A Novel Peptide Elabela is Associated with Hypertension-Related Subclinical Atherosclerosis

INTRODUCTION

Elabela is a newly identified peptide which, alongside apelin, acts as an endogenous ligand that activates the angiotensin receptor-like 1 receptor. Previous studies have shown the association of elabela with hypertension, but information about the role of elabela in hypertension-related subclinical atherosclerosis is scarce.

AIM

We aimed to determine the elabela levels in hypertensive patients and explore its association with subclinical atherosclerosis.

METHODS

A total of 104 subjects with hypertension were included in the study. Elabela levels were measured using an enzyme-linked immunosorbent assay, by first extracting the peptide following the manufacturer's instructions. Subclinical atherosclerosis was assessed by measuring the carotid intima-media thickness (IMT) using ultrasound.

RESULTS

Compared to stage 1, elabela levels decreased in stage 2 hypertension (0.23 [0.13, 0.45] ng/ml vs. 0.14 [0.09, 0.23] ng/ml; P = 0.000), and in the group with increased carotid IMT compared to normal IMT (0.24 [0.13, 0.38] ng/ml vs. 0.15 [0.10, 0.23] ng/ml; P = 0.005). Additionally, a linear correlation analysis showed that elabela had a significant negative correlation with systolic blood pressure (r = - 0.340, P = 0.000) and carotid IMT (r = - 0.213; P = 0.030). In multivariate analysis, lower elabela levels were associated with a higher cardiovascular risk group in this study (OR 5.0, 95% CI 1.8-13.5, P < 0.001).

CONCLUSIONS

This study demonstrated for the first time that circulating elabela declined in a higher stage of hypertension and hypertensive patients with increased carotid IMT, implicating that elabela may be involved in the pathogenesis of hypertension-associated subclinical atherosclerosis.

Skin Mottling as Clinical Manifestation of Cardiogenic Shock

A 59 years old male came to the emergency department with chief complain of dyspnea. Dyspnea has worsened since 3 days before admission accompanied with dyspnea on effort, orthopnea and paroxysmal nocturnal dyspnea. In the emergency department, patient experienced cardiac arrest after defecating, leading to cardiopulmonary resuscitation for 45 minutes. Administration of vasoactive drugs were done and the patient was intubated.Post resucitaiton physical examination showed that the patient was sedated, with blood pressure of 72/40 (on dobutamine support). Peripheral circulation examination showed cold and clammy extremities, skin mottling of the lower extremity with mottling score of 2. CRT is more than 2 seconds. Blood gas analysis showed severe metabolic acidosis with blood lactate of 8.1.Angiographic examination were previously done on the patient during the previous admission with the results of three vessels disease with a chronic total occlusion in the left anterior descending artery. However, patient had refused further intervention regarding the coronary problems. Patient also has longtsanding atrial fibrillation.Patient was admitted into the intensive care unit for further management. Patient was stabilized during admisison in the intensive care with inotropes, however despite the hemodynamic stablilization the skin remain mottled-regardless. Patient had complicating factors in the form of pneumonia and sepsis. Patient had difficulty in weaning the ventilator and died because of arrythmia complication.

Cost-Effectiveness of Ticagrelor for Acute Coronary Disease to Prevent Cardiovascular Events in Three Hospitals in Indonesia

Background: Acute coronary syndromes (ACS) are life-threatening CVD associated with Indonesia's significant health and economic burdens. The study objective was to evaluate the cost-effectiveness of ticagrelor in reducing CV endpoint in the Indonesia setting. Methods: Markov model was used as a decision analysis to compare ticagrelor with clopidogrel. We constructed decision tree model included four health conditions (no additional events, non-fatal myocardial infarction, non-fatal stroke, and any cause death), The probability of each state and quality-adjusted life years were derived from the PLATO trial and Indonesia life table. The outcome's resource consumption and associated costs were collected from three hospitals (public, national referral, and private hospitals) in Indonesia. The study used 5 years and lifetime horizon and discounting rate of 3%. Results: The incremental QALYs and life-year gained (LYG) of ticagrelor in five years was 0.0410 and 0.0462, respectively; in a lifetime was 0.0828, and 0.0947, respectively. The ICER per QALY of ticagrelor versus clopidogrel in private, national referral, and public hospitals was USD 2390.276, USD 3813.638, USD 1278.361, respectively for five years; and USD 2471.392, USD 5453.987, USD 2343.269, respectively for a lifetime. The probability of ticagrelor to be cost-effective was about 66.6% on a five-year and 99.7% on a lifetime with WTP USD 3634. Conclusion: Compared to the clopidogrel, QALYs and life-year gained of use ticagrelor higher. The incremental cost-effectiveness ratio in five years and lifetime model showed under one-time GDP, it means the use of ticagrelor was vastly cost-effective and acceptable to apply in the Indonesian clinical setting.

First Asian validation of ORBI score in predicting in-hospital cardiogenic shock in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention

Background

Cardiogenic shock (CS) complicating an acute coronary syndrome still worsening the prognosis with 30-day mortality rates approximating 40–45%, despite improvements in the acute management of ST-segment elevation myocardial infarction (STEMI), particularly the widespread use of timely primary percutaneous coronary intervention (pPCI). The ORBI risk score provides a readily useable and efficient tool to identify patients at high-risk of developing CS during hospitalization following STEMI which may aid in further risk-stratification and thus potentially facilitate pre-emptive clinical decision making. This is essential in developing countries with wide variation in health care facilities, scarce resources and increasing burden of cardiovascular diseases.

Purpose

To validate ORBI Score in identifying patients at high-risk of in-hospital STEMI related cardiogenic shock in a multi-ethnic developing country.

Method

The ORBI risk score was evaluated in 1934 patients STEMI without CS on admission and treated by primary percutaneous coronary intervention (pPCI) in our national cardiovascular centre included this study. Model discrimination and calibration was tested in the overall population. Eleven variables from the ORBI score were independently associated with the development of in-hospital CS: age &gt;70 years, prior stroke/transient ischaemic attack, cardiac arrest upon admission, anterior STEMI, first medical contact-to-pPCI delay &gt;90min, Killip class, heart rate &gt;90/min, a combination of systolic blood pressure &lt;125 mmHg and pulse pressure &lt;45 mmHg, glycaemia &gt;10 mmol/L, culprit lesion of the left main coronary artery, and post-pPCI thrombolysis in myocardial infarction flow grade &lt;3. The score derived from these variables allowed the classification of patients into four risk categories: low (0–7), low- to-intermediate (8–10), intermediate-to-high (11–12), and high (≥13).

Results

Observed in-hospital CS rates were 0.3%, 6.4%, 19.5%, and 32.12%, across the four risk categories, respectively. The score demonstrated high discrimination (c-statistic of 0.91 (CI 95% 0.88–0.93), p&lt;0.001 in the validation cohort)

Conclusion

The ORBI risk score is valid and can be used for predicting the development of cardiogenic shock in STEMI patients for better targeted treatment.

Funding Acknowledgement

Type of funding sources: None. ROC curveObserved in-hospital CS rates

2020 Asian Pacific Society of Cardiology Consensus Recommendations on Antithrombotic Management for High-risk Chronic Coronary Syndrome

The unique characteristics of patients with chronic coronary syndrome (CCS) in the Asia-Pacific region, heterogeneous approaches because of differences in accesses and resources and low number of patients from the Asia-Pacific region in pivotal studies, mean that international guidelines cannot be routinely applied to these populations. The Asian Pacific Society of Cardiology developed these consensus recommendations to summarise current evidence on the management of CCS and provide recommendations to assist clinicians treat patients from the region. The consensus recommendations were developed by an expert consensus panel who reviewed and appraised the available literature, with focus on data from patients in Asia-Pacific. Consensus statements were developed then put to an online vote. The resulting recommendations provide guidance on the assessment and management of bleeding and ischaemic risks in Asian CCS patients. Furthermore, the selection of long-term antithrombotic therapy is discussed, including the role of single antiplatelet therapy, dual antiplatelet therapy and dual pathway inhibition therapy.

Performance of Primary Angioplasty for STEMI during the COVID-19 Outbreak

There has been concern whether the declining cases of ST-segment elevation myocardial infarction (STEMI) during the coronavirus disease 2019 (COVID-19) outbreak associate with primary angioplasty performance. We assessed the performance of primary angioplasty in a tertiary care hospital in Jakarta, Indonesia, by comparing the door-to-device (DTD) time and thrombolysis in myocardial infarction (TIMI) flow after angioplasty between two periods of admission: during the outbreak of COVID-19 (March 1 to May 31, 2020) and before the outbreak (March 1, to May 31, 2019). Overall, there was a relative reduction of 44% for STEMI admission during the outbreak ( n  = 116) compared with before the outbreak ( N  = 208). Compared with before the outbreak period ( n  = 141), STEMI patients who admitted during the outbreak and received primary angioplasty ( n  = 70) had similar median symptom onset-to-angioplasty center admission (360 minutes for each group), similar to radial access uptake (90 vs. 89.4%, p  = 0.88) and left anterior descending infarct-related artery (54.3 vs. 58.9%, p  = 0.52). The median DTD time and total ischemia time were longer (104 vs. 81 minutes, p  < 0.001, and 475.5 vs. 449 minutes, p  = 0.43, respectively). However, the final achievement of TIMI 3 flow was similar (87.1 vs. 87.2%), and so was the in-hospital mortality (5.7 vs. 7.8%). During the COVID-19 outbreak, we found a longer DTD time for primary angioplasty, but the achievement of final TIMI 3 flow and in-hospital mortality were similar as compared with before the outbreak. Thus, primary angioplasty should remain the standard of care for STEMI during the COVID-19 outbreak.

Increase in the risk of clopidogrel resistance and consequent TIMI flow impairment by DNA hypomethylation of CYP2C19 gene in STEMI patients undergoing primary percutaneous coronary intervention (PPCI)

Clopidogrel resistance is an important risk factor of ischemic event recurrence after optimal antiplatelet therapy. This study aims to investigate the role of CYP2C19 gene DNA methylation as one of the epigenetic factors for the risk of clopidogrel resistance in STEMI patients undergoing PPCI. ST-segment elevation myocardial infarction (STEMI) patients undergoing PPCI were pretreated with clopidogrel, and their platelet function was measured using VerifyNow™ assay. The criteria for high on-treatment platelet reactivity (HPR) were defined according to the expert consensus criteria (PRU >208). DNA methylation of the CYP2C19 gene was performed using bisulfite genomic sequencing technology. Furthermore, clinical, laboratory, and angiographic data including TIMI flow were collected. Among 122 patients, clopidogrel resistance was found in 22%. DNA methylation level percentage was lower in the clopidogrel resistance group (76.7 vs. 88.8, p-value .038). But, the <50% methylation group was associated with increased risk of clopidogrel resistance (OR =4.5, 95%CI =2.1-9.3, p-value = .018). This group was also found to have suboptimal post-PCI TIMI flow (OR =3.4 95%CI =1.3-8.7, p-value =.045). The lower DNA methylation level of the CYP2C19 gene increases the risk of clopidogrel resistance and subsequent poorer clinical outcome.

Trends in reperfusion therapy for acute ST-segment elevation myocardial infarction in an academic PCI centre in the metropolitan area of a developing country

Background

Long-term reports on reperfusion therapy for acute ST-segment elevation myocardial infarction (STEMI) in developing countries are scarce.

Purpose

We reported changes in acute reperfusion therapy for STEMI that have been observed over time in an academic tertiary care percutaneous coronary intervention (PCI) centre that hosting a STEMI network in the large metropolitan area of Jakarta, Indonesia since 2010 and covering around 11 million inhabitants.

Methods

A retrospective analysis was performed in 6336 patients with STEMI who admitted to the emergency department of a PCI centre in 2008 (before STEMI network introduction), and during 2011 to 2018.

Results

Among STEMI patients admitted during 2011–2018 (mean age: 56±10 years, 86% male), 57.6% had anterior wall myocardial infarction, and 71.3% presented with Killip classification I. Compared with the period 2011–2014 (N=2766), patients who were admitted in the period 2015–2018 (N=3250) were receiving more primary percutaneous coronary intervention (PCI) (61.6% vs. 44.2%, P&lt;0.001) with shorter door-to-device time (median 72 min versus 97 min, P&lt;0.001), and less in-hospital fibrinolytic therapy (2.7% vs. 4.8%, P&lt;0.001). The percentage of STEMI patients who did not receive reperfusion treatment decreased from 51% to 35.5% (P&lt;0.001). In-hospital mortality declined from 10% in 2008 (before the STEMI network was initiated) and 8% in 2011 to 6.4% in 2018 (P for trends = 0.05). Multivariable analysis showed that primary PCI was significantly associated with better in-hospital survival (adjusted odds ratio, 0.52; 95% confidence interval, 0.42 to 0.65, P&lt;0.001).

Conclusion

The data indicate that the introduction of a STEMI network resulted in more patients receiving timely primary PCI and lower early mortality rates in recent years.

Funding Acknowledgement

Type of funding source: None

Interhospital Transfer versus Direct Admission in Patients with Acute ST-Segment Elevation Myocardial Infarction

There is concern whether patients with ST-segment elevation myocardial infarction (STEMI) who admitted to a percutaneous coronary intervention (PCI) center from interhospital transfer is associated with longer reperfusion time compared with direct admission. We evaluated the reperfusion delays in patients with STEMI who admitted to a primary PCI center through interhospital transfer or direct admission. We retrospectively analyzed 6,494 consecutive STEMI patients admitted between 2011 and 2019. Compared with direct admission (n = 4,121; 63%), interhospital transferred patients (n = 2,373) were younger (55 ± 10 vs. 56 ± 10 years, p < 0.001), had similar gender (85.6 vs. 86% male, p = 0.67), greater proportion of off-hour admission (65.2 vs. 48.3%, p < 0.001), less diabetes mellitus (28 vs. 30.8%, p = 0.019), and received more primary PCI (70.5 vs. 48.7%, p < 0.001). Interhospital transferred patients who received primary PCI (n = 3,677) or fibrinolytic (n = 238) had longer symptom-to-PCI center admission time (median, 360 vs. 300 minutes, p < 0.001), shorter door-to-device (DTD) time for primary PCI (median, 74 vs. 87 minutes, p < 0.001), and longer total ischemic time (median, 465 vs. 414 minutes, p < 0.001). Logistic regression in interhospital transferred patients showed that delay in door-in-to-door-out (DI-DO) time at the first hospital was strongly associated with prolonged total ischemic time (adjusted odds ratio = 3.92; 95% confidence interval: 3.06–5.04, p < 0.001). This study suggests that although interhospital transferred patients received more primary PCI with shorter DTD time, interhospital transfer creates longer total ischemic time that associates with the delay in DI-DO time at the first hospital that should be improved.

"Door-In to Door-Out" Delay in Patients with Acute ST-Segment Elevation Myocardial Infarction Transferred for Primary Percutaneous Coronary Intervention in a Metropolitan STEMI Network of a Developing Country

Background  Routine performance measures of primary percutaneous coronary intervention (PCI) within an ST-segment elevation myocardial infarction (STEMI) network are needed to improve care. Objective  We evaluated the door-in to door-out (DI-DO) delays at the initial hospitals in STEMI patients as a routine performance measure of the metropolitan STEMI network. Patients and Methods  We retrospectively analyzed the DI-DO time from 1,076 patients with acute STEMI who were transferred by ground ambulance to a primary PCI center for primary PCI between 4 October 2014 and 1 April 2019. Correlation analysis between DI-DO times and total ischemia time was performed using Spearman's test. Logistic regression analyses were used to find variables associated with a longer DI-DO time. Results  Median DI-DO time was 180 minutes (25th percentile to 75th percentile: 120-252 minutes). DI-DO time showed a positive correlation with total ischemia time ( r  = 0.4, p  < 0.001). The median door-to-device time at the PCI center was 70 minutes (25th percentile to 75th percentile: 58-88 minutes). Multivariate analysis showed that women patients were independently associated with DI-DO time > 120 minutes (odds ratio 1.55, 95% confidence interval 1.03 to 2.33, p  = 0.03). Conclusion  The DI-DO time reported in this study has not reached the guideline recommendation. To improve the overall performance of primary PCI in the region, interventions aimed at improving the DI-DO time at the initial hospitals and specific threat for women patients with STEMI are possibly the best efforts in improving the total ischemia time.

A health economic evaluation of using N-terminal pro brain natriuretic peptide for the management of acute heart failure: A pilot study in an Indonesian tertiary referral hospital

Heart failure represents a major health problem and economic burden also in development countries such as Indonesia. Based on current guidelines, the use of natriuretic peptides can improve diagnosis, risk stratification, and decrease in hospital length of stay. However, mostly due to the related high costs, many Indonesian physicians currently do not routinely use these biomarkers in their daily clinical practice. By comparing the results of guidance with N-terminal pro brain natriuretic peptide (NT-proBNP) and without NT-proBNP, this pilot study was aimed to determine the clinical effectiveness and costs of using natriuretic peptides in the management of acute heart failure (AHF) patients admitted at National Cardiovascular Center Harapan Kita Hospital, a tertiary referral hospital in Jakarta, Indonesia. This was a health economic evaluation using a single-blind, randomized controlled trial. AHF patients adjudicated following European Society of Cardiology guidelines were randomly assigned to the 2 groups: NT-proBNP group (group A) and control group (group B). In the group A, NT-proBNP level was obtained at admission and pre-discharge, with the target of achieving a decrease of ≥30%. Randomised patients were followed up to 90 days post-discharge to assess short-term outcomes and costs. In total, one hundred and twelve patients were enrolled, of whom 56 were randomized in group A and 56 patients in group B. Compared to Group B, in Group A the total costs of patients management resulted to be significantly higher (P<0.05), while no significant difference between the 2 groups was observed for inhospital length of stay, total mortality rate, rehospitalization, and emergency department visits within 90 days post-discharge. In this pilot study for the management of AHF at an Indonesian National Cardiovascular Center, the routine use of NT-proBNP compared to the non use, at hospital admission and discharge resulted into a significant increase of medical cost without any evident favourable impact on patients outcomes. Larger study in greater Asia Pacific populations should be performed to confirm these preliminary results.

Hospital outcomes in STEMI patients after the introduction of a regional STEMI network in the metropolitan area of a developing country

AIMS

Data on the long-term outcomes of STEMI patients treated via a network in Asian countries are very limited. We aimed to evaluate the characteristics and outcomes of STEMI patients at two different periods, before and five years after the establishment of a regional STEMI network in Jakarta, Indonesia.

METHODS AND RESULTS

Out of 6,291 patients with STEMI admitted to hospital between January 2008 to January 2016, we compared the characteristics and outcomes of STEMI patients from two different periods, January 2008 to July 2009 (before instalment of the STEMI network, N=624), and from January 2015 to January 2016 (five years after the start of the network, N=1,052). The PCI hospital is an academic tertiary care cardiac hospital and initiated the regional STEMI network in 2010. Logistic regression was used to determine the adjusted association between treatment in the latter period and mortality. Compared with data from 2008/2009, in the 2015/2016 period, more primary PCI procedures were performed (N=589 [56%] vs. N=176 [28%], p<0.001), fewer patients did not receive reperfusion therapy (37% vs. 59%, p<0.001), and median door-to-device (DTD) times were shorter (82 vs. 94 minutes, p<0.001). Overall in-hospital mortality decreased from 9.6% to 7.1% (adjusted odds ratio 0.72, 95% CI: 0.50 to 1.03, p=0.07).

CONCLUSIONS

Half a decade after the implementation of the STEMI network in Jakarta, Indonesia, the result is better and faster care for patients with STEMI and this has been associated with lower in-hospital mortality.

Ramucirumab combined with FOLFOX as front-line therapy for advanced esophageal, gastroesophageal junction, or gastric adenocarcinoma: a randomized, double-blind, multicenter Phase II trial

BACKGROUND

We report the first randomized, Phase II trial of ramucirumab, an anti-vascular endothelial growth factor receptor-2 monoclonal antibody, as front-line therapy in patients with advanced adenocarcinoma of the esophagus or gastric/gastroesophageal junction (GEJ).

PATIENTS AND METHODS

Patients from the USA with advanced esophageal, gastric, or GEJ adenocarcinoma randomly received (1:1) mFOLFOX6 plus ramucirumab (8 mg/kg) or mFOLFOX6 plus placebo every 2 weeks. The primary end point was progression-free survival (PFS) with 80% power to detect a hazard ratio (HR) of 0.71 (one-sided α = 0.15). Secondary end points included evaluation of response and overall survival (OS); an exploratory ramucirumab exposure-response analysis was undertaken.

RESULTS

Of 168 randomized patients, 52% of tumors were located in the stomach/GEJ and 48% in the esophagus. The trial did not meet the primary end point of PFS [6.4 versus 6.7 months, HR 0.98 (95% confidence interval 0.69-1.37)] or the secondary end point of OS (11.7 versus 11.5 months) in the intent-to-treat (ITT) population. Objective response rates (45.2% versus 46.4%) were similar between arms. Most Grade ≥3 toxicities did not differ significantly between arms, yet premature discontinuation of FOLFOX and ramucirumab (for reasons other than progressive disease) was more common among ramucirumab- versus placebo-treated patients. In an exploratory analysis that censored for premature discontinuation, the HR for PFS favored the ramucirumab arm (HR 0.76), particularly in patients with gastric/GEJ cancer. An exploratory exposure-response analysis indicated that patients with higher ramucirumab exposure had longer OS.

CONCLUSION

The addition of ramucirumab to front-line mFOLFOX6 did not improve PFS in the ITT population.

CLINICALTRIALSGOV IDENTIFIER

NCT01246960.

Impact of Timing of Eptifibatide Administration on Preprocedural Infarct-Related Artery Patency in Acute STEMI Patients Undergoing Primary PCI

The appropriate timing of eptifibatide initiation for acute ST segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) remains unclear. This study aimed to analyze the impact of timing of eptifibatide administration on infarct-related artery (IRA) patency in STEMI patients undergoing primary PCI. Acute STEMI patients who underwent primary PCI (n = 324) were enrolled in this retrospective study; 164 patients received eptifibatide bolus ≤ 30 minutes after emergency department (ED) admission (group A) and 160 patients received eptifibatide bolus > 30 minutes after ED admission (group B). The primary endpoint was preprocedural IRA patency. Most patients in group A (90%) and group B (89%) were late presenters (> 2 hours after symptom onset). The two groups had similar preprocedural thrombolysis in myocardial infarction 2 or 3 flow of the IRA (26 vs. 24%, p = not significant [NS]), similar creatine kinase-MB (CK-MB) levels at 8 hours after admission (339 vs. 281 U/L, p = NS), similar left ventricular ejection fraction (LVEF) (52 vs. 50%, p = NS), and similar 30-day mortality (2 vs. 7%, p = NS). Compared with group B, patients in group A had shorter door-to-device time (p < 0.001) and shorter procedural time (p = 0.004), without increased bleeding risk (13 vs. 18%, p = NS). Earlier intravenous administration of eptifibatide before primary PCI did not improve preprocedural IRA patency, CK-MB level at 8 hours after admission, LVEF and 30-day mortality compared with patients who received intravenous eptifibatide that was administered later.

A Randomized Comparison between Everolimus-Eluting Stent and Cobalt Chromium Stent in Patients with Acute ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention Using Routine Intravenous Eptifibatide: The X-MAN (Xience vs. Multi-Link Stent in Acute Myocardial Infarction) Trial, A Pilot Study

The objective of this study is to determine the efficacy and safety of an everolimus-eluting stent (EES/Xience; Abbott Vascular, Santa Clara, CA) compared with a cobalt chromium stent (CoCr/Multi-Link Vision; Abbott Vascular) in patients with acute ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) with routine administration of eptifibatide infusion. This is a prospective, single center, randomized trial comparing EES (n = 75) and CoCr stent (n = 75) implantation in patients with acute STEMI undergoing primary PCI. Intravenous eptifibatide administration was mandatory by protocol in this pilot study. The primary efficacy endpoint was major adverse cardiac events (MACE) at 30 days, defined as the composite of death, reinfarction, and target vessel revascularization. Secondary safety endpoints were stent thrombosis at 30 days and in-hospital bleeding event. Acute reperfusion parameters were also assessed. One-month MACE rate did not differ between EES and CoCr group (1.3 vs. 1.3%, p = 1.0). No stent thrombosis cases were observed in the EES group. The groups did not differ with respect to in-hospital bleeding events (5 vs. 9%, p = 0.37), achievement of final thrombolysis in myocardial infarction flow 2 or 3 (p = 0.21), achievement of myocardial blush grade 2 or 3 (p = 0.45), creatine kinase-MB level at 8 to 12 hours after stenting (p = 0.29), and left ventricular ejection fraction (p = 0.21). This pilot study demonstrates that after one-month follow-up, the use of EES is as safe and effective as the use of CoCr stents in patients with acute STEMI undergoing primary PCI with routine administration of intravenous eptifibatide.

The Use of Intra-aortic Balloon Pump in a Real-World Setting: A Comparison between Survivors and Nonsurvivors from Acute Coronary Syndrome Treated with IABP. The Jakarta Acute Coronary Syndrome Registry

Real-world data on acute coronary syndrome (ACS) patients who received intra-aortic balloon pump (IABP) support are limited. The objective of this study was to evaluate the characteristics of ACS patients who received IABP support from a real-world ACS registry. Patients with ACS (N = 121) who received IABP support were enrolled. Characteristics of survivors and nonsurvivors were compared at 30 days. Mortality rate of patients with ACS who received IABP was 47%. The survivors (N = 64) had less often cardiogenic shock (p < 0.001), more often IABP usage as back-up for a revascularization procedure (p = 0.002), less often resuscitation (p = 0.043), and less mechanical ventilator support (p < 0.001) than nonsurvivors. The nonsurvivors had a significantly higher leukocyte count (p = 0.033), a higher serum creatinine level (p < 0.001), a higher blood sugar on admission (p = 0.001), higher creatine kinase MB levels (p = 0.002), and a higher serum uric acid level (p < 0.001), but significantly lower left and right ventricular function (p = 0.014 and p = 0.003, respectively) than survivors. At 30 days, non-ST elevation (STE)-ACS patients had lower mortality rate than ST segment elevation myocardial infarction patients (log-rank test, p < 0.001), and non-STE-ACS patients who had not suffered from cardiogenic shock showed the lowest mortality rate (log-rank test, p < 0.001). By multivariate analysis, a heart rate ≥ 100 beats per minute before IABP insertion was the strongest predictor of 30-day mortality (hazard ratio = 5.69; 95% confidence interval, 1.49 to 21.78; p = 0.011). In ACS patients presenting with either cardiogenic shock, resuscitated, or patients who needed mechanical ventilation suffered from high mortality, despite the use of IABP. IABP appears to be safe and tended to be favorable in noncardiogenic shock ACS patients, particularly non-STE-ACS. A heart rate of ≥ 100 beats per minute prior to IABP insertion was the strongest predictor of 30-day mortality.

Acute myocardial infarction system of care in the third world

BACKGROUND

We studied the characteristics of ST-elevation myocardial infarction (STEMI) patients from a local acute coronary syndrome (ACS) registry in order to find and build an appropriate acute myocardial infarction (AMI) system of care in Jakarta, Indonesia.

METHODS

Data were collected from the Jakarta Acute Coronary Syndrome (JAC) registry 2008-2009, which contained 2103 ACS patients, including 654 acute STEMI patients admitted to the National Cardiovascular Center Harapan Kita, Jakarta, Indonesia.

RESULTS

The proportion of patients who did not receive reperfusion therapy was 59% in all STEMI patients and the majority of them (52%) came from inter-hospital referral. The time from onset of infarction to hospital admission was more than 12 h in almost 80% cases and 60% had an anterior wall MI. In-hospital mortality was significantly higher in patients who did not receive reperfusion therapy compared with patients receiving acute reperfusion therapy, either with primary percutaneous coronary intervention (PPCI) or fibrinolytic therapy (13.3% vs 5.3% vs 6.2%, p < 0.001).

CONCLUSION

The Jakarta Cardiovascular Care Unit Network System was built to improve the care of AMI in Jakarta. This network will harmonise the activities of all hospitals in Jakarta and will provide the best cardiovascular services to the community by giving two reperfusion therapy options (PPCI or pharmaco-invasive strategy) depending on the time needed for the patient to reach the cath-lab.