STEMI and NSTEMI: A mono versus a multivessel disease?

Outcomes of Different Reperfusion Strategies of Multivessel Disease Undergoing Newer-Generation Drug-Eluting Stent Implantation in Patients with Non-ST-Elevation Myocardial Infarction and Chronic Kidney Disease

Because available data are limited, we compared the 2-year clinical outcomes among different reperfusion strategies (culprit-only percutaneous coronary intervention (C-PCI), multivessel PCI (M-PCI), complete revascularization (CR) and incomplete revascularization (IR)) of multivessel disease (MVD) undergoing newer-generation drug-eluting stent implantation in patients with non-ST-elevation myocardial infarction (NSTEMI) and chronic kidney disease (CKD). In this nonrandomized, multicenter, retrospective cohort study, a total of 1042 patients (C-PCI, n = 470; M-PCI, n = 572; CR, n = 432; IR, n = 140) were recruited from the Korea Acute Myocardial Infarction Registry (KAMIR) and evaluated. The primary outcome was the occurrence of major adverse cardiac events, defined as all-cause death, recurrent myocardial infarction and any repeat coronary revascularization. The secondary outcome was probable or definite stent thrombosis. During the 2-year follow-up period, the cumulative incidences of the primary (C-PCI vs. M-PCI, adjusted hazard ratio (aHR), 1.020; p = 0.924; CR vs. IR, aHR, 1.012; p = 0.967; C-PCI vs. CR, aHR, 1.042; p = 0.863; or C-PCI vs. IR, aHR, 1.060; p = 0.844) and secondary outcomes were statistically insignificant in the four comparison groups. In the contemporary newer-generation DES era, C-PCI may be a better reperfusion option for patients with NSTEMI with MVD and CKD rather than M-PCI, including CR and IR, with regard to the procedure time and the risk of contrast-induced nephropathy. However, further well-designed, large-scale randomized studies are warranted to confirm these results.

Multivessel Versus Culprit-Vessel Percutaneous Coronary Intervention in Patients With Non-ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock

OBJECTIVES

The aim of this study was to compare in-hospital outcomes and long-term mortality of multivessel versus culprit vessel-only percutaneous coronary intervention (PCI) in patients with non-ST-segment elevation myocardial infarction (NSTEMI), multivessel disease (MVD) and cardiogenic shock.

BACKGROUND

The clinical benefits of complete revascularization in patients with NSTEMI, MVD, and cardiogenic shock remain uncertain.

METHODS

Among 25,324 patients included in the National Cardiovascular Data Registry CathPCI Registry from July 2009 to March 2018, the rates of in-hospital procedural outcomes were compared between those undergoing multivessel PCI and those undergoing culprit vessel-only PCI after 1:1 propensity score matching. Among patients aged ≥65 years matched to the Centers for Medicare and Medicaid Services database, long-term mortality was compared using proportional hazards analysis.

RESULTS

Multivessel PCI was performed in 9,791 patients (38.7%), which increased from 32.2% in 2010 to 44.2% in 2017 (p for trend <0.001). After 1:1 propensity matching (n = 7,864 in each group), those undergoing multivessel PCI had a 3.5% (95% confidence interval [CI]: 2.0% to 5.0%) lower absolute rate of in-hospital mortality (30.9% vs. 34.4%; p < 0.001; odds ratio [OR]: 0.85; 95% CI: 0.80 to 0.91), but a higher risk for bleeding (13.2% vs. 10.8%; p < 0.001; OR: 1.26; 95% CI: 1.15 to 1.40) and new requirement for dialysis (5.7% vs. 4.6%; p = 0.001; OR: 1.26; 95% CI: 1.10 to 1.46). Among those surviving to discharge, all-cause mortality was similar through 7 years (conditional hazard ratio: 0.95; 95% CI: 0.87 to 1.03; p = 0.20).

CONCLUSIONS

Nearly 40% of patients with NSTEMI with MVD and cardiogenic shock underwent multivessel PCI, which was associated with lower in-hospital mortality but greater peri-procedural complications. Among those surviving to discharge, multivessel PCI did not confer additional long-term mortality benefit.

Trends and predictors of coronary revascularization in patients with coronary artery anomalies and acute myocardial infarction: a nationwide analysis of 8131 patients

OBJECTIVE

Acute myocardial infarction (AMI) is rarely associated with coronary artery anomalies (CAA). This confluence makes it difficult to identify and treat the culprit lesion with percutaneous coronary intervention (PCI). Our objective was to evaluate trends and predictors of revascularization in patients with CAA and AMI using a large national database.

METHODS

We included adult patients with CAA presenting as ST segment elevation myocardial infarction (STEMI) or non-ST segment elevation myocardial infarction (NSTEMI) and undergoing coronary angiography from Nationwide Inpatient Sample from 2000 to 2011, using ICD-9 diagnosis code of 746.85 for CAA. Chi-square test for trend was used to compare revascularization rates over time. Multivariate logistic regression was used to identify predictors of revascularization.

RESULTS

There were almost 4.7 million subjects with AMI undergoing coronary angiography from 2000 to 2011. Of these, there were 8131 patients with CAA, including 3425 STEMI and 4706 NSTEMI patients. Mean age of the CAA population was 59 years with 63.6% males. Overall PCI rate was 47.8% and coronary artery bypass grafting rate was 8.8%. In STEMI patients with CAA, PCI rate increased from 49.9% in 2000 to 77.8% in 2011 (P < 0.001). In NSTEMI patients with CAA, PCI rate remained unchanged from 33.3% in 2000 to 37.3% in 2011 (P = 0.34). Revascularization trends in AMI patients with CAA mirrored those in AMI patients without CAA.

CONCLUSION

Despite the technical challenges associated with PCI in CAA, PCI rates in STEMI patients with CAA continue to increase over time. On the contrary, PCI rates continue to remain low in CAA patients with NSTEMI, reflecting overall contemporary NSTEMI treatment trends.

Real-World Data of Prasugrel vs. Ticagrelor in Acute Myocardial Infarction: Results from the RENAMI Registry

BACKGROUND

Limited data are available concerning differences in clinical outcomes for real-life patients treated with ticagrelor versus prasugrel after percutaneous coronary intervention (PCI).

OBJECTIVE

Our objective was to determine and compare the efficacy and safety of ticagrelor and prasugrel in a real-world population.

METHODS

RENAMI was a retrospective, observational registry including the data and outcomes of consecutive patients with acute coronary syndrome (ACS) who underwent primary PCI and were discharged with dual antiplatelet therapy (DAPT) between January 2012 and January 2016. The mean follow-up period was 17 ± 9 months. In total, 11 university hospitals from six European countries participated. After propensity-score matching, there were no substantial differences in the baseline clinical and interventional features. All patients were treated with acetylsalicylic acid plus prasugrel 10 mg once daily or acetylsalicylic acid plus ticagrelor 90 mg twice daily. Mean duration of DAPT was 12.04 ± 3.4 months with prasugrel and 11.90 ± 4.1 months with ticagrelor (p = 0.47). The primary and secondary endpoints were long-term net adverse clinical events (NACE) and major adverse cardiovascular events (MACE), respectively, along with their single components. Subgroup analysis for freedom from NACE and MACE was performed according to length of DAPT and clinical presentation [ST-elevation myocardial infarction (STEMI)-ACS versus non-ST-elevation myocardial infarction (NSTEMI)-ACS].

RESULTS

In total, 4424 patients (2725 ticagrelor, 1699 prasugrel) were enrolled. After propensity-score matching, 1290 patients in each cohort were included in the analysis. At 12 months, the incidence of both NACE and MACE was lower with prasugrel (NACE: 5.3% vs. 8.5% [p = 0.001]; MACE: 5% vs. 8.1% [p =  0.001]) mainly driven by a reduction in recurrent myocardial infarction (MI) (2.4 vs. 4.0%; p = 0.029) and a lower rate of Bleeding Academic Research Consortium (BARC) 3-5 bleeding (1.5 vs. 2.9%; p = 0.011). The benefit of prasugrel was confirmed for patients with NSTEMI and for those discharged with a DAPT regimen of ≤ 12 months. Only a trend in the reduction of NACE and MACE was noted for STEMI or for those treated with longer DAPT.

CONCLUSIONS

Comparison of these drugs suggested that prasugrel is safer and more efficacious than ticagrelor in combination with aspirin after NSTEMI but not STEMI. No differences were found for events occurring after 12 months. The nonrandomized design of the present research means further studies are required to support these findings.

Serum neutrophil gelatinase-associated lipocalin (NGAL) concentration is independently associated with mortality in patients with acute coronary syndrome

BACKGROUND

Circulating neutrophil gelatinase-associated lipocalin (NGAL) concentration increases in cardiovascular disease, but the long-term prognostic value of NGAL concentration has not been evaluated in acute coronary syndrome (ACS). We examined the association between NGAL concentration and prognosis in patients with ACS after non-ST-elevation myocardial infarction (NSTEMI) or STEMI.

METHODS AND RESULTS

NGAL concentration was measured in blood from 1121 consecutive ACS patients (30% women, mean age 65 years) on the first morning after admission. After adjustment for 14 variables, NGAL concentration predicted long-term (median 167 months) mortality (hazard ratio [HR] 1.33, 95% confidence interval [CI] 1.10-1.61, P = 0.003) for quartile (q) 4 of NGAL concentration. NGAL concentrations also predicted long-term mortality (HR = 1.63, 95% CI 1.31-2.03, P < 0.001, N = 741) when adjusting for Global Registry of Acute Coronary Events (GRACE) score, left ventricular ejection fraction (LVEF), and pro-B-type natriuretic peptide (proBNP) and C-reactive protein (CRP) concentrations. With these adjustments, NGAL concentration predicted long-term mortality in NSTEMI patients (HR = 2.02, 95% CI 1.50-2.72, P < 0.001) but not in STEMI patients (HR = 1.32, 95% CI 0.95-1.83, P = 0.100). In all patients, the combination of NGAL concentration and GRACE score yielded an HR of 5.56 (95% CI 4.37-7.06, P < 0.001) for q4/q4 for both variables.

CONCLUSION

NGAL concentration in ACS is associated with long-term prognosis after adjustment for clinical confounders. Measuring circulating NGAL concentration may help to identify patients-particularly those with NSTEMI-needing closer follow-up after ACS.

Type of myocardial infarction presentation in patients with chronic kidney disease

BACKGROUND AND AIM

Association of coronary and renal disease has been frequently found in epidemiological studies. Whether ECG-graphic presentation of myocardial infarction [S-T Elevated MI (STEMI) or Non S-T Elevated MI (NSTEMI)] is related to the degree of renal dysfunction is still unclear.

METHODS AND RESULTS

We examined 146 patients with acute myocardial infarction, consecutively entering the Coronary Care Unit of our ward. At entry, patients underwent clinical, ECG-graphic and echocardiographic examination, and blood samples were withdrawn for cardiac markers and general biochemistry. GFR was calculated using the CKD-EPI equation. STEMI was found in 71 cases and NSTEMI in 75 cases. Renal function was normal in 61 patients (stage 1), mildly impaired (<90 mL/min/1.73 m(2) and ≥ 60 mL/min/1.73 m(2)) in 60 (stage 2) and moderately to severely impaired (GFR <60 mL/min/1.73 m(2)) in 25 cases (stages 3-4). Patients were, thereafter, clustered into two groups (stages 1-2 and stages 3-4). Compared to stage 1-2 subjects, stages 3-4 patients were older, were more likely to be diabetic and had more frequently previous cardiovascular diseases. The probability of presentation of NSTEMI for stage 3-4 patients was 4-fold greater than for stage 1-2 patients (p = 0.02).

CONCLUSIONS

These data support the evidence that 1) NSTEMI is associated with more severe kidney dysfunction, likely due to more severe and/or longer lasting exposition to risk factors; 2) cardiac and renal impairment are strongly associated. ClinicalTrials.gov Identifier: NCT01636427.