2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction (Updating the 2007 Guideline)

Could late measurement of serum creatinine be missed for patients without early increase in serum creatinine following coronary angiography?

Most patients are discharged early (within 24 hours) after coronary angiography (CAG) and may miss identification the late (24-48 hours) increase in serum creatinine (SCr), whose characteristics and prognosis have been less intensively investigated.We prospectively recruited 3065 consecutive patients with SCr measurement, including only1344 patients with twice SCr measurement (both early and late). The late contrast-induced acute kidney injury (CI-AKI) was defined as significantly increase in SCr (≥0.3 mg/dL or ≥50%) not in early phase, but only in late phase after the procedure, and the early CI-AKI experienced a significantly increase in early phase.Overall, CI-AKI developed in 134 patients (10%), and the incidence of late and early CI-AKI were 3.6% and 6.4%, respectively. There were no difference in age, renal, and heart function, contrast volume among patients with late and early CI-AKI. With mean follow-up period of 2.45 years, long-term mortality (3 years, 29.7% and 35.6%, respectively, P = .553) was similar for patients with late and early CI-AKI. Cox analysis showed that both late (adjusted HR 2.05; 95% CI, 1.02-4.15) and early (adjusted HR 2.68; 95% CI, 1.57-4.59) CI-AKI was significantly associated with long-term mortality (all P < .001).Only late increase in SCr, as late CI-AKI, accounted for about one-third of CI-AKI incidence and has similar good predictive value for long-term mortality with that of an early increase, early CI-AKI, among patients with SCr measured twice, supporting the importance of late repeating SCr measurement after CAG, even without an early significant increase in SCr.

Pediatric Emergency Department Study of Cardiac Risk in the Novel Patient (PED SCReeN)

OBJECTIVE

We compare pediatric cardiac risk classification and management recommendations between emergency physicians (EPs) and pediatric cardiologists (PCs) in children with a suspected new cardiac disorder.

METHODS

We prospectively compared the work-up, assessment, classification, and disposition of patients aged 0 to 21 years presenting to the emergency department with a potential cardiac etiology in whom an electrocardiogram (ECG) was performed. The criterion standard was a blinded assessment by the PC-electrophysiologist after review of the history, physical examination, ancillary tests, and ECG.

RESULTS

In 508 subjects, the median age was 15 years (interquartile range, 11-17 years), with a slight female predominance (281, 55.3%). The most common reasons for obtaining an ECG were: chest pain (158, 31.1%) and syncope, presyncope, or possible seizure (146, 28.7%). The most common auxiliary study was a chest radiograph (432, 85% of subjects). A total of 617 electrocardiographic diagnoses were made by EPs and 984 diagnoses by PCs. Sensitivities and specificities varied by discrete class, but disposition decisions were concordant (home or admission). The EPs were highly accurate for the need for emergent cardiology involvement (area under the curve, 0.89).

CONCLUSIONS

The EPs and PCs agreed on the evaluation and disposition of children at either low risk or high risk for an acute cardiac presentation in the emergency department. There was considerable variation in management recommendations in the intermediate risk children needing cardiology outpatient follow-up. We recommend the development and implementation of focused training modules on emergency pediatric cardiology and increased communication with pediatric cardiology to improve patient safety and resource utilization.

Association of post-procedural early (within 24h) increases in serum creatinine with all-cause mortality after coronary angiography

BACKGROUND

The majority of patients undergoing coronary angiography (CAG) or percutaneous coronary intervention (PCI) are discharged early, with only early (within 24h) serum creatinine (SCr) data available without evidence of clinical prognosis. We aimed to systemically evaluate the association between post-procedural early increase in SCr and all-cause mortality following CAG.

METHODS

We performed a retrospective sub-study analysis within a prospective observational study including 3091 consecutive patients with baseline and post-procedural early (within 24h) SCr data. The degree (mild, moderate, or large) of absolute and relative increases in SCr from baseline. The mean follow-up time was 2.49years.

RESULT

Moderate or large early increases in SCr were relatively rare (large increase: >1.0mg/dl [0.5%], >100% [0.4%]), whereas mild absolute and relative increases in SCr were more common (mild increase: 0.25 to 0.50mg/dl [4.5%], 25% to 50% [5.9%]). During the follow-up period, there were 136 post-procedural deaths (5.6%). After adjustment for confounders, mild absolute and relative increases in SCr were associated with increased mortality (hazard ratio [HR]: 1.9 and 1.8, respectively, both P<0.05). Moderate or large increases in SCr were associated with higher mortality, even higher than with pre-existing renal dysfunction (HR: 5.36 and 4.12 for moderate increase [0.5 to 1.0mg/dl] and estimated glomerular filtration rate<60ml/min).

CONCLUSION

Post-procedural mild, moderate, or large early increase in SCr, is associated with significantly increased long-term mortality. Although moderate or large increase in SCr following CAG was relatively rare, the prognosis is more serious, and is worse than that of pre-existing renal dysfunction.

CLINICAL TRIAL REGISTRATION

Predictive Value of Contrast Volume to Creatinine Clearance Ratio (PRECOMIN, ClinicalTrials.govNCT01400295).

Case Report: INTRAPROCEDURAL STENT THROMBOSIS IN PERCUTANEOUS CORONARY ANGIOPLASTY

Stent thrombosis is a rare complication of PCI but associated with STEMI and sudden cardiac death. Intra procedural stent thrombosis (IPST) was defined new or increasing (compared with baseline) thrombus within or adjacent to a deployed stent occurring the index PCI procedure whether occlusive or nonocclusive. We describe a case with double vessel disease who has complication cardiac arrest and intra procedural stent thrombosis in LAD and Left Main coronary artery after deployed stent in bifurcation LAD-D1. Thrombectomy and rescucitation were performed, and the patient completed her hospital course without complications.

Oral N-acetylcysteine for prophylaxis of contrast-induced nephropathy in patients following coronary angioplasty: A meta-analysis

It is acknowledged that contrast-induced nephropathy (CIN) is a common cause of acute renal insufficiency after cardiac catheterization and affects mortality and morbidity. To date, it is unknown whether oral N-acetylcysteine (NAC) is able to prevent contrast-induced nephropathy (CIN) in patients undergoing coronary angioplasty. A meta-analysis of randomized controlled trials was performed to assess the effects of NAC in the prevention of CIN in patients following coronary angioplasty. A total of 19 studies published prior to January 2015 that investigated the efficacy of oral NAC for the prevention of CIN were collected from Medline, Cochrane and Embase databases and conference proceedings from cardiology and nephrology meetings. The primary point of investigation was CIN, and the secondary points were renal failure requiring dialysis, mortality and length of hospitalization. The meta-analysis was performed using fixed- or random-effect models according to heterogeneity. Up to January 2015, 19 randomized placebo-controlled clinical trials met the inclusion criteria for the meta-analysis, including 4,514 patients. The pooled data showed that oral NAC did not reduce the CIN incidence [relative risk 0.84, 95% confidence interval (CI) 0.65-1.10; P=0.20], without heterogeneity among trials (I2=29%). Thus, the present meta-analysis suggests that oral NAC therapy is not effective as an alternative treatment to prevent CIN in patients following angioplasty. Further high quality randomized clinical controlled trials are required to confirm the usage and availability of this treatment.

Association Between Helicobacter Pylori Infection and Long-term Outcome in Patients with Drug-eluting Stent Implantation

To investigate the relationship between Helicobacter pylori (Hp) infection and the long-term outcome in acute coronary syndrome (ACS) patients with drug-eluting stent (DES) implantation and so as to explore the significance of Hp eradication therapy in preventing major adverse cardiac events (MACE) and upper gastrointestinal bleeding (UGIB). 539 ACS patients with DES implantation from January 1, 2010 to December 31, 2012 were analyzed. All the patients were divided into two groups according to the result of 13C urea breath test. 253 patients with Hp infection were put into group A (Hp+), and 286 cases without Hp infection were put into group B (Hp-). Demographic data was collected and all patients went through biochemical indicators and other routine blood examinations. We explored the correlations of Hp infection with MACE and UGIB after 3 to 5 years of follow-up using survival analysis. Survival analysis showed that Hp infection was a predictor of MACE and UGI. Sub-group analysis showed that patients with Hp eradication therapy had no relationship with MACE but had a lower rate of UGIB than those without Hp eradication therapy.

Predictive value of post-procedural early (within 24 h) increase in cystatin C for contrast-induced acute kidney injury and mortality following coronary angiography or intervention

Objective

To investigate the predictive value of post-procedural early (within 24 h) increase in cystatin C for contrast-induced acute kidney injury (CI-AKI) and all-cause mortality following coronary angiography or intervention.

Methods

We prospectively investigated 1042 consecutive patients with both baseline and early post-procedural cystatin C measurement undergoing coronary angiography or intervention. CI-AKI was defined as an increase ≥0.3 mg/dL or >50% in serum creatinine from baseline within 48 h post-procedure. Mean follow-up was 2.26 years.

Results

Overall, the patients had a CI-AKI incidence was 3.6% (38/1042), mean serum creatinine of 87 µmol/L. Compared with Mehran risk score, post-procedural early absolute increase (AUC: 0.584 vs. 0.706, P = 0.060) and relative increase (AUC: 0.585 vs. 0.706, P = 0.058) in cystatin C had poorer predictive value for CI-AKI. According to multivariate analysis, post-procedural significant early increase (≥0.3 mg/dL or ≥10%) in cystatin C developed in 231 patients (22.2%), was not independent predictor of CI-AKI (adjusted OR: 1.23, 95% CI, 0.56-2.69, P = 0.612), and long-term mortality (adjusted HR: 0.90; P = 0.838).

Conclusions

Our data suggested post-procedural early increase (within 24 h) in cystatin C was not effective for predicting CI-AKI or all-cause mortality following coronary angiography or intervention among patients at relative low risk of CI-AKI, the negative finding of poor predictive value should be further evaluated in larger multicenter trials.

Comparing common doses (double-dose vs usual-dose) of atorvastatin for preventing contrast-induced acute kidney injury and mortality after coronary angiography

High-dose atorvastatin pretreatment was proved reducing the risk of contrast-induced acute kidney injury (CI-AKI), especially in patients with high C-reactive protein (CRP) levels. We evaluated the effects of common atorvastatin doses (double vs usual) on the risk of CI-AKI and mortality.We recorded outcomes from 1319 patients who were administered periprocedural common doses of atorvastatin. The risks of CI-AKI and mortality between double-dose (40 mg/d) and usual-dose atorvastatin (20 mg/d) were compared using multivariable regression models in all patients or CRP tertile subgroups.Seventy-six (5.8%) patients developed CI-AKI. Double-dose atorvastatin compared with usual-dose did not further reduce the risk of CI-AKI (adjusted odds ratio [OR]: 2.28, 95% confidence interval [CI]: 0.92-5.62, P = .074), even for patients in the highest CRP tertile (>8.33 mg/L; adjusted OR: 3.76, 95% CI: 0.83-17.05, P = .086). Similar results were observed in reducing mortality in all patients (adjusted hazard ratio: 0.47, 95% CI: 0.10-2.18; P = .339) and in the highest CRP tertiles (P = .424). In the subgroup analysis, double-dose atorvastatin increased risk of CI-AKI in patients with creatinine clearance (CrCl) < 60 mL/min, anemia, contrast volume > 200 mL and > 2 stents implanted (P = .046, .009, .024, and .026, respectively).Daily periprocedural double-dose atorvastatin was not associated with a reduced risk of CI-AKI compared with usual-dose, and did not provide an improved long-term prognosis, even in patients with high CRP levels. However, it increased the risk of CI-AKI in patients with a high contrast volume/CrCl.

Standards of specialized diabetes care. Edited by Dedov II, Shestakova MV, Mayorov AY. 8th edition

Dear Colleagues! We are glad to present the8th Editionof Standards of Diabetes Care. These evidence-based guidelines were designed to standardize and facilitate diabetes care in all regions of the Russian Federation. The Standards are updated on the regular basis to incorporate new data and relevant recommendations from national and international clinical societies, including World Health Organization Guidelines (WHO, 2011, 2013), International Diabetes Federation (IDF, 2011, 2012, 2013), American Diabetes Association (ADA, 2012, 2017), American Association of Clinical Endocrinologists (AACE, 2017), International Society for Pediatric and Adolescent Diabetes (ISPAD, 2014) and Russian Association of Endocrinologists (RAE, 2011, 2012, 2015). Current edition of the Standards also integrates results of completed randomized clinical trials (ADVANCE, ACCORD, VADT, UKPDS, SAVOR, TECOS, LEADER, EMPA-REG OUTCOME, etc.), as well as findings from the national studies of diabetes mellitus (DM), conducted in close partnership with a number of Russian hospitals. Latest data indicates that prevalence of DM in the world increased during the last decade more than two-fold, reaching some 415 million patients by the end of 2015. According to the current estimation by the International Diabetes Federation, 642 million patients will be suffering from DM by 2040. These observations resulted in the UN Resolution on Diabetes 61/225 passed on 20.12.2006, and in 2011 - UN Political Declaration, addressed to national health systems, calling for the establishment of multidisciplinary strategy in the prevention and control of non-communicable diseases, where special attention is drawn to the problem of diabetes as one of the leading causes of disability and mortality. Like many other countries, Russian Federation experiences a sharp rise in the prevalence of DM. According to Russian Federal Diabetes Register, there are at least 4.35 million patients with DM in this country by the end of 2016 (3% of population) with 92% (4 million) Type 2 DM, 6% (255 th) Type 1 DM and 2% (75 th) other types of DM. However, these results underestimates real quantity of patients, because they consider only registered cases. Results of Russian epidemiological study (NATION) confirmed that only 50% of Type 2 DM are diagnosed. So real prevalence of patients with DM in Russia is no less than 8-9 million patients (about 6% of population). This is a great long-term problem, because a lot of patients are not diagnosed, so they dont receive any treatment ant have high risk of vascular complications. Severe consequences of the global pandemics of DM include its vascular complications: nephropathy, retinopathy, coronary, cerebral, coronary and peripheral vascular disease. These conditions are responsible for the majority of cases of diabetes-related disability and death. Current edition of the Standards emphasizes the patient-oriented approach in making decisions on therapeutic goals, such as levels of glycaemia and blood pressure. It also features updated guidelines on the management of Type 2 DM and its vascular complications, added information about bariatric surgery as a method of treatment of DM with morbide obesity. This text represents a consensus by the absolute majority of national experts, achieved through a number of fruitful discussions held at national meetings and forums. These guidelines are intended for endocrinologists and diabetologists, primary care physicians, cardiologists and other medical professionals involved in prevention and treatment of DM. On behalf of the Working Group

Commentary: In the Rising Era of Big Data, Small Steps are Key

Big Data may be useful to identify and perhaps ameliorate health disparities. However, over reliance on the power on Big Data can potentially cause harm. When assessing health disparities, the use of Big Data should be limited to hypothesis generation.

Effects of four novel genetic polymorphisms on clopidogrel efficacy in Chinese acute coronary syndromes patients

Dual antiplatelet therapy is the gold standard for the clinical treatment of coronary artery disease, especially for acute coronary syndromes patients. However, a substantial number of patients do not respond to clopidogrel despite a standardized dosage regimen, and this is directly associated with poor prognosis. Genetic polymorphisms may be one of the most important factors that contribute to this phenomenon. In this study, we aimed to detect new single nucleotide polymorphisms that can influence the efficacy of clopidogrel in 851 acute coronary syndromes (ACS) patients. Four outcomes (cerebrovascular event, Acute Myocardium Infarction, unstable angina and death) were used as endpoints among three cohorts (northern, central and southern China) of acute coronary syndromes patients. Three SNPs (rs2244923, rs2773341 and rs34428341) were significantly associated with at least one outcome in all subjects. One SNP rs16863352, may play a role in predicting unstable angina in acute coronary syndrome patients ≥75years of age.

A New Preprocedure Risk Score for Predicting Contrast-Induced Acute Kidney Injury

BACKGROUND

Most of the risk models for predicting contrast-induced acute kidney injury (CI-AKI) are available for only postcontrast exposure prediction; however, prediction before the procedure is more valuable in practice. This study aimed to develop a risk scoring system based on preprocedural characteristics for early prediction of CI-AKI in patients after coronary angiography or percutaneous coronary intervention (PCI).

METHODS

We prospectively recruited 1777 consecutive patients who were randomized in an approximate 3:2 ratio to create a development data set (n = 1076) and a validation data set (n = 701). A risk score model based on preprocedural risk factors was developed using stepwise logistic regression. Validation was performed by bootstrap and split-sample methods.

RESULTS

The occurrence of CI-AKI was 5.97% (106 of 1777), 5.95% (64 of 1076), and 5.99% (42 of 701) in the overall, developmental, and validation data sets, respectively. The risk score was developed with 5 prognostic factors (age, serum creatinine levels, N-terminal pro b-type natriuretic peptide levels, high-sensitivity C-reactive protein, and primary PCI), ranged from 0-36, and was well calibrated (Hosmer-Lemeshow χ² = 4.162; P = 0.842). Good discrimination was obtained both in the developmental and validation data sets (C-statistic, 0.809 and 0.798, respectively). The risk score was highly and positively associated with CI-AKI (P for trend < 0.001) in-hospital and long-term outcomes.

CONCLUSIONS

The novel risk score model we developed is a simple and accurate tool for early/preprocedural prediction of CI-AKI in patients undergoing coronary angiography or PCI. This tool allows assessment of the risk of CI-AKI before contrast exposure, allowing for timely initiation of appropriate preventive measures.

Acute Coronary Syndrome and Suicide: A Case-Referent Study

Background

The high prevalence of acute coronary syndrome (ACS) represents a significant burden on healthcare resources. A robust association exists between depression and increased morbidity and mortality after ACS. This study examined the relationship between suicide and ACS after adjusting for depression and other comorbidities.

Methods and Results

In this case‐referent study conducted in Taiwan, the cases were people aged 35 years or older who died from suicide between 2000 and 2012 and 4 live referents, each matched by age, sex, and area of residence. The covariates adjusted for in the analysis were sociodemographic characteristics, physical comorbidities, and psychiatric disorders. We identified 41 050 persons who committed suicide and 164 200 referents. In the case and referent groups, 1027 (2.5%) and 2412 (1.5%) patients had ACS, respectively. After potential confounders were adjusted, ACS was significantly associated with increased odds of suicide (aOR=1.15, 95% confidence interval [CI]=1.05‐1.26). The odds of suicide were highest during the initial 6 months post‐ACS diagnosis (OR=3.05, 95% CI=2.55‐3.65) and remained high for at least 4 years after ACS diagnosis.

Conclusions

ACS patients are at an increased risk of suicide compared with otherwise healthy people. The risk of suicide is particularly high in the 6 months after ACS diagnosis. Our results suggest that we need to identify efficacious methods to recognize those at risk for suicide and to develop effective interventions to prevent such deaths.

Relationship between asymptomatic intra-cranial lesions and brachial-ankle pulse wave velocity in coronary artery disease patients without stroke

Little is known about the significance of asymptomatic intra-cranial lesions (ICL) identified by brain MRI in coronary artery disease (CAD) patients. Silent cerebral lesions are suggested to be associated with arterial stiffness in healthy subjects. We investigated whether subclinical ICL are associated with arterial stiffness and the prognosis in CAD patients without medical history of cerebrovascular diseases. We recruited CAD patients who required percutaneous coronary intervention (PCI), did not meet exclusion criteria, and agreed with MRI before PCI. Subjects were divided into two groups according to the presence of ICL of cerebral microbleeds or lacunar infarction. Arterial stiffness was evaluated by brachial-ankle pulse wave velocity (baPWV). Clinical outcome was defined as a composite of cardiovascular death, non-fatal myocardial infarction, stroke, unstable angina and heart failure. In total, 149 patients underwent brain MRI. Patients with ICL (n=55) had significantly higher baPWV than those without ICL (1591-2204 vs. 1450-1956 cm per sec; P=0.009). A multivariate analysis showed that male sex (odds ratio (OR), 3.15; 95% confidence interval (CI), 1.38-7.20; P=0.006) and baPWV (OR, 1.001; 95% CI, 1.000-1.002; P=0.023) were predictors of ICL. In total, 12 patients experienced a cardiovascular event. The Kaplan-Meier analysis indicated a significantly higher incidence of cardiovascular events in patients with ICL (log-rank test: P=0.018). Multivariate Cox proportional hazards analyses indicated that ICL finding was a significant predictor of clinical outcome (hazard ratio, 3.41; 95% CI, 1.02-11.5; P=0.047). Patients with subclinical ICL had a higher baPWV and worse prognoses than those without ICL.

Platelet function testing in cardiac surgery

Bleeding in cardiac surgery is known to cause increased morbidity and mortality. The rise in the use of anti-platelet medication has led to an increase in the number of patients presenting for cardiac surgery with platelet dysfunction, who are at a heightened risk of bleeding. However, the extent of platelet inhibition is well known to differ among individuals. In the past few years, a number of point-of-care platelet function testing devices, which may be able to assess platelet reactivity, have entered the market. This review will examine the devices most commonly studied and the evidence surrounding their use in cardiac surgery and their effect on blood loss.

Risk Scores After Acute Coronary Syndrome

Acute coronary syndrome (ACS) is associated with both short- and long-term unfavorable prognosis. Therefore, medical societies developed risk scores for predicting mortality and assessing decision-making regarding early aggressive treatment in patients presenting an ACS. The Thrombolysis In Myocardial Infarction and the Global Registry of Acute Coronary Events risk scores are the most extensively investigated scores for ACS. Clinical judgment is also important. Significant differences in aggressive treatment of ACS still exist with respect to gender, age, and ethnicity. The reasons for these discrepancies need to be further elucidated in future studies. Therefore, generalizability of stratifications and risk scores in certain populations should be performed with caution.

Why we need intravenous antiplatelet agents

Oral ADP-receptor antagonists combined with aspirin are the standard for dual antiplatelet therapy (DAPT) during percutaneous coronary intervention (PCI). However, the oral route of administration of ADP-receptor antagonists leaves them vulnerable to unpredictable and often inadequate platelet inhibition at the time of PCI, while their prolonged effects often lead to the decision not to load them prior to PCI. Intravenous antiplatelet agents, including glycoprotein IIb/IIIa inhibitors (GPI) and cangrelor, a reversible P2Y12 inhibitor, address these shortcomings. In June 2015, the US FDA approved cangrelor for the prevention of thrombotic events associated with coronary stenting. This review examines the current state of peri-PCI DAPT and demonstrates that the selective use of GPIs and intravenous ADP-antagonist agents reduces the risk of periprocedural thrombosis.

Excessively High Hydration Volume May Not Be Associated With Decreased Risk of Contrast-Induced Acute Kidney Injury After Percutaneous Coronary Intervention in Patients With Renal Insufficiency

BACKGROUND

No well-defined protocols currently exist regarding the optimal rate and duration of normal saline administration to prevent contrast-induced acute kidney injury (CI-AKI) in patients with renal insufficiency.

METHODS AND RESULTS

Hydration volume ratios (hydration volume/weight; HV/W) were calculated in 1406 patients with renal insufficiency (estimated glomerular filtration rate [eGFR], <90 mL/min per 1.73 m(2)) undergoing percutaneous coronary intervention (PCI) with routine speed hydration (1 or 0.5 mL/kg per hour). We investigated the relationship between hydration volume, risk of CI-AKI (increase in serum creatinine ≥0.5 mg/dL or 25% within 48-72 hours), and prognosis. Mean follow-up duration was 2.85±0.88 years. Individuals with higher HV/W were more likely to develop CI-AKI (quartiles: Q1, Q2, Q3, and Q4: 4.3%, 6.6%, 10.9%, and 15.0%, respectively; P<0.001). After adjusting 12 confounders, including age, sex, eGFR, anemia, emergent PCI, diabetes mellitus, chronic heart failure, diuretics, contrast volume, lesions, smoking status, and number of stents, multivariate analysis showed that a higher HV/W ratio was not associated with a decreased CI-AKI risk (Q2 vs Q1: adjusted odds ratio [OR], 1.13; Q3 vs Q1: adjusted OR, 1.51; Q4 vs Q1: adjusted OR, 1.87; all P>0.05) and even increased CI-AKI risk (HV/W >25 mL/kg: adjusted OR, 2.11; 95% CI, 1.24-3.59; P=0.006). Additionally, higher HV/W was significantly associated with an increased risk of death (Q4 vs Q1: adjusted hazard ratio, 3.44; 95% CI, 1.20-9.88; P=0.022).

CONCLUSIONS

Excessively high hydration volume at routine speed might be associated with increased risk of CI-AKI and death post-PCI in patients with renal insufficiency.

Prasugrel, a Platelet P2Y12 Receptor Antagonist, Improves Abnormal Gait in a Novel Murine Model of Thrombotic Hindlimb Ischemia

Background

The efficacy of P2Y₁₂ inhibition for the prevention of cardiovascular events in patients with peripheral arterial disease (PAD) has been established. However, the therapeutic effects on ischemic limb complications are less clear. Accordingly, we aimed to develop a novel murine model of thrombotic hindlimb ischemia to reflect that found in patients with PAD exhibiting ischemic limb symptoms. We further investigated the effects of P2Y₁₂ deficiency and P2Y₁₂ inhibition by prasugrel in this model.

Methods and Results

Thrombus formation induced by application of ferric chloride to the femoral artery resulted in a significant reduction in blood flow in the injured limb. In gait analysis using the CatWalk system, moderate difficulties in grounding and weight bearing of the ischemic limb, including reduction of maximum contact area and stance phase duration and increasing in swing phase duration in the ischemic limb, were observed in this model. Blood flow reduction and gait abnormalities gradually recovered over 21 days to levels present before arterial injury. Compared to wild‐type (WT) mice, significant increases in blood flow and improvement in gait were observed in P2Y₁₂‐deficient mice. In addition, daily oral administration of prasugrel (3 mg/kg per day) to WT mice resulted in significant inhibition of blood flow reduction and gait abnormalities to levels found in P2Y₁₂ deficient mice.

Conclusions

Acute femoral artery thrombosis resulted in hindlimb ischemia and moderate gait abnormalities in mice. In addition, the present study suggests a possible role of P2Y₁₂ in the complications with thrombotic limb ischemia.

CHA2DS2-VASc-HS score in non-ST elevation acute coronary syndrome patients: assessment of coronary artery disease severity and complexity and comparison to other scoring systems in the prediction of in-hospital major adverse cardiovascular events

Objective:

We recently described the CHA₂DS₂-VASc-HS score as a novel predictor of coronary artery disease (CAD) severity in stable CAD patients. We aimed to assess the accuracy of the CHA₂DS₂-VASc-HS score in the determination of CAD severity and complexity and its availability in the risk stratification of in-hospital major adverse cardiovascular events (MACE) in non-ST elevation acute coronary syndrome (NSTE-ACS) patients.

Methods:

We prospectively analyzed the clinical and angiographic data of consecutive NSTE-ACS patients in our clinic. Patients were classified into three tertiles according to their SYNTAX score (SS): tertile 1 had an SS of 0–22; tertile 2 had an SS of 23–32; and tertile 3 had an SS of >32. There were no specific exclusion criteria except for previous coronary artery bypass grafting (CABG) because SS was validated for only native coronary arteries for this study. We used the following analyses: χ² or Fisher’s exact tests, one-way analysis of variance or Kruskal–Wallis tests, Pearson’s or Spearman’s tests, the receiver operating characteristics (ROC) curve analysis, the area under the curve (AUC) or C-statistic, and pairwise comparisons of the ROC curves.

Results:

A total of 252 patients were enrolled. There were 131 patients in tertile 1, 79 in tertile 2, and 42 in tertile 3. The number of diseased vessels was correlated with the Global Registry for Acute Coronary Events (GRACE) (p<0.001), Thrombolysis in Myocardial Infarction (TIMI) (p<0.001), and CHA₂DS₂-VASc-HS (p<0.001) scores. In the ROC curve analyses, the cut-off value of the CHA₂DS₂-VASc-HS score in the prediction of in-hospital MACE was >5 with a sensitivity of 69.6% and specificity of 90.3% (AUC: 0.804, 95%: CI 0.750–0.851, p<0.001). We also compared the diagnostic accuracy of the CHA₂DS₂-VASc-HS score with the TIMI and GRACE risk scores in the determination of the in-hospital MACE and found no differences.

Conclusion:

The CHA₂DS₂-VASc-HS score was positively correlated with the severity and complexity of CAD. We also found that CHA₂DS₂-VASc-HS was comparable with other risk scores for the risk stratification of the in-hospital MACE of NSTE-ACS patients. Therefore, it may play an important role as a predictive model of NSTE-ACS patients in clinical practice. (Anatol J Cardiol 2016; 16: 742-8)

Safe limits of contrast vary with hydration volume for prevention of contrast-induced nephropathy after coronary angiography among patients with a relatively low risk of contrast-induced nephropathy

BACKGROUND

Few studies have investigated the safe limits of contrast to prevent contrast-induced nephropathy (CIN) based on hydration data. We aimed to investigate the relative safe maximum contrast volume adjusted for hydration volume in a population with a relatively low risk of CIN.

METHODS AND RESULTS

The ratios of contrast volume-to-creatinine clearance (V/CrCl) and hydration volume to body weight (HV/W) were determined in patients undergoing cardiac catheterization. Receiver-operator characteristic curve analysis based on the maximum Youden index was used to identify the optimal cutoff for V/CrCl in all patients and in HV/W subgroups. Eighty-six of 3273 (2.6%) patients with mean CrCl 71.89±27.02 mL/min developed CIN. Receiver-operator characteristic curve analysis indicated that a V/CrCl ratio of 2.44 was a fair discriminator for CIN in all patients (sensitivity, 73.3%; specificity, 70.4%). After adjustment for other confounders, V/CrCl >2.44 continued to be significantly associated with CIN (adjusted odds ratio, 4.12; P<0.001) and the risk of death (adjusted hazard ratio, 2.62; P<0.001). The mean HV/W was 12.18±7.40. We divided the patients into 2 groups (HV/W ≤12 and >12 mL/kg). The best cutoff value for V/CrCl was 1.87 (sensitivity, 67.9%; specificity, 64.4%; adjusted odds ratio, 3.24; P=0.011) in the insufficient hydration subgroup (HV/W, ≤12 mL/kg; CIN, 1.32%) and 2.93 (sensitivity, 69.0%; specificity, 65.0%; adjusted odds ratio, 3.04; P=0.004) in the sufficient hydration subgroup (HV/W, >12 mL/kg; CIN, 5.00%).

CONCLUSIONS

The V/CrCl ratio adjusted for HV/W may be a more reliable predictor of CIN and even long-term outcomes after cardiac catheterization. We also found a higher best cutoff value for V/CrCl to predict CIN in patients with a relatively sufficient hydration status, which may be beneficial during decision-making about contrast dose limits in relatively low-risk patients with different hydration statuses.

HIV Infection and Primary Prevention of Cardiovascular Disease: Lights and Shadows in the HAART Era

With the progressive increase in life-expectancy of human immunodeficiency virus (HIV)-positive patients in the "highly active antiretroviral therapy" (HAART) era, co-morbidities, particularly cardiovascular (CV) diseases (CVD) are emerging as an important concern. The pathophysiology of CVD in this population is complex, due to the interaction of classical CV risk factors, viral infection and the effects of antiretroviral therapy (ARV). The role of ARV drugs in HIV is double edged. While these drugs reduce systemic inflammation, an important factor in CV development, they may at the same time be proatherogenic by inducing dyslipidemia, body fat redistribution and insulin resistance. In these patients primary prevention is challenging, considering the lower median age at which acute coronary syndromes occur. Furthermore prevention is still limited by the lack of robust evidence-based, HIV-specific recommendations. Therefore we performed a comprehensive evaluation of the literature to analyze current knowledge on CVD prevalence in HIV-infected patients, traditional and HIV-specific risk factors and risk stratification, and to summarize the recommendations for primary prevention of CVD in this HIV population.

Clinical outcomes of percutaneous coronary intervention for acute coronary syndrome between hospitals with and without onsite cardiac surgery backup

BACKGROUND

Based on the 2011 American College of Cardiology/American Heart Association percutaneous coronary intervention (PCI) guideline, it is recommended that PCI should be performed at hospital with onsite cardiac surgery. But, data suggest that there is no significant difference in clinical outcomes following primary or elective PCI between the two groups. We examined the impact of with or without onsite cardiac surgery on clinical outcomes following PCI for acute coronary syndrome (ACS).

METHODS AND RESULTS

From August 2008 to March 2011, subjects (n=3241) were enrolled from the Kumamoto Intervention Conference Study (KICS). Patients were assigned to two groups treated in hospitals with (n=2764) or without (n=477) onsite cardiac surgery. Clinical events were followed up for 12 months. Primary endpoint was in-hospital death, cardiovascular death, myocardial infarction, and stroke. And we monitored in-hospital events, non-cardiovascular deaths, bleeding complications, revascularizations, and emergent coronary artery bypass grafting (CABG). There was no overall significant difference in primary endpoint between hospitals with and without onsite cardiac surgery [ACS, 7.6% vs. 8.0%, p=0.737; ST-segment elevation myocardial infarction (STEMI), 10.4% vs. 7.5%, p=0.200]. There was also no significant difference when events in primary endpoint were considered separately. In other events, revascularization was more frequently seen in hospitals with onsite surgery (ACS, 20.0% vs. 13.0%, p<0.001; STEMI, 21.9% vs. 14.5%, p=0.009). We performed propensity score matching analysis to correct for the disparate patient numbers between the two groups, and there was also no significant difference for primary endpoint (ACS, 8.6% vs. 7.5%, p=0.547; STEMI, 11.2% vs. 7.5%, p=0.210).

CONCLUSIONS

There is no significant difference in clinical outcomes following PCI for ACS between hospitals with and without onsite cardiac surgery backup in Japan.

Trends in use of anti-thrombotic agents and outcomes in patients with non-ST-segment elevation myocardial infarction (NSTEMI) managed with an invasive strategy

Objective

To analyze trends in utilization of anti-thrombotic agents (ATA) and in-hospital clinical outcomes in non-ST-elevation myocardial infarction (NSTEMI) patients managed with an invasive strategy from 2007 to 2010.

Methods & results

Using ACTION Registry^®-GWTG™ data, we analyzed trends in use of ATA and in-hospital clinical outcomes among 64,199 NSTEMI patients managed invasively between 2007 and 2010. ATA included unfractionated heparin (UFH), low molecular weight heparin (LMWH), glycoprotein IIb/IIIa inhibitors (GPI) and bivalirudin. Although the proportion of NSTEMI patients treated with PCI within 48 h of hospital arrival was similar in 2007 and 2010, percentage use of bivalirudin (13.4–27.3%; p < 0.01) and UFH increased (60.0–67.5%, p < 0.01), and that of GPI (62.3–41.0%; p < 0.01) and LMWH (41.5–36.8%; p < 0.01) declined. Excess dosing of UFH (75.9–59.3%, p < 0.01), LMWH (9.6–5.2%; p < 0.01) and GPI (8.9–5.9%, p < 0.01) was also significantly lower in 2010 compared with 2007. Though in-hospital mortality rates were similar in 2007 and 2010 (2.3–1.9%, p = 0.08), the rates of in-hospital major bleeding (8.7–6.6%, p < 0.01) and non-CABG related RBC transfusion (6.3–4.6%, p < 0.01) were significantly lower in 2010 compared with 2007.

Conclusion

Compared with 2007, patients with NSTEMI, who were managed invasively in 2010 received GPI and LMWH less often and bivalirudin and UFH more frequently. There were sizeable reductions in the rates of excess dosing of UFH (though still occurred in 67% of patients), GPI and LMWH. In-hospital major bleeding complications and post-procedural RBC transfusion were lower in 2010 compared with 2007.

Relationship Between the Urine Flow Rate and Risk of Contrast-Induced Nephropathy After Emergent Percutaneous Coronary Intervention

A low urine flow rate is a marker of acute kidney injury. However, it is unclear whether a high urine flow rate is associated with a reduced risk of contrast-induced nephropathy (CIN) in high-risk patients. We conducted this study to evaluate the predictive value of the urine flow rate for the risk of CIN following emergent percutaneous coronary intervention (PCI). We prospectively examined 308 patients undergoing emergent PCI who provided consent. The predictive value of the 24-hour postprocedural urine flow rate, adjusted by weight (UR/W, mL/kg/h) and divided into quartiles, for the risk of CIN was assessed using multivariate logistic regression analysis. The cumulative incidence of CIN was 24.4%. In particular, CIN was observed in 29.5%, 19.5%, 16.7%, and 32.0% of cases in the UR/W quartile (Q)-1 (≤0.94  mL/kg/h), Q2 (0.94-1.30  mL/kg/h), Q3 (1.30-1.71  mL/kg/h), and Q4 (≥1.71  mL/kg/h), respectively. Moreover, in-hospital death was noted in 7.7%, 3.9%, 5.1%, and 5.3% of patients in Q1, Q2, Q3, and Q4, respectively. After adjusting for potential confounding predictors, multivariate analysis indicated that compared with the moderate urine flow rate quartiles (Q2 + Q3), a high urine flow rate (Q4) (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.27-5.68; P = 0.010) and low urine flow rate (Q1) (OR, 2.23; 95% CI, 1.03-4.82; P = 0.041) were significantly associated with an increased risk of CIN. Moreover, a moderate urine flow rate (0.94-1.71  mL/kg/h) was significantly associated with a decreased risk of mortality. Our data suggest that higher and lower urine flow rates were significantly associated with an increased risk of CIN after emergent PCI, and a moderate urine flow rate (0.94-1.71  mL/kg/h) may be associated with a decreased risk of CIN with a good long-term prognosis after emergent PCI.

HAS-BLED score predicts risk of in-hospital major bleeding in patients with acute non-ST segment elevation myocardial infarction

BACKGROUND

The role of the Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs or alcohol use (HAS-BLED) score in the prediction of in-hospital bleeding in non-ST segment elevation myocardial infarction (NSTEMI) patients receiving dual anti-platelet therapy plus heparin was unknown. In this study, we compared the HAS-BLED score with the Can Rapid Risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) and Acute Catheterization and Urgent Intervention Triage strategY and the Harmonizing Outcomes with RevascularIZatiON and Stents in acute myocardial infarction (ACUITY-HORIZONS) bleeding risk scores for in-hospital major bleeding risk stratification in NSTEMI patients.

METHODS

A real world population of 617 NSTEMI patients receiving dual anti-platelet plus heparin as initial therapy were enrolled. CRUSADE, ACUITY-HORIZONS and HAS-BLED risk scores were calculated for each patient.

RESULTS

This cohort had a 6.5% incidence of in-hospital major bleeding. For the prediction of in-hospital major bleeding, the discriminations between CRUSADE, ACUITY-HORIZONS and HAS-BLED were good (C-statistic 0.81, 0.82 and 0.80, respectively). There was no significant difference between these three risk scores (HAS-BLED vs. CRUSADE: z=-0.08, p=0.27; HAS-BLED vs. ACUITY-HORIZONS: z=-0.06, p=0.26; CRUSADE vs. ACUITY-HORIZONS: z=-0.15, p=0.28).

CONCLUSION

The CRUSADE, ACUITY-HORIZONS and HAS-BLED scores were useful tools for risk stratification of in-hospital major bleeding in NSTEMI patients. The HAS-BLED score had a simpler calculation and a similar accuracy for risk assessment as the other two scores evaluated.

Routine early versus deferred provisional tirofiban treatment in patients with acute coronary syndrome undergoing percutaneous coronary intervention

The present study examined the optimal timing of tirofiban administration in moderate- or high-risk non-ST segment elevated acute coronary syndrome (NSTE-ACS) patients undergoing percutaneous coronary intervention (PCI). Eligible patients were randomized into two groups. Tirofiban was administered routinely at ≥ 4 h before angiography (routine early group; n = 141 patients) or provisionally only for bailout after angiography (deferred provisional group; n = 145 patients). The parameters analysed were: creatine kinase MB isoenzyme (CK-MB), thrombolysis in myocardial infarction (TIMI) flow, thrombotic complications during PCI, efficacy end-points (death, myocardial infarction or target vessel revascularization) at 7, 30 and 180 days and safety end-points (bleeding or thrombocytopenia). In the deferred provisional group, 48 patients (33.1%) required bailout tirofiban. Tirofiban was administered 5.8 h earlier in the routine early compared with the deferred provisional group. The routine early group showed a lower percentage increase in CK-MB (in U/L) 12-24 h after PCI compared with the deferred provisional group (0 (-4.0, 3.0) vs 0.4 (-3.0, 5.0), respectively; P = 0.045), as well as higher pre-PCI TIMI 3 (i.e. normal) flow (78.7% vs 64.8%, respectively; P = 0.042) and a lower incidence of thrombotic events (5.0% vs 33.1%, respectively; P < 0.0001). There were no significant differences in efficacy and safety end-points. In patients with moderate- or high-risk NSTE-ACS, early tirofiban combined with dual antiplatelet therapy was associated with better patency before PCI, attenuated minor myocardial damage and a lower prevalence of thrombotic complications during PCI, but had no significant benefit on the post-PCI TIMI 3 flow or short-term prognosis.

Differential impact of peripheral endothelial dysfunction on subsequent cardiovascular events following percutaneous coronary intervention between chronic kidney disease (CKD) and non-CKD patients

Chronic kidney disease (CKD) status might modify the predictive effect of peripheral endothelial dysfunction on cardiovascular events after percutaneous coronary intervention (PCI). The aim of this study was to examine the differential effect of peripheral endothelial dysfunction on clinical outcome after PCI between CKD and non-CKD patients. We conducted a cohort study of 435 patients following PCI. CKD was defined as estimated glomerular filtration rate <60 mL/min/1.73 m(2). Peripheral endothelial dysfunction was examined using reactive hyperemia-peripheral arterial tonometry index (RHI), and we divided patients into low- and high-natural logarithmic RHI (Ln-RHI) group. The endpoint was a composite of cardiovascular death, nonfatal myocardial infarction, ischemic stroke, hospitalization due to unstable angina pectoris, and coronary revascularization. A total of 56 patients had a cardiovascular event. Patients who suffered a cardiovascular event had significantly lower Ln-RHI than other patients in the non-CKD group (0.46 ± 0.18 versus 0.60 ± 0.25; P = 0.002). Kaplan-Meier analysis demonstrated a significantly higher probability of cardiovascular events in low Ln-RHI patients in the non-CKD group (log-rank test: P = 0.003). Multivariate Cox proportional hazards analysis identified Ln-RHI as an independent and significant predictor of future cardiovascular events in the non-CKD group (HR: 0.096; 95 % CI 0.02-0.47; P = 0.004) but not in the CKD group. There was a differential effect of peripheral endothelial dysfunction on clinical outcome after PCI between CKD and non-CKD patients, and peripheral endothelial dysfunction significantly correlates with subsequent cardiovascular events after PCI in non-CKD patients.

Duration of antiplatelet therapy cessation before coronary artery bypass surgery: Relation with platelet count

As of now, no study or data is available to determine the period of discontinuation of antiplatelet therapy and the timing of elective surgery in clopidogrel treated patients. The 2011 ACCF/AHA Guidelines have a Class-I recommendation for withdrawing clopidogrel for 5 days before elective coronary artery bypass grafting. However, 5 days period may not suit all patients as platelet count varies from 150 × 10(9)/L to 450 × 10(9)/L. Based on our retrospective data analysis, we have proposed a hypothesis to determine no of days of discontinuation of antiplatelet therapy while taking in consideration the basal count and life-span of platelets.

ENDOGENOUS CARBON MONOXIDE CONCENTRATION IN BLOOD ELEVATES IN ACUTE CORONARY SYNDROME OF NONSMOKER POPULATION

BACKGROUND

Carbon monoxide (CO) was previously only considered as a highly toxic pollutant since it binds to hemoglobin with high affinity. Recently, however, it has been recognized as a signaling molecule with regulatory roles in many physiological and pathophysiological processes within the cardiovascular system. The aim of this study was to clarify the behavior of CO in patients with acute coronary syndrome (ACS).

METHODS

We assessed 235 patients with suspected ACS, 98 smokers (88 male, 62 ± 14 years) and 137 nonsmokers (77 male, 72 ± 13 years), who had undergone emergent cardiac catheterization and blood sampling for calculation of carboxyhemoglobin (COHb). Patients were categorized into 4 groups: smoking patients with ACS (n=77), smoking patients without ACS (n=21), non-smoking patients with ACS (n=97), and non-smoker patients without ACS (n=40). We investigated whether biomarkers were related to COHb levels.

RESULTS

LogCOHb was significantly higher in the smoking patients compared to non-smoking patients (0.30 ± 0.12 vs. 0.45 ± 0.18, P < 0.01). Interestingly, among the non-smoking patients, COHb was increased in the ACS patients compared to the non ACS patients (0.31 ± 0.12 vs. 0.25 ± 0.12 P < 0.01). In contrast, among the smoking patients, there was no difference in COHb between the ACS and non-ACS patients (0.45 ± 0.18 vs. 0.44 ± 0.18, n.s.). There were no correlations between COHb and any of the biomarkers.

CONCLUSIONS

These results suggest that endogenous CO may be useful to assess the risk of cardiovascular stress.

Cumulative incidence of death and rehospitalization among the elderly in the first year after NSTEMI

BACKGROUND

Age is associated with outcomes in non-ST-segment elevation myocardial infarction; however, less is known about rehospitalization or death among elderly survivors. We aimed to evaluate mortality and cause-specific rehospitalization rates in this growing population of older adults with ischemic heart disease.

METHODS

We linked 36,711 patients aged ≥65 years who survived an index non-ST-segment elevation myocardial infarction from the CRUSADE registry to Medicare claims data for follow-up. One-year survival estimates were compared by age group-65-79, 80-84, 85-89, and ≥90 years-and Cox models were used to analyze the association between age and 1-year mortality.

RESULTS

Death at 1 year increased markedly with age (from 13.3% for 65-79 years to 45.5% for ≥90 years). In contrast, rehospitalization rates at 1 year were similar and high across ages (65-79 years, 52.7%; ≥90 years, 56.5%), with nearly as many noncardiovascular-related as cardiovascular-related rehospitalizations. At 1 year, nonagenarians had substantially higher rates of death with or without preceding rehospitalization and twice the adjusted mortality than the group aged 65-79 years.

CONCLUSIONS

Evolving care delivery models should consider the high mortality in older adults after a non-ST-segment elevation myocardial infarction. Contrary to expectations, rehospitalization rates do not rise substantially with advancing age, and rehospitalization is often for noncardiac diagnoses.

Association between public reporting of outcomes with procedural management and mortality for patients with acute myocardial infarction

BACKGROUND

Public reporting of procedural outcomes may create disincentives to provide percutaneous coronary intervention (PCI) for critically ill patients.

OBJECTIVES

This study evaluated the association between public reporting with procedural management and outcomes among patients with acute myocardial infarction (AMI).

METHODS

Using the Nationwide Inpatient Sample, we identified all patients with a primary diagnosis of AMI in states with public reporting (Massachusetts and New York) and regionally comparable states without public reporting (Connecticut, Maine, Maryland, New Hampshire, Rhode Island, and Vermont) between 2005 and 2011. Procedural management and in-hospital outcomes were stratified by public reporting.

RESULTS

Among 84,121 patients hospitalized with AMI, 57,629 (69%) underwent treatment in a public reporting state. After multivariate adjustment, percutaneous revascularization was performed less often in public reporting states than in nonreporting states (odds ratio [OR]: 0.81, 95% confidence interval [CI]: 0.67 to 0.96), especially among older patients (OR: 0.75, 95% CI: 0.62 to 0.91), those with Medicare insurance (OR: 0.75, 95% CI: 0.62 to 0.91), and those presenting with ST-segment elevation myocardial infarction (OR: 0.63, 95% CI: 0.56 to 0.71) or concomitant cardiac arrest or cardiogenic shock (OR: 0.58, 95% CI: 0.47 to 0.70). Overall, patients with AMI in public reporting states had higher adjusted in-hospital mortality rates (OR: 1.21, 95% CI: 1.06 to 1.37) than those in nonreporting states. This was observed predominantly in patients who did not receive percutaneous revascularization in public reporting states (adjusted OR: 1.30, 95% CI: 1.13 to 1.50), whereas those undergoing the procedure had lower mortality (OR: 0.71, 95% CI: 0.62 to 0.83).

CONCLUSIONS

Public reporting is associated with reduced percutaneous revascularization and increased in-hospital mortality among patients with AMI, particularly among patients not selected for PCI.

Contrast-induced nephropathy following chronic total occlusion percutaneous coronary intervention in patients with chronic kidney disease

OBJECTIVES

Contrast-induced nephropathy (CIN) has not been systematically studied in high-risk patients with chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI) for chronic total occlusion (CTO).

METHODS

We prospectively observed 515 consecutive patients with CKD undergoing PCI. Patients were divided into three groups: patients who underwent attempted PCI for CTO (group A, n = 85), patients who did not receive PCI for CTO (group B, n = 45) and patients without CTO (group C, n = 385).

RESULTS

CIN developed in 55 patients (10.68 %). Group A patients received a larger CM dose than group B or group C (p = 0.024). The intravenous hydration volume, age and CIN Mehran score were not significantly different between the three groups. The incidence of CIN was 9.4 % for group A, 6.7 % for group B and 11.4 % for group C (p = 0.344). In-hospital mortality and required renal replacement therapy (p = 0.325) were not significantly different between the groups. Multivariate analysis showed that after adjusting for potential confounding factors, the odds ratio for CIN was 1.03 (p = 0.944) for group A and 0.64 for group B (p = 0.489) compared to group C.

CONCLUSIONS

Attempts to achieve recanalization of CTO in patients with CKD might not increase the risk of CIN if appropriate preventative measures are taken.

KEY POINTS

• Contrast-induced nephropathy can increase morbidity and mortality • Chronic kidney disease patients are at the greatest risk of CIN • Patients with CKD undergoing CTO-PCI are common • Incidence of CIN has not been reported in CKD patients • CTO-PCI in CKD patients might not increase the risk of CIN.

Patients with both CYP2C19 loss-of-function allele and peripheral endothelial dysfunction are significantly correlated with adverse cardiovascular events following coronary stent implantation

BACKGROUND

There is some controversy regarding the effect of CYP2C19 polymorphism on clinical outcome in patients receiving dual antiplatelet therapy (DAPT). Peripheral endothelial dysfunction has recently been reported to predict adverse cardiovascular events. We hypothesized that CYP2C19 loss-of-function (LOF) allele carriers with peripheral endothelial dysfunction had worse prognosis. The aim of this study was to evaluate an additive effect of peripheral endothelial dysfunction on clinical outcome following percutaneous coronary intervention (PCI) in patients with a CYP2C19 variant.

METHODS

We enrolled 434 patients on DAPT following PCI. CYP2C19 genotype was examined, and we divided patients into two groups: carriers, who had at least one CYP2C19 LOF allele, and non-carriers. Peripheral endothelial dysfunction was examined using reactive hyperemia-peripheral arterial tonometry index (RHI), and we divided patients into low and high RHI. Thus, subjects were divided into four groups, and clinical events were followed up.

RESULTS

A total of 55 patients had a cardiovascular event. Kaplan-Meier analysis demonstrated a significantly higher probability of cardiovascular events in carriers with low RHI (log-rank test: p=0.007). Multivariate Cox proportional hazards analysis identified both CYP2C19 LOF allele possession (hazard ratio (HR): 1.94; 95% confidence interval (CI): 1.1-3.69; p=0.045) and low RHI (HR: 2.15; 95% CI: 1.22-3.78; p=0.008) as independent and significant predictors of future cardiovascular events.

CONCLUSIONS

CYP2C19 LOF allele carriers with peripheral endothelial dysfunction were significantly correlated with cardiovascular events. The additional evaluation of peripheral endothelial function along with CYP2C19 polymorphism might improve risk stratification after coronary stent implantation.

Anticoagulant therapy and outcomes in patients with prior or acute heart failure and acute coronary syndromes: Insights from the APixaban for PRevention of Acute ISchemic Events 2 trial

BACKGROUND

Clinical outcomes and the effects of oral anticoagulants among patients with acute coronary syndrome (ACS) and either a history of or acute heart failure (HF) are largely unknown. We aimed to assess the relationship between prior HF or acute HF complicating an index ACS event and subsequent clinical outcomes and the efficacy and safety of apixaban compared with placebo in these populations.

METHODS

High-risk patients were randomly assigned post-ACS to apixaban 5.0 mg or placebo twice daily. Median follow-up was 8 (4-12) months. The primary outcome was cardiovascular death, myocardial infarction, or stroke. The main safety outcome was thrombolysis in myocardial infarction major bleeding.

RESULTS

Heart failure was reported in 2,995 patients (41%), either as prior HF (2,076 [28%]) or acute HF (2,028 [27%]). Patients with HF had a very high baseline risk and were more often managed medically. Heart failure was associated with a higher rate of the primary outcome (prior HF: adjusted hazard ratio [HR] 1.73, 95% CI 1.42-2.10, P < .0001, acute HF: adjusted HR 1.65, 95% CI 1.35-2.01, P < .0001) and cardiovascular death (prior HF: HR 2.54, 95% CI 1.82-3.54, acute HF: adjusted HR 2.52, 95% CI 1.82-3.50). Patients with acute HF also had significantly higher rates of thrombolysis in myocardial infarction major bleeding (prior HF: adjusted HR 1.22, 95% CI 0.65-2.27, P = .54, acute HF: adjusted HR 1.78, 95% CI 1.03-3.08, P = .04). There was no statistical evidence of a differential effect of apixaban on clinical events or bleeding in patients with or without prior HF; however, among patients with acute HF, there were numerically fewer events with apixaban than placebo (14.8 vs 19.3, HR 0.76, 95% CI 0.57-1.01, interaction P = .13), a trend that was not seen in patients with prior HF or no HF.

CONCLUSIONS

In high-risk patients post-ACS, both prior and acute HFs are associated with an increased risk of subsequent clinical events. Apixaban did not significantly reduce clinical events and increased bleeding in patients with and without HF; however, there was a tendency toward fewer clinical events with apixaban in patients with acute HF.

Standards of specialized diabetes care. Edited by Dedov I.I., Shestakova M.V. (7th edition)

We are glad to present the 7th Edition of Standards of Diabetes Care.These evidence-based guidelines were designed to standardize and facilitate diabetes care in all regions of the Russian Federation.The Standards are updated on the regular basis to incorporate new data and relevant recommendations from national and international clinical societies, including World Health Organization Guidelines (WHO, 2011, 2013), International Diabetes Federation (IDF, 2011, 2012, 2013), American Diabetes Association (ADA, 2012, 2015), American Association of Clinical Endocrinologists (AACE, 2013), International Society for Pediatric and Adolescent Diabetes (ISPAD, 2014) and Russian Association of Endocrinologists (RAE, 2011, 2012).Current edition of the ?Standards? also integrates results of completed randomized clinical trials (ADVANCE, ACCORD, VADT, UKPDS, etc.), as well as findings from the national studies of diabetes mellitus (DM), conducted in close partnership with a number of Russian hospitals.Latest data indicates that prevalence of DM increased during the last decade more than two-fold, reaching some 387 million patients by the end of 2014. According to the current estimation by the International Diabetes Federation, 592 million patients will be suffering from DM by 2035. These observations resulted in the UN Resolution 61/225 passed on 20.12.2006 that encouraged all Member States "to develop national policies for the prevention, treatment and care of diabetes".Like many other countries, Russian Federation experiences a sharp rise in the prevalence of DM. According to Russian State Diabetes Register, there are at least 4.1 million patients with DM in this country. However, the epidemiological survey conducted by the Federal Endocrinology Research Centre during 2002-2010 suggests that actual prevalence is 3 to 4 times greater than the officially recognized and, by this estimate, amounts to 9-10 million persons, comprising 7% of the national population.Severe consequences of the global pandemics of DM include its vascular complications: nephropathy, retinopathy, coronary, cerebral and peripheral vascular disease. These conditions are responsible for the majority of cases of diabetes-related disability and death.Current edition of the "Standards" emphasizes the patient-oriented approach in making decisions on therapeutic goals, such as levels of glycaemia and blood pressure. It also features updated guidelines on the management of vascular complications.This text represents a consensus by the absolute majority of national experts, achieved through a number of fruitful discussions held at national meetings and forums. These guidelines are intended for endocrinologists and diabetologists, primary care physicians, cardiologists and other medical professionals involved in prevention and treatment of diabetes mellitus.

Platelet reactivity and cardiovascular events after percutaneous coronary intervention in patients with stable coronary artery disease: the Stent Thrombosis In Belgium (STIB) trial

AIMS

The Stent Thrombosis In Belgium (STIB) trial aimed to determine whether assessing platelet reactivity (PR) in patients with stable coronary artery disease undergoing elective percutaneous coronary intervention (PCI) could predict the risk of ischaemic complications and adverse clinical events up to 30 days post PCI.

METHODS AND RESULTS

PR before intervention was determined in 891 patients undergoing PCI for stable angina pectoris. Twelve to 24 hours before PCI, all patients received a 600 mg clopidogrel dose followed by 75 mg daily, and 500 mg of aspirin followed by 80-100 mg daily. Residual PR was assessed by VerifyNow point-of-care aspirin and P2Y12 assay before PCI. "Non-responders" to antiplatelet therapy were defined as aspirin reaction unit (ARU) >550 and as P2Y12 reaction unit (PRU) >230. The endpoint of the study was the composite of periprocedural myonecrosis, stent thrombosis, non-fatal myocardial infarction (MI), stroke and death at 30 days in patients with or without high PR. The endpoint was observed in 180 patients: four deaths, one stroke, 11 Q-wave MI, three non-Q-wave MI and 161 periprocedural myonecroses. At multivariate analysis, the endpoint was predicted by total stent length (OR: 1.020), GFR <60 ml/min (OR: 1.87), history of PCI (OR: 0.58), white blood cell count (OR: 1.95) and diabetes (OR: 1.83). No significant association was found between residual PR and the primary endpoint or any of its components.

CONCLUSIONS

PR measured before PCI in stable patients undergoing elective PCI who are preloaded with 500 mg of aspirin and 600 mg of clopidogrel is not predictive of periprocedural myocardial injury or adverse ischaemic complications up to 30 days.

Assessment of adherence to ACC/AHA guidelines in primary management of patients with NSTEMI in a referral cardiology hospital

Acute coronary syndromes are considered as a global major health-care problem, and Iran as a developing country is of no exception. We aimed to investigate the degree of adherence to American College of Cardiology and American Heart Association (ACC/AHA) guideline for the management of non-ST-segment elevation myocardial infarction (NSTEMI) in patients who presented to the emergency department at Tehran Heart Center. Data of the patients who presented with acute chest pain to the emergency department of Tehran Heart Center within 1 year and were diagnosed as NSTEMI by the cardiologist in charge were included. The details of the initial managements based on the ACC/AHA guideline for NSTEMI of the patients were recorded from the patients' files in the emergency department for this study. Then, the frequency of guideline-related management in the study population was calculated and reported. A total of 684 patients [mean age = 62.95 ± 12.19 years; male gender = 460 (67.3%)] were diagnosed as NSTEMI at the emergency department of our center. Initial management based on the current guideline including administration of aspirin and clopidogrel was performed in 98.4% and 95.0%, respectively. Intravenous heparin was administered in 67.0% of the patients, whereas 30.8% of patients received enoxaparin. Following the initial management, coronary angiography was performed in 563 (82.3%) patients within 48 hours from the admission. Adherence to ACC/AHA guideline for the management of NSTEMI in patients who presented to a tertiary health-care center was in a high degree.

Use of novel antiplatelet agents in acute coronary syndromes

Acute coronary syndromes (ACS) encompass a broad spectrum of clinical presentations based on underlying pathology that results in myocardial ischemia and/or infarction. Despite advancements in invasive management and secondary preventive therapies, recurrent atherothrombotic coronary events remain a prevalent cause of death and recurrent cardiac events after ACS and, in those who survive, the root of long-standing cardiac comorbidities. Antiplatelet drug therapy has proven beneficial in the reduction of these events, and novel antiplatelet agents have resulted in significant improvement in clinical outcomes over the last decade. However, the balance of optimal platelet inhibition with minimal bleeding complications remains a clinical challenge. This review focuses on more recent advances in antiplatelet therapies used in the treatment of ACS.

Translation of acute coronary syndrome therapies: from evidence to routine clinical practice

BACKGROUND

The use of evidence-based therapies has improved the outcome of patients with acute coronary syndrome (ACS), but there is a time lag between the generation of clinical evidence and its application in routine clinical practice. We sought to quantify temporal lags in the lifecycle of American College of Cardiology (ACC)/American Heart Association (AHA) class IA ACS therapies.

METHODS

Using current and historical ACC/AHA guideline publications, we retrieved publication dates of pivotal clinical trials (PCTs) and class IA guideline-recommended therapies for patients with ST-elevation myocardial infarction (STEMI) and unstable angina (UA)/non-STEMI (NSTEMI). Clinical practice uptake data for each therapy were retrieved from the National Registry for Myocardial Infarction, Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines, and Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines, which are registries containing publicly available peer-reviewed data. Descriptive data were calculated and compared for each phase of the evidence lifecycle for both STEMI and UA/NSTEMI drug classifications.

RESULTS

We identified 11 class IA- and 4 class IB/IC-recommended therapies for acute, inhospital, and discharge use for patients with STEMI or UA/NSTEMI. The median time lags were 2 years (interquartile range [IQR], 1-4 years) from PCT to practice guideline recommendation, 14 years (IQR, 11-15 years) from guideline recommendation to 90% practice uptake, and overall, a 16-year median (IQR, 13-19 years) from PCT to 90% practice uptake.

CONCLUSIONS

The time of PCT publication to meaningful uptake of class IA ACS therapies into clinical practice took a median of 16 years. This significant time lag indicates systemic barriers to the translation of therapeutics into routine clinical practice.

Relation between stent thrombosis and calcium channel blocker after drug-eluting stent implantation: Kumamoto Intervention Conference Study (KICS) registry

BACKGROUND

Stent thrombosis (ST) has emerged as a severe complication of percutaneous coronary intervention (PCI). Since the occurrence of ST is lower in Japan than Western countries, there are few data to predict ST after drug-eluting stent (DES) implantation in Japan. We examined the independent predictors of ST incidence after DES implantation in Japanese patients, including the use of calcium channel blockers (CCBs).

METHODS AND RESULTS

We used data from the Kumamoto Intervention Conference Study registry. There were 6286 consecutive patients enrolled from June 2008 to March 2011. Among them, we analyzed 3493 patients who underwent DES implantation. The incidence of definite/probable ST throughout a median follow-up period of 364 days was 0.57% (20 patients). There were 8 patients with early ST (within 30 days), 8 patients with late ST (between 31 and 365 days), and 4 patients with very late ST (after 1 year). The frequency of CCB use was significantly lower in ST than non-ST patients (25.0% versus 51.4%, respectively, p=0.016). Multiple regression analysis showed that longer stent length (p=0.034), acute coronary syndrome (p=0.039), and the absence of CCB use (p=0.046) were significant and independent predictors of ST within 1 year.

CONCLUSIONS

These results suggest that CCB use may be associated with a decreased risk of ST after DES implantation within 1 year in Japanese patients.