Anemia, hemorrhage, and transfusion in percutaneous coronary intervention, acute coronary syndromes, and ST-segment elevation myocardial infarction

Relevance of pre-existing anaemia for patients admitted for acute coronary syndrome to an intensive care unit: a retrospective cohort analysis of 7418 patients

Aims

Patients with acute coronary syndrome (ACS) frequently suffer from anaemia, but its role in patients admitted to an intensive care unit (ICU) is unclear. This analysis evaluates the prognostic relevance of different degrees of anaemia and their specific impact on disease severity and the outcome in critically ill ACS patients.

Methods and results

and results The multi-centre electronic Intensive Care Unit Collaborative Research Database was used, and all patients admitted with ACS were included in a retrospective analysis. Anaemia and its degrees were defined according to the criteria by the World Health Organization. A multi-level logistic regression analysis was used to fit three sequential regression models for the binary primary outcome of hospital mortality. A total of 7418 patients were included; 3437 patients (46%) had anaemia on admission. Patients with anaemia were significantly older [61 (53–70) vs. 70 (61–78) years, P < 0.001], more often female (P < 0.001), and required an increased rate of vasopressor use (P < 0.001) and mechanical ventilation (P < 0.001). With the higher Sequential organ failure assessment score (1 vs. 2; P < 0.001) and Acute Physiology And Chronic Health Evaluation (35 vs. 47; P < 0.001) scores, a higher degree of anaemia was associated with prolonged ICU stay (2 vs. 5 days, P < 0.001). Even patients with mild anaemia needed significantly from more intensive treatment and suffered worse outcome. Intensive care unit and hospital mortality were inversely associated with haemoglobin levels.

Conclusion

Nearly half of critically ill patients with ACS suffer from anaemia, which is associated with increased illness severity, complex ICU procedures, and mortality—even in mild anaemia. Haemoglobin on admission is an independent factor for adverse outcome.

Association between anemia and mortality in patients with acute coronary syndrome treated with percutaneous coronary intervention and contemporary lipid-lowering therapy

Despite a clear correlation between anemia and mortality in patients with the acute coronary syndrome (ACS), anemia as a mortality predictor in patients with ACS-receiving early invasive strategy and contemporary lipid-lowering therapy has not been examined. Therefore, we aimed to evaluate the association between anemia and mortality in ACS patients treated with acute revascularization and contemporary lipid-lowering treatment. This was a post-hoc study of the Heart Institute of Japan-Proper level of Lipid-Lowering with Pitavastatin and Ezetimibe in acute coronary syndrome study, in which ACS patients with dyslipidemia were randomized to receive either pitavastatin and ezetimibe or pitavastatin monotherapy. The success rate of primary percutaneous coronary intervention (PCI) was 95.2%. Eligible patients were divided into two groups: patients with anemia (anemia group) or without anemia (non-anemia group). Anemia was defined using the World Health Organization definition hemoglobin < 12 g/dL for women and < 13 g/dL for men. We compared the mortality between the two groups using propensity scores derived from 17 baseline variables. We identified 1721 eligible patients, including 420 (24.4%) in the anemia group and 1301 (75.6%) in the non-anemia group. One-to-one propensity score-matching created 381 pairs. Both unmatched and matched analyses found significantly high mortality in the anemia group compared to the non-anemia group (unmatched 12.3% vs. 3.8%, log-rank p < 0.01; matched 11.5% vs. 6.3%, log-rank p = 0.01). In ACS patients treated with an early invasive strategy era with a high PCI success rate and concurrent contemporary lipid-lowering management, all-cause mortality was still significantly higher in anemic patients than in non-anemic patients.Trial registration: Clinical trial registration URL: http://www.umin.ac.jp/ctr . Unique identifier: UMIN00000274.

Percutaneous coronary intervention in women: is sex still an issue?

Coronary artery disease among women presents differences in terms of clinical presentation and pathophysiology. To date, women present worse prognoses with more events and higher mortality rate. One the one hand, they are less likely addressed for invasive therapy. One the other hand, revascularization procedures, whether by bypass or by percutaneous coronary intervention, are associated with higher rates of complications and poorer prognosis. Despite higher risk factor burden and comorbidity, women are less affected by obstructive disease and plaque characteristics are more favorable than among men. Abnormalities of endothelial function and micro vascular flow reserve could explain part of the high prevalence of symptoms of angina observed among women. Due to the worse prognosis of microvascular dysfunction, particularly in women, proper diagnosis is mandatory and deserve invasive management. Outcome following ST elevation myocardial infarction is still more severe among women with higher in-hospital mortality, but sex discrepancies are observed even in elective percutaneous coronary intervention. However, improvement of techniques, drugs and devices benefited to both men and women and tend to decrease gender gap. Especially, changes in the design of newer-generation drug-eluting stents (DES) may be particularly important for women. Female sex remains a potent predictor of higher risk of bleeding and vascular complication; thus important efforts should be promoted to develop bleeding avoidance strategies. Sex-based differences still deserve dedicated investigations in terms of physiopathology, particular hormonal impacts, and specific responses to drugs and devices.

Anemia in patients with high-risk acute coronary syndromes admitted to Intensive Cardiac Care Units

Background

Little information exists about the role of anemia in patients with acute coronary syndromes (ACS) admitted to Intensive Cardiac Care Units (ICCU). The aim of this study was to assess the prevalence of anemia and its impact on management and outcomes in this clinical setting.

Methods

All consecutive patients admitted to eight different ICCUs with diagnosis of non-ST segment elevation ACS (NSTEACS) were prospectively included. Anemia was defined as hemoglobin < 130 g/L in men and < 120 g/L in women. The association between anemia and mortality or readmission at six months was assessed by the Cox regression method.

Results

A total of 629 patients were included. Mean age was 66.6 years. A total of 197 patients (31.3%) had anemia. Coronary angiography was performed in most patients (96.2%). Patients with anemia were significantly older, with a higher prevalence of comorbidities, poorer left ventricle ejection fraction and higher GRACE score values. Patients with anemia underwent less often coronary angiography, but underwent more often intraaortic counterpulsation, non-invasive mechanical ventilation and renal replacement therapies. Both ICCU and hospital stay were significantly longer in patients with anemia. Both the incidence of mortality (HR = 3.36, 95% CI: 1.43–7.85, P = 0.001) and the incidence of mortality/readmission were significantly higher in patients with anemia (HR = 2.80, 95% CI: 2.03–3.86, P = 0.001). After adjusting for confounders, the association between anemia and mortality/readmission remained significant (P = 0.031).

Conclusions

Almost one of three NSTEACS patients admitted to ICCU had anemia. Most patients underwent coronary angiography. Anemia was independently associated to poorer outcomes at 6 months.

Correlation of the ORBIT Score With 30-Day Mortality in Patients With ST-Segment Elevation Myocardial Infarction

A new scoring system Outcomes Registry for Better Informed Treatment (ORBIT) score is used to assess the bleeding risk in anticoagulated patients with atrial fibrillation (AF). Our aim is to investigate the possible correlations of the ORBIT score with 30-day mortality in patients with ST-segment elevation myocardial infarction (STEMI). A total of 639 patients with STEMI were enrolled in this study. The ORBIT, HAS-BLED, and TIMI scores were recorded during admission. After 30 days' follow-up, 639 patients were divided into 2 groups: the survival group and the nonsurvival group. Different clinical parameters were compared. The predictive values of the ORBIT, HAS-BLED, and TIMI scores for 30-day mortality were assessed from receiver operating characteristic (ROC) analyses. The univariate and multivariate Cox proportional hazards analyses were applied to evaluate the relationships between variables and 30-day mortality. Sixty-seven deaths occurred after a 30-day follow-up. The ORBIT, HAS-BLED, and TIMI scores in the death group were higher than those in the survival group (P < .05). The areas under the ROC curve for the ORBIT, HAS-BLED, and TIMI scores to predict the occurrence of 30-day mortality were 0.811 (95% CI: 0.779-0.841, P < .0001), 0.717 (95% CI: 0.680-0.752, P < .0001), and 0.844 (95% CI: 0.813-0.871, P < .0001), respectively. In multivariate Cox proportional hazards modeling, the high ORBIT score was positively associated with 30-day mortality (hazard ratio: 1.309, 95% CI: 1.101-1.556, P = .013) after adjustment. A graded relation is found in the elevated ORBIT score and 30-day mortality in patients with STEMI. Thus, the ORBIT score can be an independent predictor of 30-day mortality in patients with STEMI.

Usefulness of Haemoglobin Level Combined with CAMI-STEMI Score for Predicting MACCE in Patients with Acute ST-Elevation Myocardial Infarction after PCI

Anaemia and high haemoglobin levels are common in ST elevation myocardial infarction (STEMI) patients, but the effect of the haemoglobin level on the prognosis of STEMI patients remains in dispute. This study aimed to evaluate the prognostic value of the haemoglobin level combined with the CAMI-STEMI score in STEMI patients after percutaneous coronary intervention (PCI). We included 360 STEMI patients who underwent PCI. The patients were divided into 3 groups according to the first haemoglobin value after PCI. Clinical characteristics and the incidence of major adverse cardiovascular and cerebral events (MACCE) during the follow-up period were recorded. The incidence of MACCE in the 3 groups increased with a decrease in the haemoglobin level. Multivariate regression analysis showed that the CAMI-STEMI score was an independent predictor of MACCE incidence at 30 days after PCI and that anaemia was an independent predictor of MACCE incidence at 6 months and 1 year after PCI. A high haemoglobin level was an independent predictor of MACCE incidence at 1 year after PCI. The area under receiver operating characteristic curves (AUCs) of the haemoglobin level, CAMI-STEMI score, and haemoglobin level combined with CAMI-STEMI score predicting the occurrence of MACCE in STEMI patients within 30 days after PCI were 0.604, 0.614, and 0.639, respectively. In conclusion, The CAMI-STEMI score was an independent predictor of MACCE incidence at 30 days after PCI. The haemoglobin level combined with the CAMI-STEMI score improved the predictive value of MACCE in STEMI patients within 30 days after PCI. Trial Registration. This trial was a prospective cohort study and registered with ChiCTR-ROC-17011542.

Outcomes of anemic patients presenting with acute coronary syndrome: An analysis of the Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events

BACKGROUND

Anemia commonly accompanies acute coronary syndromes (ACS) and is associated with poorer outcomes. This study examines the associations between anemia, management and outcomes in an Australian ACS population.

METHODS

This analysis of the CONCORDANCE database included 8665 ACS patients presenting to 41 Australian hospitals. Baseline characteristics, management, and outcomes were compared between patients with anemia (Hb ≤ 130 for males, Hb ≤ 120 g/L for females) and non-anemia.

RESULTS

A total of 1880 (21.7%) patients presenting with ACS were anemic. These patients were older (72 years vs 63 years, P < .0001), with higher prevalence of comorbidities. STEMI patients with anemia were less likely to be emergently reperfused with either thrombolytic therapy (22% vs 33%, P < .0001) or primary percutaneous coronary intervention (PCI) (45% vs 51% P = 0.033). For all ACS, anemic patients less frequently received: coronary angiography (63% vs 86%, P < .0001); drug eluting stents if undergoing PCI (50% vs 58%, P < .0001); dual antiplatelet therapy (80% vs 89%, P < .0001) ;and parenteral anticoagulants (82% vs 88%, P < .0001). In hospital complications of heart failure (20% vs 9%, P < .0001), renal failure (13% vs 4%, P < .0001), and re-infarction (4% vs 2%, P = .0006) were more common among anemic patients. There was a near-linear inverse relationship between admission hemoglobin and in hospital mortality.

CONCLUSIONS

Anemic patients with ACS are a high risk group less likely to undergo invasive and antithrombotic therapy. Further investigation is required to determine if more active treatment of anemic patients presenting with ACS will improve their outcomes.

Bleeding Events After ST-segment Elevation Myocardial Infarction in Patients Randomized to an All-comer Clinical Trial Compared With Unselected Patients

Most studies reporting bleedings in patients with ST-segment elevation myocardial infarction (STEMI) are reports from clinical trials, which may be unrepresentative of incidences in real-life. In this study, we investigated 1-year bleeding and mortality incidences in an unselected STEMI population, and compared participants with nonparticipants of a randomized all-comer clinical trial (The Third DANish Study of Optimal Acute Treatment of Patients with STEMI (DANAMI-3)). Hospital charts were read and bleedings classified according to thrombolysis in myocardial infarction (TIMI) and Bleeding Academic Research Consortium (BARC) criteria in 2,490 consecutive STEMI patients who underwent primary percutaneous coronary intervention in a single, large, and tertiary heart center. Thrombolysis in myocardial infarction minor and/or major bleeding (TMMB) occurred in 4.4% day 0 to 30 and 2.1% day 31 to 365. DANAMI-3 nonparticipants (n = 887) had significantly higher 30-day bleeding rates than DANAMI-3-participants (n = 1,603) (7.2% vs 2.9%, p <0.0001), but not thereafter (p = 0.8). DANAMI-3 nonparticipation was significantly associated with 30-day TMMB (hazard ratio, 1.8, 95% confidence interval, 1.2 to 2.8, p = 0.007), but this did not persist after adjusting for resuscitated cardiac arrest, Killip-class>2 and anemia. Patients with cardiac arrest, Killip-class>2, and anemia accounted for 70.0% of 30-day TMMBs, and the majority of these patients were DANAMI-3 nonparticipants. TMMB day 0 to 30 was associated with increased 30-day mortality (hazard ratio 3.1, 95% confidence interval 1.9 to 5.2, p <0.0001) but not thereafter (p = 0.9). In conclusion, we found that clinical trial (DANAMI-3) nonparticipants had significantly more TMMBs within 30 days than participants. Patients with resuscitated cardiac arrest, anemia, and Killip-class>2 were accountable for a high rate of TMMBs. Bleeding incidences from clinical trials cannot be translated to an unselected STEMI population.

Outcomes of Percutaneous Coronary Interventions in Patients With Anemia Presenting With Acute Coronary Syndrome

OBJECTIVE

To study the influence of anemia on long-term outcomes of patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI).

PATIENTS AND METHODS

The study included 5668 consecutive unique patients with acute coronary syndrome who underwent PCI at Mayo Clinic from January 1, 2004, through December 31, 2014. The patients were stratified on the basis of the presence (hemoglobin [Hgb] level, <13 g/dL in men and <12 g/dL in women) and severity (moderate to severe Hgb level, <11 g/dL in men and women) of pre-PCI anemia and compared with patients without anemia. The primary outcomes were in-hospital and long-term all-cause mortality after balancing baseline comorbidities using the inverse propensity weighting method.

RESULTS

Unadjusted all-cause in-hospital mortality (4.6% [84 of 1831] vs 2.0% [75 of 3837]) and 5-year follow-up mortality (44.4% [509] vs 15.4% [323]) were higher in patients with anemia than in those without anemia (P<.001 for both). After applying inverse propensity weighting analysis, the all-cause in-hospital mortality (2.0% [37] vs 2.0% [75]; P=.85) and 5-year mortality (17.8% [203] vs 15.4% [323]; P=.05) were not significantly different between patients with and without anemia; however, there were higher rates of all-cause 5-year mortality in patients with moderate to severe anemia (22.3% [113] vs 15.4% [323]; P<.001) compared with patients without anemia. The trend in 5-year mortality was driven by increased noncardiac mortality in patients with anemia (10.2% [91] vs 7.1% [148]; P=.04) and moderate to severe anemia (10.4% [52] vs 7.1% [148]; P=.006) when compared with nonanemic patients.

CONCLUSION

After accounting for differences in risk profiles of anemic and nonanemic patients, anemia appeared to be an independent risk factor for increased long-term all-cause and noncardiac mortality.

Association between admission anemia and long-term mortality in patients with acute myocardial infarction: results from the MONICA/KORA myocardial infarction registry

BACKGROUND

Previous studies have shown that the presence of anemia is associated with increased short- and long-term outcomes in patients with acute myocardial infarction (AMI). This study aims at examining the impact of admission anemia on long-term, all-cause mortality following AMI in patients recruited from a population-based registry. Contrary to most prior studies, we distinguished between patients with mild and moderate to severe anemia.

METHODS

This prospective study was conducted in 2011 patients consecutively hospitalized for AMI that occurred between January 2005 and December 2008. Patients who survived more than 28 days after AMI were followed up until December 2011. Hemoglobin (Hb) concentration was measured at hospital admission and classified according to the World Health Organization (WHO). Mild anemia was defined as Hb concentration of 11 to < 12 g/dL in women and 11 to < 13 g/dL in men; moderate to severe anemia as Hb concentration of < 11 g/dL. Adjusted Cox regression models were calculated to compare survival in patients with and without anemia.

RESULTS

Mild anemia and moderate to severe anemia was found in 183 (9.1%) and 100 (5%) patients, respectively. All-cause mortality after a median follow-up time of 4.2 years was 11.9%. The Cox regression analysis showed significantly increased mortality risks in both patients with mild (HR 1.74, 95% CI 1.23-2.45) and moderate to severe anemia (HR 2.05, 95% CI 1.37-3.05) compared to patients without anemia.

CONCLUSION

This study shows that anemia adversely affects long-term survival following AMI. However, further studies are needed to confirm that anemia can solely explain worse long-term outcomes after AMI.

Does anemia affect the predictive ability of bleeding risk scores in patients with acute coronary syndromes?

INTRODUCTION AND OBJECTIVE

Anemia is a common comorbidity in patients with acute coronary syndromes (ACS), and is associated with higher risk for both bleeding and ischemic complications. We aimed to assess the predictive ability of bleeding risk scores (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines [CRUSADE], Mehran and Acute Coronary Treatment and Intervention Outcomes Network [ACTION]) in ACS patients with anemia.

METHODS

All consecutive ACS patients were prospectively included. The primary outcome was in-hospital major bleeding according to the CRUSADE, Mehran and ACTION definitions. Anemia was defined as hemoglobin <130 g/l in men and <120 g/l in women. The predictive ability of the bleeding risk scores was assessed by binary logistic regression, calculating receiver operating characteristic (ROC) curves and their corresponding area under the curve (AUC).

RESULTS

We included 2255 patients, mean age 62.4 years. Anemia was present in 550 patients (24.4%). Patients with anemia had a significantly higher prevalence of comorbidities. The three bleeding risk scores adequately predicted major bleeding in the whole cohort. No significant differences were observed regarding the predictive ability of each of the scores in patients with and without anemia (CRUSADE: AUC 0.73 without anemia vs. 0.74 with anemia, p=0.913; ACTION: AUC 0.68 without anemia vs. 0.73 with anemia, p=0.353; Mehran: AUC 0.69 without anemia vs. 0.61 with anemia, p=0.210). Only the Mehran score showed significantly lower predictive ability in patients with hemoglobin <11 g/dl (AUC 0.51, p=0.044).

CONCLUSIONS

Anemia was a common comorbidity in patients with ACS from our series. Currently available bleeding risk scores showed an adequate predictive ability in patients with mild anemia.

The role of Glycoprotein IIb/IIIa inhibitors in acute coronary syndromes and the interference with anemia

The role played by glycoprotein (GP) IIb/IIIa inhibitors (GPI) has continuously evolved until the most recent Guidelines whereby they were stepped down from class I to class II recommendation for treating acute coronary syndromes (ACS). GPI compete with a wider use of ADP inhibitors and novel anticoagulant drugs although GPI use has greatly narrowed. However, GPI may still have a role. Several criteria were proposed to define post-PCI anemia which is strictly related to bleeding and transfusion. In ACS, it should be important to define anemia in comparative terms versus baseline levels: ≥ 15% of red blood cell decrease should be a practical cut-off value. If one wishes to concentrate on hemoglobin (Hb), a≥2g/dl Hb decrease from baseline should be considered. It is important to recognize post-PCI anemia in the setting of ACS. There are sub-populations exposed to short-term hemorrhagic and/or long-term ischemic risks. Ischemic and hemorrhagic risks need to be carefully evaluated along with thrombocytopenia and its prognostic significance in order to put all these blood and rheological parameters into a clinically oriented perspective on which therapeutical decisions should be based. Definition of high risk procedures (complexity, angiographic characteristics and patient's risk profile, regardless whether STEMI or NSTEMI) may help selecting GPI. There are positive elements in GPI use: efficacy, rapid onset and reversibility of action, absence of pharmacogenomic variability, pharmacoeconomic considerations and the possibility of intracoronary administration. All these elements should be evaluated when selecting these agents for therapeutics.

Impact of Anemia and Dual Antiplatelet Therapy on Mortality in Patients Undergoing Percutaneous Coronary Intervention with Drug-Eluting Stents

The objective was to assess the impact of baseline anemia on all-cause mortality and whether 12-month dual antiplatelet therapy (DAPT) affects 1-year mortality linked to anemia in patients after percutaneous coronary intervention (PCI) with drug-eluting stents (DES). 4109 enrolled patients divided into three groups based on their pre-procedural hemoglobin (Hb) level: Hb < 100 mg/L represented moderate-severe anemia; 100 mg/L ≤ Hb < 120 mg/L for women and 100 mg/L ≤ Hb < 130 mg/L for men represented mild anemia; Hb ≥ 20 mg/L for women and Hb ≥ 130 mg/L for men represented no anemia. DAPT medications were prescribed when patients were discharged. There were significant differences in 30-day and 1-year mortality between moderate-severe anemia and no anemia patients (HR 8.05, 95% CI 1.46 to 44.33, P = 0.017; HR 3.93, 95% CI 1.11 to 13.98, P = 0.034), and in long-term mortality between anemia and no anemia groups (HR 1.82, 95% CI 1.17 to 2.83, P = 0.008 for mild anemia; HR 3.19,95% CI 1.29 to 7.86, P = 0.012 for moderate-severe anemia). There was not significant interaction between 12-month DAPT and anemia on mortality in anemic patients (P for interaction > 0.05). Anemia shows association with increased all-cause mortality in patients undergoing PCI. Twelve-month DAPT does not show synergy with anemia to increase the risk of all-cause 1-year mortality in anemic patients after PCI.

Editor's Choice- Gender difference in prognostic impact of in-hospital bleeding after myocardial infarction - data from the SWEDEHEART registry

BACKGROUND

Bleeding complications increase mortality in myocardial infarction patients. Potential gender difference in bleeding regarding prevalence and prognostic impact is still controversial.

OBJECTIVES

Gender comparison regarding incidence and prognostic impact of bleeding in patients hospitalised with myocardial infarction during 2006-2008.

METHODS

Observational study from the SWEDEHEART register. Outcomes were in-hospital bleedings, in-hospital mortality and one-year mortality in hospital survivors.

RESULTS

A total number of 50,399 myocardial infarction patients were included, 36.6% women. In-hospital bleedings were more common in women (1.9% vs. 3.1%, p<0.001) even after multivariable adjustment (odds ratio (OR) 1.17, 95% confidence interval (CI) 1.01-1.37). The increased risk for women was found in ST-elevation myocardial infarction (OR 1.46, 95% CI 1.10-1.94) and in those who underwent percutaneous coronary intervention (OR 1.80, 95% CI 1.45-2.24). In contrast the risk was lower in medically treated women (OR 0.79, 95% CI 0.62-1.00). After adjustment, in-hospital bleeding was associated with higher risk of one-year mortality in men (OR 1.35, 95% CI 1.04-1.74), whereas this was not the case in women (OR 0.97, 95% CI 0.72-1.31).

CONCLUSIONS

Female gender is an independent risk factor of in-hospital bleeding after myocardial infarction. A higher bleeding risk in women appeared to be restricted to invasively treated patients and ST-elevation myocardial infarction patients. Even though women have higher short- and long-term mortality, there was no difference between the genders among bleeders. After multivariable adjustment the prognostic impact of bleeding complications was higher in men.

Predicting and preventing vascular complications following percutaneous coronary intervention in women

The development of vascular complications is associated with increased morbidity and mortality in patients undergoing percutaneous coronary intervention. While the incidence of percutaneous coronary intervention-related vascular complications has greatly improved over time, female sex still persists as a significant and independent predictor of periprocedural vascular complications, which in turn is associated with a greater risk of short- and long-term mortality. This review provides a contemporary overview of the data on the important issues regarding the risk of percutaneous coronary intervention in women. It examines the intrinsic sex-related factors that may be contributing to women's heightened bleeding risk while also examining the various pharmacologic and procedural bleeding avoidance strategies currently in the literature, with a focus on their potential role and benefit in women specifically.

Prognostic significance of mean platelet volume in diabetic patients with ST-elevation myocardial infarction

PURPOSE

Mean platelet volume (MPV) is a universally available parameter with routine blood counts. It has been linked to many cardiovascular risk factors. MPV is a marker of platelet size and activity and has been linked to poor prognosis following STEMI. There has been an increasing number of reports linking diabetes mellitus (DM) to platelet dysfunction. The aim of the study was to examine the association between admission MPV and clinical outcomes in patients with DM and STEMI undergoing primary percutaneous coronary intervention (PCI). The secondary objective of the study was to evaluate whether this index can be used to determine the long-term prognosis.

METHODS

A total of 1,557 patients with STEMI undergoing primary PCI were enrolled and divided into two groups depending on their diabetes mellitus status: Group 1 - patients with diabetes mellitus (N=539) and Group 2 - patients without diabetes mellitus (N=1018).

RESULTS

MPV and peak CK-MB concentration were higher in diabetic patients as compared to non-diabetic patients. In diabetic patients, MPV was positively correlated with admission Killip class and negatively correlated with time to death during follow-up, initial TIMI flow, final TIMI flow, and erythrocyte count. In non-diabetic patients, MPV was positively correlated with the number of diseased coronary arteries, admission Killip class, and negatively correlated with time to death during follow-up and initial TIMI flow. ROC analysis revealed high diagnostic value of MPV in predicting in-hospital and one-year mortality. MPV cut-off level was lower for diabetic patients compared to non-diabetic patients.

CONCLUSIONS

Diabetic patients had higher MPV than non-diabetic patients. Both in diabetic and non-diabetic patients MPV proved to have good prognostic value for in-hospital and late mortality. MPV cut-off value for predicting mortality was lower in diabetic patients. Mortality rate was the highest in the fourth quartiles of MPV in both study groups.

Simple, effective and safe vascular access site closure with the double-ProGlide preclose technique in 162 patients receiving transfemoral transcatheter aortic valve implantation

OBJECTIVES

Aim of this study was to analyze feasibility, efficacy, and safety of a double-ProGlide preclose technique for access site closure after transfemoral transcatheter aortic valve implantation (TAVI).

BACKGROUND

An effective and safe transcutaneous closure device is advantageous in transfemoral TAVI to avoid surgical cut down of the large caliber sheath insertion site. The use of two ProGlide sutures has not been described in this context in a large patient cohort.

METHODS

ProGlide closure was used between 2010 and 2012 in 162 patients. ProGlide sutures were deployed in a preclose technique prior to insertion of the large caliber sheath. Success of the closure technique was defined as effective hemostasis and no further access site-related vascular or bleeding complications during the index hospitalization.

RESULTS

Patients were 82 ± 5 years old with a logistic EuroSCORE of 16.7 ± 12.5. Edwards SAPIEN valves were used in 81.5% and Medtronic CoreValves in 18.5%. The overall success rate of the double-ProGlide technique was 93.9%. Success rate was only 40.0% under circumstances of prolonged high-dose heparinization. Success rate was 96.8% among the patients on dual-antiplatelet therapy (DAPT). All 10 ProGlide failures could effectively be managed by either percutaneous angioplasty or surgical reconstruction. The rate of VARC major vascular complications was 4.3%. Thirty-day mortality was 5.6%.

CONCLUSION

The double-ProGlide preclose technique offers a simple, highly effective, and safe method for closure of the arterial access site after transfemoral TAVI. The double-ProGlide strategy results in low rates of major vascular complications and translates into favorable early outcome.

Anemia and mortality in acute coronary syndromes: a systematic review and meta-analysis

BACKGROUND

Anemia is a common comorbidity among patients with acute coronary syndromes (ACS) and may adversely affect cardiovascular outcomes in these patients. We conducted a systematic review and meta-analysis to examine the association between anemia and mortality among patients with ACS.

METHODS

We systematically searched MEDLINE to identify cohort studies and secondary analyses of randomized controlled trials examining the association between anemia and all-cause mortality among patients with ACS. Data were aggregated at 4 follow-up times (inhospital, 30 days, 1 year, and maximal available follow-up) using random-effects meta-analysis models.

RESULTS

Twenty-seven studies met the inclusion criteria, involving 233,144 patients. Anemia was present in 44,519 (19.1%) of these patients. Anemic patients were generally older and had a higher prevalence of comorbidities including diabetes mellitus, congestive heart failure, cerebrovascular disease, and history of major bleeding. Anemia was associated with an increased risk of crude all-cause mortality (relative risk 2.08, 95% CI 1.70-2.55) and reinfarction (relative risk 1.25, 95% CI 1.02-1.53) at maximal available follow-up. When adjusted risk ratios from individual studies' multivariable regression analyses were pooled, the magnitude of the associated mortality risk was attenuated but remained significant at maximal follow-up (hazard ratio 1.49, 95% CI 1.23-1.81). Clinically and statistically significant increases in mortality were observed as early as at 30 days post-ACS and persisted at 1 year.

CONCLUSIONS

Anemia in patients with ACS is independently associated with a significantly increased risk of early and late mortality.

Anaemia and prognosis in acute coronary syndromes: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis was conducted to summarize the association between anaemia and outcomes in patients with acute coronary syndromes (ACS).

METHODS

MEDLINE®, Cochrane Library, OVID and EMBASE databases were searched to identify studies that examined the effect of anaemia on mortality or other adverse events (heart failure, cardiogenic shock or major bleeding).

RESULTS

Nineteen studies met the final inclusion criteria (total number of patients 241 293). The risks of shortterm mortality (odds ratio [OR] 2.77; 95% confidence interval [CI] 2.09, 3.65), long-term mortality (OR 2.03; 95% CI 1.52, 2.71), heart failure (OR 1.96; 95% CI 1.47, 2.62), cardiogenic shock (OR 1.95; 95% CI 1.04, 2.64) and major bleeding (OR 4.28; 95% CI 1.05, 17.14) were increased in patients with anaemia, compared with patients without anaemia. Anaemia was also associated with a higher risk of mortality (adjusted hazard ratio 1.49, 95% CI 1.24, 1.79).

CONCLUSIONS

These study findings suggest that anaemia can be used to identify patients with ACS who are at a high risk of death or adverse events, and it may become a promising risk stratification factor in ACS.

Anaemia and the development of depressive symptoms following acute coronary syndrome: longitudinal clinical observational study

OBJECTIVE

Depressive symptoms are common following acute coronary syndrome (ACS) and predict subsequent cardiovascular morbidity. Depression in acute cardiac patients appears to be independent of clinical disease severity and other cardiovascular measures. One factor that has not been considered previously is anaemia, which is associated with fatigue and adverse cardiac outcomes. This study assessed the relationship between anaemia on admission and depressive symptoms following ACS.

DESIGN

Longitudinal clinical observational study.

SETTING

Coronary care unit.

PATIENTS

223 patients with documented ACS.

MAIN OUTCOME MEASURES

Depressive symptoms measured with the Beck Depression Inventory 3 weeks after admission.

RESULTS

Anaemia was defined with WHO criteria and was present in 30 (13.5%) patients. Anaemia predicted raised depression scores 3 weeks later independently of age, gender, marital status, educational attainment, smoking, Global Registry of Acute Cardiac Events (GRACE) risk scores, negative mood in hospital and history of depression (p=0.003). The odds of a Beck Depression Inventory score ≥10 among anaemic patients were 4.03 (95% CIs 1.48 to 11.00), adjusted for covariates. Sensitivity analyses indicated that effects were also present when haemoglobin was analysed as a continuous measure. Anaemia also predicted major adverse cardiac events over the subsequent 12 months.

CONCLUSIONS

Anaemia appears to contribute to depression following ACS and is associated with future cardiac morbidity. Studies evaluating the effects of anaemia management will help delineate the role of this pathway more precisely.

Temporal trends in gastrointestinal bleeding associated with percutaneous coronary intervention: analysis of the 1998-2006 Nationwide Inpatient Sample (NIS) database

BACKGROUND

Gastrointestinal bleeding (GIB) after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) and coronary artery disease (CAD) is associated with high morbidity and mortality.

METHODS

The NIS database from 1998 to 2006 was used to identify 1,216,759 PCIs performed for ACS and CAD. We sought to analyze temporal trends in the incidence and in-hospital outcomes of GIB associated with PCI along with its predictors.

RESULTS

The overall incidence of GIB was 1.04% (95% confidence interval (CI), 1.02%-1.06%). The incidence of GIB decreased over the study period (P for trend <.0001). The overall mortality in the GIB group was 6.0% (95% CI, 5.6%-6.4%). The adjusted OR for in-hospital mortality and GIB was 4.70 (95% CI, 4.23-5.23; P < .0001); this remained high and essentially unchanged over the study period. Independent predictors of GIB included rectum/anal cancer (OR, 4.64; 95% CI, 3.20-6.73; P < .0001), stomach cancer (OR, 2.74; 95% CI, 1.62-4.66; P = .0002), esophageal cancer (OR, 1.99; 95% CI, 1.08-3.69; P = .0288), colon cancer (OR, 1.69; 95% CI, 1.43-2.02; P < .0001), congestive heart failure (OR, 1.43; 95% CI, 1.35-1.52; P < .0001), and acute myocardial infarction (OR, 1.23; 95% CI, 1.13-1.35; P < .0001).

CONCLUSIONS

Although the incidence of GIB associated with PCI decreased from 1998 to 2006 in the face of aggressive therapies for ACS and CAD, the risk of GIB-associated death remained high. Underlying GI malignancy is a significant independent predictor of GIB associated with PCI; identifying these patients may reduce the rate of GIB.

Prior and new onset anemia in ST-elevation myocardial infarction: a different prognostic role?

The present investigation, performed in 1,122 consecutive STEMI patients treated with primary coronary intervention, was aimed at evaluating: (1) the prevalence of prior anemia and its prognostic significance in the short term; and (2) the prevalence of new anemia and its impact in the short term. The prevalence of prior anemia was 27.4%. Patients with a prior anemia were older and exhibited a higher incidence of chronic diseases and comorbidities. They showed a higher intra-hospital mortality rate (p < 0.001), a higher incidence of PCI failure (p < 0.001) and major bleedings (p < 0.001). Prior anemia was an independent predictor for intra-hospital mortality (OR 2.12; 95% CI 1.21-3.70, p = 0.009). Patients with a new anemia account for 46.8% of our series, and showed a higher early mortality rate and incidence of major bleedings in respect to those who maintained normal Hb values (p < 0.05 and <0.05, respectively). our data strengthens the prognostic role of Hb values in STEMI patients submitted to primary PCI, since the presence of prior anemia identified a subset of patients, characterized by advanced age, higher comorbidities and serious coronary artery disease, at higher risk for intra ICCU mortality and complications. Moreover, the development of anemia during an ICCU stay is common, and is associated with a higher mortality rate and incidence of complications in respect to patients who maintain normal Hb values.

Bleeding in acute coronary syndromes and percutaneous coronary interventions: position paper by the Working Group on Thrombosis of the European Society of Cardiology

Bleeding has recently emerged as an important outcome in the management of acute coronary syndromes (ACS), which is relatively frequent compared with ischaemic outcomes and has important implications in terms of prognosis, outcomes, and costs. In particular, there is evidence that patients experiencing major bleeding in the acute phase are at higher risk for death in the following months, although the causal nature of this relation is still debated. This position paper aims to summarize current knowledge regarding the epidemiology of bleeding in ACS and percutaneous coronary intervention, including measurement and definitions of bleeding, with emphasis on the recent consensus Bleeding Academic Research Consortium (BARC) definitions. It also provides an European perspective on management strategies to minimize the rate, extent, and consequences of bleeding. Finally, the research implications of bleeding (measuring and reporting bleeding in trials, the importance of bleeding as an outcome measure, and bleeding as a subject for future research) are also discussed.

STEMI patients--the more you bleed, the more you die: a comparison between classifications

BACKGROUND

In patients with acute coronary syndromes, an increase in hemorrhagic complications has been observed, and bleeding is now the most frequent noncardiac complication in these patients. Clinical trials and registries have used different scales to classify the severity of bleeding; so far, none of them has been developed for ST-segment elevation myocardial infarction (STEMI) patients in the era of primary percutaneous coronary intervention.

METHODS

We analyzed data from our Intensive Cardiac Care Florence STEMI Registry, comprising 991 STEMI patients consecutively admitted to our intensive cardiac care unit after mechanical revascularization, to assess the clinical impact of both Thrombolysis In Myocardial Infarction (TIMI) and Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) classifications in identifying patients with major bleeding at higher risk for in-hospital mortality.

RESULTS

Major bleeding events occurred in 8.9% of patients (88/991) in the TIMI classification and in 17.2% of patients (170/991) in the ACUITY classification. Among patients with major bleeding classified according to ACUITY, 82 patients did not meet the TIMI criteria for major bleeding. These patients represent the so-called gray zone, where no transfusion was performed and only 1 patient died.

CONCLUSIONS

In STEMI patients who undergo primary percutaneous coronary intervention and receive dual antiplatelet therapy, TIMI is more capable than ACUITY in identifying patients with major bleeding at higher risk for early mortality. The presence of renal failure represents an independent predictor for major bleeding.

Comparison of door-to-balloon times for primary PCI using transradial versus transfemoral approach

OBJECTIVES

The objective of this study was to compare door-to-balloon times and other variables in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) using transfemoral or transradial approaches.

BACKGROUND

Transradial PCI has been shown to lower the risk of access site complications but the procedure is not applied to STEMI patients, due to concerns of procedural complexity adversely affecting prompt reperfusion. There is paucity of real-world data comparing TRI with TFI in patients with STEMI.

METHODS

Three hundred sixteen consecutive patients with STEMI undergoing primary PCI were studied. Patients were divided in two groups, Group I (n = 204) undergoing PCI transfemorally and Group II (n = 109) patients transradially. Demographic data, door-to-balloon times, procedural variables, predischarge adverse events, access site complications, and 1 year follow-up major adverse cardiac events (MACE) were recorded.

RESULTS

Door-to-balloon time was 72 +/- 14 min in Group I compared with 70 +/- 17 min in Group II, the difference was not statistically significant (t = 1.096, P > 0.27). Group II patients had significantly fewer access site complications compared with Group I (20 vs. 1 patient, chi(2) = 10.8, P < 0.05). Demographics, predischarge adverse events, and MACE at 1 year follow-up were comparable between the two groups.

CONCLUSIONS

Transradial approach to primary PCI provides similar door-to-balloon times to transfemoral approach, and significantly lowers access site related complications, in patients presenting with STEMI.

Mechanism of hemostasis defects and management of bleeding in patients with acute coronary syndromes

The main cause of the hemostasis defects and related bleeding complications in patients with acute coronary syndromes (ACS) are the intake of multiple antithrombotic drugs, alone or concomitantly with invasive procedures such as coronary angiography and percutaneous coronary intervention (PCI). Antithrombotic drugs that impair several phases of hemostasis (platelet function, coagulation, and fibrinolysis) are causing bleeding particularly in elderly patients, in those underweight and with comorbidities such as renal insufficiency, diabetes, hypertension and malignancy. Identification of patients at high risk of bleeding is the most important preventive strategy, because the choice and dosages of drugs may to some extent be tailored to the degree of risk. Transfusions of blood products, which may become necessary in patients with major bleeding, should be used with caution, because they are associated with adverse cardiovascular events. To reduce the need of transfusion, the hemostatic drugs that decrease blood loss and transfusion requirements in cardiac surgery (antifibrinolytic amino acids, desmopressin, and recombinant factor VIIa) might be considered. However, the efficacy of these drugs in the control of bleeding complications is not unequivocally established in ACS and there is concern for an increased risk of thrombosis. In conclusion, evidence-based recommendations for the management of bleeding in patients with ACS are currently lacking, so that prevention through accurate assessment of the individual risk is the most valid strategy.

[Percentage of transradial approach for interventional cardiology in the world and learning the technique]

The transradial approach has been used for the first non selective coronary angiographies but was quickly replaced by the femoral approach until a new birth in 1989 for coronary angiography in 1989 and coronary angioplasty in 1992. Transradial approach use is extremely heterogeneous in the world, dominated by some countries in Europe, Canada, and eastern Asia (India, Taiwan, China, Japan). Risk factors of failure have been well described, allowing two kinds of learning: systematic attempt in all kind of patients when working with a proctor; patient selection when beginning the technique alone in order to get a high and stable success rate from the beginning. Systematic radial approach for coronary angiography is a must to learn the technique.