCI for STEMI from 2005 to 2013 enrolled prospectively in the Melbourne Interventional Group registry. Patients were divided into two groups: the ST group comprised patients where the STEMI was due to ST and the de novo group formed the remainder of the STEMI cohort and all patients were treated by PCI. The primary endpoint was 30-day all-cause mortality., Results: Compared to the de novo group (n = 3,835), the ST group (n = 128; 3.2% of STEMI) had higher rates of diabetes, hypertension and dyslipidemia, established cardiovascular diseases, myocardial infarction, and peripheral vascular disease, all p < .01. Within the ST group, very-late ST was the most common form of ST, followed by late and early ST (64, 19, and 17%, respectively). There was no significant difference in the primary outcome between the ST group and the de novo group (4.7 vs. 7.1%, p = .29). On multivariate analysis, ST was not an independent predictor of 30-day mortality (odds ratio: 0.62, 95% confidence interval: 0.07-1.09, p = .068)., Conclusion: The short-term prognosis of patients with STEMI secondary to ST who were treated by PCI was comparable to that of patients with STEMI due to de novo lesions., (© 2020 Wiley Periodicals, Inc.)

Aims: To evaluate the association of limited English proficiency (LEP) with reperfusion times and outcomes in patients undergoing primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI)., Methods and Results: This cohort study included 5385 patients who underwent PPCI in 2013-2017 and were prospectively enrolled in the Victorian Cardiac Outcomes Registry. Data linkage to government administrative datasets was performed to identify patients' preferred spoken language, socioeconomic status, and ambulance utilization data. Patients who had a preferred spoken language other than English were defined as having LEP. Of the study cohort, 430 patients (8.0%) had LEP. They had longer mean symptom-to-door time (STDT) [164 (95% confidence interval, CI 149-181) vs. 136 (95% CI 132-140) min, P < 0.001] but similar mean door-to-balloon time [79 (95% CI 72-87) vs. 76 (95% CI 74-78) min, P = 0.41]. They also had higher major adverse cardiovascular and cerebrovascular events (MACCE; 13.5% vs. 9.9%; P = 0.02), severe left ventricular dysfunction (11.0% vs. 8.4%, P = 0.02), and heart failure (HF) hospitalizations within 30 days of PPCI (5.1% vs. 2.0%, P < 0.001). On multivariable analysis, LEP did not independently predict 30-day MACCE [odds ratio (OR) 1.16, 95% CI 0.79-1.69; P = 0.45] but was an independent predictor of both prolonged STDT ≥ 120 min (OR 1.25, 95% CI 1.02-1.52; P = 0.03) and 30-day HF hospitalizations (OR 2.01, 95% CI 1.21-3.36; P = 0.008)., Conclusion: Patients with LEP undergoing PPCI present later and are more likely to have HF readmissions within 30 days of percutaneous coronary intervention, but with similar short-term MACCE. More effort to provide education in varied languages on early presentation in STEMI is required., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Objectives: We aimed to assess the outcomes of cardiogenic shock (CS) complicating acute coronary syndromes (ACS)., Background: CS remains the leading cause of mortality in patients presenting with ACS despite advances in care., Methods: We studied 13,184 patients undergoing percutaneous coronary intervention (PCI) for all subtypes of ACS enrolled prospectively in a large multicentre Australian registry (Melbourne Interventional Group registry) from 2005 to 2013. All-cause mortality was obtained via linkage to the National Death Index. Patients were divided into those with and those without CS., Results: Compared to the non-CS group (n = 12,548, 95.2%), the CS group (n = 636, 4.8%) had a higher proportion of out-of-hospital cardiac arrest (OHCA) (31.1 vs. 2.2%) and ST-elevation myocardial infarction (STEMI) presentation (89 vs. 34%), both p < .01. Patients in the CS group had higher rates of in-hospital (40.4 vs. 1.2%) and 30-day (41 vs. 1.7%) mortality compared to the non-CS group. Long-term mortality over a median follow-up of 4.2 years was higher in the CS group (50.6 vs. 13.8%), p < .001. Trends of in-hospital and 30-day mortality rates of CS complicating ACS were relatively stable from 2005 to 2013. Predictors of long-term NDI-linked mortality within the CS group include severe left ventricular systolic dysfunction (HR 3.0), glomerular filtration rate (GFR) <30 (HR 2.56), GFR 30-59 (HR 1.94), OHCA (HR 1.46), diabetes (HR 1.44), and age (HR 1.02), all p < .05., Conclusions: Rates of CS-related mortality complicating ACS have remained very high and steady over nearly a decade despite progress in STEMI systems of care, PCI techniques, and medical therapy., (© 2020 Wiley Periodicals, Inc.)

Background: Systems of care have been established to ensure patients with ST-elevation myocardial infarction (STEMI) get timely access to primary percutaneous coronary intervention (PPCI). In this study, we evaluated whether patients undergoing PPCI both in-hours and out-of-hours experience similar care and clinical outcomes., Methods: Of 9,865 patients who underwent PCI for STEMI from 2005 to 2016 and were enrolled in the multi-centre Melbourne Interventional Group registry, patients who had initially presented to a non-PCI capable hospital, received thrombolysis or presented >12hourspost-symptom onset were excluded. Our final study cohort of 4,590 patients were dichotomised by whether PPCI was performed in-hours or out-of-hours, and compared. The primary outcome was 30-day mortality., Results: The in-hours group included 1,865 patients (40.6%) while 2,725 patients (59.4%) had out-of-hours PPCI. Patients presenting out-of-hours had longer median door-to-balloon time (DTBT; 83 [IQR 61-109] vs. 60 [IQR 41-88] mins, p<0.01) and were more likely to receive a drug-eluting stent (p=0.001). Procedural characteristics were otherwise similar although rates of radial access were low overall (18.4%). No differences in in-hospital, 30-day or 12-month mortality were observed between the groups (p=NS). On Cox proportional hazards modelling, out-of-hours presentation was not an independent predictor of 30-day mortality (HR 0.94, 95% CI 0.71-1.22). A landmark analysis of data from 2012 did not change the primary outcome., Conclusion: Despite a slightly longer DTBT, patients undergoing PPCI out-of-hours experienced similar care and clinical outcomes to the in-hours group. Given the majority of patients with STEMI present out-of-hours, these data have implications for STEMI systems of care., (Copyright © 2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Objectives: The objective of this study was to investigate the association of proximal and nonproximal location of culprit coronary lesions with clinical outcomes of patients presenting with ST-elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PCI)., Background: Proximal culprit lesion location in patients presenting with STEMI is associated with increased mortality when compared to distal culprit lesions in the thrombolytic era. The impact of lesion location on clinical outcomes in the era of PCI remains unclear., Methods: We analyzed 3,283 patients with STEMI who enrolled in the Victorian Cardiac Outcomes Registry. We compared outcomes in those with proximal lesion location versus patients with nonproximal location., Results: Of 3,283 participants, 1,376 (41.9%) had a proximal lesion location. Patients with proximal lesion location presented with greater rates of cardiogenic shock and out-of-hospital cardiac arrest, and left ventricular systolic dysfunction, all P < .01. Procedural success rates were similar (96% vs. 95%, P = .08). Patients with proximal lesion location had higher rates of in-hospital and 30-day mortality, major adverse cardiac events (MACE; mortality, myocardial infarction, stent thrombosis, and unplanned revascularization) and major adverse cardiac and cerebrovascular events (MACCE; MACE, and stroke) compared to the nonproximal group, all P < .001. However, on multivariable regression analysis, proximal lesion location was not independently associated with MACE during in-hospital stay or at 30-days (OR 1.32, 95% CI 0.95-1.83, P = .09 and OR 1.23, 95% CI 0.92-1.65, P = .15) respectively., Conclusions: Patients with proximal lesion location had greater hemodynamic instability and higher-risk features; however, proximal lesions per se were not independently associated with worse clinical outcomes compared to nonproximal lesions., (© 2018 Wiley Periodicals, Inc.)

Background: Low socioeconomic status (SES) has been previously shown to be associated with worse cardiovascular outcomes. However, unlike in Australia, many of these studies have been performed in countries without universal healthcare where SES may be expected to have a greater impact on care and outcomes. We sought to determine whether there is an association between SES and baseline characteristics, clinical outcomes and use of secondary prevention therapy in patients with ST-segment-elevation myocardial infarction undergoing percutaneous coronary intervention (PCI)., Methods and Results: We prospectively collected data on 5665 consecutive ST-segment-elevation myocardial infarction PCI patients between 2005 and 2015 from 6 government-funded hospitals participating in a multicenter registry. Patients were categorized into SES quintiles using the Index of Relative Socioeconomic Disadvantage system, a score allocated to each residential postcode based on factors like income, educational level, and employment status by the Australian Bureau of Statistics. In our study, lower SES patients were more likely to have diabetes mellitus, smoke, and initially present to a non-PCI capable hospital (all P≤0.01). Among primary PCI patients, the median time to reperfusion was slightly higher in lower SES groups (211 [144-337] versus 193 [145-285] minutes, P<0.001). Drug-eluting stent use was higher in the higher SES groups ( P<0.001). At 12 months after PCI, lower SES patients had higher rates of ongoing smoking and lower use of guideline-recommended secondary prevention therapy (both P<0.01). Despite these differences, SES group was not found to be an independent predictor of 12-month major adverse cardiovascular events., Conclusions: Lower SES patients have more comorbidities and experienced slightly longer reperfusion times but otherwise similar care. Despite these baseline differences, clinical outcomes after ST-segment-elevation myocardial infarction PCI were similar regardless of SES.

Doctor-patient language discordance has been shown to lead to worse clinical outcomes. In this study of patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction at an Australian health service, we demonstrated that limited English proficiency (LEP) is an independent predictor of prolonged symptom-to-door time, but does not lead to worse 30-day mortality compared with English-proficient patients. More effort needs to be placed in providing public health education in varied languages to encourage early presentation to hospital for patients with LEP., (© 2018 Royal Australasian College of Physicians.)

Over the last decade, systems of care for ST-elevation myocardial infarction (STEMI) have evolved to try to improve outcomes and timely access to percutaneous coronary intervention (PCI). There have also been advances in PCI techniques and adjunctive pharmacotherapies. In this study, we sought to determine temporal changes in practices and clinical outcomes of PCI in patients with STEMI. We prospectively collected data on 8,412 consecutive patients undergoing PCI for STEMI between 2005 and 2016 in the multicenter Melbourne Interventional Group registry. Data were divided by procedure year for trends analysis. The primary end point was 30-day mortality. Patient demographics and comorbidities including smoking and diabetes have remained stable. The volume of primary PCI performed within 12 hours of symptom onset has significantly risen (65.7% to 80.1%, p < 0.01). The proportion of patients achieving the recommended door-to-balloon time ≤90 minutes has also risen (37.6% to 59.0%, p < 0.01). Patient complexity has also increased with more patients after out-of-hospital cardiac arrest with STEMI now being treated with PCI (2.6% to 9.1%, p < 0.01). A shift from mainly femoral to radial access and from bare-metal to drug-eluting stent use was seen. Glycoprotein IIb/IIIa inhibitors are being used less frequently with increasing use of newer antiplatelet agents. Thirty-day mortality has remained low throughout the study period at 6.5% overall. In conclusion, although timely access to primary PCI has improved, mortality rates have remained unchanged, but remain low and compare favorably with international data. Australian PCI practice has overall evolved in response to evidence and emergence of new adjunctive device and pharmacotherapies., (Copyright © 2017 Elsevier Inc. All rights reserved.)