Background-In patients undergoing percutaneous coronary intervention (PCI) in the modern era, the incidence and prognostic implications of acute renal failure (ARF) are unknown. Methods and Results-With a retrospective analysis of the Mayo Clinic PCI registry, we determined the incidence of, risk factors for, and prognostic implications of ARF (defined as an increase in serum creatinine [Cr] Ͼ0.5 mg/dL from baseline) after PCI. Of 7586 patients, 254 (3.3%) experienced ARF. Among patients with baseline Cr Ͻ2.0, the risk of ARF was higher among diabetic than nondiabetic patients, whereas among those with a baseline Cr Ͼ2.0, all had a significant risk of ARF. In multivariate analysis, ARF was associated with baseline serum Cr, acute myocardial infarction, shock, and volume of contrast medium administered. Twenty-two percent of patients with ARF died during the index hospitalization compared with only 1.4% of patients without ARF (PϽ0.0001). After adjustment, ARF remained strongly associated with death. Among hospital survivors with ARF, 1-and 5-year estimated mortality rates were 12.1% and 44.6%, respectively, much greater than the 3.7% and 14.5% mortality rates in patients without ARF (PϽ0.0001). Conclusions-The overall incidence of ARF after PCI is low. Diabetic patients with baseline Cr values Ͻ2.0 mg/dL are at higher risk than nondiabetic patients, whereas all patients with a serum Cr Ͼ2.0 are at high risk for ARF. ARF was highly correlated with death during the index hospitalization and after dismissal.

In AMI patients treated with primary PCI, seven risk factors readily available at the time of intervention accurately predict short- and long-term mortality. Of note, measurement of baseline left ventricular function is the single most powerful predictor of survival and should be incorporated into risk score models.

Background-Spontaneous coronary artery dissection (SCAD) is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. The angiographic characteristics of SCAD are largely undetermined. The goal of this study was to determine the prevalence of coronary tortuosity in SCAD and whether it may be implicated in the disease. Methods and Results-Patients with confirmed SCAD (n=246; 45.3±8.9 years; 96% women) and 313 control patients without SCAD or coronary artery disease who underwent coronary angiography were included in this case-control study. Angiograms were reviewed for coronary tortuosity and assigned a tortuosity score. Tortuosity was common in patients presenting with their first SCAD event (78% versus 17% in controls; P<0.0001; tortuosity score, 4.41±1.73 versus 2.33±1.49 in controls; P<0.0001) despite a low prevalence of hypertension (34%). Recurrent SCAD (n=40) occurred within segments of tortuosity in 80% of cases. Severe tortuosity (≥2 consecutive curvatures ≥180°) was associated with a higher risk of recurrent SCAD (hazard ratio, 3.29; 95% confidence interval, 0.99-8.29; P=0.05). Tortuosity score >5 was associated with a trend toward higher risk of recurrent SCAD (P=0.16). Prespecified angiographic markers of tortuosity including corkscrew appearance and multivessel symmetrical tortuosity were associated with extracoronary vasculopathy including fibromuscular dysplasia (P<0.05 for both). Conclusions-Coronary artery tortuosity is highly prevalent in the SCAD population and is associated with recurrent SCAD. Recurrent SCAD most often occurs within segments of tortuosity. Angiographic features of SCAD are associated with extracoronary vasculopathy, including fibromuscular dysplasia. These findings suggest that coronary tortuosity may serve as a marker or potential mechanism for SCAD. (Circ Cardiovasc Interv. 2014;7:656-662.)

Background While older patients frequently undergo percutaneous coronary interventions (PCI), frailty, comorbidity, and quality of life (QOL) are seldom part of risk prediction approaches. We assessed their incremental prognostic value over and above the risk factors in the Mayo Clinic risk score (MCRS). Methods and Results Patients ≥ 65 years who underwent PCI were assessed for frailty (Fried criteria), comorbidity (Charlson index), and QOL [SF-36]. Of the 628 discharged [median follow-up of 35.0 months (IQR, 22.7-42.9)], 78 died and 72 had an MI. Three year mortality was 28% for frail patients, 6% for non-frail patients. The respective 3-year rates of death or MI were 41% and 17%. Following adjustment, frailty [hazard ratio (HR) 4.19 [95% confidence interval (CI), 1.85, 9.51], physical component score of the SF-36 (HR, 1.59; 95% CI, 1.24-2.02), and comorbidity, (HR, 1.10; 95% CI, 1.05, 1.16) were associated with mortality. Frailty was associated with mortality/MI (HR, 2.61, 1.52, 4.50). Models with conventional MCRS had C-statistics of 0.628, 0.573 for mortality and mortality/MI respectively. Adding frailty, QOL, and comorbidity, the C statistic was (0.675, 0.694, 0.671) for mortality, and (0.607, 0.587, 0.576) for mortality/MI respectively. Including frailty, comorbidities, and SF-36, conferred a discernible improvement to predict death and death/MI (integrated discrimination improvement 0.027 and 0.016 and net reclassification improvement of 43% and 18% respectively). Conclusions Following PCI, frailty, comorbidity and poor QOL are prevalent and are associated with adverse long-term outcomes. Their inclusion improves the discriminatory ability of the MCRS derived from the routine cardiovascular risk factors.

Procedural success rates for CTO have not improved over time in the stent era, highlighting the need to develop new techniques and devices. Compared with the prestent era, in-hospital major adverse cardiac events and 1-year target vessel revascularization rates have declined by approximately 50%.