Outcome of the HORIZONS-AMI trial: bivalirudin enhances long-term survival in patients with ST-elevation myocardial infarction undergoing angioplasty

Cardiovascular disease is the leading cause of death in the US. For patients with ST-elevation myocardial infarction (STEMI), urgent reperfusion of the culprit arterial occlusion, often achieved via primary percutaneous coronary intervention (PCI), reduces post-MI mortality and other major adverse cardiovascular events (MACE). Adjunctive antithrombotic and antiplatelet therapies are used during PCI to reduce MACE rates. Currently, a variety of antithrombotic options are available for peri-procedural use. The most commonly used agents include unfractionated heparin or low molecular weight heparin ± glycoprotein IIb/IIIa inhibitors (GPI). These agents reduce the rates of peri-procedural ischemic and thrombotic events, though these benefits come at the cost of an increase in bleeding complications. Bivalirudin is a direct thrombin inhibitor with a short half-life and linear pharmacokinetics, which results in predictable serum concentrations and anticoagulant effect. Bivalirudin has emerged as an efficacious and safe alternative to heparin plus GP IIb/IIIa inhibitors in both stable coronary artery disease and acute coronary syndrome patients. In the HORIZONS-AMI trial, monotherapy with bivalirudin was compared with the combination of heparin and a GPI in a large population of patients with STEMI who underwent primary PCI. Bivalirudin treatment was associated with improved event-free survival at 30 days and reduced rates of major bleeding. Based on the results of the trial, the American College of Cardiology/American Heart Association and European Society of Cardiology guidelines have incorporated recommendations for bivalirudin use in the setting of STEMI. Recently, 3-year follow-up data from the HORIZONS-AMI cohort were published, demonstrating sustained benefits in patients treated with bivalirudin, including reduced rates of mortality, cardiovascular mortality, reinfarction, and major bleeding events. These results further support the use of bivalirudin in the setting of primary PCI for STEMI given that its benefits are maintained through long-term follow-up

Nonsystem Reasons for Delay in Door-to-Balloon Time and Associated In-Hospital Mortality A Report From the National Cardiovascular Data Registry

ObjectivesThe goal of this study was to characterize nonsystem reasons for delay in door-to-balloon time (D2BT) and the impact on in-hospital mortality.BackgroundStudies have evaluated predictors of delay in D2BT, highlighting system-related issues and patient demographic characteristics. Limited data exist, however, for nonsystem reasons for delay in D2BT.MethodsWe analyzed nonsystem reasons for delay in D2BT among 82,678 ST-segment elevation myocardial infarction patients who underwent primary percutaneous coronary intervention within 24 h of symptom onset in the CathPCI Registry from January 1, 2009, to June 30, 2011.ResultsNonsystem delays occurred in 14.7% of patients (n = 12,146). Patients with nonsystem delays were more likely to be older, female, African American, and have greater comorbidities. The in-hospital mortality for patients treated without delay was 2.5% versus 15.1% for those with delay (p < 0.01). Nonsystem delay reasons included delays in providing consent (4.4%), difficult vascular access (8.4%), difficulty crossing the lesion (18.8%), “other” (31%), and cardiac arrest/intubation (37.4%). Cardiac arrest/intubation delays had the highest in-hospital mortality (29.9%) despite the shortest time delay (median D2BT: 84 min; 25th to 75th percentile: 64 to 108 min); delays in providing consent had a relatively lower in-hospital mortality rate (9.4%) despite the longest time delay (median D2BT: 100 min; 25th to 75th percentile: 80 to 131 min). Mortality for delays due to difficult vascular access, difficulty crossing a lesion, and other was also higher (8.0%, 5.6%, and 5.9%, respectively) compared with nondelayed patients (p < 0.0001). After adjustment for baseline characteristics, in-hospital mortality remained higher for patients with nonsystem delays.ConclusionsNonsystem reasons for delay in D2BT in ST-segment elevation myocardial infarction patients presenting for primary percutaneous coronary intervention are common and associated with high in-hospital mortality

Status of Early-Career Academic Cardiology, A Global Perspective

Early career academic cardiologists, whom many believe are an important component of the future of cardiovascular care, face a myriad of challenges. The Early Career Section Academic Working Group of the American College of Cardiology (ACC) along with senior leadership support, assessed the progress of this cohort from 2013–2016 with a global perspective. Data consisted of accessing National Heart Lung and Blood Institute (NHLBI) public information, American Heart Association and international organizations providing data, and a membership-wide survey. Although NHBLI increased funding of career development grants, only a small number of early career ACC members have benefited as funding of the entire cohort has decreased. Personal motivation, institutional support, and collaborators continued to be positive influential factors. Surprisingly, mentoring ceased to correlate positively with obtaining external grants. Totality of findings suggests that the status of early career academic cardiologists remain challenging; therefore, we recommend a set of attainable solutions

Efficacy and safety of routine aspiration thrombectomy during primary PCI for ST-segment elevation myocardial infarction: A meta-analysis of large randomized controlled trials

Background: Recent randomized controlled trials (RCTs) have questioned the clinical efficacy and safety of routine aspiration thrombectomy (AT) during primary percutaneous coronary intervention (PCI). A systematic synthesis of these randomized data is hence very timely to address this clinical equipoise. Methods: We performed a meta-analysis of the larger (>150 patients) RCTs that compared AT with only primary PCI. Procedural endpoints were myocardial blush grade (MBG) score of 0 or 1 and ST-segment resolution (STR) >50%. Midterm endpoints were mortality, reinfarction, target vessel revascularization, and stroke >30 days after the procedure. Results: We identified 11 large RCTs, with 10,309 patients randomized to AT and 10,296 to routine strategy (RT). While AT was associated with significantly improved myocardial perfusion, as demonstrated by the MBG score (OR = 0.69; p = 0.010), and improved rates of STR >50% (OR = 1.41; p = 0.006), there were no differences in mortality (OR = 0.89; p = 0.76), reinfarction (OR = 0.9; p = 0.47), target vessel revascularization (TVR; OR = 1.06; p = 0.67), and stroke rates (OR = 1.49; p = 0.29) >30 days after the procedure. Conclusion: Our meta-analysis of 20,605 patients who participated in large RCTs demonstrates improved MBG scores and STR >50% with AT compared with only PCI, but no differences were observed in mortality, reinfarction, TVR, and stroke rates at 30 days. Our study supports the latest ACC/AHA/SCAI focused update document that recommends against the routine use of AT during primary PCI. Keywords: Aspiration thrombectomy, Manual thrombectom