Comparison of RISK-PCI, GRACE, TIMI risk scores for prediction of major adverse cardiac events in patients with acute coronary syndrome

Aim To compare the prognostic performance of three major risk scoring systems including global registry for acute coronary events (GRACE), thrombolysis in myocardial infarction (TIMI), and prediction of 30-day major adverse cardiovascular events after primary percutaneous coronary intervention (RISK-PCI). Methods This single-center retrospective study involved 200 patients with acute coronary syndrome (ACS) who underwent invasive diagnostic approach, ie, coronary angiography and myocardial revascularization if appropriate, in the period from January 2014 to July 2014. The GRACE, TIMI, and RISK-PCI risk scores were compared for their predictive ability. The primary endpoint was a composite 30-day major adverse cardiovascular event (MACE), which included death, urgent target-vessel revascularization (TVR), stroke, and non-fatal recurrent myocardial infarction (REMI). Results The c-statistics of the tested scores for 30-day MACE or area under the receiver operating characteristic curve (AUC) with confidence intervals (CI) were as follows: RISK-PCI (AUC = 0.94; 95% CI 1.790-4.353), the GRACE score on admission (AUC = 0.73; 95% CI 1.013-1.045), the GRACE score on discharge (AUC = 0.65; 95% CI 0.999-1.033). The RISK-PCI score was the only score that could predict TVR (AUC = 0.91; 95% CI 1.392-2.882). The RISK-PCI scoring system showed an excellent discriminative potential for 30- day death (AUC = 0.96; 95% CI 1.339-3.548) in comparison with the GRACE scores on admission (AUC = 0.88; 95% CI 1.018-1.072) and on discharge (AUC = 0.78; 95% CI 1.000- 1.058). Conclusions In comparison with the GRACE and TIMI scores, RISK-PCI score showed a non-inferior ability to predict 30-day MACE and death in ACS patients. Moreover, RISK-PCI was the only scoring system that could predict recurrent ischemia requiring TVR

High-dose streptokinase in the treatment of acute massive pulmonary embolism complicated with cardiogenic shock, respiratory arrest and ventricular fibrillation

Background. Despite advances in prophylaxis, diagnostic modalities, and therapeutic options, pulmonary embolism remains a commonly undiagnosed entity with lethal outcome. Clinically, pulmonary embolism ranges from massive thromboembolism with cardiogenic shock to asymptomatic, microebolism with anatomically small emboli without hemodynamic, respiratory or other disturbances. Case report. A patient with massive pulmonary embolism complicated with ventricular fibrillation, respiratory arrest and cardiogenic shock was treated with a total dose of 3 750 000 IU of intravenous streptokinase in the 8- hour time period. After successful cardiopulmonary resuscitation, and thrombolytic therapy, the patient regained hemodynamic stability six hours after admission; all clinical and electrocardiographic signs of the right ventricle insufficiency disappeared. Conclusion. This case report suggested that treatment with the high-dose of streptokinase could be beneficial in the patients with massive pulmonary embolism complicated with cardiogenic shock, which must be confirmed by further randomized trials

Prognostic significance of acute bundle branch block in patients with acute myocardial infarction

Background/Aim. Acute bundle branch block (ABBB) presence is associated with the increasing mortality of patients with acute myocardial infarction (AMI). The aim of this study was investigate ABBB influence with respect to in-hospital (IN) and long-term mortality in patients with AIM, as well as total mortality in follow-up, the presence of in-hospital congestive cardiac insufficiency (CCI) and the presence of CCI at follow-up. Methods. This study included 606 consecutive patients with AMI. A total of 415 (68.5%) were males and 191 (31.5%) females, mean age 64.0±11.9. After the dismissal the patients underwent 18-month follow-up period. Results. Acute bundle branch block was registered in 44 patients (7.2%), out of which 15 patients (2.4%) had the left (L) ABBB and 29 patients (4.8%) had the right (R) ABBB. The patients with ABBB showed higher proportion of IH CCI (Killip III and IV) and hypotension compared with the control group (patients without ABBB). In the group of patients with ABBB β-blockers, statins, aspirin and ACE-inhibitors were less applied. All the three ABBB groups exhibited an increased IH mortality (ABBB 47.7% vs 11.2%, p < 0.01, ARBBB 55.1% vs 11.2% p < 0.01, ALBBB 33.3% vs 11.2%, p < 0.01). Follow-up mortality of the patients with ABBB and ALBBB was higher in comparison with the control group (log-rank p = 0.046 and log-rank p = 0.01, respectively), whereas the group with ARBBB did not show any differences (log-rank, p = 0.59). Conclusion. The patients with ABBB AMI are a risk group of patients that commonly exhibit both early and remote CCI accompanied by high mortality. That is the reason why this sub-group of AMI patients should receive an urgent diagnostics followed by aggressive therapeutic treatment. <br><br><font color="red"><b> This article has been retracted. Link to the retraction <u><a href="http://dx.doi.org/10.2298/VSP0901074U">10.2298/VSP0901074U</a></u></b></font&gt

Dabigatran - Metabolism, Pharmacologic Properties and Drug Interactions

Background: The superiority of dabigatran has been well proven in the standard dosing regimen in prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF) and extended venous thromboembolism (VTE) treatment. Dabigatran, an anticoagulant with a good safety profile, reduces intracranial bleeding in patients with atrial fibrillation and decreases major and clinically relevant non-major bleeding in acute VTE treatment. However, several important clinical issues are not fully covered by currently available directions with regard to dabigatran administration. The prominent one is reflected in the fact that dynamic impairment in renal function due to dehydratation may lead to haemorragic complications on the one hand, while on the other hand glomerular hyperfiltration may be a possible cause of dabigatran subdosing, hence reducing the drug's efficacy. Furthermore, limitations of the Cockcroft-Gault formula, considered a standard equation for assessing the renal function, may imply that other calculations are likely to obtain more accurate estimates of the kidney function in specific patient populations. Method and Conclusions: Although not routinely recommended, a possibility of monitoring dabigatran in special clinical settings adds to optimization of its dosage regimens, timely perioperative care and administration of urgently demanded thrombolytic therapy, therefore significantly improving this drug's safety profile. Despite the fact that dabigatran has fewer reported interactions with drugs, food constituents, and dietary supplements, certain interactions still remain, requiring considerable caution, notably in elderly, high bleeding risk patients, patients with decreased renal function and those on complex drug regimens. Additionally, upon approval of idarucizumab, an antidote to dabigatran solution, hitherto being a major safety concern, has been finally reached, which plays a vital role in life-threatening bleeding and emergency interventions and surgery

Clinical challenge: heparin-induced thrombocytopenia type II (HIT II) or pseudo-HIT in a patient with antiphospholipid syndrome

Treatment of patients with heparin-induced thrombocytopenia type II (HIT II) and thrombosis in some cases that represents a clinical challenge, which, if unrecognized, may lead to treatment delay or disease progression with potentially lethal outcome. We present a case of a 19-year-old patient with antiphospholipid syndrome, factor V (FV) Leiden mutation in heterozygous state, and venous thromboembolism. The patient was subjected to intravenous infusions of unfractionated heparin (UFH), and 16 days after the beginning of the treatment, his condition worsened, with thrombocytopenia and extension of thrombosis. Whereas the patient had a high clinical score for HIT II, functional and antigenic assays for the presence of HIT antibodies were negative. After repeated negative functional and antigenic assays, pseudo-HIT was suspected and nadroparin was introduced, which resulted in further worsening of the clinical presentation. Disease remission, along with complete normalization of platelet count, was finally accomplished with the introduction of lepirudin. The presence of multiple comorbid states, such as antiphospholipid syndrome, can potentially make laboratory confirmation of disease more difficult in patients with HIT II. In our opinion, it is of great importance that HIT II diagnosis be primarily clinical and that laboratory test results are carefully interpreted, especially when HIT is indicated by high clinical score values

Time-dependent changes of myeloperoxidase in relation to in-hospital mortality in patients with the first anterior ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention

Objectives: To analyze the prognostic value of myeloperoxidase (MPO) in relation to in-hospital mortality and to identify the optimum time point for sampling in patients with the first anterior ST-segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (pPCI). Design and methods: A total of 100 consecutive patients with the first anterior STEMI undergoing pPCI were included. Blood samples were collected at baseline, 4, 8, 12, 18, 24,48 and 168 hours (h) after pPCI. Results: MPO concentrations have showed a biphasic pattern over time; the highest MPO levels were at 4 h and 2411 after pPCI. In-hospital mortality was 6%. MPO at 24 h significantly correlated with troponin I as well as heart failure. After multivariate adjustment, MPO at 24 h was an independent predictor of the in-hospital mortality (OR 3.34, 95% CI 1.13-9.86, P = 0.029). Conclusions: In patients with the first anterior STEMI treated by pPCI. MPO at 24 h after procedure was an independent predictor of the in-hospital mortality

Utility of Lipoprotein-Associated Phospholipase A(2) for Prediction of 30-day Major Adverse Coronary Event in Patients with the First Anterior ST-Segment Elevation Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention

Background: Lipoprotein-associated phospholipase A(2) (Lp-PLA(2)) has been suggested as an inflammatory marker of cardiovascular risk. The predictive value of Lp-PLA(2) in ST-segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PCI) has not been established. The aim of this study was to determine whether plasma Lp-PLA(2) is a predictor of a major adverse cardiac event (MACE) in patients with the first anterior STEMI treated by primary PCI. Methods: This study consisted of 100 consecutive patients with first anterior STEMI who underwent primary PCI within 6 hours of the symptom onset. Plasma Lp-PLA(2) level was measured on admission using a turbidimetric immunoassay (diaDexus, Inc., USA). The Receiver Operating Characteristic analysis was performed to identify the most useful Lp-PLA(2) cut-off level for the prediction of MACE. The patients were divided into two groups according to the cut-off Lp-PLA(2) level: high Lp-PLA(2) group (>= 463 ng/mL, n = 33) and low Lp-PLA(2) group ( lt 463 ng/mL, n = 67). MACE was defined as cardiac death, non-fatal reinfarction, and target vessel revascularization. Results: Patients in the high Lp-PLA(2) group had significantly higher total-, LDL-cholesterol, apolipoprotein B levels, and significantly lower estimated glomerular filtration rates compared with the low Lp-PLA(2) group. The incidence of 30-day mortality was 18.2% (6/33) in high Lp-PLA(2) group, while in the low Lp-PLA(2) group no patient died (p lt 0.001). The 30-day MACE occurred in 24.2% of the high Lp-PLA(2) group and 3% of the low Lp-PLA(2) group (p = 0.001). Multiple logistic regression analysis identified the plasma Lp-PLA(2) level as an independent predictor of MACE (OR 1.011, 95%CI 1.001 - 1.013, p = 0.037). Conclusions: In patients with first anterior STEMI treated by primary PCI, the plasma Lp-PLA(2) level is an independent predictor of 30-day MACE. (Clin. Lab. 2012;58:1135-1144. DOI: 10.7754/Clin.Lab.2012.111102

The Usefulness of Myeloperoxidase in Prediction of In-Hospital Mortality in Patients with ST-Segment Elevation Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention

Background: The predictive value of myeloperoxidase (MPO) in ST-segment elevation myocardial infarction (STEM I) treated by primary percutaneous coronary intervention (PCI) has not been established. The aim of the present study was to investigate MPO as a predictor of in-hospital mortality in STEMI patients treated by primary PCI. Methods: Study population consisted of 189 STEMI patients having undergone primary PCI. Plasma MPO level was measured 24 hours after symptom onset using chemiluminescent microparticle immunoassay (Abbott Diagnostics, Germany). The Receiver Operating Characteristic analysis was performed to identify the most useful MPO cut-off level for the prediction of in-hospital mortality. The patients were divided into two groups according to the cut-off MPO level: high MPO group (>= 840 pmol/L, n = 65) and low M PO group ( lt 840 pmol/L, n = 124). Results: The high M PO group had significantly more frequent anterior wall infarctions (p lt 0.001) and Killip class >1 on admission (p=0.013) as well as lower left ventricular ejection fraction (LVEF) (p=0.011) and higher B-type natriuretic peptide (BNP) (p=0.029) than the low MPO group. The incidence of in-hospital mortality was 5.8% and was significantly higher in the high M PO group (13.8%) than in the low MPO group (1.6%) (p=0.001). Multiple logistic regression analysis identified the plasma MPO level as an independent predictor of in-hospital mortality (OR 3.88, 95%CI 1.13 - 13.34, p=0.031). Conclusions: Plasma M PO level independently predicts in-hospital mortality in STEMI patients treated by primary PCI. (Clin. Lab. 2012;58:125-131

Percutaneous implantation of self-expandable aortic valve in high risk patients with severe aortic stenosis: The first experiences in Serbia

Background/Aim. Aortic stenosis (AS) is the most common valvular heart disease in elderly people, with rather poor prognosis in symptomatic patients. Surgical valve replacement is the therapy of choice, but a significant number of patients cannot undergo surgical procedure. We presented initial experience of transcatheter aortic valve implantation (TAVI) performed in Catheterization Laboratory of the Clinic for Cardiology, Clinical Center of Serbia. Methods. The procedures were performed in 5 patients (mean age 76 ± 6 years, 2 males, 3 female) with severe and symptomatic AS with contraindication to surgery or high surgical risk. The decision to perform TAVI was made by the heart team. Pre-procedure screening included detailed clinical and echocardiographic evaluation, coronary angiography and computed tomography scan. In all the patients we implanted a self-expandable aortic valve (Core Valve, Medtronic, USA). Six months follow-up was available for all the patients. Results. All interventions were successfully performed without significant periprocedural complications. Immediate hemodynamic improvement was obtained in all the patients (peak gradient 94.2 ± 27.6 to 17.6 ± 5.2 mmHg, p < 0.001, mean pressure gradient 52.8 ± 14.5 to 8.0 ± 2.1 mmHg, p < 0.001). None of the patients developed heart block, stroke, vascular complication or significant aortic regurgitation. After 6 months, the survival was 100% with New York Heart Association (NYHA) functional improvement in all the patients. Conclusion. This successful initial experience provides a solid basis to treat larger number of patients with symptomatic AS and high surgical risk who are left untreated. [Projekat Ministarstva nauke Republike Srbije, br. ON 175 020