Effect of previous treatment with statins on outcome of patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention

The Prognostic impact of treatments evolution in STEMI

OBJECTIVE

To evaluate in a real-world primary percutaneous coronary intervention (pPCI) registry the impact of the evolution of evidence-based treatments on prognosis.

METHODS

STEMI patients undergoing pPCI at the University Hospital of Trieste, Italy, were enrolled. The first cohort (old treatments cohort) included STEMI patients treated between January-2007 and December-2012, and the second cohort (new treatments cohort), between January-2013 and December-2020. Inverse Probability of Treatment Weighting (IPTW) Cox regression models as well as multivariable Cox regression models were performed to assess the risk of a composite primary endpoint (PE) of all cause death, reinfarction and re-PCI at 5 years.

RESULTS

A total of 2425 STEMI patients were enrolled. At multivariable Cox regression, the new-treatments cohort had lower risk of PE and mortality. Weighted (IPTW) Cox proportional hazard models confirmed the lower risk of the new treatments cohort for PE (HR 0.72; 95% CI 0.56-0.91, p = 0.007) and 5-year mortality (HR 0.70, 95%CI 0.54-0.91, p = 0.009). When considering both clinical and procedural variables, complete revascularization (HR 0.46, 95%CI 0.27-0.80, p = 0.006) and the administration of prasugrel or ticagrelor (HR 0.72, 95%CI 0.52-0.99, p = 0.013) were independent predictors of PE as well as of 5-year mortality. Patients receiving prasugrel or ticagrelor or drug eluting stent were at lower risk of 1-year stent thrombosis (HR 0.50, 95%CI 0.28-0.90, p = 0.021).

CONCLUSIONS

In a real-word STEMI population the prognosis of patients has improved in the last decades, and this was associated to the use of new antithrombotic treatments and to the implementation of complete revascularization.

Comparison of the Treatment Efficacy of Rosuvastatin versus Atorvastatin Loading Prior to Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction

The aim of this study was to compare the effect of a single high-dose rosuvastatin versus atorvastatin preloading in ST-elevation myocardial infarction (STEMI) patients receiving primary percutaneous coronary intervention (PCI.) Methods: A total of 99 patients presented with STEMI and were randomly divided into three groups—a control group (n = 33) with no statin treatment, an atorvastatin group (n = 33) with a single 80 mg atorvastatin dose and the rosuvastatin group (n = 33) with a single 40 mg rosuvastatin dose in the emergency room (ER) prior to PCI. Post-interventional thrombolysis in myocardial infarction (TIMI) flow grade and corrected TIMI frame count (CTFC) were recorded, and ST-segment resolution was measured. Results: CTFC was significantly lower for the atorvastatin group (p-value < 0.01) than in the control group. A final TIMI flow grade 3 was achieved in 32 (97.0%) patients in the rosuvastatin group and 28 (84.8%) patients in the atorvastatin group compared with only 25 (75.8%) patients in the control group (p = 0.014). Peak CK-MB in the rosuvastatin group (263.2 [207.2−315.6]) and the atorvastatin group (208 [151.0−314.1]) was lower compared to that in the control group (398.4 [303.9−459.3]); p < 0.001. Conclusions: A single extensive dose of lipophilic atorvastatin prior to primary PCI in STEMI patients showed better improvement in microvascular myocardial perfusion compared to hydrophilic rosuvastatin.

Is there association between statin usage and contrast-associated acute kidney injury after intravenous administration of iodine-based contrast media in enhanced computed tomography?

OBJECTIVES

Contrast-induced acute kidney injury (CI-AKI) is one of the leading causes of new-onset renal failure in hospitalized patients. Statin has been evaluated for its protective effect against CI-AKI but rarely in patients receiving intravenous (IV) administrations of iodine-based contrast media for enhanced computed tomography (CT).

METHODS

In total, 12,371 patients who underwent contrast-enhanced abdominopelvic CT were retrospectively reviewed and stratified into statin users and statin nonusers. Subgroup analyses comparing high-intensity statins with low- to moderate-intensity statins were conducted within statin users and similar comparisons were performed within statin users stratified based on baseline eGFR.

RESULTS

Overall, CI-AKI events did not occur less in statin users compared with non-statin users (p = 0.342). Within statin users, CI-AKI events did not decrease in high-intensity statin users compared with low- to moderate-intensity statin users (p = 0.355). Moreover, no significant difference in CI-AKI events was found between high-intensity statin users and low- to moderate-intensity statin users even after stratifying the patients with baseline eGFR.

CONCLUSIONS

Collectively, statin was not significantly associated with the risk of CI-AKI events in patients undergoing contrast-enhanced abdominopelvic CT and high-intensity statins did not show significant association with CI-AKI over low- to moderate-intensity statins in the subgroup analysis.

KEY POINTS

• Statin is not associated with risk of CI-AKI events in patients undergoing intravenous administration of contrast-enhanced CT. • CI-AKI incidence among high-intensity statin users was not significantly different from that of low- to moderate-intensity statin users.

Atorvastatin protects against contrast-induced acute kidney injury via upregulation of endogenous hydrogen sulfide

Background

Contrast-induced acute kidney injury (CIAKI) is the third leading cause of acute renal failure in hospitalized patients. This study was aimed to investigate whether atorvastatin could upregulate the expression of hydrogen sulfide (H₂S) and hence protect against CIAKI.

Methods

We treated male rats and NRK-52E cells by iopromide to establish in vivo and in vitro models of CIAKI. Pretreatment with atorvastatin was given in CIAKI rats to investigate its effect on CIAKI. We collected serum and urine samples to detect renal function. We obtained kidney tissue for histological analysis and detection of protein concentration. We tested the serum concentration of H₂S and renal expression of two H₂S synthetases [cystathionine γ-lyase (CSE) and cystathionine-β synthase (CBS)]. NaHS was pretreated in NRK-52E cells to testify its underlying effect on contrast-induced injury.

Results

Atorvastatin significantly ameliorated renal dysfunction and morphological changes in CIAKI rats, as well as inflammation, apoptosis, and excessive oxidative stress. Atorvastatin also markedly increased the serum concentration of H₂S and renal expression of CSE and CBS. Moreover, pretreatment with NaHS in NRK-52E cells considerably attenuated contrast-induced cell death and inflammation.

Conclusion

Atorvastatin protects against CIAKI via upregulation of endogenous hydrogen sulfide.

Reduction of No Reflow with a Loading Dose of Atorvastatin before Primary Angioplasty in Patients with Acute ST Myocardial Infarction

BACKGROUND

No reflow defined as an altered myocardial reperfusion and failure at microvascular level is a frequent complication in acute myocardial infarction that attenuates beneficial effect of reperfusion therapy leading to poor outcomes. There is not enough evidence to support that previous use of statins improves coronary flow in patients undergoing primary percutaneous coronary intervention (PCI).

AIM OF STUDY

To determine if a loading dose of 80 mg of atorvastatin before primary angioplasty reduces the frequency of no reflow, hs-CRP, IL6 intracoronary levels, and major combined cardiovascular events at 30 d.

METHODS

In this controlled clinical trial, we randomly assigned 103 adult patients within the 12 h of acute ST-elevation myocardial infarction (STEMI) to receive 80 mg of atorvastatin additional to standard treatment (AST) before performing primary PCI versus standard treatment (ST) alone. The primary outcomes were the occurrence of no reflow and high sensitivity C-reactive protein (hs-CRP) and interleukin 6 levels and secondary outcomes were major adverse cardiovascular events at 30 d.

RESULTS

103 patients were analyzed, 49 (48%) received AST, 54 (52%) ST. Frequency of no reflow among groups was 27 vs. 63% respectively, p ≤0.0001. hs-CRP level was 2.69 mg/dL for AST vs. 2.2 mg/dL in ST, meanwhile IL-6 levels were 5.2 pg/mL vs. 6.35 pg/mL respectively, p = ns. Cox regression model demonstrated that the treatment assigned is an independent predictor for no reflow occurrence (HR 0.34 95%, CI 0.18-0.61, p ≤0.001).

CONCLUSION

The administration of a loading dose of 80 mg atorvastatin before primary PCI is an effective strategy for prevention of no reflow improving also clinical outcomes and free survival rate for the presentation of major adverse cardiovascular events at 30 d.

Serial assessment of endothelial function 1, 6, and 12 months after ST-elevation myocardial infarction

Knowledge about the changes in endothelial function after ST-elevation myocardial infarction (STEMI) is of substantial interest, but serial data are scarce. The aim of the present study was to noninvasively evaluate whether endothelial function, as assessed shortly after primary percutaneous coronary intervention (PPCI) for STEMI, may improve until 12-month follow-up. This prospective observational cohort study was performed in patients in the RESPONSE randomized trial who participated in a substudy and underwent noninvasive assessment of endothelial function at 1 (baseline), 6, and 12-month follow-up after treatment of a STEMI by PPCI. The reactive hyperemia peripheral artery tonometry (RH-PAT) method was used to assess endothelial function (higher RH-PAT index signifies better function). Of the 70 study participants, who were 57.4 ± 9.7 years of age, 55 (78.6%) were male and 9 (13%) had diabetes. The endothelial function deteriorated significantly during follow-up: the RH-PAT index at baseline, 6, and 12-month follow-up was 1.90 ± 0.58, 1.81 ± 0.57, and 1.69 ± 0.49, respectively (p = 0.04). Although patients were carefully treated in outpatient clinics and adequate pharmacological therapy was prescribed, we noted an increase in total cholesterol (p = 0.001), LDL cholesterol (p = 0.002), HbA1C (p = 0.054), and diastolic blood pressure (p = 0.047) However, multivariate analysis revealed that this increase in cardiovascular risk factors could not explain the observed deterioration in endothelial function. In patients with STEMI, we observed a significant deterioration in endothelial function during 12 months after PPCI that could not be explained by changes in the traditional cardiovascular risk profile.

High Plasma Exposure of Statins Associated With Increased Risk of Contrast-Induced Acute Kidney Injury in Chinese Patients With Coronary Artery Disease

The role of statins in reducing the incidence of contrast-induced acute kidney injury (CI-AKI) remains controversial. We sought to evaluate the association between CI-AKI and high plasma exposure of statins in coronary artery disease (CAD) patients undergoing coronary angiography (CAG). This association was first evaluated in 1,219 patients with CAD receiving atorvastatin (AT) therapy and validated in 635 patients receiving rosuvastatin (RST) therapy. The plasma concentrations of statins were quantified using validated UPLC-MS/MS methods and CI-AKI incidence was assessed during the first 48 h postoperatively. Among all participants (n = 1,854), AKI occurred in 57 of 1219 (4.7%) in the AT cohort and 30 of 635 (4.7%) in the RST cohort. High plasma AT-all exposure was associated with increased risk of CI-AKI (odds ratio [OR]: 2.265; 95% confidence interval [CI]: 1.609–3.187; p < 0.0001). Plasma AT-all concentration in the CI-AKI group (22.40 ± 24.63 ng/mL) was 2.6-fold higher than that in the control group (8.60 ± 9.65 ng/mL). High plasma RST exposure also significantly increased the risk of CI-AKI (OR: 2.281; 95% CI: 1.441–3.612; p = 0.0004). We further divided patients into two subgroups for each statin according to baseline renal function, and association between high plasma statin exposure and CI-AKI still remained highly significant in both subgroups. This study suggests for the first time that high plasma exposure of statins may significantly increase the risk of CI-AKI. Statins should be used with greater caution in CAD patients undergoing CAG to reduce the occurrence of CI-AKI.

Long-term statin use before primary percutaneous coronary intervention improves treatment outcomes of acute myocardial infarction

Numerous studies have reported that high-dose statin loading therapy prior to primary percutaneous coronary intervention (PPCI) improves the clinical outcomes of patients following acute myocardial infarction (AMI). However, little is known about the effects of long-term statin use prior to PPCI on such outcomes. Therefore, the aim of the present analysis was to clarify the effects of long-term statin use before PPCI on the treatment outcomes of patients following AMI. The records of 213 patients who had AMI and met the inclusion criteria were retrospectively reviewed. Patients were divided into two groups: A control group (n=178) who had received no statin pretreatment before AMI onset, and a statin group (n=35) who had received statin treatment for ≥1 month before AMI onset. All patients received a standard treatment regimen for the secondary prevention of coronary artery disease after PPCI. Baseline clinical variables, details of the PPCI procedure and clinical outcomes within 3 months after treatment were reviewed. Patients in the statin group were significantly older than those in the control group (P=0.003). Compared with the control group, there was a greater proportion of patients with hyperlipidemia and previous angina pectoris in the statin group. There were no differences in the use of other drugs (aspirin, β-blockers and angiotensin-converting enzyme inhibitors) prior to PPCI between the two groups. The corrected TIMI frame count (cTFC) was significantly lower in the statin group than in the control group (24.1±12.8 vs. 29.4±14.3, respectively; P=0.043). Multivariable linear regression analysis showed that long-term statin use before AMI was a significant predictor of cTFC after PPCI (P=0.012). Furthermore, the incidence of major adverse cardiac events within 3 months after PPCI was higher in the control group than in the statin group (16.8 vs. 2.9%, respectively; P=0.032). Logistic regression analysis showed that previous statin use was associated with the incidence of major adverse cardiac events within 3 months after treatment (P=0.012). The results of the present study demonstrate that long-term statin use prior to PPCI improved treatment outcomes after AMI in actual clinical practice.

3-Hydroxy-3-methylglutaryl-CoA reductase enzyme inhibitors for prevention of contrast-induced nephropathy: a meta-analysis of prospective randomized controlled studies

Contrast-induced nephropathy (CIN) is a possible complication of interventional procedures that require administration of an iodinated contrast. Previous observational and small prospective randomized trials suggested that 3-hydroxy-3-methylglutaryl-CoA reductase enzyme inhibitors may reduce the incidence of CIN. We performed a meta-analysis of the effect of statins on CIN including prospective randomized, controlled trials of statin therapy. We conducted an EMBASE and MEDLINE search for studies in which patients were randomized to treatment with a statin plus standard treatment (or placebo) versus standard treatment (or placebo). We included studies that provided data on creatinine clearance, and incidence of CIN before the initiation of the treatment and at the end of the follow-up period. We identified 9 prospective randomized studies of high-dose statin treatment compared with placebo treatment for CIN prevention with 2504 controls and 2480 patients that received statins. A significant reduction in CIN was observed when pharmacologic intervention with statins was used (odds ratio, 0.45; 95% confidence interval, 0.34-0.58; P < 0.0001). In this meta-analysis of prospective controlled studies, we found a statistically significant reduction of CIN incidence in patients pretreated with high-dose statins before the procedure.

Statins and myocardial infarction: Type, dose, and administration time: Does it matter?

Patients with ST-elevation myocardial infarction (STEMI) constitute a vulnerable group that demands the careful assessment and application of all the up-to-date clinical and experimental knowledge, with final aim, the improvement of their prognosis. Statins are an indispensable part of the primary and secondary prevention of coronary artery disease (CAD), not only due to their strong hypolipidemic effect, but also due to their numerous pleiotropic properties that play an important role in the treatment of CAD, especially when the more vulnerable group of STEMI patients is addressed. Nevertheless, there are still issues that require further discussion and clarification, such as the type of statin, the dose of the regimen, the administration time, and the treatment duration.

Myocardial Infarct Size in Patients on Long-Term Statin Therapy Undergoing Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

Statin pretreatment has been reported to have a cardioprotective effect in patients undergoing elective or urgent percutaneous coronary intervention (PCI). However, data on patients with ST-elevation myocardial infarction (STEMI) undergoing primary PCI are still controversial. We prospectively evaluated the effect of long-term statin therapy on infarct size (IS), myocardial salvage index (MSI), and microvascular obstruction (MVO) in consecutive patients with STEMI who underwent primary PCI. Two-hundred thirty patients with STEMI (mean age 61 ± 11 years, 183 men) who underwent primary PCI were evaluated with cardiac magnetic resonance (CMR) imaging during hospitalization (median 4 days after primary PCI). In all patients, we measured peak troponin I level, whereas IS, MSI, and MVO were determined by CMR. Fifty patients (22%) were on long-term statin therapy and showed a significantly lower troponin I peak value compared to patients without previous statins (54 ± 47 vs 88 ± 106 ng/ml; p = 0.02). At CMR evaluation, IS related to the index event was significantly smaller (12.5 ± 11.5 vs 18.5 ± 18.5 g, p = 0.05), and MSI was higher (0.68 ± 0.25 vs 0.52 ± 0.30; p <0.01) in patients with previous statin therapy. MVO was also less frequent (10% vs 20%; p = 0.14) in this group. At multivariate analysis, previous statin therapy remained significantly associated with IS and MSI (p = 0.05 and 0.02, respectively). In conclusion, this study suggests that long-term statin therapy before primary PCI in patients with STEMI is associated with smaller IS and higher MSI. Future studies are warranted to confirm these findings and to investigate potential clinical implications.

Study of the possible medical and medication explanatory factors of angiographic outcomes in patients with acute ST elevation myocardial infarction undergoing primary percutaneous intervention

Background:

Myocardial blush grade (MBG), thrombolysis in myocardial infarction (TIMI) and corrected TIMI frame count (cTFC) are indices of successful angiographic reperfusion. This study sought to determine the predictors of angiographically successful reperfusion including demographic, clinical and angiographic factors in patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI).

Materials and Methods:

A cross-sectional study of patients with a confirmed diagnosis of STEMI undergoing pPCI was designed. Eligible patients referring to a university heart center were enrolled in the study from March 2012 to December 2012. Successful epicardial reperfusion was defned as TIMI flow grade 3 or cTFC<= 28 frames and successful myocardial reperfusion as MBG 2 or 3.

Results:

The study population consisted of 100 patients, including 74 males and 26 females, with mean ± standard deviation age of 58.27 ± 11.60 years. Achieving open microvasculature (MBG 2/3) was positively associated with a history of nitrate intake (P = 0.03) and history of calcium channel blocker (CCB) intake (P = 0.005). Hyperglycemia was inversely associated with achieving a final cTFC ≤ 28 frames (r = −0.32, P = 0.001).

Conclusions:

Our findings suggest that patients with a history of nitrate and CCB intake had a higher likelihood of successful PCI. In addition, patients with a higher blood glucose level on admission may have a reduced rate of reperfusion success. Future studies with a larger sample size are recommended to investigate the significant relationships observed in this study.

Impact of long-term statin pretreatment on myocardial damage in ST elevation myocardial infarction (from the AIDA STEMI CMR Substudy)

Nonrandomized studies suggested lower mortality rates with statin pretreatment in patients with acute ST elevation myocardial infarction (STEMI). However, clinical data are still inconclusive and the mechanisms of these presumed beneficial effects require further exploration. Cardiac magnetic resonance (CMR) imaging offers the possibility of studying a variety of markers of myocardial damage and reperfusion injury after myocardial infarction. The aim of this study was to assess a possible link of statin pretreatment with myocardial damage in acute STEMI. The multicenter Abciximab i.v. versus i.c. in ST-elevation Myocardial Infarction CMR substudy enrolled 795 consecutive patients with acute STEMI who underwent primary angioplasty within 12 hours of symptom onset. CMR studies assessing left ventricular ejection fraction, infarct size, microvascular obstruction, area at risk, and myocardial salvage index were performed in a median of 3 days after the clinical event. We performed a retrospective analysis to evaluate the impact of statin pretreatment on myocardial damage. Information on statin pretreatment was available in 791 of 795 patients (99%). Of these, 122 (15%) had long-term statin pretreatment. CMR results showed no significant differences in the area at risk, left ventricular ejection fraction, infarct size, microvascular obstruction, and myocardial salvage index between patients with and without statin pretreatment. Furthermore, no differences in short- and long-term outcomes could be observed. In conclusion, in this CMR study, statin pretreatment in patients with STEMI was not associated with lesser myocardial damage.

Update on the efficacy of statin treatment in acute coronary syndromes

BACKGROUND

The natural history of atherosclerosis might involve coronary plaque rupture/erosion, thrombus formation and vessel lumen occlusion, clinically recognized as acute coronary syndrome (ACS). International guidelines strongly recommend early statin administration in patients admitted for ACS. In addition to lowering circulating levels of low-density lipoprotein cholesterol (LDL-c), statin treatment was shown to promote plaque stabilization or regression in several ways, including reduction in necrotic lipid core, anti-inflammatory effects and improvement in endothelial function. The aim of this review is to summarize clinical evidence on the role of statins in secondary prevention of ACS.

MATERIALS AND METHODS

This narrative review is based on the material found on medline and pubmed up to August 2013. We looked for the terms 'statin, acute coronary syndromes' in combination with 'atherosclerosis, acute myocardial infarction, pathophysiology'.

RESULTS

This review article emphasizes the relevance of the timing of statin administration to improve the outcomes after ACS. Early and continuous statin administration has emerged as key features to prevent adverse events, especially in patients admitted for ACS undergoing percutaneous coronary intervention. Clinical trials matching the improved clinical outcome with the imaging of atherosclerotic plaque stabilization/regression, further supporting the effectiveness of statin therapy. However, the achievement of these goals requires high dose of statins, thus increasing the risk of adverse events.

CONCLUSIONS

Although clinical trials and meta-analyses have provided conflicting results, it is likely that in clinical practice, the rate of adverse events is higher, so that many concerns still remain about a statin high-dose approach in ACS patients.

Effect of High Dose Rosuvastatin Loading before Primary Percutaneous Coronary Intervention on Infarct Size in Patients with ST-Segment Elevation Myocardial Infarction

Background and Objectives

High dose rosuvastatin loading before percutaneous coronary interventions (PCI) reduces the myocardial damage and the incidence of adverse cardiac events in patients with stable angina and acute coronary syndrome. However, no studies are present yet about rosuvastatin loading in patients with ST-segment elevation myocardial infarction (STEMI) in a primary PCI setting.

Subjects and Methods

A total of 475 patients who underwent primary PCI for STEMI were studied. The study population was divided into two groups with 208 patients in the statin group=40 mg rosuvastatin loading before primary PCI and 267 patients in the control group=no statin pretreatment. At median 3 days after PCI a single-photon emission computed tomography (SPECT) was performed with technetium 99m tetrofosmin For this study were compared infarct size, corrected Thrombolysis in Myocardial Infarction (TIMI) frame count and the myocardial blush grade (MBG) between the both groups.

Results

Baseline clinical and procedural characteristics were similar between the groups. Infarct size, as assessed by SPECT, was significantly smaller (19.0±15.9% vs. 22.9±16.5%, p=0.009) in the statin group than in the control group. Patients of the statin group showed a lower corrected TIMI frame count (28.2±19.3 vs. 32.6±21.4, p=0.020), and higher MBG (2.49±0.76 vs. 2.23±0.96, p=0.001) than the patients of the control group. The multivariate analysis revealed that rosuvastatin loading {odds ratio (OR) 0.61}, pain to balloon time (OR 2.05), anterior myocardial infarction (OR 3.89) and final the MBG (OR 2.93) were independent predictors of a large infarct size.

Conclusion

A high dose rosuvastatin loading before the primary PCI reduced the infarct size by microvascular myocardial perfusion improvement.

Effect of rosuvastatin therapy on troponin I release following percutaneous coronary intervention in nonemergency patients (from the TIP 3 study)

Several randomized studies have suggested that pretreatment with statins may reduce a periprocedural biomarker release in patients who underwent percutaneous coronary intervention (PCI); however, results remain controversial. The purpose of this study was to investigate the effect of a 1-day rosuvastatin therapy on troponin I release in patients who underwent nonemergency PCI. A total of 445 patients with angina pectoris were randomly assigned to therapy with rosuvastatin (20 mg 12 hours before coronary angiography + 20 mg immediately before PCI; rosuvastatin group, 220 patients) or PCI without statin therapy (control group, 225 patients). In patients taking statins (73%), rosuvastatin was added to their long-term statin therapy. The primary end point was the incidence of TnI microleak defined as TnI elevation >1.5× upper limit of normal, and the secondary end point was the incidence of post-PCI TnI elevation >3× upper limit of normal. The incidence of primary and secondary end point in the rosuvastatin versus control group was 13.6% versus 12% (p = 0.61) and 8.2% versus 7.1% (p = 0.67), respectively. Patients with C-reactive protein ≥2.0 mg/L had a decreased release of post-PCI TnI in the rosuvastatin group (0.032 [0.010 to 0.143] μg/L vs 0.056 [0.018 to 0.241] μg/L; p = 0.04). In conclusion, 1-day rosuvastatin therapy (20 mg twice a day) did not influence post-PCI TnI release in patients with angina. However, these results suggest that, in patients with an advanced inflammatory status, rosuvastatin loading therapy might have a cardioprotective effect.

Effects of atorvastatin loading prior to primary percutaneous coronary intervention on endothelial function and inflammatory factors in patients with ST-segment elevation myocardial infarction

Previous studies have demonstrated the beneficial effect of statin loading prior to elective and early percutaneous coronary intervention (PCI), in which the 'pleiotropic effects' of statins may contribute to these clinical benefits. The aim of the present study was to examine the potential effects of atorvastatin loading prior to primary PCI on coronary endothelial function and inflammatory factors in patients with acute ST-segment elevation myocardial infarction (STEMI). A total of 60 patients with STEMI were randomized into three groups: Loading dose (80 mg atorvastatin prior to PCI; n=20), regular dose (20 mg atorvastatin prior to PCI; n=20) and control (without atorvastatin prior to PCI; n=20). The plasma samples were collected prior to, and immediately, 6 and 24 h after PCI in all the patients. The plasma concentrations of endothelial nitric oxide synthase (eNOS), nitric oxide (NO), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α) and intercellular adhesion molecule-1 (ICAM-1) were examined using ELISA. The plasma eNOS levels immediately and 24 h after PCI were significantly higher in the regular dose group compared with the other groups. However, there were no significant differences in the plasma eNOS concentration prior to and 6 h after PCI, or in the plasma NO concentration at any of the time-points among the three groups. The plasma IL-6 levels prior to PCI were significantly lower in the loading dose group compared with the other groups; however, there were no significant differences in the plasma concentration of IL-6 following PCI or in the concentrations of TNF-α and ICAM-1 at any of the time-points among the three groups. In conclusion, atorvastatin loading in patients with STEMI undergoing primary PCI may not have protective effects on endothelial function and the inflammatory reaction.

Lower admission hemoglobin levels are associated with longer symptom duration in acute ST-elevation myocardial infarction

BACKGROUND

An acute-phase response in patients with acute myocardial infarction could contribute to the development of anemia.

HYPOTHESIS

An association may exist between symptom duration, hemoglobin (Hb) concentration and serum C-reactive protein (CRP) values in patients presenting to an emergency department (ED) with acute ST-segment elevation myocardial infarction (STEMI).

METHODS

A retrospective analysis was conducted on consecutive male STEMI patients who were admitted to our medical center's ED from January 2008 to November 2012 and had presented within the first 12 hours after the onset of chest pain. Hemoglobin concentration and serum CRP levels were determined from blood samples taken prior to any drug or fluid administration. Analyses of variance were used to determine interactions between selected time-to-presentation cutoffs and admission Hb and CRP concentrations. Patients with other reasons known to cause elevation of inflammatory markers, anemia, or bleeding diathesis were excluded.

RESULTS

The study population comprised 718 patients whose mean age was 61 ± 12 years (range, 27-96 years). Blood was drawn for Hb and CRP measurements directly upon admission. Patients who presented to the ED within 3 hours of symptom onset had higher Hb concentrations (P = 0.048) and lower serum CRP levels (P < 0.001) compared with those who presented after a longer interval from symptom onset.

CONCLUSIONS

Longer symptom duration is associated with a lower admission Hb level and an early rise in the CRP level of male patients with acute STEMI.

Effect of statin pretreatment on myocardial perfusion in patients undergoing primary percutaneous coronary intervention: a systematic review and meta-analysis

BACKGROUND

To achieve sufficient myocardial perfusion in ST-segment elevation myocardial infarction (STEMI) patients receiving primary percutaneous coronary intervention (PPCI), many adjunctive therapies have been proposed. Previous trials have reported variances in myocardial perfusion improvement for statin pretreatment, which made it inconvincible to confirm the beneficial effects of statins. Therefore, we performed a systematic review and meta-analysis to determine whether statin pretreatment was effective in improving myocardial perfusion.

HYPOTHESIS

Statin pretreatment could improve myocardial perfusion in STEMI patients undergoing PPCI.

METHODS

We searched the PubMed, Web of Knowledge, and the Cochrane Library databases for studies evaluating the impact of statin pretreatment on myocardial perfusion in STEMI patients receiving PPCI.

RESULTS

Twelve trials were finally included in our meta-analysis. There were no significant differences in patients' baseline characteristics between the statin pretreatment and control groups. Overall pooled analysis showed that patients in the statin pretreatment groups had significantly better epicardial coronary blood flow (measured by Thrombosis in Myocardial Infarction [TIMI] grade, odds ratio [OR]: 0.49, 95% confidence interval [CI]: 0.28 to 0.84; measured by corrected TIMI frame count, mean difference: -5.63; 95% CI: -9.66 to -1.6). A trend toward myocardial tissue level perfusion improvement was seen in the statin pretreatment arm rather than the control arm (measured by myocardial blush grade, OR: 0.74; 95% CI: 0.50 to 1.09).

CONCLUSIONS

This present meta-analysis suggests that statin pretreatment might be effective in improving myocardial perfusion in STEMI patients.

Impact of a high loading dose of atorvastatin on contrast-induced acute kidney injury

BACKGROUND

The role of statins in the prevention of contrast-induced acute kidney injury (CIAKI) is controversial.

METHODS AND RESULTS

First, we investigated the in vivo effects of atorvastatin on CIAKI. Patients with chronic kidney disease enrolled in the Novel Approaches for Preventing or Limiting Events (NAPLES) II trial were randomly assigned to (1) the atorvastatin group (80 mg within 24 hours before contrast media [CM] exposure; n=202) or (2) the control group (n=208). All patients received a high dose of N-acetylcysteine and sodium bicarbonate solution. Second, we investigated the in vitro effects of atorvastatin pretreatment on CM-mediated modifications of intracellular pathways leading to apoptosis or survival in renal tubular cells. CIAKI (ie, an increase >10% of serum cystatin C concentration within 24 hours after CM exposure) occurred in 9 of 202 patients in the atorvastatin group (4.5%) and in 37 of 208 patients in the control group (17.8%) (P=0.005; odds ratio=0.22; 95% confidence interval, 0.07-0.69). CIAKI rate was lower in the atorvastatin group in both diabetics and nondiabetics and in patients with moderate chronic kidney disease (estimated glomerular filtration rate, 31-60 mL/min per 1.73 m(2)). In the in vitro model, pretreatment with atorvastatin (1) prevented CM-induced renal cell apoptosis by reducing stress kinases activation and (2) restored the survival signals (mediated by Akt and ERK pathways).

CONCLUSIONS

A single high loading dose of atorvastatin administered within 24 hours before CM exposure is effective in reducing the rate of CIAKI. This beneficial effect is observed only in patients at low to medium risk.

Rosuvastatin pretreatment in patients undergoing elective PCI to reduce the incidence of myocardial periprocedural necrosis: the ROMA trial

OBJECTIVES

The aim of this study is to assess the efficacy of the high-dose rosuvastatin preadministration in reducing periprocedural myocardial necrosis and major adverse cardiovascular and cerebrovascular events (MACCE) in patients undergoing elective percutaneous coronary intervention (PCI).

BACKGROUND

Elective PCI may be complicated with an elevation of cardiac biomarkers. Several studies suggested that pretreatment with statins may be associated with a reduction in periprocedural myocardial necrosis.

METHODS

One hundred and sixty patients with stable angina who underwent elective PCI were randomly assigned to receive either a preprocedural loading dose (40 mg) of rosuvastatin group (RG, n = 80) or a standard treatment [control group (CG), n = 80].The primary endpoint was the incidence of periprocedural myocardial necrosis. The secondary endpoint was the assessment of MACCE [cardiac death, all-myocardial infarction (MI), stroke, and target vessel revascularization (TVR)] at a 30-day and 12-month follow-up, as well as the rate of periprocedural rise of Troponin T-serum levels >3× upper limit of normal.

RESULTS

Twelve and 24-hr post-PCI creatinine kinase MB isoform elevation >3× occurred more frequently in the CG than in the RG (22.7 vs. 7.1; P = 0.034 and 26.4 vs. 8.7; P = 0.003). At the 30-day and 12-month follow-up, the incidence of cumulative MACCE was higher in CG than in the RG (30.0% vs. 8.7%; P = 0.001 and 35.0% vs. 12.5%; P = 0.001).The difference between the groups was mainly due to the periprocedural MI incidence (26.4% vs. 8.7%; P = 0.003).The rate of cardiac death, spontaneous MI, TVR, and stroke were similar in the two groups.

CONCLUSIONS

High loading dose of rosuvastatin within 24 hr before elective PCI seems to decrease the incidence of periprocedural myocardial necrosis during a period of 12-months compared to the standard treatment.

Effect of statins therapy prior to percutaneous coronary intervention

BACKGROUND

Many previous studies have demonstrated that statins pre-treatment before percutaneous coronary intervention (PCI) reduced myocardial infarction (MI) in statin-naive patients with both stable angina and acute coronary syndrome. However, clinical benefit of statins is controversial as some studies have shown different results.

METHODS

A search of MEDLINE, EMBASE using the term statins AND PCI, statins AND percutaneous coronary intervention. The review was limited to articles published in English between January 1990 and July 2011.

RESULTS

Most trials noted that statins pretreatment before PCI in patients are associated with risk reduction of periprocedural myocardial infarction (PMI) and major adverse cardiovascular events (MACE). The mechanisms underlying this protective action of statins possibly attribute to the pleiotropic effects. However, controversial results were also reported in some trials that early use of statins before PCI did not influence occurrence of PMI or long-term clinical outcomes.

CONCLUSION

Statins therapy among PCI patients seems to be associated with a significant mortality advantage at early and long-term follow-up. However, currently early statins use before intervention still cannot serve as a routine strategy of treatment. Further large-scale randomized studies are critically required to demonstrate the importance of early treatment with statins in pre-PCI.

Effects of atorvastatin pretreatment on infarct size in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND

Atorvastatin pretreatment has been reported to reduce myocardial damage in patients undergoing percutaneous coronary intervention (PCI). We sought to investigate the effect of atorvastatin pretreatment on infarct size in patients with ST-segment elevation myocardial infarction (STEMI).

METHODS

Patients undergoing primary PCI for ST-segment elevation myocardial infarction within 12 hours after symptom onset were randomized to an atorvastatin group (80 mg before PCI and for 5 days after PCI [n = 89]) or a control group (10 mg daily after PCI [n = 84]). The primary end point was infarct size measured by technetium Tc 99m tetrofosmin single-photon emission computed tomography between days 5 and 14.

RESULTS

Baseline clinical, angiographic, and procedural characteristics were not significantly different between groups except for age and current smoking status. There was no significant difference in infarct size (as a percentage of the left ventricle) between groups (22.2% ± 15.5% in the atorvastatin group vs 21.6% ± 15.4% in the control group, P = .79). The median infarct size was 19.0% (interquartile range 9.0-32.0) in the atorvastatin group and 18.0% (9.3-32.5) in the control group (P = .76). Achievement of myocardial blush grade 2/3 and complete ST-segment resolution at 60 minutes after PCI occurred with similar frequency (72.8% vs 81.9%, P = .33 and 43.2% vs 47.5%, P = .57, respectively).

CONCLUSIONS

Pretreatment with high-dose atorvastatin followed by further treatment for 5 days did not reduce infarct size measured by single-photon emission computed tomography in patients undergoing primary PCI.

Efficacy of high-dose atorvastatin loading before primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: the STATIN STEMI trial

OBJECTIVES

This study sought to determine the efficacy of high-dose atorvastatin in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

BACKGROUND

Previous randomized trials have demonstrated that statin pre-treatment reduced major adverse cardiac events (MACEs) in patients with stable angina pectoris and acute coronary syndrome. However, no randomized studies have been carried out with STEMI patients in a primary PCI setting.

METHODS

A total 171 patients with STEMI were randomized to 80-mg atorvastatin (n = 86) or 10-mg atorvastatin (n = 85) arms for pre-treatment before PCI. All patients were prescribed clopidogrel (600 mg) before PCI. After PCI, both groups were treated with atorvastatin (10 mg). The primary end point was 30-day incidence of MACE including death, nonfatal MI, and target vessel revascularization. Secondary end points included corrected thrombolysis in myocardial infarction frame count, myocardial blush grade, and ST-segment resolution at 90 min after PCI.

RESULTS

MACE occurred in 5 (5.8%) and 9 (10.6%) patients in the 80-mg and 10-mg atorvastatin pre-treatment arms, respectively (p = 0.26). Corrected thrombolysis in myocardial infarction frame count was lower in the 80-mg atorvastatin arm (26.9 +/- 12.3 vs. 34.1 +/- 19.0, p = 0.01). Myocardial blush grade and ST-segment resolution were also higher in the 80-mg atorvastatin arm (2.2 +/- 0.8 vs. 1.9 +/- 0.8, p = 0.02 and 61.8 +/- 26.2 vs. 50.6 +/- 25.8%, p = 0.01).

CONCLUSIONS

High-dose atorvastatin pre-treatment before PCI did not show a significant reduction of MACEs compared with low-dose atorvastatin but did show improved immediate coronary flow after primary PCI. High-dose atorvastatin may produce an optimal result for STEMI patients undergoing PCI by improving microvascular myocardial perfusion. (Efficacy of High-Dose AtorvaSTATIN Loading Before Primary Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction [STATIN STEMI]; NCT00808717).

Coronary microembolization: from bedside to bench and back to bedside

Coronary microembolization from the erosion or rupture of a vulnerable atherosclerotic plaque occurs spontaneously in acute coronary syndromes and iatrogenically during percutaneous coronary interventions. Typical consequences of coronary microembolization are microinfarcts with an inflammatory response, contractile dysfunction, and reduced coronary reserve. Apart from transient elevations of creatine kinase and troponin, microemboli can be visualized by intracoronary Doppler and the resulting microinfarcts by late-enhancement nuclear magnetic resonance. Statins, antiplatelet agents, and coronary vasodilators protect against microembolization and microinfarction when started before percutaneous coronary interventions. Distal protection devices can retrieve atherothrombotic debris and prevent its embolization into the microcirculation, but their effect on clinical outcome has been disappointing so far, except for saphenous vein bypass grafts. Devices for aspiration of thrombi and thrombus-derived vasoconstrictor, thrombogenic, and inflammatory substances, however, reduce thrombus burden, improve perfusion, and provide protection in patients with acute myocardial infarction.

Comparison of usefulness of simvastatin 20 mg versus 80 mg in preventing contrast-induced nephropathy in patients with acute coronary syndrome undergoing percutaneous coronary intervention

Contrast-induced nephropathy limits the outcomes of percutaneous coronary intervention (PCI). The present study compared the protective effects of different statin doses on renal function. A total of 228 patients with acute coronary syndrome undergoing selective PCI were randomly divided into simvastatin 20-mg group (S20, n = 115) and simvastatin 80-mg group (S80, n = 113). Serum creatinine was measured at admission, the day of PCI, and 24 and 48 hours after PCI. The creatinine clearance was calculated using the Cochcroft-Gault formula. High-sensitive C-reactive protein, P-selectin, and intercellular adhesion molecule-1 were also measured before and after the procedure. Contrast-induced nephropathy was defined as a postprocedure increase in serum creatinine of > or =0.5 mg/dl or >25% from baseline. The serum creatinine significantly increased after PCI, with the peak value occurring at 24 hours, and then began to decrease. At 48 hours, the serum creatinine had decreased to the baseline level in the S80 group, but it had failed to do so in the S20 group. At 24 and 48 hours after PCI, the serum creatinine was lower in the S80 group than in the S20 group (p <0.05 and p <0.001, respectively). The creatinine clearance significantly decreased after PCI, with the lowest value occurring at 24 hours, and then it began to increase. In the S80 group, the creatinine clearance recovered to baseline level at 48 hours, but it failed to do so in the S20 group. The creatinine clearance was greater at 24 and 48 hours in the S80 group than that in the S20 group. Although the procedure caused a significant increase in high-sensitive C-reactive protein, P-selectin, and intercellular adhesion molecule-1 levels, the value was lower in the S80 group than in the S20 group (p <0.001). In conclusion, pretreatment with simvastatin 80 mg before PCI could further decrease the occurrence of contrast-induced nephropathy compared with simvastatin 20 mg. This benefit was associated with the lowering of high-sensitive C-reactive protein, P-selectin, and intercellular adhesion molecule-1 levels.