A direct comparison of decision rules for early discharge of suspected acute coronary syndromes in the era of high sensitivity troponin.

Background: We tested the hypothesis that a single high sensitivity troponin at limits of detection (LOD HSTnT) (<5 ng/l) combined with a presentation non-ischaemic electrocardiogram is superior to low-risk Global Registry of Acute Coronary Events (GRACE) (<75), Thrombolysis in Myocardial Infarction (TIMI) (≤1) and History, ECG, Age, Risk factors and Troponin (HEART) score (≤3) as an aid to early, safe discharge for suspected acute coronary syndrome.

Methods: In a prospective cohort study, risk scores were computed in consecutive patients with suspected acute coronary syndrome presenting to the Emergency Room of a large English hospital. Adjudication of myocardial infarction, as per third universal definition, involved a two-physician, blinded, independent review of all biomarker positive chest pain re-presentations to any national hospital.

Unfractionated heparin versus bivalirudin in primary percutaneous coronary intervention (HEAT-PPCI): an open-label, single centre, randomised controlled trial.

Background: Bivalirudin, with selective use of glycoprotein (GP) IIb/IIIa inhibitor agents, is an accepted standard of care in primary percutaneous coronary intervention (PPCI). We aimed to compare antithrombotic therapy with bivalirudin or unfractionated heparin during this procedure.

Methods: In our open-label, randomised controlled trial, we enrolled consecutive adults scheduled for angiography in the context of a PPCI presentation at Liverpool Heart and Chest Hospital (Liverpool, UK) with a strategy of delayed consent.

Impact of implementation of evidence-based strategies to reduce door-to-balloon time in patients presenting with STEMI: continuous data analysis and feedback using a statistical process control plot.

Background: Strategies to reduce DTB (door-to-balloon) time have been previously described. However, there is no well-established data-monitoring system that can be used for prompt feedback. The aims of this study were to use statistical process control (SPC) methodology to measure current processes, to provide real-time feedback on the impact of a change in service delivery and to identify individual outliers for specific investigation.

Funnel plots for comparing performance of PCI performing hospitals and cardiologists: demonstration of utility using the New York hospital mortality data.

Background: The New York State Department of Health collects and reports outcome data on the hospitals and cardiologists who perform percutaneous coronary intervention (PCI) to allow them to examine their quality of care. Results are provided in tabular form. However funnel plots are the display method of choice for comparison of institutions and operators, using the principles of statistical process control (SPC).

Is it worth performing surgical ventricular restoration in patients with ischemic cardiomyopathy and akinetic but non-aneurysmal segments in the left ventricle?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is worth performing surgical ventricular restoration (SVR) in patients with ischemic cardiomyopathy and akinetic but non-aneurysmal segments in the left ventricle. Altogether 237 papers were identified using the below mentioned search.

Cumulative funnel plots for the early detection of interoperator variation: retrospective database analysis of observed versus predicted results of percutaneous coronary intervention.

Objective: To use funnel plots and cumulative funnel plots to compare in-hospital outcome data for operators undertaking percutaneous coronary interventions with predicted results derived from a validated risk score to allow for early detection of variation in performance.

Design: Analysis of prospectively collected data.

Setting: Tertiary centre NHS hospital in the north east of England.

Rescue angioplasty after failed fibrinolysis for acute myocardial infarction: predictors of a failed procedure and 1-year mortality.

Background: Rescue angioplasty (rPCI) for failed fibrinolysis is associated with a low mortality if successful, but a high mortality if it fails. The latter may reflect a high-risk group or harm in some patients. Predictors of success or failure of rPCI may aid selection of patients to be treated.

Is it ever worth contemplating an aortic valve replacement on patients with low gradient severe aortic stenosis but poor left ventricular function with no contractile reserve?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is worth performing aortic valve replacement in patients with severe aortic stenosis and poor left ventricular function but no contractile reserve on dobutamine stress testing. Altogether 251 papers were identified using the below mentioned search and all major international guidelines were included.

Modifiable risk factors remain significant causes of medium term mortality after first time Coronary artery bypass grafting.

Background: Whilst there is much current data on early outcomes after Coronary artery bypass grafting(CABG), there is relatively little data on medium term outcomes in the current era. The purpose of this study is to present a single surgeon series comprising of all first time CABG patients operated on with the technique of cross clamp fibrillation from Feb-1996 to through to Jan-2003, and to seek risk factors for medium term mortality in these patients.

Methods: Data was collected from Hospital Episode Statistics and departmental patient administration and tracking systems and cross checked using database techniques.

The impact of chronically diseased coronary arteries and stenting on the corrected TIMI frame count in elective coronary angiography and percutaneous coronary intervention procedures.

Unlabelled: The impact of chronic coronary obstructions on resting blood flow in stable cardiac patients and the response to percutaneous coronary intervention (PCI) using the TIMI frame count method has not been well documented. We studied the impact of coronary artery stenosis severity on the corrected TIMI frame count (cTFC) in chronically stenosed coronary arteries. We prospectively and quantitatively determined the impact of stenting on the cTFC during elective PCI.

Impact of catheter sizes and intracoronary glyceryl trinitrate on the TIMI frame count when digital angiograms are acquired at lower frame rates during elective angiography and PCI.

Unlabelled: The TIMI frame count (TFC) is a useful measure of coronary flow. To be widely applicable, the effect of different catheter sizes and the use of intracoronary glyceryl trinitrate (ICGTN) must be determined when films are acquired at lower acquisition rates (12.5 frames/s, f/s).

Towards an understanding of the role of rescue angioplasty for failed fibrinolysis: comparison of the MERLIN, RESCUE and REACT trials.

Unlabelled: The large randomized trials on rescue angioplasty (rPCI) have been interpreted by some as showing differing results. We compared the protocols, demographics and 6-month clinical outcomes of the MERLIN trial with the RESCUE I and REACT trials to assess their differences.

Results: The RESCUE I trial did not involve the use of stenting or glycoprotein IIb/IIIa inhibitors, and patients with previous MI were excluded.

Intra-aortic counterpulsation does not improve coronary flow early after PCI in a high-risk group of patients: observations from a randomized trial to explore its mode of action.

Unlabelled: The intra-aortic balloon pump (IABP) is the most commonly used temporary cardiac assist device. The precise role and the mechanism of any benefit in high-risk patients undergoing percutaneous coronary intervention (PCI) have not been fully determined. We hypothesized that the use of an IABP following PCI in high-risk non-shocked patients would immediately increase coronary blood flow, tissue perfusion and hence preserve left ventricular function.

Treatment of restenosis after bare-metal and drug-eluting stenting of an aorto-ostial lesion: challenges associated with excessive stent overhang.

Percutaneous coronary interventions of ostial right coronary artery stenoses are associated with increased procedural complications as well as with higher rates of angiographic and clinical restenosis. Ideally, the ostium is treated by positioning the stent with a slight degree of overhang in the aorta to ensure coverage of the aorto-ostial junction. This can potentially complicate further intervention should restenosis occur.

Should high risk patients receive clopidogrel as well as aspirin post coronary arterial bypass grafting?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether clopidogrel should be given in addition to aspirin in high risk patients after coronary bypass surgery to reduce thrombotic complications. High risk patients would include patients recently post MI or patients with a patent stent in situ.

Should clopidogrel be stopped prior to urgent cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether clopidogrel should be stopped prior to urgent cardiac surgery. Altogether 143 papers were identified using the below mentioned search and all major international guidelines were included.

Should the tricuspid valve be replaced with a mechanical or biological valve?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether patients requiring tricuspid replacement should have a mechanical or a biological valve. Using the reported search, 561 papers were identified.

Meta-analysis of valve hemodynamics and left ventricular mass regression for stentless versus stented aortic valves.

Background: Stentless aortic bioprostheses have been advocated as being superior to conventional bioprosthetic valves, with benefits including superior left ventricular mass regression and larger effective orifice area. Several high-quality randomized studies now exist on this topic, and we sought to summarize them by meta-analysis.

Methods: The literature was searched from 1995 to 2006, in MEDLINE, EMBASE, CRISP, metaRegister of Controlled Trials, and the Cochrane database.

Should patients in cardiogenic shock undergo rescue angioplasty after failed fibrinolysis: comparison of primary versus rescue angioplasty in cardiogenic shock patients.

Background: Trials of rescue angioplasty (rPCI) following failed fibrinolysis have excluded patients with cardiogenic shock and the benefit of rPCI in this setting is unknown. We compared the clinical, angiographic characteristics, 30-day and 1-year outcomes of cardiogenic shock patients undergoing rPCI with those undergoing primary percutaneous coronary intervention (PPCI).

Methods: Of the 171 patients undergoing PCI for cardiogenic shock between 1994 and 2005 at our institution, the indication was for PPCI in 65 and rPCI in 59 patients.

Early invasive versus conservative treatment in patients with failed fibrinolysis--no late survival benefit: the final analysis of the Middlesbrough Early Revascularisation to Limit Infarction (MERLIN) randomized trial.

Background: Early (30 days) and midterm (6 months) clinical outcomes in trials comparing rescue angioplasty (rescue percutaneous coronary intervention [rPCI]) with conservative treatment of failed fibrinolysis complicating ST-segment elevation myocardial infarction have shown variable results. Whether early rPCI confers late (up to 3 years) clinical benefits is not known.

Methods: The MERLIN trial compared rPCI and a conservative strategy in patients with failed fibrinolysis complicating ST-segment elevation myocardial infarction.

Meta-analysis of randomized trials comparing anti-embolic devices with standard PCI for improving myocardial reperfusion in patients with acute myocardial infarction.

Background: Failure to achieve adequate myocardial reperfusion often occurs during PCI in patients with STEMI. This is in part due to atheromatous and thrombotic distal embolization. Several anti-embolic devices have been developed to protect against distal embolization during percutaneous coronary interventions (PCI) to improve myocardial reperfusion and enhance event free survival.

A prospective randomised controlled trial to determine the early and late reactions after the use of iopamidol 340 (Niopam) and iomeprol 350 (Iomeron) in cardiac catheterisation.

Unlabelled: A new generation of intravascular contrast agents, the non-ionic monomers have safety profiles that are superior to those of older ionic compounds. There are, however, significant differences between these agents.

Aim: The aim of this study was to determine the incidence of early (<24h) and late (>24h to 7 days) reactions to two non-ionic contrast agents currently used during cardiac catheterisation: iopamidol 340 (Niopam Bracco UK Ltd.

Successful thrombus extraction with the Rescue thrombus management system during acute percutaneous coronary intervention improves flow but does not necessarily restore optimal myocardial tissue perfusion.

Unlabelled: We determined the effectiveness of the Rescue device in restoring flow and achieving optimal tissue perfusion during percutaneous coronary intervention (PCI) in thrombus-laden coronary arteries.

Methods: A total of 30 patients with an acute coronary syndrome underwent PCI using the Rescue device.

Results: The mean age was 65.