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

Effect on Platelet Reactivity From a Prasugrel Loading Dose After a Clopidogrel Loading Dose Compared With a Prasugrel Loading Dose Alone

Background—

Adding a prasugrel loading dose (LD) to a clopidogrel LD could be desirable because clopidogrel may fail to provide adequate levels of platelet inhibition in patients with acute coronary syndrome undergoing percutaneous coronary intervention.

Methods and Results—

The pharmacodynamic response of prasugrel 60 mg LD alone was compared with prasugrel 60 mg or 30 mg added ≤24 hours to clopidogrel 600 mg in Transferring from Clopidogrel Loading Dose to Prasugrel Loading Dose in Acute Coronary Syndrome Patients study—a multicenter, randomized, double-blind, double-dummy, 3-arm, parallel, active-comparator controlled study. Two hundred eighty-two patients were randomized to 3 LD strategies: placebo plus prasugrel 60 mg, clopidogrel 600 mg plus prasugrel 60 mg, or clopidogrel 600 mg plus prasugrel 30 mg. Platelet function was assessed using VerifyNow P2Y12 Reaction Units (PRU) immediately before prasugrel LD, and 2, 6, 24, and 72 hours after prasugrel LD in 149 patients with evaluable platelet function studies. At 6 hours after the prasugrel 60 mg LD, the least squares mean (95% confidence interval) difference between placebo/prasugrel 60 mg and clopidogrel 600 mg/prasugrel 60 mg (primary outcome) was 22.2 (−11.0 to 55.5; P =0.19; least squares mean PRU 57.9 versus 35.6, respectively). For clopidogrel 600 mg/prasugrel 30 mg (least squares mean PRU, 53.9), the difference was 3.9 (−28.2 to 36.1; P =0.81) versus placebo/prasugrel 60 mg. No significant differences in PRU were observed at any time point across the 3 groups. There were few bleeding events observed regardless of treatment.

Conclusions—

Platelet reactivity with prasugrel 60 mg LD added to clopidogrel 600 mg LD was not significantly different compared with prasugrel 60 mg LD alone in acute coronary syndrome patients undergoing percutaneous coronary intervention.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01115738.

Management of coronary atherosclerosis and acute coronary syndromes in patients with chronic kidney disease

Atherosclerosis of the coronary arteries is common, extensive, and more unstable among patients with chronic renal impairment or chronic kidney disease (CKD). The initial presentation of coronary disease is often acute coronary syndrome (ACS) that tends to be more complicated and has a higher risk of death in this population. Medical treatment of ACS includes antianginal agents, antiplatelet therapy, anticoagulants, and pharmacotherapies that modify the natural history of ventricular remodeling after injury. Revascularization, primarily with percutaneous coronary intervention and stenting, is critical for optimal outcomes in those at moderate and high risk for reinfarction, the development of heart failure, and death in predialysis patients with CKD. The benefit of revascularization in ACS may not extend to those with end-stage renal disease because of competing sources of all-cause mortality. In stable patients with CKD and multivessel coronary artery disease, observational studies have found that bypass surgery is associated with a reduced mortality as compared with percutaneous coronary intervention when patients are followed for several years. This article will review the guidelines-recommended therapeutic armamentarium for the treatment of stable coronary atherosclerosis and ACS and give specific guidance on benefits, hazards, dose adjustments, and caveats concerning patients with baseline CKD.

Impact of chronic kidney disease in early invasive versus early conservative revascularization strategies in non-ST-segment elevation acute coronary syndromes: a population-based study from NHIRD of Taiwan

BACKGROUND

Patients with chronic kidney disease (CKD) sustaining a non-ST-segment elevation acute coronary syndrome (NSTE-ACS) are considered high risk and an early invasive strategy (EIS) is often recommended. However, the impact of CKD on patients receiving an EIS or an early conservative strategy (ECS) is unclear in real-world practice.

METHODS

Data were analyzed from the 2005-2008 National Health Insurance Research Database (NHIRD) in Taiwan. The diagnosis of CKD was based on the International Classification of Disease-9 codes recorded by physicians. EIS was defined as coronary angiography with intent to revascularization performed within 72 h of symptom onset. The primary endpoint was time to first major adverse cardiac event (MACE) comprising cardiovascular death, myocardial infarction (MI) and stroke. The secondary endpoints included major bleeding (MB), heart failure (HF) and dialysis during admission (DDA).

RESULTS

834 patients (466 EIS and 368 ECS) were enrolled and age was 64.3 ± 12.6 years. Mean follow-up time was 1,163.96 ± 19.99 days. In the whole population an EIS was associated with a reduction in MACE (HR 0.69; 95% CI 0.50-0.95, p = 0.024) but not in the CKD population (HR 1.08; 95% CI 0.66-1.78, p = 0.76). Kaplan-Meier curves showed CKD subjects receiving an EIS had the highest MACE, HF and DDA rate (all p < 0.019) and CKD subjects receiving an ECS had the highest MB rate (p = 0.018). Cox regression analysis showed CKD predicted higher HF and DDA in those receiving an EIS and higher DDA and MB in those receiving an ECS.

CONCLUSION

An EIS reduced MACE in the overall population, and CKD was a poor outcome predictor for both revascularization strategies in NSTE-ACS.

Predictors of 1-year outcomes in the Taiwan Acute Coronary Syndrome Full Spectrum Registry

BACKGROUND/PURPOSE

Evidence-based guidelines have been formulated for optimal management of acute coronary syndrome (ACS). The Taiwan ACS Full Spectrum Registry aimed to evaluate the ACS management and identify the predictors of clinical outcomes of death/myocardial infarction/stroke 1 year post hospital discharge.

METHODS

Three thousand and eighty confirmed ACS patients enrolled in this registry were followed up for 1 year at 3-month intervals. Patient data on medical interventions as well as clinical events were recorded and analyzed by descriptive statistics.

RESULTS

One-year mortality among patients with ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI) and unstable angina was 6.1%, 10.1%, and 6.2%, respectively. Use of secondary preventive therapies was suboptimal throughout the follow-up phase, especially dual antiplatelet therapy, which fell from 74.8% patients at discharge to 24.9% patients at 1-year follow-up. The odds of an adverse incidence of death/myocardial infarction/stroke 1 year after discharge was significantly reduced in patients receiving aspirin and clopidogrel for ≥9 months and was consequently higher in patients in whom dual antiplatelet therapy was discontinued or prescribed for <9 months. Chronic renal failure, in-hospital bleeding, a diagnosis of NSTEMI, and antiplatelet therapy discontinuation had a negative association with 1-year outcomes, whereas the use of drug-eluting stents and antiplatelet agents, clopidogrel and aspirin, were predictors of positive outcomes.

CONCLUSION

There is a significant deviation from evidence-based guidelines in ACS management in Taiwan as reported in other countries. Policy adherence, especially with regard to dual antiplatelet therapy may hold the key to long-term favorable outcomes and improved survival rates in ACS patients in Taiwan.

Prognostic value of low and moderately elevated C-reactive protein in acute coronary syndrome: a 2-year follow-up study

BACKGROUND

The main goal of this study was to improve diagnostic and predictive value of low and moderately elevated C-reactive protein (CRP) in patients with acute coronary syndrome (ACS), related to noninvasive clinical parameters, in order to improve and prolong patient life with low or no additional costs.

MATERIAL/METHODS

A prospective, open clinical study was conducted at the University Hospital Split, Croatia with 112 patients with ACS and low or moderately elevated CRP (<3.0 mg/L). After diagnosing ACS, data on physical activity, alcohol consumption, and functional status were recorded. Anthropometric measurements were made. Blood and urine samples were taken for analyses. Electrocardiographic, ergometric, and echocardiographic testing was performed. A total of 72 parameters were monitored at the time of hospital admission in ACS patients to analyze which ones could predict disease outcome at the end of follow-up in patients with low or moderately elevated CRP. Patients were followed up for 2 years.

RESULTS

The variables that were predictive of major adverse cardiac events (MACE) within 2 years of ACS hospitalization were hemoglobin, fibrinogen, antithrombin III, cholesterol levels, brain natriuretic peptide, and microalbuminuria. ACS patients with CRP<3.0 mg/L had significantly higher risk of developing MACE within 2 years if ≥50% of the 8 key parameters were outside the reference values.

CONCLUSIONS

Major adverse cardiac events can be predicted in patients with acute coronary syndrome whose CRP values are low or moderately elevated.

Increased urinary IgM excretion in patients with chest pain due to coronary artery disease

BACKGROUND

Micro-albuminuria is a recognized predictor of cardiovascular morbidity and mortality in patients with coronary artery disease. We have previously reported, in diabetic and non-diabetic patients, that an increased urinary excretion of IgM is associated with higher cardiovascular mortality. The purpose of this study was to investigate the pattern of urinary IgM excretion in patients with acute coronary syndrome (ACS) and its correlation to cardiovascular outcome.

METHODS

Urine albumin, and IgM to creatinine concentration ratios were determined in 178 consecutive patients presenting with chest pain to the Department of Emergency Medicine (ED) at the University Hospital of Lund. Fifty eight (23 female) patients had ACS, 55 (19 female) patients had stable angina (SA), and 65 (35 female) patients were diagnosed as non-specific chest pain (NS).

RESULTS

Urine albumin and IgM excretions were significantly higher in patients with ACS (p = 0.001, and p = 0.029, respectively) compared to patients with NS-chest pain. During the 2 years follow-up time, 40 (19 female) patients suffered a new major cardiovascular event (ACS, acute heart failure, stroke) and 5 (4 male/1 female) patients died of cardiovascular cause. A high degree of albuminuria and IgM-uria significantly predicted cardiovascular mortality and morbidity (HR = 2.89, 95% CI: 1.48 - 5.66, p = 0.002). Microalbuminuric patients (≥3 mg/mmol) with high IgM-uria (≥0.005 mg/mmol) had a 3-fold higher risk for cardiovascular new events compared to patients with low IgM-uria (RR = 3.3, 95% CI: 1.1 - 9.9, p = 0.001).

CONCLUSION

In patients with chest pain, an increased urine IgM excretion, is associated with coronary artery disease and long-term cardiovascular complications. Measuring urine IgM concentration could have a clinical value in risk stratification of patients with ACS.

Early- and late-term clinical outcome and their predictors in patients with ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction

BACKGROUNDS

The disparity between ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) remains controversial. We compared clinical outcomes and prognostic factors between STEMI and NSTEMI using large-scale registry data.

METHODS

We recruited 28,421 patients with STEMI (n=16,607) and NSTEMI (n=11,814) between November 2005 and April 2010 from a nationwide registry in Korea. We performed landmark analysis of cardiac death, recurrent acute myocardial infarction (re-AMI), revascularization, and major adverse cardiac events (MACE) at 30 days (early term) and 1 year (late term) after admission.

RESULTS

Patients with NSTEMI had a greater number of co-morbidities than STEMI patients. Early term MACE (6.9% vs. 4.5%, p<0.001) and cardiac death (6.1% vs. 3.7%, p<0.001) were higher in STEMI patients. However, late-term MACE (8.0% vs. 9.1%, p=0.007), cardiac death (1.9% vs. 2.6%, p=0.001), and re-AMI (0.6% vs. 1.3%, p<0.001) were lower in the STEMI group. The independent predictors of cardiac death were old age, renal dysfunction, LV dysfunction, Killip class, post-thrombolysis in myocardial infarction (TIMI) flow, and major bleeding in both groups. Female gender, previous ischemic heart disease, diabetes, current smoking, multivessel disease, and body mass index were MI type- or time-dependent predictors.

CONCLUSION

The STEMI group displayed poor early term clinical outcome, whereas the NSTEMI group displayed poor late-term clinical outcome. The STEMI and NSTEMI groups had different predictor profiles for cardiac death, suggesting that different strategies are required for improving the late-term outcome of STEMI and NSTEMI patients.

Quantitative analysis of coronary plaque composition by dual-source CT in patients with acute non-ST-elevation myocardial infarction compared to patients with stable coronary artery disease correlated with virtual histology intravascular ultrasound

RATIONALE AND OBJECTIVES

To quantitatively assess coronary atherosclerotic plaque composition in patients with acute non-ST elevation myocardial infarction (NSTEMI) and patients with stable coronary artery disease (CAD) by coronary computed tomography angiography (cCTA) correlated with virtual histology intravascular ultrasound (VH-IVUS).

MATERIALS AND METHODS

Sixty patients (35 with NSTEMI) were included. Corresponding plaques were assessed by dual-source cCTA and VH-IVUS regarding volumes and percentages of fatty, fibrous, and calcified component; overall plaque burden; and maximal percent area stenosis. Possible differences between patient groups were investigated. Concordance between cCTA and VH-IVUS measurements was validated by Bland-Altman analysis.

RESULTS

Forty corresponding plaques (22 of patients with NSTEMI) were finally analyzed by cCTA and VH-IVUS. cCTA plaque analysis revealed no significant differences between plaques of patients with NSTEMI and stable CAD regarding absolute and relative amounts of any plaque component (fatty: 20 mm³/13% versus 17 mm³/14%; fibrous: 81 mm³/63% versus 80 mm³/53%; calcified: 16 mm³/14% versus 26 mm³/26%; all P > .05) or overall plaque burden (153 mm³ versus 165 mm³; P > .05), nor did VH-IVUS plaque analysis. VH-IVUS measured a higher area stenosis in patients with NSTEMI compared to patients with stable CAD (76% versus 68%, P = .01; in cCTA 69% versus 65%, P = .2). Volumes of fatty component were measured systematically lower in cCTA, whereas calcified and fibrous volumes were higher. No significant bias was observed comparing volumes of overall noncalcified component and overall plaque burden.

CONCLUSION

Plaques of patients with acute NSTEMI and of patients with stable CAD cannot be differentiated by quantification of plaque components. cCTA and VH-IVUS differ in plaque component analysis.

Clinical outcomes, health resource use, and cost in patients with early versus late dual or triple anti-platelet treatment for acute coronary syndrome

BACKGROUND

Acute coronary syndrome (ACS) guidelines recommend early dual anti-platelet therapy (thienopyridines + acetylsalicylic acid [aspirin]). However, triple therapy (thienopyridines + aspirin + glycoprotein IIb/IIIa receptor inhibitors [GRIs]) has shown benefit in clinical trials.

OBJECTIVE

This study assessed real-world ACS treatment patterns and outcomes in the acute care setting.

STUDY DESIGN

A retrospective analysis of patients admitted to hospital with ACS (index event) from January 2007 to December 2009 was conducted (Thomson's MarketScan Hospital Drug Database).

PATIENTS

Eligible patients were ≥18 years of age, of either sex, and had primary admission and discharge diagnoses of ACS.

OUTCOME MEASURES

Cohorts were defined by anti-platelet treatment and then by the timing of treatment initiation (early initiation: within ≤2 days of admission; late initiation: ≥2 days post-admission). Patient characteristics, clinical outcomes, resource utilization, and costs were assessed using descriptive statistics.

RESULTS

A total of 249,907 eligible patients were placed into four treatment cohorts (aspirin assumed for all patients): aspirin only; clopidogrel only (dual therapy); GRI only (dual therapy); and clopidogrel + GRI (triple therapy). Patients in the 'clopidogrel-only' cohort were more likely to be older, female, and have more co-morbidities than those in other cohorts; stroke (6.2 %) and re-hospitalization (15.4 %) rates were higher than in the 'GRI-only' and 'triple therapy' cohorts. The GRI-only cohort had higher major bleeding rates (3.3 %), mortality (7.6 %), and costs ($US21,975 [year 2010 values]) than the clopidogrel-only and triple-therapy cohorts. Late initiation cohorts were more likely to be older, female, and have more co-morbidities than early initiation cohorts. Major bleeding was more likely with GRI-only patients (regardless of initiation timing) than with other cohorts. Late-treated clopidogrel-only patients had higher rates of stroke (6.9 %), ACS-related re-admissions (6.1 %), and all-cause re-admissions (15.9 %) than other cohorts. Late treatment was associated with longer length of stay and significantly higher costs.

CONCLUSIONS

Real-world anti-platelet treatment patterns are consistent with ACS guidelines recommending early initiation and selective GRI use. In contrast to recommendations, some outcomes were improved with triple therapy compared with dual therapy.

Effect of private insurance incentive policy reforms on trends in coronary revascularisation procedures in the private and public health sectors in Western Australia: a cohort study

Background

The Australian federal government introduced private health insurance incentive policy reforms in 2000 that increased the uptake of private health insurance in Australia. There is currently a lack of evidence on the effect of the policy reforms on access to cardiovascular interventions in public and private hospitals in Australia. The aim was to investigate whether the increased private health insurance uptake influenced trends in emergency and elective coronary artery revascularisation procedures (CARPs) for private and public patients.

Methods

We included 34,423 incident CARPs from Western Australia during 1995-2008 in this study. Rates of emergency and elective CARPs were stratified for publicly and privately funded patients. The average annual percent change (AAPC) in trend was calculated before and after 2000 using joinpoint regression.

Results

The rate of emergency CARPs, which were predominantly percutaneous coronary interventions (PCIs) with stenting, increased throughout the study period for both public and private patients (AAPC=12.9%, 95% CI=5.0,22.0 and 14.1%, 95% CI=9.8,18.6, respectively) with no significant difference in trends before and after policy implementation. The rate of elective PCIs with stenting from 2000 onwards remained relatively stable for public patients (AAPC=−6.0, 95% C= −16.9,6.4), but increased by 4.1% on average annually (95% CI=1.8,6.3) for private patients (p_difference=0.04 between groups). This rate increase for private patients was only seen in people aged over 65 years and people residing in high socioeconomic areas.

Conclusions

The private health insurance incentive policy reforms are a likely contributing factor in the shift in 2000 from public to privately-funded elective PCIs with stenting. These reforms as well as the increasing number of private hospitals may have been successful in increasing the availability of publicly-funded beds since 2000.

ED administration of thienopyridines in non-ST-segment elevation myocardial infarction: results from the NCDR

OBJECTIVE

American Heart Association/American College of Cardiology guidelines recommend that patients with definite unstable angina or non-ST-segment elevation myocardial infarction (NSTEMI) receive dual antiplatelet therapy on presentation to the hospital when undergoing early invasive management or "as soon as possible" after admission when being managed conservatively. The guidelines do not specify whether these medications should be administered in the emergency department (ED). Our aim was to determine whether ED administration of a thienopyridine was associated with clinical outcomes among patients with NSTEMI.

METHODS

We examined thienopyridine use in 39454 patients with NSTEMI who received a thienopyridine within 24 hours of presentation in the National Cardiovascular Data Registry's Acute Coronary Treatment and Intervention Outcomes Network-Get With The Guidelines Registry from January 2007 to June 2010. Patients who were not seen initially in the ED, were transferred in, or were missing time data were excluded. We analyzed the association between ED administration of thienopyridines and outcomes and patient demographics.

RESULTS

Of the cohort receiving a thienopyridine within 24 hours, 9534 (24.2%) received it in the ED. Emergency department administration of a thienopyridine was not associated with in-hospital major bleeding (multivariable adjusted odds ratio, 0.99; 95% confidence interval, 0.91-1.09) or in-hospital mortality (adjusted 1.02; 95% confidence interval, 0.86-1.20). Independent predictors most strongly associated with ED thienopyridine administration were elevated troponin, ED length of stay, prior percutaneous coronary intervention, and initial electrocardiogram showing ischemic changes.

CONCLUSIONS

There was no association between ED thienopyridine administration and in-hospital major bleeding or mortality. Emergency department length of stay, electrocardiographic changes, and elevated troponin were associated with ED thienopyridine administration.

Standards of specialized diabetes care. Edited by Dedov II, Shestakova MV (6th edition)

Dear Colleagues!. We are glad to present the 6th Edition of Standards of Diabetes Care. These evidence-based guidelines were designed to standardize and facilitate diabetes care in all regions of the Russian Federation. The Standards are updated on the regular basis to incorporate new data and relevant recommendations from national and international clinical societies, including World Health Organization Guidelines (WHO, 2011), International Diabetes Federation (IDF, 2011), American Diabetes Association (ADA, 2013), American Association of Clinical Endocrinologists (AACE, 2009), International Society for Pediatric and Adolescent Diabetes (ISPAD, 2009) and Russian Association of Endocrinologists (RAE, 2011, 2012). Current edition of the ?Standards? also integrates results of completed randomized clinical trials (ADVANCE, ACCORD, VADT, UKPDS, etc.), as well as findings from the national studies of diabetes mellitus (DM), conducted in close partnership with a number of Russian hospitals. Latest data indicates that prevalence of DM increased during the last decade more than two-fold, reaching some 371 million patients by 2013. According to the current estimation by the International Diabetes Federation, every tenth inhabitant of the planet will be suffering from DM by 2030. These observations resulted in the UN Resolution 61/225 passed on 20.12.2006 that encouraged all Member States ?to develop national policies for the prevention, treatment and care of diabetes?. Like many other countries, Russian Federation experiences a sharp rise in the prevalence of DM. According to Russian State Diabetes Register, there are at least 3.799 million patients with DM in this country. However, the epidemiological survey conducted by the Federal Endocrinology Research Centre during 2002-2010 suggests that actual prevalence is 3 to 4 times greater than the officially recognized and, by this estimate, amounts to 9-10 million persons, comprising 7% of the national population. . Severe consequences of the global pandemics of DM include its vascular complications: nephropathy, retinopathy, coronary, cerebral and peripheral vascular disease. These conditions are responsible for the majority of cases of diabetes-related disability and death. . Current edition of the ?Standards? emphasizes the patient-oriented approach in making decisions on therapeutic goals, such as levels of glycaemia and blood pressure. It also features updated guidelines on the management of vascular complications and new RAE position statement on gestational diabetes, produced in collaboration with Russian Association of Obstetrics and Gynecology. . This text represents a consensus by the absolute majority of national experts, achieved through a number of fruitful discussions held at national meetings and forums. These guidelines are intended for endocrinologists and diabetologists, primary care physicians, cardiologists and other medical professionals involved in prevention and treatment of diabetes mellitus.

Age and clinical outcomes in patients presenting with acute coronary syndromes

CONTEXT

Elderly patients have more cardiovascular risk factors and a greater burden of ischemic disease than younger patients.

AIMS

To examine the impact of age on clinical presentation and outcomes in patients presenting with acute coronary syndrome (ACS).

METHODS AND MATERIAL

Collected data from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2), which is a prospective multicenter study from six adjacent Arab Middle Eastern Gulf countries. Patients were divided into 3 groups according to their age: ≤50 years, 51-70 years and >70 years and their clinical characteristics and outcomes were analyzed. Mortality was assessed at one and 12 months.

STATISTICAL ANALYSIS USED

One-way ANOVA test for continuous variables, Pearson chi-square (X (2)) test for categorical variables and multivariate logistic regression analysis for predictors were performed.

RESULTS

Among 7930 consecutive ACS patients; 2755 (35%) were ≤50 years, 4110 (52%) were 51-70 years and 1065 (13%) >70 years old. The proportion of women increased with increasing age (13% among patients ≤50 years to 31% among patients > 70 years). The risk factor pattern varied with age; younger patients were more often obese, smokers and had a positive family history of CAD, whereas older patients more likely to have diabetes mellitus, hypertension, and dyslipidemia. Advancing age was associated with under-treatment evidence-based therapies. Multivariate logistic regression analysis after adjusting for relevant covariates showed that old age was independent predictors for re-ischemia (OR 1.29; 95% CI 1.03-1.60), heart failure (OR 2.8; 95% CI 2.17-3.52) and major bleeding (OR 4.02; 95% CI 1.37-11.77) and in-hospital mortality (age 51-70: OR 2.67; 95% CI 1.86-3.85, and age >70: OR 4.71; 95% CI 3.11-7.14).

CONCLUSION

Despite being higher risk group, elderly are less likely to receive evidence-based therapies and had worse outcomes. Guidelines adherence is highly recommended in elderly.

Cardiac troponins I and T: molecular markers for early diagnosis, prognosis, and accurate triaging of patients with acute myocardial infarction

Acute myocardial infarction (AMI) is the leading cause of death worldwide, with early diagnosis still being difficult. Promising new cardiac biomarkers such as troponins and creatine kinase (CK) isoforms are being studied and integrated into clinical practice for early diagnosis of AMI. The cardiac-specific troponins I and T (cTnI and cTnT) have good sensitivity and specificity as indicators of myocardial necrosis and are superior to CK and its MB isoenzyme (CK-MB) in this regard. Besides being potential biologic markers, cardiac troponins also provide significant prognostic information. The introduction of novel high-sensitivity troponin assays has enabled more sensitive and timely diagnosis or exclusion of acute coronary syndromes. This review summarizes the available information on the potential of troponins and other cardiac markers in early diagnosis and prognosis of AMI, and provides perspectives on future diagnostic approaches to AMI.

Gender disparity in cardiovascular disease: bias or biology?

This article addresses gender disparity in cardiovascular disease, with selected examples used to explore whether these disparities represent bias, biology or both. Gender-specific basic and clinical cardiovascular research is needed to address these issues, with rigorous application required for the emerging knowledge. These explorations offer promise to improve cardiovascular outcomes for women and are the basis for the application of gender-based evaluation of pathophysiology, clinical presentations, preventive interventions, diagnostic strategies, therapies and outcomes of cardiovascular disease in women.

Pharmacogenetics and cardiovascular disease--implications for personalized medicine

The past decade has seen tremendous advances in our understanding of the genetic factors influencing response to a variety of drugs, including those targeted at treatment of cardiovascular diseases. In the case of clopidogrel, warfarin, and statins, the literature has become sufficiently strong that guidelines are now available describing the use of genetic information to guide treatment with these therapies, and some health centers are using this information in the care of their patients. There are many challenges in moving from research data to translation to practice; we discuss some of these barriers and the approaches some health systems are taking to overcome them. The body of literature that has led to the clinical implementation of CYP2C19 genotyping for clopidogrel, VKORC1, CYP2C9; and CYP4F2 for warfarin; and SLCO1B1 for statins is comprehensively described. We also provide clarity for other genes that have been extensively studied relative to these drugs, but for which the data are conflicting. Finally, we comment briefly on pharmacogenetics of other cardiovascular drugs and highlight β-blockers as the drug class with strong data that has not yet seen clinical implementation. It is anticipated that genetic information will increasingly be available on patients, and it is important to identify those examples where the evidence is sufficiently robust and predictive to use genetic information to guide clinical decisions. The review herein provides several examples of the accumulation of evidence and eventual clinical translation in cardiovascular pharmacogenetics.

Regional density of cardiologists and rates of mortality for acute myocardial infarction and heart failure

BACKGROUND

Cardiologists are distributed unevenly across regions of the United States. It is unknown whether patients in regions with fewer cardiologists have worse outcomes after hospitalization for acute myocardial infarction (AMI) or heart failure (HF).

METHODS AND RESULTS

Using Medicare administrative claims data from 2010, we examined the relationship between regional density of cardiologists and risk of death after hospitalization for AMI and HF using hospitalizations for pneumonia as a comparison. We defined density as the number of cardiologists divided by population aged≥65 years within hospital referral regions, categorized into quintiles. Among 171 126 admissions for AMI, 352 853 admissions for HF, and 343 053 admissions for pneumonia, we tested associations between density of cardiologists and 30-day and 1-year mortality for each condition. We used 2-level hierarchical logistic regression models that adjusted for characteristics of patients and hospital referral regions. Patients hospitalized for AMI (odds ratios [OR], 1.13; 95% confidence interval [CI], 1.06-1.21) and HF (OR, 1.19; 95% CI, 1.12-1.27) in the lowest quintile of density had modestly higher 30-day mortality risk compared with patients in the highest quintile, unlike patients hospitalized for pneumonia (OR, 1.02; 95% CI, 0.96-1.09). Patients hospitalized for AMI (OR, 1.06; 95% CI, 1.00-1.12) and HF (OR, 1.09; 95% CI, 1.04-1.13) in the lowest quintile had slightly higher 1-year mortality risk, unlike patients hospitalized for pneumonia (OR, 1.00; 95% CI, 0.95-1.05).

CONCLUSIONS

Patients hospitalized for AMI and HF in regions with a low density of cardiologists experienced modestly higher 30-day and 1-year mortality risk, unlike patients with pneumonia.

Long-term outcomes after invasive management for older patients with non-ST-segment elevation myocardial infarction

BACKGROUND

Early invasive management is recommended for patients with non-ST-segment elevation myocardial infarction (MI), but the incidence of long-term outcomes after early catheterization among older patients and the relationship of revascularization procedures with outcomes in this population have not been described.

METHODS AND RESULTS

Using data from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) registry, we linked 19 336 older patients (≥65 years) with non-ST-segment elevation MI found to have significant coronary disease during catheterization and who survived through 30 days posthospital discharge to Medicare/Medicaid data. All-cause mortality, readmission for MI, readmission for stroke, and use of repeat revascularization procedures were tracked for a median of 1181 days. Outcome comparisons were stratified by use of percutaneous coronary intervention (PCI; n=11 766, 60.8%) or coronary artery bypass grafting (n=3515, 18.2%) performed during the index hospitalization and through 30 days postdischarge, as well as by medical management without revascularization (n=4055, 21.0%). During follow-up, ≈17% of patients underwent PCI (most commonly in patients initially treated with PCI), and only 3% of patients underwent coronary artery bypass grafting. Compared with an unadjusted long-term mortality cumulative incidence through 5 years of 50% in the medical management group, mortality was lower in the PCI group (33.5%; adjusted hazard ratio, 0.75; 95% confidence interval, 0.70-0.79) and lowest in the coronary artery bypass grafting group (24.2%; adjusted hazard ratio, 0.52; 95% confidence interval, 0.47-0.57; P<0.001 for 3-way comparisons). The unadjusted cumulative incidence of the composite of death, readmission for MI, or readmission for stroke at 5 years was 62.4%, 44.9%, and 33.0% for medical management, PCI, and coronary artery bypass grafting, respectively.

CONCLUSIONS

Older patients with non-ST-segment elevation MI with significant coronary disease face high long-term risks for mortality and nonfatal cardiovascular outcomes after early catheterization that differ by type of revascularization procedure performed. These findings can help guide the design of studies evaluating long-term therapies among elderly post-MI patients.

Antiplatelet and anticoagulant strategies in acute coronary syndrome: where we are in 2013

Multiple antiplatelet and anticoagulant therapies are available for the treatment of acute coronary syndromes. The combination of agents should be tailored to the individual patient carefully considering the balance between ischemic and bleeding risk, as well as the planned revascularization strategy. Despite multiple large-scale, rigorously designed and conducted randomized controlled trials, it can be difficult to select the correct pharmacotherapy for each patient and many unanswered questions remain, such as the safety and optimal doses of differing combinations of antiplatelet/anticoagulant therapy, as well as the timing and duration of therapies. In addition, the headline results of many trials report improved efficacy outcomes at the cost of increased bleeding risk; however, very few show a clear mortality benefit. It is therefore difficult to weigh up the risk–benefit profile of emerging therapies.

Incorporation of bleeding as an element of the composite end point in clinical trials of antithrombotic therapies in patients with non-ST-segment elevation acute coronary syndrome: validity, pitfalls, and future approaches

With the large number of antithrombotic therapies available and under investigation for the treatment of non-ST-segment elevation acute coronary syndromes (NSTE ACS), practice guidelines now stress the importance of selecting an antithrombotic strategy according to the efficacy and safety profiles of the chosen agent. Contemporary trials have incorporated bleeding along with ischemic end points into a composite end point commonly referred to as net clinical benefit, which allows for simultaneous evaluation of the differences between benefit and harm for an investigational antithrombotic therapy. However, incorporating major bleeding into a composite end point that includes ischemic events is not warranted and is associated with many pitfalls. In this article, we discuss the validity of combining efficacy and safety end points to form a net clinical benefit composite end point with the traditional time-to-event analysis for trials evaluating antithrombotic therapies for NSTE ACS. We describe alternative statistical approaches for concurrent assessment of the safety and efficacy of antithrombotic therapies used to treat patients with NSTE ACS.

Contemporary Use of Prasugrel in Clinical Practice

Background—

Prasugrel is a recently approved thienopyridine for use in patients with acute coronary syndromes undergoing percutaneous coronary intervention. There are no data on contemporary use of prasugrel in routine clinical practice.

Methods and Results—

We assessed the patterns of prasugrel use among 55 821 patients who underwent percutaneous coronary intervention and were discharged alive from January 2010 to December 2011 at 44 hospitals participating in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. Potential inappropriate therapy was defined as use in patients who had a history of cerebrovascular disease, weighed <60 kg, or were aged ≥75 years old. Clopidogrel was prescribed to 83% (n=46 574) and 17% (n=9247) of patients received prasugrel on hospital discharge. A steady, linear increase in prasugrel use was seen during the study period, with discharge prescription increasing from 8.4% in quarter 1 of 2010 to 22.3% in quarter 4 of 2011. Of the total cohort, 69.1% of patients presented with acute coronary syndrome, and in this group, 17.2% received prasugrel. Among patients prescribed prasugrel, 28.3% (n=2614) received the medication for indications outside of acute coronary syndromes. One or more known contraindications to the drug were present in 6% to 10% of patients discharged on this agent.

Conclusions—

There has been a steady increase in the use of prasugrel with the drug being used in ≈22% of patients undergoing percutaneous coronary intervention by study end. Prasugrel use in patients with known contraindications is not uncommon and may be a suitable target for focused quality improvement efforts.

Diabetes Mellitus and Cardiovascular Events in Older Patients With Myocardial Infarction Prescribed Intensive-Dose and Moderate-Dose Statins

Background—

Practice guidelines recommend intensive-dose statins for patients with acute coronary syndrome, but recent data about the risk of new-onset diabetes mellitus have raised concerns about its use. Our main objective was to evaluate the association between intensive statin therapy and new-onset diabetes mellitus in patients with myocardial infarction and to evaluate the association of intensive statin therapy with long-term adverse clinical outcomes.

Methods and Results—

A propensity score–matched cohort was created consisting of 17 080 patients with myocardial infarction aged >65 years old, hospitalized in Ontario, Canada, from 2004 to 2010. Clinical outcomes were compared in patients prescribed intensive-dose versus moderate-dose statins at hospital discharge. At 5 years, 13.6% of patients receiving intensive-dose statins and 13.0% of patients receiving moderate-dose statins had new-onset diabetes, which was not significantly different ( P =0.19). By contrast, the 5-year rate of death or acute coronary syndrome was significantly lower at 44.8% in the intensive-dose statin group compared with 46.5% in the moderate-dose group ( P =0.044). The reduction in combined clinical outcome was driven mainly by a significantly lower rate of acute coronary syndrome ( P =0.039) associated with intensive-dose statins. No significant difference in mortality rates (34.8% in both groups) was observed between the treatment groups during the study period ( P =0.89).

Conclusions—

In older patients with myocardial infarction, we found intensive-dose statin therapy to be effective in reducing repeat hospitalization for acute coronary syndrome. The rate of new-onset diabetes mellitus at long term was not significantly different between intensive-dose and moderate-dose statins.

Effects of obesity on the impact of short-term changes in anthropometric measurements on coronary heart disease in women

OBJECTIVE

To assess the impact of short-term changes in body mass index (BMI), waist circumference (WC), hip circumference (HC), and waist-to-hip ratio on the risk of future coronary heart disease (CHD) among women.

PARTICIPANTS AND METHODS

The study sample consisted of 2468 women aged 30 years or older without cardiovascular disease at baseline who underwent 2 consecutive examinations, the first between January 31, 1999, and August 21, 2001, and second between October 20, 2001, and September 22, 2005, and were followed up until March 31, 2010. Cox proportional hazard regression was performed to estimate the hazard ratios (HRs) of the anthropometric measures for CHD events.

RESULTS

During a mean follow-up of 6.6 years, CHD occurred in 127 of the study participants (5.1%). There were significant interactions between a BMI of 30 kg/m(2) or greater and anthropometric changes in prediction of CHD events (all P<.04). Among nonobese individuals, a 1-SD increase in HC changes, independent of WC and BMI changes, was inversely associated with risk of CHD events (HR, 0.60 [95% CI, 0.44-0.83]). Among obese individuals, a 1-SD increase in WC, independent of other changes, increased the risk of CHD. Conversely, a 1-SD increase in BMI decreased the risk of CHD by 35% (HR, 0.65 [95% CI, 0.45-0.94]).

CONCLUSION

In this study, the impact of changes in anthropometric measures on CHD was modified by obesity at baseline. Among nonobese women, increases in HC could significantly reduce the risk of CHD events. Among obese individuals, although increases in WC were associated with a higher risk of CHD, increases in BMI decreased the risk.

Selection and timing for invasive therapy in non-ST-segment-elevation acute coronary syndrome

While outcomes for ST-segment-elevation myocardial infarction has significantly decreased over the last years, patients presenting with non-ST-segment-elevation acute coronary syndromes (NSTEACS) still have a rather high mortality. Longer term mortality over 4 years is about double the mortality after a ST-segment-elevation myocardial infarction. The reason for the poorer prognosis is unclear but is very likely to be partially explained by the generally older age of NSTEACS patients. The optimal therapy for NSTEACS is less well defined. In this review, the authors specifically discuss the role of coronary angiography, how to decide which patient should undergo this procedure and whether there is an optimal time point. The review provides an up-to-date discussion about the best treatment strategies for NSTEACS.

Use of the contrast volume or grams of iodine-to-creatinine clearance ratio to predict mortality after percutaneous coronary intervention

BACKGROUND

Few studies have assessed the predictive value of the ratio of the contrast media volume or grams of iodine to the creatinine clearance (V/CrCl or g-I/CrCl, respectively) for the risk of contrast-induced nephropathy (CIN) and mortality after percutaneous coronary intervention (PCI).

METHODS

The association between V/CrCl and mortality was prospectively evaluated in 1,135 consecutive patients undergoing PCI. Cox regression models were used to adjust for the V/CrCl ratio and other confounding factors for risk of death within 1 year.

RESULTS

Fifty-five patients (4.84%) developed CIN. The 1-year mortality was higher in patients with a V/CrCl ratio >2.62 (g-I/CrCl >0.97) than in others (4.44% vs 0.40%; P < .001). After adjusting for other risk factors, the 1-year mortality risk remained associated with increased V/CrCl ratio. The risk of death was significant for V/CrCl >2.62 (adjusted risk ratio [RR] for death 2.605, 95% CI 1.040-6.529, P = .041), V/CrCl >3.0 (g-I/CrCl >1.11) (adjusted RR 4.338, 95% CI 1.689-11.142, P = .002), and V/CrCl >3.7 (g-I/CrCl >1.37) (adjusted RR 2.557, 95% CI 1.162-5.627, P = .002).

CONCLUSION

The data further support the prognostic significance of calculating the V/CrCl ratio to predict the relative maximum contrast volume during PCI. Use of a contrast dose determined based on the estimated renal function with a planned V/CrCl ratio <3.7 (g-I/CrCl <1.37) and preferably <2.62 (g-I/CrCl <0.97) might be valuable in reducing the risks of CIN and even death after PCI.

Transfusion outcomes in patients undergoing coronary artery bypass grafting treated with prasugrel or clopidogrel: TRITON-TIMI 38 retrospective data analysis

OBJECTIVE

Coronary artery bypass grafting-related bleeding and associated transfusion is a concern with dual antiplatelet therapy in patients with acute coronary syndromes. The objective of the present study was to characterize a potential risk-adjusted difference in transfusion requirements between prasugrel and clopidogrel cohorts.

METHODS

The data from 422 patients undergoing isolated coronary artery bypass grafting from the TRial to assess Improvement in Therapeutic Outcomes by optimizing platelet InhibitioN with prasugrel Thrombolysis In Myocardial Infarction 38 were analyzed retrospectively.

RESULTS

We found no difference in baseline transfusion risk scores between cohorts. As predicted, the number of units of red blood cells transfused perioperatively correlated with the transfusion risk score (P < .0001). Overall, the 12-hour chest tube drainage volumes and platelet transfusion rates in the prasugrel cohort were significantly greater. However, no statistically significant differences were found in the number of red blood cell transfusions, total hemostatic components transfused, or total blood donor exposure. A significantly greater number of platelet units were transfused postoperatively in the prasugrel patients who underwent surgery within 5 days or less after withdrawal of drug. In an analysis adjusted for the predicted risk of mortality, total donor exposure was not associated with increased mortality.

CONCLUSIONS

The use of prasugrel compared with clopidogrel was associated with greater 12-hour chest tube drainage volumes and platelet transfusion rates but without any significant differences in red blood cell transfusions, total hemostatic components transfused, or total blood donor exposure.

HIV and coronary heart disease: time for a better understanding

Cardiovascular disease, and particularly coronary heart disease, is an emerging area of concern in the HIV population. Since the advent of efficient antiretroviral therapies and the consequent longer patient life span, an increased risk for myocardial infarction has been observed in HIV-infected patients compared with the general population in Western countries. The pathophysiology of this accelerated atherosclerotic process is complex and multifactorial. Traditional cardiovascular risk factors-overrepresented in the HIV population-associated with uncontrolled viral replication and exposure to antiretroviral drugs (per se or through lipid and glucose disturbances) could promote acute ischemic events. Thus, despite successful antiviral therapy, numerous studies suggest a role of chronic inflammation, together with immune activation, that could lead to vascular dysfunction and atherothrombosis. It is time for physicians to prevent coronary heart disease in this high-risk population through the use of tools employed in the general population. Moreover, the lower median age at which acute coronary syndromes occur in HIV-infected patients should shift prevention to include patients <45 years of age. Available cardiovascular risk scores in the general population usually fail to screen young patients at risk for myocardial infarction. Moreover, the novel vascular risk factors identified in HIV-related atherosclerosis, such as chronic inflammation, immune activation, and some antiretroviral agents, are not taken into account in the available risk scores, leading to underestimation of cardiovascular risk in the HIV population. Cardiovascular prevention in HIV-infected patients is a challenge for both cardiologists and physicians involved in HIV care. We require new tools to assess this higher risk and studies to determine whether intensive primary prevention is warranted.

Postoperative care and follow-up after coronary stenting

BACKGROUND

The diagnosis and treatment of coronary heart disease have improved in recent years. Most patients can return to their everyday routine a few days after a successful percutaneous coronary intervention (PCI). How should patients be followed up after the successful implantation of a coronary stent?

METHOD

Selective review of the pertinent literature, including current practice guidelines and recommendations.

RESULTS

After a PCI, the patient should be followed up both by the primary care physician and by the cardiologist one week after the procedure, and then every three to six months for the first year. Clinical history taking and physical examination, including an assessment of cardiovascular risk factors and of potential evidence of myocardial ischemia, constitute the best way to detect possible progression of coronary heart disease. Diagnostic coronary angiography is not routinely indicated after coronary stent implantation. If progression of heart disease is suspected, a stress test should be performed; patients who develop symptoms or show evidence of ischemia in a stress test should undergo diagnostic cardiac catheterization.

CONCLUSION

Repeated history taking and physical examination play an important role after PCI. For patients at high risk of restenosis and those with complex coronary morphology, coronary angiography may be indicated regardless of the findings of non-invasive stress tests.

Novel antiplatelet agent use for acute coronary syndrome in the emergency department: a review

Background. Acute Coronary Syndrome (ACS) is a clinical condition encompassing ST Segment Elevation Myocardial Infarction (STEMI), Non-ST Segment Elevation Myocardial Infarction (NSTEMI), and Unstable Angina (UA) and is characterized by ruptured coronary plaque, ischemic stress, and/or myocardial injury. Emergency department (ED) physicians are on the front lines of ACS management. The role of new antiplatelet agents ticagrelor and prasugrel in acute ED management of ACS has not yet been defined. Objective. To critically review clinical trials using ticagrelor and prasugrel in the treatment of ACS and inform practitioners of their potential utility in treating ACS in the ED. Results. Trials on the efficacy of ticagrelor and prasugrel achieve statistical significance in decreasing composite endpoints in select patient populations. Conclusion. The use of ticagrelor and prasugrel as first line ED treatment of ACS is not well established. Current evidence supports the use of several agents with the final decision based on treatment protocols conjointly developed between cardiology and emergency medicine (EM). Further clinical trials involving head-to-head trials or comparisons of drug-based strategies are required to show superiority in reducing cardiac endpoints with regard to ED initiation of treatment.

Prediction of clopidogrel efficacy and safety: phenotyping and/or genotyping?

In patients undergoing percutaneous coronary intervention the role of platelet function assessment (phenotyping) while on-clopidogrel and/or genotyping for outcome prediction is being intensively investigated. The study under evaluation reported the diagnostic accuracy of phenotyping versus genotyping for prediction of ischemic and bleeding events in 416 such patients during 1-year follow-up. Their data shows that the phenotyping of platelet response to clopidogrel by multiple electrode aggregometry was a better predictor of stent thrombosis than other platelet function assays used and even genotyping for the CYP2C19*2 allele. The authors recognize that it is premature to recommend any assay to guide the antiplatelet treatment in routine clinical practice. However, the need for properly powered randomized trials to address this issue is emphasized.

The CYP2C19(∗)1/(∗)2 Genotype Does Not Adequately Predict Clopidogrel Response in Healthy Malaysian Volunteers

Background. The CYP2C19∗2 allele may be associated with a reduced antiplatelet effect for clopidogrel. Here, we assessed whether CYP2C19∗2 alleles correlate with clopidogrel responsiveness following the administration of clopidogrel in healthy Malaysian volunteers. Methods. Ninety volunteers were genotyped for CYP2C19∗2 and CYP2C19∗3 alleles. Forty-five of 90 volunteers were included in the clopidogrel response studies and triaged into three genotypes, namely, CYP2C19∗1/∗1 (n = 17), CYP2C19∗1/∗2 (n = 21), and CYP2C19∗2/∗2 (n = 7). All subjects received 300 mg of clopidogrel, and platelet reactivity was assessed after a four-hour loading utilizing the VerifyNow-P2Y12 assay. Platelet activity was reported using P2Y12 reaction units (PRUs), and nonresponder status was prespecified at PRU ≥ 230. Results. Following clopidogrel intake, CYP2C19∗2/∗2 carriers had a significantly higher mean PRU compared to the CYP2C19∗1/∗2 and CYP2C19∗1/∗1 (291.0 ± 62.1 versus 232.5 ± 81.4 versus 147.4 ± 87.2 PRU, P < 0.001) carriers. Almost half of the participants (46.7%) were found to be nonresponders (3 were CYP2C19∗1/∗1, 11 were CYP2C19∗1/∗2, and 7 were CYP2C19∗2/∗2). Conclusion. In healthy Malaysian volunteers, CYP2C19∗2 allele was associated with a decrease in platelet responsiveness to clopidogrel. However, clopidogrel nonresponders can be found not only in the carriers of CYP2C19∗2/∗2, but also in the carriers of CYP2C19∗1/∗2 and CYP2C19∗1/∗1. The present paper demonstrated that genotype information does not correlate with clopidogrel response, and genotyping may represent a less robust approach compared to platelet activity testing in guiding clopidogrel therapy.

Rationale and design of the ETN-STEP (Early administration of Tirofiban in mid to high risk patients with non-ST elevation acute coronary syndrome referred for percutaneous coronary intervention) project: A multi-center, randomized, controlled clinic trial in Chinese patients

As a member of Glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors, Tirofiban had been shown to improve myocardial reperfusion and clinical outcomes in patients undergoing percutaneous coronary intervention (PCI), but the optimal timing of administration of Tirofiban remains unclear. In order to compare the effects of upstream versus downstream administration of Tirofiban in Chinese patients with mid to high risk, non-ST elevation acute coronary syndrome (ACS) referred for PCI, a multi-center, randomized, controlled, prospective study will be conducted. A total of 500 mid to high risk, non-ST-segment elevation myocardial infarction (NSTEMI) ACS patients will be recruited for this study. Patients will be randomized to Tirofiban upstream administration group (initiated 12 h before PCI) and Tirofiban downstream administration group (initiated at cath-lab after angiography). Thrombolysis in myocardial infarction (TIMI) flow grades, TIMI myocardial perfusion grades (TMPG), and Corrected TIMI frame counting (CTFC) before and after PCI, as well as clinical outcomes during the hospital stay, and within 30 days after PCI will be compared between the two groups. This study will provide evidence on the optimal timing for initiating administration of Tirofiban in mid to high NSTEMI ACS subjects undergoing PCI.

Prasugrel vs clopidogrel in patients with acute coronary syndrome undergoing percutaneous coronary intervention: a model-based cost-effectiveness analysis for Germany, Sweden, the Netherlands, and Turkey

OBJECTIVE

To evaluate the long-term cost-effectiveness of 12-months treatment with prasugrel vs clopidogrel from four European healthcare systems' perspectives (Germany, Sweden, the Netherlands, and Turkey).

METHODS

In the TRITON-TIMI 38 trial, patients with an acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) were treated with prasugrel or clopidogrel. Prasugrel reduced the composite end-point (cardiovascular death, MI, or stroke), but increased TIMI major bleeding. A Markov model was constructed to facilitate a lifetime horizon for the analysis. A series of risk equations constructed using individual patient data from TRITON-TIMI 38 was used to estimate risks of clinical events. Quality-adjusted life-years (QALYs) were derived by weighting survival time by estimates of health-related quality-of-life. Incremental cost-effectiveness is presented based on differences in treatments' mean costs and QALYs for the licensed population in TRITON-TIMI 38, and the sub-groups of UA-NSTEMI, STEMI, diabetes, and the 'core clinical cohort' (<75 years, ≥60 kg, no history of stroke or TIA).

RESULTS

Mean cost of study drug was €364 (Turkey) to €818 (Germany) higher for prasugrel vs clopidogrel. Rehospitalization costs at 12 months were lower for prasugrel due to reduced rates of revascularization, although hospitalization costs beyond 12 months were higher due to longer life expectancy associated with lower rates of non-fatal MI in the prasugrel group. The incremental cost per QALY saved with prasugrel in the licensed population ranged from €6520 (for Sweden) to €14,350 for (Germany). Prasugrel's cost per QALY was more favourable still in the STEMI and diabetes sub-groups of the licensed population.

LIMITATIONS

Probabilistic analyses of the whole trial population is impractical due to the number of individual patient profiles over which population level results are calculated.

CONCLUSION

Among patients undergoing PCI for ACS, treatment with prasugrel compared with clopidogrel resulted in favourable cost-effectiveness profiles from these healthcare systems' perspectives.

The relationship between hyperuricemia and the risk of contrast-induced acute kidney injury after percutaneous coronary intervention in patients with relatively normal serum creatinine

OBJECTIVES

Hyperuricemia is a risk factor for contrast-induced acute kidney injury in patients with chronic kidney disease. This study evaluated the value of hyperuricemia for predicting the risk of contrast-induced acute kidney injury in patients with relatively normal serum creatinine who were undergoing percutaneous coronary interventions.

METHODS AND RESULTS

A total of 788 patients with relatively normal baseline serum creatinine (<1.5 mg/dL) undergoing percutaneous coronary intervention were prospectively enrolled and divided into a hyperuricemic group (n = 211) and a normouricemic group (n = 577). Hyperuricemia is defined as a serum uric acid level>7 mg/ dL in males and >6 mg/dL in females. The incidence of contrast-induced acute kidney injury was significantly higher in the hyperuricemic group than in the normouricemic group (8.1% vs. 1.4%, p<0.001). In-hospital mortality and the need for renal replacement therapy were significantly higher in the hyperuricemic group. According to a multivariate analysis (adjusting for potential confounding factors) the odds ratio for contrast-induced acute kidney injury in the hyperuricemic group was 5.38 (95% confidence interval, 1.99-14.58; p = 0.001) compared with the normouricemic group. The other risk factors for contrast-induced acute kidney injury included age >75 years, emergent percutaneous coronary intervention, diuretic usage and the need for an intra-aortic balloon pump.

CONCLUSION

Hyperuricemia was significantly associated with the risk of contrast-induced acute kidney injury in patients with relatively normal serum creatinine after percutaneous coronary interventions. This observation will help to generate hypotheses for further prospective trials examining the effect of uric acid-lowering therapies for preventing contrast-induced acute kidney injury.

Platelet function normalization after a prasugrel loading-dose: time-dependent effect of platelet supplementation

BACKGROUND

Hemostatic benefits of platelet transfusions in thienopyridine-treated acute coronary syndrome (ACS) patients may be compromised by residual metabolite in circulation.

OBJECTIVES

To estimate the earliest time after a prasugrel loading-dose when added platelets are no longer inhibited by prasugrel's active metabolite.

METHODS

Baseline platelet reactivity of healthy subjects (n=25, 30 ± 5 years, 68% male) on ASA 325 mg was tested using maximum platelet aggregation (MPA, ADP 20 μm) and VerifyNow(®) P2Y12 and was followed by a 60 mg prasugrel loading-dose. At 2, 6, 12 and 24 h post-dose, fresh concentrated platelets from untreated donors were added ex-vivo to subjects' blood, raising platelet counts by 0% (control), 40%, 60% and 80%. To estimate the earliest time when prasugrel's active metabolite's inhibitory effect on the added platelets ceases, platelet function in supplemented samples was compared across time-points to identify the time when effect of supplementation on platelet function stabilized (i.e. the increase in platelet reactivity was statistically similar to that at the next time-point).

RESULTS

Supplemented samples showed concentration-dependent increases in platelet reactivity vs. respective controls by both MPA and VerifyNow(®) at all assessment time-points. For each supplementation level, platelet reactivity showed a sharp increase from 2 to 6 h but was stable (P=NS) between 6 and 12 h.

CONCLUSIONS

The earliest measured time when supplemented platelets were not inhibited by circulating active metabolite of prasugrel was 6 h after a prasugrel loading-dose. These findings may have important implications for prasugrel-treated ACS patients requiring platelet transfusions during surgery.

Updating an institutional chest pain algorithm: incorporating new evidence on emerging pharmacotherapy

Clinical treatment pathways are useful to ensure that evidence-based medicine is consistently applied in hospital systems and have been shown to improve patient outcomes. Such pathways need to be regularly updated and revised by incorporating new evidence from clinical trials to ensure optimal clinical care. In 2011, we published the Columbia University Medical Center/New York Presbyterian Hospital - Clinical Pathways for Acute Coronary Syndromes and Chest Pain. This algorithm includes primary percutaneous coronary intervention for all patients with ST-segment elevation myocardial infarction and an early invasive approach for patients with non-ST-segment elevation myocardial infarction. Since our last chest pain algorithm update, the novel antiplatelet agent ticagrelor has been introduced in the United States, resulting in an important revision of our acute coronary syndrome clinical pathways. Herein, we present our updated chest pain algorithm and provide rationale for the changes that we have made to our protocol.