Percutaneous coronary intervention–related time delay, patient's risk profile, and survival benefits of primary angioplasty vs lytic therapy in ST-segment elevation myocardial infarction

The Impact of COVID-19 on Lombardy Region ST-Elevation Myocardial Infarction Emergency Medical System Network-A Three-Year Study

Objectives: The COVID-19 pandemic had a significant impact on emergency medical systems (EMS). Regarding the ST-elevation myocardial infarction (STEMI) dependent time network, however, there is little evidence linked to the post-pandemic phase regarding this issue. Such information could prove to be of pivotal importance regarding STEMI clinical management, especially pre-hospital clinical protocols such as fibrinolysis. Methods: A retrospective observational cohort study of all STEMI rescues recorded in the Lombardy EMS registry from the 1st of January 2019 to the 30th of December 2021. Results: Regarding the number of STEMI diagnoses, March 2020 (first pandemic wave in Italy) saw a reduction compared to March 2019 (OR 0.76 [0.60-0.93], p = 0.011). The average time of the entire mission increased to 63.1 min in 2021, reaching 64.7 min in 2020, compared with 57.7 min in 2019. The number of HUBs for STEMI patients saw a reduction, falling from 52 HUBs in the pre-pandemic phase to 13 HUBs during the first wave. Conclusions: During the pandemic phase, there was an increase in the transportation times of STEMI patients from home to the hospital. Such changes did not alter the clinical approach in the out-of-hospital phase. Indeed, the implementation of fibrinolysis was not required.

Risk Factors of Ischemia Reperfusion Injury After PCI in Patients with Acute ST-Segment Elevation Myocardial Infarction and its Influence on Prognosis

Purpose

To explore the risk factors of ischemia reperfusion injury (IRI) after percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI) and its influence on prognosis.

Methods

The clinical data of 80 patients with STMEI undergoing PCI in our hospital from June 2020 to June 2021 were collected. According to whether IRI occurred after PCI, STMEI patients were divided into IRI group and non-IRI group. The basic information, clinical characteristics, examination parameters and other data of all patients were collected, and the prognosis of the two groups was observed. Risk factors were analyzed by fitting binary Logistic regression model. The survival prognosis was analyzed by Kaplan-Meier survival curve.

Results

Logistic regression analysis showed that type 2 diabetes mellitus (T2DM), pre-hospital delay time (PHD) and door-to-balloon expansion time (DTB) were the influencing factors of IRI in patients with STMEI (p < 0.05). MACE occurred in 11 cases (32.35%) in the IRI group and 13 cases (28.26%) in the non-IRI group. Log-rank test showed p = 0.503, indicating no statistically significant difference.

Conclusion

T2DM, PHD and DTB were the influencing factors of IRI in patients with STMEI, and IRI will not reduce the prognosis of patients.

Association between vitamin D deficiency and serum Homocysteine levels and its relationship with coronary artery disease

Homocysteine (Hcy) elevation and vitamin D deficiency have emerged as potential markers of coronary artery disease (CAD). However, even tough hypovitaminosis D has been suggested to interfere with Hcy catabolism, no study has so far addressed the interaction of vitamin D and Hcy and their impact on CAD, that was the aim of present study. A cohort of consecutive patients undergoing coronary angiography in a single center were included and analyzed within the year 2019. Significant CAD was defined as at least 1 vessel stenosis > 50%, while severe CAD as left main and/or three-vessel disease. Hcy and vitamin D levels were assesssed at admission. We included 3150 patients undergoing coronary angiography at our centre, who were divided according to the quartiles values of vitamin D. Patients with lower levels of Vitamin D displayed a higher cardiovascular risk profile and a higher prevalence of CAD. We observed an inverse linear relationship between lower levels of vitamin D and higher Hcy (r = − 0.092, p < 0.001) and a higher prevalence of hyperhomocysteinemia in patients with lower quartiles values of vitamin D (p < 0.001). By forward conditional regression model, low vitamin D appeared as independent predictors of Homocysteine levels above the median (OR[95%CI] = 1.79[1.37–2.33], p < 0.001). In addition, patients with low vitamin D (below the median) and increased Hcy displayed a non-significantly higher rate of CAD (81% vs 77.7%, p = 0.13, adjusted OR[95%CI] = 1.16[0.88–1.54], p = 0.29) but a significant increase in the rate of severe left main/3-vessel CAD (37.4% vs 30.5%, p = 0.005, adjusted OR[95%CI] = 1.29[1.02–1.67], p = 0.04). Among patients with vitamin D levels above the median, Hcy levels did not impact on the prevalence and extent of CAD (77.7 vs 77.2%, p = 0.81, adjusted OR[95%CI] = 0.94[0.73–1.20], p = 0.60 for CAD and 31.8% vs 27.7%, p = 0.08, adjusted OR[95%CI] = 0.97[0.75–1.25], p = 0.81 for severe left main/3-vessel CAD). No significant interaction between Hcy and vitamin D with CAD or severe CAD was observed. The present study shows an independent inverse linear relationship between vitamin D and Hcy values. Moreover, the association of Hcy with the extent of CAD was significant only among patients with hypovitaminosis D, and not in the cohort of subjects with vitamin D levels above the median, suggesting that a normal vitamin D status can prevent the deleterious effects of hyperhomocysteinemia on coronary atherosclerosis, a hypothesis that certainly needs further confirmation in larger randomized trials.

2019 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Guidelines on the Acute Management of ST-Elevation Myocardial Infarction: Focused Update on Regionalization and Reperfusion

Rapid reperfusion of the infarct-related artery is the cornerstone of therapy for the management of acute ST-elevation myocardial infarction (STEMI). Canada's geography presents unique challenges for timely delivery of reperfusion therapy for STEMI patients. The Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology STEMI guideline was developed to provide advice regarding the optimal acute management of STEMI patients irrespective of where they are initially identified: in the field, at a non-percutaneous coronary intervention-capable centre or at a percutaneous coronary intervention-capable centre. We had also planned to evaluate and incorporate sex and gender considerations in the development of our recommendations. Unfortunately, inadequate enrollment of women in randomized trials, lack of publication of main outcomes stratified according to sex, and lack of inclusion of gender as a study variable in the available literature limited the feasibility of such an approach. The Grading Recommendations, Assessment, Development, and Evaluation system was used to develop specific evidence-based recommendations for the early identification of STEMI patients, practical aspects of patient transport, regional reperfusion decision-making, adjunctive prehospital interventions (oxygen, opioids, antiplatelet therapy), and procedural aspects of mechanical reperfusion (access site, thrombectomy, antithrombotic therapy, extent of revascularization). Emphasis is placed on integrating these recommendations as part of an organized regional network of STEMI care and the development of appropriate reperfusion and transportation pathways for any given region. It is anticipated that these guidelines will serve as a practical template to develop systems of care capable of providing optimal treatment for a wide range of STEMI patients.

Annual Trends in Total Ischemic Time and One-Year Fatalities: The Paradox of STEMI Network Performance Assessment

This study is aimed at assessing trends and relations between total ischemic time, the major quality measure of systemic delay, and case-fatality at the population or patient level in response to growing cardiovascular risk and a constant need to shorten the time to treatment in ST-segment elevation myocardial infarction (STEMI). Data from a prospective nationwide registry of STEMI patients admitted between 2006 and 2013 who were treated with primary percutaneous coronary intervention (PCI) were analyzed. Total ischemic time was calculated as the time from the onset of symptoms to primary PCI and was determined as individual and annual. The primary end-point was one-year, all-cause case-fatality. Among the total 70,093 analyzed patients, temporal trends showed significant decrease in total ischemic time (268 vs. 230 minutes, p < 0.001), a worsening of the risk profile and an increase in one-year case-fatality (7.1% vs. 10.8%, p < 0.001). In the multivariate analysis, longer individual total ischemic time was a risk factor for higher mortality (HR 1.024, 95%CI 1.015–1.034, p < 0.001) and remained significant after adjustment for the year of admission. An inverse relation was observed for the median annual time (HR 0.992, 95%CI 0.989–0.994, p < 0.001). Thus, the observed increasing annual trends in case-fatality cannot directly measure the quality of STEMI network performance.

A quality improvement project to reduce door-to-electrocardiogram time: A multicenter study

Objective

To improve compliance with a target door-to-electrocardiogram (EKG) time of 10 minutes or less in patients presenting with symptoms concerning for acute coronary syndrome.

Methods

A pre-post study was performed between January 2014 and May 2016 at five emergency departments (EDs) in Saudi Arabia. Patients who presented to ED with symptoms concerning for acute coronary syndrome were included in the study. The primary outcome of interest was whether EKG was completed within 10 minutes after the patient arrival to ED. Quality improvement interventions consisted of human resources adjustments, education, technological improvements, and improved interdepartmental collaboration. Multivariate analysis was used to model the percentage of EKGs that were completed within the targeted time.

Results

During the study period, 11,518 patients received EKGs. Prior to the intervention, compliance with a door-to-EKG time of 10 minutes or less was found to be 62.6%. Post intervention, compliance improved to 87.7%. On multivariate analysis, male patients were significantly more likely to receive EKG within 10 minutes than female patients (odds ratio = 1.231, 95% confidence interval = 1.113–1.361; p < 0.001).

Conclusion

A quality improvement project can successfully increase the percentage of patients receiving EKG within 10 minutes of presentation to ED. Further research is required to demonstrate the clinical significance of improved door-to-EKG times.

Time course, predictors and clinical implications of stent thrombosis following primary angioplasty

Primary percutaneous coronary intervention (pPCI) has improved survival as compared to thrombolysis. Concerns still remain regarding the risk of stent thrombosis in the setting of STEMI, especially after drugeluting stent (DES) implantation. Therefore, the aim of this study was to report on the timing of stent thrombosis (ST) with both DES and bare metal stents (BMS) and its prognostic significance in patients undergoing pPCI. The Drug-Eluting Stent in Primary Angioplasty (DESERT) cooperation is based on a pooled database including individual data of randomised trials that evaluate the long-term safety and effectiveness of DES as compared to BMS in patients undergoing pPCI for STEMI. Follow-up data were collected for 3–6 years after the procedure. ST was defined as definite or probable, based on the ARC definition. The study population consists of 6,274 STEMI patients undergoing primary angioplasty with BMS or DES. At 1201±440 days, ST occurred in 267 patients (4.25%). Most of the events were acute or subacute (within 30 days) and very late (> 1 years), with different distribution between DES vs BMS. Patients with ST were more often diabetic (21.7% vs 15.1%, p=0.005), more frequently had post-procedural TIMI 0–2 flow (14.0% vs 9.3%, p = 0.01), and were less often treated with dual antiplatelet therapy at one year follow-up. Diabetes (p = 0.036), post-procedural TIMI 0–2 Flow (p = 0.013) and ischaemia time > 6 hours (p = 0.03) were independent predictors of ST. Post-procedural TIMI 0–2 flow (p = 0.001) and ischaemia time > 6 hours (p < 0.001) were independent predictors of early ST, ischaemia time > 6 hours (p=0.05) was independent predictor of late ST, whereas diabetes (p = 0.022) and use of DES (p=0.002) were independent predictors of very late ST. ST was associated with a significantly higher mortality (23.6% vs 6%, p < 0.001). The greatest impact on mortality was observed with subacute (40.4%) and late (20.9%) ST, as compared to acute (12.5%) and very late (9.1%) ST. ST was an independent predictor of mortality (HR [95%CI]=3.73 [2.75–5.07], p < 0.001). In conclusion, ST occurs relatively frequently also beyond the first year for up to six years after pPCI in STEMI, with higher late occurrence rates among patients treated with first generation DES. ST after pPCI is a powerful predictor of mortality, especially subacute ST.

Resting Pd/Pa and haemodynamic relevance of coronary stenosis as evaluated by fractional flow reserve

BACKGROUND

Fractional flow reserve (FFR) currently represents the gold standard in the evaluation of the haemodynamic relevance of coronary stenoses. However, both intracoronary and intravenous adenosine may be tolerated poorly by some patients. Therefore, considerable interest had been focused in the last few years on new adenosine-free indexes to define the haemodynamic relevance of coronary stenoses. So far, few data have been reported on resting Pd/Pa and its correlation with FFR as evaluated with high-dose intracoronary adenosine administration, which is the aim of the current study.

MATERIALS AND METHODS

FFR was assessed in 120 patients with 137 intermediate lesions during cardiac catheterization by a pressure-recording guidewire (PrimeWire). FFR was calculated as the ratio of the distal coronary pressure to the aortic pressure at hyperaemia. Intracoronary doses of adenosine were administered up to 720 μg as intracoronary boli. Exclusion criteria were as follows: (a) allergy to adenosine; (b) baseline bradycardia (heart rate <50 bpm); (c) hypotension (blood pressure <90 mmHg); and (d) refusal to provide signed informed consent.

RESULTS

High doses of intracoronary adenosine were well tolerated, with no major side effects. Increasing doses up to 720 μg progressively decreased FFR values and increased the percentage of patients showing an FFR less than 0.80. Resting Pd/Pa showed good accuracy in the identification of patients with significant FFR values (<0.80) [area under the curve=0.9 (0.84-0.96), P<0.0001]. Using receiver-operating characteristic curves, we identified a threshold less than 0.93 as the best accurate cut-off value in the prediction of a positive FFR value. A value up to 0.88 was associated with a 100% positive predictive value, whereas a value of at least 0.95 was associated with a 95% negative predictive value.

CONCLUSION

This study showed that in intermediate lesions, resting Pd/Pa was related linearly to FFR. We identified 0.93 as the best cut-off value in the prediction of haemodynamically significant coronary stenosis as evaluated by FFR. However, cut-off values of 0.88 and 0.95 could provide the maximal predictive positive and negative values, suggesting the additional use of FFR only in patients with resting values within this range.

Impact of polymorphism rs7041 and rs4588 of Vitamin D Binding Protein on the extent of coronary artery disease

BACKGROUND AND AIM

25-hydroxyvitamin D deficiency represents a widespread social problem but also an emerging risk factor for cardiovascular disease. Genetic variants of the Vitamin D Binding Protein (VDBP), the main transporter of vitamin D in the bloodstream, have been shown to account for a significant variability in the levels and systemic effects of vitamin D. We investigated whether the single nucleotide polymorphisms, rs7041 and rs4588, of VDBP are associated to the prevalence and extent of coronary artery disease.

METHODS AND RESULTS

A consecutive cohort of patients undergoing coronary angiography in a single centre were included. Significant CAD was defined as at least 1 stenosis >50%, severe CAD for as left main and/or three-vessel disease. VDBP genetic status was assessed by polymerase chain reaction and restriction fragment length polymorphism technique. We included 1080 patients, 57% carried the mutated G allele of rs7041, whereas 22% carried the A allele of rs4588. Higher levels of C- reactive protein were observed in the carriers of G allele of rs7041 (p = 0.02), whereas 25-hydroxyvitamin D levels were similar across groups. A higher prevalence of lesions in the left anterior descending artery and a longer lesion length were observed in "A" carriers for rs4588 (p = 0.04 and p = 0.03, respectively). On the contrary, a higher prevalence of bifurcation lesions and chronic occlusions was observed in G carriers (p = 0.002 and p = 0.01 respectively). Both polymorphisms of VDBP did not affect the prevalence of CAD (rs7041: 79.1% TT vs 80.3% TG vs 78.5% GG, p = 0.81; rs4588 = 80.3% CC vs 78.5% AC + AA, p = 0.49) and severe CAD, (rs7041: 31.1% TT % vs 31.3% TG vs 30.6% GG, p = 0.88; rs4588: 32.2% CC vs 29.3% AC + AA, p = 0.31). Results were confirmed at multivariate analysis, for both rs7041 and rs4588. However, when including the levels of 25-hydroxyvitamin D in the multivariate model, we observed that 25(OH)D status and not genetic variants of VDBP were significantly associated with CAD (25-hydroxyvitamin D OR [95% CI] = 0.99 [0.97-1.0], p = 0.05; rs7041 TG: OR [95% CI] = 1.26 [0.73-2.19], p = 0.41; rs7041 GG: OR [95% CI] = 1.25 [0.82-1.91], p = 0.30; rs4588 AC + AA: OR [95% CI] = 0.76 [0.51-1.13], p = 0.18).

CONCLUSION

This study showed in a large cohort of patients undergoing coronary angiography, that the polymorphisms rs7041 and rs4588 of VDBP are not associated with the levels of 25-hydroxyvitamin D nor with the prevalence and extent of CAD. In fact, 25-hydroxyvitamin D levels but not VDBP genetic status independently predicted the occurrence of coronary lesions at angiography.

Everolimus eluting stent vs first generation drug-eluting stent in primary angioplasty: A pooled patient-level meta-analysis of randomized trials

BACKGROUND

Several concerns have emerged about the higher risk of very late stent thrombosis (ST) with first generation drug-eluting stent (DES) especially among STEMI patients. Newer generation DES has demonstrated to reduce ST at mid-term follow-up. Therefore, the aim of the present study is to perform an individual patient's data meta-analysis of trials comparing 1st generation DES vs. 2nd generation DES (everolimus-eluting stent, EES) in patients undergoing primary percutaneous coronary intervention (PCI) for STEMI.

METHODS

We performed a formal search of electronic databases (MEDLINE and CENTRAL) and scientific session presentations from January 2010 to June 2016. We included all completed randomized trials comparing 1st vs. EES for patient presenting with STEMI.

RESULTS

Individual patients data were obtained from 3 trials, including a total of 1581 patients (686 or 43.4% randomized to 1st generation DES and 895 or 56.4% randomized to EES). At long-term follow-up (1584±588days), EES did not significantly reduce mortality (7.8.% vs 11.7%, HR [95%CI]=0.77 [0.52, 1.13], p=0.18, p_{heterogeneity}=0.93), cardiac mortality (6.2% vs 7.6%, HR [95%CI]=0.90 [0.56, 1.44], p=0.65, p_{heterogeneity}=0.85), and reinfarction (8.1% versus 11.2%, respectively; HR [95%CI]=0.74 [0.51, 1.07], p=0.11, p_{heterogeneity}=0.52). However, EES significantly reduced the occurrence of ST (3.4% versus 6.1% respectively, HR [95%CI]=0.56 [0.32, 0.97], p=0.04, p_{heterogeneity}=0.42) and target vessel revascularization (TVR) (14.2% versus 20.1%; HR [95%CI]=0.63 [0.42, 0.96], p=0.03, p_{heterogeneity}=0.55). Landmark analysis showed more consistent benefits in ST with EES within 1year, whereas benefits in TVR were mostly observed later than 1year.

CONCLUSIONS

The present pooled patient-level meta-analysis demonstrates that among STEMI patients undergoing primary PCI, EES as compared to 1st generation DES is associated with a significant reduction in ST and TVR at long-term follow-up.

Direct Transfer From the Referring Hospitals to the Catheterization Laboratory to Minimize Reperfusion Delays for Primary Percutaneous Coronary Intervention: Insights From the National Cardiovascular Data Registry

BACKGROUND

For patients with ST-segment-elevation myocardial infarction (STEMI) requiring interhospital transfer for primary percutaneous coronary intervention, direct transfer from the STEMI referral hospital to the catheterization laboratory (cath lab) at the STEMI receiving hospital may expedite reperfusion, but can be logistically challenging.

METHODS AND RESULTS

We studied 33,901 STEMI patients transferred for primary percutaneous coronary intervention in the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines from July 2008 to December 2012. The majority of patients were transferred directly to the cath lab (26,510 [78.2%]), and 7391 patients (21.8%) were transferred first to the hospital emergency department/ward. We observed significant interhospital variation in transfer patterns; only 21% of STEMI receiving hospitals routinely transferred >90% of STEMI patients to the cath lab directly. Compared with patients transferred first to the emergency department/ward, STEMI patients transferred to the cath lab had significantly lower first door-to-balloon times (median 191 versus 116 minutes, P<0.0001). After multivariable logistic regression, patients transferred directly to the cath lab also had lower adjusted mortality risk (odds ratio 0.58, 95% confidence interval 0.51-0.66, P<0.0001). Cardiogenic shock, heart failure signs/symptoms, and nonsystem reasons for reperfusion delay were present in 11%, 15%, and 28% of patients transferred first to the emergency department/ward, respectively. The association of direct cath lab transfer with lower mortality persisted after excluding patients with these reasons for delay to primary percutaneous coronary intervention (adjusted odds ratio 0.62, 95% confidence interval 0.46-0.84, P=0.002).

CONCLUSIONS

Direct transfer of STEMI patients to the cath lab for primary percutaneous coronary intervention was associated with significantly faster reperfusion and lower mortality risk compared with transfer first to the emergency department/ward.

Comparison of Resolute zotarolimus-eluting stents versus everolimus-eluting stents in patients with metabolic syndrome and acute myocardial infarction: propensity score-matched analysis

BACKGROUND

Despite common use of second-generation drug-eluting stents in treating patients with coronary artery disease, there is lack of data comparing these stents exclusively in patients with acute myocardial infarction (AMI), especially with metabolic syndrome (MetS), which is highly prevalent in AMI and potential to worsen clinical outcomes. The aim of this study was to compare clinical outcomes of everolimus-eluting stent (EES) and Resolute-zotarolimus-eluting stent (R-ZES) in AMI patients with MetS, in terms of stent-related and patient-related outcomes.

METHODS

A total of 3942 AMI patients in the KAMIR (Korea Acute Myocardial Infarction Registry) were grouped according to the presence of MetS and stent type: EES (N=1582) and R-ZES (N=255) in MetS (1837). Target lesion failure (TLF) and patient-oriented composite events (POCE) at 1 year were evaluated.

RESULTS

In MetS patients, TLF (3.7% vs. 2.7%, p=0.592) and POCE (7.9% vs. 6.7%, p=0.764) were similar between EES and R-ZES. Also in Non-MetS patients, TLF (3.9% vs. 3.1%, p=0.307) and POCE (6.4% vs. 7.3%, p=0.866) were similar between 2 groups. TLF was similar between MetS and Non-MetS patients (3.6% vs. 3.8%), while POCEs (7.7% vs. 6.6%) were higher in MetS. Propensity-score matching analysis showed similar results between stent groups in MetS and Non-MetS. In multivariate analysis, left ventricular ejection fraction and symptom-to-door time were independent predictors of TLF and POCE in MetS patients with AMI.

CONCLUSIONS

In MetS patients with AMI, EES and R-ZES showed excellent performance and safety. However, patient-oriented composite events were relatively high, suggesting more efforts to improve them.

[Primary angioplasty in diabetic and non-diabetic patients with acute myocardial infarction: Predictors of mortality]

BACKGROUND AND AIMS

Diabetes mellitus is one of the major risk factors for coronary artery disease. The aim of this study was to evaluate in-hospital mortality and during follow-up of diabetic patients with acute myocardial infarction treated with primary angioplasty and to determine its predictors.

MATERIALS AND METHODS

Eight hundred and sixty six patients were retrospectively enrolled from January 1993 to December 2013. A hundred patients with a diagnosis of diabetes were evaluated. The median follow-up was 121 months in 90% of the population.

RESULTS

Of the 100 diabetic patients included (11.56%) 86% were male and 50% older than 70 years. Overall, 76% presented with a Killip-Kimball grade of 1 at admission and 16% presented with a Killip-Kimball 4. The most frequent location of myocardial infarction was anterior and 65% had 2 or more coronary vessel disease. In-hospital mortality was 15%. The only independent variable significantly associated was the Killip-Kimball at admission. Mortality during follow up was 35% and its independent predictors were: age, Killip-Kimball at admission and use of angiotensin-converting enzyme inhibitors Interestingly, in the non-diabetic group, Killip-kimball at admission failed to predict long-term mortality

CONCLUSION

This group of diabetic patients was older, and with a higher prevalence of 2 or more vessel disease. Cardiogenic shock on admission was the only independent predictor of in-hospital death and along with age and angiotensin-converting enzyme inhibitor use, an independent predictor of mortality during long term follow-up.

Haemoglobin levels correlates with the presence of coronary artery disease

RATIONALE, AIMS AND OBJECTIVES

Although the condition of low haemoglobin (Hb) levels has been established as a risk factor in the development of coronary artery disease (CAD), it is still a debate particularly in patients with angiographically documented disease. In the present study, we sought to identify the relationship between Hb levels and the presence of CAD.

METHODS

The study consisted of 356 consecutive patients referred for elective coronary angiography (CAG). Exclusion criteria included a history of prior MI within last 3 months, presence of neoplastic disorders or any inflammatory diseases or overt diabetes mellitus. Blood samples for haematologic and biochemical measurements were collected on admission following at least 12 hours of overnight fasting. Patients were divided into four groups based on the quartiles of Hb (quartile I < 13.50 g/dL, quartile II 13.50-14.70 g/dL, quartile III 14.71-15.74 g/dL, quartile IV > 15.74 g/dL). Additionally, patients filled out a questionnaire of asking their brief medical histories and baseline characteristics.

RESULTS

Lower Hb quartiles were independently related to the presence of CAD in subjects who were referred to elective CAG. The patients with older age [P = 0.008, odds ratio (OR) = 1.042], male gender (P = 0.007, OR = 3.408), in quartile I (P = 0.003, OR = 5.697), in quartile II (P < 0.001, OR = 8.767), in quartile III (P = 0.011, P = 3.076), higher white blood cells count (P = 0.037, OR = 1.208), lower platelet count (P = 0.049, OR = 0.995), condition of current smoker (P = 0.030, OR = 2.548), higher value of fasting glucose (P = 0.014, OR = 1.038), estimated glomerular filtration rate < 60 (mL/min/1.73 m(2) ; P = 0.004, OR = 3.269) were more likely associated with the risk of the presence of CAD.

CONCLUSIONS

The present study revealed that lower quartiles of Hb levels were independently related to the presence of CAD in subjects who were referred to elective CAG. Hb levels, which can be measured easily in almost all medical centres, may be considered as a potential predictor for the presence of CAD in patients at high risk for CAD.

Impact of diabetes on fibrinogen levels and its relationship with platelet reactivity and coronary artery disease: A single-centre study

BACKGROUND

Previous reports have suggested an association between elevated fibrinogen and CAD. Few studies have so far investigated the impact of diabetes on fibrinogen levels and its association with coronary artery disease (CAD) and platelet reactivity in diabetic patients that are therefore the aims of the current study.

METHODS

We measured fibrinogen in 3280 consecutive patients undergoing coronary angiography. Samples were collected at admission for fibrinogen levels assessment. Coronary disease was defined for at least 1 vessel stenosis >50% as evaluated by QCA.

RESULTS

Diabetes was observed in 1201 out of 3280 patients. Diabetic patients were older with more hypercholesterolemia, hypertension, higher BMI, more renal failure, previous MI or coronary revascularization (p<0.001, respectively) and smoking (p=0.001). Diabetic patients were more often on ACE-inhibitors, ARBs, b-blockers, calcium-antagonists, diuretics, statins (p<0.001, respectively), and ASA (p=0.004). Diabetic patients displayed higher glycaemia and HbA1c (p<0.001), higher creatinine and triglycerides (p<0.001) but lower total and HDL cholesterol (p<0.001) and haemoglobin (p<0.001). Diabetic patients had higher fibrinogen levels (p=0.003), however neither diabetes nor glucose homeostasis parameters resulted as independent predictors of hyperfibrinogenemia. Furthermore, among diabetic patients, higher fibrinogen levels did not affect platelet reactivity and were not associated with the prevalence of CAD (adjusted OR[95%CI]=0.99 [0.82-1.19], p=0.9). Similar results were found for severe CAD (adjusted OR[95%CI]=0.94 [0.82-1.08], p=0.40).

CONCLUSIONS

Our study showed that diabetes and glycaemic control are not independent predictors of hyperfibrinogenemia. Among diabetic patients, elevated fibrinogen is not associated with platelet reactivity and the prevalence and extent of CAD.

Relationship between serum vitamin D levels and angiographic severity and extent of coronary artery disease

BACKGROUND

Vitamin D is known for its effect in calcium and bone homeostasis. There is an increasing evidence for health benefits accomplished by activated vitamin D that go beyond these classical functions. Previous studies have suggested that lower vitamin D levels are associated with increased cardiovascular disease risk. Therefore, we aimed to evaluate relationship between vitamin D levels and extent and severity of coronary artery disease.

MATERIALS AND METHODS

A total of 746 patients in whom coronary angiography was performed between August 2012 and July 2013 were enrolled in this study. Serum vitamin D levels were measured, and patients were grouped according to their serum vitamin D levels (vitamin D <20 ng/mL (n = 602) Group 1 versus >20 ng/dL (n = 144) Group 2). Gensini score system was used to evaluate the association between serum vitamin D levels and severity and extent of coronary artery disease.

RESULTS

There was no significant difference between the groups in terms of baseline characteristics and demographic characteristics. Mean serum vitamin D levels of all patient cohort was 15.54 ± 7.46 ng/mL. Group 1 and Group 2 had an average serum vitamin D levels of 12.6 ± 3.3 ng/mL and 27.5 ± 7.8 ng/mL, respectively. Gensini score for all cohort was 26.25 ± 34.32. Group 1 had an average Gensini score of 26.4 ± 35.7; on the other hand, Gensini score was 25.5 ± 27.5 in Group 2 (P = 0.097).

CONCLUSIONS

This study failed to demonstrate significant relationship between serum vitamin D levels and the severity and extent of coronary artery disease. Further studies with more participation and homogenous groups with comparable individual and environmental features are needed to evaluate the association of serum vitamin D levels and cardiovascular diseases.

Impact of diabetes on the benefits from everolimus-eluting stent as compared to first-generation drug-eluting stent in patients with ST elevation myocardial infarction

BACKGROUND

Drug-eluting stent has been shown to reduce the risk of repeated revascularization. However, as shown for first-generation drug-eluting stent, they may be counterbalanced by a potential higher risk of stent thrombosis, especially among ST-segment elevation myocardial infarction patients. In addition, diabetes has been shown to be an independent predictor of poor survival and repeated target vessel revascularization. No data have been reported so far on the long-term benefits and safety of new-generation drug-eluting stent in ST-segment elevation myocardial infarction according to diabetes. Therefore, the aim of this study was to evaluate whether diabetes may impact on the benefits from everolimus-eluting stent versus first-generation drug-eluting stent in patients undergoing primary angioplasty.

METHODS

We combined data from two randomized trials (PaclitAxel or Sirolimus-Eluting Stent vs Bare-Metal Stent in Primary Angioplasty and randomized comparison of everolimus-eluting stents and sirolimus-eluting stents in patients with ST elevation myocardial infarction) including consecutive ST-segment elevation myocardial infarction patients admitted within 12 h of symptom onset undergoing primary angioplasty and stent implantation at a tertiary centre with 24-h primary percutaneous coronary intervention capability. Primary endpoint of this study was major adverse cardiac events at 3-year follow-up. Secondary endpoints were as follows: (1) death, (2) reinfarction, (3) definite or probable ST and (4) target vessel revascularization at 3-year follow-up. No patient was lost to follow-up.

RESULTS

Our population is represented by 680 ST-segment elevation myocardial infarction patients treated with drug-eluting stent (180 enrolled in the PaclitAxel or Sirolimus-Eluting Stent vs Bare-Metal Stent in Primary Angioplasty trial, treated with first-generation drug-eluting stent, and 500 patients in the randomized comparison of everolimus-eluting stents and sirolimus-eluting stents in patients with ST elevation myocardial infarction, randomized to everolimus-eluting stent or sirolimus-eluting stent). Diabetes was observed in a total of 178 patients (26.1%) and associated with higher major adverse cardiac events, mortality, reinfarction, stent thrombosis and target vessel revascularization. Similar outcome was observed in terms of overall major adverse cardiac events, mortality, recurrent myocardial infarction, target vessel revascularization, with everolimus-eluting stent as compared to first-generation drug-eluting stent in both diabetic and non-diabetic patients, whereas everolimus-eluting stent was associated with a significantly lower rate of stent thrombosis only in diabetic patients (1.6% vs 9.6%, hazard ratio (95% confidence interval) = 0.15 (0.02-0.98), p = 0.04) whereas no difference was observed in non-diabetic patients.

CONCLUSION

This study shows that among ST-segment elevation myocardial infarction patients undergoing primary angioplasty, diabetes is associated with a significantly worse outcome at 3-year follow-up. A similar outcome was observed between everolimus-eluting stent and first-generation drug-eluting stent in non-diabetic patients, whereas among diabetic patients everolimus-eluting stent was associated with a significant reduction in stent thrombosis.

Switching from Clopidogrel to Prasugrel in patients undergoing PCI: A meta-analytic overview

Despite the demonstrated benefits of Prasugrel, a new generation thienopyridine, in the prevention of thrombotic complications after percutaneous coronary interventions (PCI) for Acute Coronary Syndromes (ACS), its use is still precluded to those many patients arriving to the cath lab pre-treated with Clopidogrel. Conclusive data on the strategy of switching from Clopidogrel to Prasugrel are still missing, therefore we aimed to perform a meta-analysis of current studies evaluating the safety and efficacy of switching from Clopidogrel to Prasugrel (PS) as compared to a standard thienopyridine therapy with Clopidogrel or Prasugrel in patients undergoing PCI. Literature archives and main scientific sessions' abstracts were scanned for studies comparing a switching strategy from Clopidogrel to Prasugrel vs. Prasugrel or Clopidogrel. Primary efficacy endpoint was overall mortality. Secondary endpoints were: non-fatal myocardial infarction and definite/probable stent thrombosis. Safety endpoint was the rate of major bleedings according to a per-protocol definition. A total of 12 studies, involving 3956 patients, were included. Among them, 1396 patients (35.3%), received Prasugrel after a Clopidogrel treatment (PS), while 2560 (64.7%) received either Prasugrel or Clopidogrel. The switch from Clopidogrel to Prasugrel was in the majority of the studies periprocedural. The mortality was numerically lower, but not statistically significant, in the PS group as compared with patients who did not switch (1.7% vs. 3.8%, OR [95% CI] = 0.68 [0.40,1.15], p = 0.15, phet = 0.61), without any relationship with patients' risk profile (r = -0.68 [-2.09, 0.73], p = 0.35). Similar results were obtained for secondary efficacy endpoints and at sensitivity analysis in the majority of subgroups evaluated. Moreover, the PS strategy did not increase major bleedings as compared with standard therapy (1.4% vs. 2.5%, OR [95% CI = 0.70 [0.39, 1.25], p = 0.23, phet = 0.6). The present meta-analysis confirms that, among patients undergoing PCI, switching from Clopidogrel to Prasugrel may be safely performed and therefore should be encouraged among patients eligible to Prasugrel.

Glycosylated hemoglobin and the risk of periprocedural myocardial infarction in non-diabetic patients

BACKGROUND

Alterations of glucose homeostasis have been reported to occur even in non-diabetic patients, thus increasing the risk of cardiovascular events and worsening the outcome after an acute myocardial infarction (AMI). Still debated is the role of impaired glucose control in patients undergoing percutaneous coronary intervention (PCI), as hyperglycemia, represents an important pro-thrombotic stimulus, increasing platelet reactivity and potentially procedural complications. Therefore, the aim of our study was to assess the association between glycosylated hemoglobin and periprocedural myocardial infarction (PMI) in non-diabetic patients undergoing PCI.

METHODS

We included patients without history of diabetes undergoing elective PCI. PMI was defined as creatine kinase-MB increase by 3 times the upper limit normal or by 50% of an elevated baseline value, whereas periprocedural myonecrosis as Troponin I increase by 3× ULN or 50% of baseline.

RESULTS

Our population is represented by 1199 patients, who were divided according to tertile values of glycosylated hemoglobin (HbA1c). Higher HbA1c was associated with ageing (p<0.001), hypertension (p=0.005), previous myocardial infarction (p=0.009), PCI (p<0.001) or CABG (p=0.001), treatment with diuretics (p<0.001), higher levels of glycemia (p<0.001) and white blood cells (p=0.02), multivessel coronary artery disease (p=0.03), higher rate of instent restenosis (p=0.02). HbA1c did not impact on periprocedural myocardial infarction (p=0.85; adjusted OR [95% CI]=0.91 [0.74-1.12], p=0.38) or myonecrosis (p=0.69; adjusted OR [95% CI]=0.95 [0.80-1.13], p=0.56). Similar results were obtained fasting glycemia for PMI (p=0.82, adjusted OR [95% CI]=0.90 [0.71-1.14], p=0.37) and myonecrosis (p=0.21, adjusted OR [95% CI]=1.02 [0.84-1.24], p=0.84) and confirmed in high-risk subsets of patients.

CONCLUSIONS

In non-diabetic patients undergoing elective PCI, neither glycosylated hemoglobin levels nor fasting glycemia are associated with the risk of periprocedural myocardial infarction and necrosis.

Impact of time from symptom onset to drug administration on outcome in patients undergoing glycoprotein IIb-IIIa facilitated primary angioplasty (from the EGYPT cooperation)

Contrasting data have been so far reported on facilitation with glycoprotein IIb-IIIa inhibitors (GpIIbIIIa) in patients who underwent primary percutaneous coronary intervention. However, it has been demonstrated a time-dependent composition of coronary thrombus in ST-segment elevation myocardial infarction, with more platelets in the first hours. Subsequently, the benefits of early administration of GpIIbIIIa may be affected by the time from symptoms onset to GpIIbIIIa, that therefore is the aim of this study. Our population is represented by 814 patients who underwent GpIIbIIIa facilitated primary angioplasty included in the Early glycoprotein IIb-IIIa inhibitors in primary angioplasty database. Patients were divided according to quartiles of time from symptom onset to GpIIbIIIa administration (≤65 minutes; 65 to 100 minutes; 101 to 178 minutes; and >178 minutes). Myocardial perfusion was evaluated by myocardial blush grade and ST-segment resolution. Time from symptoms onset to GpIIbIIIa was linearly associated with hypertension, diabetes, hypercholesterolemia, and previous myocardial infarction but inversely associated with smoking. Abciximab was more often administrated later from symptoms onset. Time from symptoms onset to GpIIbIIIa was significantly associated with the rate of preprocedural recanalization (thrombolysis in myocardial infarction [TIMI] 2 to 3; p <0.001), postprocedural TIMI 3 flow (p <0.001), the rate of complete ST-segment resolution (p <0.001), and the rate of myocardial blush grade 2 to 3 (p <0.001) and inversely associated with the occurrence of distal embolization (p <0.001). Follow-up data were collected at a median (twenty-fifth to seventy-fifth) of 360 (30 to 1,095) days. A total of 52 patients had died. Time to GpIIbIIIa had a significant impact on mortality (hazard ratio [95% confidence interval] 1.46 [1.11 to 1.92], p = 0.007) that was confirmed after correction for baseline confounding factors (adjusted hazard ratio [95% confidence interval] 1.41 [1.02 to 2.21], p = 0.042). In conclusion, this study showed that in patients who underwent primary angioplasty with upstream GpIIbIIIa, time from symptoms onset to GpIIbIIIa strongly impacts on preprocedural recanalization, distal embolization, myocardial perfusion, and long-term survival.

Effect of diabetes on scintigraphic infarct size in STEMI patients undergoing primary angioplasty

BACKGROUND

It has been shown that among patients with ST-segment elevation myocardial infarction (STEMI), diabetes is associated with a significantly higher mortality, mainly because of impaired reperfusion. However, few data have been reported so far on infarct size as evaluated by well-refined techniques, such as nuclear imaging techniques. Therefore, the aim of the current study was to investigate the effect of diabetes in infarct size as evaluated by myocardial scintigraphy in a large cohort of STEMI patients undergoing primary PCI.

METHODS

We included 830 STEMI patients undergoing primary PCI. Infarct size was evaluated at 30 days by technetium-99 m-sestamibi. A logistic regression analysis was performed to determine the relation between diabetes and infarct size (as above the median) after correction for baseline confounding factors.

RESULTS

A total of 115 (13.8%) out of 830 patients suffered from diabetes. Diabetic patients were older (p < 0.001), with larger prevalence of female gender (p = 0.006) and hypertension (p = 0.001) but were less often smokers (p = 0.003). Diabetic patients had more often preprocedural thrombolysis in myocardial infarction grade 3 flow (p = 0.034) and less complete ST-segment resolution (p = 0.009). No difference was observed in scintigraphic infarct size between diabetes and control patients (p = 0.6)), which was confirmed at multivariate analysis after correction for baseline confounding factors (Adjusted OR [95% CI] = 0.87 [0.57-1.31, p = 0.51).

CONCLUSION

Our study showed that among STEMI patients undergoing primary angioplasty, diabetes did not affect infarct size as compared with non-diabetic patients.

Clinical results of intraarterial thrombolysis according to tPA administration and perfusion/diffusion mismatching

BACKGROUND

IA-Tx and advanced dynamic imaging studies have been adopted for ischemic stroke patient treatment. Many patients are treated with IV-tPA, but this treatment is not always feasible. In this study, IA-Tx was used for patients for whom IV-tPA was not indicated or when IV-tPA did not result in recanalization.

METHODS

A total of 156 patients treated with IA-Tx were retrospectively reviewed. Of these, 72 patients were treated with a full dose of IV-tPA before receiving the IA-Tx; the remaining 84 patients only received IA-Tx. An initial imaging study using CTA and acute stroke MRI followed. Patients' demographics and clinical results were recorded and compared according to P/D mismatching and IV-tPA.

RESULTS

Among P/D-mismatched patients, the recanalization rate was 80 % and the symptomatic intracranial hemorrhage rate was 14.5 %, while among P/D-matched patients, the rates were 63 % and 41.3 % respectively (p < 0.05). A favorable clinical outcome occurred in 49.1 % of P/D-mismatched, but only in 21.7 % of P/D-matched patients (p < 0.05). Among patients who were treated with IV-tPA before undergoing IA-Tx, the recanalization rate was 79.2 % and the sICH rate was 27.8 %, while it was 71.4 % and 17.9 % in patients who did not receive IV-tPA (p < 0.05).

CONCLUSIONS

Patients who have P/D mismatching and are treated with IA-Tx have higher recanalization rates and a greater probability of a favorable outcome than patients who have P/D matching and receive IA-Tx. For patients who do not undergo successful recanalization after IV-tPA or who are not indicated for IV-tPA, the authors recommend IA-Tx after undergoing appropriate imaging evaluation.

Preprocedural TIMI flow and infarct size in STEMI undergoing primary angioplasty

Despite optimal epicardial recanalization, primary angioplasty for STEMI is still associated with suboptimal reperfusion in a relatively large proportion of patients. The aim the current study was to evaluate the impact of preprocedural TIMI flow on myocardial scintigraphic infarct size among STEMI undergoing primary angioplasty. Our population is represented by 793 STEMI patients undergoing primary PCI. Infarct size was evaluated at 30 days by technetium-99m-sestamibi. Poor preprocedural TIMI flow (TIMI 0-1) was observed in 645 patients (81.3%). Poor preprocedural TIMI flow was associated with more hypercholesterolemia (p = 0.012), and a trend in lower prevalence of diabetes (p = 0.081). Preprocedural TIMI flow significantly affected scintigraphic and enzymatic infarct size. Similar findings were observed in the analysis restricted to patients with postprocedural TIMI 3 flow. The impact of preprocedural TIMI flow on scintigraphic infarct size was confirmed when the analysis was performed according to the percentage of patients above the median (p < 0.001) and after adjustment for baseline confounding factors (Hypercholesterolemia and diabetes) [adjusted OR (95% CI) for pre preprocedural TIMI 3 flow = 0.59 (0.46-0.75), p < 0.001]. This study shows that among patients with STEMI undergoing primary angioplasty, poor preprocedural TIMI flow is independently associated with larger infarct size.

Worse outcome in women with STEMI: a systematic review of prognostic studies

BACKGROUND

Treatment of ST elevation myocardial infarction (STEMI) has improved enormously since the introduction of primary percutaneous coronary intervention (pPCI). It remains unclear whether differences in survival between women and men treated with pPCI exist and whether these potential differences can be explained by gender or by differences in baseline- or procedural characteristics. Therefore we systematically reviewed the available evidence.

MATERIALS AND METHODS

On 10 May 2013 PubMed, Embase and Cochrane were searched for studies comprising original data on STEMI patients treated with pPCI. A separate gender analysis including > 100 women was a requirement. Data were extracted and pooled whenever possible.

RESULTS

21 studies were included from 2001 to 2013 comprising 47.439 men and 16.927 women. Women were older, had more diabetes (women 24%, men 15%) and hypertension (women 58%, men 45%), and were less current smokers (women 30%, men 54%). The procedural characteristics were comparable except for a longer symptom-to-balloon time (women 266 min, men 240 min) and less use of GP IIb/IIIa inhibitors in women (women 51%, men 57%). Crude short- and long-term mortality was higher in women. Although we could not pool adjusted mortality proportions due to heterogeneity, generally the difference in mortality disappeared after adjustment for baseline- and procedural characteristics.

CONCLUSION

Mortality is higher in women with STEMI and can be explained by their unfavourable risk profile and longer symptom-to-balloon time.

Effects of HDL-modifiers on cardiovascular outcomes: a meta-analysis of randomized trials

BACKGROUND AND AIM

High density lipoproteins (HDL) have been addressed as a potential strategy for cardiovascular prevention, with great controversies on pharmacological approaches for HDL-elevation. Our aim was to compare HDL-rising treatment with niacin or CETP-inhibitors with optimal medical therapy in cardiovascular outcome.

METHODS AND RESULTS

Randomized trials were searched. Primary endpoint was cardiovascular death, secondary were: non fatal myocardial infarction; coronary revascularization; cerebrovascular accidents and safety endpoints. As many as 18 randomized trials, for a total of 69,515 patients, were included. HDL-modifiers did not reduce cardiovascular mortality (2.3%vs3.4%; OR [95%CI] = 0.96 [0.87-1.05], p = 0.37, phet = 0.58), with no benefit from niacin/CETP inhibitors according to patients' risk profile (beta [95%CI] = -0.14 [-0.29 to 0.02], p = 0.09) or the amount of HDL increase (beta [95%CI] = 0.014 [-0.008 to 0.04], p = 0.21). Niacin but not CETP-I reduced myocardial infarction and coronary revascularization, but higher rate of SAE occurred with HDL-modifiers (OR [95%CI] = 1.24 [1.18-1.31], p < 0.00001, phet = 0.02), in particular new onset of diabetes with niacin and worsening of hypertension with CETP-inhibitors.

CONCLUSIONS

Niacin and CETP inhibitors do not influence cardiovascular mortality. Significant benefits in MI and coronary revascularization were observed with niacin, despite the higher occurrence of diabetes.

Effect of diabetes mellitus on periprocedural myocardial infarction in patients undergoing coronary stent implantation

BACKGROUND

Diabetic patients undergoing percutaneous coronary interventions are still regarded as a very high risk category because of an increased platelet reactivity and risk of complications, especially in patients with inadequate glycaemic control. However, although its prognostic effect on long-term outcome is well-defined, still unclear is the effect of diabetes on the risk of periprocedural myocardial infarction in patients undergoing percutaneous coronary interventions, which was therefore the aim of our study.

METHODS

Myonecrosis biomarkers were dosed at intervals from 6 to 48 h after nonemergent percutaneous coronary interventions. Periprocedural myocardial infarction was defined as creatine kinase-MB increase by three times the upper limit normal or by 50% of an elevated baseline value, whereas periprocedural myonecrosis as troponin I increase by three times the upper limit normal or 50% of baseline.

RESULTS

Of 1311 patients, diabetes mellitus was found in 458 patients (34.9%) and associated with age (p = 0.03), hypertension (p < 0.001), renal failure (p = 0.01), previous MI (p = 0.03), previous coronary revascularization (p < 0.001), higher fasting glycaemia and lower haemoglobin (p < 0.001), more severe coronary disease (p < 0.001), multivessel percutaneous coronary interventions (p = 0.03), coronary calcification (p = 0.003) and in-stent restenosis (p < 0.001) but lower presence of thrombus (p = 0.03). Diabetic patients were receiving significantly more frequent specific pharmacological treatment at admission. Diabetic status did not influence the risk of periprocedural myocardial infarction or periprocedural myonecrosis [adjusted OR(95%CI) = 0.90(0.64-1.27), p = 0.57 and adjusted OR(95%CI) = 0.92(0.70-1.21), p = 0.55]. Amongst diabetic patients, we did not observe any effect of chronic glycaemic control on periprocedural myocardial infarction.

CONCLUSIONS

Diabetic status, independent of chronic glycaemic control, is not associated with increased risk of periprocedural myocardial infarction and myonecrosis in patients undergoing percutaneous coronary interventions.

Relationship Between Glycoprotein IIIa Platelet Receptor Gene Polymorphism and Coronary Artery Disease

Glycoprotein IIb/IIIa (GP IIb/IIIa) is a key receptor for platelet aggregation and adhesion. We investigated whether a single-nucleotide polymorphism of GP IIIa subunit (Leu33Pro-PlA1/PlA2 allele) is associated with the extent of coronary artery disease (CAD) in a consecutive cohort of 1518 patients undergoing coronary angiography. Significant CAD was defined as at least a stenosis >50% and severe CAD as left main disease and/or trivessel disease. Additionally, carotid intima–media thickness (cIMT) was evaluated in 339 patients. The PlA2 allele was observed in 458 (30.2%) patients and associated with hypercholesterolemia ( P = .03). No difference was observed in the prevalence of CAD (72.6% vs 70.1%, P = .29; adjusted odds ratio, OR [95% confidence interval, CI] = 0.85 [0.67-1.08], P = .19) and severe CAD (27.5% vs 26.5%, adjusted OR [95% CI] = 0.93 [0.72-1.19], P = .55). Furthermore, Leu33Pro polymorphism did not affect cIMT and the prevalence of carotid plaques. Therefore, this polymorphism cannot be regarded as a risk factor for coronary or carotid atherosclerosis.

Pre-diabetes and the risk of contrast induced nephropathy in patients undergoing coronary angiography or percutaneous intervention

BACKGROUND

Contrast induced nephropathy (CIN) is a complication of coronary angiography/percutaneous intervention (PCI). It is known that diabetes is an independent risk factor for CIN, but we have no data regarding the association between CIN and glycemic levels in patients without diabetes. Aim of our study was to evaluate whether high level of glycated-haemoglobin in patients without diabetes is associated with an increased risk of CIN.

METHODS

A total of 1324 patients without diabetes, undergoing elective/urgent coronary angiography/angioplasty were divided according to quartiles of baseline glycated-haemoglobin. CIN was defined as an absolute ≥ 0.5mg/dL or a relative ≥ 25% increase in creatinine level at 24-48 h after the procedure.

RESULTS

Patients with elevated glycated-haemoglobin were older, with hypertension, metabolic syndromes, previous history of AMI, PCI and CABG. They had higher gycaemia, fasting-glycaemia and triglycerides but lower HDL-cholesterol. Patients with higher glycated-haemoglobin were more often on therapy with statins, diuretics and calcium-antagonist at admission, had higher basal, 24 and 48 h creatinine, lower creatinine clearance and lower ejection fraction. They had the highest incidence of PCI and contrast volume-eGFR rate. CIN occurred in 10.6% of patients with a linear association with glycated-haemoglobin (p=0.001). No relationship was found between glycaemia/fasting glycaemia at admission and CIN. The multivariate analysis confirmed the association between elevated glycated haemoglobin (above the median value 5.7%) and the risk of CIN after adjustment for baseline confounding factors (Adjusted OR [95% CI]=1.69 [1.14-2.51], p=0.009). In fact, the results were consistent in major high-risk subgroups.

CONCLUSION

This is the first study showing that among patients without diabetes undergoing coronary angiography/PCI elevated glycated-haemoglobin but not glucose levels is independently associated with the risk of CIN.

Benefits from new ADP antagonists as compared with clopidogrel in patients with stable angina or acute coronary syndrome undergoing invasive management: a meta-analysis of randomized trials

AIMS

New P2Y12 receptor inhibitors have provided new and more potent antiplatelet strategies, although raising several concerns on possible increase of bleedings. The aim of current meta-analysis was to evaluate the efficacy and safety of new adenosine diphosphate (ADP) receptor antagonists as compared with clopidogrel in elective or ACS patients managed invasively.

METHODS AND RESULTS

Literature archives (Pubmed, EMBASE, Cochrane) and main scientific sessions abstracts were scanned for randomized trials comparing new ADP antagonists with clopidogrel in patients with acute coronary syndromes or stable angina. Primary endpoint was mortality. Secondary endpoints were: (1) nonfatal myocardial infarction (MI), (2) recurrent ischemia symptoms or ischemia-driven revascularization (RI/IDR), (3) stent thrombosis (ST), and (4) safety endpoints, defined as for TIMI major bleeding criteria. A total of 8 randomized clinical trials were finally included, for a total population of 67,851 patients. Mean follow-up was 7.6 months, ranging from 48 hours to 30 months. New ADP antagonists significantly reduced mortality {3.1% vs. 3.6%, odds ratio [OR] [95% confidence interval (CI)], 0.86 [0.79-0.94], P = 0.0008, P(het) = 0.18}, with greater impact of oral drugs. Similar benefits were found for MI [6.1% vs. 7%; OR (95% CI) (random-effect model) = 0.88 (0.79-0.98), P = 0.01, P(het) = 0.02], RI [2.7% vs. 3.1%; OR (95% CI) = 0.85 (0.77-0.93), P = 0.0005, P(het) = 0.09], or ST [1.1% vs. 1.7%; OR (95% CI) = 0.60 (0.51-0.71), P < 0.00001, P(het) = 0.13]. By meta-regression analysis, no relationship was observed between benefits in mortality, new MI, RI, and ST with new ADP antagonists and patients' risk profile [beta (95% CI) = -0.01 [-0.30 to 0.27], P = 0.94; beta (95% CI) = -0.05 [-1.49 to 1.43], P = 0.96); beta (95% CI) = 0.19 (-0.18 to 0.57), P = 0.31, and beta (95% CI) = -0.08 (-0.86 to 0.70), P = 0.84, respectively].

CONCLUSIONS

Present meta-analysis shows that the new ADP antagonists prasugrel, ticagrelor, and cangrelor are associated to significant reduction of mortality, reinfarction, RI, and ST respect to clopidogrel alone, without significant increase in bleeding complications.

Gender, age and risk of ST segment elevation myocardial infarction

BACKGROUND

Exact associations of gender and age with occurrence of ST segment elevation myocardial infarction are inadequately known.

DESIGN

Gender and age differences in frequency and incidence of ST segment elevation myocardial infarction (STEMI were studied using a nationwide, population-based (26 723 956 person-years) registry of hospital admissions in patients aged ≥ 30 during 2001-2008 in Finland. Data were collected from all 22 hospitals with a coronary angiolaboratory nationwide.

RESULTS

The study period included 27 993 STEMI admissions. Of these patients, 65·9% were men and 34·1% women, RR 2·37 (95% CI 2·05-2·74, P < 0·0001). Women were significantly older than men (74·3 ± 11·7 vs. 64·7 ± 12·4 years, P < 0·0001). Standardized incidence rate of STEMI was 113·0/100 000 person-years overall, 170·9/100 000 in men and 66·6/100 000 in women. Men had a 3·03 (95% CI 2·86-3·21; P < 0·0001)-fold age-adjusted relative risk of STEMI compared with women with highest risk difference in population under the age of 55 years (RR 5·94; 95% CI 5·36-6·58, P < 0·0001). Incidence increased with age up to 90 years old, with estimated gender-adjusted increase rate of 41% (95% CI 40-42%; P < 0·0001) per 5-year increase in age. Incidence rate had a slowly declining trend (-2·2%; 95% CI -3·4 to -1·0% per year, P < 0·001) during the study period.

CONCLUSIONS

Men have a tripled overall risk of STEMI compared with women with highest relative risk in younger adults. Incidence rate of ST segment elevation myocardial infarction increases by estimated 41% per 5-year increase in age.

Glycosylated hemoglobin and coronary artery disease in patients without diabetes mellitus

BACKGROUND

Abnormal glucose metabolism is a major determinant of coronary artery disease (CAD) and mortality in developed countries. Glycosylated hemoglobin (HbA1c) is a more stable, accurate parameter of glucose homeostasis than fasting glycemia, thus providing prognostic information in diabetics. However, its role and relationship with CAD remains unclear in non-diabetics.

PURPOSE

To evaluate the relationship between HbA1c and CAD in a consecutive cohort of patients without diabetes mellitus.

METHODS

Non-diabetic patients undergoing coronary angiography between April 2007 and October 2012 were included. Additionally carotid intima-media thickness (C-IMT) was evaluated during hospitalization in a consecutive cohort of patients.

RESULTS

1,703 consecutive patients were included and divided according to HbA1c tertiles (<5.5%, 5.5%-5.79%, ≥5.8%). HbA1c was associated with aging (p<0.001); hypercholesterolemia (p=0.01); renal failure (p=0.006); hypertension (p=0.002); previous myocardial infarction (p=0.004); previous percutaneous coronary intervention (p=0.01); indication to angiography (p=0.01); use of angiotensin receptor blockers (p=0.01); beta-blockers (p=0.03); nitrates (p=0.02); statins (p=0.008); calcium antagonists (p=0.01); diuretics (p<0.001); acetylsalicylic acid (p<0.001); baseline glycemia (p<0.001); triglycerides (p=0.02); and uric acid (p=0.04). HbA1c, but not fasting glycemia, was significantly associated with the prevalence of CAD (adjusted OR=1.51, 95% CI=1.15, 1.97, p=0.002), with 5.8% identified by the receiver operating characteristic (ROC) curve as the best cut-off value for CAD prediction. HbA1c was significantly associated with C-IMT and carotid plaques prevalence.

CONCLUSIONS

Among non-diabetic patients, higher HbA1c even within the normal range is significantly associated with the risk of CAD. Future large studies are needed to evaluate whether more aggressive cardiovascular prevention can reduce the risk of CAD among patients with HbA1c ≥ 5.8%.

Vitamin D deficiency is independently associated with the extent of coronary artery disease

BACKGROUND

Vitamin D (25-OH D3) deficiency represents a rising social and economic problem in Western countries. Vitamin D has been recently reported to modulate inflammatory processes, endothelium and smooth muscle cell proliferation and even platelet function, thus potentially modulating atherothrombosis. Great interest has been addressed on its impact on cardiovascular outcome, with contrasting results. The aim of current study was to evaluate the relationship between 25-OH D3 and the extent of coronary artery disease (CAD) in a consecutive cohort of patients undergoing coronary angiography.

MATERIALS AND METHODS

Patients undergoing elective coronary angiography were included in a cross-sectional study. Fasting samples were collected for 25-OH D3 levels assessment. Significant CAD was defined as at least 1 vessel stenosis > 50%, while severe CAD as left main and/or trivessel disease, as evaluated by quantitative coronary angiography.

RESULTS

Hypovitaminosis D was observed in 70·4% of 1484 patients. Patients were divided according to vitamin D tertiles (< 9·6; 9·6-18·4; ≥ 18·4). Lower vitamin D levels were associated with age, female gender (P < 0·001), renal failure (P = 0·05), active smoking (P = 0·001), acute coronary syndrome at presentation (P < 0·001), therapy with calcium antagonists (P = 0·02) and diuretics (P < 0·001), less beta-blockers (P = 0·02) and statins (P = 0·001) use. Vitamin D was directly related to haemoglobin (P < 0·001) and inversely with platelet count (P = 0·002), total and low-density-lipoprotein cholesterol (P = 0·002 and P < 0·001) and triglycerides (P = 0·01). Vitamin D did not influence angiographic features of coronary lesions, but was associated with higher prevalence of left main or right CAD (P = 0·03). Vitamin D deficiency was significantly associated with higher prevalence of CAD (adjusted OR [95%CI] = 1·32[1·1-1·6], P = 0·004) and severe CAD (adjusted OR [95%CI] = 1·18[1-1·39], P = 0·05).

CONCLUSION

Hypovitaminosis D was observed in the vast majority of patients undergoing coronary angiography. Vitamin D deficiency is significantly associated with the prevalence and extent of CAD, especially for patients with values < 10 ng/mL. Therefore, future large studies are needed to evaluate whether vitamin D supplementation may prevent CAD and its progression.

Impact of hypertension on infarct size in ST elevation myocardial infarction patients undergoing primary angioplasty

BACKGROUND

Hypertension is a well known risk factor for atherosclerosis. However, data on the impact of hypertension in patients with ST-segment elevation myocardial infarction (STEMI) are inconsistent, and mainly related to studies performed in the thrombolytic era, with very few data on patients undergoing primary angioplasty. The aim of the current study was to evaluate the impact of hypertension on scintigraphic infarct size in STEMI patients undergoing primary percutaneous coronary intervention (PCI).

METHOD

Our population is represented by 830 STEMI patients undergoing primary PCI. Infarct size was evaluated at 30 days by technetium-99m-sestamibi.

RESULTS

Hypertension was associated with more advanced age (P<0.001), a larger prevalence of diabetes (P=0.001), female sex (P<0.001), but lower prevalence of smoking (P<0.001) and anterior infarction (P=0.042). No difference was observed in ischemia time, cardiogenic shock at presentation, in preprocedural thrombolysis in myocardial infarction (TIMI) flow, and collateral circulation. Hypertension did not affect the rate of postprocedural TIMI 3 flow. Hypertension did not affect infarct size [12.5% (4.1-23.8%) vs. 12.8% (4.3-24.7%), P=0.38]. Similar results were observed in subanalyses in major high-risk subgroups. No impact of hypertension on infarct size was confirmed when the analysis was conducted according to the percentage of patients with infarct size above the median [adjusted odds ratio (95% CI)=0.97 (0.72-1.33), P=0.92].

CONCLUSION

This study shows that among STEMI patients, undergoing primary PCI hypertension does not affect scintigraphic infarct size.

Relationship between homocysteine and coronary artery disease. Results from a large prospective cohort study

BACKGROUND

Coronary artery disease (CAD) still represents the major cause of mortality in developed countries. Large research programs have been focused on the identification of new risk factors to prevent CAD, with special attention to homocysteine (Hcy), due to the known associated increased thrombogenicity, oxidative stress status and endothelial dysfunction. However, controversy still exists on the association between Hcy and CAD. Therefore, aim of the current study was to investigate the association of Hcy with the prevalence and extent of CAD in a large consecutive cohort of patients undergoing coronary angiography.

METHODS

Our population is represented by a total of 3056 consecutive patients undergoing coronary angiography between at the Azienda Ospedaliera "Maggiore della Carità", Novara, Italy. Fasting samples were collected for homocysteine levels assessment. Coronary disease was defined for at least 1 vessel stenosis>50% as evaluated by QCA.

RESULTS

Study population was divided according to Hcy tertiles (<13,3, 13,3-18.2, >18.2nmol/ml). High plasmatic level of homocysteine was related with age (p<0.001), male gender (p<0.001), hypertension (p<0.001) renal failure (p<0.001), family history of CAD (p<0.001), previous cerebrovascular accident (p<0.001), previous MI (p=0.002), previous CABG (p=0.003), ejection fraction (p<0.001), higher baseline creatinine (p<0.001), in treatment with nitrates (p<0.001), calcium antagonists (p<0.001), diuretics (p<0.001), Ace inhibitors (ACE-I) (p=0.006), Clopidogrel (p=0.05), haemoglobin (p=0.001), white blood cells (WBC) count (p=0.008), total cholesterol (p=0.04), Low-Density Lipoproteins (LDL) (p=0.01). A significant relationship was found between Hcy levels and the extent of coronary artery disease (71.8% vs 77.8% vs 77.4%, OR[95%CI]=1.18[1.11-1.252.], p<0.001 and severe CAD (23.6% vs 29.5% vs 32.1%, OR [95%CI]=1.275 [1.209-1.344], p<0.001). Elevated Hcy was significantly associated with increased risk of CAD (adjusted OR[95%CI]=1.087[1.009-1.171], p=0.02 and severe CAD (adjusted OR [95%CI]=1.07 [1.01-1.16, P=0.04]). The results were confirmed in the majority of high risk subsets of patients.

CONCLUSIONS

This study showed that high levels of plasmatic Hcy are independently associated with CAD. Further large studies are certainly needed to explore the adjunctive benefits from vitamin administration in patients with elevated Hcy to prevent the occurrence and progression of CAD.

Elevated Homocysteine and the Risk of Contrast-Induced Nephropathy

Contrast-induced nephropathy (CIN) is a common complication in patients with impaired kidney function undergoing coronary angiography/angioplasty. We evaluated whether elevated homocysteine (known to be associated with free radical generation and oxidative stress) increases the risk of CIN. Patients (n = 876) with creatinine clearance <60 mL/min undergoing coronary angiography or percutaneous coronary intervention (PCI) were divided into tertiles of homocysteine levels. Contrast-induced nephropathy was defined as ≥0.5 mg/dL or ≥25% creatinine increase 24 to 48 hours post-PCI. A significant relationship was observed between homocysteine levels and the risk of CIN ( P = .033), confirmed after correction for baseline confounding factors, adjusted odds ratio, OR (95% confidence interval, [CI]) = 1.68 (1.09-2.59), P = .019. This association was also significant applying the new definition of contrast-induced acute kidney injury (11.9% in group 1, 10.4% in group 2, and 22.8% in group 3; P < .001), adjusted OR (95% CI) = 1.96 (1.3-2.95), P = .001. Future studies are needed to confirm our findings and to define the role of homocysteine in CIN.

Implementation of a physician-staffed helicopter: impact on time to primary PCI

AIMS

This study aimed to compare air (AIR) and ground transport (GRD) of STEMI patients bound for primary percutaneous coronary intervention (pPCI).

METHODS AND RESULTS

This was a prospective, controlled, observational study, including patients in whom STEMI was suspected outside a 30-minute driving distance from the PCI centre. AIR patients in a 12-month period (May 1, 2010, to April 30, 2011) were compared with GRD patients in a 16-month period (January 1, 2010, to April 30, 2011). The primary endpoint was time from ECG consistent with STEMI to arrival in the cardiac catheterisation laboratory. We included 450 patients, 114 AIR and 336 GRD patients. The median (5-95% range) transport distance was 97 (62-162) vs. 94 (64-172) kilometres, respectively (p=0.01). Time from ECG to cardiac catheterisation laboratory arrival was significantly lower in the AIR group (median 84 minutes (60-160) vs.104 minutes [63-225], p<0.01). Time from ECG to balloon was 114 (78-221) minutes vs.132 (84-262) (p<0.01), respectively. The 30-day mortality was 2.2% (2/91) for AIR and 6.9% (18/262) for GRD patients (p=0.10). One-year mortality was 6.7%, (6/90) vs. 9.9% (26/262) (p=0.35), respectively.

CONCLUSIONS

Air transport seemed superior to ground transportation in reducing time from ECG diagnosis to arrival in the catheterisation laboratory for STEMI patients outside a 30-minute driving distance to the PCI centre.

Uric acid and risk of periprocedural myocardial infarction in patients undergoing percutaneous coronary intervention

BACKGROUND

Periprocedural myocardial infarction still occurs in patients undergoing percutaneous coronary intervention. However, very little is known about the role of biomarkers possibly predicting this complication. Serum uric acid has been associated with enhanced inflammatory status, higher thrombotic risk and poorer outcome after percutaneous coronary intervention. We therefore, evaluated the association between uric acid levels and periprocedural myocardial infarction in patients undergoing percutaneous coronary intervention.

METHODS

We evaluated 1272 consecutive patients undergoing percutaneous coronary intervention. We measured myonecrosis biomarkers at intervals from 8 to 48 h after percutaneous coronary intervention. Periprocedural myonecrosis was defined as a troponin I increase by 3 times the upper limit normal (ULN) or by 50% of an elevated baseline value and periprocedural myocardial infarction as creatine kinase-Myocardial Band increase by 3 times the ULN or 50% of baseline.

RESULTS

Patients were divided according to tertile values of uric acid (< 5.40, ≥ 6.70 mg/dL). Serum uric acid was related to age, male gender, hypertension, smoking, renal failure (p < 0.001), previous coronary artery bypass grafts (p = 0.05), therapy with ACE inhibitors (p = 0.001) and diuretics (p < 0.001), glycaemia (p = 0.001), creatinine (p < 0.001), haemoglobin (p = 0.002) and white blood cells (p = 0.02). Serum uric acid was inversely related to type C lesions (p = 0.03) and coronary thrombus (p = 0.02). SUA did not affect the risk of periprocedural myocardial infarction (p = 0.29; adjusted odds ratio = 1.11[0.93-1.32], p = 0.26) or periprocedural myonecrosis (p = 0.97; adjusted odds ratio = 0.99[0.86-1.14], p = 0.89). Results were confirmed at subgroup analyses of higher-risk subsets of patients.

CONCLUSION

This is the first large study showing that serum uric acid is not associated with an increase in the risk of periprocedural myocardial infarction in patients undergoing percutaneous coronary revascularization.

Impact of diabetes on uric acid and its relationship with the extent of coronary artery disease and platelet aggregation: a single-centre cohort study

BACKGROUND

Serum uric acid (SUA) elevation has been associated with the main determinants of atherosclerosis and metabolic syndrome, although an independent relationship between SUA and coronary artery disease (CAD) has never been confirmed. Recent reports suggested a central role of SUA in diabetic patients, possibly being an early marker of impaired glucose metabolism and best predicting the risk of cardiovascular events in these patients. Aim of current study was to evaluate the relationship between diabetes and uric acid and its association with the extent of CAD and platelet aggregation among diabetics.

METHODS

In diabetic patients undergoing coronary angiography, fasting samples were collected for uric acid levels assessment. Coronary disease was defined for at least 1 vessel stenosis>50% as evaluated by QCA.

RESULTS

Diabetes was observed in 1173 out of 3280 (35.7%) diabetes was related to age, hypercholesterolemia, hypertension, BMI, renal failure, previous MI or coronary revascularization (p<0.001, respectively) and smoking (p=0.001). Diabetics were more frequently treated with ACE-inhibitors, ARBs, b-blockers, calcium-antagonists, diuretics, statins (p<0.001, respectively), and ASA (p=0.004). Diabetics displayed higher glycemia and HbA1c (p<0.001), higher creatinine and triglycerides (p<0.001) but lower total and HDL cholesterol (p<0.001) and haemoglobin (p<0.001). No significant difference was found in SUA levels between diabetic and non diabetic patients (p=0.09). In fact, we identified age, renal failure, hypertension, smoking, BMI, use of diuretics, statins, haemoglobin, triglycerides and HDL cholesterol levels as independent predictors of higher levels of uric acid (3rd tertile,≥6.7mg/dl or 0.39mmol/l). Among diabetic patients, no relationship was found between uric acid and the extent of coronary artery disease (p=0.27; adjusted OR [95%CI]=0.93 [0.76-1.1], p=0.48), or severe (LM-trivessel) CAD (P=0.05; adjusted OR [95%CI]=1.01 [0.86-1.18], p=0.94). Furthermore, SUA levels did not influence platelet aggregation.

CONCLUSION

Ageing, BMI, renal failure, hypertension, smoking, use of statins and diuretics, haemoglobin, HDL cholesterol and tryglicerides levels but not diabetes or glycemic control are independent predictors of hyperuricemia. Among diabetic patients, higher SUA is not independently associated with the extent of CAD or with platelet aggregation.

Impact of hypertension on clinical outcome in STEMI patients undergoing primary angioplasty with BMS or DES: insights from the DESERT cooperation

BACKGROUND

Hypertension is a well known risk factor for atherosclerosis. However, data on the prognostic impact of hypertension in patients with ST elevation myocardial infarction (STEMI) are inconsistent and mainly related to studies performed in the thrombolytic era, with very few data in patients undergoing primary angioplasty. Therefore, the aim of the current study was to evaluate the impact hypertension on clinical outcome in STEMI patients undergoing primary PCI with BMS or DES.

METHODS

Our population is represented by 6298 STEMI patients undergoing primary angioplasty included in the DESERT database from 11 randomized trials comparing DES vs BMS for STEMI.

RESULTS

Hypertension was observed in 2764 patients (43.9%), and associated with ageing (p<0.0001), female gender (p<0.001), diabetes (p<0.0001), hypercholesterolemia (p<0.0001), previous MI (p=0.002), previous revascularization (p=0.002), longer time-to-treatment (p<0.001), preprocedural TIMI 3 flow, and with a lower prevalence of smoking (41% vs 53.9%, p<0.001) and anterior MI (42% vs 45.9%, p=0.002). Hypertension was associated with impaired postprocedural TIMI 0-2 flow (Adjusted OR [95% CI]=1.22 [1.01-1.47], p=0.034). At a follow-up of 1,201 ± 440 days, hypertension was associated with higher mortality (adjusted HR [95% CI]=1.24 [1.01-1.54], p=0.048), reinfarction (adjusted HR [95% CI]=1.31 [1.03-1.66], p=0.027), stent thrombosis (adjusted HR [95% CI]=1.29 [0.98-1.71], p=0.068) and TVR (adjusted HR [95% CI]=1.22 [1.04-1.44], p=0.013).

CONCLUSIONS

This study showed that among STEMI patients undergoing primary angioplasty with DES or BMS, hypertension is independently associated with impaired epicardial reperfusion, mortality, reinfarction and TVR, and a trend in higher ST.