2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (updating the 2005 Guideline and 2007 Focused Update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Prasugrel Results in Higher Decrease in High-Sensitivity C-Reactive Protein Level in Patients Undergoing Percutaneous Coronary Intervention Comparing to Clopidogrel

OBJECTIVES

A growing body of clinical and laboratory evidence indicates that inflammation plays a crucial role in atherosclerosis. In the present study, we compared the effects of clopidogrel and prasugrel on high-sensitivity C-reactive protein (hs-CRP) in patients undergoing percutaneous coronary intervention (PCI).

METHODS

The present randomized, double-blind clinical trial included 120 patients who underwent PCI. Eligible patients were randomly assigned 2:1 to one of the two groups: 80 patients in the first group received clopidogrel (Plavix^®; loading dose and maintenance dose of 300 and 75 mg daily, respectively) and 40 patients in the second group received prasugrel (Effient^®; loading dose and maintenance dose of 60 and 10 mg, respectively) for 12 weeks. The hs-CRP levels between baseline and 12th week were compared.

RESULTS

Of the 120 patients, 69 patients (57.5%) were male. Pretreatment hs-CRP level was statistically comparable in clopidogrel (median, 15.10 mg/dL; interquartile range [IQR], 9.62–23.75 mg/dL) and prasugrel groups (median, 18 mg/dL; IQR, 14.25–22 mg/dL; P = 0.06). Patients taking clopidogrel showed a significant reduction in hs-CRP level compared with the baseline values (P < 0.001). Prasugrel administration also resulted in a significant reduction in hs-CRP level (P < 0.001). A significant 73% overall reduction in the hs-CRP level was seen with prasugrel compared with 39% overall reduction in hs-CRP level with clopidogrel (P = 0.002).

CONCLUSION

Prasugrel seems to be superior to clopidogrel in the reduction of hs-CRP in patients undergoing PCI.

Contemporary Management of ST-Elevation Myocardial Infarction

Recent advances have caused a major shift in the way ST-elevation myocardial infarctions are managed. This review explores the pharmacological and interventional techniques that have evidence for improving outcomes and the landmark trials that have sparked change. The new P2Y₁₂ inhibitors, ticagrelor and prasugrel, have been shown to be superior to clopidogrel in STEMI patients undergoing primary percutaneous coronary intervention. Concurrently, many technical aspects of percutaneous coronary intervention have been further clarified by trial data, with bare-metal stents, routine thrombus aspiration and femoral access showing evidence of inferiority. Ongoing trials will provide more information on the role of non-culprit lesion PCI, bioresorbable vascular scaffolds, mechanical devices in persistent ischaemia and early automatic implantable cardioverter-defibrillators for inducible ventricular tachycardia.

Initial experience with pre-activation of the cardiac catheterization lab and emergency room bypass for patients with ST-elevation myocardial infarction in Halifax, Nova Scotia

BACKGROUND

To determine whether pre-activation of the cardiac catheterization lab by Emergency Health Services (EHS) with a single call system in the field was associated with reduced time to reperfusion in patients with ST-Elevation Myocardial Infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI).

METHODS

Consecutive STEMI patients identified by EHS and subsequently taken to the Queen Elizabeth II Health Sciences Center (QEIIHSC) for PPCI between February 1, 2011 and January 30, 2013 were examined. Patients who had pre-activation of the catheterization lab from the field (pre-act group) after the acquisition of the LifeNet® system (Physio Control, Redmond Washington) were compared to those who had usual activation (routine group) prior to the acquisition of the LifeNet® system, for outcomes including treatment timeline data and mortality.

RESULTS

271 patients were included in the analysis, 149 patients in the pre-act group and 122 patients in the routine group. Door-to-device (DTD) times of less than 90min were achieved more frequently in the Pre-act group (91.9% vs. 62.2%; P<0.001). DTD time was shorter in the Pre-act group (48min IQR: 38 to 63min vs. 78min IQR: 64-101min; p=0.001) as was first medical contact-to-device (FMCTD) time (91min IQR: 78 to 106min vs. 115min IQR: 90 to 139min; P<0.001). False activation of the catheterization lab was infrequent (1.3%).

CONCLUSIONS

Implementation of catheterization lab pre-activation using the LifeNet® system was associated with more efficient reperfusion times as measured by reduced FMCTD and DTD times without excess false activation rates.

Combined administration of mesenchymal stem cells overexpressing IGF-1 and HGF enhances neovascularization but moderately improves cardiac regeneration in a porcine model

Background

Insulin-like growth factor 1 (IGF-1) and hepatocyte growth factor (HGF) are among the most promising growth factors for promoting cardiorepair. Here, we evaluated the combination of cell- and gene-based therapy using mesenchymal stem cells (MSC) genetically modified to overexpress IGF-1 or HGF to treat acute myocardial infarction (AMI) in a porcine model.

Methods

Pig MSC from adipose tissue (paMSC) were genetically modified for evaluation of different therapeutic strategies to improve AMI treatment. Three groups of infarcted Large White pigs were compared (I, control, non-transplanted; II, transplanted with paMSC-GFP (green fluorescent protein); III, transplanted with paMSC-IGF-1/HGF). Cardiac function was evaluated non-invasively using magnetic resonance imaging (MRI) for 1 month. After euthanasia and sampling of the animal, infarcted areas were studied by histology and immunohistochemistry.

Results

Intramyocardial transplant in a porcine infarct model demonstrated the safety of paMSC in short-term treatments. Treatment with paMSC-IGF-1/HGF (1:1) compared with the other groups showed a clear reduction in inflammation in some sections analyzed and promoted angiogenic processes in ischemic tissue. Although cardiac function parameters were not significantly improved, cell retention and IGF-1 overexpression was confirmed within the myocardium.

Conclusions

The simultaneous administration of IGF-1- and HGF-overexpressing paMSC appears not to promote a synergistic effect or effective repair. The combined enhancement of neovascularization and fibrosis in paMSC-IGF-1/HGF-treated animals nonetheless suggests that sustained exposure to high IGF-1 + HGF levels promotes beneficial as well as deleterious effects that do not improve overall cardiac regeneration.

Electronic supplementary material

The online version of this article (doi:10.1186/s13287-016-0350-z) contains supplementary material, which is available to authorized users.

Admission Endocan Level may be a Useful Predictor for In-Hospital Mortality and Coronary Severity Index in Patients With ST-Segment Elevation Myocardial Infarction

We assessed the prognostic role of serum endocan level in patients with ST-segment elevation myocardial infarction (STEMI) and compared the results with a normal coronary angiography group. A total of 133 patients were included in the study (88 patients with STEMI and 45 patients with normal coronary arteries). The SYNTAX score was determined based on the baseline coronary angiogram. Multivariate logistic regression analysis indicated that endocan independently correlated with the presence of STEMI. Moreover, high-sensitivity C-reactive protein (hsCRP), peak troponin I, and left ventricular ejection fraction (LVEF) were found to be independently associated with STEMI. Endocan level correlated significantly with hsCRP and SYNTAX score. We analyzed the discriminatory capability of endocan level for the presence of STEMI using a receiver–operating characteristics curve. A cutoff endocan level of 1.7 (ng/mL) predicted the presence of STEMI with a sensitivity of 76.1% and specificity of 73.6%. In conclusion, a high endocan level on hospital admission is an independent predictor of a worse cardiovascular outcome and a high SYNTAX score in patients with STEMI.

Myocardial perfusion grade predicts final infarct size and left ventricular function in patients with ST-elevation myocardial infarction treated with a pharmaco-invasive strategy (thrombolysis and early angioplasty)

AIMS

Primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) usually restores TIMI 3 flow in the occluded artery, but microvascular impairment may persist in >30% of patients. Less is known about microvascular reperfusion in STEMI patients treated with thrombolysis followed by early PCI. We aimed to assess the association between TIMI myocardial perfusion (TMP) at the end of the PCI procedure and left ventricular function (LVEF) and infarct size after three months in such patients.

METHODS AND RESULTS

Patients with STEMI treated with thrombolysis and early PCI were included. TMP grade was assessed at the end of the PCI procedure, and MRI was performed after three months. Of the 89 patients included, 92% (n=82) had TIMI 3 flow at the end of the PCI procedure, while only 62% (n=55) had TMP grade 2 or 3. Patients with TMP grade 2-3 had significantly higher LVEF (59% [53-67] vs. 50% [41-56], p<0.0001) and smaller infarct size (8.3 ml [2.7-15.5] vs. 20.7 ml [13.0-36.0], p<0,0001) after three months.

CONCLUSIONS

In STEMI patients treated with thrombolysis and early PCI, the TMP grade at the end of the PCI procedure was significantly associated with LVEF and infarct size after three months.

The Severity of Bleeding and Mortality in Trauma Patients Taking Dabigatran

BACKGROUND

Dabigatran, a direct thrombin inhibitor, has been shown to be more effective than warfarin in the prevention of stroke in patients with atrial fibrillation. Until recently, it lacked a reversal agent, and its contribution to the risk of transfusion in injured patients is unknown.

OBJECTIVE

We sought to determine whether patients who sustain traumatic injuries while taking dabigatran receive more blood transfusions than matched patients taking warfarin, aspirin, clopidogrel, or controls.

METHODS

This retrospective, single-center cohort consisted of injured patients who were taking dabigatran before admission to a major trauma center (January 2010-December 2013) who were compared with cohorts of patients taking warfarin, clopidogrel, or aspirin and a control group. The outcome was bleeding risk as measured by the use of blood products, with mortality as a secondary outcome. Outcomes were controlled for by age, sex, injury severity, and blunt mechanism.

RESULTS

Thirty-eight patients were taking dabigatran. Compared with the general trauma population, patients taking dabigatran were more likely to be male, older, and to have higher injury severity. Patients taking dabigatran received transfusions (odds ratio [OR] 1.31 [95% confidence interval {CI} 0.56-3.04]), packed red blood cells (OR 1.43 [95% CI 0.54-3.77]), frozen plasma (OR 1.20 [95% CI 0.42-3.49]), and platelets (OR 2.01 [95% CI 0.63-6.37]) as often as matched controls. The mortality rate among patients on dabigatran was 12.5% (OR 1.51 [95% CI 0.39-5.89]) compared with 9.1% in matched controls. None of these results was statistically significant.

CONCLUSIONS

In this small study, injured patients taking dabigatran were transfused as often and had similar in-hospital mortality as matched controls who were not taking anticoagulants.

Impact of Sleep-Disordered Breathing on Long-Term Outcomes in Patients With Acute Coronary Syndrome Who Have Undergone Primary Percutaneous Coronary Intervention

BACKGROUND

Sleep-disordered breathing (SDB) has been recognized as an important risk factor for cardiovascular diseases; however, the impact of SDB on long-term outcomes in patients with acute coronary syndrome has not been fully evaluated.

METHODS AND RESULTS

We performed overnight cardiorespiratory monitoring of 241 patients with acute coronary syndrome who were successfully treated with primary percutaneous coronary intervention between January 2005 and December 2008. The presence of SDB was defined as apnea-hypopnea index ≥5 events per hour. The end point was incidence of major adverse cardiocerebrovascular events, defined as a composite of all-cause death, recurrence of acute coronary syndrome, nonfatal stroke, and hospital admission for congestive heart failure. Patients were followed for a median period of 5.6 years. Among the 241 patients who were finally enrolled, comorbidity of SDB with acute coronary syndrome was found in 126 patients (52.3%). The cumulative incidence of major adverse cardiocerebrovascular events was significantly higher in patients with SDB than in those without SDB (21.4% versus 7.8%, P=0.006). Multivariable analysis revealed that the presence of SDB was a significant predictor of major adverse cardiocerebrovascular events (hazard ratio 2.28, 95% CI 1.06-4.92; P=0.035).

CONCLUSIONS

The study's results showed that the presence of SDB among patients with acute coronary syndrome following primary percutaneous coronary intervention is associated with a higher incidence of major adverse cardiocerebrovascular events during long-term follow-up.

Acute Type A Aortic Dissection Presenting as ST-Segment Elevation Myocardial Infarction Referred for Primary Percutaneous Coronary Intervention

BACKGROUND

When acute aortic dissection is complicated with acute myocardial infarction, the diagnosis of dissection can be problematic. In these cases, patients might be treated with primary percutaneous coronary intervention (PCI) and suffer acatastrophic outcome. However, there are few reports or algorithm to facilitate the accurate management of this clinical situation.

METHODS

We evaluated 385 consecutive patients who underwent primary PCI arising from an initial diagnosis of STEMI at our hospitalbetween January 2006 and March 2011. Clinical characteristics, coronary angiographic findings, and outcomes were obtained from medical charts and databases.

RESULTS

Five patients (1.3%) with STEMI secondary to aortic dissection were identified. All patients (100%) had sudden-onset of chest pain and a history of hypertension without diabetes or hyperlipidemia. An increased resistance while advancing the diagnostic catheter was reported by the operators in 3 of 5 patients (60%). Aortography performed by manual contrast-medium injection showed the discrepancy in the diameter between the aortic root and the ascending aorta in 4 patients (100%), and ascending aortic intimal flap dissections were noted in 3 patients (75%). Alternating appearance and disappearance of the coronary artery ostium was observed in 2 patients, and bedside echocardiography showed intimal flap extension inall 4 patients (100%) who underwent this examination. The mortality rate at 30days was 40%.

CONCLUSIONS

We construct an algorithm that incorporated factors including careful history evaluation, bedside echocardiography, resistance encountered while advancing a catheter, and findings of aortography performed with manual injection,which could b evaluable for this clinical situation.

Image-based quantification of 3D morphology for bifurcations in the left coronary artery: Application to stent design

BACKGROUND

Improved strategies for stent-based treatment of coronary artery disease at bifurcations require a greater understanding of artery morphology.

OBJECTIVE

We developed a workflow to quantify morphology in the left main coronary (LMCA), left anterior descending (LAD), and left circumflex (LCX) artery bifurcations.

METHODS

Computational models of each bifurcation were created for 55 patients using computed tomography images in 3D segmentation software. Metrics including cross-sectional area, length, eccentricity, taper, curvature, planarity, branching law parameters, and bifurcation angles were assessed using open-sources software and custom applications. Geometric characterization was performed by comparison of means, correlation, and linear discriminant analysis (LDA).

RESULTS

Differences between metrics suggest dedicated or multistent approaches should be tailored for each bifurcation. For example, the side branch of the LCX (i.e., obtuse marginal; OM) was longer than that of the LMCA (i.e., LCXprox) and LAD (i.e., first diagonal; D1). Bifurcation metrics for some locations (e.g., LMCA Finet ratio) provide results and confidence intervals agreeing with prior findings, while revised metric values are presented for others (e.g., LAD and LCX). LDA revealed several metrics that differentiate between artery locations (e.g., LMCA vs. D1, LMCA vs. OM, LADprox vs. D1, and LCXprox vs. D1).

CONCLUSIONS

These results provide a foundation for elucidating common parameters from healthy coronary arteries and could be leveraged in the future for treating diseased arteries. Collectively the current results may ultimately be used for design iterations that improve outcomes following implantation of future dedicated bifurcation stents. © 2015 Wiley Periodicals, Inc.

Treatment with non-steroidal anti-inflammatory drugs in patients after myocardial infarction - a systematic review

INTRODUCTION

Studies over the past decade have shown that NSAIDs are associated with increased cardiovascular risk and may predispose to myocardial infarction in healthy individuals. Despite this knowledge patients with established cardiovascular disease are frequently treated with NSAIDs. The benefits versus potential harm of treatment need careful assessment.

AREAS COVERED

Observational studies and clinical trials providing information about outcome of NSAID treatment in post MI patients were retrieved; fourteen articles in total: two case-control studies, two randomized double-blind trials and ten cohort studies. The studies had a follow-up time between 30 days and 15 years. Two studies reported of risk of atrial fibrillation, and only one addressed antithrombotic treatment.

EXPERT OPINION

The risk of death and reinfarction in this group of patients is well established. Further studies are needed to investigate factors increasing the risk of atrial fibrillation. The correlation between recommended pharmaceutical treatment post MI and NSAIDs needs to be further examined. None of the studies examined correlated their results to dosages available over the counter.

Impact of a Rural Regional Myocardial Infarction System of Care in Wyoming

Background

Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for patients presenting with ST‐segment elevation myocardial infarction; however, to be effective, PCI must be performed in a timely manner. Rural regions are at a severe disadvantage, given the relatively sparse number of PCI hospitals and long transport times.

Methods and Results

We developed a standardized treatment and transfer protocol for ST‐segment elevation myocardial infarction in the rural state of Wyoming. The study design compared the time‐to‐treatment outcomes during the pre‐ and postintervention periods. Details of the program, changes in reperfusion strategies over time, and outcome improvements in treatment times were reported. From January 1, 2013, to December 31, 2014, 889 patients were treated in 11 PCI‐capable hospitals (4 in Wyoming, 7 in adjoining states). Given the large geographic distance in the state (median of 47 miles between patient and PCI center), 52% of all patients were transfers, and 36% were administered fibrinolysis at the referral facility. Following the intervention, there was a significant shift toward greater use of primary PCI as the dominant reperfusion strategy (from 47% to 60%, P=0.002), and the median total ischemic time from symptom onset to arterial reperfusion was decreased by 92 minutes (P<0.001). There was a similar significant reduction in median time from receiving center door to balloon of 11 minutes less than the baseline time (P<0.01).

Conclusions

Rural systems of care for ST‐segment elevation myocardial infarction require increased levels of cooperation between emergency medical services agencies and hospitals. This study confirms that total ischemic times can be reduced through a coordinated rural statewide initiative.

Impact of thrombus aspiration during ST-Elevation Myocardial Infarction: a six month composite endpoint and risk of stroke analyses of the TASTE trial

BACKGROUND

Routine thrombus aspiration during primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) did not reduce the primary composite endpoint in the "A Randomised Trial of Routine Aspiration ThrOmbecTomy With PCI Versus PCI ALone in Patients With STEMI Undergoing Primary PCI" (TOTAL) trial. We aimed to analyse a similar endpoint in "The Thrombus Aspiration in ST-Elevation myocardial infarction in Scandinavia" (TASTE) trial up to 180 days.

METHODS

In TASTE, 7244 patients with STEMI were randomised to thrombus aspiration followed by PCI or to PCI alone. We analysed the quadruple composite endpoint of cardiovascular death, cardiogenic shock, rehospitalisation for myocardial infarction, or new hospitalisation for heart failure. Furthermore, an extended net-benefit composite endpoint including stent thrombosis, target vessel revascularization or stroke within 180 days was analysed.

RESULTS

The primary quadruple composite endpoint occurred in 8.7 % (316 of 3621) in the thrombus aspiration group compared to 9.3 % (338 of 3623) in the PCI alone group (hazard ratio (HR), 0.93; 95 % confidence interval (CI); 0.80 - 1.09, P = 0.36) and the extended net-benefit composite endpoint in 12.0 % (436) vs. 13.2 % (479) (HR, 0.90; 95 % CI; 0.79 - 1.03, P = 0.12). Stroke within 30 days occurred in 0.7 % (27) vs. 0.7 % (24) (HR, 0.89; 95 % CI; 0.51-1.54, P = 0.68).

CONCLUSIONS

A large and an extended composite endpoint analysis from the TASTE trial did not demonstrate any clinical benefit of routine thrombus aspiration during PCI in patients with STEMI. There was no evidence of an increased risk of stroke with thrombus aspiration.

The real-world prevalence of cardiovascular events related to coronary spasm after percutaneous coronary intervention

BACKGROUND

It is unknown to what extent coronary spasm affects cardiovascular events after percutaneous coronary intervention (PCI) in clinical practice. The aim was to examine the prevalence of cardiovascular events related to coronary spasm following PCI according to stent type.

METHODS

We enrolled 933 consecutive patients treated with coronary stent implantation, including bare metal stents (BMS; n=238), first-generation drug-eluting stents (1st DES; n=185), and second-generation DES (2nd DES; n=510). We compared stent-oriented endpoints (SOEs; stent thrombosis, target vessel myocardial infarction or unstable angina, target lesion revascularization, and cardiac death) and the differences in SOE related to coronary spasm across stent types. Among the SOEs, spasm-related cardiac event was defined based on JCS guideline.

RESULTS

The prevalence of SOE for each stent type was 16.8% (BMS), 16.8% (1st DES), and 7.8% (2nd DES) (p<0.001) and the rates of cardiovascular events related to coronary spasm were 2.9%, 3.2%, and 0.4%, respectively (p=0.005). Multivariate analysis identified the non-use of statin (HR, 0.275, 95% CI, 0.087-0.871, p=0.028) and non-use of 2nd DES (hazard ratio, 0.196, 95% confidence interval, 0.043-0.887, p=0.034) as independent predictors of cardiac events related to coronary spasm.

CONCLUSION

The prevalence of cardiovascular events related to coronary spasm was the lowest in patients with 2nd DES. The 2nd DES may be more efficacious and safer from the point of view of the reduction of cardiac events due to coronary spasm during statin therapy.

Perceiving one's heart condition to be cured following hospitalization for acute coronary syndromes: Implications for patient-provider communication

OBJECTIVE

We examined the proportion of patients perceiving their heart condition to be cured following hospitalization for ACS and identified characteristics associated with these perceptions.

METHODS

We conducted a prospective cohort study of adults hospitalized with ACS (N=396). Patient interviews during hospitalization and one week post-discharge provided demographic and psychosocial characteristics. Medical records provided clinical characteristics. At one week, patients who rated "My heart condition is cured" as "definitely true" or "mostly true" were considered to perceive their heart condition cured.

RESULTS

Participants were aged 60.7 (SD:11.0) years, 26.5% female, and 89.0% non-Hispanic white; 16.7% had unstable angina, 59.6% NSTEMI, and 23.7% STEMI. One week post-discharge, 30.3% perceived their heart condition to be cured. Characteristics associated with cure perceptions were older age (OR=2.2; 95% CI: 1.2-4.0 for ≥65 years vs <55 years), male sex (OR=2.4; 95%CI: 1.3-4.2), history of hypertension (OR=1.8; 95%CI: 1.1-3.1), history of stroke (OR=4.2; 95%CI: 1.1-16.7), no history of CHD (OR=2.8; 95%CI: 1.6-4.9), and receipt of CABG during hospitalization (OR=4.8, 95%CI: 1.9-12.0 vs medical management).

CONCLUSION

One week post-discharge, 3 in 10 patients perceived their heart condition to be cured.

PRACTICE IMPLICATIONS

Conversations with patients should frame ACS as a chronic disease and dispel cure perceptions.

Aichi cohort study of the prognosis in patients newly initiated into dialysis (AICOPP): baseline characteristics and trends observed in diabetic nephropathy

BACKGROUND

Over 300,000 patients receive maintenance dialysis in Japan; managing these patients is extremely important. This study aimed to report on prior management of chronic kidney diseases and prognostication after dialysis initiation.

PATIENTS AND METHODS

Seventeen institutions participated in the Aichi cohort study of prognosis in patients newly initiated into dialysis and recruited patients over a period of 2 years. Exclusion criteria were (1) patients under 20 years; (2) patients who died before hospital discharge; and (3) patients who could not provide consent.

RESULT

Here, we showed data on dialysis initiation time. Of 1524 patients with mean age of 67.5 ± 13.0 years, 659 patients were put on dialysis following diabetic nephropathy diagnosis. At dialysis initiation time, creatinine and estimated glomerular filtration rate levels were 8.97 ± 3.21 mg/dl and 5.45 ± 2.22 ml/min/1.73 m², respectively. Medications taken were angiotensin II receptor blockers in 866; angiotensin-converting enzyme inhibitors in 135; calcium antagonist in 1202; and diuretics, alone or in combination, in 1059. Among patients with diabetic nephropathy, many had increased body weight and systolic blood pressure and were taking loop and thiazide diuretics at dialysis initiation time. Many patients with diabetic nephropathy had coronary artery disease and percutaneous coronary intervention.

CONCLUSION

Many patients with diabetic nephropathy who registered for this study had coronary artery disease and problems with excess body fluid. Further analyses may clarify how underlying conditions and disease management before and after dialysis initiation affect prognosis.

Neighborhood and Acute Myocardial Infarction Mortality as Related to the Driving Time to Percutaneous Coronary Intervention-Capable Hospital

BACKGROUND

Driving time to a percutaneous coronary intervention (PCI)-capable hospital is important in timely treatment of acute myocardial infarction (AMI). Our objective was to determine whether driving time from one's residence to a PCI-capable hospital contributes to AMI deaths. We conducted a cross-sectional study of age- and sex-adjusted mortality in census block groups to evaluate this question.

METHODS AND RESULTS

We studied all (14 027) AMI deaths that occurred during 2008-2012 in Arkansas to assess the relationship between driving time from the population center of a block group (neighborhood) to the nearest PCI-capable hospital. We estimated standardized mortality ratios in block groups that were adjusted for education (population over 25 years of age who did not graduate from high school), poverty (population living below federal poverty level), population density (population per square mile), mobility (population residing at the same address as 1 year ago), black (population that is black), rurality (rural households), geodesic distance, and driving time. The median geodesic distance and driving time were 12.8 miles (interquartile range 3.6-30.1) and 28.3 minutes (interquartile range 9.6-58.7), respectively. Risks in neighborhoods with long driving times (90th percentile) were 26% greater than risks in neighborhoods with short driving times (10th percentile), even after adjusting for education, poverty, population density, rurality, and black race (P<0.0001).

CONCLUSIONS

AMI mortality increases with increasing driving time to the nearest PCI-capable hospital. Improving the healthcare system by reducing time to arrive at a PCI-capable hospital could reduce AMI deaths.

Predictors of Medical Management in Patients Undergoing Elective Cardiac Catheterization for Chronic Ischemic Heart Disease

BACKGROUND

Compared with medical therapy, percutaneous coronary intervention (PCI) does not reduce mortality or myocardial infarction in patients with stable angina. Therefore, PCI should be guided by refractory anginal symptoms and not just lesion characteristics.

HYPOTHESIS

We hypothesized that angiographic lesion characteristics and stress test results would have a greater role in the decision to proceed with PCI than would symptom severity.

METHODS

We performed a retrospective cohort study of patients undergoing elective cardiac catheterization and possible PCI at an academic medical center. Anginal symptoms, optimal medical therapy, antianginal therapy, stress test results, and angiographic lesions (including American College of Cardiology/American Heart Association [ACC/AHA] lesion type) were analyzed. Logistic regression was used to determine predictors of medical management among patients not referred for coronary artery bypass surgery.

RESULTS

Of the 207 patients with obstructive lesions amenable to PCI, 163 underwent PCI and 44 were referred to medical therapy. In the multivariable logistic model, the following variables were associated with medical management: advancing age (odds ratio [OR] per 1 year: 0.94, 95% confidence interval [CI]: 0.91-0.98), chronic kidney disease (OR: 0.23, 95% CI: 0.06-0.95), distal location (OR: 0.21, 95% CI: 0.09-0.48), and ACC/AHA type C lesion (OR: 0.08, 95% CI: 0.03-0.22). There was no association with sex, race, symptoms, optimal medical therapy, maximal antianginal therapy, referral status, or type of interventional cardiologist (academic vs private practice).

CONCLUSIONS

For patients undergoing cardiac catheterization for stable angina, the decision to proceed to PCI vs medical management appears to depend largely on patient and angiographic characteristics, but not on symptoms or ischemia. Distal and high-risk lesions (ACC/AHA type C) are more often referred for medical therapy.

Could ten questions asked by the dispatch center predict the outcome for patients with chest discomfort?

BACKGROUND AND AIMS

From 2009 to 2010, approximately 14,000 consecutive persons who called for the EMS due to chest discomfort were registered. From the seventh month, dispatchers ask 2285 patient ten pre-specified questions. We evaluate which of these questions was independently able to predict an acute coronary syndrome (ACS), life-threatening condition (LTC) and death.

METHODS

The questions asked mainly dealt with previous history and type of symptoms, each with yes/no answers. The dispatcher took a decision on priority; 1) immediately with sirens/blue light; 2) EMS on the scene within 30min; 3) normal waiting time.We examined the relationship between the answers to these questions and subsequent dispatch priority, as well as outcome, in terms of ACS, LTC and all-cause mortality.

RESULTS

2285 patients (mean age 67years, 49% women) took part, of which 12% had a final diagnosis of ACS and 15% had a LTC. There was a significant relationship between all the ten questions and the priority given by dispatchers. Localisation of the discomfort to the center of the chest, more intensive pain, history of angina or myocardial infarction as well as experience of cold sweat were the most important predictors when evaluating the probability of ACS and LTC. Not breathing normally and having diabetes were related to 30-day mortality.

CONCLUSIONS

Among individuals, who call for the EMS due to chest discomfort, the intensity and the localisation of the pain, as well as a history of ischemic heart disease, appeared to be the most strongly associated with outcome.

Use, patient selection and outcomes of P2Y12 receptor inhibitor treatment in patients with STEMI based on contemporary European registries

AIMS

Among acute coronary syndromes (ACS), ST-segment elevation myocardial infarction (STEMI) has the most severe early clinical course. We aimed to describe the effectiveness and safety of P2Y12 receptor inhibitors in patients with STEMI based on the data from contemporary European ACS registries.

METHODS AND RESULTS

Twelve registries provided data in a systematic manner on outcomes in STEMI patients overall, and seven of these also provided data for P2Y12 receptor inhibitor-based dual antiplatelet therapy. The registries were heterogeneous in terms of site, patient, and treatment selection, as well as in definition of endpoints (e.g. bleeding events). All-cause death rates based on the data from 84 299 patients (9612 patients on prasugrel, 11 492 on ticagrelor, and 27 824 on clopidogrel) ranged between 0.49 and 6.68% in-hospital, between 3.07 and 7.95% at 30 days (reported in 6 registries), between 8.15 and 9.13% at 180 days, and between 2.41 and 9.58% at 1 year (5 registries). Major bleeding rates were 0.09-3.55% in-hospital (8 registries), 0.09-1.65% at 30 days, and 1.96% at 1 year (only 1 registry). Fatal/life-threatening bleeding was rare occurring between 0.08 and 0.13% in-hospital (4 registries) and 1.96% at 1 year (1 registry).

CONCLUSIONS

Real-world evidence from European contemporary registries shows that death, ischaemic events, and bleeding rates are lower than those reported in Phase III studies of P2Y12 inhibitors. Regarding individual P2Y12 inhibitors, patients on prasugrel, and, to a lesser degree, ticagrelor, had fewer ischaemic and bleeding events at all time points than clopidogrel-treated patients. These findings are partly related to the fact that the newer agents are used in younger and less ill patients.

Impact of Chronic Total Occlusion in a Noninfarct-related Artery on Clinical Outcomes in Patients With Acute ST-elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

In the setting of primary percutaneous coronary intervention (PCI), encountering with chronic total occlusion (CTO) in a noninfarct-related artery (IRA) is not a rare situation. Limited information on the impact of CTO on clinical outcomes in acute ST-elevation myocardial infarction (STEMI) patients undergoing primary PCI has raised more concerns. The aim of the present study was to evaluate the effect of concurrent CTO in a non-IRA on the clinical outcomes in patients with STEMI undergoing primary PCI.In the present prospective study, 555 consecutive patients with STEMI who underwent early primary PCI from January 2010 to December 2013 were included. The patients were divided into 2 groups: no CTO and CTO. Data on 12 months follow-up was obtained from 449 patients. The primary endpoint was the composite of hospitalization from angina, reinfarction, heart failure, or re-revascularization, and cardiac death at 12 months follow-up.Of the 555 patients, 75 (13.5%) had CTO in a non-IRA. Compared with patients in no CTO group, more patients in CTO group had hypertension (62.7% vs 46.5%, P = 0.009), diabetes (49.3% vs 35.0%, P = 0.024), and 3-vessel disease (52.0% vs 32.3%, P = 0.001). Patients with CTO had a lower left ventricular ejection fraction (LVEF) (40.1% ± 16.8% vs 54.3% ± 12.1%, P = 0.038), more presented with cardiogenic shock on admission (13.3% vs 4.8%, P = 0.008), compared with patients without CTO. Complete revascularization (CR) was less achieved in CTO group than in no CTO group (33.3% vs 49.1%, P = 0.013). The 12-month cardiac mortality rate was 14.5% versus 6.2% (P = 0.039), the incidence of 12-month primary endpoint was 38.7% versus 21.2% (P = 0.003) for CTO and no CTO group, respectively. Multivariate analysis revealed that after correction for baseline differences, CTO in a non-IRA (hazard ratio 4.183, 95% confidence interval 1.940-6.019, P = 0.001), cardiogenic shock on admission (hazard ratio 3.286, 95% confidence interval 1.097-9.845, P = 0.034), and 3-vessel disease (hazard ratio 2.678, 95% confidence interval 1.221-5.874, P = 0.014) remained an independent predictor of 1-year cardiac mortality in patients with STEMI undergoing primary PCI.CTO in a non-IRA in patients with STEMI undergoing primary PCI is associated with a poor prognosis. The presence of CTO in a non-IRA, cardiogenic shock on admission and 3-vessel disease might be an independent risk factor for greater 1-year cardiac mortality in patients with acute STEMI undergoing primary PCI.

Managing Antiplatelet Therapy and Anticoagulants in Patients with Coronary Artery Disease and Atrial Fibrillation

Oral anticoagulation (OAC) is essential in patients with atrial fibrillation (AF). Interestingly coronary artery disease coexists in 20-30% of these patients.[1,2] Balancing the risk of bleeding and thromboembolism is very important for the management of patients on OAC, especially than when such patients require percutaneous coronary intervention (PCI). Lack of data and clear societal guidelines for peri-procedural and post-procedural management of anticoagulated patients has resulted in diverse clinical practices among clinicians, hospitals, and countries. Furthermore with expanding number of available oral antiplatelet and anticoagulant agents, the uncertainty regarding optimal combination therapy in this growing pool of the patients with overlapping clinical indications is also growing. Given the high proportion of patients with atherothrombosis and requiring OAC for conditions particularly like AF, it is important that physicians are aware of the clinical implications and management of these overlapping syndromes. In this article we discuss; this evolving dilemma of peri-procedural and post-procedural management of anticoagulated patient's, burden of the disease, available data, risk factors that could identify high risk patients and propose a well-balanced management strategy.

Stress Testing After Complete and Successful Coronary Revascularization

BACKGROUND

Noninvasive stress tests play a determinant role in the initial management of patients with chronic angina. Nonetheless, their use in the same patient population is considered inappropriate within 2 years after percutaneous coronary intervention (PCI). Indeed, early abnormal results correlate less well with angiographic control and are attributed to a number of confounding factors. We prospectively assessed prevalence and impact on the quality of life of abnormal stress test results in a highly selected patient population.

METHODS

Patients with no cardiac comorbidities who underwent successful and complete PCI with stenting for typical angina and had an abnormal exercise stress test (EST) under guideline-directed medical treatment were administered the Seattle Angina Questionnaire (SAQ). Clinical evaluation, EST, and the SAQ were repeated at 1, 6, and 12 months after the index PCI.

RESULTS

One hundred ninety-eight patients qualified and were included in the study (mean age, 64 years; 79% men). Although the majority had normal EST results or an increased threshold to angina, at 1 month after the index PCI, 29% of patients still had an abnormal result. At 6 and 12 months, 31% and 29% of patients had abnormal results, respectively. Quality-of-life assessment by the SAQ showed consistent results, with persistent angina in one third of patients. Control angiography documented a critical lesion, attributable to in-stent coronary restenosis, in only 8% of patients.

CONCLUSIONS

When stress testing is systematically performed after PCI, the prevalence of abnormal results is high and is associated with impaired quality of life. Prognostic significance along with the underlying pathophysiological mechanisms of such findings should be investigated.

The pharmacokinetic and pharmacodynamic interaction of clopidogrel and cilostazol in relation to CYP2C19 and CYP3A5 genotypes

AIM

The primary objective of the present study was to evaluate the pharmacokinetic and pharmacodynamic interactions between clopidogrel and cilostazol in relation to the CYP2C19 and CYP3A5 genotypes.

METHODS

In a randomized, three-way crossover study, 27 healthy subjects were administered clopidogrel (300 mg), cilostazol (100 mg) or clopidogrel + cilostazol orally. Plasma concentrations of clopidogrel, cilostazol and their active metabolites (clopidogrel thiol metabolite, 3,4-dehydrocilostazol and 4″-trans-hydroxycilostazol), and adenosine diphosphate-induced platelet aggregation were measured for pharmacokinetic and pharmacodynamic assessment.

RESULTS

The area under the plasma concentration-time curve (AUC) of the active thiol metabolite of clopidogrel was highest in the CYP2C19 extensive metabolizers (EM) and lowest in the poor metabolizers (PM). Cilostazol decreased the thiol metabolite AUC by 29% in the CYP3A5*1/*3 genotype [geometric mean ratio (GMR) 0.71; 90% confidence interval (CI) 0.58, 0.86; P = 0.020] but not in the CYP3A5*3/*3 genotype (GMR 0.93; 90% CI 0.80, 1.10; P = 0.446). Known effects of the CYP2C19 and CYP3A5 genotypes on the exposure of cilostazol and its metabolites were observed but there was no significant difference in the AUC of cilostazol and 3,4-dehydrocilostazol between cilostazol and clopidogrel + cilostazol. The inhibition of platelet aggregation from 4 h to 24 h (IPA4-24 ) following the administration of clopidogrel alone was highest in the CYP2C19 EM genotype and lowest in the CYP2C19 PM genotype (59.05 ± 18.95 vs. 36.74 ± 13.26, P = 0.023). However, the IPA of the CYP2C19 PM following co-administration of clopidogrel and cilostazol was comparable with that of the CYP2C19 EM and intermediate metabolizers (IM) only in CYP3A5*3/*3 subjects.

CONCLUSIONS

The additive antiplatelet effect of cilostazol plus clopidogrel is maximized in subjects with both the CYP2C19 PM and CYP3A5*3/*3 genotypes because of a lack of change of clopidogrel thiol metabolite exposure in CYP3A5*3/*3 as well as the highest cilostazol IPA in CYP2C19 PM and CYP3A5*3/*3 subjects.

Clinical characteristics, management and 1-year outcomes of patients with acute coronary syndrome in Iran: the Iranian Project for Assessment of Coronary Events 2 (IPACE2)

OBJECTIVES

To assess contemporary data on characteristics, management and 1-year postdischarge outcomes in Iranian patients hospitalised with acute coronary syndrome (ACS).

SETTING

11 tertiary care hospitals in 5 major cities in the Islamic Republic of Iran.

PARTICIPANTS

Patients aged ≥ 20 and ≤ 80 years discharged alive with confirmed diagnosis of ACS including ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI) and high-risk unstable angina (HR-UA).

PRIMARY AND SECONDARY OUTCOME MEASURES

Patients were followed up regarding the use of medications and the end points of the study at 1 month and 1 year after discharge. The primary end point of the study was 1-year postdischarge major adverse cardiac and cerebrovascular events (MACCEs), defined as mortality (cardiac and non-cardiac), ACS and cerebrovascular attack (stroke and/or transient ischaemic attack). The secondary end points were hospital admission because of congestive heart failure, revascularisation by coronary artery bypass grafting surgery or percutaneous coronary intervention (PCI), and major and minor bleeds.

RESULTS

A total of 1799 patients (25.7% STEMI and 74.3% HR-UA/NSTEMI) discharged alive with confirmed diagnosis of ACS were included in the final analysis. During hospitalisation, the majority of the patients received aspirin (98.6%), clopidogrel (91.8%), anticoagulants (93.4%), statins (94.3%) and β-blockers (89.3%). Reperfusion therapy was performed in 62.6% of patients with STEMI (46.3% thrombolytic therapy and 17.3% primary PCI). The mean door-to-balloon and door-to-needle times were 82.9 and 45.6 min, respectively. In our study, 64.7% and 79.5% of the patients in HR-UA/NSTEMI and STEMI groups, respectively, underwent coronary angiography. During the 12 months after discharge, MACCEs occurred in 15.0% of all patients.

CONCLUSIONS

Our study showed that the composition of Iranian patients with ACS regarding the type of ACS is similar to that in developed European countries and is unlike that in developing countries of the Middle East and Africa. We found that our patients with ACS are treated with high levels of adherence to guideline-recommended in-hospital medications.

Monocyte to high-density lipoprotein ratio as a new prognostic marker in patients with STEMI undergoing primary percutaneous coronary intervention

BACKGROUND

Monocyte count to high-density lipoprotein ratio (MHR) has recently emerged as an indicator of inflammation and oxidative stress in the literature. We aimed to investigate the prognostic value of MHR in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention (PCI).

METHODS

A total of 513 patients who were hospitalized with diagnosis of acute ST-segment elevation myocardial infarction and treated with primary PCI were retrospectively enrolled in the study. Demographic and clinical data, admission laboratory parameters, and MHR values were recorded. Inhospital major adverse cardiac events (MACE) and mortality were reported as the clinical outcomes.

RESULTS

Twenty-six patients (5%) died, and MACE was observed in 86 patients (17%) during hospital follow-up. Patients were categorized in 3 groups according to tertiles of admission MHR. The rates of inhospital mortality and MACE were significantly higher in tertile 3 group compared to tertile 1 group (10% vs 1%, 27% vs 11%; P < .01 and P < .01). In multivariate regression analysis, age, sex, presence of Killip 3 or 4, left ventricular ejection fraction, troponin I, C-reactive protein, and increased MHR levels (odds ratio, 1.03; 95% confidence interval, 1.01-1.05; P < .01) independently predicted inhospital mortality; age, presence of Killip 3 or 4, troponin I, and increased MHR levels (odds ratio, 1.02; 95% confidence interval, 1.01-1.04; P < .01) independently predicted MACE.

CONCLUSION

Admission MHR values were found to be independently correlated with inhospital MACE and mortality after primary PCI.

Granulocytes in coronary thrombus evolution after myocardial infarction--time-dependent changes in expression of matrix metalloproteinases

BACKGROUND

Remodeling of extracellular matrix is a key process during wound healing, which is strictly regulated by matrix metalloproteinases (MMPs) and their tissue inhibitors [tissue inhibitors of metalloproteinases (TIMPs)]. In this study, we evaluated intrathrombotic MMPs and TIMPs and their cellular origin during thrombus evolution after disruption of coronary atherosclerotic plaque.

MATERIALS AND METHODS

Thrombectomy materials (N=120) obtained from patients with acute myocardial infarction were histologically classified in three groups based on thrombus age: fresh (<1day), lytic (1-5days), or organized (>5days) thrombi; materials showing a heterogeneous composition were classified according to oldest part. Presence and cellular origin of MMPs (MMP-1, MMP-2, MMP-8, MMP-9, and MMP-14) and TIMPs (TIMP-1, TIMP-2, and TIMP-3) was evaluated with immunostains (double) and with polymerase chain reaction.

RESULTS AND CONCLUSION

MMPs and TIMPs were present in all the thrombectomy samples. A distinct temporal change in extent and cellular origin of MMPs and TIMPs during thrombus evolution was observed. In the early (fresh and lytic) stages of thrombus, high numbers of neutrophilic granulocytes occupy the thrombus mass and produce large amounts of MMPs and TIMPs. However, with progression of thrombus evolution (organizing stage) and diminishment of neutrophil granulocytes, there is disappearance of MMP-8 and MMP-9, steep decline of MMP-1 and TIMP-2, and progressive decrease of TIMP-3. In contrast, intrathrombotic MMP-2 and MMP-14 are present at a constant high level during the entire process of thrombus evolution. These temporal changes indicate a complex time-dependent function of MMPs, which are largely granulocyte derived, in the healing process of thrombus after plaque disruption.

Six-Year Prognostic Value of Microvascular Obstruction After Reperfused ST-Elevation Myocardial Infarction as Assessed by Contrast-Enhanced Cardiovascular Magnetic Resonance

Although recent studies showed the prognostic value of cardiac magnetic resonance (CMR) parameters especially microvascular obstruction (MO) after reperfused ST-elevation myocardial infarction (STEMI), a study assessing their prognostic significance for long-term follow-up is missing so far. The objective of this study was to determine the prognostic impact of MO on long-term prognosis after reperfused first STEMI in a setting allocating CMR-assessed parameters to hard clinical events only. In 249 patients, CMR was performed after reperfused STEMI, and hereby, left ventricular ejection fraction (LVEF), infarct size (IS), and the amount of MO were quantified. Follow-up (median 6.0 years) was obtained regarding occurrence of major adverse cardiac events (MACE). MACE occurred more often in patients showing presence of MO (MO vs no MO: n = 61 [54%] vs n = 12 [9%], p <0.0001). By multivariate analysis, the extent of MO remained the strongest predictor (p <0.001) for occurrence of MACE and provided incremental prognostic value over clinical variables and LVEF (p = 0.028, c-index increase from 0.723 to 0.817). In conclusion, CMR-assessed MO proves predictive for assessment of 6-year prognosis in patients after reperfused first STEMI and provides incremental prognostic information over clinical variables and LVEF in a setting based on hard end points.

Predictive factors of cardiac rupture in patients with ST-elevation myocardial infarction

Cardiac rupture (CR) is a potentially fatal mechanical complication of ST-elevation myocardial infarction (STEMI). We aimed to determine the incidence and risk factors of CR in Chinese STEMI patients. A total of 9798 consecutive STEMI patients from four centers in China were retrospectively analyzed, among which 178 patients had CR. STEMI patients without CR were chosen as a control group. Clinical characteristics were compared between STEMI patients with CR and those without CR. The incidence of CR in STEMI patients was 1.82%, and the 30-d mortality was up to 61.2%. CR patients were significantly older, more female, and associated with a longer time from onset of pain to hospital admission than their non-CR counterparts (P<0.001). More patients with anterior myocardial infarction (82.1%) were found in the CR group, and CR patients had significantly higher heart rates than the control group ((91±19) bpm vs. (71±16) bpm; P<0.001). In multiple-adjusted models, the independent risk factors of CR were advanced age, female gender, anaemia, increased heart rate, anterior myocardial infarction, increased white blood cell (WBC) count, delayed admission, and renal dysfunction. The level of hemoglobin remained a significant determinant factor of CR (OR (95% CI): 0.82 (0.75-0.89); P<0.001) after adjusting for various potential confounding factors. Counts of WBC also remained a significant determinant of the CR (OR (95% CI): 1.08 (1.04-1.12); P<0.001). A number of variables were independently related to CR. This study indicated, for the first time, that both hemoglobin and WBC levels were independently correlated with occurrence of CR.

Field triage in the ambulance versus referral via non-percutaneous coronary intervention centre in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention: A systematic review

AIMS

The purpose of this study was to determine whether direct ambulance transport of ST-elevation myocardial infarction (STEMI) patients to a percutaneous coronary intervention (PCI) hospital (field triage) leads to a lower 30-day mortality compared to transport via a referral non-PCI hospital (referral via a spoke centre) in STEMI patients.

METHODS AND RESULTS

We performed a systematic review of interventions. An experienced librarian searched in PubMed, EMBASE.com and The Cochrane Library (via Wiley) from January 1980-February 2013. Studies that examined field triage and/or referral via a spoke centre in STEMI patients treated with primary or facilitated PCI were included. Two authors independently conducted the study selection and data extraction. Multivariable frequency weighted logistic regression analysis was performed to assess the effect of the type of transfer on the outcome measures. We identified 14 randomised clinical trials (RCTs), including 20 transfer groups and 4474 participants. Thirty-day mortality was lower in patients who underwent field triage (3.0%; 95% confidence interval (CI) 2.2-4.2) compared to patients who were referred via a spoke centre (4.7%; 95% CI 4.0-5.5). In multivariable frequency weighted logistic regression analysis, field triage was independently associated with a lower incidence of 30-day mortality (odds ratio (OR): 0.58; 95% CI 0.37-0.89).

CONCLUSION

Field triage compared to referral via a spoke centre leads to a lower 30-day mortality in STEMI patients. Therefore, direct ambulance transport to a PCI hospital should become the transfer type for STEMI patients.

The Relationship among N-Terminal Pro-B-Type Natriuretic Peptide, High-Sensitivity C-Reactive Protein and Infarct Size in Patients with Acute ST-Elevation Myocardial Infarction

Background and Objectives

We sought to investigate the relationship between levels of high-sensitivity C-reactive protein (hs-CRP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) and the infarct size and left ventricular (LV) volume after acute myocardial infarction (MI).

Subjects and Methods

Eighty-six patients with acute ST-elevation MI underwent delayed enhancement multidetector computed tomography immediately after they underwent percutaneous coronary intervention to determine the infarct size. LV function and remodeling were assessed by echocardiography. Hs-CRP and NT-proBNP were measured at admission, 24 hours and two months later.

Results

Both hs-CRP and NT-proBNP at 24 hours showed a positive correlation with infarct size and a negative correlation with LV ejection fraction at the baseline and two months later. NT-proBNP at two months correlated with infarct size, LV ejection fraction, and LV end diastolic and systolic volume indices at two months. In patients with high NT-proBNP levels at 24 hours and two months, infarct size was larger and LV ejection fraction was lower. NT-proBNP was higher in patients who developed LV remodeling at two months: 929 pg/mL vs. 134 pg/mL, p=0.002. In contrast, hs-CRP at two months showed no relationship to infarct size, LV function, or LV volumes at two months.

Conclusion

Elevated hs-CRP level 24 hours after the onset of acute MI is associated with infarct size and LV dysfunction, whereas elevated levels of NT-proBNP 24 hours and two months after the onset of acute MI are both correlated with infarct size, LV dysfunction, and LV remodeling.

Use of a fixed, body weight-unadjusted loading dose of unfractionated heparin for extracorporeal cardiopulmonary resuscitation

Background

Extracorporeal cardiopulmonary resuscitation (ECPR) is being used increasingly in the emergency and critical care field in Japan. A major complication of ECPR is bleeding; however, the optimal initial heparin dose and activated coagulation time (ACT) remain unknown. The aim of this study was to assess the appropriateness of our initial anticoagulation protocol.

Methods

We retrospectively evaluated the initial heparin dose, ACT value, and incidence of bleeding and thrombotic complications in post-cardiopulmonary arrest patients who received a fixed, body weight-unadjusted loading dose of unfractionated heparin (3000 U) prior to veno-arterial extracorporeal membrane oxygenator (ECMO) between February 2011 and November 2013 at Mie University Hospital, Japan.

Results

ACT was evaluated within 3 h of initiation of 32 consecutive ECPR patients. The mean heparin dose per body weight was 53.6 U/kg and the mean ACT was 231.3 s. In 17 patients, ACT exceeded 200 s. Three patients experienced fatal bleeding in the chest wall within 24 h of receiving ECMO. The mean heparin dose per kilogram body weight, mean initial ACT, and mean duration of cardiopulmonary resuscitation (CPR) did not statistically differ between the patients who experienced fatal bleeding and those who did not.

Conclusions

Fixed-dose heparin of 3000-U bolus resulted in a mean heparin dose per kilogram body weight of 53.6 U/kg and an ACT of 231.3 s and experienced 3 out of 32 fatal bleedings. Further researches are warranted to optimize anticoagulation protocol for ECPR patients.

Intracoronary infusion of Wharton's jelly-derived mesenchymal stem cells in acute myocardial infarction: double-blind, randomized controlled trial

BACKGROUND

The use of adult stem cells is limited by the quality and quantity of host stem cells. It has been demonstrated that Wharton's jelly-derived mesenchymal stem cells (WJMSCs), a primitive stromal population, could integrate into ischemic cardiac tissues and significantly improve heart function. In this randomized, controlled trial, our aim was to assess the safety and efficacy of intracoronary WJMSCs in patients with ST-elevation acute myocardial infarction (AMI).

METHODS

In a multicenter trial, 116 patients with acute ST-elevation MI were randomly assigned to receive an intracoronary infusion of WJMSCs or placebo into the infarct artery at five to seven days after successful reperfusion therapy. The primary endpoint of safety: the incidence of adverse events (AEs) within 18 months, was monitored and quantified. The endpoint of efficacy: the absolute changes in myocardial viability and perfusion of the infarcted region from baseline to four months, global left ventricular ejection fraction (LVEF) from baseline to 18 months were measured using F-18-fluorodeoxyglucose positron emission computed tomography (F-18-FDG-PET) and 99mTc-sestamibi single-photon emission computed tomography (99mTc-SPECT), and two-dimensional echocardiography, respectively.

RESULTS

During 18 months follow-up, AEs rates and laboratory tests including tumor, immune, and hematologic indexes were not different between the two groups. The absolute increase in the myocardial viability (PET) and perfusion within the infarcted territory (SPECT) was significantly greater in the WJMSC group [6.9 ± 0.6 % (95 %CI, 5.7 to 8.2)] and [7.1 ± 0.8 % (95 %CI, 5.4 to 8.8) than in the placebo group [3.3 ± 0.7 % (95 %CI, 1.8 to 4.7), P <0.0001] and 3.9 ± 0.6(95 %CI, 2.8 to 5.0), P = 0.002] at four months. The absolute increase in the LVEF at 18 months in the WJMSC group was significantly greater than that in the placebo group [7.8 ± 0.9 (6.0 to approximately 9.7) vs. 2.8 ± 1.2 (0.4 to approximately 5.1), P = 0.001]. Concomitantly, the absolute decreases in LV end-systolic volumes and end-diastolic volumes at 18 months in the WJMSC group were significantly greater than those in the placebo group (P = 0.0004, P = 0.004, respectively).

CONCLUSIONS

Intracoronary infusion of WJMSCs is safe and effective in patients with AMI, providing clinically relevant therapy within a favorable time window. This study encourages additional clinical trials to determine whether WJMSCs may serve as a novel alternative to BMSCs for cardiac stem cell-based therapy.

TRIAL REGISTRATION

Clinical Trials NCT01291329 (02/05/2011).

CYP2C19 Phenoconversion by Routinely Prescribed Proton Pump Inhibitors Omeprazole and Esomeprazole: Clinical Implications for Personalized Medicine

The phenotype pantoprazole-(13)C breath test (Ptz-BT) was used to evaluate the extent of phenoconversion of CYP2C19 enzyme activity caused by commonly prescribed proton pump inhibitors (PPI) omeprazole and esomprazole. The Ptz-BT was administered to 26 healthy volunteers and 8 stable cardiovascular patients twice at baseline and after 28 days of PPI therapy to evaluate reproducibility of the Ptz-BT and changes in CYP2C19 enzyme activity (phenoconversion) after PPI therapy. The average intrapatient interday variability in CYP2C19 phenotype (n = 31) determined by Ptz-BT was considerably low (coefficient of variation, 17%). Phenotype conversion resulted in 25 of 26 (96%) nonpoor metabolizer (non-PM) volunteers/patients as measured by the Ptz-BT at baseline and after PPI therapy. The incidence of PM status by phenotype following administration of omeprazole/esomeprazole (known inhibitors of CYP2C19) was 10-fold higher than those who are genetically PMs in the general population, which could have critical clinical implications for personalizing medications primarily metabolized by CYP2C19, such as clopidogrel, PPI, cyclophosphamide, thalidomide, citalopram, clonazepam, diazepam, phenytoin, etc. The Ptz-BT can rapidly (30 minutes) evaluate CYP2C19 phenotype and, more importantly, can identify patients with phenoconversion in CYP2C19 enzyme activity caused by nongenetic factors such as concomitant drugs.

Early Medication Nonadherence After Acute Myocardial Infarction: Insights into Actionable Opportunities From the TReatment with ADP receptor iNhibitorS: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome (TRANSLATE-ACS) Study

BACKGROUND

Nonadherence to prescribed evidence-based medications after acute myocardial infarction (MI) can contribute to worse outcomes and higher costs. We sought to better understand the modifiable factors contributing to early nonadherence of evidence-based medications after acute MI.

METHODS AND RESULTS

We assessed 7425 acute MI patients treated with percutaneous coronary intervention at 216 US hospitals participating in TReatment with ADP receptor iNhibitorS: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome (TRANSLATE-ACS) between April 2010 and May 2012. Using the validated Morisky instrument to assess cardiovascular medication adherence at 6 weeks post MI, we stratified patients into self-reported high (score, 8), moderate (score, 6-7), and low (score, <6) adherence groups. Moderate and low adherence was reported in 25% and 4% of patients, respectively. One third of low adherence patients described missing doses of antiplatelet therapy at least twice a week after percutaneous coronary intervention. Signs of depression and patient-reported financial hardship because of medication expenses were independently associated with a higher likelihood of medication nonadherence. Patients were more likely to be adherent at 6 weeks if they had follow-up appointments made before discharge and had a provider explain potential side effects of their medications. Lower medication adherence may be associated with a higher risk of 3-month death/readmission (adjusted hazard ratio, 1.35; 95% confidence interval, 0.98-1.87) although this did not reach statistical significance.

CONCLUSIONS

Even early after MI, a substantial proportion of patients report suboptimal adherence to prescribed medications. Tailored patient education and pre discharge planning may represent actionable opportunities to optimize patient adherence and clinical outcomes.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01088503.

Persistence with secondary prevention medications after acute myocardial infarction: Insights from the TRANSLATE-ACS study

BACKGROUND

Persistent use of secondary prevention therapies after acute myocardial infarction (MI) is critical to optimizing long-term outcomes.

METHODS

Medication persistence was assessed among 7,955 MI patients in 216 hospitals participating in the Treatment with Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome study from 2010 to 2012. Persistence was defined as continuation of aspirin, adenosine diphosphate receptor inhibitors, β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins from discharge to 6 months post-MI. Multivariable logistic regression modeling was used to determine factors associated with nonpersistence, defined as <80% persistence with all medication classes.

RESULTS

Overall, 31% of MI patients stopped taking a least 1 medication by 6 months. The most common reasons cited for medications discontinuation were side effects and physician instruction (57%), whereas financial concerns were cited in 8% overall. After multivariable modeling, black race (odds ratio 1.36, 95% CI 1.15-1.62), older age (odds ratio 1.07, 95% CI 1.02-1.12), atrial fibrillation (odds ratio 1.67, 95% CI 1.33-2.09), dialysis (odds ratio 1.79, 95% CI 1.15-2.78), and depression (odds ratio 1.22, 95% CI 1.02-1.45) were associated with lower likelihood of persistence. Private insurance (odds ratio 0.85, 95% 0.76-0.95), prescription cost assistance (odds ratio 0.63, 95% CI 0.54-0.75), and outpatient follow-up arranged before discharge (odds ratio 0.89, 95% CI 0.80-0.99) were associated with higher persistence.

CONCLUSIONS

Nearly one-third of MI patients are no longer persistent with their prescribed medications by 6 months. Patients at high risk for nonpersistence may be identified by clinical and sociodemographic features. These observations underscore key opportunities to optimize longitudinal use of secondary prevention therapies.

Design and methods of the Gentle Cardiac Rehabilitation Study--A behavioral study of tai chi exercise for patients not attending cardiac rehabilitation

INTRODUCTION

Cardiac rehabilitation (CR) programs reduce overall and cardiovascular mortality in patients with a history of acute coronary events or revascularization procedures, but only 30% of patients enroll in CR and attrition rates reach up to 60%. Tai chi, a mind-body practice based on light/moderate aerobic exercise accompanied by meditative components could be a possible exercise option for patients who do not attend CR.

METHODS/DESIGN

Sixty patients will be randomized to a "LITE" condition (one tai chi session twice weekly for 12 weeks) or to a "PLUS" condition (one tai chi session 3 times weekly for 12 weeks, followed by maintenance classes 1-2 times weekly for an additional 12 weeks). Measurements will be conducted at baseline, 3-, 6-, and 9 months after enrollment. The primary outcome is to determine the feasibility, acceptability and safety of each dose. Secondary outcomes include estimates of effect size of each dose on accelerometry-assessed physical activity; the proportion of patients meeting current recommendations for physical activity; and measures of fitness, quality of life, body weight, and sleep. In addition, we will collect exploratory information on possible mediators (exercise self-efficacy, perceived social support, resilience, mindfulness, and depression).

CONCLUSIONS

Findings from this pilot study will provide preliminary indications about the usefulness of tai chi as an exercise option for patients not attending traditional CR programs. Results will also shed light on the possible mechanisms by which tai chi practice may improve overall physical activity among patients with atherosclerotic coronary heart disease.

PHD2/3-dependent hydroxylation tunes cardiac response to β-adrenergic stress via phospholamban

Ischemic heart disease is the leading cause of heart failure. Both clinical trials and experimental animal studies demonstrate that chronic hypoxia can induce contractile dysfunction even before substantial ventricular damage, implicating a direct role of oxygen in the regulation of cardiac contractile function. Prolyl hydroxylase domain (PHD) proteins are well recognized as oxygen sensors and mediate a wide variety of cellular events by hydroxylating a growing list of protein substrates. Both PHD2 and PHD3 are highly expressed in the heart, yet their functional roles in modulating contractile function remain incompletely understood. Here, we report that combined deletion of Phd2 and Phd3 dramatically decreased expression of phospholamban (PLN), resulted in sustained activation of calcium/calmodulin-activated kinase II (CaMKII), and sensitized mice to chronic β-adrenergic stress-induced myocardial injury. We have provided evidence that thyroid hormone receptor-α (TR-α), a transcriptional regulator of PLN, interacts with PHD2 and PHD3 and is hydroxylated at 2 proline residues. Inhibition of PHDs increased the interaction between TR-α and nuclear receptor corepressor 2 (NCOR2) and suppressed Pln transcription. Together, these observations provide mechanistic insight into how oxygen directly modulates cardiac contractility and suggest that cardiac function could be modulated therapeutically by tuning PHD enzymatic activity.

Multiple procedures and cumulative individual radiation exposure in interventional cardiology: A long-term retrospective study

INTRODUCTION

Various studies address discrepancies between guideline recommendations for coronary angiographies and clinical practice. While the issue of the appropriateness of recurrent angiographies was studied focusing on the role of the cardiologist, little is known about individual patients' histories and the associated radiation exposures.

METHODS

We analyzed all patients with coronary artery disease (CAD) in an academic teaching practice who underwent at least one angiography with or without intervention between 2004 and 2009. All performed angiographies in these patients were analyzed and rated by three physicians for appropriateness levels according to cardiology guidelines. Typical exposure data from the medical literature were used to estimate individual radiation exposure.

RESULTS

In the cohort of 147 patients, a total of 441 procedures were analyzed: between 1981 and 2009, three procedures were performed per patient (range 1-19) on average. Appropriateness ratings were 'high/intermediate' in 71%, 'low/no' in 27.6% and data were insufficient for ratings in 1.4%. Procedures with 'low/no' ratings were associated with potentially avoidable exposures of up to 186 mSv for single patients.

CONCLUSIONS

Using retrospective data, we exemplify the potential benefit of guideline adherence to decrease patients' radiation exposures.

KEY POINTS

• A cohort study of 147 patients showed 27.6% low appropriateness procedures. • Potentially avoidable radiation exposure cumulated up to about 186 mSv for single patients. • Predisposing factors were prior bypass surgery and first treatment in a tertiary centre. • 7.5% of the patients received 58% of the potentially avoidable radiation exposure. • The benefits of guideline adherence in decreasing patient radiation exposure are exemplified.

Major publications in the critical care pharmacotherapy literature: January-December 2013

PURPOSE

Ten recently published articles with important implications for critical care pharmacotherapy are summarized.

SUMMARY

The Critical Care Pharmacotherapy Literature Update (CCPLU) group is a national assembly of experienced intensive care unit (ICU) pharmacists across the United States. Group members monitor 25 peer-reviewed journals on an ongoing basis to identify literature relevant to pharmacy practice in the critical care setting. After evaluation by CCPLU group members, selected articles are chosen for summarization and distribution to group members nationwide based on (1) applicability to critical care practice, (2) relevance to pharmacy practitioners, and (3) quality of evidence or research methodology. Hundreds of relevant articles were evaluated by the group during the period January-December 2013, of which 98 were summarized and disseminated nationally to CCPLU group members. Among those 98 publications, 10 deemed to be of particularly high utility to critical care practitioners were included in this review. The 10 articles address topics such as rapid lowering of blood pressure in patients with intracranial hemorrhage, adjunctive therapy to prevent renal injury due to acute heart failure, triple-drug therapy to improve neurologic outcomes after cardiac arrest, and continuous versus intermittent infusion of β-lactam antibiotics in severe sepsis.

CONCLUSION

There were many important additions to the critical care pharmacotherapy literature in 2013, including an updated guideline on the management of myocardial infarction and reports on advances in research focused on improving outcomes in patients with stroke or cardiac arrest and preventing the spread of drug-resistant pathogens in the ICU.