Faculty Bibliography

BACKGROUND:The COMPLETE trial demonstrated a reduction in cardiovascular (CV) death or new myocardial infarction (MI) after complete, rather than culprit-only, revascularisation in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD). However, it is unknown whether this benefit varies according to baseline left ventricular ejection fraction (LVEF). AIMS/OBJECTIVE:We aimed to determine the effects of complete versus culprit-only revascularisation according to LVEF. METHODS:Baseline LVEF was available for 2,214 of 4,041 randomised patients. The effect of both strategies on the first co-primary outcome of CV death or new MI and the second co-primary outcome of CV death, new MI, or ischaemia-driven revascularisation (IDR) was determined within the prespecified LVEF ranges of <45% (N=660) and ≥45% (N=1,554). An analysis of clinical outcomes by LVEF according to thirds was also conducted. RESULTS:Patients with LVEF <45% experienced a significantly higher incidence of the first co-primary outcome compared with those with LVEF ≥45% (4.2%/year vs 2.8%/year; hazard ratio [HR] 1.51, 95% confidence interval [CI]: 1.15-1.98; p=0.003). Compared with a culprit-only strategy, complete revascularisation consistently reduced the first co-primary outcome in patients with LVEF <45% (3.0%/year vs 5.5%/year; HR 0.55, 95% CI: 0.36-0.86) and those with LVEF ≥45% (2.4%/year vs 3.2%/year; HR 0.74, 95% CI: 0.52-1.04; interaction p=0.31). Complete revascularisation also consistently reduced the second co-primary outcome in patients with LVEF <45% (3.5%/year vs 7.3%/year; HR 0.49, 95% CI: 0.33-0.74) and those with LVEF ≥45% (2.7%/year vs 6.3%/year; HR 0.44, 95% CI: 0.33-0.60; interaction p=0.67). Consistent results were observed for both co-primary outcomes when LVEF was further stratified into categories of LVEF ≤35%, 36-49% and ≥50%. CONCLUSIONS:Among patients presenting with STEMI and MVD, those with reduced LVEF are at higher risk of ischaemic events than patients with preserved LVEF. There is a consistent benefit of complete revascularisation regardless of baseline LVEF.

BACKGROUND:A contemporary, comprehensive risk score for the prediction of in-hospital fatal and nonfatal adverse events after percutaneous coronary intervention has been recently developed, albeit its external validation in patients with acute coronary syndrome is lacking. The objective of this study is to validate the Mayo Clinic integer risk score in a large cohort of patients with acute coronary syndrome undergoing percutaneous coronary intervention from the MATRIX (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox) trial. METHODS:The risk score is composed of a common set of 23 clinical and procedural variables (model A) and 18 preprocedural variables (model B). The primary objective was to appraise the receiver-operator characteristics of both models for in-hospital mortality, bleeding, contrast-associated acute kidney injury, and stroke. The impact of risk score categories on 1-year outcomes was also investigated. RESULTS:Among the 6724 patients undergoing percutaneous coronary intervention in the MATRIX trial, the receiver-operator characteristics-area under the curves for in-hospital mortality, bleeding, contrast-associated acute kidney injury, and stroke were 0.88 (95% CI, 0.85-0.91), 0.66 (95% CI, 0.63-0.69), 0.70 (95% CI, 0.67-0.72), and 0.65 (95% CI, 0.52-0.78) for model A and 0.88 (95% CI, 0.84-0.92), 0.63 (95% CI, 0.60-0.66), 0.66 (95% CI, 0.63-0.69), and 0.65 (95% CI, 0.52-0.78) for model B, respectively. Mortality (model A), bleeding, and stroke risks were well calibrated, whereas mortality (model B) and contrast-associated acute kidney injury risk were underestimated. There was a gradual risk increase for 1-year mortality and bleeding as a function of the risk score tertile using both models. CONCLUSIONS:The risk score identifies patients with acute coronary syndrome at incremental risk of in-hospital mortality, bleeding, contrast-associated acute kidney injury, and stroke, representing a valuable tool for mitigation of modifiable risk factors. REGISTRATION/BACKGROUND:URL: https://www.clinicaltrials.gov; Unique Identifier: NCT01433627.

The reduction in bleeding and vascular complications in radial access compared with femoral access has been repeatedly demonstrated over the past decade of observational and randomized studies. This review summarizes the data and underscores the role of radial approach in reducing bleeding, vascular complications, and mortality in ST-segment elevation myocardial infarction. In addition, the review notes the potential for increased time to reperfusion and provides guidance on implementation of transradial primary percutaneous coronary interventions.

IMPORTANCE/UNASSIGNED:Previous data suggest that the time changes associated with daylight savings time (DST) may be associated with an increased incidence of acute myocardial infarction (AMI). OBJECTIVE/UNASSIGNED:To determine whether the incidence of patients presenting with AMI is greater during the weeks during or after DST and compare the in-hospital clinical events between the week before DST and after DST. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This cross-sectional study examined patients enrolled in the Chest Pain MI Registry from 2013 to 2022. The study included patients who presented 1 week before DST, during the week of DST, or 1 week after DST (spring or fall) and assessed incidence of AMI, in-hospital mortality, stroke, and clinical outcomes during those times and compared the DST weeks with the week before or after. Data were analyzed from March 2024 to May 2025. MAIN OUTCOME AND MEASURE/UNASSIGNED:The main outcome was in-hospital mortality rate. The incidence ratio (IR) of AMI cases was calculated using the observed number of patients with AMI in the DST week divided by the number of patients with AMI who arrived 1 week before or after DST. RESULTS/UNASSIGNED:The final cohort included 168 870 patients (median [IQR] age, 65 [56-75] years, 57 023 females [33.8%]; 111 847 males [66.2%]) at 1124 hospitals during the study period. There were 28 678 patients (17.0%) with AMI treated during spring DST, 28 596 (16.9%) the week before, and 28 169 (16.7%) the week after. There were 27 942 patients (16.5%) with AMI treated during fall DST, 27 365 (16.2%) the week before, and 28 120 (16.7%) the week after. Patient characteristics were similar for the spring and fall DST analyses (spring and fall DST median [IQR] age across groups: 65 [56-74] years and 65 [56-75] years, respectively), and there were 28 725 females (33.6%) in the spring and 28 298 females (33.9%) in the fall. There was no significant difference in the incidence of AMI for the following time periods: spring DST week vs 1 week prior, spring DST week vs 1 week after, fall DST week vs 1 week prior, and fall DST week vs 1 week after. There were no significant differences in adjusted in-hospital outcomes for the 1 week before or after fall or spring DST. CONCLUSIONS AND RELEVANCE/UNASSIGNED:This study found no significant difference in the incidence rates of AMI in DST weeks compared with the week before or after. Additionally, there were no differences in in-hospital clinical outcomes.

BACKGROUND/UNASSIGNED:Studies suggest percutaneous coronary intervention (PCI) guided by intracoronary imaging (ICI) results in larger balloon/stent diameters and longer stents. Whether this occurs in real-world PCI is poorly understood. METHODS/UNASSIGNED:De novo PCIs performed at 48 nonfederal Michigan hospitals between July 2019 and June 2022 were evaluated with regression modeling to evaluate associations between ICI-guided PCI and balloon/stent dimensions. The association between ICI-guided PCI and coronary dissection/perforation was assessed using adjusted odds ratios. RESULTS/UNASSIGNED:=0.33 for trend, respectively). CONCLUSIONS/UNASSIGNED:In real-world practice, ICI-guided PCI was associated with larger stent/balloon diameters and longer stents. While ICI use was associated with dissections and perforations, there was no significant increase in the rate of these complications despite significant increases in ICI use and stent/balloon sizes during the study period. Further research is needed to evaluate the association between ICI use and procedural complications.

IMPORTANCE/UNASSIGNED:Both myocardial infarction (MI) and anemia have deleterious effects on health-related quality of life (QOL). Red blood cell (RBC) transfusion may improve QOL after MI by relieving symptoms and/or increasing functional capacity. OBJECTIVE/UNASSIGNED:To evaluate whether a liberal transfusion strategy compared with a more restrictive transfusion strategy affects QOL in patients with MI and anemia. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This analysis of QOL as a prespecified secondary outcome of the Myocardial Ischemia and Transfusion (MINT) trial, a randomized clinical trial comparing a liberal vs restrictive RBC transfusion strategy, included participants from 144 sites across 6 countries. Hospitalized adults with acute MI and anemia (hemoglobin [Hb] less than 10 g/dL). The MINT trial randomized 3504 patients, and this analysis included those who had QOL data collected and those who died before the 30-day follow-up period. Data were collected from April 2017 to April 2023, and data were analyzed from February 2024 to January 2025. INTERVENTIONS/UNASSIGNED:The MINT trial randomized patients to a restrictive (Hb of 7 to 8 g/dL) or a liberal (Hb of less than 10 g/dL) RBC transfusion strategy. MAIN OUTCOMES AND MEASURES/UNASSIGNED:QOL was measured using the EQ-5D-5L 30 days after randomization. RESULTS/UNASSIGNED:Of 2844 included patients, 1551 (54.5%) were male, and the mean (SD) age was 71.9 (11.5) years. A total of 2525 (88.8%; 1254 [49.7%] in the restrictive group and 1271 [50.3%] in the liberal group) had QOL data, and 319 (11.2%) died before 30-day follow-up. Overall, there were no differences in mean or median scores for any EQ-5D-5L QOL outcome between assigned transfusion strategies at 30 days postrandomization. Although a higher percentage of patients in the liberal compared with the restrictive transfusion group reported no problems compared with any problem in usual activities (506 of 1268 [39.9%] vs 473 of 1247 [37.9%]), mobility (474 of 1270 [37.3%] vs 460 of 1254 [36.7%]), and self-care (858 of 1271 [67.5%] vs 803 of 1254 [64.0%]) domains, none of these differences were statistically significant. Adjusted mixed-effects linear regressions showed no association between assigned transfusion strategy and mean differences in any QOL outcome. Adjusted regressions in several prespecified subgroups showed an association between a liberal transfusion strategy and better QOL scores in domains related to functional capacity, but the effects were only statistically significant in patients with a history of heart failure (Health Today rating: β, 2.06 [95% CI, -0.23 to 4.35] vs -1.44 [95% CI, -3.81 to 0.92]; P = .04). CONCLUSIONS AND RELEVANCE/UNASSIGNED:This secondary analysis of the MINT trial found that in patients with MI and anemia, a liberal transfusion strategy compared with a restrictive transfusion strategy did not affect QOL outcomes 30 days after randomization. This suggests that higher Hb levels maintained with RBC transfusion may not offer significant benefits to QOL overall in patients with MI and anemia. Additional studies may be useful for further examining and validating transfusion's effect on QOL in patients with MI and heart failure. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT02981407.

[This corrects the article DOI: 10.1016/j.jscai.2024.102397.].