2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/Non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines

Prescription Patterns of Clopidogrel, Prasugrel, and Ticagrelor After Percutaneous Coronary Intervention With Stent Implantation (from the NCDR PINNACLE Registry)

The use of prasugrel and ticagrelor as part of dual antiplatelet therapy is increasing in patients after percutaneous coronary intervention (PCI). Accordingly, we aimed to evaluate their prescription patterns in the National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) registry. We analyzed patients enrolled in NCDR PINNACLE registry from January 2013 to March 2015 who underwent PCI with drug-eluting stent and were prescribed dual antiplatelet therapy. All patients received aspirin. The primary study outcome was a 3-level variable denoting the second antiplatelet agent prescribed: (1) clopidogrel, (2) prasugrel, or (3) ticagrelor. Baseline characteristics were compared among the 3 groups. Odds ratios and 95% credible intervals were calculated from a nested hierarchical Bayesian logistic regression models to identify independent predictors of prescription of antiplatelet medications, incorporating practice and provider as random effects. Our study cohort consisted of 26,710 patients during our study period January 2013 to March 2015. Seventy nine percent of patients were prescribed clopidogrel, 12% prasugrel, and 11% ticagrelor. Patients aged ≥75 years, women, history of tobacco use, Peripheral Arterial Disease (PAD), hypertension, diabetes, previous vascular complication, heart failure, and stroke/transient ischemic attack were more likely to be on clopidogrel than prasugrel or ticagrelor. The relative percentages of ticagrelor and prasugrel were higher in patients with history of myocardial infarction, compared with those without myocardial infarction. In summary, our study highlights the prescription patterns associated with prescription of antiplatelet agents after PCI. We found that both ticagrelor and prasugrel were mostly prescribed per the current practice guidelines, thus reflecting appropriate guideline adherence by practices in NCDR PINNACLE registry.

Stronger correlation with myocardial ischemia of high-sensitivity troponin T than other biomarkers

BACKGROUND

Acute myocardial infarction (AMI) is considered a major cause of death and disability. Myocardial perfusion scintigraphy (MPS) as a non-invasive diagnostic imaging procedure and certain biomarkers associated with myocardial ischemia (ISCH), such as ischemia-modified albumin (IMA), neuropeptide Y (NPY), N-terminal pro b-type natriuretic peptide (NT-proBNP), and high-sensitivity troponin T (hsTnT) could probably aid in the detection of myocardial infarction.

METHODS

Between December 2011 and June 2012, we prospectively analyzed patients who underwent a MPS study with the clinical question of myocardial ISCH. An exercise test was performed along with a MPS. Blood was drawn from the patients before exercise and the within 3 minutes from achieving maximum load and was analyzed for the aforementioned biomarkers.

RESULTS

A total of 71 patients (56 men and 15 women) were enrolled with a mean age of 61 ± 12 years. Twenty-six patients (36.6%) showed reduced uptake on stress MPS images that normalized at rest, a finding consistent with ISCH. Between ISCH and non-ISCH groups, only hsTnT levels showed a significant difference with the highest levels pertaining to the former group both before (0.0075 ng/ml vs 0.0050 ng/ml, P = 0.023) and after stress exercise (0.0085 vs 0.0050, P = 0.015). The most prominent differences were seen in higher stages of the Bruce protocol (stress duration > 9.05 minutes - P < 0.017). None of the IMA, NPY, and NP-pro BNP showed significant differences in time between the two groups.

CONCLUSIONS

Although IMA, NPY, and NT-pro BNP may not detect minor ischemic myocardial insults, serum hsTnT holds a greater ability of detecting not only myocardial infarction but also less severe ischemia. Further studies with larger cohorts of patients are warranted in order to better define the role of hsTnT as a screening tool for myocardial ischemia.

Evaluation of the impact of the GRACE risk score on the management and outcome of patients hospitalised with non-ST elevation acute coronary syndrome in the UK: protocol of the UKGRIS cluster-randomised registry-based trial

INTRODUCTION

For non-ST-segment elevation acute coronary syndrome (NSTEACS) there is a gap between the use of class I guideline recommended therapies and clinical practice. The Global Registry of Acute Coronary Events (GRACE) risk score is recommended in international guidelines for the risk stratification of NSTEACS, but its impact on adherence to guideline-indicated treatments and reducing adverse clinical outcomes is unknown. The objective of the UK GRACE Risk Score Intervention Study (UKGRIS) trial is to assess the effectiveness of the GRACE risk score tool and associated treatment recommendations on the use of guideline-indicated care and clinical outcomes.

METHODS AND ANALYSIS

The UKGRIS, a parallel-group cluster randomised registry-based controlled trial, will allocate hospitals in a 1:1 ratio to manage NSTEACS by standard care or according to the GRACE risk score and associated international guidelines. UKGRIS will recruit a minimum of 3000 patients from at least 30 English National Health Service hospitals and collect healthcare data from national electronic health records. The co-primary endpoints are the use of guideline-indicated therapies, and the composite of cardiovascular death, non-fatal myocardial infarction, new onset heart failure hospitalisation or cardiovascular readmission at 12 months. Secondary endpoints include duration of inpatient hospital stay over 12 months, EQ-5D-5L responses and utilities, unscheduled revascularisation and the components of the composite endpoint over 12 months follow-up.

ETHICS AND DISSEMINATION

The study has ethical approval (North East - Tyne & Wear South Research Ethics Committee reference: 14/NE/1180). Findings will be announced at relevant conferences and published in peer-reviewed journals in line with the funder's open access policy.

TRIAL REGISTRATION NUMBER

ISRCTN29731761; Pre-results.

Prognostic value of fibrinogen-to-albumin ratio in predicting 1-year clinical progression in patients with non-ST elevation acute coronary syndrome undergoing percutaneous coronary intervention

Previous studies have indicated that fibrinogen and low serum albumin levels are associated with poor cardiovascular outcomes. The objective of the present study was to examine whether the fibrinogen-to-albumin ratio (FAR) was able to predict the 1-year prognosis of patients with non-ST elevation acute coronary syndrome (NSTE-ACS) following percutaneous coronary intervention (PCI). A total of 1,352 patients with NSTE-ACS undergoing PCI were included in this prospective study and were divided into a low-FAR group (FAR ≤8.713, n=901) and a high-FAR group (FAR>8.713, n=451). FAR was defined as the concentration ratio of fibrinogen (mg/dl) to albumin (mg/dl) multiplied by 100. The endpoint was the incidence of major adverse cardiovascular events (MACEs), including all-cause mortality, cardiac mortality, non-fatal myocardial reinfarction and unscheduled repeat revascularisation. The predictive performance was validated by receiver-operator characteristic (ROC) curve analysis. A total of 127 MACEs were noted during the 1-year follow-up period. Multivariate Cox analysis suggested that a high FAR was an independent predictor of all-cause mortality (hazard ratio=2.223, 95% confidence interval: 1.002-4.931, P=0.049). Regarding the predictor of MACEs, the FAR exhibited an area under the ROC curve of 0.676 with a sensitivity of 0.630 and a specificity of 0.726. The cut-off value was 9.114. The FAR was an independent prognostic factor in NSTE-ACS. The present results suggest that the FAR may serve as a potential prognostic indicator for patients with NSTE-ACS undergoing PCI (approval no. NCT02667548; January 29, 2016; Shengjing Hospital of China Medical University).

Safety and cost analysis of early discharge following percutaneous coronary intervention for acute coronary syndrome in patients with diabetes mellitus

Objective

To evaluate the safety and cost of early discharge compared with ordinary discharge in patients with diabetes mellitus (DM) following percutaneous coronary intervention (PCI) for acute coronary syndrome.

Methods

We performed a retrospective analysis of prospectively collected data from 474 patients with DM who were discharged from hospital following PCI at a regional center between 2012 and 2015.

Results

A total of 192 patients (40.5%) were included in the early discharge group and 282 patients (59.5%) were included in the ordinary group. Mortality and morbidity after PCI were recorded. Kaplan–Meier analysis showed similar prognosis between the two groups at 30 days and at 1 year after discharge. However, hospitalization expenses for the regular discharge group were significantly higher than those of the early discharge group (RMB65,750 vs. RMB50,983).

Conclusion

Our findings demonstrate that early discharge of patients with DM following PCI for acute coronary syndrome is safe compared with ordinary discharge, and may reduce hospitalization costs.

Left ventricular ejection fraction adds value over the GRACE score in prediction of 6-month mortality after ACS: the MADDEC study

Background

Reduced left ventricular ejection fraction (LVEF) is a risk marker for mortality after an acute coronary syndrome (ACS). Global Registry of Acute Coronary Events (GRACE) risk score, developed almost two decades ago, is the preferred scoring system for risk stratification in ACS. The aim of this study was to validate the GRACE score and evaluate whether LVEF has incremental predictive value over the GRACE in predicting 6-month mortality after ACS in a contemporary setting.

Methods

A retrospective analysis of all 1576 consecutive patients who were admitted to Tays Heart Hospital and underwent coronary angiography for a first episode of ACS (2015–2016). Clinical risk factors were extensively recorded. Adjusted Cox regression analysis was used to analyse the associations between LVEF and the GRACE score with 6-month all-cause mortality. The incremental predictive value was assessed by the change in C-statistic by Delong’s method for paired samples and by index of discrimination improvement (IDI).

Results

In univariable analysis, both LVEF and the GRACE were associated with 6-month mortality, and after applying both variables into the same model, the results remained significant (GRACE score: HR: 1.036, 95% CI 1.030 to 1.042; LVEF: HR: 0.965, 95% CI 0.948 to 0.982, both HRs corresponding to a one unit change in the exposure variable). The GRACE score demonstrated good discrimination for mortality (C-statistic: 0.833, 95% CI 0.795 to 0.871). Adding LVEF to the model with the GRACE score improved model performance significantly (C-statistic: 0.848, 95% CI 0.813 to 0.883, p=0.029 for the improvement and IDI 0.0171, 95% CI 0.0016 to 0.0327, p=0.031).

Conclusions

Adding LVEF to the GRACE score significantly improves risk prediction of 6-month mortality after ACS.

Maintenance dose of warfarin beyond time in therapeutic range for preventing vascular events

BACKGROUND

The quality of anticoagulation is closely associated with efficacy and safety in warfarin users. Although genetic polymorphisms have been related to warfarin dosages and vascular events(VE), genetic evaluations have not been recommended for all warfarin users. The aim is to evaluate the significance of the maintenance dose of warfarin (MDW) on VE, considering the time in therapeutic range (TTR).

METHODS

This retrospective study analyzed the data of patients who received warfarin for any reasons. A total of 11,835 patients with warfarin were divided into quartiles by MDW. We assessed TTR using the Rosendaal method and VE.

RESULTS

VE occurred in 9.1% of the warfarin users. The mean TTR level was 34.0 ± 25.7%, and the MDW was 3.38 ± 1.06 mg per day. Patients with VE were more likely to have a lower MDW and lower TTR levels. In moderate- or well-controlled TTR status, a lower MDW was significantly related to under-controlled anticoagulation and associated with higher risks of VE. Lower MDW had a higher risk of stroke or arterial/venous thromboembolism (Q1: OR, 1.57; 95% CI 1.25 to 1.96; Q2: OR, 1.40; 95% CI 1.12 to 1.75; Q3: OR, 1.35; 95% CI 1.08 to 1.68).

CONCLUSIONS

We suggest that patients with very low MDW might be at risk when using warfarin. Therefore, we propose that patients with a very low MDW might be alternatively considered for novel oral anticoagulants rather than warfarin.

Chronic spontaneous coronary artery dissection in association with antiphospholipid syndrome presenting as stable angina

A 52-year-old man presented to our cardiology service for an elective diagnostic coronary angiogram for risk stratification in the context of stable angina. He was diagnosed with antiphospholipid syndrome 2 years prior and had three known thrombotic episodes in the form of a stroke, retinal artery occlusion and deep vein thrombosis. Our initial differential was atherosclerotic coronary artery disease, however, coronary angiography demonstrated a dominant right coronary artery with a long segment of chronic spontaneous dissection distally but with thrombolysis in myocardial infarction III flow. He was treated medically with antianginals which rendered him asymptomatic and is currently on regular follow-up in the cardiology outpatient department.

Early diagnostic value of circulating microRNAs in patients with suspected acute myocardial infarction

BACKGROUND/AIMS

Evidence has shown that several microRNAs (miRNAs) may be involved in coronary plaque rupture and local thrombus. However, the diagnostic ability of these miRNAs in acute myocardial infarction (AMI) is less known. The aim of this study is to explore the diagnostic value of these circulating miRNAs in patients presenting with acute chest pain in the emergency department.

METHODS AND RESULTS

In a nested case-control study, 140 of 1,206 patients finally diagnosed with AMI were matched with 70 unstable angina and 70 noncardiac chest pain patients. Five candidate miRNAs (miR-483-5p, miR-155-5p, miR-451, miR-19b, and miR-223) were selected for validation. Among them, miR-19b, miR-223, and miR-483-5p were significantly higher in AMI patients compared with those without AMI. A multivariate analysis showed that these miRNAs were independent predictors of AMI. The overall areas under the receiver operating curves (AUCs) for miR-19b, miR-223, and miR-483-5p were 0.74, 0.65, and 0.70, respectively. However, serial sampling in AMI patients showed that these miRNAs already peaked on admission, which was earlier than troponin I. Among 170 patients with a negative troponin result at presentation, a panel of three miRNAs improved the discrimination ability to a clinical model. In 119 patients presenting within 3 hr after chest-pain onset, the diagnostic accuracy of each miRNAs was higher than Point of care (POC) troponin assay. And a panel of these miRNAs had an AUC of 0.92.

CONCLUSION

Circulating miR-19b, miR-223, and miR-483-5p may provide clinically useful information for diagnosis in the early phases of AMI.

Acupuncture therapy for the treatment of stable angina pectoris: An updated meta-analysis of randomized controlled trials

BACKGROUND AND PURPOSE

Stable angina pectoris is a common symptom imperiling patients' life quality. The purpose of this meta-analysis is to assess the effectiveness of acupuncture alone or acupuncture plus medicine for the treatment of stable angina pectoris.

METHODS

Seven databases were searched ranging from 1959 to February 2018. Quantitative analysis of randomized controlled trials (RCTs) was performed by RevMan 5.3 software and STATA 12.0 program, and Cochrane criteria for risk-of-bias was used to assess the methodological quality of the trials.

RESULTS

A total of 12 RCTs involving 974 patients were enrolled in this study. The pooled results showed that both acupuncture group (RR: 0.35, P < 0.00001; RR: 0.49, P < 0.00001) and acupuncture plus medicine group (RR: 0.26, P < 0.00001; RR: 0.52, P = 0.03) were associated with a higher percentage of improved anginal symptoms as well as electrocardiographic (ECG) results compared to medicine group. The acupuncture plus medicine group also had a lower intake rate of nitroglycerin than medicine group (Non-event RR: 0.79, P = 0.03). However, there was no significant difference in the reduction or discontinuation of nitroglycerin intake between acupuncture group and medicine group. No acupuncture-related adverse effects were observed or reported in the included trials.

CONCLUSION

Acupuncture therapy may improve anginal symptoms and ECG results in patients with stable angina pectoris, and can serve as an adjunctive treatment for this condition.

Outcomes of medically managed patients with myocardial infarction

AIMS

The purpose of this study was to compare outcomes associated with medical management of ST-elevation myocardial infarction and non-ST-elevation myocardial infarction patients presenting to hospitals with and without onsite catheterization facilities.

METHODS

All patients (n=25,921) with ST-elevation myocardial infarction (n=10,563) or non-ST-elevation myocardial infarction (n=15,358) in Alberta, Canada between April 2010-March 2016 were categorized according to availability of catheterization facilities at the hospital they presented to and their management strategy (medically managed without coronary angiography or medically managed after coronary angiography).

RESULTS

Overall, 51% presented to hospitals without catheterization facilities; and 34% were managed medically (18% without coronary angiography, and 16% after coronary angiography). Rates of medical management were higher at hospitals without versus those with catheterization facilities (43% vs. 24%, p<0.01). However, both the rate of presentation to hospitals without catheterization facilities (70% non-ST-elevation myocardial infarction, 24% ST-elevation myocardial infarction, p<0.01) and medical management (45% non-ST-elevation myocardial infarction, 18% ST-elevation myocardial infarction, p<0.01) differed by myocardial infarction type. The lack of catheterization facilities at the presenting hospital had no association with in-hospital mortality in patients medically managed without coronary angiography, but was associated with a lower risk of mortality among patients medically managed after coronary angiography. However, the latter benefit was restricted to non-ST-elevation myocardial infarction patients only (adjusted hazard ratio 0.43, 95% confidence interval: 0.25-0.76).

CONCLUSION

The availability of catheterization facilities at the hospital at which non-ST-elevation myocardial infarction and ST-elevation myocardial infarction patients presented influenced their likelihood of being medically managed, but was not associated with adverse short- or long-term mortality outcomes.

Is There Any Relationship between TSH Levels and Prognosis in Acute Coronary Syndrome?

Background

Some small studies have related higher levels of thyrotropin (TSH) to potentially worse prognosis in acute coronary syndromes. However, this relationship remains uncertain.

Objective

To analyze the outcomes of patients with acute coronary syndromes in relation to the value of TSH at admission.

Methods

Observational and retrospective study with 505 patients (446 in group I [TSH ≤ 4 mIU/L] and 59 in group II [TSH > 4 mIU/L]) with acute coronary syndromes between May 2010 and May 2014. We obtained data about comorbidities and the medications used at the hospital. The primary endpoint was in-hospital all-cause death. The secondary endpoint included combined events (death, non-fatal unstable angina or myocardial infarction, cardiogenic shock, bleeding and stroke). Comparisons between groups were made by one-way ANOVA and chi-square test. Multivariate analysis was determined by logistic regression. Analyses were considered significant when p < 0.05.

Results

Significant differences between groups I and II were observed regarding the use of enoxaparin (75.2% vs. 57.63%, p = 0.02) and statins (84.08% vs. 71.19%, p < 0.0001), previous stroke (5.83% vs. 15.25%, p = 0.007), combined events (14.80% vs. 27.12%, OR = 3.05, p = 0.004), cardiogenic shock (4.77% vs. 6.05%, OR = 4.77, p = 0.02) and bleeding (12.09% vs. 15.25%, OR = 3.36, p = 0.012).

Conclusions

In patients with acute coronary syndromes and TSH > 4 mIU/L at admission, worse prognosis was observed, with higher incidences of in-hospital combined events, cardiogenic shock and bleeding.

Prognostic Differences between Men and Women with Acute Coronary Syndrome. Data from a Brazilian Registry

Background

Gender-related differences have been reported in patients with acute coronary syndrome. The description of this comparative finding in a Brazilian registry has not yet been documented.

Objective

To compare male vs. female patients regarding the baseline characteristics, coronary findings, treatment and in-hospital and long-term prognosis.

Methods

This is a retrospective, multicenter and observational study that included 3,745 patients (2,437 males and 1,308 females) between May 2010 and May 2015. The primary in-hospital outcome was all-cause mortality. The secondary outcome consisted of combined events (cardiogenic shock, reinfarction, death, stroke and bleeding). The comparison between groups was performed using the chi-square and the t test, considering p < 0.05 as significant. In the long term, mortality and combined events were assessed using the Kaplan-Meier method, with a mean follow-up of 8.79 months.

Results

The mean age was 60.3 years for males and 64.6 for females (p < 0.0001). The most prevalent risk factor was systemic arterial hypertension in 72.9% of the women and 67.8% of the men (p = 0.001). Percutaneous coronary intervention was carried out in 44.9% of the males and 35.4% of the females (p < 0.0001), and coronary artery bypass grafting (CABG) was performed in 17% of the males and 11.8% of females (p < 0.0001), with a higher prevalence of three-vessel coronary artery disease in males (27.3% vs. 16.2%, p < 0.0001). Approximately 79.9% of the female patients received a diagnosis of acute coronary syndrome without ST-segment elevation, while in the male patients, this diagnosis was attained in 71.5% (p < 0.0001). No significant differences were observed between the groups in the short and long term, regarding both mortality and the combined events.

Conclusion

Several gender-related differences were observed in patients with acute coronary syndrome regarding the demographic characteristics, coronary artery disease pattern and implemented treatment. However, the prognostic evolution was similar between the groups.

Trends in the Incidence and In-Hospital Outcomes of Patients With Atrial Fibrillation Complicated by Non-ST-Segment Elevation Myocardial Infarction

Atrial fibrillation (AF) can present with non-ST-segment elevation myocardial infarction (NSTEMI). The incidence, characteristics, outcomes, and treatment of this subgroup of patients with AF remains poorly studied. Using data from the National Inpatient Sample database, we (1) compared baseline characteristics of patients with AF with/without NSTEMI, (2) evaluated their outcomes and associated trends over the study period (2004-2013), and (3) evaluated revascularization (by percutaneous coronary intervention or coronary artery bypass graft [CABG]) and the impact on patient outcomes. Of the 3 923 436 patients admitted with a primary diagnosis of AF, 47 785 (1.2%) had a secondary diagnosis of NSTEMI. In this subgroup with AF and NSTEMI, there was a significant trend toward a decrease in mortality ( P = .002), stroke ( P < .001), and gastrointestinal bleeding ( P < .001) during the study period. Compared to unrevascularized patients, revascularized patients were more likely to be younger (72.2 ± 10.2 vs 77.0 ± 11.8 years old, P < .001), male (57.8 vs 42.7%, P < .001), and had a much higher incidence of coronary risk factors. Revascularization was associated with increased survival in multivariable analysis (odds ratio: 0.562, 95% confidence interval: 0.334-0.946, P = .03). In conclusion, among patients admitted with AF, 1.2% were diagnosed with NSTEMI. A minority of patients with AF and NSTEMI underwent revascularization and had better in-hospital outcomes.

Probabilistic modeling personalized treatment pathways using electronic health records

BACKGROUND

Modeling personalized treatment pathways plays an important role in understanding essential/critical treatment behaviors performed on patients during their hospitalizations and thus provides the opportunity for the improvement of better health service delivery in treatment pathways.

OBJECTIVE

Unlike traditional business process mining, modeling personalized treatment pathways is more challenging because they are typically case-specific. Although several studies have been devoted to modeling patient treatment pathways, limited efforts have been made on the extraction of latent semantics and their transitions behind patient treatment pathways, which are often ambiguous and poorly understood.

METHODS

In this article, we propose an extension of the Hidden Markov Model to mine and model personalized treatment pathways by extracting latent treatment topics and identifying their sequential dependencies in pathways, in the form of probabilistic distributions and transitions of patients' raw Electronic Health Record (EHR) data.

RESULTS

We evaluated the proposed model on 48,024 patients with cardiovascular diseases. A total of 15 treatment topics and their typical transition routes were discovered from EHR data that contained 1,391,251 treatment events with 2786 types of interventions and that were evaluated by ten clinicians manually. The obtained p-values are 0.000146 and 0.009106 in comparison with both Latent Dirichlet Allocation and Sequent Naïve Bayes models, respectively; this outcome indicate that our approach achieves a better understanding of human evaluators on modeling personalized treatment pathway than that of benchmark models.

CONCLUSION

The experimental results on a real-world data set clearly suggest that the proposed model has efficiency in mining and modeling personalized treatment pathways. We argue that the discovered treatment topics and their transition routes, as actionable knowledge that represents the practice of treating individual patients in their clinical pathways, can be further exploited to help physicians better understand their specialty and learn from previous experiences for treatment analysis and improvement.

Comparison of enoxaparin and unfractionated heparin in patients with non-ST-segment elevation acute coronary syndrome undergoing percutaneous coronary intervention: a systematic review and meta-analysis

Background

No randomized trial has been conducted to directly compare enoxaparin with unfractionated heparin (UFH) in patients undergoing percutaneous coronary intervention (PCI) for non-ST-segment elevation acute coronary syndrome (NSTE-ACS). In an era where early invasive strategies are recommended in high risk patients, the effect of enoxaparin and UFH needs to be re-evaluated. The authors performed a meta-analysis to determine whether enoxaparin is superior to UFH in patients with NSTE-ACS undergoing PCI.

Methods

The composite efficacy end point included all-cause mortality and myocardial infarction (MI) in the hospital or within 60 days. Major bleeding, as defined in the individual clinical trials evaluated, was the main safety endpoint within the same time period. Pooled estimates of the difference in outcome between enoxaparin and UFH were calculated using fixed or random effects models.

Results

A total of 8,861 patients from 4 trials were included. In the pooled analysis, rates of death or MI were similar in patients treated with enoxaparin and UFH [risk ratio (RR), 0.89, 95% confidence interval (CI): 0.77-1.02, P=0.09; I² =50%]. Major bleeding was also similar between enoxaparin and UFH (RR, 1.21, 95% CI: 0.94-1.56, P=0.15, I²=39%). A subgroup analysis, including randomized trials only or trials with a large sample size, and a leave-one-out sensitivity analysis, demonstrated similar results with above, respectively.

Conclusions

In patients undergoing PCI for NSTE-ACS, rates for both death/MI and major bleeding were similar between patients treated with enoxaparin and UFH.

Serum gamma-glutamyl transferase is a predictor of mortality in patients with acute myocardial infarction

Gamma-glutamyl transferase (GGT) is involved in the pathogenesis of atherosclerosis and has been associated with adverse cardiovascular outcomes in patients with ischemic heart disease. However, the association between GGT and long-term mortality has not been studied in patients with acute myocardial infarction (AMI).A total of 2239 AMI patients for whom serum GGT values were available and who underwent percutaneous coronary intervention (PCI) were enrolled in the COREA-AMI (CardiOvascular Risk and idEntificAtion of potential high-risk population in Korean patients with AMI) registry. Patients with acute liver injury were excluded. Patients were classified into 2 groups according to normal (n = 1983) or elevated (n = 256) levels of serum GGT. The primary clinical outcome was all-cause mortality. The secondary outcome was cardiac death and recurrent non-fatal myocardial infarction (MI).The median follow-up period was 3.7 years, and both groups had similar characteristics. Patients with elevated GGT had significantly higher all-cause mortality compared to patients with normal GGT (21.9% vs. 14.4%, P = .001). The multivariate Cox proportional hazards model showed that elevated serum GGT level was independently correlated with mortality (hazard ratio 2.12[1.44-3.11]; P < .001). Although elevated serum GGT was independently associated with long-term mortality after 30 days after PCI, there was no association within 30 days after PCI. Elevated GGT was also associated with death of cardiac causes with statistical significance. In the subgroup analysis, stronger associations were observed in the young and female patients and in patients who had ST-segment elevation MI and preserved left ventricular ejection fraction at the first echocardiography after the indexed PCI.Elevated serum GGT is an independent predictor of long-term mortality in AMI patients.

Ticagrelor Use in Acute Myocardial Infarction: Insights From the National Cardiovascular Data Registry

BACKGROUND

Ticagrelor is a P2Y12 receptor inhibitor with superior clinical efficacy compared with clopidogrel. However, it is associated with reduced efficacy when combined with a high-dose aspirin.

METHODS AND RESULTS

Patients in the acute coronary treatment and intervention outcomes network (ACTION) Registry-Get With The Guidelines (GWTG) with acute myocardial infarction from October 2013 through December 2014 were included in the study (167 455 patients; 622 sites). We evaluated temporal trends in the prescription of P2Y12 inhibitors, and identified factors associated with ticagrelor use at discharge. Among patients discharged on ticagrelor and aspirin (21 262 patients), we evaluated the temporal trends and independent factors associated with high-dose aspirin prescription at discharge. Ticagrelor prescription at discharge increased significantly from 12% to 16.7% (P<0.0001). Decreases in prasugrel and clopidogrel use at discharge (15.7%-13.9% and 54.2%-51.1%, respectively, P<0.0001) were also observed. Independent factors associated with preferential ticagrelor prescription at discharge over clopidogrel included younger age, white race, home ticagrelor use, invasive management, and in-hospital re-infarction and stroke (P<0.0001 for all), whereas older age, female sex, prior stroke, home ticagrelor use, and in-hospital stroke (P<0.0001 for all) were associated with preferential ticagrelor prescription at discharge over prasugrel. High-dose aspirin was used in 3.1% of patients discharged on ticagrelor. Independent factors associated with high-dose aspirin prescription at discharge included home aspirin use, diabetes mellitus, previous myocardial infarction, previous coronary artery bypass graft, ST-segment-elevation myocardial infarction, cardiogenic shock, and geographic region (P=0.01).

CONCLUSIONS

Our contemporary analysis shows a modest but significant increase in the use of ticagrelor and a high rate of adherence to the use of low-dose aspirin at discharge.

Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association

Spontaneous coronary artery dissection (SCAD) has emerged as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, particularly among young women and individuals with few conventional atherosclerotic risk factors. Patient-initiated research has spurred increased awareness of SCAD, and improved diagnostic capabilities and findings from large case series have led to changes in approaches to initial and long-term management and increasing evidence that SCAD not only is more common than previously believed but also must be evaluated and treated differently from atherosclerotic myocardial infarction. High rates of recurrent SCAD; its association with female sex, pregnancy, and physical and emotional stress triggers; and concurrent systemic arteriopathies, particularly fibromuscular dysplasia, highlight the differences in clinical characteristics of SCAD compared with atherosclerotic disease. Recent insights into the causes of, clinical course of, treatment options for, outcomes of, and associated conditions of SCAD and the many persistent knowledge gaps are presented.

Secondary prevention after coronary artery bypass graft surgery: a primer

PURPOSE OF REVIEW

Despite the benefits of surgical coronary revascularization, patients continue to be at risk for ischemic events in the years that follow coronary artery bypass graft surgery (CABG), mandating the role for postoperative secondary preventive therapy. The purpose of this review was to present a summary on the subject of secondary prevention after CABG, including an overview of a recently published scientific statement, and highlight the newest studies in the field.

RECENT FINDINGS

Aspirin and statin therapy continue to be the mainstay of secondary prevention after CABG, although newer antiplatelet and lipid-lowering medicines are being actively studied for their potential benefits. Other important elements to secondary prevention after CABG include the aggressive management of hypertension, smoking cessation, and the initiation of cardiac rehabilitation.

SUMMARY

Secondary prevention is an essential component of postoperative care after CABG. Instituting preventive therapies after surgery optimizes graft patency and helps patients achieve the highest level of physical health and quality of life following CABG.

Severity of OSAS, CPAP and cardiovascular events: A follow-up study

BACKGROUND

Previous studies suggested obstructive sleep apnoea syndrome (OSAS) as a major risk factor for incident cardiovascular events. However, the relationship between OSAS severity, the use of continuous positive airway pressure (CPAP) treatment and the development of cardiovascular disease is still matter of debate.

STUDY OBJECTIVES

The aim was to test the association between OSAS and cardiovascular events in patients with concomitant cardio-metabolic diseases and the potential impact of CPAP therapy on cardiovascular outcomes.

METHODS

Prospective observational cohort study of consecutive outpatients with suspected metabolic disorders who had complete clinical and biochemical workup including polysomnography because of heavy snoring and possible OSAS. The primary endpoint was a composite of major adverse cardiovascular and cerebrovascular events (MACCE).

RESULTS

Median follow-up was 81.3 months, including 434 patients (2701.2 person/years); 83 had a primary snoring, 84 had mild, 93 moderate and 174 severe OSAS, respectively. The incidence of MACCE was 0.8% per year (95% confidence interval [CI] 0.2-2.1) in primary snorers and 2.1% per year (95% CI 1.5-2.8) for those with OSAS. A positive association was observed between event-free survival and OSAS severity (log-rank test; P = .041). A multivariable Cox regression analysis showed obesity (HR = 8.011, 95% CI 1.071-59.922, P = .043), moderate OSAS (vs non-OSAS HR = 3.853, 95% CI 1.069-13.879, P = .039) and severe OSAS (vs non-OSAS HR = 3.540, 95% CI 1.026-12.217, P = .045) as predictors of MACCE. No significant association was observed between CPAP treatment and MACCE (log-rank test; P = .227).

CONCLUSIONS

Our findings support the role of moderate/severe OSAS as a risk factor for incident MACCE. CPAP treatment was not associated with a lower rate of MACCE.

Sensitive Troponin I Assay in Patients with Chest Pain - Association with Significant Coronary Lesions with or Without Renal Failure

Introduction

Despite having higher sensitivity as compared to conventional troponins, sensitive troponins have lower specificity, mainly in patients with renal failure.

Objective

Study aimed at assessing the sensitive troponin I levels in patients with chest pain, and relating them to the existence of significant coronary lesions.

Methods

Retrospective, single-center, observational. This study included 991 patients divided into two groups: with (N = 681) and without (N = 310) significant coronary lesion. For posterior analysis, the patients were divided into two other groups: with (N = 184) and without (N = 807) chronic renal failure. The commercial ADVIA Centaur^® TnI-Ultra assay (Siemens Healthcare Diagnostics) was used. The ROC curve analysis was performed to identify the sensitivity and specificity of the best cutoff point of troponin as a discriminator of the probability of significant coronary lesion. The associations were considered significant when p < 0.05.

Results

The median age was 63 years, and 52% of the patients were of the male sex. The area under the ROC curve between the troponin levels and significant coronary lesions was 0.685 (95% CI: 0.65 - 0.72). In patients with or without renal failure, the areas under the ROC curve were 0.703 (95% CI: 0.66 - 0.74) and 0.608 (95% CI: 0.52 - 0.70), respectively. The best cutoff points to discriminate the presence of significant coronary lesion were: in the general population, 0.605 ng/dL (sensitivity, 63.4%; specificity, 67%); in patients without renal failure, 0.605 ng/dL (sensitivity, 62.7%; specificity, 71%); and in patients with chronic renal failure, 0.515 ng/dL (sensitivity, 80.6%; specificity, 42%).

Conclusion

In patients with chest pain, sensitive troponin I showed a good correlation with significant coronary lesions when its level was greater than 0.605 ng/dL. In patients with chronic renal failure, a significant decrease in specificity was observed in the correlation of troponin levels and severe coronary lesions.

Apixaban following acute coronary syndromes in patients with prior stroke: Insights from the APPRAISE-2 trial

BACKGROUND AND PURPOSE

Patients with prior stroke are at greater risk for recurrent cardiovascular events post-acute coronary syndromes (ACS) and may have a different risk/benefit profile with antithrombotic therapy than patients without prior stroke.

METHODS

We studied 7391 patients with ACS from APPRAISE-2, stratified by the presence or absence of prior stroke. Baseline characteristics and outcomes of cardiovascular death, myocardial infarction (MI), or stroke were compared between groups. Interactions between prior stroke, treatment assignment (apixaban vs placebo), and outcomes were tested before and after multivariable adjustment with Cox proportional hazards models.

RESULTS

A total of 902 patients (12%) had prior stroke. Those with prior stroke were older (69 vs 67 years), had more hypertension (91% vs 77%), peripheral vascular disease (22% vs18%), and impaired renal function (38% vs 30%) but less diabetes (44% vs 48%) than those without prior stroke. Patients with prior stroke vs no prior stroke had higher unadjusted rates of cardiovascular death (4.8% vs 4.0%), MI (11.2% vs 7.1%), and ischemic stroke (3.2% vs 0.9%). Patients with prior stroke assigned to apixaban had similar rates of the composite of cardiovascular death, MI, or stroke compared with those assigned to placebo (HR 1.39; 95% CI 0.92-2.08). Patients without prior stroke assigned to apixaban had similar rates of cardiovascular death, MI, or ischemic stroke compared with those assigned to placebo (HR 0.87; 95% CI 0.73-1.04; P-interaction=.041). Median follow-up was 240 days.

CONCLUSIONS

Patients with prior stroke are at higher risk for recurrent cardiovascular events post-ACS and had a differential risk/benefit profile with oral anticoagulation.

Hyperglycemia in Acute Coronary Syndromes: From Mechanisms to Prognostic Implications

Numerous studies have documented that hyperglycemia is frequent in patients hospitalized with acute coronary syndromes, affects patients with and without established diabetes, and is associated with adverse outcomes, with incremental increase in risk of mortality and complications observed across the spectrum of glucose elevations. This article reviews present knowledge about the association between glucose levels and outcomes of patients hospitalized with acute coronary syndromes; describes available data regarding inpatient glucose management in this patient group, and comparative data across the spectrum of critically ill hospitalized patients; addresses some controversies in this field; and offers practical recommendations for patient management based on existing data.

Two-year Follow-up of Patients With Unstable Angina/Non-ST Segment Elevation Myocardial Infarction Undergoing Early Invasive Strategy: Predictors of Normal or Near-Normal Coronary Angiography and Mortality

BACKGROUND

Predictors of normal or near-normal coronary angiography (NONCAG) in patients with unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) and their importance regarding the prognosis are not understood. Accordingly, we determined these predictors as well as mortality risk factors at 2-year follow-up of UA/NSTEMI patients managed by the early invasive strategy.

METHODS

We prospectively studied consecutive patients with UA/NSTEMI managed with the early invasive strategy at Tehran Heart Center, in 1-year period. Echocardiography was performed before coronary angiography (CAG) for all the patients. Baseline characteristics, laboratory parameters, echocardiographic findings, invasive treatment modalities, and survival status after 2 years of follow-up were collected. We identified the predictors of NONCAG in the first phase of the study and then the risk factors of mortality in the second phase.

RESULTS

In the study period, 298 patients including 211 (71%) males, with the age of 59.31 ± 10.72 years were enrolled. The following factors were predictors of NONCAG: the female sex (P < 0.001); negative family history of CAD (P = 0.028); Thrombolysis in Myocardial Infarction (TIMI) risk score (P < 0.001); and early transmitral flow velocity/mean mitral annular velocity (E/E'mean) (P = 0.003). The following items were significant protective factors against mortality: percutaneous coronary intervention (PCI) (P = 0.012), age (P = 0.001), and E/E'mean (P = 0.020).

CONCLUSION

Patients' baseline characteristics as well as echocardiographic data could help in predicting those with NONCAG and PCI can be considered as the treatment of strategy with the most protection against mortality.

Randomized trial of one-hour sodium bicarbonate vs standard periprocedural saline hydration in chronic kidney disease patients undergoing cardiovascular contrast procedures

Background

Guidelines advise periprocedural saline hydration for prevention of contrast induced-acute kidney injury (CI-AKI). We analysed whether 1-hour sodium bicarbonate hydration administered solely prior to intra-arterial contrast exposure is non-inferior to standard periprocedural saline hydration in chronic kidney disease (CKD) patients undergoing elective cardiovascular diagnostic or interventional contrast procedures.

Methods

We performed an open-label multicentre non-inferiority trial between 2011–2014. Patients were randomized to 1 hour pre-procedure sodium bicarbonate hydration (250 ml 1.4%, N = 168) or 4–12 hours saline hydration (1000 ml 0.9%, N = 165) prior to and following contrast administration (2000 ml of saline total). Primary outcome was the relative serum creatinine increase (%) 48–96 hours post contrast exposure. Secondary outcomes were: incidence of CI-AKI (serum creatinine increase>25% or >44μmol/L), recovery of renal function, the need for dialysis, and hospital costs within two months follow-up.

Results

Mean relative creatinine increase was 3.1% (95%CI 0.9 to 5.2%) in the bicarbonate and 1.1% (95%CI -1.2 to 3.5%) in the saline arm, mean difference 1.9% (95%CI -1.2 to 5.1%, p-non-inferiority <0.001). CI-AKI occurred in 11 (6.7%) patients randomized to sodium bicarbonate and 12 (7.5%) to saline (p = 0.79). Renal function did not fully recover in 40.0% and 44.4% of CI-AKI patients, respectively (p = 0.84). No patient required dialysis. Mean costs for preventive hydration and clinical preparation for the contrast procedure were $1158 for sodium bicarbonate vs. $1561 for saline (p < 0.001).

Conclusion

Short hydration with sodium bicarbonate prior to elective cardiovascular diagnostic or therapeutic contrast procedures is non-inferior to standard periprocedural saline hydration in CKD patients with respect to renal safety and results in considerable healthcare savings.

Trial registration

Netherlands Trial Register (http://www.trialregister.nl/trialreg/index.asp), Nr NTR2699

Third generation P2Y12 antagonists inhibit platelet aggregation more effectively than clopidogrel in a myocardial infarction registry

The current standard of antiplatelet therapy of patients after myocardial infarction includes the P2Y12 receptor antagonists clopidogrel, prasugrel or ticagrelor. This study aimed to compare the antiplatelet effect of clopidogrel, prasugrel and ticagrelor in patients after myocardial infarction. In a single-centre registry the antiplatelet effect of clopidogrel, prasugrel and ticagrelor was investigated by aggregometry in patients after myocardial infarction. To assess the overall capacity of platelet aggregation whole blood was induced with thrombin receptor activating peptide (TRAP; 32 μM). To specifically quantify the effect of P2Y12 antagonists, whole blood was stimulated with 6.4 μM adenosine diphophosphate (ADP). Relative ADP induced aggregation (r-ADP-agg) was defined as the ADP-TRAP ratio to reflect an individual degree of P2Y12-dependent platelet inhibition. Platelet function of 238 patients was analysed [clopidogrel (n=58), prasugrel (n=65), ticagrelor (n=115)]. The r-ADP-agg was 35 ± 14% for patients receiving clopidogrel, 28 ± 10% for patients receiving prasugrel and 26 ± 11% for patients receiving ticagrelor. The r-ADP-agg was significantly lower in patients treated with prasugrel (p=0.0024) or ticagrelor (p<0.0001) compared to clopidogrel. There was no significant difference between patients receiving prasugrel or ticagrelor (p=0.2559). In conclusion, prasugrel and ticagrelor provide a stronger platelet inhibition compared to clopidogrel in patients after myocardial infarction. No significant difference in platelet inhibition was detected between prasugrel and ticagrelor. (registry for patients after Myocardial Infarction Treated with AntiPlatelet agents; DRKS00003146).

Polypill, hypertension and medication adherence: The solution strategy?

INTRODUCTION

Hypertension is an important global health challenge and a leading preventable risk factor for premature death and disability worldwide. In current cardiology practice, the main obstacles in the management of patients affected by hypertension are comorbidities and poor adherence to pharmacological treatments. The World Health Organization has recently highlighted increased adherence as a key development need for reducing cardiovascular disease.

METHODS

Principal observational and clinical trial data regarding adherence, reductions in cardiovascular risk and safety of the polypill approach are summarized and reviewed.

CONCLUSIONS

The polypill approach has been conclusively shown to increase adherence relative to usual care in all cardiovascular patients, furthermore, concomitant risk factor reductions have also been suggested. To date, the use of polypill could represent a solution strategy in patients affected by hypertension, comorbidities and non-adherence even though further studies, especially in the real-world settings, are needed in order to better understand its role in clinical practice.

A novel fibroblast growth factor-1 ligand with reduced heparin binding protects the heart against ischemia-reperfusion injury in the presence of heparin co-administration

AIMS

Fibroblast growth factor 1 (FGF1), a heparin/heparan sulfate-binding growth factor, is a potent cardioprotective agent against myocardial infarction (MI). The impact of heparin, the standard of care for MI patients entering the emergency room, on cardioprotective effects of FGF1 is unknown, however.

METHODS AND RESULTS

To address this, a rat model of MI was employed to compare cardioprotective potentials (lower infarct size and improve post-ischemic function) of native FGF1 and an engineered FGF1 (FGF1ΔHBS) with reduced heparin-binding affinity when given at the onset of reperfusion in the absence or presence of heparin. FGF1 and FGF1ΔHBS did not alter heparin's anticoagulant properties. Treatment with heparin alone or native FGF1 significantly reduced infarct size compared to saline (P < 0.05). Surprisingly, treatment with FGF1ΔHBS markedly lowered infarct size compared to FGF1 (P < 0.05). Both native and modified FGF1 restored contractile and relaxation function (P < 0.05 versus saline or heparin). Furthermore, FGF1ΔHBS had greater improvement in cardiac function compared to FGF1 (P < 0.05). Heparin negatively impacted the cardioprotective effects (infarct size, post-ischemic recovery of function) of FGF1 (P < 0.05) but not of FGF1ΔHBS. Heparin also reduced the biodistribution of FGF1, but not FGF1ΔHBS, to the left ventricle. FGF1 and FGF1ΔHBS bound and triggered FGFR1-induced downstream activation of ERK1/2 (P < 0.05); yet, heparin co-treatment decreased FGF1-produced ERK1/2 activation, but not that activated by FGF1ΔHBS.

CONCLUSION

These findings demonstrate that modification of the heparin-binding region of FGF1 significantly improves the cardioprotective efficacy, even in the presence of heparin, identifying a novel FGF ligand available for therapeutic use in ischemic heart disease.

Comparison of Outcomes of Acute Coronary Syndrome in Patients ≥80 Years Versus Those <80 Years in Israel from 2000 to 2013

Although patients ≥80 years old constitute the fastest-growing segment of the population and have a high prevalence of coronary artery disease, few data exist regarding the outcome of octogenarians with acute coronary syndrome (ACS). In a retrospective study based on data of 13,432 ACS patients who were enrolled in the ACS Israel Survey, we first evaluated the clinical outcome of 1,731 ACS patients ≥80 years (13%) compared with 11,701 ACS patients <80 years (87%) hospitalized during 2000 to 2013. Second, we evaluated the clinical outcome of patients ≥80 years hospitalized during the 2000 to 2006 ("early") period (n = 1,037) compared with those of the same age group of patients hospitalized during the 2008 to 2013 ("late") period (n = 694). Implementation of the ACS AHA/ACC/ESC therapeutic guidelines was lower in ACS patients ≥80 years compared with patients <80 years. Multivariate Cox regression analysis demonstrated a worse 1-year survival rate in the ACS patients ≥80 years compared with those <80 years. During the late period, patients ≥80 years were more frequently treated with guideline-recommended therapies compared with patients from the same age group who were hospitalized in the early period. Multivariate Cox regression analysis demonstrated a better 1-year survival rate of patients ≥80 years during the late period compared with the early period (hazard ratio 1.17, 95% confidence interval 1.15 to 1.61; p = 0.01). In addition, adverse outcome rates of ACS patients ≥80 years were significantly higher compared with those of patients <80 years. However, survival rates of ACS patients ≥80 years were improved over the 200 to 2013 period.

Effect of ligustrazine on preventing contrast-induced nephropathy in patients with unstable angina

Objective

Our purpose was to assess the effect of ligustrazine in the prevention of contrast-induced nephropathy (CIN) in patients with unstable angina (UA).

Methods

148 patients with UA undergoing coronary angiography and/or percutaneous coronary intervention (PCI) were selected for observation; the patients were divided into a control group (group A, n=74) and a ligustrazine group (group B, n=74). Group A was given routine treatment, while group B was given routine treatment combined with ligustrazine. Serum creatinine (Scr), cystatin C and glomerular filtration rate (eGFR) concentrations were measured before and 1 day, 2 days and 3 days after treatment, and the incidence of contrast-induced nephropathy (CIN) and major cardiovascular events (MACE) were observed in both groups.

Results

The Scr, Cystatin C and eGRF levels in group B were better than in group A after 1 day (OR: 2.64, 95% CI: 2.47-4.98; OR: 2.66, 95% CI: 2.62-5.77; OR: 4.02, 95% CI: 3.02-5.53, respectively), 2 days (OR: 3.58, 95% CI: 2.41-4.92; OR: 2.92, 95% CI: 2.83-5.02; OR: 3.28, 95% CI: 3.24-5.14, respectively) and 3 days of treatment (OR: 3.26, 95% CI: 2.17-4.35; OR: 2.85, 95% CI: 2.26-4.02; OR: 3.19, 95% CI: 2.53-4.34, respectively). The incidence of CIN (9.26% vs 16.67%) and MACE (7.41% vs 18.51%) of group B were significantly lower than in group A (P<0.05).

Conclusions

Our study suggests that ligustrazine can reduce CIN and MACE in patients with UA when undergoing coronary angiography and/or PCI.

Six-month adherence to Statin use and subsequent risk of major adverse cardiovascular events (MACE) in patients discharged with acute coronary syndromes

BACKGROUND

The evidence of adherence to statin decreasing risk of major adverse cardiovascular events (MACEs) is still lack among patients discharged with acute coronary syndrome (ACS). Our objective is to determine the relationship between six-month adherence to statins and subsequent risk of MACEs in patients discharged with ACS.

METHODS

Using two prospective registry cohorts (CPACS-1 and -2), we analyzed data from 12,516 consecutive patients with ACS who were prescribed statin at hospital discharge and survived beyond 6 months without recurrent myocardial infarction (MI) or stroke. Adherence to statin was defined as good (using statin at discharge and 6 months without declined dosage) and poor adherence groups (using statin at discharge but declining dosage or stopping at 6 months). We compared the hazard ratios of all-cause mortality and MACE in subsequent 6 months between groups, using Cox-regression models, adjusting for multiple potential confounders.

RESULTS

Seventy two percent of patients adhered to statin therapy at 6 months. The incident MACE in the poor adherence group was significantly higher than in good adherence group (2.7% vs. 1.8%, p = 0.002). Compared with poor adherence group, the good adherence group showed a 27% lower relative risk of MACE during the 6 month follow up (fully-adjusted hazard ratio (HR) = 0.73; 95%CI: 0.56-0.97). The protective effects of good adherence were similar in groups with different statin dose as well as groups by other baseline clinical characteristics and treatments (p > 0.05 for interaction).

CONCLUSION

Our study highlights the importance of adherence to statin therapy in prevention of MACE and clinicians should aim to achieve higher dosage if tolerable.

CLINICAL TRIAL REGISTRATION

CPACS2 was registered on URL: http://www.anzctr.org.au/default.aspx and unique identifier is ACTRN12609000491268 . CPACS1 was not a clinical trial and thus not registered.

Triggering Receptor Expressed on Myeloid cells-1: a new player in platelet aggregation

Triggering Receptor Expressed on Myeloid cells-1 (TREM-1) is an immunoreceptor initially known to be expressed on neutrophils and monocytes/macrophages. TREM-1 acts as an amplifier of the inflammatory response during both infectious and aseptic inflammatory diseases. Another member of the TREM family, The Triggering receptor expressed on myeloid cells Like Transcript-1 (TLT-1) is exclusively expressed in platelets and promotes platelet aggregation. As the gene that encodes for TLT-1 is located in the TREM-1 gene cluster, this prompted us to investigate the expression of TREM-1 on platelets. Here we show that TREM-1 is constitutively expressed in α-granules and mobilised at the membrane upon platelet activation. Pharmacologic inhibition of TREM-1 reduces platelet activation as well as platelet aggregation induced by collagen, ADP, and thrombin in human platelets. Aggregation is similarly impaired in platelets from Trem-1^-/- mice. In vivo, TREM-1 inhibition decreases thrombus formation in a carotid artery model of thrombosis and protects mice during pulmonary embolism without excessive bleeding. These findings suggest that TREM-1 inhibition could be useful adducts in antiplatelet therapies.

Relative efficacy and safety of ticagelor vs clopidogrel as a function of time to invasive management in non-ST-segment elevation acute coronary syndrome in the PLATO trial

BACKGROUND

Guidelines suggest that "upstream" P2Y₁₂ receptor antagonists should be considered in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS).

HYPOTHESIS

Early use of ticagrelor in patients managed with an invasive strategy would be more effective than clopidogrel because of its more rapid onset of action and greater potency.

METHODS

In the PLATO trial, 6792 NSTE-ACS patients were randomized to ticagrelor or clopidogrel (started prior to angiography) and underwent angiography within 72 hours of randomization. We compared efficacy and safety outcomes of ticagrelor vs clopidogrel as a function of "early" (<3h) vs "late" (≥3h) time to angiography. Adjusted Cox proportional hazards models evaluated interaction between randomized treatment and time from randomization to angiography on subsequent outcomes.

RESULTS

Overall, a benefit of ticagrelor vs clopidogrel for cardiovascular death/myocardial infarction/stroke was seen at day 7 (hazard ratio [HR]: 0.67, P = 0.002), day 30 (HR: 0.81, P = 0.042), and 1 year (HR: 0.80, P = 0.0045). There were no significant interactions in the <3h vs ≥3h groups at any timepoint. For major bleeding, overall there was no significant increase (HR: 1.04, 95% confidence interval: 0.85-1.27); but there was a significant interaction with no difference between ticagrelor and clopidogrel in the early group (HR: 0.79), but higher bleeding risk with ticagrelor in the late angiography group, at 7 days (HR: 1.51, P_int = 0.002). Patterns were similar at 30 days and 1 year.

CONCLUSIONS

The benefit of ticagrelor over clopidogrel was consistent in those undergoing early and late angiography, supporting upstream use of ticagrelor.

Low adherence to national guidelines for proton-pump inhibitor prescription in patients receiving combination aspirin and anticoagulation

BACKGROUND

Aspirin, when used with concurrent anticoagulation, increases the risk of gastrointestinal bleeding (GIB). Therefore, multisociety guidelines recommend prophylactic proton-pump inhibitors (PPIs) for patients receiving aspirin and anticoagulation. We aimed to determine rates and predictors of adherence to these recommendations.

METHODS

All adult inpatients discharged from the hospital on aspirin and anticoagulation from July 2009 to June 2014 were retrospectively evaluated for PPI prescription on discharge instructions. We used univariate and multivariate logistic regression to test for predictors of PPI prescription.

RESULTS

A total of 2422 patients were discharged on aspirin and anticoagulation; the mean age was 68 years and 53.2% were male; 42.2% were prescribed a PPI at discharge. On univariate analysis, factors associated with discharge PPI prescription included increased age (47.1% versus 37.9%), white race (47.3% versus 37.1-40.2%), higher aspirin dose (55.1% versus 39.4%), being married (46.2% versus 39.4%) and preadmission PPI use (96.6% versus 23.4%). On multivariate analysis, significant predictors of discharge PPI prescription were age 60-69 years [odds ratio (OR) 1.61] and 70-79 years (OR 1.48), and preadmission PPI use (OR 120.03). Lower odds of discharge PPI prescription included Medicaid (OR 0.55) or Medicare (OR 0.71) insurance, Spanish language (OR 0.63), and lower dose aspirin (81 mg) (OR 0.40).

CONCLUSIONS

A total of 42.2% of patients discharged on aspirin and anticoagulation were prescribed PPIs. Older age and preadmission PPI use were predictive of PPI prescription, while Medicaid/Medicare insurance, Spanish language, and lower dose aspirin decreased the likelihood of discharge PPI prescription. This creates an opportunity to improve primary GIB prevention through quality improvement interventions.

Optimal secondary prevention medication use in acute myocardial infarction patients with nonobstructive coronary artery disease is modified by management strategy: insights from the TRIUMPH Registry

BACKGROUND

Patients with acute myocardial infarction (AMI) and nonobstructive coronary artery disease (nonobCAD) may be perceived to be at lower risk for cardiac events, relative to those with obstructive CAD (obCAD), and thus less likely to receive optimal preventive medications in the year following AMI.

HYPOTHESIS

We aimed to determine if AMI patients with nonobCAD, compared to obCAD, received lower rates of prevention medications in the year following AMI.

METHODS

We compared optimal prevention medication use at hospital discharge, 1, 6, and 12 months after hospitalization. Optimal medication use was defined as the receipt of all prevention medications for which that patient was eligible (eg, aspirin, clopidogrel, statins, β-blockers, and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers). We used multivariable logistic regression analyses to determine the association between nonobCAD to medication use and adjusted for potential confounders.

RESULTS

Three thousand six hundred thirty AMI patients were studied, of whom 200 (5.2%) had nonobCAD. Fewer nonobCAD patients received optimal medication use compared to obCAD patients at discharge (31% vs 65%, P < 0.001), driven primarily by lower rates of clopidogrel use (40.5% vs 83.3%, P < 0.001). After adjustment for percutaneous coronary intervention (PCI), differences in medication use were similar at discharge and 1 year after hospitalization. Stratified analyses by receipt of PCI suggested patients confined to medical management had less optimal medication use, regardless of their CAD burden.

CONCLUSIONS

Lower rates of unadjusted optimal medication use were seen in nonobCAD patients, driven by low clopidogrel use among medically managed patients, suggesting improvement efforts should focus on these patients.

Predictive values of D-dimer assay, GRACE scores and TIMI scores for adverse outcome in patients with non-ST-segment elevation myocardial infarction

Purpose

To determine the predictive values of D-dimer assay, Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) risk scores for adverse outcome in patients with non-ST-segment elevation myocardial infarction (NSTEMI).

Patients and methods

A total of 234 patients (mean age: 57.2±11.7 years, 75.2% were males) hospitalized with NSTEMI were included. Data on D-dimer assay, GRACE and TIMI risk scores were recorded. Logistic regression analysis was conducted to determine the risk factors predicting increased mortality.

Results

Median D-dimer levels were 349.5 (48.0–7,210.0) ng/mL, the average TIMI score was 3.2±1.2 and the GRACE score was 90.4±27.6 with high GRACE scores (>118) in 17.5% of patients. The GRACE score was correlated positively with both the D-dimer assay (r=0.215, P=0.01) and TIMI scores (r=0.504, P=0.000). Multivariate logistic regression analysis revealed that higher creatinine levels (odds ratio =18.465, 95% confidence interval: 1.059–322.084, P=0.046) constituted the only significant predictor of increased mortality risk with no predictive values for age, D-dimer assay, ejection fraction, glucose, hemoglobin A1c, sodium, albumin or total cholesterol levels for mortality.

Conclusion

Serum creatinine levels constituted the sole independent determinant of mortality risk, with no significant values for D-dimer assay, GRACE or TIMI scores for predicting the risk of mortality in NSTEMI patients.

A randomized clinical trial comparing long-term clopidogrel vs aspirin monotherapy beyond dual antiplatelet therapy after drug-eluting coronary stent implantation: Design and rationale of the Harmonizing Optimal Strategy for Treatment of coronary artery stenosis-Extended Antiplatelet Monotherapy (HOST-EXAM) trial

Percutaneous coronary intervention (PCI) has been developed by drug-eluting stent (DES), but stent implantation has brought the issue of stent thrombosis and optimal antiplatelet therapy. Guidelines recommend at least 6- to 12 months of dual antiplatelet therapy (DAPT) with aspirin and a P2Y₁₂ receptor inhibitor such as clopidogrel. Beyond DAPT after PCI with DES, however, there has been still a debate for antiplatelet regimen. Therefore, we report on the upcoming HOST-EXAM trial (NCT02044250), which will evaluate the efficacy and safety of aspirin and clopidogrel monotherapies beyond DAPT after DES implantation.

TRIAL DESIGN

The HOST-EXAM is a prospective, randomized, open-label, multicenter, comparative effectiveness trial, to compare between clopidogrel (75 mg once daily) and aspirin (100 mg once daily) as long-term antiplatelet agents. A total of 5,530 patients with no clinical events during combined antiplatelet therapy for 12±6 months after index PCI will be screened, enrolled, and randomized to either group (1:1 ratio) receiving antiplatelet monotherapy for 2 years. The primary endpoint will be the rate of clinical events defined as a composite of all-cause death, nonfatal myocardial infarction, stroke, readmission due to acute coronary syndrome, or major bleeding at 24 months after randomization.

CONCLUSIONS

The HOST-EXAM will be the first large-scale randomized controlled study to directly compare the efficacy and safety of long-term antiplatelet monotherapy beyond DAPT after DES implantation. This study will provide clinical evidence to establish optimal regimen for long-term antiplatelet therapy after DES implantation.

Remnant cholesterol predicts periprocedural myocardial injury following percutaneous coronary intervention in poorly-controlled type 2 diabetes

BACKGROUND

Remnant cholesterol (RC) is receiving increasing attention regarding its relation to cardiovascular risk. Whether RC is associated with periprocedural myocardial injury (PMI) following percutaneous coronary intervention (PCI) in type 2 diabetes (T2D) is currently unknown.

METHODS

We prospectively enrolled 1182 consecutive T2D patients who were scheduled for PCI but with baseline normal preprocedural cardiac troponin I (cTnI). Patients were divided according to their glycemic control status: group A [glycated hemoglobin (HbA1c)<7%, n=563] and group B (HbA1c≥7%, n=619). PMI was evaluated by cTnI analysis within 24h. The associations of preprocedural RC and the RC to high-density lipoprotein cholesterol ratio (RC/HDL-C) with PMI were investigated.

RESULTS

The associations of RC and RC/HDL-C with PMI were observed in group B (both p<0.05) but not in group A (both p>0.05). Patients in group B, a 1-SD increase of RC produced 30% and 32% increased risk for postprocedural cTnI>3× upper limit of normal (ULN) and >5×ULN, respectively. The odds ratios for RC/HDL-C were the highest compared with any cholesterol fractions including total cholesterol (TC)/HDL-C, low density lipoprotein cholesterol (LDL-C)/HDL-C, nonHDL-C/HDL-C, and triglyceride/HDL-C with 1.43 [95% confidence interval (CI): 1.10-1.88] for >3× ULN and 1.49 (95% CI: 1.13-1.97) for >5× ULN. However, no such associations were found in group A. Furthermore, patients with RC >27.46mg/dL (third tertile) [RC≤14.15mg/dL (first tertile) as reference] were associated with a 1.57-fold and 2-fold increased risk for >3× ULN and >5× ULN in group B, respectively.

CONCLUSIONS

RC and RC/HDL-C might be valuable, independent predictors for PMI in poorly-controlled diabetic patients undergoing PCI.