Sam Firoozi | St George's, University of London (original) (raw)

Papers by Sam Firoozi

Clinical science. Supplement (1979), Jul 1, 2002

Circulation-cardiovascular Interventions, Jun 1, 2015

P rimary percutaneous coronary intervention (PPCI) is the preferred reperfusion strategy for acut... more P rimary percutaneous coronary intervention (PPCI) is the preferred reperfusion strategy for acute ST-segmentelevation myocardial infarction (STEMI) 1 and should be available at all hours. 2 It is widely recognized that there are variations in healthcare provision during night and day and that resources, including availability of medical personnel, are limited during out of working hours (OWH), particularly at night. 3,4 There are conflicting data on outcomes after PPCI performed during Background-Primary percutaneous coronary intervention (PPCI) is the treatment of choice for ST-segment-elevation myocardial infarction. Resources are limited during out of working hours (OWH). Whether PPCI outside working hours is associated with worse outcomes and whether outcomes have improved over time are unknown. Methods and Results-We analyzed 11 466 patients undergoing PPCI between 2004 and 2011 at all 8 tertiary cardiac centers in London, United Kingdom. We defined working hours as 9 am to 5 pm (Monday to Friday). We analyzed in-hospital bleeding and all-cause mortality ≤3 years, comparing OWH versus in-working hours. A total of 7494 patients (65.3%) were treated during OWH. Multivariable analyses demonstrated that PPCI during OWH was not a predictor for bleeding (odds ratio, 1.47; 95% confidence interval [CI], 0.97-2.24; P=0.071) or 3-year mortality (hazard ratio, 1.11; 95% CI, 0.94-1.32; P=0.20). This was confirmed in propensity-matched analyses. Time-stratified analyses demonstrated that PPCI during OWH was a predictor for bleeding (odds ratio, 2.00; 95% CI, 1.06-3.80; P=0.034) and 3-year mortality during 2005 to 2008 (hazard ratio, 1.23; 95% CI, 1.00-1.50; P=0.050), but this association was lost during 2009 to 2011. During 2005 to 2008, transradial access was predominantly used during in-working hours and PPCI during OWH was predictive of reduced transradial access use (odds ratio, 0.83; 95% CI, 0.71-0.98; P=0.033), but this association was lost during 2009 to 2011. Conclusions-In this study of unselected patients with ST-segment-elevation myocardial infarction, PPCI during OWH versus in-working hours had comparable bleeding and mortality. Time-stratified analyses demonstrated a reduction in adjusted bleeding and mortality during OWH over time. This may reflect the improved service provision, but the increased adoption of transradial access during OWH may also be contributory.

Background: Outcome following ST-segment elevation myocardial infarction (STEMI) is thought to be... more Background: Outcome following ST-segment elevation myocardial infarction (STEMI) is thought to be worse in women than in age-matched men. We assessed whether such differences occur in the UK Pan-London dataset and if age, and particularly menopause, influences upon outcome. Methods: We undertook an observational cohort study of 26,799 STEMI patients (20,633 men, 6,166 women) between 2005-2015 at 8 centres across London, UK. Patient details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society (BCIS) PCI dataset. Primary outcome was all-cause mortality at a median follow-up of 4.1 years (IQR: 2.2-5.8 years). Results: Kaplan-Meier analysis demonstrated a higher mortality rate in women versus men (15.6% men vs. 25.3% women, P<0.0001). Univariate Cox analysis revealed that female sex was a predictor of all-cause mortality (HR: 1.69 95% CI: 1.59-1.82). However, after multivariate adjustment, this effect of female sex diminished (HR: 1.05 95% CI: 0.90-1.25). In a subgroup analysis, we compared the sexes separated by age into the ≤55 and the >55 year olds. Age-stratified Cox analysis revealed that female sex was a univariate predictor of all-cause mortality (HR: 1.60 95% CI: 1.25-2.05) in the ≤55 group and in the >55 group (HR: 1.38 95% CI: 1.28-1.47). However, after regression adjustment incorporating the propensity score into a proportional hazard model as a covariate, whilst female sex was not a significant predictor of all-cause mortality in the ≤55 group it was a predictor in the >55 group. Moreover, whilst age did not influence outcome in <55 group, this effect in the >55 group was correlated with age. Conclusions: Overall women have a worse all-cause mortality following primary PCI for STEMI compared to men. However, this effect was driven predominantly by women >55 years of age since after adjusting for co-morbidities the risk in younger women did not differ significantly from that in men. These observations support the view that as women advance past the menopausal years their risk of further events following revascularization increases substantially and we suggest that routine assessment of hormonal status may improve clinical decision-making and ultimately outcome for women post-PCI.

Cardiovascular Revascularization Medicine, Mar 1, 2020

European heart journal. Acute cardiovascular care, Dec 1, 2020

Background and aims: In patients with ST-segment elevation myocardial infarction (STEMI), mortali... more Background and aims: In patients with ST-segment elevation myocardial infarction (STEMI), mortality is directly related to time to reperfusion with guidelines recommending patients be delivered directly to centres for primary percutaneous coronary intervention (PCI). The aim of this study was to describe the impact of inter-hospital transfer on reperfusion time and to assess whether or not treatment delays influenced clinical outcomes in comparison with direct admission to a primary PCI centre in a large regional network. Method and results: We undertook an observational cohort study of patients with STEMI treated with primary PCI between 2005 and 2015 in London, UK. Patient details were recorded at the time of the procedure in databases using the British Cardiovascular Intervention Society PCI dataset. The primary end-point was all-cause mortality at a median of 4.1 years (interquartile range: 2.2-5.8 years). Secondary outcomes were in-hospital major adverse cardiac events. Of 25,315 patients, 17,560 (69.4%) were admitted directly to a primary PCI centre and 7755 (31.6%) were transferred from a non-primary PCI centre. Patients in the direct admission group were older and more likely to have left ventricular impairment compared with the inter-hospital transfer group. Median time from call for help to reperfusion in transferred patients was 52 minutes longer compared with patients admitted directly (p <0.001). However, call to first hospital admission was similar. Kaplan-Meier analysis demonstrated significantly lower mortality rates in patients who were transferred directed to a primary PCI centre compared with patients who were transferred from a non-PCI centre (17.4% direct vs. 18.7% transfer, p=0.017). Furthermore, after propensity matching, direct admission for primary PCI was still a predictor of all-cause mortality (hazard ratio: 0.89, 95% confidence interval: 0.64-0.95). Conclusions: In this large registry of over 25,000 STEMI patients treated by primary PCI survival was better in patients admitted directly to a cardiac centre versus patients transferred for primary PCI, most likely due to longer call to balloon times in patient transferred from other hospitals.

Journal of the American Heart Association, Jun 16, 2020

BACKGROUND: Limited information exists regarding procedural success and clinical outcomes in pati... more BACKGROUND: Limited information exists regarding procedural success and clinical outcomes in patients with previous coronary artery bypass grafting (CABG) undergoing percutaneous coronary intervention (PCI). We sought to compare outcomes in patients undergoing PCI with or without CABG. METHODS AND RESULTS: This was an observational cohort study of 123 780 consecutive PCI procedures from the Pan-London (UK) PCI registry from 2005 to 2015. The primary end point was all-cause mortality at a median follow-up of 3.0 years (interquartile range, 1.2-4.6 years). A total of 12 641(10.2%) patients had a history of previous CABG, of whom 29.3% (n=3703) underwent PCI to native vessels and 70.7% (n=8938) to bypass grafts. There were significant differences in the demographic, clinical, and procedural characteristics of these groups. The risk of mortality during follow-up was significantly higher in patients with prior CABG (23.2%; P=0.0005) compared with patients with no prior CABG (12.1%) and was seen for patients who underwent either native vessel (20.1%) or bypass graft PCI (24.2%; P<0.0001). However, after adjustment for baseline characteristics, there was no significant difference in outcomes seen between the groups when PCI was performed in native vessels in patients with previous CABG (hazard ratio [HR],1.02; 95%CI, 0.77-1.34; P=0.89), but a significantly higher mortality was seen among patients with PCI to bypass grafts (HR,1.33; 95% CI, 1.03-1.71; P=0.026). This was seen after multivariate adjustment and propensity matching. CONCLUSIONS: Patients with prior CABG were older with greater comorbidities and more complex procedural characteristics, but after adjustment for these differences, the clinical outcomes were similar to the patients undergoing PCI without prior CABG. In these patients, native-vessel PCI was associated with better outcomes compared with the treatment of vein grafts.

Journal of the American College of Cardiology, Oct 1, 2013

Background: The aim was to compare treatment and clinical outcomes of cardiogenic shock (CS) AMI ... more Background: The aim was to compare treatment and clinical outcomes of cardiogenic shock (CS) AMI patients with and without severe renal dysfunction (SRD) on admission. Methods: We analyzed 676 patients with CS and AMI from PL-ACS registry. Follow-up mortality was obtained from the government database. Results: Patients with SRD comprised 16% of CS AMI pts. They were of higher risk profile and were less frequently treated invasively (table). Early and 2-year mortalities are show in the table and figure. Conclusions: Invasive treatment reduces mortality in patients with cardiogenic shock and severe renal dysfunction, however only less than 5% of SRD patients is alive after 2 years.

Open heart, Oct 1, 2020

Objectives To understand the impact of COVID-19 on delivery and outcomes of primary percutaneous ... more Objectives To understand the impact of COVID-19 on delivery and outcomes of primary percutaneous coronary intervention (PPCI). Furthermore, to compare clinical presentation and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) with active COVID-19 against those without COVID-19. Methods We systematically analysed 348 STEMI cases presenting to the PPCI programme in London during the peak of the pandemic (1 March to 30 April 2020) and compared with 440 cases from the same period in 2019. Outcomes of interest included ambulance response times, timeliness of revascularisation, angiographic and procedural characteristics, and in-hospital clinical outcomes Results There was a 21% reduction in STEMI admissions and longer ambulance response times (87 (62-118) min in 2020 vs 75 (57-95) min in 2019, p<0.001), but that this was not associated with a delays in achieving revascularisation once in hospital (48 (34-65) min in 2020 vs 48 (35-70) min in 2019, p=0.35) or increased mortality (10.9% (38) in 2020 vs 8.6% (38) in 2019, p=0.28). 46 patients with active COVID-19 were more thrombotic and more likely to have intensive care unit admissions (32.6% (15) vs 9.3% (28), OR 5.74 (95%CI 2.24 to 9.89), p<0.001). They also had increased length of stay (4 (3-9) days vs 3 (2-4) days, p<0.001) and a higher mortality (21.7% (10) vs 9.3% (28), OR 2.72 (95% CI 1.25 to 5.82), p=0.012) compared with patients having PPCI without COVID-19. Conclusion These findings suggest that PPCI pathways can be maintained during unprecedented healthcare emergencies but confirms the high mortality of STEMI in the context of concomitant COVID-19 infection characterised by a heightened state of thrombogenicity.

Circulation-cardiovascular Quality and Outcomes, Nov 1, 2014

I n patients presenting with ST-segment-elevation myocardial infarction (STEMI), primary percutan... more I n patients presenting with ST-segment-elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PPCI) is associated with improved clinical outcomes. 1,2 It is estimated that 40% to 65% of patients presenting with STEMI have bystander disease seen at the time of PPCI. 3,4 In this setting, the presence of multivessel disease Background-It is estimated that up to two thirds of patients presenting with ST-segment-elevation myocardial infarction have multivessel disease. The optimal strategy for treating nonculprit disease is currently under debate. This study provides a real-world analysis comparing a strategy of culprit-vessel intervention (CVI) versus multivessel intervention at the time of primary percutaneous coronary intervention in patients with ST-segment-elevation myocardial infarction. Methods and Results-We compared CVI versus multivessel intervention in 3984 patients with multivessel disease undergoing primary percutaneous coronary intervention between 2004 and 2011 at all 8 tertiary cardiac centers in London. Multivariable-adjusted models were built to determine independent predictors for in-hospital major adverse cardiovascular events (MACEs) and all-cause mortality at 1 year. To reduce confounding and bias, propensity score methods were used. CVI was associated with reduced in-hospital MACE (4.6% versus 7.2%; P=0.010) and mortality at 1 year (7.4% versus 10.1%; P=0.031). CVI was an independent predictor for reduced in-hospital MACE (odds ratio, 0.49; 95% confidence interval [CI], 0.32-0.75; P<0.001) and survival at 1 year (hazard ratio, 0.65; 95% CI, 0.47-0.91; P=0.011) in the complete cohort; and in 2821 patients in propensity-matched cohort (in-hospital MACE: odds ratio, 0.49; 95% CI, 0.32-0.76; P=0.002; and 1-year survival: hazard ratio, 0.64; 95% CI, 0.45-0.90; P=0.010). Inverse probability treatment weighted analyses also confirmed CVI as an independent predictor for reduced in-hospital MACE (odds ratio, 0.38; 95% CI, 0.15-0.96; P=0.040) and survival at 1 year (hazard ratio, 0.44; 95% CI, 0.21-0.93; P=0.033). Conclusions-In this observational analysis of patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention, CVI was associated with increased survival at 1 year. Acknowledging the limitations with observational analyses, our findings support current recommended practice guidelines. (Circ Cardiovasc Qual Outcomes. 2014;7:936-943.

Journal of the American College of Cardiology, Sep 1, 2014

all patients were obtained; adverse events were externally adjudicated by an independent committe... more all patients were obtained; adverse events were externally adjudicated by an independent committee. The primary endpoint was target vessel failure (TVF) at 1-year, a composite of cardiac death, target vessel related MI, and clinically indicated target vessel revascularization. Secondary endpoints included all the individual components of the primary endpoint, the incidence of stent thrombosis (ST), and the patient-oriented clinical endpoint (POCE). Results: Patient and lesion characteristics did not differ between groups with the only exception being higher proportions of severely calcified lesions (87/548(16%) vs. 108/ 500(22%), p¼0.02) and stent postdilatation in EES (402/548 (73%) vs. 400/500 (80%), p¼0.01). At one year, TVF did not differ significantly between the two stent arms (20/421(5%) vs. 15/396 (4%, p¼0.50). In addition, POCE was 8% (32/421) for ZES and 6% (23/396) for EES (p¼0.31). Definite-or-probable ST rates were very low and similar in both groups (2/421 (0.5%) vs. 1/396 (0.3%), p¼1.00). Conclusions: One-year follow-up of DUTCH PEERS patients, who were treated for acute MI, demonstrated excellent clinical results with a similar and sustained safety and efficacy of the Resolute Integrity ZES and the Promus Element EES.

Journal of the American College of Cardiology, Apr 1, 2014

background: In primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocard... more background: In primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI), the relative safety of drug-eluting stents (DES) versus bare metal stents (BMS) continues to be debated. Whilst DES use is associated with reduced target lesion revascularization rates, stent thrombosis continues to be a major concern. We compared the effect of DES vs. BMS on 1-year mortality in patients with STEMI undergoing primary PCI. methods: We conducted an observational analysis for patients with STEMI who underwent PPCI between 2004-2011 at all 8 tertiary cardiac centres in London, UK. The primary outcome was all-cause mortality at 1 year. We used 4 analytic methods to adjust for selection bias: multivariate Cox proportional hazards regression; propensity-based matching; inverse probability weighted analysis and instrumental variable analysis. results: Of the 10,803 patients in the analysis, 4239 patients (39%) received DES and 6564 patients received BMS (61%). The following DES were used: paclitaxel-eluting stent (PES), 16.5%; sirolimus-eluting stent (SES), 26.4%; everolimus-eluting stent (EES), 19.9%; zotaralimus-eluting stent (ZES), 21.8%; or other stent, 19.5%. 1-year mortality was similar between both groups (BMS vs. DES: 7.9% vs. 7.6%, p=0.630). Multivariate analyses demonstrated that DES use did not affect mortality (HR=0.99, 95% CI:0.82-1.20, p=0.991). This was confirmed in propensity-matched cohorts with 5506 patients (HR=0.95, 95% CI:0.76-1.19, p=0.667) and inverse probability weighted analyses (HR=1.08 , 95% CI: 0.85-1.36, p=0.533). Using enrollment year as an instrumental variable, DES use did not affect mortality (absolute difference=-0.26, 95% CI:-4.08,3.57, p=0.896). Propensitymatched analyses demonstrated no difference in mortality when comparing the different DES with BMS:

Journal of the American College of Cardiology, Oct 1, 2013

Background: Rotational atherectomy (RA) facilitates delivery of stents in calcific lesions. Calci... more Background: Rotational atherectomy (RA) facilitates delivery of stents in calcific lesions. Calcified coronary lesions are an established risk factor for long-term failure after both bare metal stents (BMS) and drug-eluting stent (DES) implantation. Whilst DES use following RA may result in high procedural success and acceptable restenosis rates, there is limited data on their long-term efficacy and prognostic benefit when used with RA. Methods: We examined an observational cohort of 661 consecutive patients treated with RA between 2005-2011 at 8 tertiary cardiac centers across London, UK. Multivariate Cox-proportional hazards models using forward stepwise variable selection were used to determine independent predictors of mortality. Results: 209 patients (32%) were treated with BMS and 452 patients (68%) were with DES. Patients in the BMS group were older (75.5y vs. 73.2y, p¼0.002). The female:male ratio; presence of cardiogenic shock; presence of diabetes; previous PCI and CABG was similar between both groups. A greater proportion of patients in the BMS group had ACS. GP 2b-3a inhibitor use was greater in the BMS group. The length of stented segment was greater in the DES group (24mm vs.28mm, p<0.001). Multivariate analysis identified the use of DES as an independent predictor of 1-year mortality (HR¼0.45, 95% CI: 0.26-0.78, p¼0.005) and 3-year mortality (HR¼0.64, 95% CI: 0.42-0.98, p¼0.041). Conclusions: This study represents the largest reported dataset of patients treated with RA in the DES era with long-term follow-up. The use of DES following RA appears to be associated with reduced long-term mortality.

European Heart Journal, Apr 10, 2019

Aims The public reporting of healthcare outcomes has a number of potential benefits; however, uni... more Aims The public reporting of healthcare outcomes has a number of potential benefits; however, unintended consequences may limit its effectiveness as a quality improvement process. We aimed to assess whether the introduction of individual operator specific outcome reporting after percutaneous coronary intervention (PCI) in the UK was associated with a change in patient risk factor profiles, procedural management, or 30-day mortality outcomes in a large cohort of consecutive patients.

European Heart Journal, Oct 1, 2019

European Heart Journal, Aug 1, 2018

PCI group and CABG group (27.9% vs.25.3%, log-rank p=0.363, adjusted hazard ratio (HR): 0.891 [95... more PCI group and CABG group (27.9% vs.25.3%, log-rank p=0.363, adjusted hazard ratio (HR): 0.891 [95% confidence interval (CI): 0.694-1.143, p=0.365]). The adjusted risks for all-cause death were not significantly different between the 2 groups (p=0.347). Target vessel revascularization in PCI was significantly higher than in CABG (p<0.001), but stroke was lower in PCI than CABG (p=0.048). Figure 1. Cumulative rates of MACCE betwe Conclusion: In patients with ULMCAD, PCI was noninferior to CABG for the long term outcome. There was no significant difference between-group difference in the incidence of MACCE. In patients with ULMCAD, PCI was similar to CABG for the long term outcome. There was higher TVR rates in PCI group and higher stroke rates in CABG patients.

Journal of the American College of Cardiology, Apr 1, 2014

background: Current guidelines discourage percutaneous coronary intervention (PCI) of non-infarct... more background: Current guidelines discourage percutaneous coronary intervention (PCI) of non-infarct-related arteries at the time of primary PCI in patients with ST-elevation myocardial infarction (STEMI) without cardiogenic shock. The optimal strategy for treating non-culprit disease is currently under debate. methods: We conducted an observational analysis comparing culprit vessel intervention (CVI) versus multivessel intervention (MVI) in patients who had primary PCI between 2004-2011 at all 8 tertiary cardiac centres in London. Patients with cardiogenic shock and bystander left main-stem disease (>50% stenosis) were excluded. Cox proportional hazard models were built to determine independent predictors for all-cause mortality. A propensity-matched analysis was performed on patients with multivessel disease (defined as stenosis >50% in ≥2 epicardial coronary arteries). results: Of the 9377 patients included in the analysis, 8755 patients (93%) had CVI and 622 patients (7%) had MVI. CVI was as an independent predictor for survival at 1 year in the full patient cohort (HR=0.61, 95% CI:0.45-0.82, p=0.001); in 3984 patients with multivessel disease (HR=0.65, 95% CI:0.47-0.91, p=0.011); and in 734 patients in propensity-matched cohorts (HR=0.52, 95% CI:0.23-0.95, p=0.034). Conclusions: In this observational analysis of patients with STEMI undergoing primary PCI, CVI was independently associated with reduced 1-year mortality. Our findings support current recommended practice guidelines.

European Heart Journal, 2003

The patent foramen ovale (PFO) is a very common anatomical variant of the interatrial septum and ... more The patent foramen ovale (PFO) is a very common anatomical variant of the interatrial septum and is associated with a number of paradoxical embolism syndromes including cryptogenic stroke, decompression illness in divers and migraine with visual aura. There is a particularly strong association between cryptogenic stroke and PFO in young individuals and the association is particularly strong in the presence of both a PFO and an atrial septal aneurysm. Catheter closure of a PFO was introduced in the early 1990s and has developed considerably as a safe and effective treatment, such that surgical closure of a PFO is a near obsolete procedure. With new techniques in imaging, such as intra-cardiac echocardiography, a large proportion of percutaneous PFO closure procedures are carried out as day cases under local anaesthesia. Perhaps the most challenging aspect in the management of patients with PFO remains the selection of target populations for percutaneous device closure. At present, th...

Journal of the American College of Cardiology, 2015

Clinical science. Supplement (1979), Jul 1, 2002

Circulation-cardiovascular Interventions, Jun 1, 2015

P rimary percutaneous coronary intervention (PPCI) is the preferred reperfusion strategy for acut... more P rimary percutaneous coronary intervention (PPCI) is the preferred reperfusion strategy for acute ST-segmentelevation myocardial infarction (STEMI) 1 and should be available at all hours. 2 It is widely recognized that there are variations in healthcare provision during night and day and that resources, including availability of medical personnel, are limited during out of working hours (OWH), particularly at night. 3,4 There are conflicting data on outcomes after PPCI performed during Background-Primary percutaneous coronary intervention (PPCI) is the treatment of choice for ST-segment-elevation myocardial infarction. Resources are limited during out of working hours (OWH). Whether PPCI outside working hours is associated with worse outcomes and whether outcomes have improved over time are unknown. Methods and Results-We analyzed 11 466 patients undergoing PPCI between 2004 and 2011 at all 8 tertiary cardiac centers in London, United Kingdom. We defined working hours as 9 am to 5 pm (Monday to Friday). We analyzed in-hospital bleeding and all-cause mortality ≤3 years, comparing OWH versus in-working hours. A total of 7494 patients (65.3%) were treated during OWH. Multivariable analyses demonstrated that PPCI during OWH was not a predictor for bleeding (odds ratio, 1.47; 95% confidence interval [CI], 0.97-2.24; P=0.071) or 3-year mortality (hazard ratio, 1.11; 95% CI, 0.94-1.32; P=0.20). This was confirmed in propensity-matched analyses. Time-stratified analyses demonstrated that PPCI during OWH was a predictor for bleeding (odds ratio, 2.00; 95% CI, 1.06-3.80; P=0.034) and 3-year mortality during 2005 to 2008 (hazard ratio, 1.23; 95% CI, 1.00-1.50; P=0.050), but this association was lost during 2009 to 2011. During 2005 to 2008, transradial access was predominantly used during in-working hours and PPCI during OWH was predictive of reduced transradial access use (odds ratio, 0.83; 95% CI, 0.71-0.98; P=0.033), but this association was lost during 2009 to 2011. Conclusions-In this study of unselected patients with ST-segment-elevation myocardial infarction, PPCI during OWH versus in-working hours had comparable bleeding and mortality. Time-stratified analyses demonstrated a reduction in adjusted bleeding and mortality during OWH over time. This may reflect the improved service provision, but the increased adoption of transradial access during OWH may also be contributory.

Background: Outcome following ST-segment elevation myocardial infarction (STEMI) is thought to be... more Background: Outcome following ST-segment elevation myocardial infarction (STEMI) is thought to be worse in women than in age-matched men. We assessed whether such differences occur in the UK Pan-London dataset and if age, and particularly menopause, influences upon outcome. Methods: We undertook an observational cohort study of 26,799 STEMI patients (20,633 men, 6,166 women) between 2005-2015 at 8 centres across London, UK. Patient details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society (BCIS) PCI dataset. Primary outcome was all-cause mortality at a median follow-up of 4.1 years (IQR: 2.2-5.8 years). Results: Kaplan-Meier analysis demonstrated a higher mortality rate in women versus men (15.6% men vs. 25.3% women, P<0.0001). Univariate Cox analysis revealed that female sex was a predictor of all-cause mortality (HR: 1.69 95% CI: 1.59-1.82). However, after multivariate adjustment, this effect of female sex diminished (HR: 1.05 95% CI: 0.90-1.25). In a subgroup analysis, we compared the sexes separated by age into the ≤55 and the >55 year olds. Age-stratified Cox analysis revealed that female sex was a univariate predictor of all-cause mortality (HR: 1.60 95% CI: 1.25-2.05) in the ≤55 group and in the >55 group (HR: 1.38 95% CI: 1.28-1.47). However, after regression adjustment incorporating the propensity score into a proportional hazard model as a covariate, whilst female sex was not a significant predictor of all-cause mortality in the ≤55 group it was a predictor in the >55 group. Moreover, whilst age did not influence outcome in <55 group, this effect in the >55 group was correlated with age. Conclusions: Overall women have a worse all-cause mortality following primary PCI for STEMI compared to men. However, this effect was driven predominantly by women >55 years of age since after adjusting for co-morbidities the risk in younger women did not differ significantly from that in men. These observations support the view that as women advance past the menopausal years their risk of further events following revascularization increases substantially and we suggest that routine assessment of hormonal status may improve clinical decision-making and ultimately outcome for women post-PCI.

Cardiovascular Revascularization Medicine, Mar 1, 2020

European heart journal. Acute cardiovascular care, Dec 1, 2020

Background and aims: In patients with ST-segment elevation myocardial infarction (STEMI), mortali... more Background and aims: In patients with ST-segment elevation myocardial infarction (STEMI), mortality is directly related to time to reperfusion with guidelines recommending patients be delivered directly to centres for primary percutaneous coronary intervention (PCI). The aim of this study was to describe the impact of inter-hospital transfer on reperfusion time and to assess whether or not treatment delays influenced clinical outcomes in comparison with direct admission to a primary PCI centre in a large regional network. Method and results: We undertook an observational cohort study of patients with STEMI treated with primary PCI between 2005 and 2015 in London, UK. Patient details were recorded at the time of the procedure in databases using the British Cardiovascular Intervention Society PCI dataset. The primary end-point was all-cause mortality at a median of 4.1 years (interquartile range: 2.2-5.8 years). Secondary outcomes were in-hospital major adverse cardiac events. Of 25,315 patients, 17,560 (69.4%) were admitted directly to a primary PCI centre and 7755 (31.6%) were transferred from a non-primary PCI centre. Patients in the direct admission group were older and more likely to have left ventricular impairment compared with the inter-hospital transfer group. Median time from call for help to reperfusion in transferred patients was 52 minutes longer compared with patients admitted directly (p <0.001). However, call to first hospital admission was similar. Kaplan-Meier analysis demonstrated significantly lower mortality rates in patients who were transferred directed to a primary PCI centre compared with patients who were transferred from a non-PCI centre (17.4% direct vs. 18.7% transfer, p=0.017). Furthermore, after propensity matching, direct admission for primary PCI was still a predictor of all-cause mortality (hazard ratio: 0.89, 95% confidence interval: 0.64-0.95). Conclusions: In this large registry of over 25,000 STEMI patients treated by primary PCI survival was better in patients admitted directly to a cardiac centre versus patients transferred for primary PCI, most likely due to longer call to balloon times in patient transferred from other hospitals.

Journal of the American Heart Association, Jun 16, 2020

BACKGROUND: Limited information exists regarding procedural success and clinical outcomes in pati... more BACKGROUND: Limited information exists regarding procedural success and clinical outcomes in patients with previous coronary artery bypass grafting (CABG) undergoing percutaneous coronary intervention (PCI). We sought to compare outcomes in patients undergoing PCI with or without CABG. METHODS AND RESULTS: This was an observational cohort study of 123 780 consecutive PCI procedures from the Pan-London (UK) PCI registry from 2005 to 2015. The primary end point was all-cause mortality at a median follow-up of 3.0 years (interquartile range, 1.2-4.6 years). A total of 12 641(10.2%) patients had a history of previous CABG, of whom 29.3% (n=3703) underwent PCI to native vessels and 70.7% (n=8938) to bypass grafts. There were significant differences in the demographic, clinical, and procedural characteristics of these groups. The risk of mortality during follow-up was significantly higher in patients with prior CABG (23.2%; P=0.0005) compared with patients with no prior CABG (12.1%) and was seen for patients who underwent either native vessel (20.1%) or bypass graft PCI (24.2%; P<0.0001). However, after adjustment for baseline characteristics, there was no significant difference in outcomes seen between the groups when PCI was performed in native vessels in patients with previous CABG (hazard ratio [HR],1.02; 95%CI, 0.77-1.34; P=0.89), but a significantly higher mortality was seen among patients with PCI to bypass grafts (HR,1.33; 95% CI, 1.03-1.71; P=0.026). This was seen after multivariate adjustment and propensity matching. CONCLUSIONS: Patients with prior CABG were older with greater comorbidities and more complex procedural characteristics, but after adjustment for these differences, the clinical outcomes were similar to the patients undergoing PCI without prior CABG. In these patients, native-vessel PCI was associated with better outcomes compared with the treatment of vein grafts.

Journal of the American College of Cardiology, Oct 1, 2013

Background: The aim was to compare treatment and clinical outcomes of cardiogenic shock (CS) AMI ... more Background: The aim was to compare treatment and clinical outcomes of cardiogenic shock (CS) AMI patients with and without severe renal dysfunction (SRD) on admission. Methods: We analyzed 676 patients with CS and AMI from PL-ACS registry. Follow-up mortality was obtained from the government database. Results: Patients with SRD comprised 16% of CS AMI pts. They were of higher risk profile and were less frequently treated invasively (table). Early and 2-year mortalities are show in the table and figure. Conclusions: Invasive treatment reduces mortality in patients with cardiogenic shock and severe renal dysfunction, however only less than 5% of SRD patients is alive after 2 years.

Open heart, Oct 1, 2020

Objectives To understand the impact of COVID-19 on delivery and outcomes of primary percutaneous ... more Objectives To understand the impact of COVID-19 on delivery and outcomes of primary percutaneous coronary intervention (PPCI). Furthermore, to compare clinical presentation and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) with active COVID-19 against those without COVID-19. Methods We systematically analysed 348 STEMI cases presenting to the PPCI programme in London during the peak of the pandemic (1 March to 30 April 2020) and compared with 440 cases from the same period in 2019. Outcomes of interest included ambulance response times, timeliness of revascularisation, angiographic and procedural characteristics, and in-hospital clinical outcomes Results There was a 21% reduction in STEMI admissions and longer ambulance response times (87 (62-118) min in 2020 vs 75 (57-95) min in 2019, p<0.001), but that this was not associated with a delays in achieving revascularisation once in hospital (48 (34-65) min in 2020 vs 48 (35-70) min in 2019, p=0.35) or increased mortality (10.9% (38) in 2020 vs 8.6% (38) in 2019, p=0.28). 46 patients with active COVID-19 were more thrombotic and more likely to have intensive care unit admissions (32.6% (15) vs 9.3% (28), OR 5.74 (95%CI 2.24 to 9.89), p<0.001). They also had increased length of stay (4 (3-9) days vs 3 (2-4) days, p<0.001) and a higher mortality (21.7% (10) vs 9.3% (28), OR 2.72 (95% CI 1.25 to 5.82), p=0.012) compared with patients having PPCI without COVID-19. Conclusion These findings suggest that PPCI pathways can be maintained during unprecedented healthcare emergencies but confirms the high mortality of STEMI in the context of concomitant COVID-19 infection characterised by a heightened state of thrombogenicity.

Circulation-cardiovascular Quality and Outcomes, Nov 1, 2014

I n patients presenting with ST-segment-elevation myocardial infarction (STEMI), primary percutan... more I n patients presenting with ST-segment-elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PPCI) is associated with improved clinical outcomes. 1,2 It is estimated that 40% to 65% of patients presenting with STEMI have bystander disease seen at the time of PPCI. 3,4 In this setting, the presence of multivessel disease Background-It is estimated that up to two thirds of patients presenting with ST-segment-elevation myocardial infarction have multivessel disease. The optimal strategy for treating nonculprit disease is currently under debate. This study provides a real-world analysis comparing a strategy of culprit-vessel intervention (CVI) versus multivessel intervention at the time of primary percutaneous coronary intervention in patients with ST-segment-elevation myocardial infarction. Methods and Results-We compared CVI versus multivessel intervention in 3984 patients with multivessel disease undergoing primary percutaneous coronary intervention between 2004 and 2011 at all 8 tertiary cardiac centers in London. Multivariable-adjusted models were built to determine independent predictors for in-hospital major adverse cardiovascular events (MACEs) and all-cause mortality at 1 year. To reduce confounding and bias, propensity score methods were used. CVI was associated with reduced in-hospital MACE (4.6% versus 7.2%; P=0.010) and mortality at 1 year (7.4% versus 10.1%; P=0.031). CVI was an independent predictor for reduced in-hospital MACE (odds ratio, 0.49; 95% confidence interval [CI], 0.32-0.75; P<0.001) and survival at 1 year (hazard ratio, 0.65; 95% CI, 0.47-0.91; P=0.011) in the complete cohort; and in 2821 patients in propensity-matched cohort (in-hospital MACE: odds ratio, 0.49; 95% CI, 0.32-0.76; P=0.002; and 1-year survival: hazard ratio, 0.64; 95% CI, 0.45-0.90; P=0.010). Inverse probability treatment weighted analyses also confirmed CVI as an independent predictor for reduced in-hospital MACE (odds ratio, 0.38; 95% CI, 0.15-0.96; P=0.040) and survival at 1 year (hazard ratio, 0.44; 95% CI, 0.21-0.93; P=0.033). Conclusions-In this observational analysis of patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention, CVI was associated with increased survival at 1 year. Acknowledging the limitations with observational analyses, our findings support current recommended practice guidelines. (Circ Cardiovasc Qual Outcomes. 2014;7:936-943.

Journal of the American College of Cardiology, Sep 1, 2014

all patients were obtained; adverse events were externally adjudicated by an independent committe... more all patients were obtained; adverse events were externally adjudicated by an independent committee. The primary endpoint was target vessel failure (TVF) at 1-year, a composite of cardiac death, target vessel related MI, and clinically indicated target vessel revascularization. Secondary endpoints included all the individual components of the primary endpoint, the incidence of stent thrombosis (ST), and the patient-oriented clinical endpoint (POCE). Results: Patient and lesion characteristics did not differ between groups with the only exception being higher proportions of severely calcified lesions (87/548(16%) vs. 108/ 500(22%), p¼0.02) and stent postdilatation in EES (402/548 (73%) vs. 400/500 (80%), p¼0.01). At one year, TVF did not differ significantly between the two stent arms (20/421(5%) vs. 15/396 (4%, p¼0.50). In addition, POCE was 8% (32/421) for ZES and 6% (23/396) for EES (p¼0.31). Definite-or-probable ST rates were very low and similar in both groups (2/421 (0.5%) vs. 1/396 (0.3%), p¼1.00). Conclusions: One-year follow-up of DUTCH PEERS patients, who were treated for acute MI, demonstrated excellent clinical results with a similar and sustained safety and efficacy of the Resolute Integrity ZES and the Promus Element EES.

Journal of the American College of Cardiology, Apr 1, 2014

background: In primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocard... more background: In primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI), the relative safety of drug-eluting stents (DES) versus bare metal stents (BMS) continues to be debated. Whilst DES use is associated with reduced target lesion revascularization rates, stent thrombosis continues to be a major concern. We compared the effect of DES vs. BMS on 1-year mortality in patients with STEMI undergoing primary PCI. methods: We conducted an observational analysis for patients with STEMI who underwent PPCI between 2004-2011 at all 8 tertiary cardiac centres in London, UK. The primary outcome was all-cause mortality at 1 year. We used 4 analytic methods to adjust for selection bias: multivariate Cox proportional hazards regression; propensity-based matching; inverse probability weighted analysis and instrumental variable analysis. results: Of the 10,803 patients in the analysis, 4239 patients (39%) received DES and 6564 patients received BMS (61%). The following DES were used: paclitaxel-eluting stent (PES), 16.5%; sirolimus-eluting stent (SES), 26.4%; everolimus-eluting stent (EES), 19.9%; zotaralimus-eluting stent (ZES), 21.8%; or other stent, 19.5%. 1-year mortality was similar between both groups (BMS vs. DES: 7.9% vs. 7.6%, p=0.630). Multivariate analyses demonstrated that DES use did not affect mortality (HR=0.99, 95% CI:0.82-1.20, p=0.991). This was confirmed in propensity-matched cohorts with 5506 patients (HR=0.95, 95% CI:0.76-1.19, p=0.667) and inverse probability weighted analyses (HR=1.08 , 95% CI: 0.85-1.36, p=0.533). Using enrollment year as an instrumental variable, DES use did not affect mortality (absolute difference=-0.26, 95% CI:-4.08,3.57, p=0.896). Propensitymatched analyses demonstrated no difference in mortality when comparing the different DES with BMS:

Journal of the American College of Cardiology, Oct 1, 2013

Background: Rotational atherectomy (RA) facilitates delivery of stents in calcific lesions. Calci... more Background: Rotational atherectomy (RA) facilitates delivery of stents in calcific lesions. Calcified coronary lesions are an established risk factor for long-term failure after both bare metal stents (BMS) and drug-eluting stent (DES) implantation. Whilst DES use following RA may result in high procedural success and acceptable restenosis rates, there is limited data on their long-term efficacy and prognostic benefit when used with RA. Methods: We examined an observational cohort of 661 consecutive patients treated with RA between 2005-2011 at 8 tertiary cardiac centers across London, UK. Multivariate Cox-proportional hazards models using forward stepwise variable selection were used to determine independent predictors of mortality. Results: 209 patients (32%) were treated with BMS and 452 patients (68%) were with DES. Patients in the BMS group were older (75.5y vs. 73.2y, p¼0.002). The female:male ratio; presence of cardiogenic shock; presence of diabetes; previous PCI and CABG was similar between both groups. A greater proportion of patients in the BMS group had ACS. GP 2b-3a inhibitor use was greater in the BMS group. The length of stented segment was greater in the DES group (24mm vs.28mm, p<0.001). Multivariate analysis identified the use of DES as an independent predictor of 1-year mortality (HR¼0.45, 95% CI: 0.26-0.78, p¼0.005) and 3-year mortality (HR¼0.64, 95% CI: 0.42-0.98, p¼0.041). Conclusions: This study represents the largest reported dataset of patients treated with RA in the DES era with long-term follow-up. The use of DES following RA appears to be associated with reduced long-term mortality.

European Heart Journal, Apr 10, 2019

Aims The public reporting of healthcare outcomes has a number of potential benefits; however, uni... more Aims The public reporting of healthcare outcomes has a number of potential benefits; however, unintended consequences may limit its effectiveness as a quality improvement process. We aimed to assess whether the introduction of individual operator specific outcome reporting after percutaneous coronary intervention (PCI) in the UK was associated with a change in patient risk factor profiles, procedural management, or 30-day mortality outcomes in a large cohort of consecutive patients.

European Heart Journal, Oct 1, 2019

European Heart Journal, Aug 1, 2018

PCI group and CABG group (27.9% vs.25.3%, log-rank p=0.363, adjusted hazard ratio (HR): 0.891 [95... more PCI group and CABG group (27.9% vs.25.3%, log-rank p=0.363, adjusted hazard ratio (HR): 0.891 [95% confidence interval (CI): 0.694-1.143, p=0.365]). The adjusted risks for all-cause death were not significantly different between the 2 groups (p=0.347). Target vessel revascularization in PCI was significantly higher than in CABG (p<0.001), but stroke was lower in PCI than CABG (p=0.048). Figure 1. Cumulative rates of MACCE betwe Conclusion: In patients with ULMCAD, PCI was noninferior to CABG for the long term outcome. There was no significant difference between-group difference in the incidence of MACCE. In patients with ULMCAD, PCI was similar to CABG for the long term outcome. There was higher TVR rates in PCI group and higher stroke rates in CABG patients.

Journal of the American College of Cardiology, Apr 1, 2014

background: Current guidelines discourage percutaneous coronary intervention (PCI) of non-infarct... more background: Current guidelines discourage percutaneous coronary intervention (PCI) of non-infarct-related arteries at the time of primary PCI in patients with ST-elevation myocardial infarction (STEMI) without cardiogenic shock. The optimal strategy for treating non-culprit disease is currently under debate. methods: We conducted an observational analysis comparing culprit vessel intervention (CVI) versus multivessel intervention (MVI) in patients who had primary PCI between 2004-2011 at all 8 tertiary cardiac centres in London. Patients with cardiogenic shock and bystander left main-stem disease (>50% stenosis) were excluded. Cox proportional hazard models were built to determine independent predictors for all-cause mortality. A propensity-matched analysis was performed on patients with multivessel disease (defined as stenosis >50% in ≥2 epicardial coronary arteries). results: Of the 9377 patients included in the analysis, 8755 patients (93%) had CVI and 622 patients (7%) had MVI. CVI was as an independent predictor for survival at 1 year in the full patient cohort (HR=0.61, 95% CI:0.45-0.82, p=0.001); in 3984 patients with multivessel disease (HR=0.65, 95% CI:0.47-0.91, p=0.011); and in 734 patients in propensity-matched cohorts (HR=0.52, 95% CI:0.23-0.95, p=0.034). Conclusions: In this observational analysis of patients with STEMI undergoing primary PCI, CVI was independently associated with reduced 1-year mortality. Our findings support current recommended practice guidelines.

European Heart Journal, 2003

The patent foramen ovale (PFO) is a very common anatomical variant of the interatrial septum and ... more The patent foramen ovale (PFO) is a very common anatomical variant of the interatrial septum and is associated with a number of paradoxical embolism syndromes including cryptogenic stroke, decompression illness in divers and migraine with visual aura. There is a particularly strong association between cryptogenic stroke and PFO in young individuals and the association is particularly strong in the presence of both a PFO and an atrial septal aneurysm. Catheter closure of a PFO was introduced in the early 1990s and has developed considerably as a safe and effective treatment, such that surgical closure of a PFO is a near obsolete procedure. With new techniques in imaging, such as intra-cardiac echocardiography, a large proportion of percutaneous PFO closure procedures are carried out as day cases under local anaesthesia. Perhaps the most challenging aspect in the management of patients with PFO remains the selection of target populations for percutaneous device closure. At present, th...

Journal of the American College of Cardiology, 2015