Real-world clopidogrel utilization in acute coronary syndromes : patients selection and outcomes in a single-center experience

Background: With this study, we sought to identify patient characteristics associated with clopidogrel prescription and its relationship with in-hospital adverse events in an unselected cohort of ACSs patients. Materials and Methods: We studied all consecutive patients admitted at our institution for ACSs from 2012 to 2014. Patients were divided into two groups based on clopidogrel or novel P2Y12 inhibitors (prasugrel or ticagrelor) prescription and the relationship between clopidogrel use and patient clinical characteristics and in-hospital adverse events was evaluated using logistic regression analysis. Results: The population median age was 68 years (57\u201377 year) and clopidogrel was prescribed in 230 patients (46%). Patients characteristics associated with clopidogrel prescription were older age, female sex, non-ST-elevation ACS diagnosis, the presence of diabetes mellitus and anemia, worse renal and left ventricular functions and a higher Killip class. Patients on clopidogrel demonstrated a significantly higher incidence of in-hospital mortality (4.8%) than prasugrel and ticagrelor-treated patients (0.4%), while a nonstatistically significant trend emerged considering bleeding events. However, on multivariable logistic regression analysis female sex, the presence of anemia and Killip class were the only variables independently associated with in-hospital death. Conclusion: Patients treated with clopidogrel showed a higher in-hospital mortality. However, clinical variables associated with its use identify a population at high risk for adverse events and this seems to play a major role for the higher in-hospital mortality observed in clopidogrel-treated patients

Climate change and the Antarctic marine ecosystem: an essay on management implications

In this paper we review evidence for, and anticipated consequences of, climate change in Antarctic marine communities, examining the potential impacts on invertebrates and vertebrates alike and exploring plausible outcomes for species, with examples principally from the Antarctic literature. We suggest that industries with the greatest potential to aggravate climate change impacts on marine communities are marine capture fisheries. In the Southern Ocean, harvesting is governed under the Convention for the Conservation of Antarctic Marine Living Resources (CCAMLR). CCAMLR espouses an ecological management framework and so has the capacity to mitigate harvesting impacts such that they do not worsen impacts from climate change. We discuss some of the implications of climate change and advocate that CCAMLR address certain key issues if it is to fulfil its international obligations. It will be essential for CCAMLR to determine relative risks (uncertainties), impacts and timescales, of various processes consequent on climate change. Such risk assessments should be feasible with current knowledge and should provide a focus for future work. We believe it will be important to prioritize issues that reduce impacts and uncertainties by the greatest degree, and propose that future plans should involve shared responsibility (e.g. with SCAR etc.) for each of the risks described

Truncal fat determined by dual-energy X-ray absorptiometry is an independent predictor of coronary artery disease extension

BACKGROUND: Exercise testing after acute myocardial infarction has limited prognostic accuracy. We prospectively used stress-recovery, heart rate-adjusted, ST-segment analysis to predict cardiac death in this clinical setting. METHODS: The stress-recovery index, defined as the difference in absolute values of the areas designated by ST depression in the heart-rate domain during exercise and recovery, was derived in 708 survivors of a first myocardial infarction. To assess whether it contributed additional prognostic information to routinely obtained information, clinical data, resting ejection fraction, and exercise testing data were entered into a sequential Cox model; the stress-recovery index was entered last. Model validation was performed by bootstrapping adjusted for the degree of optimism in estimates. Survival curves were set up using Kaplan-Meier analysis and compared by the log-rank test. RESULTS: Hypertension (OR 1.3, 95%CI 0.9-4.6), exercise capacity (OR 0.6, 95%CI 0.3-1.1 for the interquartile difference in kilopounds per minute), and the stress-recovery index (OR 0.7, 95%CI 0.5-0.9 for the interquartile difference) were independent predictors of cardiac death at a median follow-up of 32 months. However, the stress-recovery index enhanced the prognostic power of the model on top of clinical and exercise testing variables in all diagnostic subgroups according to ST-segment analysis and significantly discriminated survival. A simple nomogram was generated from the fitted Cox model to estimate risk in individual patients. CONCLUSIONS: Stress-recovery, heart rate-adjusted, ST-segment analysis predicts cardiac death after acute myocardial infarction and provides additional prognostic information over clinical and exercise testing data

Prevention of contrast-induced nephropathy: a single center randomized study

Background: Contrast-induced nephropathy (CIN) is the third cause of acute deterioration of renal function in hospitalized patients. Hypothesis: The purpose of the study was to compare the efficacy of saline infusion, saline infusion plus N-acetylcysteine (NAC), and sodiumbicarbonate (SB) infusion to prevent CIN in patients undergoing coronary angiography and/or percutaneous coronary intervention. Methods: We prospectively studied 156 patients with a baseline creatinine level 651.2mg/dL. The primary endpoint was the development of CIN, defined as an increase in serum creatinine concentration 6525% over the baseline value within 5 days fromcontrast exposure. Results: Contrast-induced nephropathy developed in 23 patients (14.7%). Incidence of the primary endpoint was similar in the 3 groups of treatment, occurring in 7 patients (14%) in the saline infusion group, in 9 (17%) in the saline infusion plus NAC group, and in 7 (14%) in the SB infusion group. Conclusions: Our findings suggest that neither the addition of NAC nor the administration of SB add further benefit in CIN prevention, compared to standard hydration with isotonic saline infusion