Impact of dementia and drug compliance on patients with acute myocardial infarction

Background

There has been a worrying rise in the number of people with dementia, especially with many of them also suffering from acute myocardial infarction (AMI), a disease with a high mortality rate.

Purpose

We evaluated the impact of dementia on the mortality of patients with AMI and how drug compliance affects this relationship.

Methods

The data were derived from National Health Insurance Service-Senior. The total number of patients diagnosed with AMI for the first time between 2007 and 2013 was 16,835, among whom 2,021 had dementia. Medication possession ratio (MPR) was used to assess medication adherence.

Results

AMI patients with dementia had unfavorable baseline characteristics; they had significantly higher risk of all-cause mortality (Hazard ratio [HR]: 2.49; 95% confidence interval (CI): 2.34–2.66; P<0.001) and lower MPR (aspirin: 21.9% vs. 42.8%; P<0.001). AMI patients were stratified by presence of dementia and medication adherence, and the survival rate was the highest among those with no dementia and good adherence. followed by those with no dementia and poor adherence, those with dementia and good adherence, and those with dementia and poor adherence. The multivariable analysis revealed that dementia (HR: 1.64; 95% CI: 1.53–1.75; P<0.001) and poor adherence to medication (HR: 1.60; 95% CI: 1.49–1.71; P<0.001) had a significant association with all-cause mortality in AMI patients.

Conclusions

AMI patients with dementia have a higher mortality rate. Patients with dementia have poorer medication adherence than those without, negatively affecting their prognosis.

Funding Acknowledgement

Type of funding sources: None.

Prediction of endogenous thrombolytic activity in patients with coronary artery disease

Background

Endogenous thrombolytic activity (ETA) has been suggested as an essential factor related to the acute coronary syndrome. However, there have been little data regarding clinical characteristics of ETA in East Asians.

Method

As an interim study of the entire cohort (n=2,000), we analyzed a total of 278 patients who underwent percutaneous coronary intervention (PCI) due to coronary artery disease (CAD). Informed consent was obtained from all research subjects. Blood samples of patients were brought before the procedure. The Global Thrombosis Test (GTT, Thromboquest, UK), a novel test for examining ETA, was used. Lysis time (LT), which means the time interval between blood flow occlusion and restart, was used as an indicator for ETA. Clinical, laboratory and angiographic characteristics were obtained. LT=3000 seconds was used as a cut-off value to divide patients into two groups. P value<0.05 was regarded as significant.

Results

LT of Korean CAD patients showed bimodal distribution. Median value was 1695 [IQR: 1099, 5932] and it was higher than previous data from Europeans (Figure 1). Patients with impaired ETA (LT>3000) were older and more diabetic. They showed higher creatinine, aPTT, fibrinogen, D-dimer, c-reactive protein, and proBNP values. Moreover, they had lower hemoglobin and platelet levels. Intracoronary thrombus was more frequently observed in LT>3000 group. In the multivariable regression analysis, hemoglobin (per g/dL, odds ratio 0.766, 95% confidence interval (CI) 0.632–0.928) and fibrinogen level(per 10mg/L, odds ratio 1.054, 95% CI 1.015–1.095) could significantly predict impaired ETA.

Conclusion

East Asian patients showed a right-shifted distribution of ETA compared to that of Europeans. Patients with impaired ETA had different clinical, laboratory and angiographic characteristics from those with intact ETA. Hemoglobin and fibrinogen level were significantly associated with impaired ETA. Further studies are warranted to confirm causal relationship among these factors.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Research Foundation, Republic of Korea

Three-dimensional myocardial strain for the prediction of clinical events in patients with successfully reperfused ST-segment elevation myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Two-dimensional (2D) myocardial strain analysis can be used to evaluate the prognosis of patients with acute myocardial infarction and has comparable predictive power as conventional echocardiographic parameters such as left ventricular ejection fraction (LV EF). Three-dimensional (3D) myocardial strain analysis is also expected to have similar clinical usefulness and overcome several inherent limitations of 2D strain analysis. However, no large-scale studies have been reported to date.

Purpose

We aimed to clarify the prognostic significance of 3D strain analysis in patients with ST-segment elevation myocardial infarction (STEMI) who are most likely to benefit from 3D strain analysis.

Methods

 Patients who underwent successful revascularization for STEMI from June 2011 to April 2017 were retrospectively recruited. In addition to conventional echocardiographic parameters, 3D global area strain (GAS), 3D global longitudinal strain (GLS), as well as 2D GLS were obtained.

 To evaluate the clinical outcomes, we constructed a composite outcome consisting of all-cause death or re-hospitalisation due to acute decompensation of heart failure.

Results

From June 2011 to April 2017, 632 patients were retrospectively recruited in our hospital. Of these patients, 545 patients (86.2%) had a reliable 3D strain analysis. The clinical course of each patient was followed up for a maximum of 96 months (median 49.5 months). During follow-up periods, 55 (10.1%) among 545 patients experienced the composite outcome of all-cause death or re-hospitalisation due to acute decompensation of heart failure. Patients with adverse events were older, had more underlying diseases such as obesity, dyslipidemia, previous history of stroke, or chronic kidney disease. (all, p < 0.05) LV EF was significantly lower, while 2D GLS, 3D GLS, and 3D GAS were significantly higher in patients with poor outcomes. (all, p < 0.001) The area under the receiver operating characteristic curve (AUC) values of LV EF, 2D GLS, 3D GLS, and 3D GAS were 0.70, 0.71, 0.67, and 0.65, respectively. (all, p < 0.05) Kaplan-Meier analysis of composite outcomes based on the best cut-off values of each parameter demonstrated similar results. (Figure 1) In the Cox proportional hazard model, the hazard ratios of LV EF, 2D GLS, and 3D GLS were 3.0, 5.5, and 2.0, respectively. (all, p < 0.05) The maximum likelihood-ratio test was performed to evaluate the additional prognostic value of 2D GLS or 3D GLS over the basic prognostic model consisting of baseline clinical characteristics and LV EF, and the likelihood ratio was 15.9 for 2D GLS (p < 0.001) and 1.49 for 3D GLS (p = 0.22).

Conclusion(s)

 3D strain could be reliably measured in the majority of the patients and had a significant prognostic value. However, the predictive power of the 3D strain was lower than that of the 2D strain. The clinical implications of 3D strain indices should be investigated further.

Abstract Figure.

1272Physical activity and mortality with and without cardiovascular disease

Background/Introduction

Physical activity has been shown to reduce mortality in a dose-response fashion. Current guidelines recommend 500 to 1,000 MET-min per week of regular physical activity. However, evidence is limited regarding the specific dose-response relationship in patients with cardiovascular disease.

Purpose

Our aim was to compare the impact of physical activity on mortality in primary versus secondary cardiovascular prevention.

Methods

We analyzed 441,798 individuals with complete information on physical activity levels between 2009 and 2015 were extracted from a population-based cohort (National Health Insurance Service-National Health Screening cohort). Physical activity measured by self-report questionnaires. A rating of 2.9, 4.0, and 7.0 METs were assigned for light-intensity, moderate-intensity, and vigorous-intensity activities, respectively. Physical activity-related energy expenditure (MET-min/week) was calculated by summing the product of frequency, intensity, and duration. The level of physical activity was classified into 0, 0 to 499, 500 to 999, 1,000 to 1,499, and ≥1,500 MET-min/week. Study participants were stratified by the presence of cardiovascular disease, defined as prior myocardial infarction, ischemic heart disease, prior stroke, and/or chronic heart failure. The main study outcome was all-cause mortality. The median follow-up duration was 5.9 years.

Results

Individuals with cardiovascular disease had lower physical activity levels and a higher risk of mortality than those without cardiovascular disease. There was an inverse relationship between the physical activity level and the mortality risk in both groups. The benefit in the secondary prevention group was shown to be greater than that in the primary prevention group: every 500 MET-min/week increase in physical activity resulted in a 14% and 7% risk reduction in mortality in the secondary and primary prevention groups, respectively (interaction P<0.001). In addition, while individuals without cardiovascular disease benefited the most between 0 and 500 MET-min/week of physical activity, the benefit in those with cardiovascular disease continued above 500 to 1,000 MET-min/week. The adjusted mortality risk of individuals with cardiovascular disease who performed a high level of physical activity (≥1,000 MET-min/week) was shown to be comparable to or lower than that of their counterparts without cardiovascular disease.

Adjusted risk of mortality

Conclusion

Individuals with cardiovascular disease may benefit from physical activity to a greater extent than do healthy subjects without cardiovascular disease. Clinicians should encourage patients with cardiovascular disease to maintain a physically active lifestyle as much as possible.

Vitamin C prevents radiation-induced endothelium-dependent vasomotor dysfunction and de-endothelialization by inhibiting oxidative damage in the rat

1. The present study was undertaken to determine whether endothelial function or morphology was altered in aortic rings of rats after irradiation, to investigate the mechanism of radiation effects on the endothelium and to examine the effect of vitamin C treatment against radiation-induced damage of the endothelium. 2. Female Sprague-Dawley rats were randomized into four groups (control, radiation, radiation + vitamin C, radiation + vitamin C + NG-nitro-L-arginine methyl ester (L-NAME); n = 10 for each group and n = 7 for the control group) and were irradiated with 10 Gy of 137Cs as a radiation source. Segments of the thoracic aorta were obtained and isometric tension, levels of 8-hydroxydeoxyguanosine (OH-dG) and immunohistochemical staining were measured. 3. Irradiation significantly impaired the acetylcholine-induced vasodilation of aortic segments, an effect that could be prevented by pretreatment with vitamin C (500 mg/kg per day). This beneficial effect of vitamin C was abolished by the addition of L-NAME (100 microg/kg per day), an inhibitor of nitric oxide (NO) synthesis. Irradiation significantly increased the level of OH-dG in the aorta (1.02 +/- 0.27 vs 2.61 +/- 0.78 OH-dG/105 deoxyguanosine (dG) for control and irradiated tissues, respectively; P < 0.01), an increase that was prevented by vitamin C treatment (1.59 +/- 0.23 OH-dG/105 dG; P < 0.01). Irradiation caused significant de-endothelialization (von Willebrand factor (vWF) staining was 93 +/- 7 vs 100% in irradiated and control tissues, respectively; P < 0.05) and this was prevented by vitamin C treatment (vWF staining 98 +/- 3%; P < 0.05). 4. Radiation caused endothelial damage and impaired NO production through oxidative injury, resulting in a selective impairment of endothelial-dependent vasodilation that could be prevented by vitamin C, partly through anti-oxidant mechanisms.

Off-pump coronary artery bypass may decrease the patency of saphenous vein grafts

BACKGROUND

There is concern that a hypercoagulable status is caused after coronary artery bypass grafting without cardiopulmonary bypass (off-pump coronary artery bypass grafting, or OPCAB) and may potentially endanger the patency of the anastomosis. The aims of this study were: (1) to compare 1-year graft patency after OPCAB with that of conventional coronary artery bypass grafting (CABG) and that of on-pump beating CABG; and (2) to demonstrate any differences in patency of various conduits among the three groups.

METHODS

We analyzed the results of 122 consecutive OPCAB cases (group 1) compared with those of 65 consecutive conventional CABG cases (group II) and those of 19 consecutive on-pump beating CABG cases (group III). In group I, coronary angiography (CAG) was performed immediately postoperatively and 1 year after surgery. In groups II and III, CAG was performed 1 year after surgery. Graft patency was graded as grade A (excellent), grade B (fair), or grade O (occluded).

RESULTS

The average number of distal anastomoses in groups I, II, and III were 3.1 +/- 1.1, 3.7 +/- 0.9, and 3.6 +/- 0.9, respectively. In group I, postoperative CAG was performed in 92% of patients (112/122) before discharge. The patency rate (grade A + B) was 96.4% (162/168) for arterial grafts, and 85.6% (160/187) for saphenous vein grafts (SVG). One-year follow-up CAG was performed in 74% of patients (90/122). The patency rate was 97.8% (132/135) for arterial grafts and 67.9% (106/156) for SVG. In group II, 1-year follow-up CAG was performed in 65% of patients (42/65). The patency rate (grade A + B) was 93.5% (43/46) for arterial grafts and 88.3% (98/111) for SVG. In group III, 1-year follow-up CAG was performed in 89% of patients (17/19). The patency rate (grade A + B) was 100% (19/19) for arterial grafts and 86.8% (33/38) for SVG.

CONCLUSIONS

Our results demonstrate that the patency rate ot SVG after OPCAB was significantly lower than that of arterial grafts in the early postoperative CAG (p < 0.001), and was also significantly lower than those of SVG of group II (p < 0.001) and group III (p < 0.01) in the postoperative 1-year CAG, although there was no significant difference in 1-year patency of arterial grafts among the three groups. Our data suggest that a specific perioperative anticoagulant therapy may be advisable in patients undergoing OPCAB with SVG.

Potential predictors of asymptomatic ischemic heart disease in patients with vasculogenic erectile dysfunction

OBJECTIVES

To prospectively define the potential predictors of asymptomatic ischemic heart disease in patients with vasculogenic erectile dysfunction using a simple and practical method. Most patients with vasculogenic erectile dysfunction are known to have at least one significant cardiovascular risk factor.

METHODS

After baseline evaluations, patients with erectile dysfunction of presumed vascular origin, who were older than 45 years and with no history of ischemic heart disease, were enrolled in the study. According to the results of repeated pharmacologic erection tests, we divided patients into responders and nonresponders. The cardiologic evaluations consisted of a comprehensive history taking, the assessment of cardiovascular risk factors, a physical examination, and an exercise treadmill test.

RESULTS

A total of 97 patients completed the study. Fifteen (32.6%) of 46 responders and 25 (49.0%) of 51 nonresponders, respectively, had two or more cardiovascular risk factors (P = 0.101). Ischemic ST-segment changes on the exercise treadmill test were only observed in 8 nonresponders (15.7%) (P = 0.006). All these patients were older than 55 years, and seven had two or more cardiovascular risk factors, including hypertension.

CONCLUSIONS

On the basis of these preliminary data, we suggest that cardiovascular evaluations may prove beneficial before prescribing sildenafil to patients with vasculogenic erectile dysfunction who are nonresponders to the pharmacologic erection test, are older than 55 years, and have two or more risk factors, including hypertension.

CORRELATION OF FAS AND FAS LIGAND EXPRESSION WITH REJECTION STATUS OF TRANSPLANTED HEART IN HUMAN1

BACKGROUND

Activation of pro-apoptotic systems has been proven in rejection model of animal heart transplantation. The role of Fas and Fas ligand (FasL) in graft rejection is not fully understood, and the expression changes of these genes in human transplanted heart have not been elucidated.

METHODS

Endomyocardial biopsy samples were taken from 13 consecutive patients undergoing heart transplantation at various times, and they were classified into rejection (REJ, grade 3A or more) and lack of rejection (TOL, grade 1B or less) by International Society of Heart and Lung Transplantation rejection grade. Semiquantitative reverse transcription-polymerase chain reaction and immunohistochemistry were performed to evaluate the status of Fas and FasL expression in each sample.

RESULTS

Fas was constitutively expressed both in REJ and TOL specimens (expression levels normalized by glyceraldehyde-3-phosphate dehydrogenase expression in semiquantitative reverse transcription-polymerase chain reaction of REJ vs. TOL, 0.842+/-0.096 vs. 0.848+/-0.103, P=0.776); however, FasL expression was detected in 66% of REJ samples and 40% of TOL samples. Normalized levels of FasL expression were 0.591+/-0.494 (REJ) and 0.383+/-0.507 (TOL) (P<0.05). FasL was expressed by cardiomyocytes as well as graft-infiltrating cells.

CONCLUSIONS

This up-regulation of FasL may be one of possible mechanisms of apoptosis in rejection process of human cardiac allograft.

Effect of hypercholesterolemia on macrophage infiltration after balloon injury to rabbit iliac artery

Both hypercholesterolemia and vascular injury have been reported to induce macrophage infiltration, but their combined effect and the mechanism by which hypercholesterolemia enhances the infiltration remain to be clarified in vivo. To evaluate the effect of hypercholesterolemia on macrophage infiltration after vascular injury, the iliac arteries of hypercholesterolemic (HC) and normocholesterolemic (NC) rabbits were examined 2h, 1 day, 3 days, 7 days, and 14 days after balloon injury using immunohistochemical staining for macrophages, intercellular adhesion molecule (ICAM)-1, and vascular cell adhesion molecule (VCAM)-1. Nuclear factor kappa-B (NF-kappaB) activation was also evaluated in fresh frozen iliac arteries using the electrophoretic mobility shift assay method. The fundamental difference between HC and NC was the amount of macrophage infiltration seen in HC from 7 days after balloon injury. Two out of 4 HC iliac arteries on the 7th day, and 3 out of 4 HC iliac arteries on the 14th day were positively stained with ICAM-1 in regenerated endothelium and neointima, whereas there were no positively stained NC iliac arteries. Neither HC nor NC tissues showed positive staining with VCAM-1. NF-kappaB was activated in HC 7 and 14 days after balloon injury, but not in NC. In conclusion, in vivo hypercholesterolemia induces macrophage infiltration after balloon injury and it is mediated by increased NF-kappaB activation promoting ICAM-1 expression.

Effect of hypercholesterolemia on the sequential changes of apoptosis and proliferation after balloon injury to rabbit iliac artery

To evaluate the effect of hypercholesterolemia on apoptosis and proliferation after vascular injury, iliac arteries of hypercholesterolemic (HC) and normocholesterolemic (NC) rabbits were examined after balloon injury using TUNEL, immunohistochemical staining of PCNA, macrophages, smooth muscle actin and p53. In media, apoptosis occurred massively early after injury and then decreased. HC did not affect this early post-injury apoptosis but significantly increased apoptosis 14 days later (D14). Immediate apoptosis in media was followed by active proliferation. HC sustained a high activity of proliferation until D14. The changes of immunoreactivity to p53 over the same 14 day period parallel that of apoptosis. In intima, where cells were scarce initially, proliferative activity reached a peak at D7 and then decreased. HC significantly enhanced proliferation at D14. In intima proliferation was accompanied by a later low-level apoptosis. HC significantly enhanced this low-level apoptosis at D14. These effects of HC resulted in significantly increased areas of intima and media. The fundamental difference between HC and NC was the infiltration of macrophages in HC. In conclusion, balloon injury induces early massive p53-associated apoptosis followed by proliferation in media, whereas in intima, it induces active proliferation followed by a low-level apoptosis. Hypercholesterolemia does not affect the early post-injury apoptosis but enhances proliferation and low-level apoptosis at a later stage, which in turn results in intimal and medial hyperplasia.