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

Role of cardiovascular magnetic resonance in assessment of acute coronary syndrome

Cardiovascular disease (CVD) is the leading cause of death in the western world and is becoming more important in the developing world. Recently, advances in monitoring, revascularisation and pharmacotherapy have resulted in a reduction in mortality. However, although mortality rates have declined, the burden of disease remains large resulting in high direct and indirect healthcare costs related to CVDs. In Australia, acute coronary syndrome (ACS) accounts for more than 300000 years of life lost due to premature death and a total cost exceeding eight billion dollars annually. It is also the main contributor towards the discrepancy in life expectancy between indigenous and non-indigenous Australians. The high prevalence of CVD along with its associated cost urgently requires a reliable but non-invasive and cost-effective imaging modality. The imaging modality of choice should be able to accelerate the diagnosis of ACS, aid in the risk stratification of de novo coronary artery disease and avail incremental information of prognostic value such as viability which cardiovascular magnetic resonance (CMR) allows. Despite its manifold benefits, there are limitations to its wider use in routine clinical assessment and more studies are required into assessing its cost-effectiveness. It is hoped that with greater development in the technology and imaging protocols, CMR could be made less cumbersome, its imaging protocols less lengthy, the technology more inexpensive and easily applied in routine clinical practice.

Clinical usefulness and cost effectiveness of fractional flow reserve among Indian patients (FIND study)

OBJECTIVES

To study the clinical usefulness, cost benefit, and medium term outcome of fractional flow reserve (FFR) based management of coronary artery disease of intermediate severity.

BACKGROUND

In spite of the advantages of FFR there is paucity of data in Indian population who have frequent diffuse, small and multivessel disease where it would probably be more beneficial in terms of cost and outcome.

METHODS

The treating cardiologist's management decision with both FFR and angiographic data was compared with that of a reviewing cardiologist decision based on a retrospective analysis of angiogram alone.

RESULTS

Eighty-one vessels with intermediate lesions in 59 patients required 26 stents lesser when FFR data was added to the angiogram. The concordance of management decision was about 58% which means that >40% of intermediate lesions would be misclassified as significant based on angiography alone. There were no major events at a mean follow up of 11 ± 5 months. The net cost benefit in favor of FFR based management was INR 8,57,600 (USD 15,600) in our centre.

CONCLUSION

Indians with more severe form of CAD benefit from a FFR based management plan for intermediate lesions, both clinically and economically. © 2014 Wiley Periodicals, Inc.

Serum tryptase: a new biomarker in patients with acute coronary syndrome?

BACKGROUND

Mast cell tryptase has recently been reported to be involved in atherosclerotic plaque destabilization. However, the results of these reports are conflicting.

METHODS

The aim of this study was to characterize the role of tryptase as a prognostic marker of patient cardiovascular complexity in acute coronary syndrome (ACS). Furthermore, its association with an angiographic scoring system [defined by the SYNergy between percutaneous coronary intervention (PCI) with the TAXUS drug-eluting stent and the cardiac surgery (SYNTAX) score] was examined. The serum tryptase was measured at admission in 65 consecutive ACS patients and in 35 healthy controls. In the patients with ACS, a composite measure of clinical and angiographic patient cardiovascular complexity was indicated by two of the following: clinical adverse events at hospitalization, at least 2 epicardial coronary arteries involved in the atherosclerotic disease, more than 1 stent implanted or more than 2 coronary artery disease risk factors.

RESULTS

The tryptase measurements were lower in patients without the composite measure (p < 0.0005). Linear regression showed a significant relationship between tryptase levels and the SYNTAX score (SX-score). Conversely, high-sensitivity troponin values did not correlate with either the composite outcome or the SX-score. The predictive accuracy of serum tryptase for the composite outcome was set at the cut-off point of 5.22 ng/ml (sensitivity 81% and specificity 95.7%).

CONCLUSION

In ACS patients, serum tryptase levels at admission may predict patient cardiovascular complexity more reliably than currently known biomarkers. Further studies are needed to demonstrate the long-term prognostic role of this biomarker in ACS.

Early discharge after primary percutaneous coronary intervention for ST-elevation myocardial infarction

BACKGROUND

To assess safety of early discharge following primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI).

METHODS AND RESULTS

Retrospective analysis of prospectively collected data of 2448 STEMI patients treated with PPCI surviving to hospital discharge. Post-discharge all-cause mortality was reported at 1, 7, and 30 days and long-term follow up. A total of 1542 patients (63.0%) were discharged within 2 days of admission (early discharge group) and 906 patients (37.0%) after 2 days (late discharge group). In both groups, no deaths were recorded 1 day post discharge. The early and late discharge group mortality figures for 7 days were 0 and 4 patients (0.04%) and between 7 and 30 days were 11 (0.7%) and 11 patients (1.2%), respectively. During a mean follow up of 584 days, 178 patients (7.3%) died: 67 in the early discharge group (4.3%) and 111 in the late discharge group (12.3%).

CONCLUSIONS

This exploratory, observational study demonstrates that discharging low-risk STEMI patients within 2 days following PPCI is safe. For providers of health care, early discharge can help to allay the cost of providing a 24-hour PPCI service and adds to the recognized benefits arising from PPCI.

The quality of antiplatelet and anticoagulant medication administration among ST-segment elevation myocardial infarction patients transferred for primary percutaneous coronary intervention

BACKGROUND

Timely and appropriate use of antiplatelet and anticoagulant therapies has been shown to improve outcomes among ST-segment elevation myocardial infarction (STEMI) patients but has not been well described in patients transferred for primary percutaneous coronary intervention (PCI).

METHODS

We examined 16,801 (26%) transfer and 47,329 direct-arrival STEMI patients treated with primary PCI at 441 Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines hospitals. Medication use was compared between transfer and direct-arrival patients to determine if these therapies were delayed or dosed in excess.

RESULTS

Although transfer patients were more likely to receive antiplatelet and anticoagulant therapies before catheterization, they had longer delays to initiation of heparin (35 vs. 25 minutes), clopidogrel (119 vs. 84 minutes), and glycoprotein IIb/IIIa inhibitor (107 vs. 60 minutes, P < .0001 for both). Administration of low-molecular-weight heparin and glycoprotein IIb/IIIa inhibitor at the STEMI-referring hospital was associated with longer delays to reperfusion compared with deferred administration at the STEMI-receiving hospital, whereas early use of unfractionated heparin was not. Among treated patients, those transferred were more likely to receive excess heparin dosing (adjusted odds ratio [OR] 1.28 [95% CI 1.04-1.58] for unfractionated heparin, adjusted OR 1.54 [95% CI 1.09-2.18] for low-molecular-weight heparin) and are associated with higher risks of major bleeding complications (adjusted OR 1.10, 95% CI 1.03-1.17).

CONCLUSIONS

ST-segment elevation myocardial infarction patients transferred for primary PCI in community practice are at risk for delayed and excessively dosed antithrombotic therapy, highlighting the need for continued quality improvement to maximize the appropriate use of these important adjunctive therapies.

Cell therapy for myocardial infarction

Ischemic heart disease, particularly acute myocardial infarction (MI), is the worldwide health care problem and the leading cause of morbidity and mortality. The fundamental treatment of MI remains a major unmet medical need. Although recent tremendous advances have been made in the treatment for acute MI such as percutaneous coronary intervention (PCI) and medical and surgical therapies, myocardial cell loss after ischemia and subsequent, adverse cardiac remodeling and heart failure are demanding for new therapeutic strategy. Since the first experimental studies of adult stem cell therapy into the ischemic heart were performed in the early 1990s, the identification and potential application of stem and/or progenitor cells has triggered attempts to regenerate damaged heart tissue and cell-based therapy is a promising option for treatment of MI. In this review, we would like to discuss the pathogenesis of acute MI, current standard treatments and their limitation, clinical results of recent stem or progenitor cell therapy which have shown a favorable safety profile with modest improvement in cardiac function, and putative mechanisms of benefits.

Angiographic and Clinical Impact of Successful Manual Thrombus Aspiration in Diabetic Patients Undergoing Primary PCI

Background. Diabetes mellitus is associated with worse angiographic and clinical outcomes after percutaneous coronary intervention (PCI). Aim. To investigate the impact of manual thrombus aspiration on in-stent restenosis (ISR) and clinical outcome in patients treated by bare-metal stent (BMS) implantation for ST-segment elevation myocardial infarction (STEMI). Methods. 100 diabetic patients were prospectively enrolled. They were randomly assigned to undergo either standard primary PCI (group A, 50 patients) or PCI with thrombus aspiration using Export catheter (group B, 50 patients). The primary endpoint was the rate of eight-month ISR. The secondary endpoint included follow-up for major adverse cardiac events (MACE). Results. Mean age of the study cohort was 59.86 ± 8.3 years, with 64 (64%) being males. Baseline characteristics did not differ between both groups. Eight-month angiogram showed that group B patients had significantly less late lumen loss (0.17 ± 0.35 versus 0.60 ± 0.42 mm, P < 0.001), with lower incidence of ISR (4% versus 16.6%, P < 0.001). There was a trend towards lower rate of MACE in the same group of patients. Conclusion. In diabetic patients undergoing primary PCI, manual thrombus aspiration (compared with standard PCI) was associated with better ISR rate after BMS implantation.

Evaluation of proper prescribing of cardiac medications at hospital discharge for patients with acute coronary syndromes (ACS) in two Lebanese hospitals

Background

Coronary artery disease (CAD) is the major leading cause of death worldwide. The national practice guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) promote the use of several medical therapies for secondary prevention for patients with CAD. The purpose of this study was to evaluate whether ACS patients, admitted into two tertiary referral medical centers in Beirut, Lebanon, are discharged on optimal medical therapy based on the current AHA/ACC guidelines.

Methods

We reviewed the medical records of all patients with ACS who were admitted to the coronary care units (CCU) of two hospitals in Beirut, Lebanon between May and August 2012. Discharge prescriptions were reviewed and rating for the appropriateness of discharge cardiac medications was based on the AHA/ACC guidelines. We assessed whether patients were discharged on antiplatelet therapy, β-blockers, angiotensin converting enzymes inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), statins, and nitrates, unless contraindicated or not tolerated. In addition, we assessed whether patients and/or their caregivers were counseled about their disease(s) and discharge medications.

Results

186 patients with a mean age of 63 ± 11.78 years, 70.4% of which were males, were admitted with ACS and were included in the study. Fifty three (28.5%) patients had ST elevation MI (STEMI), 64 (34.4%) had non-ST-elevation myocardial infarction (NSTEMI) and 69 (37.1%) had unstable angina (USA). Sixty two patients (33.3%) were treated with medical therapy and 124 patients (66.7%) underwent percutaneous coronary intervention (PCI).

Among eligible patients, 98.9% were discharged on aspirin, 89.1% on dual antiplatelet therapy (aspirin + thienopyridine or ticagrelor), 90.5% on a β-blocker, 81.9% on an ACEI or ARB, 89.8% on a statin, and 19.4% on nitroglycerin. Overall, 62.9% of the patients received the optimal cardiovascular drug therapy (the combination of dual antiplatelet therapy, a β-blocker, an ACEIs or an ARB, and a statin), 55.1% were counseled on their disease state(s) and drug therapy, and 92.2% and 55.9% were counseled on smoking cessation and life style changes, respectively.

Conclusion

In patients admitted with ACS, discharge cardiac medications are prescribed at suboptimal rates. Education of healthcare providers and implementation of ACS discharge protocols may help improve compliance with ACC/AHA guidelines. In addition, clinicians should be encouraged to provide adequate patient counseling.

Dietary fiber intake and mortality among survivors of myocardial infarction: prospective cohort study

OBJECTIVE

To evaluate the associations of dietary fiber after myocardial infarction (MI) and changes in dietary fiber intake from before to after MI with all cause and cardiovascular mortality.

DESIGN

Prospective cohort study.

SETTING

Two large prospective cohort studies of US women and men with repeated dietary measurements: the Nurses' Health Study and the Health Professionals Follow-Up Study.

PARTICIPANTS

2258 women and 1840 men who were free of cardiovascular disease, stroke, or cancer at enrollment, survived a first MI during follow-up, were free of stroke at the time of initial onset of MI, and provided food frequency questionnaires pre-MI and at least one post-MI.

MAIN OUTCOME MEASURES

Associations of dietary fiber post-MI and changes from before to after MI with all cause and cardiovascular mortality using Cox proportional hazards models, adjusting for drug use, medical history, and lifestyle factors.

RESULTS

Higher post-MI fiber intake was significantly associated with lower all cause mortality (comparing extreme fifths, pooled hazard ratio 0.75, 95% confidence interval 0.58 to 0.97). Greater intake of cereal fiber was more strongly associated with all cause mortality (pooled hazard ratio 0.73, 0.58 to 0.91) than were other sources of dietary fiber. Increased fiber intake from before to after MI was significantly associated with lower all cause mortality (pooled hazard ratio 0.69, 0.55 to 0.87).

CONCLUSIONS

In this prospective study of patients who survived MI, a greater intake of dietary fiber after MI, especially cereal fiber, was inversely associated with all cause mortality. In addition, increasing consumption of fiber from before to after MI was significantly associated with lower all cause and cardiovascular mortality.

Efficacy and safety of adjusted-dose prasugrel compared with clopidogrel in Japanese patients with acute coronary syndrome: the PRASFIT-ACS study

BACKGROUND

Prasugrel is an antiplatelet agent that shows more prompt, potent, and consistent platelet inhibition than clopidogrel. The objective of this study was to confirm the efficacy and safety of prasugrel at loading/maintenance doses of 20/3.75 mg.

METHODS AND RESULTS

Japanese patients (n=1,363) with acute coronary syndrome undergoing percutaneous coronary intervention were randomized to either prasugrel (20/3.75 mg) or clopidogrel (300/75 mg), both in combination with aspirin (81-330 mg for the first dose and 81-100 mg/day thereafter), for 24-48 weeks. The primary efficacy endpoint was the incidence of major adverse cardiovascular events (MACE) at 24 weeks, defined as a composite of cardiovascular death, nonfatal myocardial infarction, and nonfatal ischemic stroke. We compared the incidence of MACE between the 2 groups using point estimates. Safety outcomes included the incidence of bleeding events until 2 weeks after the last dose. The incidence of MACE at 24 weeks was 9.4% in the prasugrel group and 11.8% in the clopidogrel group (risk reduction 23%, hazard ratio 0.77, 95% confidence interval 0.56-1.07). The incidence of non-coronary artery bypass graft-related major bleeding was similar in both groups (1.9% vs. 2.2%).

CONCLUSIONS

Prasugrel 20/3.75 mg was associated with a low incidence of ischemic events, similar to the results of TRITON-TIMI 38, and with a low risk of clinically serious bleeding in Japanese ACS patients.

Impact of mode of transportation on time to treatment in patients transferred for primary percutaneous coronary intervention

BACKGROUND

Patients suffering ST segment elevation myocardial infarction (STEMI) requiring transfer from a non-percutaneous coronary intervention (PCI) hospital to a PCI-capable hospital often have prolonged treatment times.

OBJECTIVE

For STEMI transfers, we changed from air to ground transportation, and carefully documented the impact on treatment times.

METHODS

This is a retrospective report between two hospitals within one STEMI system. The referring facility controls both air and ground ambulance services. After a 2-year period of air transportation with suboptimal treatment times, the referring hospital switched to ground transport. All pertinent times were carefully recorded and are reported here.

RESULTS

There were 43 patients included, approximately half were transported by air and half by ground. Comparing our early experience (air only) vs. our later experience (predominantly ground-transported patients), median door-in-door-out (DIDO) time at the first facility was 70 min vs. 35 min (p<0.001), median transport time was 20 min vs. 30 min (p<0.001), and median first medical contact to balloon time (FMC2b time) was 123 min vs. 90 min (p<0.001). After changing mode of transport, achievement of the national FMC2b time goal of <120 min rose from 47% to 92% (p<0.001).

CONCLUSIONS

We document a significantly reduced DIDO and FMC2b time after changing mode of transportation for STEMI patients transferred 30 miles for primary PCI. Utilizing ground rather than air transportation, the median FMC2b time was reduced from 123 to 90 min. We show that mode of transportation can dramatically reduce both DIDO time and FMC2b time.

Effect of Early Treatment With Tirofiban on Initial TIMI Grade 3 Flow of Patients With ST Elevation Myocardial Infarction

Background:

Before primary percutaneous coronary intervention (PCI) in patients with ST elevation myocardial infarction (STEMI), it is not clear whether a routine early administration of glycoprotein IIb/IIIa inhibitors in the emergency ward is beneficial or their administration in selected cases in the catheterization laboratory.

Objectives:

The present randomized clinical trial sought to investigate whether an earlier administration of Tirofiban could exert any impact on TIMI grade 3 flows and ST resolution in the electrocardiography of patients with STEMI before primary PCI.

Materials and Methods:

Patients with STEMI within twelve hours of symptom commencement were included if primary PCI was planned to be performed within ninety minutes of admission and excluded if they had contraindications for Tirofiban. Seventy patients were randomized to receive 25 μg/kg of bolus Tirofiban early in the emergency ward (the early Tirofiban group) in three minutes and 70 did not receive Tirofiban (the control group). The primary endpoint of the study was a Thrombolysis in Myocardial Infarction (TIMI) grade 3 flows on the initial angiogram. The study is registered as IRCT201105126463N1 in: www.irct.ir.

Results:

The study population had a mean age of 57.17 ± 10.09 years and included 79.3 % males. TIMI grade 3 flow was seen in 15 (21.4 %) patients of the Tirofiban group and 7 (10 %) of the control group (P = 0.06, odds ratio = 0.407, and 95 % confidence interval = 0.155-1.072). Complete ST resolution was seen in 30 (42.9 %) patients of the Tirofiban group and 34 (48.6 %) of the control group (P = 0.5).

Conclusion:

Although TIMI grade 3 flows trended to be higher in the patients who received early Tirofiban in the emergency ward, the difference did not constitute statistical significance and possible benefits, therefore, require further clarification.

Comparing newer oral anti-platelets prasugrel and ticagrelor in reduction of ischemic events-evidence from a network meta-analysis

The two newer antiplatelet drugs, prasugrel and ticagrelor have both been incorporated in various national guidelines and are both under consideration for approval or have already been approved by various drug regulatory authorities. Mortality benefits with clopidogrel were comparable to newer anti-platelets, and prasugrel had great anti-ischemic potency than ticagrelor. We searched PubMed, EMBASE and Cochrane Central Register of Controlled Trials' databases for randomized controlled trials conducted between 1990 and 2012 that assessed clinical outcomes with prasugrel or ticagrelor. The comparator was standard dosage of clopidogrel. Outcomes assessed were the risk of all causes mortality, TIMI non-CABG major bleeding, and a composite of stent thrombosis, recurrent ischemia and serious recurrent ischemia in the intervention groups versus the comparator groups. Event rates were compared using a forest plot of relative risk using a random effects model (Mantel-Haenszel); and Odd's ratio was calculated in the absence of significant heterogeneity. Prasugrel was indirectly compared with ticagrelor using network meta-analysis. Four studies (total N = 34,126) met the inclusion/exclusion criteria. Both drugs had improved mortality and greater risk of bleeding compared to clopidogrel; but outcomes were comparable for both (p = NS). However a composite of recurrent ischemic events, including rates of stent thrombosis (p = 0.045) was reduced to a modest degree with prasugrel compared with ticagrelor. This systematic review suggests greater clinical efficacy of both prasugrel and ticagrelor compared with clopidogrel and an indirect comparison indicates prasugrel may be more effective than ticagrelor for preventing stent thrombosis and recurrent ischemic events.

Patterns of statin initiation, intensification, and maximization among patients hospitalized with an acute myocardial infarction

BACKGROUND

Intensive statins are superior to moderate statins in reducing morbidity and mortality after an acute myocardial infarction. Although studies have documented rates of statin prescription as a quality performance measure, variations in hospitals' rates of initiating, intensifying, and maximizing statin therapy after acute myocardial infarction are unknown.

METHODS AND RESULTS

We assessed statin use at admission and discharge among 4340 acute myocardial infarction patients from 24 US hospitals (2005-2008). Hierarchical models estimated site variation in statin initiation in naïve patients, intensification in those undergoing submaximal therapy, and discharge on maximal therapy (defined as a statin with expected low-density lipoprotein cholesterol lowering ≥ 50%) after adjustment for patient factors, including low-density lipoprotein cholesterol level. Site variation was explored with a median rate ratio, which estimates the relative difference in risk ratios of 2 hypothetically identical patients at 2 different hospitals. Among statin-naïve patients, 87% without a contraindication were prescribed a statin, with no variability across sites (median rate ratio, 1.02). Among patients who arrived on submaximal statins, 26% had their statin therapy intensified, with modest site variability (median rate ratio, 1.47). Among all patients without a contraindication, 23% were discharged on maximal statin therapy, with substantial hospital variability (median rate ratio, 2.79).

CONCLUSIONS

In a large, multicenter acute myocardial infarction cohort, statin therapy was begun in nearly 90% of patients during hospitalization, with no variability across sites; however, rates of statin intensification and maximization were low and varied substantially across hospitals. Given that more intense statin therapy is associated with better outcomes, changing the existing performance measures to include the intensity of statin therapy may improve care.

Long-term outcomes and risk analyses of coronary bypass for left main disease

BACKGROUND

We retrospectively analyzed the long-term outcomes and risk predictors of conventional coronary artery bypass grafting routinely employed for patients with left main disease.

METHODS

From January 2000 through December 2009, conventional coronary artery bypass grafting was routinely employed in 193 consecutive patients with left main disease. Long-term analyses were performed, looking at the primary endpoint of major adverse cardiac and cerebrovascular events which included all-cause death, stroke, myocardial infarction, and repeat revascularization. We also analyzed the effects of variables on major adverse cardiac and cerebrovascular events at 9 years after the operation.

RESULTS

The overall 9-year rates of combined outcomes (death, stroke, myocardial infarction), repeat revascularization, and major adverse cardiac and cerebrovascular events were 20.2%, 8.9%, 27.7%, respectively. The SYNTAX score was demonstrated to be the only significant predictor of combined outcomes at 9 years (hazard ratio 1.04, p = 0.033), repeat revascularization at 9 years (hazard ratio 1.11, p = 0.0030), and major adverse cardiac and cerebrovascular events at 9 years (hazard ratio 1.07, p = 0.0003).

CONCLUSIONS

With our routine strategy of conventional coronary artery bypass for left main disease, patients revealed excellent long-term outcomes in terms of major adverse cardiac and cerebrovascular events. These results provide a suitable benchmark against which long-term outcomes of percutaneous coronary intervention for left main disease can be compared. The SYNTAX score, which was introduced to determine treatment for complex coronary disease, is indicative of long-term outcomes after coronary artery bypass for left main disease.

Risk of cardiac rupture after acute myocardial infarction is related to a risk of hemorrhage

Although cardiac rupture (CR) is a fatal mechanical complication of acute myocardial infarction (AMI), to date no predictive model for CR has been described. CR has common pathological characteristics with major bleeding. We aimed to investigate the relationship between the risk factors of major bleeding and CR. A total of 10202 consecutive AMI patients were recruited, and mechanical complications occurred in 72 patients. AMI patients without CR were chosen as control group. Clinical characteristics including bleeding-related factors were compared between the groups. The incidences of free wall rupture (FWR), ventricular septal rupture (VSR), and papillary muscle rupture (PMR) were 0.39%, 0.21%, and 0.09%, respectively, and the hospital mortalities were 92.5%, 45.5%, and 10.0%, respectively. Female proportion and average age were significantly higher in the groups of FWR and VSR than in the control group (P<0.01); higher white blood cell count and lower hemoglobin were found in all CR groups (P<0.01). Compared to the control group, patients with CR were more likely to receive an administration of thrombolysis [26.39% vs. 13.19%, P<0.05], and were less likely to be treated with primary percutaneous coronary intervention (PCI) [41.67% vs. 81.60%, P<0.05]. The major bleeding scores (integer scores) of FWR, VSR, and PMR were (17.70±7.24), (21.91±8.33), and (18.60±7.88), respectively, and were significantly higher than that of the control group (11.72±7.71) (P<0.05). A regression analysis identified age, increased heart rate, anemia, higher white blood cell count, and thrombolysis as independent risk factors of CR, most of which were major bleeding-related factors. The patients with CR have a significantly higher risk of hemorrhage compared to the group without CR. Risk of CR after AMI is related to the risk of hemorrhage.

New antithrombotics for secondary prevention of acute coronary syndrome

Patients with acute coronary syndrome (ACS) usually receive acetylsalicylic acid plus an adenosine diphosphate (ADP) receptor inhibitor to reduce the long-term risk of recurrent events. However, patients receiving standard antiplatelet prophylaxis still face a substantial risk of recurrent events. Strategies involving 3 antithrombotic agents with different modes of action have now been tested. In Thrombin Receptor Antagonists for Clinical Event Reduction (TRA-CER), compared with standard care alone, bleeding complications including intracranial hemorrhage (ICH) were increased with the addition of vorapaxar, without efficacy benefit. In Trial to Assess the Effects of SCH 530348 in Preventing Heart Attack and Stroke in Patients With Atherosclerosis (TRA 2°P-TIMI 50), the addition of vorapaxar reduced recurrent events compared with standard care in stable patients with prior myocardial infarction. This study was terminated early in patients with prior stroke owing to excess ICH, though an increased risk of ICH or fatal bleeding was not detected in patients with prior myocardial infarction. The Apixaban for Prevention of Acute Ischemic and Safety Events 2 (APPRAISE-2) trial of standard-dose apixaban added to standard care in patients with ACS was also stopped early owing to excess serious bleeding. However, in Rivaroxaban in Combination With Aspirin Alone or With Aspirin and a Thienopyridine in Patients With Acute Coronary Syndromes (ATLAS ACS 2 TIMI 51), fatal bleeding or fatal ICH did not increase with low-dose rivaroxaban added to low-dose acetylsalicylic acid-based standard care compared with standard care alone. In that trial, a significant reduction of recurrent vascular events was shown with 3 antithrombotic regimens compared with standard care. Therefore, depending on drug dose and patient population, further reductions in recurrent vascular events after ACS may be possible in future clinical practice, with a favorable benefit-risk profile.

Acute inferior myocardial infarction in a young male patient associated with Behcet's disease and sildenafil

Behcet's disease (BD) is a multisystemic inflammatory disorder of unknown origin, presenting with mucocutaneous, ocular, articular, vascular, gastrointestinal and central nervous system manifestations. Coronary involvement is very rare in patients with BD. Sildenafil, an oral drug used to treat erectile dysfunction, was shown to cause significant cardiovascular problems including acute myocardial infarction (MI) and sudden cardiac death. Acute MI associated with BD and sildenafil has not been reported previously. We present a case of a 23-year-old male patient with an acute inferior MI associated with BD diagnosed after admission of sildenafil, who was successfully treated with thrombus aspiration and tirofiban administration.

Reperfusion therapy for ST elevation acute myocardial infarction 2010/2011: current status in 37 ESC countries

AIMS

Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion therapy in ST-elevation myocardial infarction (STEMI). We conducted this study to evaluate the contemporary status on the use and type of reperfusion therapy in patients admitted with STEMI in the European Society of Cardiology (ESC) member countries.

METHODS AND RESULTS

A cross-sectional descriptive study based on aggregated country-level data on the use of reperfusion therapy in patients admitted with STEMI during 2010 or 2011. Thirty-seven ESC countries were able to provide data from existing national or regional registries. In countries where no such registries exist, data were based on best expert estimates. Data were collected on the use of STEMI reperfusion treatment and mortality, the numbers of cardiologists, and the availability of PPCI facilities in each country. Our survey provides a brief data summary of the degree of variation in reperfusion therapy across Europe. The number of PPCI procedures varied between countries, ranging from 23 to 884 per million inhabitants. Primary percutaneous coronary intervention and thrombolysis were the dominant reperfusion strategy in 33 and 4 countries, respectively. The mean population served by a single PPCI centre with a 24-h service 7 days a week ranged from 31 300 inhabitants per centre to 6 533 000 inhabitants per centre. Twenty-seven of the total 37 countries participated in a former survey from 2007, and major increases in PPCI utilization were observed in 13 of these countries.

CONCLUSION

Large variations in reperfusion treatment are still present across Europe. Countries in Eastern and Southern Europe reported that a substantial number of STEMI patients are not receiving any reperfusion therapy. Implementation of the best reperfusion therapy as recommended in the guidelines should be encouraged.

Regional systems of care demonstration project: Mission: Lifeline STEMI Systems Accelerator: design and methodology

ST-segment elevation myocardial infarction (STEMI) systems of care have been associated with significant improvement in use and timeliness of reperfusion. Consequently, national guidelines recommend that each community should develop a regional STEMI care system. However, significant barriers continue to impede widespread establishment of regional STEMI care systems in the United States. We designed the Regional Systems of Care Demonstration Project: Mission: Lifeline STEMI Systems Accelerator, a national educational outcome research study in collaboration with the American Heart Association, to comprehensively accelerate the implementation of STEMI care systems in 17 major metropolitan regions encompassing >1,500 emergency medical service agencies and 450 hospitals across the United States. The goals of the program are to identify regional gaps, barriers, and inefficiencies in STEMI care and to devise strategies to implement proven recommendations to enhance the quality and consistency of care. The study interventions, facilitated by national faculty with expertise in regional STEMI system organization in partnership with American Heart Association representatives, draw upon specific resources with proven past effectiveness in augmenting regional organization. These include bringing together leading regional health care providers and institutions to establish common commitment to STEMI care improvement, developing consensus-based standardized protocols in accordance with national professional guidelines to address local needs, and collecting and regularly reviewing regional data to identify areas for improvement. Interventions focus on each component of the reperfusion process: the emergency medical service, the emergency department, the catheterization laboratory, and inter-hospital transfer. The impact of regionalization of STEMI care on clinical outcomes will be evaluated.

Reduced risk of recurrent myocardial infarction in homozygous carriers of the chromosome 9p21 rs1333049 C risk allele in the contemporary percutaneous coronary intervention era: a prospective observational study

OBJECTIVES

Chromosome 9p21 single nucleotide polymorphism (SNP) is a susceptibility variant for acute myocardial infarction (AMI) in the primary prevention setting. However, it is controversial whether this SNP is also associated with recurrent myocardial infarction (ReMI) in the secondary prevention setting. The purpose of this study is to evaluate the impact of chromosome 9p21 SNP on ReMI in patients receiving secondary prevention programmes after AMI.

DESIGN

A prospective observational study.

SETTING

Osaka Acute Coronary Insufficiency Study (OACIS) in Japan.

PARTICIPANTS

2022 patients from the OACIS database.

INTERVENTIONS

Genotyping of the 9p21 rs1333049 variant.

PRIMARY OUTCOME MEASURES

ReMI event after survival discharge for 1 year.

RESULTS

A total of 43 ReMI occurred during the 1 year follow-up period. Although the rs1333049 C allele had an increased susceptibility to their first AMI in an additive model when compared with 1373 healthy controls (OR 1.20, 95% CI 1.09 to 1.33, p=2.3*10(−4)), patients with the CC genotype had a lower incidence of ReMI at 1 year after discharge of AMI (log-rank p=0.005). The adjusted HR of the CC genotype as compared with the CG/GG genotypes was 0.20 (0.06 to 0.65, p=0.007). Subgroup analysis demonstrated that the association between the rs1333049 CC genotype and a lower incidence of 1 year ReMI was common to all subgroups.

CONCLUSIONS

Homozygous carriers of the rs1333049 C allele on chromosome 9p21 showed a reduced risk of 1 year ReMI in the contemporary percutaneous coronary intervention era, although the C allele had conferred susceptibility to their first AMI.

Lifetime cost-effectiveness analysis of ticagrelor in patients with acute coronary syndromes based on the PLATO trial: a Singapore healthcare perspective

INTRODUCTION

Ticagrelor is a novel antiplatelet drug developed to reduce atherothrombosis. The PLATO trial compared ticagrelor and aspirin to clopidogrel and aspirin in patients with acute coronary syndromes (ACS). Ticagrelor was found to be superior in the primary composite endpoint of cardiovascular death, myocardial infarction or stroke, without increasing major bleeding events. The current study estimates the lifetime cost-effectiveness of ticagrelor relative to generic clopidogrel from a Singapore public healthcare perspective.

METHODS

This study used a two-part cost-effectiveness model. The first part was a 12-month decision tree (using PLATO trial data) to estimate the rates of major cardiovascular events, healthcare costs and health-related quality of life. The second part was a Markov model estimating lifetime quality-adjusted survival and costs conditional on events during the initial 12 months. Daily drug costs applied were SGD 1.05 (generic clopidogrel) and SGD 6.00 (ticagrelor). Cost per quality-adjusted life years (QALY) was estimated from a Singapore public healthcare perspective using life tables and short-term costs from Singapore, and long-term costs from South Korea. Deterministic and probabilistic sensitivity analyses were performed.

RESULTS

Ticagrelor was associated with a lifetime QALY gain of 0.13, primarily driven by lower mortality. The resulting incremental cost per QALY gained was SGD 10,136.00. Probabilistic sensitivity analysis indicated that ticagrelor had a > 99% probability of being cost-effective, given the lower recommended WHO willingness-to-pay threshold of one GDP/capita per QALY.

CONCLUSION

Based on PLATO trial data, one-year treatment with ticagrelor versus generic clopidogrel in patients with ACS, relative to WHO reference standards, is cost-effective from a Singapore public healthcare perspective.

The FReedom from Ischemic Events-New Dimensions for Survival (FRIENDS) registry: design of a prospective cohort study of patients with advanced peripheral artery disease

BACKGROUND

Advanced lower extremity peripheral artery disease (PAD), whether presenting as acute limb ischemia (ALI) or chronic critical limb ischemia (CLI), is associated with high rates of cardiovascular ischemic events, amputation, and death. Past research has focused on strategies of revascularization, but few data are available that prospectively evaluate the impact of key process of care factors (spanning pre-admission, acute hospitalization, and post-discharge) that might contribute to improving short and long-term health outcomes.

METHODS/DESIGN

The FRIENDS registry is designed to prospectively evaluate a range of patient and health system care delivery factors that might serve as future targets for efforts to improve limb and systemic outcomes for patients with ALI or CLI. This hypothesis-driven registry was designed to evaluate the contributions of: (i) pre-hospital limb ischemia symptom duration, (ii) use of leg revascularization strategies, and (iii) use of risk-reduction pharmacotherapies, as pre-specified factors that may affect amputation-free survival. Sequential patients would be included at an index "vascular specialist-defined" ALI or CLI episode, and patients excluded only for non-vascular etiologies of limb threat. Data including baseline demographics, functional status, co-morbidities, pre-hospital time segments, and use of medical therapies; hospital-based use of revascularization strategies, time segments, and pharmacotherapies; and rates of systemic ischemic events (e.g., myocardial infarction, stroke, hospitalization, and death) and limb ischemic events (e.g., hospitalization for revascularization or amputation) will be recorded during a minimum of one year follow-up.

DISCUSSION

The FRIENDS registry is designed to evaluate the potential impact of key factors that may contribute to adverse outcomes for patients with ALI or CLI. Definition of new "health system-based" therapeutic targets could then become the focus of future interventional clinical trials for individuals with advanced PAD.

Sex differences in the treatment and outcome of patients with acute coronary syndrome after percutaneous coronary intervention: a population-based study

BACKGROUND

This study was performed to assess the influence of sex on drug therapy and long-term outcomes in acute coronary syndrome (ACS) patients who underwent percutaneous coronary intervention (PCI).

METHODS

This is a retrospective cohort study of ACS patients who underwent PCI [women (n=8,884) and men (n=23,937)] between January 1, 2006, and December 31, 2007, with at least a 1-year follow-up, based on the National Health Insurance Research Database in Taiwan. Propensity score was used to identify a 1:1 matched cohort (n=17,768) for multivariable adjustment. The influence of sex on drug therapy and outcomes was examined by multivariate logistic regression and multivariable Cox proportional hazards regression.

RESULTS

Female patients had an 18% and 12% lower likelihood of receiving aspirin (adjusted odds ratio [OR(adj)]=0.82, 95% confidence interval [CI]=0.77-0.88) and clopidogrel (OR(adj)=0.88, 95% CI=0.81-0.95), respectively, than male patients but had a 17% and 22% higher likelihood of receiving beta-blockers (OR(adj)=1.17, 95% CI=1.10-1.24) and statins (OR(adj)=1.22, 95% CI=1.14-1.29), respectively, than male patients in the matched cohort. The adjusted hazard ratio (HR(adj)) of rehospitalization for revascularization in women was 0.84 (95% CI=0.79-0.90) compared with men after at least a 1-year follow-up in the matched cohort.

CONCLUSIONS

Female patients with ACS who underwent PCI were less likely to receive aspirin and clopidogrel but were more likely to receive beta-blockers and statins than male patients. Male sex was associated with a higher risk of rehospitalization for revascularization than female sex.

Emergency medical services as a strategy for improving ST-elevation myocardial infarction system treatment times

BACKGROUND

Reducing delays in time to treatment is a key goal of ST-elevation myocardial infarction (STEMI) emergency care. Emergency medical services (EMS) are a critical component of the STEMI chain of survival.

STUDY OBJECTIVE

We sought to assess the impact of the careful integration of EMS as a strategy for improving systemic treatment times for STEMI.

METHODS

We conducted a study of all 747 nontransfer STEMI patients who underwent primary percutaneous coronary intervention (PCI) in Dallas County, Texas from October 1, 2010 through December 31, 2011. EMS leaders from 24 agencies and 15 major PCI receiving hospitals collected and shared common, de-identified patient data. We used 15 months of data to develop a generalized linear regression to assess the impact of EMS on two treatment metrics-hospital door to balloon (D2B) time, and symptom onset to arterial reperfusion (SOAR) time, a new metric we developed to assess total treatment times.

RESULTS

We found statistically significant reductions in median D2B (11.1-min reduction) and SOAR (63.5-min reduction) treatment times when EMS transported patients to the receiving facility, compared to self-transport. In addition, when trained EMS paramedics field-activated the cardiac catheterization laboratory using predefined specified protocols, D2B times were reduced by 38% (43 min) after controlling for confounding variables, and field activation was associated with a 21.9% reduction (73 min) in the mean SOAR time (both with p < 0.001).

CONCLUSION

Active EMS engagement in STEMI treatment was associated with significantly lower D2B and total coronary reperfusion times.

Accuracy of dedicated risk scores in patients undergoing primary percutaneous coronary intervention in daily clinical practice

BACKGROUND

Comparisons between dedicated risk scores in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) in real-world clinical practice are scarce. The aim of this study was to assess the diagnostic performance of the Global Registry of Acute Coronary Events (GRACE), Primary Angioplasty in Myocardial Infarction (PAMI), Thrombolysis in Myocardial Infarction (TIMI), and Zwolle scores in STEMI patients undergoing pPCI in contemporary clinical practice.

METHODS

This was a prospective cohort study of consecutive patients with STEMI undergoing pPCI between December 2009 and November 2010 in a high-volume tertiary referral centre. The outcomes assessed were major cardiovascular events (MACEs) and death within 30 days. The diagnostic accuracy of the scores was assessed using receiver operating characteristic curves, and scores were compared using the DeLong method.

RESULTS

During the study period, 501 patients were included. Within 30 days, 62 patients (12.4%) presented a MACE and 39 individuals (7.8%) died. All scores were statistically associated with death and MACE within 30 days (P < 0.01). The c-statistic and 95% confidence intervals for 30-day mortality were: GRACE, 0.84 (0.78-0.90); TIMI, 0.81 (0.74-0.87); Zwolle, 0.80 (0.73-0.87); and PAMI, 0.75 (0.68-0.82) (P < 0.01). There was no statistically significant difference regarding the accuracy of the TIMI, GRACE, and Zwolle scores for 30-day mortality, but the GRACE score was superior to the PAMI score (P < 0.01).

CONCLUSIONS

The TIMI, GRACE, and Zwolle scores performed equally well as predictors of mortality in patients who underwent pPCI in current practice. These results suggest that these scores are suitable options for risk assessment in a real-world setting.