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Pilgrim T, Maznyczka A. Strategies to minimise bleeding secondary to large-bore vascular access complications: an ounce of prevention is worth a pound of cure. EUROINTERVENTION 2024; 20:e335-e337. [PMID: 38506740 PMCID: PMC10941668 DOI: 10.4244/eij-e-23-00063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Affiliation(s)
- Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annette Maznyczka
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Maznyczka A, Mozid A. The limited antegrade subintimal tracking technique to retrieve a trapped rotablator burr: a case report. Eur Heart J Case Rep 2024; 8:ytae044. [PMID: 38328602 PMCID: PMC10849080 DOI: 10.1093/ehjcr/ytae044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 01/06/2024] [Accepted: 01/23/2024] [Indexed: 02/09/2024]
Abstract
Background Burr entrapment is a rare, but potentially serious complication of rotablation. This report describes the percutaneous options available for Rota burr retrieval. Case summary A 62-year-old Caucasian man with stable angina presented for percutaneous coronary intervention. Attempted rotablation with a 1.75 mm burr resulted in Rota burr entrapment, in the heavily calcified proximal right coronary artery. A chronic total occlusion angioplasty technique (limited antegrade subintimal tracking) was successfully used to remove the trapped Rota burr, by enabling subintimal dilatation to externally crush plaque and dislodge the burr. The angioplasty procedure was then completed using the wire that had a short subintimal passage, before re-entering the true lumen. Discussion The mechanism for Rota burr entrapment, in this case, was initiating rotablation on the heavily calcified lesion and not more proximal to allow a pecking motion. The learning points are (i) to start the rotablator several millimetres proximal to the actual lesion, and (ii) if unable to wire alongside a trapped Rota burr in the true lumen, then subintimal crossing and balloon dilatation in the subintimal space may work to dislodge the burr.
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Affiliation(s)
- Annette Maznyczka
- Swiss Cardiovascular Center, Bern University Hospital, Freiburgstrasse 18, Bern CH-3010, Switzerland
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Maznyczka A, Pilgrim T. Antithrombotic Treatment After Transcatheter Valve Interventions: Current Status and Future Directions. Clin Ther 2024; 46:122-133. [PMID: 37926630 DOI: 10.1016/j.clinthera.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/15/2023] [Accepted: 09/29/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE The optimal antithrombotic strategy after transcatheter valve interventions is a subject of ongoing debate. Although there is evidence from randomized trials in patients undergoing transcatheter aortic valve replacement (TAVR), current evidence on optimal antithrombotic management after transcatheter mitral or tricuspid valve interventions is sparse. This article appraises the current evidence on this topic. METHODS This narrative review presents key research findings and guideline recommendations, as well as highlights areas for future research. FINDINGS After TAVR, randomized trial evidence suggests that single antiplatelet therapy is reasonable for patients without pre-existing indications for oral anticoagulation (OAC). If there is a concurrent indication for OAC, the addition of antiplatelet therapy increases bleeding risk. Whether direct oral anticoagulants achieve better outcomes than vitamin K antagonists is uncertain in this setting. Although OAC has been shown to reduce subclinical leaflet thrombosis (which may progress to structural valve degeneration), bleeding events are unacceptably high. There is a lack of randomized trial data comparing antithrombotic strategies after transcatheter mitral or tricuspid valve replacement or after mitral or tricuspid transcatheter edge-to-edge repair. Single antiplatelet therapy after mitral or tricuspid transcatheter edge-to-edge repair may be appropriate, whereas at least 3 months of OAC is suggested after transcatheter mitral valve replacement or transcatheter tricuspid valve replacement. IMPLICATIONS Randomized studies are warranted to address the knowledge gaps in antithrombotic therapy after transcatheter valve interventions and to optimize outcomes.
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Affiliation(s)
- Annette Maznyczka
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Bern University Hospital, Bern, Switzerland.
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Maznyczka A, Arockiam S, Bulluck H, Mozid A. Follow-up optical coherence tomography to evaluate circumflex ostium after fenestration of left main Papyrus covered stent: a case report. Eur Heart J Case Rep 2023; 7:ytad415. [PMID: 37662583 PMCID: PMC10473851 DOI: 10.1093/ehjcr/ytad415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 08/03/2023] [Accepted: 08/16/2023] [Indexed: 09/05/2023]
Abstract
Background Left main (LM) perforations necessitating a covered stent risk sacrificing the side branch. The lost side branch can be promptly recovered by fenestration of the covered stent, using a stiff wire. However, it is unclear whether subsequent balloon angioplasty of the recovered side branch ostium is sufficient to preserve side branch patency. We report the longer-term patency of the circumflex (LCx) ostium after LM covered stenting. Case summary A 78-year-old lady, with stable angina, presented for elective angiography. Percutaneous coronary intervention of the left anterior descending (LAD) artery to LM was complicated by a distal LM perforation. A covered stent across the LM sealed the perforation but resulted in acute occlusion of the LCx. The LCx was rescued by fenestration of the covered stent with a stiff wire, followed by balloon angioplasty to the LCx ostium. At follow-up, the angina had resolved. However, follow-up angiography demonstrated a new severe stenosis at the LCx ostium, with remnants of the polyurethane membrane seen protruding into the LCx ostium on optical coherence tomography. Therefore, the LCx ostium was stented, using the reverse Culotte technique. Conclusion This case demonstrates that stenting the LCx ostium should be considered after covered stent implantation from LM to LAD, because balloon angioplasty of the LCx ostium may not provide a durable result in this scenario.
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Affiliation(s)
- Annette Maznyczka
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds LS1 3EX, UK
| | - Sacchin Arockiam
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds LS1 3EX, UK
| | - Heerajnarain Bulluck
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds LS1 3EX, UK
| | - Abdul Mozid
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds LS1 3EX, UK
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Maznyczka A, Arunothayaraj S, Egred M, Banning A, Brunel P, Ferenc M, Hovasse T, Wlodarczak A, Pan M, Schmitz T, Silvestri M, Erglis A, Kretov E, Lassen JF, Chieffo A, Lefevre T, Burzotta F, Cockburn J, Darremont O, Stankovic G, Morice MC, Louvard Y, Hildick-Smith D. Bifurcation left main stenting with or without intracoronary imaging: Outcomes from the EBC MAIN trial. Catheter Cardiovasc Interv 2023; 102:415-429. [PMID: 37473405 DOI: 10.1002/ccd.30785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/10/2023] [Accepted: 07/12/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND The impact of intracoronary imaging on outcomes, after provisional versus dual-stenting for bifurcation left main (LM) lesions, is unknown. OBJECTIVES We investigated the effect of intracoronary imaging in the EBC MAIN trial (European Bifurcation Club LM Coronary Stent study). METHODS Four hundred and sixty-seven patients were randomized to dual-stenting or a stepwise provisional strategy. Four hundred and fifty-five patients were included. Intravascular ultrasound (IVUS) or optical coherence tomography (OCT) was undertaken at the operator's discretion. The primary endpoint was death, myocardial infarction or target vessel revascularization at 1-year. RESULTS Intracoronary imaging was undertaken in 179 patients (39%; IVUS = 151, OCT = 28). As a result of IVUS findings, operators reintervened in 42 procedures. The primary outcome did not differ with intracoronary imaging versus angiographic-guidance (17% vs. 16%; odds ratio [OR]: 0.92 (95% confidence interval [CI]: 0.51-1.63) p = 0.767), nor for reintervention based on IVUS versus none (14% vs. 16%; OR: 0.88 [95% CI: 0.32-2.43] p = 0.803), adjusted for syntax score, lesion calcification and ischemic symptoms. With angiographic-guidance, primary outcome events were more frequent with dual versus provisional stenting (21% vs. 10%; adjusted OR: 2.11 [95% CI: 1.04-4.30] p = 0.039). With intracoronary imaging, there were numerically fewer primary outcome events with dual versus provisional stenting (13% vs. 21%; adjusted OR: 0.56 [95% CI: 0.22-1.46] p = 0.220). CONCLUSIONS In EBC MAIN, the primary outcome did not differ with intracoronary imaging versus none. However, in patients with angiographic-guidance, outcomes were worse with a dual-stent than provisional strategy When intracoronary imaging was used, there was a trend toward better outcomes with the dual-stent than provisional strategy.
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Affiliation(s)
| | | | | | | | | | - Miroslaw Ferenc
- Universitats-Herzzentrum Bad Krozingem, Bad Krozingen, Germany
| | | | | | - Manuel Pan
- Department of Cardiology, Reina Sofia Hospital, (IMIBIC), University of Cordoba, Cordoba, Spain
| | | | | | | | - Evgeny Kretov
- Sibirsky Federal Biomedical Research Center Novosibrisk, Novosibirsk, Russia
| | | | | | | | - Francesco Burzotta
- Fondazione Policlinico Universitario A. Genelli, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - James Cockburn
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK
| | | | - Goran Stankovic
- Departmenet of Cardiology, Clinical Centre of Serbia, University of Belgrade, Belgrade, Serbia
| | | | - Yves Louvard
- Institute Cardiovasculaire Paris Sud, Massy, France
| | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, UK
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Arockiam S, Staniforth B, Kepreotis S, Maznyczka A, Bulluck H. A Contemporary Review of Antiplatelet Therapies in Current Clinical Practice. Int J Mol Sci 2023; 24:11132. [PMID: 37446310 DOI: 10.3390/ijms241311132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
Antiplatelet therapy plays a crucial role in a number of cardiovascular disorders. We currently have a range of antiplatelet agents in our armamentarium. In this review, we aim to summarise the common antiplatelet agents currently available, and their use in clinic practice. We not only highlight recent trials exploring antiplatelet therapy in atherosclerotic cardiovascular disease, but also in trials related to transcatheter aortic valve implantation and coronavirus disease 2019. Inevitably, the antithrombotic benefits of these drugs are accompanied by an increase in bleeding complications. Therefore, an individualised approach to weighing each patient's thrombotic risk versus bleeding risk is imperative, in order to improve clinical outcomes.
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Affiliation(s)
- Sacchin Arockiam
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Brittany Staniforth
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Sacha Kepreotis
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Annette Maznyczka
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Heerajnarain Bulluck
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK
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Maznyczka A, Arunothayaraj S, Egred M, Banning A, Brunel P, Ferenc M, Hovasse T, Wlodarczak A, Pan M, Schmitz T, Silvestri M, Erglis A, Kretov E, Lassen J, Chieffo A, Lefevre T, Burzotta F, Cockburn J, Darremont O, Stankovic G, Morice MC, Louvard Y, Hildick-Smith D. TCT-54 Bifurcation Left Main Coronary Stenting With or Without Intracoronary Imaging: Outcomes From the European Bifurcation Club Left Main Trial. J Am Coll Cardiol 2022. [DOI: 10.1016/j.jacc.2022.08.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Maznyczka A, Rajkumar C, Hobson A, Haworth PA. Effect of coronary tortuosity on invasive physiology. BMJ Case Rep 2022; 15:15/6/e249095. [PMID: 35688575 PMCID: PMC9189850 DOI: 10.1136/bcr-2022-249095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present a case of angina, where extreme coronary tortuosity affected invasive physiology interpretation. Extreme coronary tortuosity may lower fractional flow reserve and instantaneous wave-free ratio. Therefore, invasive physiology can be misleading in this setting, when used to evaluate stenosis significance, or when used post-percutaneous coronary (PCI) intervention for physiology guided stent optimisation.
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Affiliation(s)
- Annette Maznyczka
- Department of Cardiology, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Christopher Rajkumar
- Department of Cardiology, Imperial College London National Heart and Lung Institute, London, UK
| | - Alex Hobson
- Department of Cardiology, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Peter Aj Haworth
- Department of Cardiology, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
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Mahadevan K, Sharma D, Walker C, Maznyczka A, Hobson A, Strike P, Griffiths H, Dana A. Impact of paramedic education on door-to-balloon times and appropriate use of the primary PCI pathway in ST-elevation myocardial infarction. BMJ Open 2022; 12:e046231. [PMID: 35210332 PMCID: PMC8883211 DOI: 10.1136/bmjopen-2020-046231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Evidence supports improved outcomes and reduced mortality with rapid reperfusion through primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI). UK national audit data (Myocardial Ischaemia National Audit Project [MINAP]) demonstrates minor improvements in door-to-balloon times (DTB) of <90 min but increasing call-to-balloon times (CTB). We evaluate the effect of a regional Cardiologist delivered paramedic education programme (PEP) on DTB times and appropriate use of the PPCI pathway. METHODS This was a prospective single-centre study of patients with STEMI brought directly to hospital via ambulance services. Data sources included ambulance charts, in-patient notes, British Cardiovascular Interventional Society (BCIS) database and local MINAP data. All DTB breaches were investigated. A local PEP was implemented with focus on ECG interpretation, STEMI diagnosis and appropriate use of the PPCI pathway. Non-parametric Wilcoxon rank test was used for comparisons of DTB and CTB times between direct versus ED-associated cath lab transfer. RESULTS A total of 728 patients with STEMI were admitted directly to our centre via ambulance, 66% (n=484) directly to the Catheterisation Laboratory (Cath Lab) and 34% (n=244) via the Emergency Department (ED). There was a significant increase in median DTB, 83 vs 37 min (p<0.001) and median CTB 144 vs 97.5 min (p<0.001) when transfer to the Cath Lab occurred via the ED versus direct transfer. The PEP increased direct cath lab transfers (52%-85%) and generated annual reductions in median DTB times, with sustained improvement seen throughout the 7-year study period. CONCLUSIONS Paramedic education increases direct transfer of STEMI patients to the Cath Lab, and reduces DTB times. This is an effective and reproducible intervention to facilitate timely reperfusion in STEMI.
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Affiliation(s)
- Kalaivani Mahadevan
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Divyesh Sharma
- Department of Cardiology, Altnagelvin Hospitals Health and Social Services Trust, Londonderry, UK
| | - Christopher Walker
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Annette Maznyczka
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Alex Hobson
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Philip Strike
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Huw Griffiths
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Ali Dana
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
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McCartney P, Ang D, Mangion K, Maznyczka A, McEntegart M, Eteiba H, Greenwood J, Muir D, Chowdhary S, Appleby C, Cotton J, Wragg A, Curzen N, Oldroyd K, Good R, Robertson K, Ford T, Collison D, Gillespie L, Petrie M, Weir R, Macfarlane P, Ford I, McConnachie A, Berry C. TCT-189 Effect of Low-Dose Intracoronary Alteplase on Global Circumferential Strain: Myocardial Strain Cardiovascular Magnetic Resonance Substudy of the T-TIME Trial. J Am Coll Cardiol 2021. [DOI: 10.1016/j.jacc.2021.09.1042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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McCartney P, Ang D, Mangion K, McEntegart M, Greenwood JP, Muir D, Chowdhary S, Appleby C, Cotton JM, Eteiba H, Oldroyd KG, Maznyczka A, Radjenovic A, McConnachie A, Berry C. Effect of low dose intracoronary alteplase on global circumferential strain (myocardial strain CMR substudy from the T-TIME trial). Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Microvascular obstruction affects half of patients with ST-segment elevation myocardial infarction (STEMI) and confers an adverse prognosis. Feature-tracking (FT) cardiac magnetic resonance (CMR) allows myocardial strain assessment from standard cine images without the need for specialist sequences. Myocardial strain reflects both systolic and diastolic function allowing the assessment of both global and regional myocardial deformation. Strain recovery is impaired in patients with microvascular obstruction. There is growing evidence to suggest that global circumferential strain may offer incremental value beyond traditional CMR endpoints.
Purpose
We aimed to determine whether a therapeutic strategy involving low-dose intracoronary alteplase improves global circumferential strain in STEMI.
Methods
Between March 17, 2016, and December 21, 2017, 440 patients presenting at 11 hospitals in the United Kingdom within 6 hours of STEMI were randomised in a 1:1:1 dose-ranging trial design. Participants were randomly assigned to treatment with placebo (n=151), alteplase 10mg (n=144), or alteplase 20mg (n=145). The primary outcome was the amount of microvascular obstruction (%left ventricular mass) quantified by CMR at 2–7 days. Global circumferential strain was a prespecified secondary endpoint measured at 2–7 days and 3 months. Troponin T AUC was measured at 0, 2, and 24 hours post reperfusion. Patients were followed up to 1 year with all events adjudicated by an independent committee.
Results
Among the 440 patients who were randomised (mean age 60.5 years; 85% male), the primary endpoint was achieved in 396 (90%), all patients were followed up to 1 year for clinical events. The amount (mean, standard deviation) of microvascular obstruction was not different between the groups (2.3% vs. 2.6% vs. 3.5% left ventricular mass); p=0.28. Global circumferential strain was worse in patients receiving alteplase. −23.1% (placebo) vs −20.6 (10mg alteplase) vs −22.0% (20mg alteplase); mean difference for both doses combined vs placebo: 1.8% (95% CI 0.5, 3.2), p=0.009. There were no differences between groups in the other CMR endpoints including LV ejection fraction (LVEF). The area-under-the-curve for troponin T measured in 317 (72%) patients was increased in both treatment groups compared to placebo, mean difference 1.53 (95% CI: 1.16, 2.01), p=0.002. There were no differences in MACE at 1 year; placebo n=16 (10.6%), 10mg alteplase n=22 (15.3%), 20mg alteplase group n=15 (10.3%).
Conclusion
In patients presenting within 6 hours of STEMI, low-dose intracoronary alteplase compared with placebo did not reduce microvascular obstruction. There was a reduction in global circumferential strain and an increase in Troponin T AUC supporting an increase in myocardial injury early after reperfusion in patients receiving alteplase. There was no differences in MACE at one year suggesting no long-term clinical sequelae.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): T-TIME was supported by grant 12/170/4 from the Efficacy and Mechanism Evaluation (EME) programme of the National Institute for Health Research (NIHR-EME). Boehringer-Ingelheim U.K. Ltd. provided the study drugs (alteplase 10mg, 20mg), matched placebo, and sterile water for injection. Study recruitment flowchartTable- Study endpoints
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Affiliation(s)
- P McCartney
- Golden Jubilee national hospital, Glasgow, United Kingdom
| | - D Ang
- Golden Jubilee national hospital, Glasgow, United Kingdom
| | - K Mangion
- University of Glasgow, ICAMS, Glasgow, United Kingdom
| | - M McEntegart
- Golden Jubilee national hospital, Glasgow, United Kingdom
| | | | - D Muir
- James Cook University Hospital, Middlesbrough, United Kingdom
| | - S Chowdhary
- Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - C Appleby
- Cardiothoracic Centre Trust of Liverpool, Liverpool, United Kingdom
| | - J M Cotton
- New Cross Hospital, Wolverhampton, United Kingdom
| | - H Eteiba
- Golden Jubilee national hospital, Glasgow, United Kingdom
| | - K G Oldroyd
- Golden Jubilee national hospital, Glasgow, United Kingdom
| | - A Maznyczka
- Golden Jubilee national hospital, Glasgow, United Kingdom
| | - A Radjenovic
- University of Glasgow, ICAMS, Glasgow, United Kingdom
| | - A McConnachie
- Cardiovascular Research Centre of Glasgow, Glasgow, United Kingdom
| | - C Berry
- University of Glasgow, ICAMS, Glasgow, United Kingdom
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12
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Maznyczka A, Carrick D, Oldroyd KG, James-Rae G, McCartney P, Greenwood J, Good R, McEntegart MB, Eteiba H, Lindsay M, Cotton J, Petrie M, Berry C. Thermodilution-derived temperature recovery time: a novel predictor of microvascular reperfusion and prognosis after myocardial infarction. EUROINTERVENTION 2021; 17:220-228. [PMID: 32122822 PMCID: PMC9724875 DOI: 10.4244/eij-d-19-00904] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Novel parameters that detect failed microvascular reperfusion might identify better the patients likely to benefit from adjunctive treatments during primary percutaneous coronary intervention (PCI). AIMS The aim of this study was to test the hypothesis that a novel invasive parameter, the thermodilution-derived temperature recovery time (TRT), would be associated with microvascular obstruction (MVO) and prognosis. METHODS TRT was derived and validated in two independent ST-elevation myocardial infarction populations and was measured immediately post PCI. TRT was defined as the duration (seconds) from the nadir of the hyperaemic thermodilution curve to 20% from baseline body temperature. MVO extent (% left ventricular mass) was assessed by cardiovascular magnetic resonance imaging at 2-7 days. RESULTS In the retrospective derivation cohort (n=271, mean age 60±12 years, 72% male), higher TRT was associated with more MVO (coefficient: 4.09 [95% CI: 2.70-5.48], p<0.001), independently of IMR >32, CFR ≤2, hyperaemic Tmn >median, thermodilution waveform, age and ischaemic time. At five years, higher TRT was multivariably associated with all-cause death/heart failure hospitalisation (OR 4.14 [95% CI: 2.08-8.25], p<0.001) and major adverse cardiac events (OR 4.05 [95% CI: 2.00-8.21], p<0.001). In the validation population (n=144, mean age 59±11 years, 80% male), the findings were confirmed prospectively. CONCLUSIONS TRT represents a novel diagnostic advance for predicting MVO and prognosis. ClinicalTrials.gov Identifiers: NCT02072850 & NCT02257294 Visual summary. Thermodilution-derived temperature recovery time (TRT): a novel predictor of microvascular reperfusion & prognosis after STEMI. CMR: cardiovascular magnetic resonance; MACE: major adverse cardiac events; MVO: microvascular obstruction; PCI: percutaneous coronary intervention; STEMI: ST-segment elevation myocardial infarction.
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Affiliation(s)
- Annette Maznyczka
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom,Portsmouth University Hospitals NHS Trust, Portsmouth, United Kingdom
| | - David Carrick
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Keith G. Oldroyd
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Greg James-Rae
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom
| | - Peter McCartney
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - John Greenwood
- Leeds University and Leeds Teaching Hospital NHS Trust, Leeds, United Kingdom
| | - Richard Good
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Margaret B. McEntegart
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Hany Eteiba
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Mitchell Lindsay
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - James Cotton
- Wolverhampton University Hospital NHS Trust, Wolverhampton, United Kingdom
| | - Mark Petrie
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom,West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Colin Berry
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, Scotland, United Kingdom
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Maznyczka A, Haworth PAJ. Adjunctive Intracoronary Fibrinolytic Therapy During Primary Percutaneous Coronary Intervention. Heart Lung Circ 2021; 30:1140-1150. [PMID: 33781699 DOI: 10.1016/j.hlc.2021.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 01/06/2021] [Accepted: 02/20/2021] [Indexed: 12/24/2022]
Abstract
Despite routinely restoring epicardial coronary patency, with primary percutaneous coronary intervention (PCI), microvascular obstruction affects approximately half of patients and confers an adverse prognosis. There are no evidence-based treatments for microvascular obstruction. A key contributor to microvascular obstruction is distal embolisation and microvascular thrombi. Adjunctive intracoronary fibrinolytic therapy may reduce thrombotic burden, potentially reducing distal embolisation of atherothrombotic debris to the microcirculation. In this review, the evidence from published randomised trials on the effects of adjunctive intracoronary fibrinolytic therapy during primary PCI is critically appraised, the ongoing randomised trials are described, and conclusions are made from the available evidence. Clinical uncertainties, to be addressed by future research, are highlighted.
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Affiliation(s)
- Annette Maznyczka
- Cardiology Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK; British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
| | - Peter A J Haworth
- Cardiology Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
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McCartney P, Maznyczka A, McEntegart M, Eteiba H, Greenwood J, Muir D, Chowdhary S, Gershlick A, Appleby C, Cotton J, Wragg A, Curzen N, Oldroyd K, Lindsay M, Rocchiccioli P, Shaukat A, Good R, Watkins S, Robertson K, Malkin CJ, Collison D, Gillespie L, Martin L, Ford T, Petrie M, Weir R, Murphy A, Petrie C, Wetherall K, Macfarlane P, McConnachie A, Berry C. TCT CONNECT-28 Left Ventricular End-Diastolic Pressure in Acute Myocardial Infarction, Association With Infarct Pathology, Left Ventricular Function, and Health Outcomes. J Am Coll Cardiol 2020. [DOI: 10.1016/j.jacc.2020.09.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Maznyczka A, McCartney P, Duklas P, Greenwood J, Muir D, Chowdhary S, Curzen N, McEntegart M, Oldroyd K, Gershlick A, Appleby C, Tait C, Cotton J, Wragg A, Sattar N, Fox K, Eteiba H, McConnachie A, Berry C. TCT CONNECT-16 Implications of Impaired Coronary Flow on the Effects of Intracoronary Alteplase During Primary Percutaneous Coronary Intervention. J Am Coll Cardiol 2020. [DOI: 10.1016/j.jacc.2020.09.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Maznyczka A, McCartney P, Oldroyd K, Greenwood J, Cotton J, Weir R, McConnachie A, Berry C. TCT CONNECT-15 Risk Stratification Guided by the Index of Microcirculatory Resistance and Left Ventricular End-Diastolic Pressure During Primary Percutaneous Coronary Intervention. J Am Coll Cardiol 2020. [DOI: 10.1016/j.jacc.2020.09.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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17
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Maznyczka A, McCartney P, Oldroyd KG, McEntegart M, Lindsay M, Eteiba H, Rocchiccioli P, Good R, Shaukat A, Kodoth V, Greenwood J, Robertson K, Cotton J, McConnachie A, Berry C. P2707Invasive coronary physiology during primary percutaneous coronary intervention in patients treated with intracoronary alteplase or placebo: the double-blind T-TIME physiology substudy. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.1024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Impaired microcirculatory reperfusion worsens prognosis post-primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). Intracoronary (IC) alteplase targets persisting thrombus post-reperfusion & distal embolisation. In the T-TIME trial microvascular obstruction on cardiac magnetic resonance (CMR) did not differ with IC alteplase vs placebo.
Purpose
To prospectively determine if index of microcirculatory resistance (IMR) is lower & coronary flow reserve (CFR) or resistive reserve ratio (RRR) are higher (improved) with IC alteplase, & to provide mechanistic insights.
Methods
A pre-planned substudy of the main protocol. From 2016–2017, STEMI patients from 3 UK hospitals ≤6 hrs ischaemic time were randomised in a 1:1:1 dose-ranging, double-blind design. Following standard care reperfusion, alteplase (10 or 20mg) or placebo was infused over 5–10 mins proximal to the culprit lesion pre-stenting. IMR (primary outcome), CFR & RRR (secondary outcomes) were measured in the culprit artery post-PCI. Physiology results were obscured from clinicians acquiring the data, to maintain blinding. CMR was performed 2 days & 3 months post-STEMI. Subgroup analyses were prespecified including by ischaemic time (<2 hours, 2–4 hrs, >4 hrs) & IMR threshold >32.
Results
In 144 patients (mean age 59 yrs, 80% male), IMR, CFR or RRR post-PCI did not differ with alteplase vs placebo (Table). Patients with ischaemic time <2 hrs had a dose related increase in CFR (placebo 1.2 [IQR 1.1–1.7], alteplase 10mg 1.4 [IQR 1.0–1.8], alteplase 20mg 2.0 [IQR 1.8–2.3] p=0.01 for interaction) & RRR (placebo 1.5 [IQR 1.3–1.9], alteplase 10mg 1.6 [1.1–2.2], alteplase 20mg 2.2 [2.0–2.6], p=0.03 for interaction). In subjects with post-PCI IMR>32, % ST-resolution at 60 mins was worse with alteplase 10mg vs placebo (23.1±53.9 vs 50.9±31.5) & in those with IMR≤32% ST-resolution at 60 mins was better with alteplase 20mg vs placebo (68.0±30.7 vs 39.1±43.2), p=0.002 for interaction. The CMR findings in the substudy & overall trial populations were consistent.
Main results Placebo Alteplase 10mg Alteplase 20mg (n=53) (n=41) (n=50) IMR, median (IQR) 33.0 (17.0–57.0) 22.0 (17.0–42.0) 37.0 (20.0–57.8) p=0.15 p=0.78 CFR, median (IQR) 1.3 (1.1–1.8) 1.4 (1.1–1.9) 1.5 (1.1–2.0) p=0.92 p=0.74 RRR, median (IQR) 1.6 (1.3–2.2) 1.6 (1.4–2.6) 1.8 (1.3–2.4) p=0.69 p=0.81 P-values for comparison of alteplase with placebo.
Conclusions
In acute STEMI with ischaemic time ≤6 hrs, IMR, CFR or RRR post-PCI did not differ with alteplase vs placebo. In those with shorter ischaemic times (<2 hrs) CFR & RRR, but not IMR, were improved with alteplase. We observed interactions between alteplase dose, ischaemic time & mechanisms of effect.
Acknowledgement/Funding
Dr Maznyczka is funded by a fellowship from the British Heart Foundation (FS/16/74/32573). T-TIME was funded by grant 12/170/4 from NIHR-EME
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Affiliation(s)
- A Maznyczka
- University of Glasgow, Glasgow, United Kingdom
| | - P McCartney
- University of Glasgow, Glasgow, United Kingdom
| | - K G Oldroyd
- University of Glasgow, Glasgow, United Kingdom
| | - M McEntegart
- Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - M Lindsay
- Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - H Eteiba
- Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - P Rocchiccioli
- Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - R Good
- Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - A Shaukat
- Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - V Kodoth
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - J Greenwood
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - K Robertson
- Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - J Cotton
- New Cross Hospital, Wolverhampton, United Kingdom
| | | | - C Berry
- University of Glasgow, Glasgow, United Kingdom
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McCartney P, Maznyczka A, Eteiba H, McEntegart M, Greenwood JP, Schmitt M, Maredia N, McCann GP, Fairbairn T, McAlindon E, Oldroyd KG, Orchard V, Radjenovic A, McConnachie A, Berry C. 6030Effects of adjunctive treatment with low-dose alteplase during primary percutaneous coronary intervention according to ischaemic time. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Microvascular obstruction affects half of patients with acute ST-segment elevation myocardial infarction and confers an adverse prognosis.
Purpose
We aimed to determine whether the efficacy and safety of a therapeutic strategy involving low-dose intra-coronary alteplase infused early after coronary reperfusion associates with ischaemic time.
Methods
We conducted a prospective, multicentre, parallel group, 1:1:1 randomised, dose-ranging trial in patients undergoing primary percutaneous coronary intervention. Ischaemic time, defined as the time from symptom onset to coronary reperfusion, was a pre-specified sub-group of interest. Between March 17, 2016, and December 21, 2017, 440 patients presenting at 11 hospitals in the UK were enrolled with follow up to 3 months. Patients with acute myocardial infarction due to occlusion of a major coronary artery presenting ≤6 hours from symptom onset were randomly assigned to treatment with placebo, alteplase 10mg or alteplase 20mg. The primary outcome was the amount of microvascular obstruction disclosed by cardiac magnetic resonance imaging at 2–7 days. Secondary outcomes included infarct size, myocardial haemorrhage, left ventricular ejection fraction, and troponin T area-under-the curve.
Results
440 patients were randomized (figure), the primary endpoint was achieved in 396 (90%), seventeen (3.9%) withdrew and all other patients were followed up to 3 months. In the primary analysis, the amount of microvascular obstruction did not differ between the groups. Their ischaemic times were: ≤2 hours, n=98; ≥2–<4 hours, n=215; and ≥4–6 hours, n=83.
In patients with an ischaemic time ≥4 hours, treatment with alteplase (10 mg, n=26; 20 mg, n=30) was associated with a dose dependent increase in the amount (mean) of microvascular obstruction (% left ventricular mass) compared to placebo (n=27) 1.14 vs. 3.11 vs. 5.20; mean difference on square root scale 0.81 (95% CI 0.21, 1.42), p=0.009. The interaction test between ischaemic time and treatment (active vs. placebo) was not statistically significant p=0.06, however when the interaction was assessed for a trend across treatment groups this did reach statistical significance, p=0.018.
Furthermore, a higher proportion of patients presenting ≥4–6 hours treated with 20 mg of alteplase had myocardial haemorrhage (59.3%) compared to the placebo group (28.0%), odds ratio 3.81 (95% CI 1.19, 12.25), p=0.025. The amount of haemorrhage was also greater; estimated mean difference 3.49 (95% CI 1.22, 5.75), p=0.0026. No between-treatment group differences for myocardial haemorrhage were observed in patients presenting with shorter ischaemic times.
Study flow diagram
Conclusions
In patients presenting with an ischaemic time ≥4 hours, adjunctive treatment with low-dose intra-coronary alteplase during primary PCI was associated with increases in microvascular obstruction and myocardial haemorrhage. The mechanism may involve haemorrhagic transformation within the infarct core.
Acknowledgement/Funding
NIHR EME programme (reference: 12/170/45); British Heart Foundation (BHF reference FS/16/74/32573)
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Affiliation(s)
- P McCartney
- University of Glasgow, British Heart Foundation Glasgow Cardiovascular Research Centre, Glasgow, United Kingdom
| | - A Maznyczka
- University of Glasgow, British Heart Foundation Glasgow Cardiovascular Research Centre, Glasgow, United Kingdom
| | - H Eteiba
- Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - M McEntegart
- Golden Jubilee National Hospital, Glasgow, United Kingdom
| | | | - M Schmitt
- University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - N Maredia
- James Cook University Hospital, Middlesbrough, United Kingdom
| | - G P McCann
- University Hospital of Leicester, Leicester, United Kingdom
| | - T Fairbairn
- Cardiothoracic Centre Trust of Liverpool, Liverpool, United Kingdom
| | - E McAlindon
- New Cross Hospital, Wolverhampton, United Kingdom
| | - K G Oldroyd
- Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - V Orchard
- Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - A Radjenovic
- University of Glasgow, British Heart Foundation Glasgow Cardiovascular Research Centre, Glasgow, United Kingdom
| | - A McConnachie
- University of Glasgow, Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, UK, Glasgow, United Kingdom
| | - C Berry
- University of Glasgow, British Heart Foundation Glasgow Cardiovascular Research Centre, Glasgow, United Kingdom
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Maznyczka A, Berry C. Contrast fractional flow reserve: Attractive alternative to non-hyperaemic pressure ratios for coronary disease evaluation. Int J Cardiol 2019; 275:46-47. [PMID: 30509373 DOI: 10.1016/j.ijcard.2018.10.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/05/2018] [Accepted: 10/17/2018] [Indexed: 01/10/2023]
Affiliation(s)
- Annette Maznyczka
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK.
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Haig C, Carrick D, Carberry J, Mangion K, Maznyczka A, Wetherall K, McEntegart M, Petrie MC, Eteiba H, Lindsay M, Hood S, Watkins S, Davie A, Mahrous A, Mordi I, Ahmed N, Teng Yue May V, Ford I, Radjenovic A, Welsh P, Sattar N, Oldroyd KG, Berry C. Current Smoking and Prognosis After Acute ST-Segment Elevation Myocardial Infarction: New Pathophysiological Insights. JACC Cardiovasc Imaging 2018; 12:993-1003. [PMID: 30031700 PMCID: PMC6547246 DOI: 10.1016/j.jcmg.2018.05.022] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/15/2018] [Accepted: 05/17/2018] [Indexed: 01/25/2023]
Abstract
Objectives The aim of this study was to mechanistically investigate associations among cigarette smoking, microvascular pathology, and longer term health outcomes in patients with acute ST-segment elevation myocardial infarction (MI). Background The pathophysiology of myocardial reperfusion injury and prognosis in smokers with acute ST-segment elevation MI is incompletely understood. Methods Patients were prospectively enrolled during emergency percutaneous coronary intervention. Microvascular function in the culprit artery was measured invasively. Contrast-enhanced magnetic resonance imaging (1.5-T) was performed 2 days and 6 months post-MI. Infarct size and microvascular obstruction were assessed using late gadolinium enhancement imaging. Myocardial hemorrhage was assessed with T2* mapping. Pre-specified endpoints included: 1) all-cause death or first heart failure hospitalization; and 2) cardiac death, nonfatal MI, or urgent coronary revascularization (major adverse cardiovascular events). Binary logistic regression (odds ratio [OR] with 95% confidence interval [CI]) with smoking status was used. Results In total, 324 patients with ST-segment elevation MI were enrolled (mean age 59 years, 73% men, 60% current smokers). Current smokers were younger (age 55 ± 11 years vs. 65 ± 10 years, p < 0.001), with fewer patients with hypertension (52 ± 27% vs. 53 ± 41%, p = 0.007). Smokers had better TIMI (Thrombolysis In Myocardial Infarction) flow grade (≥2 vs. ≤1, p = 0.024) and ST-segment resolution (none vs. partial vs. complete, p = 0.010) post–percutaneous coronary intervention. On day 1, smokers had higher circulating C-reactive protein, neutrophil, and monocyte levels. Two days post-MI, smoking independently predicted infarct zone hemorrhage (OR: 2.76; 95% CI: 1.42 to 5.37; p = 0.003). After a median follow-up period of 4 years, smoking independently predicted all-cause death or heart failure events (OR: 2.20; 95% CI: 1.07 to 4.54) and major adverse cardiovascular events (OR: 2.79; 95% CI: 2.30 to 5.99). Conclusions Smoking is associated with enhanced inflammation acutely, infarct-zone hemorrhage subsequently, and longer term adverse cardiac outcomes. Inflammation and irreversible myocardial hemorrhage post-MI represent mechanistic drivers for adverse long-term prognosis in smokers. (Detection and Significance of Heart Injury in ST Elevation Myocardial Infarction. [BHF MR-MI]; NCT02072850)
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Affiliation(s)
- Caroline Haig
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom
| | - David Carrick
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Jaclyn Carberry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Kenneth Mangion
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Annette Maznyczka
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Kirsty Wetherall
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom
| | - Margaret McEntegart
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Mark C Petrie
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Hany Eteiba
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Mitchell Lindsay
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Stuart Hood
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Stuart Watkins
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Andrew Davie
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Ahmed Mahrous
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Ify Mordi
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Nadeem Ahmed
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Vannesa Teng Yue May
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom
| | - Aleksandra Radjenovic
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Paul Welsh
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Naveed Sattar
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Keith G Oldroyd
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom; West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom.
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Maznyczka A, Barakat M, Ussen B, Abu-Own H, Jouhra F, Wendler O, Kolvekar S, Okonko D. CALCULATED PLASMA VOLUME STATUS PREDICTS EARLY AND LATE OUTCOMES AFTER CORONARY ARTERY BYPASS GRAFTING. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)30643-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Maznyczka A, Aldalati O, Barakat MF, Eskandari M, Tzalamouras V, Dworakowski R, Deshpande R, Byrne J, Monaghan M, Shah A, Wendler O, MacCarthy P, Okonko D. CALCULATED PLASMA VOLUME STATUS PREDICTS OUTCOMES AFTER TRANSCATHETER AORTIC VALVE REPLACEMENT. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)31588-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Finegold JA, Shun-Shin MJ, Cole GD, Zaman S, Maznyczka A, Zaman S, Al-Lamee R, Ye S, Francis DP. Distribution of lifespan gain from primary prevention intervention. Open Heart 2016; 3:e000343. [PMID: 27042321 PMCID: PMC4800759 DOI: 10.1136/openhrt-2015-000343] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/29/2015] [Accepted: 01/02/2016] [Indexed: 01/14/2023] Open
Abstract
Objective When advising patients about possible initiation of primary prevention treatment, clinicians currently do not have information on expected impact on lifespan, nor how much this increment differs between individuals. Methods First, UK cardiovascular and non-cardiovascular mortality data were used to calculate the mean lifespan gain from an intervention (such as a statin) that reduces cardiovascular mortality by 30%. Second, a new method was developed to calculate the probability distribution of lifespan gain. Third, we performed a survey in three UK cities on 11 days between May–June 2014 involving 396 participants (mean age 40 years, 55% male) to assess how individuals evaluate potential benefit from primary prevention therapies. Results Among numerous identical patients, the lifespan gain, from an intervention that reduces cardiovascular mortality by 30%, is concentrated within an unpredictable minority. For example, men aged 50 years with national average cardiovascular risk have mean lifespan gain of 7 months. However, 93% of these identical individuals gain no lifespan, while the remaining 7% gain a mean of 99 months. Many survey respondents preferred a chance of large lifespan gain to the equivalent life expectancy gain given as certainty. Indeed, 33% preferred a 2% probability of 10 years to fivefold more gain, expressed as certainty of 1 year. Conclusions People who gain lifespan from preventative therapy gain far more than the average for their risk stratum, even if perfectly defined. This may be important in patient decision-making. Looking beyond mortality reduction alone from preventative therapy, the benefits are likely to be even larger.
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Affiliation(s)
- Judith A Finegold
- International Centre for Circulatory Health, National Heart and Lung Institute , London , UK
| | - Matthew J Shun-Shin
- International Centre for Circulatory Health, National Heart and Lung Institute , London , UK
| | - Graham D Cole
- International Centre for Circulatory Health, National Heart and Lung Institute , London , UK
| | - Saman Zaman
- International Centre for Circulatory Health, National Heart and Lung Institute , London , UK
| | | | - Sameer Zaman
- International Centre for Circulatory Health, National Heart and Lung Institute , London , UK
| | - Rasha Al-Lamee
- International Centre for Circulatory Health, National Heart and Lung Institute , London , UK
| | - Siqin Ye
- Department of Medicine , Center for Behavioral Cardiovascular Health , New York, New York , USA
| | - Darrel P Francis
- International Centre for Circulatory Health, National Heart and Lung Institute , London , UK
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Abstract
The ischaemic cascade is the concept that progressive myocardial oxygen supply-demand mismatch causes a consistent sequence of events, starting with metabolic alterations and followed sequentially by myocardial perfusion abnormalities, wall motion abnormalities, ECG changes, and angina. This concept would suggest that investigations that detect expressions of ischaemia earlier in the cascade should be more sensitive tests of ischaemia than those that detect expressions appearing later in the cascade. However, careful review of the studies on which the ischaemic cascade is based suggests that the ischaemic cascade concept may be less well supported by the literature than assumed. In this review we explore this, discuss an alternative method for conceptualising ischaemia, and discuss the potential implications of this new approach to clinical studies and clinical practice.
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Affiliation(s)
- Annette Maznyczka
- Department of Medical Sciences , University College London , London , UK ; King's College London, British Heart Foundation Centre of Research Excellence , London , UK
| | - Sayan Sen
- National Heart and Lung Institute, Imperial College London , London , UK
| | - Christopher Cook
- National Heart and Lung Institute, Imperial College London , London , UK
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London , London , UK
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Maznyczka A, Howard J, Banning A, Gershlick A. 112 A Propensity Matched Study of Return to Work Outcomes after Percutaneous Coronary Intervention and Coronary Artery Bypass Graft Surgery. Heart 2015. [DOI: 10.1136/heartjnl-2015-308066.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Maznyczka A, Kaier T, Marber M. Troponins and other biomarkers in the early diagnosis of acute myocardial infarction. Postgrad Med J 2015; 91:322-30. [DOI: 10.1136/postgradmedj-2014-133129] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 05/08/2015] [Indexed: 12/24/2022]
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Kunadian V, Bawamia B, Maznyczka A, Zaman A, Qiu W. Outcomes following primary percutaneous coronary intervention in the setting of cardiac arrest: a registry database study. Eur Heart J Acute Cardiovasc Care 2014; 4:6-15. [PMID: 24818951 DOI: 10.1177/2048872614534079] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The mortality rate among patients undergoing primary percutaneous coronary intervention (PPCI) in the setting of cardiac arrest (CA) and whether the location where the patient sustains CA influences the outcome is not known in the contemporary era. METHODS Prospectively collected data at a tertiary cardiac centre on all patients undergoing PPCI for ST elevation myocardial infarction (STEMI) in the setting of CA was analysed. RESULTS In total, 484/4118 (11.8%) patients sustained CA during the study period. Of these, 91/484 (18.8%) sustained CA prior to ambulance arrival, the remainder occurred either after ambulance arrival or in hospital. The overall in-hospital mortality was 20.5% in this cohort. Those sustaining CA before ambulance arrival experienced the highest unadjusted mortality compared to those that had CA after ambulance arrival, in hospital and in the catheterisation laboratory (29.7% versus 12.0%, 16.1% and 23.8% respectively, p=0.03). Multiple logistic regression analysis showed that the following parameters are independent predictors of in-hospital mortality: age (odds ratio (OR) for each year increment of age 1.05; 95% confidence interval (CI) 1.02-1.08, p=0.0009); female gender (OR 2.42; 95% CI 1.17-4.99, p=0.0173); previous PCI (OR 7.59; 95% CI 1.72-33.53, p=0.0075); asystole/ electromechanical dissociation (EMD) (OR 13.43; 95% CI 5.34-33.80, p<0.0001); and patient location at arrest (OR 5.77 for before ambulance arrival; 95% CI 2.55-13.07, p<0.0001). CONCLUSIONS In conclusion, in-hospital mortality remains high among patients undergoing PPCI in the context of CA, particularly among those that arrest prior to ambulance arrival.
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Affiliation(s)
- Vijay Kunadian
- Institute of Cellular Medicine, Newcastle University, UK Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Bilal Bawamia
- Institute of Cellular Medicine, Newcastle University, UK Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Annette Maznyczka
- Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Azfar Zaman
- Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Weiliang Qiu
- Channing Division of Network Medicine, Brigham and Women's Hospital/Harvard Medical School, USA
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Ghoorah K, Campbell P, Kent A, Maznyczka A, Kunadian V. Obesity and cardiovascular outcomes: a review. Eur Heart J Acute Cardiovasc Care 2014; 5:77-85. [PMID: 24526749 DOI: 10.1177/2048872614523349] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 01/08/2014] [Indexed: 11/16/2022]
Abstract
The prevalence of obesity is increasing at an epidemic rate globally with more than 1 billion adults overweight and at least 300 million of them clinically obese. This is expected to rise further in the next 20 to 30 years. Obesity is known to be an independent risk factor for serious health conditions, including hypertension, type 2 diabetes, and cardiovascular diseases. Given the association of obesity with cardiovascular disease, it could be speculated that obese individuals would have adverse outcomes after a cardiovascular event compared to those with normal body mass index (BMI). However, various studies have reported a paradoxical U-shaped relationship between obesity and mortality from various diseases, including myocardial infarction and heart failure, suggesting that patients with higher BMI have similar or lower short- and long-term mortality rates. This phenomenon has been termed the 'obesity paradox' or 'reverse epidemiology'. The goal of this review is to evaluate the potential mechanisms behind the obesity paradox and its implications.
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Affiliation(s)
- Kuldeepa Ghoorah
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | | | - Alexandra Kent
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | | | - Vijay Kunadian
- Newcastle University, Newcastle, UK Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
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Maznyczka A, Myat A, Gershlick A. Discontinuation of metformin in the setting of coronary angiography: clinical uncertainty amongst physicians reflecting a poor evidence base. EUROINTERVENTION 2012; 7:1103-10. [PMID: 21959259 DOI: 10.4244/eijv7i9a175] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Metformin is widely prescribed for the treatment of type 2 diabetes mellitus and is associated with a reduction in diabetes-induced cardiovascular morbidity and mortality. Concerns about metformin-associated lactic acidosis (M-ALA) in patients undergoing contrast-based angiographic procedures have led to the development and publication of a number of guidelines to improve the management of this patient cohort. METHODS AND RESULTS This review focuses on the evidence behind these guidelines and, in particular, that concerning metformin discontinuation in diabetic patients undergoing coronary angiography and percutaneous intervention. This review addresses and compares guideline-directed management of such patients and includes the results of a UK physician survey to highlight variations in clinical practice. CONCLUSIONS We conclude that evidence for M-ALA in diabetics on metformin undergoing coronary intervention is lacking and existing guidance on the management of such patients is inconsistent. More robust evidence is needed in the form of a large, adequately-sized randomised trial or extensive registry so that we can optimally manage those patients requiring contrast-based coronary interventions who are also taking metformin.
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Affiliation(s)
- Annette Maznyczka
- Department of Cardiology, Glenfield Hospital, Leicester, United Kingdom.
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Affiliation(s)
- Annette Maznyczka
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.
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Maznyczka A, Mangino M, Whittaker A, Braund P, Palmer T, Tobin M, Goodall AH, Bradding P, Samani NJ. Leukotriene B4 production in healthy subjects carrying variants of the arachidonate 5-lipoxygenase-activating protein gene associated with a risk of myocardial infarction. Clin Sci (Lond) 2007; 112:411-6. [PMID: 17176247 DOI: 10.1042/cs20060271] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Leukotrienes are implicated in the pathogenesis of coronary artery disease. Recently two haplotypes (HapA and HapB) in the gene encoding ALOX5AP (arachidonate 5-lipoxygenase-activating protein), the main regulator of 5-lipoxygenase, have been associated with a doubling of the risk of myocardial infarction. Studies have also shown that treatment with a leukotriene inhibitor reduces biomarkers of coronary risk in patients carrying HapA, raising the possibility of developing genotype-specific therapy. In the present study, we examined whether carriage of HapA or HapB is associated with increased LTB4 (leukotriene B4) production in healthy subjects. Age- and gender-matched healthy HapA carriers (n=21), HapB carriers (n=20) and non-A/non-B carriers (n=18), with no reported history of cardiovascular disease, were recruited following DNA screening of 1268 subjects from a population-based study. Blood neutrophils were isolated, and LTB4 production was measured in response to stimulation with 1 μmol/l of the calcium ionophore A23187. There was no difference in the mean level for LTB4 production in the three groups (non-A/non-B, 24.9±8.3 ng/106 cells; HapA, 22.2±11.9 ng/106 cells; HapB, 19.8±4.8 ng/106; P=0.14). The findings indicate that if either the HapA or the HapB haplotype of ALOX5AP indeed increases cardiovascular risk, then the mechanism is not simply due to a systematically observable effect of the haplotype on LTB4 production in response to stimulation. The results suggest that knowledge of a patient's haplotype may not provide useful information on the probable clinical response to ALOX5AP inhibitors.
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Affiliation(s)
- Annette Maznyczka
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield Hospital, Leicester, UK
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