The Use of Novel Oral Anti-Coagulant's (NOAC) compared to Vitamin K Antagonists (Warfarin) in patients with Left Ventricular thrombus after Acute Myocardial Infarction (AMI).

This is a pre-copyedited, author-produced version of an article accepted for publication in European Heart Journal - Cardiovascular Pharmacotherapy following peer review. The version of record: Daniel A Jones, Paul Wright, Momin A Alizadeh, Sadeer Fhadil, Krishnaraj S Rathod, Oliver Guttmann, Charles Knight, Adam Timmis, Andreas Baumbach, Andrew Wragg, Anthony Mathur, Sotiris Antoniou, The Use of Novel Oral Anti-Coagulant’s (NOAC) compared to Vitamin K Antagonists (Warfarin) in patients with Left Ventricular thrombus after Acute Myocardial Infarction (AMI), European Heart Journal - Cardiovascular Pharmacotherapy, pvaa096, https://doi.org/10.1093/ehjcvp/pvaa096AIM: Current guidelines recommend the use of Vitamin K Antagonist (VKA) for up to 3 - 6 months for treatment of LV thrombus post-acute myocardial infarction (AMI). However, based on evidence supporting non-inferiority of Novel Oral Anti-Coagulant's (NOAC) compared to VKA for other indications such as DVT, PE and thrombo-embolic prevention in atrial fibrillation, NOACs are being increasingly used off licence for the treatment of LV thrombus post AMI. In this study we investigated the safety and effect of NOACs compared to VKA on LV thrombus resolution in patients presenting with AMI. METHODS AND RESULTS: This was an observational study of 2,328 consecutive patients undergoing Coronary Angiography +/- Percutaneous Coronary Intervention (PCI) for AMI between May 2015- December 2018, at a UK cardiac centre. Patients' details were collected from the hospital electronic database. The primary end-point was rate of LV thrombus resolution with bleeding rates a secondary outcome.Left ventricular (LV) thrombus was diagnosed in 101 (4.3%) patients. Sixty patients (59.4%) were started on VKA and 41 patients (40.6%) on NOAC therapy (rivaroxaban: 58.5%, apixaban, 36.5% and edoxaban: 5.0%). Both groups were well matched in terms of baseline characteristics including age, previous cardiac history (Previous MI, PCI, CABG), and cardiovascular risk factors (Hypertension, Diabetes, Hypercholesterolaemia).Over the follow up period (median 2.2 years), overall rates of LV thrombus resolution were 86.1%. There was greater and earlier LV thrombus resolution in the NOAC group compared to patients treated with warfarin (82% vs 64.4%, p = 0.0018, at 1 year), which persisted after adjusting for baseline variables (OR 1.8 95% CI 1.2-2.9). Major bleeding events during the f/u period were lower in the NOAC group, compared with VKA group (0% vs 6.7%, p = 0.030) with no difference in rates of systemic thromboembolism (5% vs 2.4%, p = 0.388). CONCLUSION: This data suggests improved thrombus resolution in post ACS LV thrombosis in patients treated with NOACs compared to vitamin K antagonists. This improvement in thrombus resolution was accompanied with a better safety profile for NOAC patients' vs VKA treated patients. Thus, provides data to support a randomised trial to answer this question

UP-TITRATION OF SECONDARY PREVENTION FOLLOWING ACUTE CORONARY SYNDROME (ACS)

Meeting AbstractBritish Cardiovascular So

The Cardioprotective Effect Of Selenium In Myocardial Ischemia Reperfusion Injury

The objective of the current study is to assess the possible cardioprote-ctive effect of selenium in myocardial ischemia reperfusion injury induced by ligation of coronary artery in a male rat model. 24 adult male spraguedawley rats were randomized into 4 equal groups: (1), Sham group, rats underwent the same anesthetic and surgical procedures as the control group except for LAD ligation; (2), Active control group, rats subjected to regional ischemia for 30 min by ligation of LAD coronary artery and reperfusion for 2 hours; (3), Control vehicle group, rats received D.W (vehicle of selenium) via IP route and subjected to ischemia for 30 minutes before ligation of LAD coronary artery & reperfusion for 2 hr; (4), Seleniumtreated group, rats pretreated with selenium5mg/kg via IP injection 30minutes before ligation of  LAD coronary artery & then subjected to reperfusion for 2 hr. In control group, as compared with sham, tissue TNF-α, IL-6, IL-10, caspase-3 and BAX, plasma cTn-T and serum MDA significantly increased (P<0.05), while serum GSH significantly decreased (P<0.05). Histopathologically, control group showed a significant cardiac injury (P<0.05) compared with sham group. Selenium significantly counteracted (P<0.05) the increase of TNF-α, IL-6, caspase-3 and BAX and counteracted the increase in plasma cTn-T and serum MDA. Selenium produces a significant elevation (P<0.05) in cardiac IL-10 and serum GSH with significant reduction in (P<0.05) cardiac injury. In Conclusions, Selenium minimizes myocardial I/R injury in male rats via interfering with inflammatory reactions and apoptosis which were induced by I/R injury

Risk scoring to guide antiplatelet therapy post-percutaneous coronary intervention for acute coronary syndrome results in improved clinical outcomes.

Aims: To use the Global Registry of Acute Coronary Events (GRACE) and Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) scores to risk stratify antiplatelet treatment post-acute coronary syndrome (ACS). Methods and results: This was a prospective registry of 3374 patients undergoing percutaneous coronary intervention for ACS between 2013 and 2015 at a UK cardiac centre. Patients with either low GRACE or high CRUSADE risk scores were stratified either to clopidogrel therapy or ticagrelor was used. The primary endpoint was major adverse cardiac events (MACE) defined as death, non-fatal myocardial infarction, stroke, or target vessel revascularization with bleeding rates as a secondary outcome, assessed at a median follow-up of 1.8 years (interquartile range 0.8-3.4 years). A total of 1723 (51.1%) patients were risk stratified to either clopidogrel (n = 520) or ticagrelor treatment (n = 1203), with the remaining 1651 not risk scored and treated with clopidogrel therapy. Patients in the risk score stratified group were older than the control group otherwise the groups were similar. Over the follow-up period, a significant reduction in MACE rates between the patients' risk score stratified and control (clopidogrel therapy) (13.7% vs. 19.7%, P < 0.0001) was seen [hazard ratio (HR) 0.61, 95% confidence interval (CI) 0.31-0.86]. This persisted after adjusting for baseline variables (HR 0.65, 95% CI 0.37-0.89) and propensity matching (HR = 0.63, 95% CI 0.27-0.93; P = 0.0015) No significant differences in the rate of major bleeding were seen between the groups (5.3% vs. 5.1%, P = 0.86). In the risk-stratified group, no difference in outcome (ischaemic/bleeding) was seen between clopidogrel and ticagrelor. Conclusion: Our registry data suggest that using appropriate risk scoring to guide antiplatelet therapy after ACS is safe and can result in improved clinical outcomes

An exploration of the early discharge approach for low-risk STEMI patients following primary percutaneous coronary intervention.

Recently, there has been growing interest in the early discharge strategy for low-risk patients who have undergone primary percutaneous coronary intervention (PCI) to treat ST-segment elevation myocardial infarction (STEMI). So far findings have suggested there are multiple advantages of shorter hospital stays, including that it could be a safe way to be more cost- and resource-efficient, reduce cases of hospital-acquired infection and boost patient satisfaction. However, there are remaining concerns surrounding safety, patient education, adequate follow-up and the generalisability of the findings from current studies which are mostly small-scale. By assessing the current research, we describe the advantages, disadvantages and challenges of early hospital discharge for STEMI and discuss the factors that determine if a patient can be considered low risk. If it is feasible to safely employ a strategy like this, the implications for healthcare systems worldwide could be extremely beneficial, particularly in lower-income economies and when we consider the detrimental impacts of the recent COVID-19 pandemic on healthcare systems

Early Hospital Discharge Following PCI for Patients With STEMI

Background: 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. Objectives: This study aimed to assess the safety and feasibility of a novel early hospital discharge pathway for low-risk STEMI patients. Methods: 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 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 for >48 hours (>48-hour control group) (mortality, 0.7%; MACE, 1.9%) both in unadjusted and propensity-matched analyses. Conclusions: 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

Early Hospital Discharge Following PCI for Patients With STEMI

Background: 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. Objectives: This study aimed to assess the safety and feasibility of a novel early hospital discharge pathway for low-risk STEMI patients. Methods: 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 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 for >48 hours (>48-hour control group) (mortality, 0.7%; MACE, 1.9%) both in unadjusted and propensity-matched analyses. Conclusions: 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

Velocity distributions of He+, Ne+ and Ar+ in parent gases

10.1088/0022-3700/18/9/023Journal of Physics B: Atomic and Molecular Physics1891897-190