Prognostic impact of diabetes mellitus and hypertension for mid-term outcome of patients with acute myocardial infarction who underwent percutaneous coronary intervention

Impact of Comorbid Disease Burden on Clinical Outcomes of Female Acute Myocardial Infarction Patients

Owing to the paucity of information on the clinical outcomes in female patients with acute myocardial infarction (AMI) in relation to the comorbid disease burden, we explored the differences in their clinical outcomes and identified predictive indicators. A total of 3,419 female AMI patients were stratified into two groups: Group A (those with zero or one comorbid diseases) (n=1,983) and Group B (those with two to five comorbid diseases) (n=1,436). Five comorbid conditions were considered: hypertension, diabetes mellitus, dyslipidemia, prior coronary artery disease, and prior cerebrovascular accidents. The primary outcome was major adverse cardiac and cerebrovascular events (MACCEs). The incidence of MACCEs was higher in Group B than in Group A in both the unadjusted and propensity score-matched data. Among the comorbid conditions, hypertension, diabetes mellitus, and prior coronary artery disease were found to be independently associated with an increased incidence of MACCEs. Higher comorbid disease burden was positively associated with adverse outcomes in the female population with AMI. Since both hypertension and diabetes mellitus are modifiable and independent predictors of adverse outcomes after AMI, it may be necessary to focus on the optimal management of blood pressure and glucose levels to improve cardiovascular outcomes.

Prevalence of Moderate to Severe Anxiety Symptoms among Patients with Myocardial Infarction: a Meta-Analysis

This study attempted to synthesize the evidence on the prevalence of moderate to severe anxiety symptoms among myocardial infarction (MI) patients to offer a reliable and accurate estimate on the number of MI patients suffering from moderate to severe anxiety symptoms. Comprehensive electronic searches (PubMed, Embase and Web of Science) were performed from their inception to February 2021. Between-study heterogeneity was analyzed using the Cochran's Q test and [Formula: see text] statistic, and if it was high across the eligible studies, meta-regression and subgroup analyses were conducted to examine the source of heterogeneity. Publication bias and the robustness of the pooled results were also examined. A total of 18 eligible studies covering 8,532 MI patients were included, of which 3,443 were identified with moderate to severe anxiety symptoms. Between-study heterogeneity was high ([Formula: see text]=98.8%) with the reported prevalence ranging from 9.6% to 69.17%, and the pooled prevalence was 38.08% (95% confidence interval: 28.82-47.81%) by a random-effects model. Meta-regression analyses indicated that publication year (β = -0.014) was significant moderators contributing 16.11% to the heterogeneity. Subgroup analyses indicated that studies using the anxiety subscale of Brief Symptom Inventory to assess anxiety were homogenous ([Formula: see text]=0.0). Furthermore, the pooled prevalence of moderate to severe anxiety symptoms varied significantly by geographic region, instrument used to assess anxiety, methodological quality, sex, education level, a history of previous MI and hypercholesterolemia. Additionally, the results of Egger's linear test (t = -0.630) and Begg's rank test (z = -0.190) indicated no evidence of publication bias, and the sensitivity of the pooled results was low. Nearly two fifth of MI patients suffered from moderate to severe anxiety symptoms, which emphasizes the importance of early identification of anxiety symptoms after MI, as well as the need of implementing psychological interventions for those with elevated anxiety symptoms.

Impact of diabetes mellitus on mortality rates and outcomes in myocardial infarction

BACKGROUND

Diabetes mellitus (DM) represents a major cardiovascular risk factor for increased risk of coronary artery disease and myocardial infarction (MI). DM is also associated with a poorer clinical outcome in MI.

MATERIALS AND METHODS

The nationwide German inpatient population treated between 2005 and 2016 was used for statistical analyses. Hospitalized MI patients were stratified by the presence of DM and investigated for the impact of DM on in-hospital events.

RESULTS

In total, 3,307,703 hospitalizations for acute MI (37.6% female patients, 56.8% aged ≥ 70 years) treated in Germany during 2005-2016 were included in this analysis. Of these patients, 410,737 (12.4%) died while in hospital. Overall, 1,007,326 (30.5%) MI cases were coded for DM. While the rate of MI patients with DM increased slightly over time, from 29.8% in 2005 to 30.7% in 2016 (β = 7.04, 95% CI: 4.13-9.94; P <  0.001), their in-hospital mortality decreased from 15.2% to 11.5% (β = -0.36, 95% CI: -0.38 to -0.34; P <  0.001). Rates of in-hospital death (13.2% vs 12.1%; P <  0.001) and recurrent MI (0.8% vs 0.6%; P <  0.001) were higher in MI patients with vs without DM. Also, in MI patients with DM, significantly lower use of coronary artery angiography (51.5% vs 56.8%; P <  0.001) and interventional revascularization (37.6% vs 43.9%; P <  0.001) was noted.

CONCLUSION

Although in-hospital mortality of patients with MI decreased in both diabetes and non-diabetes patients, in-hospital deaths were still higher in diabetes patients, thereby revealing the impact of this metabolic disorder on cardiovascular outcomes.

The impact of diabetes mellitus and hypertension on clinical outcomes in a population of Iranian patients who underwent percutaneous coronary intervention: A retrospective cohort study

There are heterogeneous data regarding the impact of diabetes mellitus (DM) and hypertension (HTN) on clinical outcomes after percutaneous coronary intervention (PCI). This study explored the effect of history of DM (hDM) and HTN (hHTN), separately and in combination with each other, on major adverse cardiac events (MACE) in short-, mid-, and long-term intervals after PCI. Between 2000 and 2017, 1799 patients who had PCI were registered. They were categorized in four different groups: hDM, hHTN, hDM + hHTN, and no hDMQuery no hHTN. Incidence of myocardial infarction, revascularization, and coronary death totally considered as MACE was sought in short- (<24 hours), mid- (24 hours up to 6 months), and long-term (more than 6 months) intervals after PCI. Among the subjects, 176 had hDM, 648 had hHTN, 370 had hDM + hHTN, and 605 were in no hDM no hHTN group. The median follow-up time was 66.5 months. Time-to-event (time to the first MACE) was not significantly different between four groups. hHTN group was older and hDM group was younger at the time of enrollment PCI. Female gender was dominant only in hDM + hHTN group. Of the total, 130 patients (7.22%) experienced MACE. There was no MACE in short term, 23.07% of the MACEs were in mid-term, and the remaining happened in long term. However, according to the rate ratio, incidence rate of MACE in mid-tem was significantly higher than the long term. Also, MACE occurrence was significantly higher in hDM + hHTN and hHTN groups than the no hDM no hHTN group. Our study showed that the history of HTN significantly increases post-PCI MACE rather than the history of DM. Having history of both DM and HTN synergistically raised MACE incidence. Incidence of MACE per month was higher in mid-term than the long-term interval.

Hypertension, Microvascular Pathology, and Prognosis After an Acute Myocardial Infarction

The rationale for our study was to investigate the pathophysiology of microvascular injury in patients with acute ST-segment-elevation myocardial infarction in relation to a history of hypertension. We undertook a cohort study using invasive and noninvasive measures of microvascular injury, cardiac magnetic resonance imaging at 2 days and 6 months, and assessed health outcomes in the longer term. Three hundred twenty-four patients with acute myocardial infarction (mean age, 59 [12] years; blood pressure, 135 [25] / 79 [14] mm Hg; 237 [73%] male, 105 [32%] with antecedent hypertension) were prospectively enrolled during emergency percutaneous coronary intervention. Compared with patients without antecedent hypertension, patients with hypertension were older (63 [12] years versus 57 [11] years; P<0.001) and a lower proportion were cigarette smokers (52 [50%] versus 144 [66%]; P=0.007). Coronary blood flow, microvascular resistance within the culprit artery, infarct pathologies, inflammation (C-reactive protein and interleukin-6) were not associated with hypertension. Compared with patients without antecedent hypertension, patients with hypertension had less improvement in left ventricular ejection fraction at 6 months from baseline (5.3 [8.2]% versus 7.4 [7.6]%; P=0.040). Antecedent hypertension was a multivariable associate of incident myocardial hemorrhage 2-day post-MI (1.81 [0.98-3.34]; P=0.059) and all-cause death or heart failure (n=47 events, n=24 with hypertension; 2.53 [1.28-4.98]; P=0.007) postdischarge (median follow-up 4 years). Severe progressive microvascular injury is implicated in the pathophysiology and prognosis of patients with a history of hypertension and acute myocardial infarction. Clinical Trial Registration- URL: http://www.clinicaltrials.gov . Unique identifier: NCT02072850.

In-hospital, short-term and long-term adverse clinical outcomes observed in patients with type 2 diabetes mellitus vs non-diabetes mellitus following percutaneous coronary intervention: A meta-analysis including 139,774 patients

BACKGROUND

Several studies have shown that patients with type 2 diabetes mellitus (T2DM) have worse clinical outcomes in comparison to patients without diabetes mellitus (DM) following Percutaneous Coronary Intervention (PCI). However, the adverse clinical outcomes were not similarly reported in all the studies. Therefore, in order to standardize this issue, a meta-analysis including 139,774 patients was carried out to compare the in-hospital, short-term (<1 year) and long-term (≥1 year) adverse clinical outcomes in patients with and without T2DM following PCI.

METHODS

Electronic databases including MEDLINE, EMBASE, and the Cochrane Library were searched for Randomized Controlled Trials (RCTs) and observational studies. The adverse clinical outcomes which were analyzed included mortality, myocardial infarction (MI), major adverse cardiac events (MACEs), stroke, bleeding, target vessel revascularization (TVR), target lesion revascularization (TLR), and stent thrombosis. Risk Ratios (RR) with 95% confidence intervals (CI) were used to express the pooled effect on discontinuous variables and the analysis was carried out by RevMan 5.3 software.

RESULTS

A total number of 139,774 participants were assessed. Results of this analysis showed that in-hospital mortality and MACEs were significantly higher in patients with T2DM (RR 2.57; 95% CI: 1.95-3.38; P = .00001) and (RR: 1.38; 95% CI: 1.10-1.73; P = .005) respectively. In addition, majority of the short and long-term adverse clinical outcomes were also significantly higher in the DM group as compared to the non-DM group. Stent thrombosis was significantly higher in the DM compared to the non-DM group during the short term follow-up period (RR 1.59; 95% CI: 1.16-2.18;P = .004). However, long-term stent thrombosis was similarly manifested.

CONCLUSION

According to this meta-analysis including a total number of 139,774 patients, following PCI, those patients with T2DM suffered more in-hospital, short as well as long-term adverse outcomes as reported by most of the Randomized Controlled Trials and Observational studies, compared to those patients without diabetes mellitus.

Risk factors for cardiac rupture complicating myocardial infarction: a PRISMA meta-analysis and systematic review

Cardiac rupture (CR) is a complication of acute myocardial infarction (AMI) that is associated with a high mortality rate. This study aimed to identify the risk factors for CR in patients with AMI. Medline, Cochrane, EMBASE, and Google Scholar databases were searched for relevant literature published through September 16, 2018. Eligible studies included patients with AMI and compared factors between patients with and without CR. Sixteen studies were identified and included in the meta-analysis. Results revealed that female gender (pooled OR=2.72, 95% CI 2.04 to 3.63, p<0.001), older age (pooled difference in means=6.91, 95% CI 4.20 to 9.62, p<0.001), infarction at left anterior descending coronary artery (LAD) (pooled OR=1.85, 95% CI 1.03 to 3.32, p=0.039), and anterior wall infarction (pooled OR=1.87, 95% CI 1.30 to 2.68, p=0.001) were associated with increased risk of CR, whereas history of MI, smoking, and multivessel disease were associated with reduced risk of CR. Patients treated with primary percutaneous coronary intervention (PCI) had reduced risk of CR, while patients who had received any thrombolysis had increased risk of CR. In conclusion, results of systematic review and meta-analysis of existing literature suggest that risk factors for CR in patients with AMI include female gender, older age, new-onset MI, non-smoking status, LAD infarction, anterior wall infarction, and single-vessel disease. Furthermore, treatment with primary PCI may help reduce the risk for CR, while thrombolysis might increase the risk for CR.

Integrated models of care for diabetes and hypertension in low- and middle-income countries (LMICs) : Protocol for a systematic review

BACKGROUND

In low- and middle-income countries (LMICs), the burden of non-communicable diseases (NCDs) is growing against an existing burden of other diseases such as HIV/AIDS. Integrated models of care can help address the rising burden of multi-morbidity. Although integration of care can occur at various levels and has been defined in numerous ways, our aim is to assess the effects of integration of service delivery at primary healthcare level in LMICs.

METHODS

We will consider randomised controlled trials (RCTs), cluster RCTs, non-randomised trials, controlled before-after studies and interrupted time series that examine integrated models of care among people with multi-morbidities, of which diabetes or hypertension is one, living in LMICs. We will compare fully integrated models of care to stand-alone care, partially integrated models of care to stand-alone care and fully integrated models to partially integrated models of care. Primary outcomes include all-cause mortality, disease-specific morbidity, HbA1c, systolic blood pressure and cholesterol levels. Secondary outcomes include access to care, retention in care, adherence, continuity of care, quality of care and cost of care. We will conduct a comprehensive search in the following databases: MEDLINE, EMBASE, the Cochrane Central Register of Control Trials, LILACS, Africa-Wide Information, CINAHL and Web of Science. In addition, we will search trial registries, relevant conference abstracts and check references lists of included studies. Selection of studies, data extraction and assessment of risk of bias will be performed independently by two review authors. We will resolve discrepancies through discussion with a third author. We will contact study authors in case of missing data. If included studies are sufficiently homogenous, we will pool results in a meta-analysis. Clinical heterogeneity related to the population, intervention, outcomes and context will be documented in table format and explored through subgroup analysis. We will assess χ 2 and I 2 tests for statistical heterogeneity. We will use GRADE to make judgements about the certainty of evidence and present findings in a summary of findings table.

DISCUSSION

In light of limited evidence on the provision of comprehensive care for diabetes and hypertension, and its comorbidity in LMCIs, we believe that the findings of this systematic review will provide a synthesis of evidence on effective models of integrated care for diabetes and hypertension and their comorbidities at primary healthcare level. This will enable policy-makers to device policies and programs that are evidence informed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018099314 .

Adequacy of control of cardiovascular risk factors in ambulatory patients with type 2 diabetes attending diabetes out-patients clinic at a county hospital, Kenya

BACKGROUND

Type 2 diabetes is associated with substantial cardiovascular morbidity and mortality arising from the high prevalence of cardiovascular risk factors such as hypertension, dyslipidaemia, obesity, poor glycaemic control and albuminuria. Adequacy of control of these risk factors determines the frequency and outcome of cardiovascular events in the patients. Current clinical practice guidelines emphasize primary prevention of cardiovascular disease in type 2 diabetes. There is scarce data from the developing countries, Kenya included, on clinical care of patients with type 2 diabetes in the regions that are far away from tertiary health facilities. So we determined the adequacy of control of the modifiable risk factors: glycaemic control, hypertension, dyslipidemia, obesity and albuminuria in the study patients from rural and peri-urban dwelling.

METHODS

This was a cross-sectional study on 385 randomly selected ambulatory patients with type 2 diabetes without overt complications. They were on follow up for at least 6 months at the Out-patient diabetes clinic of Nyeri County Hospital, a public health facility located in the central region of Kenya.

RESULTS

Females were 65.5%. The study subjects had a mean duration of diabetes of 9.4 years, IQR of 3.0-14 years. Their mean age was 63.3 years, IQR of 56-71 years. Only 20.3% of our subjects had simultaneous optimal control of the three (3) main cardiovascular risk factors of hypertension, high LDL-C and hyperglycaemia at the time of the study. The prevalence of cardiovascular risk factors were as follows: HbA1c above 7% was 60.5% (95% CI, 55.6-65.5), hypertension, 49.6% of whom 76.6% (95% CI, 72.5-80.8) were poorly controlled. High LDL-Cholesterol above 2.0 mmol/L was found in 77.1% (95% CI 73.0-81.3) and Albuminuria occurred in 32.7% (95% CI 27.8-37.4). The prevalence of the other habits with cardiovascular disease risk were: excess alcohol intake at 26.5% (95% CI 27.8-37.4) and cigarette-smoking at 23.6%. A modest 23.4% of the treated patients with hypertension attained target blood pressure of <140/90 mmHg. Out of a paltry 12.5% of the statin-treated patients and others not actively treated, only 22.9% had LDL-Cholesterol of target <2.0 mmol/L. There were no obvious socio-demographic and clinical determinants of poor glycaemic control. However, old age above 50 yrs., longer duration with diabetes above 5 yrs. and advanced stages of CKD were significantly associated with hypertension. Female gender and age, statin non-use and socio-economic factor of employment were the significant determinants of high levels of serum LDL-cholesterol.

CONCLUSION

The majority of the study patients attending this government-funded health facility had high prevalence of cardiovascular risk factors that were inadequately controlled. Therefore patients with type 2 diabetes should be risk-stratified by their age, duration of diabetes and cardiovascular risk factor loading. Consequently, composite risk factor reduction strategies are needed in management of these patients to achieve the desired targets safely. This would be achieved through innovative care systems and modes of delivery which would translate into maximum benefit of primary cardiovascular disease prevention in those at high risk. It is a desirable quality objective to have a higher proportion of the patients who access care benefiting maximally more than the numbers we are achieving now.

Long-term mortality after acute myocardial infarction among individuals with and without diabetes: A systematic review and meta-analysis of studies in the post-reperfusion era

AIMS

To conduct a systematic review and meta-analysis with the aim of providing robust estimates of the association between diabetes and long-term (≥1 year) mortality after acute myocardial infarction (AMI).

MATERIAL AND METHODS

Medline, Embase and Web of Science databases were searched (January 1985 to July 2016) for terms related to long-term mortality, diabetes and AMI. Two authors independently abstracted the data. Hazard ratios (HRs) comparing mortality in people with and without diabetes were pooled across studies using Bayesian random-effects meta-analysis.

RESULTS

A total of 10 randomized controlled trials and 56 cohort studies, including 714 780 patients, reported an estimated total of 202 411 deaths over the median (range) follow-up of 2.0 (1-20) years. The risk of death over time was significantly higher among those with diabetes compared with those without (unadjusted HR 1.82, 95% credible interval [CrI] 1.73-1.91). Mortality remained higher in the analysis restricted to 23/64 cohorts reporting data adjusted for confounders (adjusted HR 1.48, 95% CrI 1.43-1.53). The excess long-term mortality in diabetes was evident irrespective of the phenotype and modern treatment of AMI, and persisted in early survivors (unadjusted HR 1.82, 95% CrI 1.70-1.95).

CONCLUSIONS

Despite medical advances, individuals with diabetes have a 50% greater long-term mortality compared with those without. Further research to understand the determinants of this excess risk are important for public health, given the predicted rise in global diabetes prevalence.

Hypertension is associated with increased mortality in patients with ischaemic heart disease after revascularization with percutaneous coronary intervention - a report from SCAAR

BACKGROUND

The prognostic role of hypertension on long-term survival after percutaneous coronary intervention (PCI) is limited and inconsistent. We hypothesize that hypertension increases long-term mortality after PCI.

METHODS

We analyzed data from SCAAR (Swedish Coronary Angiography and Angioplasty Registry) for all consecutive patients admitted coronary care units in Sweden between January 1995 and May 2013 and who underwent PCI due to ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI)/unstable angina (UA) or stable angina pectoris. We used Cox proportional-hazards regression for statistical modelling on complete-case data as well as on imputed data sets. We used interaction test to evaluate possible effect-modulation of hypertension on risk estimates in several pre-specified subgroups: age categories, gender, diabetes, smoking and indication for PCI (STEMI, NSTEMI/UA and stable angina).

RESULTS

During the study period, 175,892 consecutive patients underwent coronary angiography due to STEMI, NSTEMI/UA or stable angina. 78,100 (44%) of these had hypertension. Median follow-up was 5.5 years. After adjustment for differences in patient's characteristics, hypertension was associated with increased risk for mortality (HR 1.12, 95% CI 1.09-1.15, p < .001). In subgroup analysis, risk was highest in patients less than 65 years, in smokers and in patients with STEMI. The risk was lowest in patients with stable angina (p < .001 for interaction test).

CONCLUSION

Hypertension is associated with higher mortality in patients with STEMI, NSTEMI/UA or stable angina who are treated with PCI.

Impact of diabetes and hypertension on cardiovascular outcomes in patients with coronary artery disease receiving percutaneous coronary intervention

BACKGROUND

Percutaneous coronary intervention (PCI) is a necessary procedure commonly performed for patients with coronary artery disease (CAD). However, the impact of diabetes and hypertension on long-term outcomes of patients after receiving PCI has not yet been determined.

METHODS

The data of 1234 patients who received PCI were collected prospectively, and patients were divided into four groups, including patients with and without DM and those with either DM or hypertension alone. Baseline characteristics, risk factors, medications and angiographic findings were compared and determinants of cardiovascular outcomes were analyzed in patients who received PCI.

RESULTS

Patients with DM alone had the highest all-cause mortality (P < 0.001), cardiovascular mortality and myocardial infarctions (MI) (both P < 0.01) compared to the other groups. However, no differences were found between groups in repeat PCI (P = 0.32). Cox proportional hazard model revealed that age, chronic kidney disease (CKD), previous MI and stroke history were risk factors for all-cause mortality (OR: 1.05,1.89, 2.87, and 4.12, respectively), and use of beta-blockers (BB) and statins reduced all-cause mortality (OR: 0.47 and 0.35, respectively). Previous MI and stroke history, P2Y12 inhibitor use, and syntax scores all predicted CV mortality (OR: 4.02, 1.89, 2.87, and 1.04, respectively). Use of angiotensin converting enzyme inhibitors (ACEI), beta-blockers (BB), and statins appeared to reduce risk of CV death (OR: 0.37, 0.33, and 0.32, respectively). Previous MI and syntax scores predicted MI (OR: 3.17 and 1.03, respectively), and statin use reduced risk of MI (OR: 0.43). Smoking and BB use were associated with repeat PCI (OR: 1.48 and 1.56, respectively).

CONCLUSIONS

After PCI, patients with DM alone have higher mortality compared to patients without DM and hypertension, with both DM and hypertension, and with hypertension alone. Comorbid hypertension does not appear to increase risk in DM patients, whereas comorbid DM appears to increase risk in hypertensive patients.

TRIAL REGISTRATION

REC103-15 IRB of Taichung Tzu-chi Hospital.

Efficacy of Zofenopril Compared With Placebo and Other Angiotensin-converting Enzyme Inhibitors in Patients With Acute Myocardial Infarction and Previous Cardiovascular Risk Factors: A Pooled Individual Data Analysis of 4 Randomized, Double-blind, Controlled, Prospective Studies

In the Survival of Myocardial Infarction Long-term Evaluation (SMILE) 1, 3, and 4 studies, early administration of zofenopril in acute myocardial infarction showed to be prognostically beneficial versus placebo or ramipril. The SMILE-2 showed that both zofenopril and lisinopril are safe and showed no significant differences in the incidence of major cardiovascular (CV) complications. In this pooled analysis of individual data of the SMILE studies, we evaluated whether the superior efficacy of zofenopril is maintained also in patients with ≥1 CV risk factor (CV+, n = 2962) as compared to CV- (n = 668). The primary study end point was set to 1-year combined occurrence of death or hospitalization for CV causes. The risk of CV events was significantly reduced with zofenopril versus placebo either in the CV+ (-37%; hazard ratio: 0.63; 95% confidence interval: 0.51-0.78; P = 0.0001) or in the CV- group (-55%; hazard ratio: 0.45; 0.26-0.78; P = 0.004). Also, the other angiotensin-converting enzyme inhibitors reduced the risk of major CV outcomes, though the reduction was not statistically significant versus placebo (CV+: 0.78; 0.58-1.05; P = 0.107; CV-: 0.71; 0.36-1.41; P = 0.334). The benefit was larger in patients treated with zofenopril than other angiotensin-converting enzyme inhibitors, with a statistically significant difference for CV+ (0.79; 0.63-0.99; P = 0.039) versus CV- (0.62; 0.37-1.06; P = 0.081). In conclusion, zofenopril administered to patients after acute myocardial infarction has a positive impact on prognosis, regardless of the patient's CV risk profile.

Antecedent hypertension and myocardial injury in patients with reperfused ST-elevation myocardial infarction

BACKGROUND

Antecedent hypertension is associated with poor outcome in patients with ST-elevation myocardial infarction (STEMI). Whether differences in myocardial salvage, infarct size and microvascular injury contribute to the adverse outcome is unknown. We investigated the association between antecedent hypertension and cardiovascular magnetic resonance (CMR) parameters of myocardial salvage and damage in a multicenter CMR substudy of the AIDA-STEMI trial (Abciximab Intracoronary versus intravenously Drug Application in ST-elevation myocardial infarction).

METHODS

We analyzed 792 consecutive STEMI patients reperfused within 12 h after symptom onset. Patients underwent CMR imaging for assessment of myocardial salvage, infarct size and microvascular obstruction within 10 days after infarction. Major adverse cardiac events (MACE) were recorded at 12-month follow-up.

RESULTS

Antecedent hypertension was present in 540 patients (68 %) and was associated with a significantly increased baseline risk profile (advanced age, higher body mass index, higher incidence of diabetes, hypercholesterolemia, previous angioplasty and multivessel disease, p < 0.001 for all). MACE were more frequent in patients with hypertension as compared to patients without hypertension (45 [8 %] vs. 8 [3 %], p < 0.01). Antecedent hypertension remained an independent predictor of MACE after multivariate adjustment (hazard ratio 3.42 [confidence interval 1.45-8.08], p < 0.01). There was, however, no significant difference in the area at risk, infarct size, myocardial salvage index, extent of microvascular obstruction, and left ventricular ejection fraction between the groups (all p > 0.05).

CONCLUSION

Despite a higher rate of MACE in contemporary reperfused STEMI patients with antecedent hypertension, there was no difference in reperfusion efficacy, infarct size and reperfusion injury as visualized by CMR.

TRIAL REGISTRATION

NCT00712101 .

A systematic review and meta-regression of temporal trends in the excess mortality associated with diabetes mellitus after myocardial infarction

BACKGROUND/OBJECTIVES

It is not well known whether the gap in outcomes after myocardial infarction (MI) between patients with and without diabetes mellitus (DM) has changed over time. We performed a systematic review and metaregression of temporal trends in the excess mortality associated with DM after MI.

METHODS

We searched the PubMed database for studies reporting mortality data according to diabetic status in patients hospitalized for MI or acute coronary syndromes (ACS). We included 139 studies/cohorts for analysis (432,066 diabetic patients and 1,182,108 nondiabetic patients).

RESULTS

When compared to their non-diabetic counterparts, patients with DM had an odds ratio (OR) [95% CI] of 1.66 [1.59-1.74] (P<0.0001) for early mortality, and of 1.86 [1.75-1.97] (P<0.0001) for 6-12months mortality. When all data from the 116 studies reporting early mortality were pooled, there was no significant relationship between calendar year and Log (OR). Likewise, when considering the 61 studies reporting 6-12months mortality, there was no significant relationship between calendar year and Log (OR). Similar to the overall pooled analysis, no significant relationship between inclusion year and Log (OR) for mortality in diabetic patients was observed in sensitivity analyses performed in studies with ST-elevation MI as inclusion criteria, in randomized trials, in studies including >2000 patients, and in studies with DM prevalence >20%.

CONCLUSIONS

We found no evidence for temporal changes in the incremental mortality risk associated with DM in the setting of MI. The improvements in management of MI patients during the last decades have not been associated with a reduction of the gap between diabetic and non-diabetic patients.

Impact of Modifiable Cardiovascular Risk Factors on Mortality After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of 100 Studies

Modifiable cardiovascular risk factors such as obesity, hypertension, dyslipidemia, smoking, diabetes mellitus, and metabolic syndrome can easily give rise to coronary heart disease (CHD). However, due to the existence of the so-called "obesity paradox" and "smoking paradox," the impact of these modifiable cardiovascular risk factors on mortality after percutaneous coronary intervention (PCI) is still not clear. Therefore, in order to solve this issue, we aim to compare mortality between patients with low and high modifiable cardiovascular risk factors after PCI. Medline and EMBASE were searched for studies related to these modifiable cardiovascular risk factors. Reported outcome was all-cause mortality after PCI. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated, and the pooled analyses were performed with RevMan 5.3 software. A total of 100 studies consisting of 884,190 patients (330,068 and 514,122 with high and low cardiovascular risk factors respectively) have been included in this meta-analysis. Diabetes mellitus was associated with a significantly higher short and long-term mortality with RR 2.11; 95% CI: (1.91-2.33) and 1.85; 95% CI: (1.66-2.06), respectively, after PCI. A significantly higher long-term mortality in the hypertensive and metabolic syndrome patients with RR 1.45; 95% CI: (1.24-1.69) and RR 1.29; 95% CI: (1.11-1.51), respectively, has also been observed. However, an unexpectedly, significantly lower mortality risk was observed among the smokers and obese patients. Certain modifiable cardiovascular risk subgroups had a significantly higher impact on mortality after PCI. However, mortality among the obese patients and the smokers showed an unexpected paradox after coronary intervention.

Effect of arginase inhibition on ischemia-reperfusion injury in patients with coronary artery disease with and without diabetes mellitus

BACKGROUND

Arginase competes with nitric oxide synthase for their common substrate L-arginine. Up-regulation of arginase in coronary artery disease (CAD) and diabetes mellitus may reduce nitric oxide bioavailability contributing to endothelial dysfunction and ischemia-reperfusion injury. Arginase inhibition reduces infarct size in animal models. Therefore the aim of the current study was to investigate if arginase inhibition protects from endothelial dysfunction induced by ischemia-reperfusion in patients with CAD with or without type 2 diabetes (

CLINICAL TRIAL REGISTRATION NUMBER

NCT02009527).

METHODS

Male patients with CAD (n = 12) or CAD + type 2 diabetes (n = 12), were included in this cross-over study with blinded evaluation. Endothelium-dependent vasodilatation was assessed by flow-mediated dilatation (FMD) of the radial artery before and after 20 min ischemia-reperfusion during intra-arterial infusion of the arginase inhibitor (Nω-hydroxy-nor-L-arginine, 0.1 mg/min) or saline.

RESULTS

The forearm ischemia-reperfusion was well tolerated. Endothelium-independent vasodilatation was assessed by sublingual nitroglycerin. Ischemia-reperfusion decreased FMD in patients with CAD from 12.7±5.2% to 7.9±4.0% during saline administration (P<0.05). Nω-hydroxy-nor-L-arginine administration prevented the decrease in FMD in the CAD group (10.3±4.3% at baseline vs. 11.5±3.6% at reperfusion). Ischemia-reperfusion did not significantly reduce FMD in patients with CAD + type 2 diabetes. However, FMD at reperfusion was higher following nor-NOHA than following saline administration in both groups (P<0.01). Endothelium-independent vasodilatation did not differ between the occasions.

CONCLUSIONS

Inhibition of arginase protects against endothelial dysfunction caused by ischemia-reperfusion in patients with CAD. Arginase inhibition may thereby be a promising therapeutic strategy in the treatment of ischemia-reperfusion injury.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Coronary artery disease screening in type II diabetic patients: prognostic value of rest and stress echocardiography

AIM

Presence of inducible ischemia in type II diabetic patients is associated with an adverse outcome, but less is known about prognostic value of resting wall motion abnormalities (WMA).

MATERIALS AND METHODS

From October 2006 to May 2008, 278 patients underwent to CAD screening, according to ADA criteria, by dobutamine stress echocardiography (DSE). Between July and September 2009, all patients were contacted to verify the occurrence of new cardiac events.

RESULTS

Resting-WMA were present in 63 patients; 88 subjects showed inducible ischemia. During the follow-up, we observed 24 new cardiac events; patients with a good outcome showed less frequently resting WMA (19 vs 50%). Inducible ischemia (71% vs 28%; p<0.001) and a more extensive area of inducible ischemia, expressed by a higher value of peak WMSI (1.63±0.45 vs 1.17±0.31; p<0.0001), were more frequent in patients with adverse outcome. A Cox regression analysis showed that only a higher peak WMSI (HR 6.645, 95% CI 2.782-15.874, p<0.0001) was associated with a bad outcome. Event-free survival was lower in presence of rest WMA (79% vs 94%, p<0.0001) and a higher peak WMSI (66% vs 95%, p<0.0001).

CONCLUSIONS

In diabetic patients presence of an extensive inducible ischemia was independently associated with a worst outcome; resting WMA were associated with reduced event-free survival.

Clinical impact of acute hyperglycemia on development of diabetes mellitus in non-diabetic patients with acute myocardial infarction

BACKGROUND

Acute hyperglycemia (AH) after the onset of acute myocardial infarction (AMI) is a manifestation of transient abnormal glucose metabolism that may reflect AMI severity, and thus be a predictor of poor prognosis. However, it remains unknown whether AH may predict development of de novo diabetes mellitus (dn-DM) in non-diabetic AMI patients.

METHODS AND RESULTS

Among AMI patients registered in the Osaka Acute Coronary Insufficiency Study between 1998 and 2007, we investigated hospital records of 1493 patients who had an admission glycated hemoglobin A1c (HbA1c) level of ≤6.0% and were subjected to glycometabolic profiling after survival discharge. dn-DM was defined as initiation of diabetic medication or documentation of an HbA1c level of ≥6.5% during the 5-year follow-up period. AH, defined as an admission serum glucose level of ≥200mg/dl, was observed in 133 (8.9%) patients. dn-DM development was more frequent in post-AMI patients with AH than those without [24.8% vs 12.0%, adjusted hazard ratio (HR) 1.776, p=0.021], particularly among patients with an HbA1c of <5.6% on admission. Treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was associated with a reduced incidence of dn-DM in patients with AH (adjusted HR 0.397, p=0.031).

CONCLUSION

Admission AH was a predictor of dn-DM in non-diabetic post-AMI patients. Renin-angiotensin system inhibitors were associated with reduced incidence of dn-DM in post-AMI patients with AH.

Clinical manifestation of early phase left ventricular rupture complicating acute myocardial infarction in the primary PCI era

OBJECTIVE

Before reperfusion therapy was introduced, the incidence of ventricular septal and left ventricular free wall rupture complicating acute myocardial infarction (AMI) was 1-3%. Primary percutaneous coronary intervention (PCI) was expected to reduce the incidence of such mechanical complications.

METHODS

We retrospectively analysed 1290 AMI patients referred to our institute from January 2005 to January 2011. Primary PCI was done in 1002 cases of the study patients (77.7%).

RESULTS

Ventricular septal rupture (VSR) occurred in 19 cases (1.5%) and left ventricular free wall rupture (LVFR) in 17 cases (1.3%). Mean observation periods from onset to VSR and LVFR were 2.6 days. We demonstrated that risk factors for LV rupture were advanced age, female sex, absence of history of angina or myocardial infarction, lack of previous PCI, and absence of previous hypertension. Coronary angiography revealed that the culprit lesions of the left anterior descending artery or single vessel disease were the risk factors for LV rupture. Furthermore, in the present observation, 9 patients (47.4%) with VSR and 8 patients (47.1%) with LVFR developed LV rupture within 24h after symptoms onset (early rupture). The early rupture demonstrated extremely poor outcome compared with late rupture (in-hospital mortality was 88.2% in early rupture and 63.1% in late rupture).

CONCLUSION

Even in the patients' cohort with higher prevalence of primary PCI, LV rupture cases were not decreased in contrast to our expectations. More attention should be paid to early LV rupture cases within 24 h from symptom onset in those cases.

Efficacy of the combination of amlodipine and candesartan in hypertensive patients with coronary artery disease: a subanalysis of the HIJ-CREATE study

BACKGROUND

The effects of the combination of angiotensin II receptor blocker (ARB) plus dihydropyridine calcium channel blockers (DHP-CCBs), which is known as a potent antihypertensive drug regimen, on cardiovascular events remain unclear.

OBJECTIVE

The purpose of this post hoc subgroup analysis was to compare the incidence of major adverse cardiovascular events (MACE) of patients treated with candesartan and amlodipine with that of those with candesartan and non-amlodipine CCBs in hypertensive patients with coronary artery disease (CAD).

METHODS

HIJ-CREATE was a multicenter, prospective, randomized, controlled study that compared the effects of candesartan-based with those of non-ARB-based standard therapy on MACE in 2049 hypertensive patients with CAD. In the candesartan group, a total of 335 patients were treated with DHP-CCBs (amlodipine: 170 and non-amlodipine-CCBs: 165) at the baseline. In this sub-analysis, we compared, among the participants allocated to candesartan regimen, the long-term effects of amlodipine and non-amlodipine CCBs that were concomitantly given with ARB, although the choice of CCB was not randomized.

RESULTS

The median follow-up was 3.9 years. Treatment using amlodipine with candesartan reduced the risk of MACE by 38% (hazard ratio, 0.62; 95% confidence interval, 0.41-0.94, p=0.025), as compared to patients treated with non-amlodipine-CCBs and candesartan. In a multivariate analysis, combination therapy of candesartan with amlodipine was an independent predictor of reduced risk of MACE.

CONCLUSIONS

The results suggest that the combination of amlodipine and candesartan is more beneficial in reducing MACE in hypertensive patients with CAD compared to non-amlodipine-DHP-CCBs in combination therapy with candesartan. Further investigation in larger-scale prospective randomized studies is required to reach any conclusion as to the superiority of combination therapy of candesartan with amlodipine.

Gender differences in the impact of diabetes on mortality in patients with established coronary artery disease: a report from the eastern Taiwan integrated health care delivery system of Coronary Heart Disease (ET-CHD) registry, 1997-2006

OBJECTIVES

The effect of type 2 diabetes mellitus (DM) on mortality was more pronounced in women than men with coronary artery disease (CAD) in the pre-stent era before 1996. However this relationship is controversial in the post-stent era.

METHODS

We studied a cohort of 1073 patients with angiographically defined CAD from the Eastern Taiwan integrated health care delivery system of Coronary Heart Disease (ET-CHD) registry during 1997-2003 in Tzu-Chi General Hospital, Hualien, Taiwan. To evaluate gender-specific DM effect on mortality, the subjects were divided into 4 groups: diabetic women (n=147), non-diabetic women (n=127), diabetic men (n=239), and non-diabetic men (n=560). At a mean follow-up of 5.4 years, cardiac and all-cause mortality were the primary end points.

RESULTS

Annual total mortality rates were 10.2%, 5.1%, 7.2%, and 4.8%; annual cardiac mortality rates were 8.2%, 3.0%, 4.3%, and 2.6% for diabetic women, non-diabetic women, diabetic men, and non-diabetic men, respectively. Multivariate Cox regression models, adjusted for possible confounders showed that gender-specific hazard ratios (HRs) of DM for total mortality were 2.02 (95% CI: 1.32-3.09), and 1.72 (95% CI: 1.32-2.25) for women and men, respectively. The HRs for total mortality associated with diabetes were not different between women and men (p=0.53). Similarly, adjusted gender-specific HRs of DM for cardiac mortality were 2.46 (95% CI: 1.45-4.19) for women, and 1.83 (95% CI: 1.28-2.62) for men, which were also not significantly different (p=0.36).

CONCLUSIONS

Among patients with CAD, the impact of DM on mortality was consistently higher in women than in men, but the differences across sexes were not statistically significant after 1996 in Taiwan.