Association of plasma miR-223 and platelet reactivity in patients with coronary artery disease on dual antiplatelet therapy: A preliminary report

Decreased plasma levels of microRNA-223 (miR-223), predominantly of platelet origin, were proposed as a surrogate marker of efficacy of antiplatelet therapy. However, higher on-treatment platelet reactivity was associated with lower plasma miR-223 in patients with coronary artery disease (CAD) on dual antiplatelet therapy (DAPT) including clopidogrel and aspirin. Our aim was to compare plasma miR-223 and platelet reactivity in CAD patients on DAPT with newer P2Y12 antagonists vs. clopidogrel. We studied 21 men with CAD admitted to our centre owing to a non-ST-elevation acute coronary syndrome, and with an uncomplicated hospital course. From the day of admission, the patients were receiving either clopidogrel (n = 11) or prasugrel/ticagrelor (n = 10) in addition to aspirin. Before discharge, miR-223 expression in plasma was estimated by quantitative polymerase chain reaction using the comparative Ct method relative to miR-16 as an endogenous control. Multiple electrode aggregometry was used to assess platelet aggregation in response to adenosine diphosphate (ADP). ADP-induced platelet reactivity was decreased in the patients treated with prasugrel or ticagrelor compared with those on clopidogrel (mean ± SD: 139 ± 71 vs. 313 ± 162 arbitrary units [AU]*min, p = 0.006), due to a more potent antiplatelet activity of the novel P2Y12 antagonists. Consequently, six out of seven patients in the lower tertile of the ADP-induced platelet aggregation were treated with the newer P2Y12 blockers, whereas six out of seven patients in the upper tertile were on clopidogrel. Plasma miR-223 was elevated with decreasing platelet reactivity (Spearman's rho = -0.52; p = 0.015 for trend), being significantly higher in the lower tertile of the ADP-induced platelet aggregation (median [range]: 1.06 [0.25-2.31]) vs. the upper tertile (0.20 [0.13-2.30]) (p = 0.04). In conclusion, our preliminary results argue against the notion of low plasma miR-223 as a marker of platelet responsiveness to DAPT. On the contrary, more potent platelet inhibition associated mainly with newer P2Y12 antagonists appears to coincide with higher miR-223 relative to the subjects with attenuated responsiveness to DAPT.

No long-term clinical benefit from manual aspiration thrombectomy in ST-elevation myocardial infarction patients. Data from NRDES registry

BACKGROUND

Current STEMI guidelines recommend thrombectomy should be considered during primary PCI. Multiple data from randomized clinical trials, registries, and metanalysis have confirmed the efficacy of thrombectomy in terms of surrogate endpoints like better myocardial perfusion, less pronounced distal embolization, and conflicting results on lower all-cause mortality. Our aim was to analyze long-term outcome of STEMI patients treated with manual thrombectomy during primary PCI in a contemporary national registry.

METHODS

There were 13 catheterization laboratories in Poland that enrolled patients in NRDES Registry. Patients were divided into two groups: those that were treated with manual thrombectomy for their primary PCI vs. those who were not.

RESULTS

There were altogether 2,686 patients enrolled in the NRDES Registry of whom 1,763 were diagnosed with STEMI (66%). Aspiration thrombectomy was used in 673 of these cases (38%) and 1,090 (62%) patients were treated without thrombectomy during the index primary PCI. Overall mortality at 1 year was 11.03% in thrombectomy and 7.46% in no thrombectomy group respectively (P = 0.0292 which became insignificant after propensity score matching adjustment P = 0.613). Specific subgroup analyses revealed that there was no benefit from aspiration thrombectomy in neither subgroup.

CONCLUSIONS

Manual aspiration thrombectomy in patients undergoing primary PCI for STEMI was not associated with improved long-term 1-year clinical outcome. Subgroup analysis did not reveal any specific setting in which thrombectomy would be clinically superior. © 2014 Wiley Periodicals, Inc.

Impact of infarct related artery patency after early abciximab administration on one-year mortality in patients with ST-segment elevation myocardial infarction (data from the EUROTRANSFER Registry)

BACKGROUND

Spontaneous early infarct related artery (IRA) recanalisation before primary percutaneous coronary intervention (pPCI) has a favourable impact on outcome. However, the role played by pharmacotherapy driven patency prior to pPCI is still a matter of debate.

AIM

To assess the role of early IRA patency (TIMI flow 2 or 3) after early abciximab administration in patients with ST-segment elevation myocardial infarction (STEMI) transferred for pPCI.

METHODS

Data was gathered for 1,650 consecutive STEMI patients transferred for pPCI from hospital networks in seven countries in Europe between November 2005 and January 2007. We identified 691 patients who were pretreated with abciximab before transportation to a cathlab hospital and underwent PCI.

RESULTS

Angiography showed early IRA patency (TIMI flow 2 or 3) in 233 (33.7%) patients, and occluded IRA (TIMI flow 0 or 1) in 458 (66.3%) patients. In patients with patent IRA, in baseline angiography the rate of TIMI 3 flow and ECG ST-segment resolution 〉 50% after PCI was higher compared to patients with occluded IRA. One year mortality was significantly lower in patients with patent IRA, 1.3% vs 7% (OR 0.17; CI 0.05-0.6; p = 0.001). In multivariable Cox regression analysis, IRA patency at baseline was identified as an independent predictor of one-year mortality.

CONCLUSIONS

Infarct related artery recanalisation after early pharmacological pretreatment in STEMI patients undergoing transportation for pPCI is associated with better post-procedural myocardial perfusion and lower one-year mortality.

Predictors of infarct-related artery patency following combined lytic therapy in patients with ST-segment elevation myocardial infarction treated with immediate percutaneous coronary intervention

BACKGROUND AND AIM

Patency of infarct-related artery (IRA) before percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is associated with better outcomes. Little is known of the clinical or angiographic predictors of IRA recanalisation after administration of combined fibrinolytic therapy before PCI.

METHODS

A total of 225 STEMI patients, admitted to remote hospitals with anticipated transfer time to cathlab > 90 min were enrolled. All patients received a half dose of alteplase and a full dose of abciximab at the remote hospital and were immediately transferred for angiography. In angiographic analysis, the culprit lesion (CL) was defined as the minimal lumen diameter (MLD) point in IRA (CLMLD) (in group with occluded IRA, measurement was done after the first pass of the guidewire).

RESULTS

Occluded IRA (TIMI 0+1) was found in 14.2% of patients (n = 32) and patent IRA (TIMI 2+3) in 85.8% (n = 193) at baseline angiography. Baseline and angiographic characteristics were similar in both groups, except for a higher rate of smoking in the TIMI 2+3 group (73.1% vs 50%; p = 0.009) and longer distance from CLMLD point to the nearest proximal side branch in the TIMI 0+1 group (21.2 ± 10.3 mm vs 13.8 ± 11.2 mm; p = 0.002). In multivariate analysis, smoking and distance from CLMLD to the nearest proximal side branch were independent predictors of IRA patency at baseline.

CONCLUSIONS

Angiographic (anatomical) IRA parameter as distance from CLMLD point to nearest proximal side branch may influence the efficacy of combined fibrinolytic therapy before PCI despite the similar clinical characteristics and time delay to angiography. Smoking has a paradoxical beneficial effect on combined thrombolytic therapy effectiveness.

Thrombus aspiration followed by direct stenting: a novel strategy of primary percutaneous coronary intervention in ST-segment elevation myocardial infarction. Results of the Polish-Italian-Hungarian RAndomized ThrombEctomy Trial (PIHRATE Trial)

BACKGROUND

Previous studies with thrombectomy showed different results, mainly due to use of thrombectomy as an additional device not instead of balloon predilatation. The aim of the present study was to assess impact of aspiration thrombectomy followed by direct stenting.

METHODS

Patients with ST elevation myocardial infarction (STEMI) <6 hours from pain onset and occluded infarct-related artery in baseline angiography were randomized into aspiration thrombectomy followed by direct stenting (TS, n = 100) or standard balloon predilatation followed by stent implantation (n = 96). The primary end point of the study was the electrocardiographic ST-segment elevation resolution >70% (STR > 70%) 60 minutes after primary angioplasty (percutaneous coronary intervention [PCI]). Secondary end points included angiographic myocardial blush grade (MBG) after PCI, combination of STR > 70% immediately after PCI and MBG grade 3 (optimal myocardial reperfusion), Thrombolysis In Myocardial Infarction flow after PCI, angiographic complications, and in-hospital major adverse cardiac events.

RESULTS

Aspiration thrombectomy success rate was 91% (crossing of the lesion with thrombus reduction and flow restoration). There was no significant difference in STR ≥ 70% after 60 minutes (53.7% vs 35.1%, P = .29). STR > 70% immediately after PCI (41% vs 26%, P < .05), MBG grade 3 (76% vs 58%, P < .03), and optimal myocardial reperfusion (35.1% vs 11.8%, P < .001) were more frequent in TS. There was no difference in between the groups in 6-month mortality (4% vs 3.1%, P = .74) and reinfarction rate (1% vs 3.1%, P = .29).

CONCLUSIONS

Aspiration thrombectomy and direct stenting is safe and effective in STEMI patients with early presentation (<6 hours). The angiographic parameters of microcirculation reperfusion and ECG ST-segment resolution directly after PCI were significantly better in thrombectomy group despite the lack of the difference in ST-segment resolution 60 minutes after PCI.

Transportation with very long transfer delays (>90 min) for facilitated PCI with reduced-dose fibrinolysis in patients with ST-segment elevation myocardial infarction: the Krakow Network

BACKGROUND

The majority of ST-segment elevation myocardial infarction (STEMI) patients are admitted to centers without primary percutaneous coronary intervention (PCI) facilities. Purpose of the study was to determine safety and outcomes in STEMI patients with transfer delay to PCI>90 min receiving half-dose alteplase and abciximab before PCI (facilitated PCI with reduced-dose fibrinolysis).

METHODS AND RESULTS

Outcomes of 669 STEMI patients (<12 h chest pain, non shock, fibrinolysis eligible, <75 years) with transfer delay to PCI>90 min who received half-dose alteplase and full-dose abciximab and were immediately transferred for PCI were compared with primary PCI effects in 1311 patients with transfer delay <90 min. Mean time from symptom-onset to PCI was longer (357 ± 145 min vs. 201 ± 177; P<0.001) in facilitated PCI with reduced-dose fibrinolysis group. In-hospital and 12-month outcomes were similar in both groups, however bleeding events were more frequent in facilitated PCI group (hemorrhagic stroke 0.9% vs. 0%; P<0.001; severe+moderate 5.5% vs. 2.3%; P<0.001).

CONCLUSIONS

This is the first large report showing the safety and benefits of transportation with very long transfer delay (>90 min) for facilitated PCI with reduced-dose fibrinolysis in STEMI patients. In fact, pharmacological treatment (combotherapy) was effective in overcoming the deleterious effects of long time-delay on outcome, with similar survival as compared to short-time transportation, despite higher risk of major bleeding complication.

Relationship between chronic obstructive pulmonary disease and in-hospital management and outcomes in patients with acute myocardial infarction

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is associated with unfavourable short- and long-term outcome in patients with coronary artery disease undergoing revascularisation procedures.

AIM

To assess the associations of COPD with in-hospital management and mortality in patients with acute myocardial infarction (MI) admitted to hospitals without on-site invasive facilities.

METHODS

We identified 81 (11.3%) patients with COPD and 633 (88.7%) without COPD treated in the Krakow Registry of Acute Coronary Syndromes from February 2005 to March 2005 and from December 2005 to January 2006. Data concerning in-hospital management and mortality were assessed.

RESULTS

Patients with COPD were older and were more likely to have prior angina, prior heart failure symptoms, prior stroke, and lower left ventricular ejection fraction. Patients with COPD diagnosis were less likely to be transferred for invasive treatment [COPD (-) vs. COPD (+), 12.3 vs. 34.9%; p < 0.0001] and to receive aspirin and clopidogrel during index hospital stay. In-hospital mortality was higher in patients with COPD diagnosis [COPD (-) vs. COPD (+), 58 of 412 (14.1%) vs. 21 of 71 (29.6%); p = 0.002]. COPD was an independent predictor of in-hospital death in multivariate Cox regression analysis.

CONCLUSIONS

Coexistence of COPD with acute MI may be associated with less frequent transfer for invasive treatment, less aggressive pharmacotherapy, and higher in-hospital mortality in patients admitted to community hospitals without on-site invasive facilities. These differences may be partially driven by a higher risk profile of COPD patients.

Impact of admission glucose level and presence of diabetes mellitus on mortality in patients with non-ST-segment elevation acute coronary syndrome treated conservatively

Elevated glucose level on admission is common in patients with acute coronary syndrome (ACS) and has been shown to be a strong predictor of adverse outcome in patients both with and without diabetes. The purpose of the study was to assess the impact of admission glucose on in-hospital mortality in patients with non-ST-segment elevation ACS treated in hospitals without on-site invasive facilities. We identified 807 patients with non-ST-segment elevation ACS treated conservatively in the 29 hospitals participating in the Krakow Registry of Acute Coronary Syndromes; 763 patients with complete admission glucose data were stratified according to admission glucose level. Of these, 24.2% had admission glucose level <5, 50.6% had a level 5 to 6.9, 10.9% had a level 7 to 8.9, 6.7% had a level 9 to 10.9, and 7.6% had a level > or =11 mmol/L. In-hospital mortality was higher in patients with higher admission glucose (admission glucose <5, 5 to 6.9, 7 to 8.9, 9 to 10.9, and > or =11 mmol/L: 0.5%, 2.6%, 7.2%, 9.8%, and 24.1% respectively, p <0.0001). Similarly, significant mortality difference was observed in patient subgroups stratified by admission glucose level and presence of diabetes mellitus and cardiogenic shock. Independent predictors of in-hospital death were age, cardiogenic shock, admission glucose, chronic obstructive pulmonary disease, and renal insufficiency. In conclusion, admission glucose level is a strong predictor of in-hospital death in patients with non-ST-segment elevation ACS remaining in hospitals without on-site invasive facilities. Impact of admission glucose on mortality is independent of diabetes and cardiogenic shock presence.

[Successful recanalisation of chronic total occlusion using retrograde approach]

Chronic total occlusion (CTO) is defined as an occlusion of a coronary vessels (TIMI 0 flow) lasting longer than 3 months. Successful recanalisation of CTO improves left ventricular function and survival. Retrograde technique can be used in patients, who have well-developed collaterals, when the antegrade approach is ineffective or difficult to perform. A 68-year-old male was referred for coronary angiography because of exercise angina chest pain. Coronary angiogram showed a CTO of RCA with collaterals from LAD. Following the unsuccessful traditional antegrade approach in 2004, we attempted a retrograde approach. The PCI procedure was performed successfully and without complications.

Management and mortality in patients with non-ST-segment elevation vs. ST-segment elevation myocardial infarction. Data from the Malopolska Registry of Acute Coronary Syndromes

BACKGROUND

According to the presenting electrocardiogram, acute myocardial infarction (MI) can by categorised generally as non-ST-segment elevation MI (NSTEMI) and ST-segment elevation MI (STEMI).

AIM

To assess the impact of the different acute MI categories on in-hospital management and mortality in hospitals without on-site invasive facilities.

METHODS

We identified 380 NSTEMI and 334 STEMI patients treated in the Malopolska Registry of Acute Coronary Syndromes from February to March 2005 and from December 2005 to January 2006. Data concerning in-hospital management and mortality were assessed.

RESULTS

Patients with NSTEMI were older and were more likely to have prior angina, prior MI and prior heart failure symptoms than STEMI patients. The NSTEMI patients were less likely to be transferred for invasive treatment (23.9 vs. 41.9%, p <0.0001) and receive glycoprotein IIb/IIIa inhibitors during index hospital stay. The use of low-molecular-weight heparin, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin II antagonists, nitrates and statins was more frequent in NSTEMI patients. Among patients treated non-invasively, in-hospital mortality was high, but was lower in NSTEMI than STEMI patients (12.1 vs. 22.7%, p <0.0001). Independent predictors of in-hospital death in this group were age, cardiogenic shock, chronic obstructive pulmonary disease, and STEMI.

CONCLUSIONS

Despite current recommendations, NSTEMI patients are still less likely to be transferred for invasive treatment than STEMI patients. Among patients treated non-invasively during index hospital stay, NSTEMI is associated with more favourable prognosis than STEMI, but the risk of in-hospital death is high. The hospital network should implement more frequently the strategy of early and urgent invasive treatment of NSTEMI patients.

Effects of early abciximab administration before primary percutaneous coronary intervention on left ventricular function assessed by cardiac magnetic resonance

BACKGROUND

It has been shown that early abciximab administration before primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI) improves efficacy of treatment. However, there are no data on the impact of this strategy on left ventricular (LV) function during long-term follow-up.

AIM

To analyse the effects of early abciximab administration in patients with first anterior STEMI treated with pPCI on infarct size and LV function assessed by cardiac magnetic resonance.

METHODS

A total of 59 patients with STEMI, <12 hours from the chest pain onset, without cardiogenic shock, admitted to local hospitals without interventional facilities, with anticipated delay to pPCI <90 min were randomly assigned to two study groups: 27 patients received abciximab before transfer to the catheterisation laboratory (early abciximab group), and 32 patients received abciximab in the catheterisation laboratory just before pPCI (late abciximab group). All patients received aspirin and heparin (70 U/kg) before transfer to the cath lab. Clopidogrel loading dose was administered in the cath lab before angiography.

RESULTS

Cardiac magnetic resonance was performed in 14 patients from each study group 1 year after pPCI and revealed a significantly lower LV end-systolic volume index (p=0.003), end-diastolic volume index (p=0.009) and better ejection fraction (p <0.05) in patients who received abciximab early.

CONCLUSIONS

Early abciximab administration prior to transfer for pPCI in patients with first anterior STEMI results in a lower degree of LV remodelling and better LV ejection fraction at 1-year follow-up compared to late abciximab administration in the cath lab during pPCI.

Local hospital networks for STEMI treatment for a population of half a million inhabitants increase the use of invasive treatment of acute coronary syndromes to the European recommended level. The Małopolska Registry of Acute Coronary Syndromes 2005-2006

BACKGROUND

According to the European Society of Cardiology (ESC) consensus, over 75% of patients with ST-elevation myocardial infarction (STEMI) should receive reperfusion therapy. An early invasive strategy is also advocated for high-risk non-ST elevation acute coronary syndromes (NSTE ACS). Until 2005, a single high-volume percutaneous coronary intervention (PCI) centre provided 24-hour service for the population of 3.2 million inhabitants in the Krakow Hospital Network Region. In August 2005 and December 2005 two additional round-the-clock duty PCI centres were launched in remote municipal hospitals (Tarnow and Nowy Sacz).

METHODS

29 non-PCI centres participated in the Registry of ACS in February-March 2005 (Period 1) and in December 2005-January 2006 (Period 2), so while Period 2 was conducted, three PCI centres provided 24-hour service for the Małopolska Region.

RESULTS

A total of 1404 patients with ACS were enrolled - 695 during Period 1 and 709 in Period 2. In comparison to Period 1, a non-significant trend towards more frequent mechanical reperfusion of STEMI patients with chest pain onset <12 hours was observed in Period 2 (54 vs. 60%; p=NS). A steep and significant rise was observed particularly among STEMI patients treated in non-PCI centres outside of the Krakow City Network (51 vs. 78%; p=0.001). In the newly established Tarnow and Nowy Sacz (eastern Małopolska) PCI networks the reperfusion rates for STEMI patients with chest pain <12 hours were 78% and 88%, respectively, in comparison to 55% in western Małopolska (p=0.001). The transfer rate for invasive treatment of NSTE ACS has increased from 13.8% in Period 1 to 19% in Period 2 (p=0.031) in the entire region. The in-hospital mortality for patients receiving conservative treatment in community hospitals has decreased among NSTE ACS patients (6.8 vs. 3.9%; p=0.045) and remained unchanged in STEMI (21.3 vs. 19%; p=NS).

CONCLUSIONS

Opening of new PCI centres, based on population magnitude and structure, improves local adherence to the guideline-recommended invasive approach in high-risk ACS patients. The Małopolska Programme model showed that one high-volume 24-hour duty PCI centre with a network of cooperating non-PCI centres for a population of 0.5 million might be sufficient to provide invasive treatment according to the ESC guidelines for eligible patients.

Immediate angioplasty versus standard therapy with rescue angioplasty after thrombolysis in the Combined Abciximab REteplase Stent Study in Acute Myocardial Infarction (CARESS-in-AMI): an open, prospective, randomised, multicentre trial

BACKGROUND

Thrombolysis remains the treatment of choice in ST-segment elevation myocardial infarction (STEMI) when primary percutaneous coronary intervention (PCI) cannot be done within 90 min. However, the best subsequent management of patients after thrombolytic therapy remains unclear. To assess the best management, we randomised patients with STEMI treated by thrombolysis and abciximab at a non-interventional hospital to immediate transfer for PCI, or to standard medical therapy with transfer for rescue angioplasty.

METHODS

600 patients aged 75 years or younger with one or more high-risk features (extensive ST-segment elevation, new-onset left bundle branch block, previous myocardial infarction, Killip class >2, or left ventricular ejection fraction < or =35%) in hospitals in France, Italy, and Poland were treated with half-dose reteplase, abciximab, heparin, and aspirin, and randomly assigned to immediate transfer to the nearest interventional centre for PCI, or to management in the local hospital with transfer only in case of persistent ST-segment elevation or clinical deterioration. The primary outcome was a composite of death, reinfarction, or refractory ischaemia at 30 days, and analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number 00220571.

FINDINGS

Of the 299 patients assigned to immediate PCI, 289 (97.0%) underwent angiography, and 255 (85.6%) received PCI. Rescue PCI was done in 91 patients (30.3%) in the standard care/rescue PCI group. The primary outcome occurred in 13 patients (4.4%) in the immediate PCI group compared with 32 (10.7%) in the standard care/rescue PCI group (hazard ratio 0.40; 95% CI 0.21-0.76, log rank p=0.004). Major bleeding was seen in ten patients in the immediate group and seven in the standard care/rescue group (3.4%vs 2.3%, p=0.47). Strokes occurred in two patients in the immediate group and four in the standard care/rescue group (0.7%vs 1.3%, p=0.50).

INTERPRETATION

Immediate transfer for PCI improves outcome in high-risk patients with STEMI treated at a non-interventional centre with half-dose reteplase and abciximab.

Renal insufficiency increases mortality in acute coronary syndromes regardless of TIMI risk score

BACKGROUND

Non ST-segment elevation acute coronary syndromes (NSTE ACS) are the most frequent cause of admission to intensive care units. Early risk assessment and implementation of optimal treatment are of special importance in these patients. Previous studies have demonstrated that renal insufficiency is an independent risk factor in patients with cardiovascular disease.

AIM

To assess the effects of renal function on the course of treatment and prognosis in patients with NSTE ACS admitted to hospitals without on-site invasive facilities but with a possibility of immediate transfer to a reference centre with a catheterisation laboratory.

METHODS

Twenty-nine community hospitals without on-site invasive facilities participated in the Krakow Registry of Acute Coronary Syndromes - a prospective, multicentre, web-based, observational registry. Renal insufficiency (RI) was defined as creatinine clearance (CrCl) <60 ml/min.

RESULTS

NSTE ACS was diagnosed in 1396 patients. Renal insufficiency was diagnosed in 34% of all patients. Only 17% of them had been diagnosed with RI prior to admission. Transfer for invasive treatment was undertaken in 10% of RI patients as compared to 16% of patients with CrCl >60 ml/min (NS). In-hospital mortality among patients remaining on conservative treatment in community hospitals was significantly higher among RI patients (4.0 vs. 0.6%; p <0.001). Thienopyridines were less frequently used in RI patients (46 vs. 54%; p <0.05). In-hospital mortality among RI patients remaining in community hospitals and treated conservatively was higher than among non-RI patients in each TIMI risk score group: 7.3 vs. 2.4% (p <0.05) in the high risk group, 4.1 vs. 1.4% (NS) in the moderate and 3.6 vs. 0% (p <0.001) in the low risk group. Multivariate logistic regression analysis identified reduced creatinine clearance and a history of heart failure as independent factors influencing mortality.

CONCLUSIONS

Renal insufficiency was present in one-third of NSTE ACS patients. Patients with renal insufficiency had worse clinical risk profile and received less aggressive treatment. Patients with NSTE ACS and renal insufficiency treated conservatively had higher in-hospital mortality. Renal insufficiency modifies mortality irrespective of the TIMI risk score. Creatinine clearance should be considered in modification of the TIMI risk score scale.

In-hospital management and mortality in elderly patients with non-ST-segment elevation acute coronary syndromes treated in centers without on-site invasive facilities

BACKGROUND

The purpose was to assess age-related differences in hospital management and mortality in non-ST-elevation acute coronary syndrome (NSTE ACS) patients treated conservatively, with a focus on the influence of aggressive pharmacological treatment on in-hospital clinical outcome.

METHODS

We identified 807 NSTE ACS patients treated conservatively in the 29 hospitals participating in the Krakow Registry of Acute Coronary Syndromes from February to March 2005 and from December 2005 to January 2006. Out of 807 patients' 32.1% were less than 65 years of age, 33% from 65 to 74, 30.5% from 75 to 84, and 5.3% >or= 85. For all patients, pharmacotherapy index based on the use of pharmacological treatment regimen during hospital stay was assessed. Each patient received 1 point for each of the following guideline-recommended drugs used: aspirin, clopidogrel, glycoprotein IIb/IIIa inhibitor, LMWH, beta-blocker, ACE inhibitor/angiotensin II receptor blocker and statin - the range of points being from 0 to 7.

RESULTS

Significant age-related differences in baseline characteristics and pharmacotherapy index values were found. In-hospital mortality was higher in elderly patients (2.4% vs. 3.4% vs. 8.9% vs. 14.0%, respectively for age groups, p < 0.0001). Similarly, in non-shock patients and in patients with elevated cardiac markers, age-dependent differences in mortality were observed. Independent predictors of in-hospital death were: age, cardiogenic shock, elevated cardiac markers and pharmacotherapy index.

CONCLUSIONS

Advanced age is associated with less aggressive pharmacological treatment and higher in-hospital mortality in NSTE ACS patients remaining in community hospitals for conservative treatment. Broader implementation of current guidelines and more frequent invasive treatment might improve the outcomes of NSTE ACS patients regardless of age.

More aggressive pharmacological treatment may improve clinical outcome in patients with non-ST-elevation acute coronary syndromes treated conservatively

INTRODUCTION

Increased adherence to guideline-recommended therapies, especially early invasive strategy introduction may improve clinical outcome in patients with non-ST-elevation acute coronary syndromes. The aim of this study was to assess the impact of more aggressive pharmacological treatment and application of current guidelines in everyday clinical practice in hospitals without on-site invasive facility, with a special focus on its influence on in-hospital mortality in non-ST-elevation acute coronary syndromes patients.

METHODS

We identified 807 non-ST-elevation acute coronary syndromes patients treated conservatively in the 29 hospitals participating in the Malopolska Registry of Acute Coronary Syndromes from February to March 2005 and from December 2005 to January 2006. For all patients, pharmacotherapy index based on the use of pharmacological treatment regimen during hospital stay was assessed. Each patient received 1 point for each of the following guideline-recommended drugs used: aspirin, clopidogrel, glycoprotein IIb/IIIa inhibitor, low-molecular-weight heparin, beta-blocker, angiotensin converting enzyme inhibitor/angiotensin II receptor blocker, statin - range of points from 0 to 7.

RESULTS

The in-hospital mortality decreased with increase of pharmacotherapy index (0 points - 80.0%, 1 point - 36.4%, 2 points - 17.4%, 3 points - 7.6%, 4 points - 5.6%, 5 points - 1.7%, 6 points - 0.0%; P<0.0001, total mortality-5.3%). Independent predictors of in-hospital death were cardiogenic shock, thrombolysis in myocardial infarction (TIMI) risk score, renal insufficiency and pharmacotherapy index.

CONCLUSIONS

Our findings support the need for more aggressive pharmacological treatment of patients with non-ST-elevation acute coronary syndromes remaining in community hospitals for conservative treatment. Broader implementation of current guidelines and more frequent invasive treatment could improve the outcomes of non-ST-elevation acute coronary syndromes patients.

Management of myocardial infarction with ST-segment elevation in district hospitals without catheterisation laboratory--Acute Coronary Syndromes Registry of Małopolska 2002-2003

INTRODUCTION

Early reperfusion therapy significantly reduces mortality and improves outcome in ST-elevation myocardial infarction (STEMI). Primary percutaneous intervention has been proven to be a better therapeutic option than fibrinolysis when it can be performed by an experienced team of interventional cardiologists, within 90 minutes from the first medical contact. Despite the publication of guidelines of the European and American Scientific Societies (ESC and ACC/AHA), treatment of patients with STEMI is far from the optimum. The registry is an effective and reliable method to estimate the quality of treatment and demographic and epidemiologic characteristics of the population of a given region.

AIM

To evaluate the therapeutic strategies of treatment of STEMI in district hospitals without a catheterisation laboratory in Małopolska.

METHODS

29 district hospitals from Cracow and Małopolska province participated in the Registry of Acute Coronary Syndromes in Małopolska. Finally, 2382 patients with an initial diagnosis of acute coronary syndrome were included. In 867 of them, STEMI was finally diagnosed.

RESULTS

In district hospitals, most patients with STEMI (63%) did not receive any reperfusion therapy (25% of them were >75 years old, in 20% chest pain lasted longer than 12 hours, in 7% cardiogenic shock was diagnosed and 12% had contraindications for thrombolysis or were at increased risk of haemorrhagic complications). Fifteen percent of all 867 patients were transferred to the interventional cardiology centre (63% for primary PCI, 20% for facilitated PCI and the remaining 17% for rescue PCI). Fibrinolysis was applied in 21% of all patients with STEMI. In-hospital mortality rate was 14.3% in patients treated with fibrinolysis as compared to 15.9% in those treated conservatively. Multivariate logistic regression revealed that younger age (OR 0.93; 95% CI 0.91-0.95; p <0.0001), lack of diabetes (OR 0.54; 95% CI 0.30-0.98; p=0.04) and higher systolic blood pressure (OR 0.93; 95% CI 1.00-1.02; p=0.006) were independent factors predicting the referral of patients with STEMI for PCI. GP IIb/IIIa inhibitors were used in 5% of all patients and in 30% of those referred for PCI.

CONCLUSIONS

Only one in every 7 patients with STEMI is qualified for PCI. Patients transferred to the centre with PCI facilities are younger, have no diabetes or hypotension. The use of GP IIb/IIIa inhibitors is limited. There is a need to establish local networks of hospitals with 24-hour catheterisation laboratory availability to increase frequency and efficacy of reperfusion therapy, especially in regions far from centres of interventional cardiology.

Inferior wall myocardial infarction with or without right ventricular involvement--treatment and in-hospital course

INTRODUCTION

Right ventricular infarction (RVI) is most commonly associated with inferior wall infarction (20-50% of cases). Clinical presentation of RVI may vary.

AIM

Assessment of outcome and clinical course of myocardial infarction in patients with inferior wall myocardial infarction with or without RVI. Additionally, risk stratification was attempted in the above-mentioned groups of patients.

METHODS

The analysis involved 181 consecutive patients (pts) with inferior wall myocardial infarction hospitalised between 1 July 2000 and 1 July 2002.

RESULTS

Nineteen in-hospital deaths were noted in the study group (mortality 10.5%), reinfarction occurred in 6 (3.3%) pts, ischaemic stroke in 1 (0.6%) patient, and 2 (1.1%) pts had transient ischaemic attack. Cardiogenic shock occurred in 20 (11.0%) pts , ventricular fibrillation in 15 (8.3%) pts, and pulmonary oedema in 9 (4.9%) pts. In the subgroup of 161 pts without cardiogenic shock 8 (4.9%) pts died. Thrombolytic therapy was administered in 96 (53%) subjects. Isolated inferior wall myocardial infarction was diagnosed in 94 (51.9%) of 181 pts and RVI in 65 (35.9%) pts. Mortality rate in the RVI group was significantly higher than in inferior wall myocardial infarction without RVI and was 18.5% vs 2.12% (p=0.0003), respectively (excluding patients with cardiogenic shock: 11.1% vs 1.2%, respectively; p=0.016). In patients with RVI aged above 70 years, the mortality rate was significantly higher than in younger patients (32% vs 10%, p=0.002). In a subgroup with RVI treated with thrombolysis mortality was considerably higher in subjects aged >70 years compared to patients below 70 years (38.5% vs 7.7%, p=0.017).

CONCLUSIONS

RVI is associated with worse prognosis and increased number of in-hospital complications. Older patients aged >70 years have definitely poorer prognosis. Thrombolytic therapy in a subgroup of older patients with RVI remains ineffective.

Angiographic and clinical outcome after percutaneous coronary interventions following combined fibrinolytic therapy in acute myocardial infarction

INTRODUCTION

Combined therapy with fibrinolytic agent and platelet GPIIb/IIIa inhibitor not followed by an interventional procedure does not improve prognosis in patients presenting with acute ST-segment elevation myocardial infarction (STEMI) when compared to fibrinolysis alone. On the other hand, in the past percutaneous coronary interventions (PCI) performed after fibrinolysis were associated with low angiographic efficacy, a high risk of bleeding and a high rate of early cardiovascular events.

AIM

Evaluation of angiographic and clinical outcomes in patients with STEMI treated with PCI following combined fibrinolytic therapy.

METHODS AND RESULTS

Complete angiographic and clinical data of 187 patients who underwent PCI immediately after combined fibrinolytic therapy were obtained from a survey of 669 consecutive patients with STEMI <12 hours, at age <75 years, without cardiogenic shock, who were transferred from regional hospitals to the catheterisation laboratory within 90 minutes and after the initiation of combined fibrinolytic therapy (alteplase 15 mg iv as a bolus followed by an infusion of 35 mg over 60 minutes; abciximab iv bolus of 0.25 mg/kg followed by a 12 h infusion of 0.125 microg/kg per minute; unfractionated heparin). At baseline angiographic examination revealed no flow (TIMI 0+1) in the infarct-related artery in 17.1% of patients, impaired flow (TIMI 2) in 17.1% and normal (TIMI 3) in 65.8% of cases. After immediate PCI, a significant improvement in epicardial perfusion (TIMI 2+3, 99.5%) and in microcirculation was achieved. This favourable effect was seen only in the group of patients with baseline TIMI 0+1 flow, whereas PCI in the group with baseline TIMI 3 flow did not cause any further improvement in microcirculatory perfusion. The rate of cardiovascular events within the first 30 days and 12 months after the procedures were similar in the studied subgroup of patients.

CONCLUSIONS

PCI performed after combined fibrinolytic therapy in STEMI patients is associated with high efficacy and improvement in indices of epicardial perfusion and microcirculation. These benefits are confined mainly to patients with primarily impaired flow in the infarction-related artery (TIMI 0+1). However, the clinical results of this strategy, particularly in patients undergoing PCI following successful combined fibrinolytic therapy, must still be proved in further randomised trials.

Inter-individual variability in response to clopidogrel in patients with coronary artery disease

BACKGROUND

Clopidogrel, especially when combined with aspirin, reduces the rate of ischaemic events in patients with coronary artery disease (CAD). There are scare data in literature on the inter-individual variability in response to clopidogrel.

AIM

To assess the incidence of clopidogrel resistance using rapid whole blood platelet function assessment, and to examine the possibility of early identification of non-responders.

METHODS

In 31 consecutive patients with stable angina treated with aspirin, the degree of platelet aggregation inhibition (DPAI) in the whole blood was assessed at baseline and 3, 6, 12 as well as 24 hours after administration of loading dose of clopidogrel (300 mg). Response to clopidogrel was measured by calculating the absolute difference between the baseline DPAI and DPAI obtained at the investigated time-points (DPAI).

RESULTS

After 24 hours from clopidogrel administration, seven (22.6%) patients were identified as non-responders (DPAI < or =10%). Demographic and clinical variables as well as baseline DPAI were similar in responders and non-responders (DPAI: 5.8+/-3.7% vs 7.1+/-5.3%, p=NS). Out of the patients who were found to be resistant to clopidogrel at the six-hour time-point, 87.5% remained resistant to this agent 24 hours after drug administration. DPAI calculated at the 24-hour time-point highly correlated with the six-hour DPAI (r=0.74). No differences in the rate of ischaemic or bleeding complications between responders and non-responders were noted.

CONCLUSIONS

The assessment of the degree of platelet aggregation inhibition allows early (six hours from the initiation of treatment) identification of patients who are resistant to clopidogrel. The method of the rapid whole blood platelet function assessment is feasible in every-day clinical practice.

Percutaneous thrombectomy with the RESCUE system in acute myocardial infarction

BACKGROUND

Percutaneous coronary interventions (PCI) in acute myocardial infarction with ST segment elevation (STEMI) are associated with distal coronary embolisation. It may be speculated that percutaneous thrombectomy preceding stent implantation may prevent coronary microcirculation from embolisation.

AIM

To assess safety and efficacy of percutaneous thrombectomy in patients with STEMI.

METHODS

Seventy two patients with STEMI were randomised to PCI with stent implantation alone (n=32) or percutaneous thrombectomy with the RESCUE system, followed by stent implantation (n=40). Coronary flow in infarct related artery before and after the procedure was assessed using TIMI scale and corrected TIMI frame count - cTFC. Myocardial blood flow was measured using TIMI myocardial perfusion grade - tMPG. The degree of ST segment resolution 60 min after PCI was also assessed. Left ventricular ejection fraction (LVEF) was measured in hospital and three months later.

RESULTS

The two groups did not differ with respect to the time from the onset of symptoms to the procedure (236+/-162 min vs 258+/-198 min, NS) or the baseline TIMI, cTFC and tMPG values. An effective thrombectomy procedure was performed in 35 (87%) patients from group B. After the procedure, the number of patients with TIMI 3 grade as well as cTFC values and the proportion of patients with tMPG 3 were similar in both groups (86% vs 85%, NS; 19 vs 21, NS; and 38% vs 54%, NS). The sum of ST segment elevations after the procedure was significantly greater in patients who underwent PCI only compared with patients who had thrombectomy and PCI (6.8+/-5.2 mm vs 3.6+/-2.9 mm, p=0.004). Complete normalisation of ST segment was achieved in 68% of patients treated with thrombectomy and PCI compared with 25% of patients who had PCI only (p=0.005). CK-MB peak values occurred significantly earlier in patients treated with thrombectomy (92.1% vs 66.7% up to 360 min, p=0.01). After 3 months of follow-up, LVEF tended to be greater in patients treated with thrombectomy and PCI than in those who underwent PCI only (55.3+/-14.7% vs 60.3+/-9.2%, NS).

CONCLUSIONS

Thrombectomy with the RESCUE system in patients with STEMI is safe and effectively restores patency of infarct related artery. Thrombectomy better improves myocardial perfusion than standard PCI.

Primary coronary angioplasty in patients with ST segment elevation acute myocardial infarction and diabetes

BACKGROUND

Subjects with diabetes constitute 13-25% of patients with ST segment elevation acute myocardial infarction (STEMI). In spite of the introduction of thrombolytic therapy, patients with STEMI and diabetes continue to have worse prognosis than those without diabetes. Primary percutaneous coronary intervention (PCI) has been shown in recent years to be the most effective therapy in patients with STEMI.

AIM

To compare the outcome of STEMI patients with or without diabetes who underwent primary PCI.

METHODS

The study group consisted of 500 consecutive patients with STEMI. The occurrence of major adverse cardiac events (MACE) which included death, reinfarction or repeated PCI of the target vessel, was analysed peri-operatively and during a six-month follow-up period.Results. Diabetes was diagnosed in 68 (13.6%) patients. The mean time duration from the onset of STEMI symptoms to treatment was similar in patients with or without diabetes (230+/-97 min vs 231+/-139 min, NS). Patients with diabetes were older (61.9+/-8.9 vs 57.9+/-10.8 years, p=0.004), had higher body mass index (29+/-4 vs 27+/-5, p=0.002), more frequent history of coronary artery disease (57.4% vs 37.9%, p=0.002), higher prevalence of arterial hypertension (71.6% vs 56.8%, p=0.02) and more frequently the left anterior descending artery as the infarct-related artery (58.8% vs 42.1%, p=0.01). Immediately after PCI, epicardial and myocardial reperfusion rates were lower in patients with rather than without diabetes (TIMI 3: 84.9% vs 91.3%, p=NS, cTFC: 32+/-26 vs 22+/-16, p<0.0001, and MPG3: 25% vs 41.9% p=0.008). Diabetes increased the risk of MACE during in-hospital period by 2.7 times. The rate of MACE during a six-month follow-up period was almost two times higher in patients with rather than without diabetes (death: 8.8% vs 5.1%, reinfarction: 1.5% vs 1.2%, repeated PCI: 11.8% vs 6.9%).

CONCLUSIONS

Primary PCI-achieved epicardial and myocardial reperfusion rate is lower in STEMI patients with rather than without diabetes. The presence of diabetes almost doubles the risk of MACE during a six-month follow-up.

[Primary percutaneous coronary interventions in acute myocardial infraction with ST-segment elevation. Experience in a heart catheterization unit without surgical backup]

BACKGROUND

Primary percutaneous coronary intervention (PCI) in patients (pts) with ST-segment elevation myocardial infarction is regarded as treatment superior to thrombolysis. Coronary stents and GP IIb/IIIa receptor inhibitors improved safety and clinical outcome of interventional procedures. Safety of primary PCI procedure in catheterisation laboratories which do not have on-site surgical backup is still under evaluation.

METHODS

In a cohort of 249 consecutive patients we analysed short and long-term clinical outcome of primary PCI performed in catheterisation laboratory which is located several kilometres from a cardiac surgery department, with an effective transfer time < 30 minutes.

RESULTS

Coronary stents were implanted in 43% pts. GP IIb/IIIa receptor inhibitors were used in 54.2% pts. Cardiogenic shock on admission was diagnosed in 7.2% pts. Intra-aortic balloon counterpulsation usage was necessary in 6.4% pts. In-hospital mortality was 6% (3.5% in non-shock pts). In two pts (0.8%) during hospitalization repeat PCI was performed--in one case due to reinfarction. No urgent cardiosurgery intervention was necessary. Mortality and myocardial infarction rate after hospital discharge during 6 month follow up was 2.4% and 2.8% respectively. In 4% pts repeated PCI was performed due to restensosis. Cumulative event free survival was 84%.

CONCLUSION

Primary PCI procedure for acute myocardial infarction seems to be feasible and safe in catheterisation laboratories without on-site surgical backup provided usage of stents, GPIIb/IIIa receptor inhibitors and intraaortic balloon counterpulsation and cooperation with a nearby cardiosurgery department with short transfer time.

Efficacy and safety of percutaneous coronary interventions in patients with non ST segment elevation acute coronary syndrome in catheterisation laboratory without on-site surgical back-up

BACKGROUND

Percutaneous coronary intervention (PCI) in patients with non ST segment elevation acute coronary syndrome (NSTEACS) is regarded as a procedure which carries a high risk of immediate and long-term adverse cardiac events. This may potentially limit the use of PCI in catheterisation laboratories which do not have on-site surgical back up. However, stents and GP IIb/IIIa receptor inhibitors improved safety of interventional procedures.

AIM

To analyse the immediate and long-term outcome of patients with NSTEACS in whom PCI was performed in a catheterisation laboratory without on-site surgical back-up in.

METHODS

In a cohort of 479 consecutive patients (160 with NSTEACS - group A, 319 with stable angina - group B) we analysed short and long-term clinical outcome of PCI performed in our catheterisation laboratory which is located several kilometres from a cardiac surgery department, with an effective transfer time <30 minutes.

RESULTS

Stent implantation rate and the usage of GP IIb/IIIa blockers were higher in group A than in group B (61.3% vs 50.2%, p=0.04, and 17.5% vs 6.3%; p<0.001, respectively). The in- hospital outcome was similar in both groups (death: 0.6 vs 0.6%; myocardial infarction (MI): 2.5 vs 1.6%; and urgent reintervention (rePCI): 1.9 vs 1.3%, all differences NS). Acute PCI complications requiring urgent surgical operation occurred in 1 (0.6%) patient from group A and in 1 (0.3%) patient from group B (NS). Both patients were successfully transferred for cardiac surgery. During a long-term follow-up the incidence of death (2.0 vs 2.0%), MI (0.7 vs 0.7%), rePCI (21.8 vs 25.2%), CABG (1.4 vs 1.4%) or coronary rehospitalisation (5.4 vs 7.7%) was similar in both groups. The Kaplan-Meier survival and event-free curves were parallel.

CONCLUSIONS

In the era of coronary stents and platelet GP IIb/IIIa receptor inhibitors the short and long-term outcome after PCI in patients with NESTACS and stable angina is similar. The early aggressive approach to patients with NESTACS is feasible and safe in a catheterisation laboratory without on-site cardiac surgery. Surgical back-up is still necessary for only few PCI complications.