Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology

Oxygen therapy for patients with acute myocardial infarction: a meta-analysis of randomized controlled clinical trials

BACKGROUND

Oxygen therapy is widely used for patients with acute myocardial infarction (AMI). However, there is uncertainty about its safety and benefits. The aim of this study is to perform a systematic review and meta-analysis to assess the effectiveness and safety of oxygen therapy for patients with AMI.

MATERIALS AND METHODS

We searched MEDLINE, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials from 1 January 1967, through 31 December 2017. We included randomized controlled clinical trials that used oxygen therapy for patients with suspected or confirmed AMI less than 24 h of symptoms onset. Hyperbaric and aqueous oxygen therapy trials were excluded.

RESULTS

A total of six randomized controlled clinical trials with 7190 individuals were included in this meta-analysis. Compared with no oxygen group, oxygen therapy did not reduce the risk of all-cause mortality [pooled risk ratio (RR): 1.06, 95% confidence interval (CI): 0.56-2.02, P=0.19], recurrent myocardial infarction (pooled RR: 1.57, 95% CI: 0.88-2.80, P=0.18), and pain (pooled RR: 0.97, 95% CI: 0.82-1.14, P=0.25).

CONCLUSION

In this meta-analysis, oxygen inhalation did not benefit patients with AMI with normal oxygen saturation.

The Strategy of Management Patients with non-ST Elevation Acute Coronary Syndrome

The review covers issues of epidemiology, diagnostics, management strategy, and treatment outcomes in patients with non-ST elevation acute coronary syndrome. Numerous factors affecting the choice of an invasive strategy are analyzed as well as its correspondence to existing recommendations of patient’s management. The stratification of risk of development of adverse coronary events, which is a part of the formation of a treatment strategy, is discussed.

The association between symptom onset characteristics and prehospital delay in women and men with acute coronary syndrome

BACKGROUND

A decision to delay seeking treatment for symptoms of acute coronary syndrome increases the risk of serious complications, disability, and death.

AIMS

The purpose of this study was to determine if there was an association between gradual vs abrupt symptom onset and prehospital delay for patients with acute coronary syndrome and to examine the relationship between activities at symptom onset and gradual vs abrupt symptom onset.

METHODS

This was a secondary analysis of a large prospective multi-center study. Altogether, 474 patients presenting to the emergency department with symptoms of acute coronary syndrome were included in the study. Symptom characteristics, activity at symptom onset, and prehospital delay were measured with the ACS Patient Questionnaire.

RESULTS

Median prehospital delay time was four hours. Being uninsured (β=0.120, p=0.031) and having a gradual onset of symptoms (β=0.138, p=0.003) were associated with longer delay. A diagnosis of ST-elevation myocardial infarction (β=-0.205, p=0.001) and arrival by ambulance (β=-0.317, p<0.001) were associated with shorter delay. Delay times were shorter for patients who experienced an abrupt vs gradual symptom onset (2.57 h vs 8 h, p<0.001). Among men with an abrupt onset of symptoms and a ST-elevation myocardial infarction diagnosis, 54% reported that symptoms were triggered by exertion (p=0.046).

CONCLUSION

Patients should be counselled that a gradual onset of symptoms for potential acute coronary syndrome is an emergency and that they should call 911. Men with ischemic heart disease or with multiple risk factors should be cautioned that symptom onset following exertion may represent acute coronary syndrome.

Screening for the Biomarkers Associated with Myocardial Infarction by Bioinformatics Analysis

We aimed to find novel biomarkers associated with myocardial infarction (MI). The array data of GSE62646 were downloaded from the Gene Expression Omnibus database. The differentially expressed genes (DEGs) were analyzed with limma package. Functional enrichment analyses were performed by DAVID v6.7 online tool. The micro-RNA-messenger RNA (miRNA-mRNA) pairs were predicted by miRWalk database, and the protein-mRNA interactions were predicted by StarBase. Then, miRNA-mRNA-protein regulatory network was constructed. Antigen processing and presentation were only the pathway enriched by DEG1 set such as KLRC4 (killer cell lectin-like receptor subfamily C, member 4) and KLRC2 (killer cell lectin-like receptor subfamily C, member 2). KLRC4 and KLRC2 were differentially expressed in MI patients. DLC1 (DLC1 Rho GTPase activating protein, degree = 179) was the most significant node in miRNA-mRNA-protein network. EIF4AIII (eukaryotic translation initiation factor 4A3) and FUS (FUS RNA binding protein) were the key proteins that regulated the most DEGs. KLRC4, KLRC2, and DLC1 were the biomarkers and may play important roles in the progression of MI. Furthermore, EIF4AIII and FUS may also be involved in MI progression.

Correlation between intracoronary thrombus components and coronary blood flow after percutaneous coronary intervention for acute myocardial infarction at different onset time

BACKGROUND

Acute myocardial infarction (AMI) is a leading cause of mortality. Early reperfusion to restore blood flow is crucial to successful treatment. In the current reperfusion regimen, an increasing number of patients have benefited from direct percutaneous coronary intervention (PCI). In order to understand whether there is a correlation between the components of coronary thrombosis and the absence of reflow or slow blood flow after coronary stent implantation in direct PCI, we collected data on direct PCI cases in our hospital between January 2016 and November 2018.

AIM

To investigate the correlation between intracoronary thrombus components and coronary blood flow after stent implantation in direct PCI in AMI.

METHODS

We enrolled 154 patients (85 male and 69 female, aged 36–81 years) with direct PCI who underwent thrombus catheter aspiration within < 3, 3–6 or 6–12 h of onset of AMI between January 2016 and November 2018. The thrombus was removed for pathological examination under a microscope. The patients of the three groups according to the onset time of AMI were further divided into those with a white or red thrombus. The thrombolysis in myocardial infarction (TIMI) blood flow after stent implantation was recorded based on digital subtraction angiography during PCI. The number of patients with no-reflow and slow blood flow in each group was counted. Statistical analysis was performed based on data such as onset time, TIMI blood flow.

RESULTS

There were significant differences in thrombus components between the patients with acute ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction (P < 0.01). In the group with PCI < 3 h after onset of AMI, there was no significant difference in the incidence of no-reflow and slow-flow between the white and red thrombus groups. In the groups with PCI 3-6 and 6-12 h after onset of AMI, there was a significant difference in the incidence of no-reflow and slow-flow between the white and red thrombus groups (P < 0.01). There was a significant correlation between the onset time of AMI and the occurrences of no-reflow and slow blood flow during PCI (P < 0.01).

CONCLUSION

In direct PCI, the onset time of AMI and color of coronary thrombus are often used to predict whether there will be no reflow or slow blood flow after stent implantation.

Antiplatelet therapy and coronary artery bypass grafting: Protocol for a systematic review and network meta-analysis

INTRODUCTION

Saphenous vein graft (SVG) is the most common conduit used for coronary artery bypass grafting (CABG) surgery. Unfortunately, SVG are associated with poor long-term patency rates; a significant predictor of re-operation rates and survival. As such, medical therapy to prevent SVG narrowing or occlusion is of paramount importance. Aspirin (ASA) monotherapy is the standard of care after CABG, to improve long-term major adverse cardiovascular events (MACE) and graft patency. Benefits of dual antiplatelet therapy (DAPT) have not been well established in all CABG patients. We present a protocol for a network meta-analysis (NMA) comparing the effects of various antiplatelet therapy regimens on SVG patency, mortality, and bleeding among adult patients following CABG.

METHODS

We will search CENTRAL, MEDLINE, EMBASE, CINAHL ACPJC, and grey literature sources (AHA, ACC, ESC, and CCC conference proceedings, ISRCTN Register, and WHO ICTRP) for randomized controlled trials (RCTs) which fit our criteria. RCTs that evaluate different antiplatelet regimens at least 3-months after CABG and have any of SVG patency, mortality, MACE, and major bleeding as outcomes will be selected. We will perform title and abstract screening, full-text screening, and data extraction independently and in duplicate. Two independent reviewers will also assess risk of bias (ROB) for each study, as well as evaluate quality of evidence using the GRADE framework. We will use R to perform the NMA and use low-dose ASA as reference within our network. We will report results as odds ratios with confidence intervals for direct comparisons, and credible intervals for indirect or mixed comparisons. We will use the surface under the cumulative ranking curve (SUCRA) to estimate the ranking of interventions.

DISCUSSION

Given the limited direct comparison of various antiplatelet regimens, a network approach is ideal to clarify the optimum antiplatelet therapy after CABG. We hope that our NMA will be the largest quantitative synthesis evaluating antiplatelet regimens among patients requiring CABG. It should inform clinicians and guideline developers in selecting the most effective and safest antiplatelet regimen.Systematic Review registration: International Prospective Register for Systematic Reviews (PROSPERO)-CRD42019127695.

The Association Between Modified Intracoronary Thrombus Grade and Cardiovascular Risk Factors and Initial Laboratory Findings in Patients Undergoing Primary Percutaneous Coronary Intervention

The thrombus burden has been shown to affect the immediate results of primary coronary intervention and the outcome of the patients. The aim of the present study was to determine the cardiovascular risk factors and initial laboratory findings associated with angiographic thrombotic grade based on the new reclassified grading method. A total of 394 consecutive patients presenting with a first ST-elevation myocardial infarction treated by primary coronary intervention were retrospectively evaluated between March 2014 and March 2017. Patients were divided into 2 groups of low thrombus grade (grades 1-3) and high thrombus grade (grade 4). The results showed that the patients with high thrombus grade had markedly higher white blood cell (WBC) counts, platelet counts, and initial troponin levels (P values were <0.001, 0.004, and <0.001, respectively). After logistic regression analysis, high WBC count had the strongest association with high thrombus grade [odds ratio: 3.185, 95% confidence interval: 1.349-7.520; P = 0.008]. The initial troponin level also had significant association with high thrombus grade, whereas high platelet count had a borderline statistical significance (odds ratio: 2.250, 95% confidence interval: 0.928-5.459; P = 0.073). In conclusion, the present study demonstrated that high WBC and higher levels of baseline troponin were associated with high angiographic thrombus grade in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Sustained Release of Basic Fibroblast Growth Factor (bFGF) Encapsulated Polycaprolactone (PCL) Microspheres Promote Angiogenesis In Vivo

Coronary heart disease (CHD) is the leading cause of death in the Unites States and globally. The administration of growth factors to preserve cardiac function after myocardial infarction (MI) is currently being explored. Basic fibroblast growth factor (bFGF), a potent angiogenic factor has poor clinical efficacy due to its short biological half-life and low plasma stability. The goal of this study was to develop bFGF-loaded polycaprolactone (PCL) microspheres for sustained release of bFGF and to evaluate its angiogenic potential. The bFGF-PCL microspheres (bFGF-PCL-MS) were fabricated using the emulsion solvent-evaporation method and found to have spherical morphology with a mean size of 4.21 ± 1.28 µm. In vitro bFGF release studies showed a controlled release for up to 30 days. Treatment of HUVECs with bFGF-PCL-MS in vitro enhanced their cell proliferation and migration properties when compared to the untreated control group. Treatment of HUVECs with release media from bFGF-PCL-MS also significantly increased expression of angiogenic genes (bFGF and VEGFA) as compared to untreated cells. The in vivo angiogenic potential of these bFGF-PCL-MS was further confirmed in rats using a Matrigel plug assay with subsequent immunohistochemical staining showing increased expression of angiogenic markers. Overall, bFGF-PCL-MS could serve as a potential angiogenic agent to promote cell survival and angiogenesis following an acute myocardial infarction.

Current research trends and challenges in tissue engineering for mending broken hearts

Cardiovascular disease (CVD) is among the leading causes of mortality worldwide. The shortage of donor hearts to treat end-stage heart failure patients is a critical problem. An average of 3500 heart transplant surgeries are performed globally, half of these transplants are performed in the US alone. Stem cell therapy is growing rapidly as an alternative strategy to repair or replace the damaged heart tissue after a myocardial infarction (MI). Nevertheless, the relatively poor survival of the stem cells in the ischemic heart is a major challenge to the therapeutic efficacy of stem-cell transplantation. Recent advancements in tissue engineering offer novel biomaterials and innovative technologies to improve upon the survival of stem cells as well as to repair the damaged heart tissue following a myocardial infarction (MI). However, there are several limitations in tissue engineering technologies to develop a fully functional, beating cardiac tissue. Therefore, the main goal of this review article is to address the current advancements and barriers in cardiac tissue engineering to augment the survival and retention of stem cells in the ischemic heart.

Delayed PCI 12 Hours after the Onset of Symptoms Is Associated with Improved Outcomes for Patients with ST-Segment Elevation Myocardial Infarction: A Real-World Study

BACKGROUND

Primary percutaneous coronary intervention (PPCI) plays a pivotal role in the treatment of ST-segment elevation myocardial infarction (STEMI). However, it remains controversial whether PCI delayed beyond the recommended time window of 12 h after the onset of symptoms is applicable to STEMI.

OBJECTIVE

The acute myocardial infarction (AMI) registration study in Xinjiang, China, is a real-world clinical trial (retrospective cohort study) that includes hospitalized patients. The purpose of this study was to compare delayed PCI and medication therapy beyond the recommended time window of 12 h after the onset of symptoms on the outcomes of STEMI patients.

METHODS AND RESULTS

From May 2012 to December 2015, a total of 1072 STEMI patients received delayed PCI (n=594) or standard medication therapy (MT) (n=478) more than 12 h after the onset of symptoms. The number of all-cause deaths in the delayed PCI group and that in the MT group were 55 (9.3%) and 138 (28.9%), respectively, and a significant difference between the groups was indicated for this variable (P<0.001). The number of cardiac deaths in the delayed PCI group and that in the medication therapy group were 47 (7.9%) and 120 (25.1%), respectively, and a significant difference between the groups was indicated for this variable (P<0.001). We also found that the MACE incidence in the delayed PCI group was significantly higher than it was in the MT group (32.2% versus 43.5%, P<0.001). Propensity score matching (PSM) analyses remained significant differences between the delayed PCI group and the MT group, respectively, in all-cause deaths (9.3% versus 25.8%, P<0.001) and cardiac death (8.7% versus 21.6%, P<0.001).

CONCLUSION

Compared to medication therapy, PCI for STEMI delayed beyond 12 h after the onset of symptoms can better reduce mortality and the incidence of MACEs.

TRIAL REGISTRATION

This study is registered with the following: Trial Registration: clinicaltrials.gov; Identifier: NCT02737956.

Impact on long-term mortality of access and non-access site bleeding after primary percutaneous coronary intervention

OBJECTIVES

The influence of the bleeding site on long-term survival after the primary percutaneous coronary intervention (PCI) is poorly understood. This study sought to investigate the relationship between in-hospital access site versus non-access site bleeding and very late mortality in unselected patients treated with primary PCI.

METHODS

Data of the 2715 consecutive patients with ST-segment elevation myocardial infarction treated with primary PCI, enrolled in a prospective registry of a high volume tertiary centre, were analysed. Bleeding events were assessed according to the Bleeding Academic Research Consortium (BARC) criteria. The primary outcome was 4-year mortality.

RESULTS

The BARC type ≥2 bleeding occurred in 171 patients (6.3%). Access site bleeding occurred in 3.8%, and non-access site bleeding in 2.5% of patients. Four-year mortality was significantly higher for patients with bleeding (BARC type ≥2) than in patients without bleeding (BARC type 0+1), (36.3% vs 16.2%, p<0.001). Patients with non-access site bleeding had higher 4 year mortality (50.7% vs 26.5%, p=0.001). After multivariable adjustment, BARC type ≥2 bleeding was the independent predictor of 4 year mortality (HR 2.01; 95% CI 1.49 to 2.71, p<0.001). Patients with a non-access site bleeding were at 2-fold higher risk of very late mortality than patients with an access site bleeding (HR 2.62; 1.78 to 3.86, p<0.001 vs HR 1.57; 1.03 to 2.38, p=0.034).

CONCLUSIONS

Both access and non-access site BARC type ≥2 bleeding is independently associated with a high risk of 4-year mortality after primary PCI. Patients with non-access site bleeding were at higher risk of late mortality than patients with access site bleeding.

A risk score to predict postdischarge bleeding among acute coronary syndrome patients undergoing percutaneous coronary intervention: BRIC-ACS study

BACKGROUND

Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) prevents ischemic events while increasing bleeding risk. Real-world-based metrics to accurately predict postdischarge bleeding (PDB) occurrence and its potential impact on postdischarge major cardiovascular event (MACE) remain undefined. This study sought to evaluate the impact of PDB on MACE occurrence, and to develop a score to predict PDB risk among Chinese acute coronary syndrome (ACS) patients after PCI.

METHODS AND RESULTS

From May 2014 to January 2016, 2496 ACS patients who underwent PCI were recruited consecutively from 29 nationally representative Chinese tertiary hospitals. Among 2,381 patients (95.4%, 2,381/2,496) who completed 1-year follow-up, the cumulative incidence of PDB (bleeding academic research consortium type [BARC] ≥2) and postdischarge MACE (a composite of all-cause death, nonfatal myocardial infarction, ischemic stroke, or urgent revascularization) was 4.9% (n = 117) and 3.3% (n = 79), respectively. The association between PDB and MACE during 1-year follow-up, as well as the impact of DAPT with ticagrelor or clopidogrel on PDB were evaluated. PDB was associated with higher risk of postdischarge MACE (7.7 vs. 3.1%; adjusted hazard ratio: 2.59 [95% confidence interval: 1.17-5.74]; p = .02). For ticagrelor versus clopidogrel, PDB risk was higher (8.0 vs. 4.4%; 2.05 [1.17-3.60]; p = .01), while MACE risk was similar (2.0 vs. 3.4%; 0.70 [0.25-1.93]; p = .49). Based on identified PDB predictors, the constructed bleeding risk in real world Chinese acute coronary syndrome patients (BRIC-ACS) score for PDB was established. C-statistic for the score for PDB was 0.67 (95% CI: 0.62-0.73) in the overall cohort, and >0.70 in subgroups with non-ST- and ST-segment elevation myocardial infarction, diabetes and receiving more than two drug eluting stents.

CONCLUSIONS

In Chinese ACS patients, PDB with BARC ≥2 was associated with higher risk for MACE after PCI. The constructed BRIC-ACS risk score provides a useful tool for PDB discrimination, particularly among high ischemic and bleeding risk patients.

Cultural factors and the circadian rhythm of ST elevation myocardial infarction in patients in a Mediterranean island

INTRODUCTION

The circadian rhythm of onset of myocardial infarction shows an increased risk during the morning hours. However, it is not clear whether habits, culture and sunshine hours differentiate circadian rhythm. The aim of this study was to investigate the influence of cultural factors on the circadian rhythm of acute myocardial infarction with ST segment elevation in a Mediterranean island.

METHOD

The study was a retrospective correlational survey. It included 123 patients with ST elevation myocardial infarction (mean age 60.7±12.6; 82% men). The 24 h of a day were divided into four six-hour periods of time for study purposes (00:01-06:00; 06:01-12:00; 12:01-18:00; and 18:01-24:00) and the chi-square test was used for the analysis.

RESULTS

A morning peak of symptoms onset of ST-elevation myocardial infarction was detected during the period 06:01-12:00 (p=0.044). In patients who were smokers, a bimodal pattern involving a morning (06:01-12:00) and an afternoon-to-night peak (18:01-24:00) (p=0.005) was detected. For patients with a history of hypertension, a morning peak of their symptoms was also detected (p=0.028). Different circadian variations were found between patients over the age of 60 years old and patients under the age of 60 years old (p=0.025).

CONCLUSIONS

Patients with ST elevation myocardial infarction seem to follow a circadian rhythm with a peak of onset of symptoms in the morning. In the smokers' subgroup, a different circadian pattern was found. The habit of smoking is likely to affect the circadian rhythm of the onset of ST elevation myocardial infarction in the Mediterranean area and culture.

A Narrative Review on Thrombolytics in Advanced CKD: Is it an Evidence-Based Therapy?

PURPOSE

A timely pharmacoinvasive strategy consisting of thrombolytic therapy (TT) plays a pivotal role in three major scenarios: acute ischemic stroke (AIS), acute myocardial infarction (STEMI), and massive pulmonary embolism (PE). Presence of advanced chronic kidney disease (CKD) (estimated glomerular filtration rate < 30 mL/min/1.73 m2), known to disturb thrombotic/thrombolytic equilibrium, causes difficulties for clinicians in evaluating risk-benefit balance, as current guidelines do not address the relationship between TT and the advanced CKD. This narrative review aims to evaluate the most important scientific resources regarding the evidences, benefits, and risks of using thrombolytics in advanced CKD.

METHODS

We searched the electronic database of PubMed for studies evaluating the relationship between renal dysfunction and TT in patients with STEMI, AIS, and massive PE. Randomized controlled trials (RCTs), observational studies including prospective or retrospective cohort studies, reviews, meta-analyses, and guidelines were included if referring to TT for one of the three scenarios in advanced CKD.

RESULTS

Prothrombotic conditions in CKD, associated with an increased risk of hemorrhages, can affect the safety and efficacy of TT. Concerns regarding in-hospital bleeding events and poor clinical outcomes subsequent to TT in advanced CKD continue to cause underutilization or delaying routine reperfusion therapy.

CONCLUSIONS

The impact of TT on the outcomes of advanced CKD patients is poorly understood to date, with scarce data available in current guidelines and conflicting results from observational studies. Until evidence-based data from RCTs will be obtained, the clinical challenge of maximizing benefits for this high-risk subgroup lays in the hands of practicing clinicians.

Achievement of low density lipoprotein (LDL) cholesterol targets in primary and secondary prevention: Analysis of a large real practice database in Italy

BACKGROUND AND AIMS

Target and intensity of low-density lipoprotein cholesterol (LDL-C) lowering therapy should be tailored according to the individual global cardiovascular (CV) risk. We aimed at retrospectively evaluating real-life LDL-C goal attainment and predictive factors for predefined LDL-C therapeutic goals both in primary and secondary prevention.

METHODS

We collected data from a large cohort of outpatients aged 40-65 years, followed by general practitioners, cardiologists and diabetologists in Italy. All data were centrally analysed for global CV risk assessment and rates of control of major CV risk factors, including LDL-C. Study population was stratified according to the presence or absence of previous CV events, including coronary artery disease (CAD), peripheral artery disease (PAD) or stroke/TIA. CV risk profile characterization was based on the European SCORE. Predefined therapeutic goals were set according to the European guidelines on dyslipidaemia: LDL-C levels <70 mg/dl for very high CV risk patients in primary prevention and for those in secondary prevention; <100 mg/dl LDL-C levels for high CV risk patients in primary prevention. Logistic regression analysis with clinical covariates was used to identify predictive factors for achieving these goals; lipid lowering therapy entered in the analysis as continuous (model 1) or categorical variable (model 2).

RESULTS

We included 4,142 outpatients (43,7% female, age 58.0 ± 5.2 years, BMI 28.5 ± 5.0 kg/m²) among whom 2,964 (71.6%) in primary and 1,178 (28.4%) in secondary prevention. In primary prevention, none of the patients at very high CV risk had LDL-C <70 mg/dl and 8.9% of patients at high CV risk showed LDL-C <100 mg/dl. Only 5.8% of patients in secondary prevention had LDL-C levels <70 mg/dl, specifically 6.5% of patients with CAD, 2.6% of patients with PAD and 4.7% of patients with CVD (p < 0.001). Beyond diabetes and lipid lowering therapy, high risk SCORE estimation resulted a strong and independent predictor for the lack of achieving all predefined therapeutic targets, including LDL-C <100 mg/dl [OR: 0.806 (0.751-0.865)); p < 0.001], and LDL-C <70 mg/dl [OR: 0.712 (0-576-0.880); p = 0.002], in primary prevention.

CONCLUSIONS

Despite high or very high SCORE risk and use of lipid lowering therapies, we observed poor achievement of LDL-C targets in this large cohort of outpatients followed in a setting of real practice in Italy.

The Impact of Air Transport for Acute Coronary Syndrome Patients

OBJECTIVE

For patients with acute coronary syndrome (ACS), percutaneous coronary intervention (PCI) within 120 minutes from onset is recommended. A helicopter emergency medical service (HEMS) is useful for transporting ACS patients. The purposes of this study were to investigate whether patients with ACS in the eastern part of Hokkaido could be transported to a PCI hospital by HEMS and undergo PCI within 120 minutes and to clarify the factors most related to delayed access to PCI.

METHODS

This was a retrospective cohort study that analyzed 513 patients diagnosed with ACS at our institution, an HEMS base/PCI hospital. We investigated transport modes for each patient and identified the processes by which access to PCI was delayed.

RESULTS

HEMS reduced transport time compared with ground emergency medical services but did not contribute to access to PCI within 120 minutes. The most important factor was transport directly to a PCI hospital (P < .01).

CONCLUSION

HEMS did not achieve a total transport time of patients to a PCI hospital within 120 minutes from onset. Transport using HEMS is insufficient to access early PCI; patient condition must also be considered to determine whether to go through a non-PCI hospital.

Cell signaling and biological pathway in cardiovascular diseases

Currently, coronary artery disease accounts for a large proportion of deaths occurring worldwide. Damage to the heart muscle over a short period of time leads to myocardial infarction (MI). The biological mechanisms of atherosclerosis, one of the causes of MI, have been well studied. Resistin, a type of adipokine, is closely associated with intravascular level of low-density lipoprotein cholesterol and augmentation of the expression of adhesion molecules in endothelial cells. Therefore, resistin, which is highly associated with inflammation, can progress into coronary artery disease. Adenylyl cyclase associated protein 1, a binding partner of resistin, also plays an important role in inducing pro-inflammatory cytokines. The induction of these cytokines can aggravate atherosclerosis by promoting severe plaque rupture of the lesion site. Recently, drugs, such as statins that can inhibit inflammation have been extensively studied. The development of effective new drugs that can directly or indirectly block pro-inflammatory cytokines may have a great potential in the treatment of coronary artery disease in the future.

Mon2 predicts poor outcome in ST-elevation myocardial infarction

AIMS

There are limited data on the role of human monocyte subsets in ST-elevation myocardial infarction (STEMI). The study aimed to establish the relationship between monocyte subsets, their phagocytic and nuclear factor κB (NFκB) activity and outcomes in STEMI.

METHODS

Monocyte subsets and their phagocytic activity and intracellular levels of inhibitory κB kinase β (IKKβ, marker of NFκB activity) were measured by flow cytometry in 245 patients with STEMI, median follow-up of 46 months.

RESULTS

Mon2 (CD14++CD16+CCR2+) counts were independently predictive of major adverse cardiovascular events (MACE) [4th quartile HR 3.42 (95% CI 1.43-8.16), P = 0.006 and 3rd quartile HR 2.88 (95% CI 1.19-7.00), P = 0.02 vs. 1st quartile]. Mon2 subset was the only subset associated with higher occurrence of heart failure (4th quartile vs. 1st quartile, sevenfold, P = 0.001 on univariate analysis; fivefold, P = 0.04 on multivariable analysis). On receiver operating characteristic, analysis including of Mon2 improved prognostic value of troponin T and creatine kinase for MACE and heart failure (HF). Higher intracellular Mon2 IKKβ levels were associated with 10-fold lower occurrence of HF on multivariable analysis (4th vs. 1st quartiles, P = 0.03). Abnormal Mon1 and Mon2 phagocytic capacities were related to HF development, but the association was dependent on the infarct size and other prognosticators. High Mon2 levels were associated with lower ejection fraction after STEMI onset (P = 0.001) and at 6-month follow-up (P < 0.001).

CONCLUSIONS

Abnormal Mon2 characteristics have a unique association with poor outcome in patients with STEMI. The relation of Mon2 with occurrence of HF is strongly and independently related to their functional status, which may have potential therapeutic implications.

Protective effect of influenza vaccination on outcomes in geriatric stroke patients: A nationwide matched cohort study

BACKGROUND AND AIMS

The effects of influenza vaccination (IV) on stroke outcomes are unclear. The purpose of this study is to evaluate the outcomes after stroke in elderly individuals who have received an IV.

METHODS

We used Taiwan's National Health Insurance Research Database 2000-2009 claims data to conduct a nested stroke cohort study including 148,909 hospitalized stroke patients aged 66 years and older. Using a matching procedure by propensity score, we selected 25,248 stroke patients with IV and 25,248 stroke patients without IV for comparison. Logistic regression was used to calculate the odds ratios (ORs) and 95% CIs of post-stroke complications and in-hospital mortality associated with IV.

RESULTS

Stroke patients with IV had significantly lower risks of post-stroke pneumonia (OR = 0.79; 95% CI, 0.74-0.83), septicemia (OR = 0.78; 95% CI, 0.70-0.86), urinary tract infection (OR = 0.87; 95% CI, 0.83-0.92), and 30-day in-hospital mortality (OR = 0.60; 95% CI, 0.54-0.67) compared with non-IV stroke patients. Vaccinated stroke patients also had shorter hospital stays (p < 0.0001) and less medical expenditures (p < 0.0001) during stroke admission than the control group. Lower rates of post-stroke adverse events in patients with IV were noted in both sexes of all age groups with various types of stroke.

CONCLUSIONS

Stroke patients with IV showed fewer complications and lower mortality compared with non-IV patients. These findings suggest the urgent need to promote IV for this susceptible population of stroke patients.

Adiponectin in Relation to Coronary Plaque Characteristics on Radiofrequency Intravascular Ultrasound and Cardiovascular Outcome

Background

Prospective data on the associations of adiponectin with in-vivo measurements of degree, phenotype and vulnerability of coronary atherosclerosis are currently lacking.

Objective

To investigate the association of plasma adiponectin with virtual histology intravascular ultrasound (VH-IVUS)-derived measures of atherosclerosis and with major adverse cardiac events (MACE) in patients with established coronary artery disease.

Methods

In 2008-2011, VH-IVUS of a non-culprit non-stenotic coronary segment was performed in 581 patients undergoing coronary angiography for acute coronary syndrome (ACS, n = 318) or stable angina pectoris (SAP, n = 263) from the atherosclerosis-intravascular ultrasound (ATHEROREMO-IVUS) study. Blood was sampled prior to coronary angiography. Coronary plaque burden, tissue composition, high-risk lesions, including VH-IVUS-derived thin-cap fibroatheroma (TCFA), were assessed. All-cause mortality, ACS, unplanned coronary revascularization were registered during a 1-year-follow-up. All statistical tests were two-tailed and p-values < 0.05 were considered statistically significant.

Results

In the full cohort, adiponectin levels were not associated with plaque burden, nor with the various VH-tissue types. In SAP patients, adiponectin levels (median[IQR]: 2.9(1.9-3.9) µg/mL) were positively associated with VH-IVUS derived TCFA lesions, (OR[95%CI]: 1.78[1.06-3.00], p = 0.030), and inversely associated with lesions with minimal luminal area (MLA) ≤ 4.0 mm² (OR[95%CI]: 0.55[0.32-0.92], p = 0.025). In ACS patients, adiponectin levels (median[IQR]: 2.9 [1.8-4.1] µg/mL)were not associated with plaque burden, nor with tissue components. Positive association of adiponectin with death was present in the full cohort (HR[95%CI]: 2.52[1.02-6.23], p = 0.045) and (borderline) in SAP patients (HR[95%CI]: 8.48[0.92-78.0], p = 0.058). In ACS patients, this association lost statistical significance after multivariable adjustment (HR[95%CI]: 1.87[0.67-5.19], p = 0.23).

Conclusion

In the full cohort, adiponectin levels were associated with death but not with VH-IVUS atherosclerosis measures. In SAP patients, adiponectin levels were associated with VH-IVUS-derived TCFA lesions. Altogether, substantial role for adiponectin in plaque vulnerability remains unconfirmed.

Is there sufficient evidence to supplement omega-3 fatty acids to increase muscle mass and strength in young and older adults?

Omega-3 (ω-3) is a polyunsaturated fatty acid with anti-inflammatory properties that presents three main forms: alpha-linolenic acid, eicosapentaenoic acid, and docosahexaenoic acid. Recently, studies performed in both young and older adults suggest that ω-3 may improve gains in muscle mass and/or enhance physical function. Thus, the aim of this narrative review was to evaluate the current evidence of ω-3 intake/supplementation on muscle/lean mass (LM) and physical function in young and older adults, and draw research-based conclusions as to the practical implications of findings. We first assessed whether ω-3 intake is associated with muscle mass and strength (observational studies), and then sought to determine whether evidence shows that supplementation of ω-3 increases muscle protein synthesis, LM and strength in adults and older adults (interventional studies). The search was carried out in PubMed and Scopus databases for the periods between 1997 and November 2018. The following keywords were used alone and in combination: ω-3, fish oil, muscle protein synthesis, muscle mass, lean mass, body composition, and physical function. In general, the evidence is mixed as to the effects of ω-3 supplementation on muscle mass in sedentary young and older adults; the hypertrophic effects of supplementation when combined with resistance training remain equivocal. Moreover, there is conflicting evidence as to whether supplementation confers a beneficial effect on muscle function in older adults. Importantly, this conclusion is based on limited data and more studies are needed before ω-3 supplementation can be recommended as a viable strategy for such purposes in clinical practice.

Reclassification of Hypertensive Outpatients According to New US Guidelines on High Blood Pressure

BACKGROUND

US guidelines on high blood pressure (BP) have recently proposed a new BP stratification.

OBJECTIVE

To evaluate the redistribution of adult outpatients according to 2003 and 2017 US hypertension guidelines.

METHODS

We extracted data referred to individuals aged between 40 and 70 years with valid BP assessment from a national, cross-sectional database. The following systolic/diastolic BP strata were considered: (i) 2003 guidelines: 0 = normal (<120/180 mm Hg), 1 = prehypertension (≥120 and ≤139/≥80 and ≤89 mm Hg), 2 = stage 1 (≥140 and ≤159/≥90 and ≤99 mm Hg), 3 = stage 2 (≥160/≥100 mm Hg) and (ii) 2017 American College of Cardiology/American Heart Association guidelines: 0 = normal (<120/80 mm Hg), 1 = elevated (≥120 and ≤129/<80 mm Hg); 2 = stage 1 (≥130 and ≤139/≥80 and ≤89 mm Hg), 3 = stage 2 (≥140/≥90 mm Hg). Cardiovascular (CV) risk profile characterization was based on Framingham, 10-year risk of a first atherosclerotic cardiovascular disease and European score equations.

RESULTS

From an overall population sample of 10,012 individuals, we selected 8,911 (89.0%) with valid clinic BP data (44.4% female, age = 60.7 ± 6.6 years, body mass index = 28.2 ± 4.9 kg/m2, clinic BP = 136.8 ± 14.5/82.1 ± 8.3 mm Hg), among whom 339 (3.8%) were in the normal BP range. According to 2003 guidelines, 3,919 (44.0%) patients had prehypertension, 3,698 (41.5%) had stage-1 and 955 (10.7%) had stage-2 hypertension. According to 2017 guidelines, 635 (3.8%) patients had elevated BP, 3,284 (36.9%) had stage-1 and 4,653 (52.2%) had stage-2 hypertension. New BP classification moved 37% individuals from "pre-hypertension" to "stage 1" and 41% from "stage 1" to "stage 2" hypertension, respectively.

CONCLUSIONS

Redistribution of hypertensive patients according to 2017 US hypertension guidelines compared with previous ones may help to better identify uncontrolled hypertensive patients with high CV risk profile.

Microvascular obstruction extent predicts major adverse cardiovascular events in patients with acute myocardial infarction and preserved ejection fraction

OBJECTIVES

To investigate the prognostic role of early post-infarction cardiac magnetic resonance (CMR) on long-term risk stratification of ST segment elevation myocardial infarction (STEMI) patients with preserved left ventricular ejection fraction (LVEF).

METHODS

Seventy-seven STEMI patients treated by primary percutaneous coronary intervention (PCI) and LVEF > 50% at CMR were included. The median time between STEMI and CMR was 5 days (IQR 2-8). LV volumes and function, area at risk (on T2 weighted images), infarcted myocardium (on late enhanced images), intramyocardial hemorrhage, and early and late microvascular obstruction (MVO) were detected and measured. CMR tissue determinants were correlated with the incidence of major adverse cardiovascular events (MACEs) over a 5-year follow-up.

RESULTS

During median follow-up of 4 years (range 3 to 5 years), eight (10%) patients experienced MACE, yielding an annualized event rate of 2.1%. All CMR tissue markers were not significantly different between MACE and no-MACE patients, except for the presence of late MVO (50% vs. 16%, respectively; p = 0.044) and its extent (2.30 ± 1.64 g vs. 0.18 ± 0.12 g, respectively; p = 0.000). From receiver-operating characteristic (ROC) curve (area under the curve 0.89; 95% confidence interval, 0.75-1.0; p = 0.000), late MVO extent > 0.385 g was a strong independent predictor of MACE at long-term follow-up (sensitivity = 87%, specificity = 90%; hazard ratio = 2.24; 95% confidence interval, 1.51-3.33; p = 0.000).

CONCLUSIONS

Late MVO extent after primary PCI on CMR seems to be a strong predictor of MACE at 5-year follow-up in patients with LVEF > 50%. Noticeably, late MVO extent > 0.385 g provided relevant prognostic insights leading to improved long-term risk stratification.

KEY POINTS

• Tissue markers provided by cardiac magnetic resonance aid in prognostic stratification after myocardial infarction • The occurrence of late microvascular obstruction after acute myocardial infarction increases risk of major adverse events at 5-year follow-up. • The greater microvascular obstruction extent on late gadolinium enhanced images is related to an increased risk of adverse events in patients with myocardial infarction and preserved left ventricular function.

De-Ritis Ratio Improves Long-Term Risk Prediction after Acute Myocardial Infarction

Background: Recent evidence suggested levels of aspartate aminotransferase (AST), alanine transaminase (ALT), and AST/ALT ratio (De-Ritis ratio) were associated with a worse outcome after acute myocardial infarction (AMI). However, their value for predicting long-term prognosis remained unknown. Therefore, we investigated the prognostic potential of transaminases on patient outcome after AMI from a long-term perspective. Methods: Data of a large AMI registry including 1355 consecutive patients were analyzed. The Cox regression hazard analysis was used to assess the impact of transaminases and the De-Ritis ratio on long-term mortality. Results: The median De-Ritis ratio for the entire study population was 1.5 (interquartile range [IQR]: 1.0–2.6). After a median follow-up time of 8.6 years, we found that AST (crude hazard ratio (HR) of 1.19 per 1-SD [95% confidence interval (CI): 1.09–1.32; p < 0.001]) and De-Ritis ratio (crude HR of 1.31 per 1-SD [95% CI: 1.18–1.44; p < 0.001]), but not ALT (p = 0.827), were significantly associated with long-term mortality after AMI. After adjustment for confounders independently, the De-Ritis ratio remained a strong and independent predictor for long-term mortality in the multivariate model with an adjusted HR of 1.23 per 1-SD (95% CI: 1.07–1.42; p = 0.004). Moreover, the De-Ritis ratio added prognostic value beyond N-terminal pro-B-Type Natriuretic Peptide, Troponin T, and Creatine Kinase. Conclusion: The De-Ritis ratio is a strong and independent predictor for long-term mortality after AMI. As a readily available biomarker in clinical routine, it might be used to identify patients at risk for fatal cardiovascular events and help to optimize secondary prevention strategies after AMI.

Human Tissue-Engineered Model of Myocardial Ischemia-Reperfusion Injury

IMPACT STATEMENT

Reducing ischemia-reperfusion injury would significantly improve patient survival. Current preclinical models are inadequate because they rely on animals, which do not emulate human physiology and the clinical setting. We developed a human tissue platform that allowed us to assess the human cardiac response, and demonstrated the platform's utility by measuring injury during ischemia-reperfusion and the effects of cardioprotective strategies. The model provides a foundation for future studies on how patient-specific backgrounds may affect response to therapeutic strategies. These steps will be necessary to help translate therapies into the clinical setting.

Reducing Health Inequalities: Comparison of Survival After Acute Myocardial Infarction According to Health Provider in Chile

Health inequalities are marked in Chile. To address this situation, a health reform was implemented in 2005 that guarantees acute myocardial infarction (AMI) health care for the entire population. We evaluated if the health reform changed AMI early and long-term survival rates by hospital provider (public/private) using a longitudinal population-based study of patients ≥15 years with a first AMI in Chile between 2002 and 2011. Time trends and early (within 28 days) and long-term (29-365 days) survival by age were assessed. We identified 59,557 patients: median age of 64 years; 68.9% men; 83.2% treated at public hospitals; 74.4% with public insurance. Early and long-term case-fatality was higher at public hospitals (14.6% vs 9.3%; P < .001 and 5.8% vs 3.3%; P < .001, respectively). There was a higher annual increase for early and long-term survival in public hospitals, 0.008 percentage points (95% CI: 0.006, 0.009; P < .0001) and 0.03 (0.002, 0.003; P < .0001), than in private hospitals, 0.0002 (95% CI: -0.0001, 0.005; P = .10) and 0.002 (95% CI: 0.0007, 0.003; P = .004), respectively. Being served at public hospitals affected early and long-term survival, especially in patients <70 years: hazard ratio was 2.01 (95% CI: 1.77, 2.28) and 3.11 (2.41, 4.01), respectively. Therefore, even if inequalities persist, there was a higher increase in early and long-term survival in public versus private hospitals.

24-Hour ambulatory blood pressure levels and control in a large cohort of adult outpatients with different classes of obesity

Effective and sustained blood pressure (BP) control in hypertensive patients with moderate-to-severe obesity is often difficult to achieve. We evaluated clinic, 24h, day-time and night-time systolic/diastolic BP levels and control in a large cohort of adult outpatients with different classes of obesity. A single center, prospective, cohort study was conducted at Hypertension Unit, Division of Cardiology, Sant'Andrea Hospital, Rome Italy. All BP measurements were performed and BP thresholds were set according to guidelines. Study population was stratified according to BMI. We included 4,766 individuals (women 48.6%, age 60.3 ± 11.6 years, clinic BP 143.8 ± 18.2/90.9 ± 12.3 mmHg, 24h BP 130.2 ± 13.3/79.1 ± 9.5 mmHg), among whom 36.0% had normal weight, 43.5% were overweight, 15.7% had class I, and 4.8% class II/III obesity. Obese outpatients had higher prevalence of risk factors, and were treated more frequently and with more antihypertensive drugs than those with normal body weight. Obese outpatients showed higher systolic BP levels at all BP measurements, mostly 24h and night-time periods, than those observed in normal weight outpatients. BMI resulted significantly related with clinic (r = 0.053; P < 0.001), 24h (r = 0.098; P < 0.001) and night-time systolic BP (r = 0.126; P < 0.001), and left ventricular mass indexed by height^2.7 (r = 0.311; P < 0.001). BMI was also negatively and independently associated with predefined BP goals at all types of BP measurements. Obesity was associated with higher systolic BP levels during the entire 24h period and increased left ventricular mass. These effects were independently observed, even after correction for major cardiovascular risk factors and comorbidities, as well as the number and type of antihypertensive drug classes.

In-hospital mortality of patients with cardiogenic shock after acute myocardial infarction; impact of early revascularization

OBJECTIVES

The purpose of this study was to determine the frequency of in-hospital mortality in 351 patients who developed cardiogenic shock after acute myocardial infarction and by determining this; we might find that how efficiently we could manage this serious condition in our population by knowing the factors which are associated with high mortality after cardiogenic shock. Moreover impact of early revascularization like thrombolytic therapy or angioplasty was also evaluated.

RESULTS

Mean age was 65.41 ± 7.78 years in our study. In-hospital mortality with cardiogenic shock after acute myocardial infarction was found to be 44.73%. Significant association of in-hospital mortality was noted with age, hypertension, diabetes mellitus and BMI. Patients receiving early revascularization were noted to have lower in-hospital mortality compared to those in whom revascularization was not done due to delayed presentation. This study concluded that there is a high frequency (44.73%) of in-hospital mortality in patients with cardiogenic shock after acute myocardial in our population. So, we recommend that for achieving a good outcome and to reduce in-hospital mortality; in addition to rapid diagnosis of this condition, underlying risk factors like hypertension and diabetes should be evaluated and managed accordingly and early revascularization should be done when possible.

Prognostic impact of familial hypercholesterolemia on long-term outcomes in patients undergoing percutaneous coronary intervention

BACKGROUND

Patients with familial hypercholesterolemia (FH) are at increased risk for premature and subsequent cardiovascular disease. Data on long-term major adverse cardiovascular events (MACE) in patients with FH after percutaneous coronary intervention (PCI) in the era of high-intensity statins are scarce.

OBJECTIVE

We assessed the prognostic impact of clinically diagnosed FH on long-term MACE, a composite of all-cause death, myocardial infarction, and ischemic stroke in patients admitted for stable coronary artery disease (SCAD) or acute coronary syndromes (ACSs) undergoing PCI.

METHODS

FH was diagnosed according to the Dutch Lipid Clinic Network diagnosis criteria: "Unlikely FH" diagnosis was defined as 0 to 2 points, "possible FH" as 3 to 5 points, and "probable/definite FH" diagnosis as 6 or higher.

RESULTS

From a total of 1550 eligible patients (47.4% were admitted for SCAD and 52.6% for ACS), 77 (5.0%) were classified as probable/definite FH, 332 (21.4%) as possible FH, and 1141 (73.6%) as unlikely FH. Mean follow-up was 6.0 ± 2.4 years. After adjustment for possible confounders, patients classified with probable or definite FH (hazard ratio [HR] 1.922 [95% confidence interval (CI) 1.220-2.999]; P = .004), but not patients with possible FH (HR 1.105 [95% CI 0.843-1.447]; P = .470) faced a significant, approximately 2-fold increased risk of MACE compared with patients with unlikely FH.

CONCLUSION

After adjustment for confounders, patients with probable or definite FH faced an approximate 2-fold increased risk for long-term MACE compared with patients without FH despite the widespread use of high-intensity statins. The new option of proprotein convertase subtilisin/kexin type 9 gene inhibitors in addition to other current optimal lipid-lowering strategies might help to further improve clinical outcome in patients with probable/definite FH.

Copeptin as a prognostic biomarker in acute myocardial infarction

BACKGROUND

Copeptin - the C-terminal section of vasopressin precursor - is a novel biomarker, that has been shown to be a useful prognostic factor in heart failure, ischemic stroke and in acute myocardial infarction (MI) but with restricted population and follow-up in ST-segment elevation MI (STEMI) setting. We evaluated in this study the hypothesis that copeptin measured on admission is an independent predictor of one-year all-cause mortality after a STEMI.

METHODS

Copeptin was measured immediately on arrival in the catheterization laboratory in a cohort of unselected STEMI patients and was compared to the peak of cardiac troponin I as a prognosis marker. One-year follow-up was performed.

RESULTS

We included 401 STEMI patients (77% of men, mean age 64 ± 14 years) treated by primary percutaneous coronary intervention. Copeptin on admission was significantly higher in patients who died during the one-year follow-up than in survivors (154.8 pmol/L; IQR [63.9-304.8] vs 30.3 pmol/L; IQR [10.8-93.5]); p < 0.0001). There was an increase in mortality at one year from the lowest to the highest quartile of copeptin. After Cox regression analysis, copeptin was an independent predictor of death at one year (adjHR 3.1, 95% CI [1.5-6.2], p = 0.001). When compared to the peak value of cardiac troponin I, copeptin measured on admission had a better prognostic value to predict one-year mortality (AUC of 0.74 vs 0.60, p = 0.022).

CONCLUSION

Copeptin measured on admission is a reliable and independent prognostic biomarker of one-year mortality in acute myocardial infarction patients.

Rationale, design and preliminary results of the GALIPEMIAS study (prevalence and lipid control of familial dyslipidemia in Galicia, northwest Spain)

AIMS

There is little information on the familial nature of dyslipidemias in the Spanish population. This knowledge could have potential diagnostic and treatment implications. The objective of the GALIPEMIAS study was to determine the prevalence of familial dyslipidemia in Galicia, as well as determine the degree of lipid control in the participants. Prevalence of atherosclerotic cardiovascular disease (ASCVD) was also estimated. This paper presents the design, methodology and selected preliminary results.

METHODOLOGY

A cross-sectional study was performed in the population aged ≥18 years using cluster sampling and then random sampling. A sample of 1000 subjects was calculated and divided into three sequential phases with a specific methodology for each one. Phase I: selection of subjects from the general population and collection of informed consent documents; Phase II: collection of data from the digital clinical history to select subjects with dyslipidemia according to study criteria; Phase III: personal interview, blood analysis, family tree, and definitive diagnosis of dyslipidemia. Prevalence of different diseases and active medication was analysed. Corrected prevalence (to the reference population) of different risk factors and ASCVD was estimated.

RESULTS

Phase I participation was 89.5%. We extracted complete information from 93% of the participants (Phase II). According to the study's own criteria, 56.5% (n = 527) of the participants had some form of dyslipidemia and almost 33.7% of them had familial dyslipidemia with autosomal dominant inherit pattern. The corrected prevalence of ASCVD was 5.1% (95% CI 3.1-7.2).

CONCLUSIONS

Dyslipidemia was the most prevalent cardiovascular risk factor in our population with an autosomal dominant inheritance pattern in one out of every three dyslipidemia cases. Approximately, 5.1% of the sample population aged ≥18 has suffered an episode of ACVD.

Risk of intracranial hemorrhage (RICH) in users of oral antithrombotic drugs: Nationwide pharmacoepidemiological study

Background

The risks of intracranial haemorrhage (ICH) associated with antithrombotic drugs outside clinical trials are gaining increased attention. The aim of this nationwide study was to investigate the risk of ICH requiring hospital admission in users of antithrombotic drugs.

Methods and findings

Data from the Norwegian Patient Registry and Norwegian Prescription Database were linked on an individual level. The primary outcome was incidence rates of ICH associated with use of antithrombotic drugs. Secondary endpoints were risk of ICH and fatal outcome following ICH assessed by Cox models. Among 3,131,270 individuals ≥18 years old observed from 2008 through 2014, there were 729,818 users of antithrombotic medications and 22,111 ICH hospitalizations. Annual crude ICH rates per 100 person-years were 0.076 (95% CI, 0.075–0.077) in non-users and 0.30 (95% CI, 0.30–0.31) in users of antithrombotic medication, with the highest age and sex adjusted rates observed for aspirin-dipyridamole plus clopidogrel (0.44; 95% CI, 0.19–0.69), rivaroxaban plus aspirin (0.36; 95% CI, 0.16–0.56), warfarin plus aspirin (0.34; 95% CI, 0.26–0.43), and warfarin plus aspirin and clopidogrel (0.33; 95% CI, 0.073–0.60). With no antithrombotic medication as reference, the highest adjusted hazard ratios (HR) for ICH were observed for aspirin-dypiridamole plus clopidogrel (6.29; 95% CI 3.71–10.7), warfarin plus aspirin and clopidogrel (4.38; 95% CI 2.71–7.09), rivaroxaban plus aspirin (3.82; 95% CI, 2.46–5.95), and warfarin plus aspirin (3.40; 95% CI, 2.99–3.86). All antithrombotic medication regimens were associated with an increased risk of ICH, except dabigatran monotherapy (HR 1.20; 95% CI, 0.88–1.65) and dabigatran plus aspirin (HR 1.79; 95% CI, 0.96–3.34). Fatal outcome within 90 days was more common in users (2,603 of 8,055) than non-users (3,228 of 14,056) of antithrombotic medication (32.3% vs 23.0%, p<0.001), and was associated with use of warfarin plus aspirin and clopidogrel (HR 2.89; 95% CI, 1.49–5.60), warfarin plus aspirin (HR 1.37; 95% CI, 1.11–1.68), aspirin plus clopidogrel (HR 1.30; 95% CI, 1.05–1.61), and warfarin (HR 1.19; 95% CI, 1.09–1.31). Increased one-year mortality was observed in users of antithrombotic medication following hemorrhagic stroke, subdural hemorrhage, subarachnoid hemorrhage, and traumatic ICH (all p<0.001). Limitations include those inherent to observational studies including the inability to make causal inferences, certain assumptions regarding drug exposure, and the possibility of residual confounding.

Conclusions

The real-world incidence rates and risks of ICH were generally higher than reported in randomized controlled trials. There is still major room for improvement in terms of antithrombotic medication safety (clinicaltrials.gov NCT02481011).

Improvements in long standing cardiac pathologies by individualized homeopathic remedies: A case series

We present three cases of cardiac arrest at different stages of pathology. Acute myocardial infarction and resulting heart failure is emerging as the leading cause of mortality. In the long run, acute episodes and cardiac remodelling can cause considerable damage and result in heart failure. In these cases, individualized homeopathic therapy was instituted along with the conventional medicines and the results were encouraging. The changes in the laboratory diagnostic parameters (single-photon emission computed tomography, electrocardiograph, echocardiography and ejection fraction as the case may be) are demonstrated over time. The key result seen in all three cases was the preservation of general well-being while the haemodynamic states also improved. While the three cases provide evidence of positive outcomes for homeopathic therapy, more extensive studies are required in a hospital setting to establish the real extent to which this therapy may be employed.

9-year clinical follow-up of patients with ST-segment elevation myocardial infarction with Genous or TAXUS Liberté stents

Objectives

This matched-cohort retrospective study investigated the long-term (9-year) safety and efficacy outcomes of patients with ST-segment elevation myocardial infarction (STEMI) and primary percutaneous coronary intervention (pPCI) with Genous (n = 102) versus TAXUS Liberté (n = 101) stents in 2006–2008.

Background

In the era of off-label use of drug-eluting stents for pPCI in patients with STEMI, the use of first-generation Genous stents (endothelial progenitor cell capture stents that have a passive coating and accelerate re-endothelialization) was proposed.

Methods

The primary endpoint was 9-year major adverse cardiac and cerebrovascular events (MACCE), including all-cause death, re-infarction, target vessel revascularization (TVR), and stroke. The secondary endpoints were the separate primary endpoint events at pre-defined time-points (in-hospital, 6 months, and yearly) and stent thrombosis. Time-dependent 9-year composite MACCE, all-cause death, and TVR were compared using Kaplan-Meier estimates and multivariate Cox regression models.

Results

Propensity score analysis confirmed the comparability of the groups. Patients in the Genous and TAXUS groups had 7 and 1 acute definitive stent thrombosis events, respectively (p<0.001). There was a trend towards higher in-hospital MACCE in the Genous group (10.8%) versus the TAXUS group (4.0%). Kaplan-Meier analysis showed that 9-year MACCE was significantly worse in the Genous than in the TAXUS group. The in-hospital, 6-month, 1-year, and 9-year mortality rates were 7.8%, 8.8%, 9.8%, and 23.5% in the Genous group and 2.0%, 3.0%, 4.0%, and 16.8% in the TAXUS group.

Conclusions

Higher peri-procedural, in-hospital, and short-term mortality led to worse outcomes for first-generation Genous stents versus TAXUS Liberté stents for pPCI in STEMI. TAXUS Liberté stents had more favorable 9-year clinical outcomes.

Nocturnal blood pressure patterns and cardiovascular outcomes in patients with masked hypertension

Masked hypertension (MHT) is characterized by normal clinic and above normal 24-hour ambulatory blood pressure (BP) levels. We evaluated clinical characteristics and CV outcomes of different nocturnal patterns of MHT. We analyzed data derived from a large cohort of adult individuals, who consecutively underwent home, clinic, and ambulatory BP monitoring at our Hypertension Unit between January 2007 and December 2016. MHT was defined as clinic BP <140/90 mm Hg and 24-hour BP ≥ 130/80 mm Hg, and stratified into three groups according to dipping status: (a) dippers, (b) nondippers, and (c) reverse dippers. From an overall sample of 6695 individuals, we selected 2628 (46.2%) adult untreated individuals, among whom 153 (5.0%) had MHT. In this group, 67 (43.8%) were nondippers, 65 (42.5%) dippers, and 21 (13.7%) reverse dippers. No significant differences were found among groups regarding demographics, clinical characteristics, and prevalence of risk factors, excluding older age in reverse dippers compared to other groups (P < 0.001). Systolic BP levels were significantly higher in reverse dippers than in other groups at both 24-hour (135.6 ± 8.5 vs 130.4 ± 6.0 vs 128.2 ± 6.8 mm Hg, respectively; P < 0.001) and nighttime periods (138.2 ± 9.1 vs 125.0 ± 6.3 vs 114.5 ± 7.7 mm Hg; P < 0.001). Reverse dipping was associated with a significantly higher risk of stroke, even after correction for age, gender, BMI, dyslipidemia, and diabetes (OR 18.660; 95% IC [1.056-33.813]; P = 0.046). MHT with reverse dipping status was associated with higher burden of BP and relatively high risk of stroke compared to both dipping and nondipping profiles, although a limited number of CV outcomes have been recorded during the follow-up.

Clinical associations of microvascular obstruction and intramyocardial hemorrhage on cardiovascular magnetic resonance in patients with acute ST segment elevation myocardial infarction (STEMI): An observational cohort study

Acute myocardial infarction (AMI) is recognized as being a life-threatening event. Both microvascular obstruction (MVO) and intramyocardial hemorrhage (IMH) have been recognized as poor prognostic factors in myocardial infarct (MI) since they adversely affect left ventricular remodeling. MVO refers to small vessels changes that prevent adequate tissue perfusion despite revascularization whereas IMH is a severe form of MVO. A limited number of studies have demonstrated the segmental intervention time and the clinical factors in the presence of MVO and IMH. Therefore, we aimed in this study to determine the correlations of the intervention-associated and clinical indexes with malignant cardiovascular magnetic resonance (CMR) signs in patients with AMI.Sixty-three patients with STEMI who underwent primary percutaneous coronary intervention (PPCI) within 12 hours were included in this study. A 3.0-T CMR scan was prescribed, and the subsequent image analysis was conducted by researchers blinded to the clinical index results. Late-gadolinium enhancement (LGE) and T2* sequences were mainly used for MVO and IMH identification and quantification.Patients exhibiting both MVO and IMH had the highest level of LGE (P < .001) and were significantly more frequently assigned to a pre-PPCI thrombolysis in myocardial infarction (TIMI) flow class of 0 (n=25, 89.3%). The MVO size correlated positively with the IMH size (r = 0.81, P < .01). A pre-PPCI TIMI flow class of 0 was found to reliably predict the presence of IMH (P < .001). Patients who received the intervention 4 to 6 hours after MI onset were more likely to exhibit MVO and IMH, although this trend was not statistically significant.We showed in our study that both MVO and IMH correlated with the degree of AMI and the pre-PPCI coronary flow, and both tended to occur more frequently in cases involving an interval of 4 to 6 hours between the onset of MI and the intervention. CMR is a reliable method for assessing MVO and IMH and its imaging features following gadolinium administration are characteristic. These findings stress the importance of using CMR in evaluating and improving the outcome of the medical management.

Achievement of multiple therapeutic targets for cardiovascular disease prevention: Retrospective analysis of real practice in Italy

BACKGROUND

Pharmacological therapy in patients at high cardiovascular (CV) risk should be tailored to achieve recommended therapeutic targets.

HYPOTHESIS

To evaluate individual global CV risk profile and to estimate the control rates of multiple therapeutic targets for in adult outpatients followed in real practice in Italy.

METHODS

Data extracted from a cross-sectional, national medical database of adult outpatients in real practice in Italy were analyzed for global CV risk assessment and rates of control of major CV risk factors, including hypertension, dyslipidemia, diabetes, and obesity. CV risk characterization was based on the European SCORE equation and the study population stratified into 3 groups: low risk (<2%), intermediate risk (≥2%-<5%), and high to very high risk (≥5%).

RESULTS

We analyzed data from 7158 adult outpatients (mean age, 57.7 ±5.3 years; BMI, 28.3 ±5.0 kg/m² , BP, 136.0 ±14.3/82.2 ±8.3 mm Hg; total cholesterol, 212.7 ±40.7 mg/dL), among whom 2029 (45.2%) had low, 1730 (24.2%) intermediate, and 731 (16.3%) high to very high risk. Increased SCORE risk was an independent predictor of poor achievement of diastolic BP <90 mm Hg (OR: 0.852, 95% CI: 0.822-0.882), LDL-C < 130 mg/dL (OR: 0.892, 95% CI: 0.861-0.924), HDL-C > 40 (males)/>50 (females) mg/dL (OR: 0.926, 95% CI: 0.895-0.958), triglycerides <160 mg/dL (OR: 0.925, 95% CI: 0.895-0.957), and BMI <25 kg/m² (OR: 0.888, 95% CI: 0.851-0.926), even after correction for diabetes, renal function, pharmacological therapy, and referring physicians (P < 0.001).

CONCLUSIONS

Despite low prevalence and optimal medical therapy, individuals with high to very high SCORE risk did not achieve recommended therapeutic targets in a real-world practice.

Usefulness of The C-Reactive Protein/Albumin Ratio for Predicting No-Reflow in ST-elevation myocardial infarction treated with primary percutaneous coronary intervention

BACKGROUND

The ratio of serum C-reactive protein (CRP) to albumin has been proven to be a more accurate indicator than albumin and CRP levels alone in determining the prognosis of patients with cancer and critical illness. The aim of this study was to determine whether the CRP/albumin ratio (CAR) can be linked to imperfect reperfusion that can worsen the prognosis of ST-elevation myocardial infarction (STEMI) in patients treated with primary percutaneous coronary intervention (pPCI).

MATERIALS AND METHODS

A total of 1217 consecutive STEMI patients who achieved epicardial vessel patency with pPCI were recruited to this study.

RESULTS

The study population was divided into 2 groups: reflow (n = 874) and no-reflow (NR) (n = 343) groups. The white blood cell count (WBC), neutrophil-to-lymphocyte ratio (NLR) and CAR (0.03 [0.01-0.04] vs 0.06 [0.03-0.12] (P < .001) were significantly higher in the NR group than in the reflow group, and these factors were found to be independent predictors of NR development. The best cut-off value of CAR predicting NR was 0.59 with a sensitivity of 54.7% and specificity of 86.7. The predictive power of CAR surpassed that of CRP, albumin, WBC count and NLR in the receiver operator curve (ROC) curve comparison.

CONCLUSION

No-reflow can be predicted by systemic inflammation markers including WBC count, NLR and CAR measured from the blood sample obtained on admission. CAR has a higher clinical value than CRP, albumin level, WBC count and NLR in NR prediction.