Predictors of coronary intervention-related myocardial infarction in stable angina patients pre-treated with statins

Comparison between In-Hospital and Out-of-Hospital Acute Myocardial Infarctions: Results from the Regional Myocardial Infarction Registry of Saxony-Anhalt (RHESA) Study

AIMS

Risk factors and outcomes of in-hospital ST elevation myocardial infraction (STEMI) are well explored. Recent findings show that non-ST elevation myocardial infarction (NSTEMI) accounts for the majority of in-hospital infarctions (IHMIs). Our aim was to identify differences between IHMI and out-of-hospital myocardial infraction (OHMI) in terms of risk factors, treatment and outcomes, including both STEMI and NSTEMI.

METHODS

We analyzed the Regional Myocardial Infarction Registry of Saxony-Anhalt dataset. Patient characteristics, treatments and outcomes were compared between IHMI and OHMI. The association between clinical outcomes and myocardial infarction type was assessed using generalized additive models.

RESULTS

Overall, 11.4% of the included myocardial infractions were IHMI, and the majority were NSTEMI. Patients with IHMI were older and had more comorbidities than those with OHMI. Compared to OHMI, in-hospital myocardial infarction was associated with higher odds of 30-day mortality (OR = 1.85, 95% CI 1.32-2.59) and complications (OR = 2.36, 95 % CI 1.84-3.01).

CONCLUSIONS

We provided insights on the full spectrum of IHMI, in both of its classifications. The proportion of IHMI was one ninth of all AMI cases treated in the hospital. Previously reported differences in the baseline characteristics and treatments, as well as worse clinical outcomes, in in-hospital STEMI compared to out-of-hospital STEMI persist even when including NSTEMI cases.

[In-hospital Myocardial Infarction: Scale of the Problem]

All cases of acute myocardial infarction (AMI) can be divided into outpatient-onset AMI and in-hospital-onset AMI depending on the place and circumstances of their development. In this review we consider the problem of in-hospital AMI. Special attention is paid to specific features of its clinical manifestations and the scale of the clinical problem. Possible causes of difficulties in the diagnosis and treatment of this condition are presented in comparison with those in patients with outpatient-onset AMI.

Inpatient versus outpatient onsets of acute myocardial infarction

BACKGROUND

There are few studies on patients suffering acute myocardial infarction (AMI) when already in hospital for other reasons; therefore, this study aimed to compare patients with in-hospital-onset AMI admitted for either medical or surgical reasons versus patients with outpatient-onset AMI.

METHODS

Patients enrolled in the AMIS Plus registry from 2002 to 2014 were analyzed. The main endpoint was in-hospital mortality.

RESULTS

Among 35,394 AMI patients, 356 (1%) had inpatient-onset AMI following hospital admission due to other pathologies (surgical 175, non-surgical 181). These patients were older (74 vs. 66 years; P<0.001), more often female (35% vs. 27%; P<0.001), had less frequently ST-elevation myocardial infarction (35.5% vs. 55.5%; P<0.001), but higher risk profiles: hypertension (83% vs. 62%; P<0.001), diabetes (28% vs. 20%; P=0.001), known coronary artery disease (54% vs. 35%; P<0.001), and more comorbidities (Charlson Comorbidity Index above 1 in 51% vs. 22%; P<0.001) than those with outpatient-onset AMI. Percutaneous coronary intervention was less frequently applied (OR 0.45; 95% CI 0.36-0.57), and they were less likely to be treated with aspirin (OR 0.43; 95% CI 0.37-0.59), P2Y12 blockers (OR 0.42; 0.34-0.52) or statins (OR 0.51; 95% CI 0.41-0.63). Crude mortality was higher (14.3% vs. 5.5%; P<0.001) and inpatient-onset AMI was an independent predictor of in-hospital mortality (OR 2.35; 95% CI 1.63-3.39; P<0.001).

CONCLUSIONS

Patients with in-hospital-onset AMI were at greater risk of death than those with outpatient-onset AMI. More work is needed to improve the identification of hospitalized patients at risk of AMI in order to provide the appropriate management.

Cardiac remote ischaemic preconditioning reduces periprocedural myocardial infarction for patients undergoing percutaneous coronary interventions: a meta-analysis of randomised clinical trials

AIMS

To establish the cardioprotective effect of remote ischaemic preconditioning (RIPC) in patients undergoing percutaneous coronary intervention (PCI).

METHODS AND RESULTS

Pubmed (MEDLINE), Cochrane and Embase were systematically searched for randomised controlled trials of RIPC in patients undergoing PCI. Periprocedural myocardial infarction (PMI) was the primary endpoint (defined as troponin elevation >3 times upper reference limit) and C-reactive protein (CRP) was a secondary endpoint. Five studies with 731 patients were included. The median age of the patients was 62 (59-68) years old, 25% were female (23-33), 29% (25-33) had diabetes mellitus, and 26.5% (19-31) presented with multivessel disease. RIPC significantly reduced the incidence of PMI (odds ratio: 0.58 [0.36, 0.93]; I2 43%), with a greater benefit when performed using the lower limb (0.21 [0.07-0.66]) compared to the upper limb (0.67 [0.46-0.99]). This reduction was enhanced for patients with multivessel disease (beta -0.05 [-0.09;-0.01], p=0.01) and with type C lesion (beta -0.014 [-0.04;-0.010], p=0.01) and did not vary according to age, female gender, diabetes mellitus, use of beta-blockers and of angiotensin converting enzyme inhibitors. Absolute risk difference was -0.10 [-0.19, -0.02], with a number needed to treat of 10 [6-50] patients to avoid one event. CRP -0.69 [-1.69, 0.31] was not significantly reduced by RIPC.

CONCLUSIONS

RIPC reduced the incidence of PMI following PCI, especially when performed in the lower limb and for patients with multivessel disease and complex lesions.

Efficacy and safety of a biodegradable polymer sirolimus-eluting stent in primary percutaneous coronary intervention: a randomized controlled trial

INTRODUCTION

With long-term follow-up, whether biodegradable polymer drug-eluting stents (DES) is efficient and safe in primary percutaneous coronary intervention (PCI) remains a controversial issue. This study aims to assess the long-term efficacy and safety of DES in PCI for ST-segment elevation myocardial infarction (STEMI).

MATERIAL AND METHODS

A prospective, randomized single-blind study with 3-year follow-up was performed to compare biodegradable polymer DES with durable polymer DES in 332 STEMI patients treated with primary PCI. The primary end point was major adverse cardiac events (MACE) at 3 years after the procedure, defined as the composite of cardiac death, recurrent infarction, and target vessel revascularization. The secondary end points included in-segment late luminal loss (LLL) and binary restenosis at 9 months and cumulative stent thrombosis (ST) event rates up to 3 years.

RESULTS

The rate of the primary end points and the secondary end points including major adverse cardiac events, in-segment late luminal loss, binary restenosis, and cumulative thrombotic event rates were comparable between biodegradable polymer DES and durable polymer DES in these 332 STEMI patients treated with primary PCI at 3 years.

CONCLUSIONS

Biodegradable polymer DES has similar efficacy and safety profiles at 3 years compared with durable polymer DES in STEMI patients treated with primary PCI.

Effect of statins on platelet function in patients with hyperlipidemia

INTRODUCTION

It is generally assumed that cholesterol reduction by statins is the predominant therapeutic result underlying their beneficial effects in cardiovascular disease. However, the action of statins may be partially independent of their effects on plasma cholesterol levels, as they combine lipid lowering with positive effects on hemorheological conditions and endothelial function. We evaluated the impact of statin treatment on platelet adhesion to fibrinogen (spontaneous and ADP-activated), along with ADP, collagen or ristocetin-induced aggregation in type II hyperlipidemic patients.

MATERIAL AND METHODS

The study group included 70 persons: 50 patients affected by type II hyperlipidemia without concomitant diseases and 20 healthy volunteers. The effects of 8-week statin treatment (atorvastatin 10 mg/day, simvastatin 20 mg/day, or pravastatin 20 mg/day) on platelet activation were evaluated.

RESULTS

Regardless of the type of statin, a significant decrease in ADP-induced platelet aggregation was observed: for atorvastatin 50.6 ±12.8% vs. 41.1 ±15.8% (p < 0.05), for simvastatin 57.2 ±18.0% vs. 44.7 ±22.1% (p = 0.05), and for pravastatin 55.8 ±19.5% vs. 38.8 ±23.3% (p < 0.05). There was no significant effect of statins on collagen or ristocetin-induced platelet aggregation and adhesion.

CONCLUSIONS

Therapy with statins beneficially modifies ADP-induced platelet aggregation in patients with hyperlipidemia and does not affect spontaneous or ADP-induced platelet adhesion to fibrinogen and platelet aggregation induced by collagen or ristocetin.

Examination of serum pregnancy-associated plasma protein A clinical value in acute coronary syndrome prediction and monitoring

INTRODUCTION

Chronic vascular inflammatory process promotes and intensifies all atherogenic events. The aim of this research was to estimate the clinical value of pregnancy-associated plasma protein A (PAPP-A) measurement associated with plaque destabilization and rupture in prediction and monitoring of acute coronary syndromes (ACS) as well as to assess the predictive value of this biomarker in comparison to traditional myocardial infarction (MI) risk markers.

MATERIAL AND METHODS

The study included 119 patients in 2 investigated groups and one control group. PAPP-A assay was performed using manual ELISA kit, DRG. All other parameters were determined using automatic analyzers: Olympus and Dade Behring.

RESULTS

A statistically significant difference between PAPP-A concentration median value was found in the investigated group MI individuals' serum and control group individuals' serum (11.42 ng/ml and 7.22 ng/ml respectively, p = 0.003). PAPP-A assay had the highest specificity (83.3%) and sensitivity (53.8%), and therefore the highest clinical value. In patients with clinically and laboratory confirmed MI we proved that PAPP-A serum level is a clinically useful biomarker in ACS prediction, better than C-reactive protein (hsCRP) and fibrinogen (FBG) level.

CONCLUSIONS

The highest diagnostic efficiency for ACS prediction was proved for simultaneous panel assays consisting of 2-3 parameters (PAPP-A - hsCRP, PAPP-A - FBG, PAPP-A - hsCRP - FBG), while PAPP-A itself does not show characteristics necessary for it to be used as a biomarker for MI dynamic monitoring. It is possible that prothrombotic component is mainly responsible for repeated major adverse cardiac events, more than inflammatory process.