Pharmacoinvasive strategy and its role in the management of patients with acute ST-segment elevation myocardial infarction

Učinkovita, rana i brza reperfuzijska terapija je najvažniji cilj u liječenju bolesnika s akutnim infarktom s elevacijom ST-segmenta (STEMI). Pravovremeno učinjena primarna perkutana koronarna intervencija (pPCI) je nesumnjivo strategija izbora u liječenju STEMI i u posljednjih desetak godina pPCI kao način revaskularizacijske strategije je zamijenila fibrinolitičku terapiju. Mnoga klinička istraživanja su pokazala da bolesnike liječene fibrinolizom treba rutinski premjestiti u invazivni kardiološki centar radi elektivne perkutane koronarne intervencije (PCI) unutar 24 sata te da ovakva rana invazivna strategija dovodi do stabilizacije ciljne lezije i manje pojavnosti rekurentne ishemije. Najnovije Smjernice Europskog kardiološkog društva za zbrinjavanje bolesnika sa STEMI farmakoinvazivnoj strategiji daju klasu I indikacija. U ovom preglednom članku su prikazana najvažnija klinička istraživanja o farmakoinvazivnoj strategiji i mjesto ovog načina liječenja STEMI. Ovakav način reperfuzije dovodi do značajnog smanjenja reinfarkta i rekurentne ishemije bez povišenog rizika od krvarenja te bi implementiranje ove strategije u regionalne protokole zbrinjavanja bolesnika sa STEMI povećalo broj bolesnika kojima je pružena pravilna i pravodobna primjena reperfuzijske terapije.Effective, early and rapid reperfusion therapy is the most important goal in the treatment of patients with acute ST-segment elevation myocardial infarction (STEMI). Timely performed primary percutaneous coronary intervention (pPCI) is undoubtedly the strategy of choice in the treatment of STEMI and in the last decade pPCI has replaced fibrinolytic therapy as a way revascularization strategy. Many clinical studies have shown that patients treated with fibrinolysis should be routinely moved to the invasive cardiology center for elective percutaneous coronary intervention (PCI) within 24 hours and that this early invasive strategy leads to a stabilization of the target lesion and lowers the incidence of recurrent ischemia. The latest European Society of Cardiology Guidelines for the management of patients with STEMI award the Class I indication to the pharmacoinvasive strategy. This review article presents the most important clinical research on pharmacoinvasive strategy and importance of this method of treatment of STEMI. This method of reperfusion leads to a significant reduction in reinfarction and recurrent ischemia without increased risk of bleeding and implementing this strategy in regional protocols for the management of patients with STEMI would increase the number of patients who are to receive proper and timely reperfusion therapy

Application of pharmacoinvasive strategy in primary percutaneous coronary intervention network in Western Slavonia

Hrvatska mreža primarne perkutane intervencije međunarodno je prepoznati sustav dobre organizacije urgentnog liječenja kardioloških bolesnika. U svakodnevnoj kliničkoj praksi svjedoci smo da je vrijeme potrebno za organiziranje primarne perkutane koronarne intervencije (pPCI), koja predstavlja najbolji način reperfuzijske terapije u liječenju bolesnika s akutnim infarktom s elevacijom ST-segmenta, često predugo i povezano s neprihvatljivo dugim kašnjenjima. Farmakoinvazivna strategija obuhvaća selektivnu primjenu fibrinolitičke terapije nakon koje slijedi neodložan transport bolesnika u centar s mogućnošću perkutane koronarne intervencije i organiziranje invazivne obrade unutar 3-24 sata. Obzirom na organizacijske teškoće koje uzrokuju nemogućnost pravovremene pPCI, primjenom farmakoinvazivnog pristupa povećao bi se broj bolesnika kojima bi bila omogućena pravilna i pravodobna reperfuzijska terapija. Donosimo praktične preporuke za implementaciju farmakoinvazivne strategije u svakodnevnu kliničku praksu te protokol lokalne organizacije mreže pPCI u Općoj bolnici „Dr. Josip Benčević“ u Slavonskom Brodu, Hrvatska.Croatian Primary Percutaneous Intervention Network is an internationally recognized system of good organization of urgent treatment of cardiac patients. In everyday clinical practice, we have witnessed that the time required for the organization of primary percutaneous coronary intervention (pPCI), which represents the best way of reperfusion therapy in the treatment of patients with acute ST-segment elevation myocardial infarction is often too long and associated with unacceptably long de- lays. Pharmacoinvasive strategy encompasses a selective use of fibrinolytic therapy to be followed by prompt transportation of patients to a center capable of undertaking percutanous coronary intervention and organizing invasive treatment within 3-24 hours. Considering the organizational difficulties caused by the incapability of undertaking prompt pPCI, the application of pharmacoinvasive approach would increase the number of patients that would be provided proper and timely reperfusion therapy. Here are some practical recommendations for implementation of the pharmacoinvasive strategy in everyday clinical practice and protocol of the local organization of the pPCI network in the General Hospital “Dr. Josip Benčević “ in Slavonski Brod, Croatia

Developing a Treatment Quality Monitoring Program for Patients with Acute Coronary Syndrome in Western Slavonia

Dobra organizacija mreže primarne perkutane koronarne intervencije (pPCI) ima najvažnije mjesto u pružanju optimalne zdravstvene skrbi bolesnika s akutnim koronarnim sindromom (AKS). Organizacija mreže pPCI dugotrajan je i logistički kompleksan posao. Prikupljanje, analiziranje i dijeljenje podataka o funkcioniranju mreže zbrinjavanja bolesnika s AKS-om ima za cilj poboljšanje funkcioniranja sustava. Monitoriranje svakodnevnog rada, prikupljanje, analiziranje i dijeljenje podataka ključni je element za kontinuirano poboljšanje rada. U ovome članku opisujemo napore u razvoju programa praćenja kvalitete liječenja bolesnika s AKS-om u zapadnoj Slavoniji, dijagnostičke, terapijske i destinacijske protokole te način i vrstu podataka koje ćemo monitorirati kao pokazatelje kvalitetete i sveobuhvatnosti skrbi za bolesnike s AKS-om.A well-organized network for primary percutaneous coronary intervention (pPCI) is of paramount importance in providing optimal healthcare for patients with acute coronary syndrome (ACS). Organizing a pPCI network is a lengthy and logistically complex task. The purpose of gathering, analyzing, and sharing data on the functioning of the network is to improve the system. Monitoring everyday work and gathering, analyzing, and sharing data are the key elements of continuous improvement. This article describes the efforts to develop a quality monitoring program for the treatment of patients with ACS in western Slavonia – a region in Croatia. We also explain the diagnostic, treatment, and destination protocols used and the types of data we will monitor as indicators of quality and comprehensiveness of care for patients with ACS

Application of pharmacoinvasive strategy in primary percutaneous coronary intervention network in Western Slavonia

Hrvatska mreža primarne perkutane intervencije međunarodno je prepoznati sustav dobre organizacije urgentnog liječenja kardioloških bolesnika. U svakodnevnoj kliničkoj praksi svjedoci smo da je vrijeme potrebno za organiziranje primarne perkutane koronarne intervencije (pPCI), koja predstavlja najbolji način reperfuzijske terapije u liječenju bolesnika s akutnim infarktom s elevacijom ST-segmenta, često predugo i povezano s neprihvatljivo dugim kašnjenjima. Farmakoinvazivna strategija obuhvaća selektivnu primjenu fibrinolitičke terapije nakon koje slijedi neodložan transport bolesnika u centar s mogućnošću perkutane koronarne intervencije i organiziranje invazivne obrade unutar 3-24 sata. Obzirom na organizacijske teškoće koje uzrokuju nemogućnost pravovremene pPCI, primjenom farmakoinvazivnog pristupa povećao bi se broj bolesnika kojima bi bila omogućena pravilna i pravodobna reperfuzijska terapija. Donosimo praktične preporuke za implementaciju farmakoinvazivne strategije u svakodnevnu kliničku praksu te protokol lokalne organizacije mreže pPCI u Općoj bolnici „Dr. Josip Benčević“ u Slavonskom Brodu, Hrvatska.Croatian Primary Percutaneous Intervention Network is an internationally recognized system of good organization of urgent treatment of cardiac patients. In everyday clinical practice, we have witnessed that the time required for the organization of primary percutaneous coronary intervention (pPCI), which represents the best way of reperfusion therapy in the treatment of patients with acute ST-segment elevation myocardial infarction is often too long and associated with unacceptably long de- lays. Pharmacoinvasive strategy encompasses a selective use of fibrinolytic therapy to be followed by prompt transportation of patients to a center capable of undertaking percutanous coronary intervention and organizing invasive treatment within 3-24 hours. Considering the organizational difficulties caused by the incapability of undertaking prompt pPCI, the application of pharmacoinvasive approach would increase the number of patients that would be provided proper and timely reperfusion therapy. Here are some practical recommendations for implementation of the pharmacoinvasive strategy in everyday clinical practice and protocol of the local organization of the pPCI network in the General Hospital “Dr. Josip Benčević “ in Slavonski Brod, Croatia

Duke Treadmill Score in Prioritizing Patients for Coronary Angiography: Retrospective Study of a Croatian Regional Hospital

Aim of the study was to determine the potential of Duke Treadmill Score (DTS) in prioritizing patients for coronary angiography in a transitional country clinical setting.We analyzed 114 patients with suspected stable coronary artery disease who underwent exercise treadmill testing, and coronary angiography in Slavonski Brod General Hospital. DTS was calculated from treadmill test as: exercise time – (5 ST deviation in mm) – (4 exercise angina). Regarding the score, patients were grouped into three groups of risk for coronary artery disease: low risk, medium risk, and high risk patients. All patients underwent coronary angiography, and were grouped in accordance to the severity of the coronary artery disease into three groups: insignificant, significant, or severe coronary artery disease. All patients scored as high risk DTS had significant or severe coronary artery disease. Medium and low risk DTS patients had insignificant coronary artery disease in 50%, and 90% of cases, respectively. Medium risk patients with significant or severe coronary artery disease were significantly older, and had more frequent history of typical chest pain with higher number of episodes per week (P<0.05), whereas there were no differences regarding gender or presence of risk factors. There were no significant differences among medium risk patients regarding the severity of coronary artery disease in exercise time or ST deviation. However, the presence of limiting exercise angina in medium risk patients was significantly more related with significant and severe coronary artery disease (P<0.05). High risk DTS result showed great potential in stratifying patients for immediate coronary angiography. This scoring system may be used in prioritizing patients for coronary angiography in a transitional clinical setting

Percutaneous Coronary Interventions with Drug-eluting Balloons: Croatian Experience

Uvod: Lijekom obloženi baloni (DEB) predstavljaju novu tehnološku platformu u području perkutane koronarne intervencije. Jedina prihvaćena indikacija za njihovu uporabu je liječenje in-stent stenoze, a za sve ostale indikacije nema jasnog konsenzusa. Cilj: Evaluirati upotrebu DEB-a u rutinskoj kliničkoj praksi u Republici Hrvatskoj. Metode: Restrospektivni nerandomizirani multicentrični registar svih liječenih bolesnika u sedam hrvatskih centara između veljače 2011. i siječnja 2014. godine. Podatci su sakupljeni uvidom u dostupnu medicinsku dokumentaciju. Nije bilo kliničkih niti angiografskih isključnih kriterija, niti pisanog zajedničkog protokola za indikacije niti praćenje bolesnika. Praćena su velika nepovoljna događanja (MACE) definirana kao kombinacija srčane smrti, infarkta miokarda na tretiranoj krvnoj žili (MI) ili klinički indicirane reintervencije na tretiranoj krvnoj žili TLR za sve bolesnike tijekom iste hospitalizacije, nakon 6 mjeseci kliničkog praćenja te dostupni angiografski podatci. Rezultati: Kod 248 bolesnika tretirane su 284 lezije. Najčešća indikacija bila je in-stent restenoza u 31,4% bolesnika, u 21,4% bolesnika DEB je implantiran u žilama manjim od 2,75 mm, a ostale indikacije su bile: lezije veće od 2,8 mm, bifurkacije, ostijalne lezije, kronične totalne okluzije (redom: 11,3%; 11,3%; 7,3%; 1,6% ). U 39 bolesnika (15,6%) nakon prethodne implantacije običnih metalnih stentova (BMS) rađena je postdilatacija DEB-om. MACE su se tijekom hospitalizacije javili u 1,6% bolesnika: 1 smrt (0,4%), 3 akutne tromboze (1,2%), 1 MI (0,4%). Nakon 6 mjeseci praćenja dostupni su podatci za 83 bolesnika (33%). U 6% bolesnika je rađena TLR, a nije bilo registriranih smrti niti akutnih infarkta miokarda. Angiografska kontrola nakon 6 mjeseci učinjena je u 55 bolesnika (22%). U 69% bolesnika nalaz je opisivan kao potpuno uredan, nesignifikantna stenoza opisana je u 20% bolesnika, a u 11% bolesnika je opisana stenoza u rasponu od >50% do potpune okluzije. Zaključak: Naše kliničko iskustvo u svakodnevoj kliničkoj praksi pokazuje da se DEB u Hrvatskoj koristi u najvećem slučaju u prihvaćenim indikacijama in-stent restenoze, ali i u velikom postotku i za indikacije za koje ne postoji jasni konsenzus u literaturi. Akutni angiografski rezultati i rani klinički ishodi su odlični, a uporaba DEB-a je izrazito sigurna.Introduction: Drug-eluting balloons (DEB) represent a new technological platform in the area of percutaneous coronary interventions. The only accepted indication for their use is the treatment of in-stent stenosis, with no clear consensus for all other indications. Aim: To evaluate the use of DEB in routine clinical practice in Croatia. Methods: Retrospective nonrandomized multicentric register of all treated patients in seven Croatian centers in the time frame from February 2011 to January 2014. The data were collected from available medical documents. There were no clinical or angiographic exclusion criteria, nor was there any written common protocol for indications or for for the clinical follow up of patients. Major adverse cardiac events (MACE) were monitored. MACE were defined as the combination of cardiac death, development of myocardial infarction (MI) on treated vessel, and/or target lesion revascularization (TLR) for all patients during the same hospitalization, following a 6-month clinical observation and through available angiographic data. Results: 248 patients were treated for 284 lesions. The most common indication was the in-stent restenosis present in 31.4% of the patients, for 21.4% of the patients DEB was implanted in vessels smaller than 2.75 mm, and other indications were: lesions larger than 2.8 mm, bifurcations, ostial lesion, chronic total occlusions (11.3%; 11.3%; 7.3%; 1.6% respectively). On 39 patients (15.6%) following the previous implantation of bare metal stents (BMS), postdilatation with DEB was conducted. MACE during hospitalization appeared in 1.6% of the patients: 1 death (0.4%), 3 acute thromboses (1.3%), 1 MI (0.4%). Following the 6 month long observation, data is available for 83 patients (33%). TLR was performed on 6% of the patients, and there were no registered deaths or acute myocardial infarctions. Angiographic follow-up was performed on 55 patients (22%) after 6 months. In 69% of the patients the findings were described as completely clean, insignificant stenosis was described for 20% of the patients, and for 11% of the patients a stenosis to the amount of >50% of full occlusion was described. Conclusion: Our clinical experience in everyday clinical practice shows that in Croatia DEB is mostly used in cases of accepted indications of in-stent re-stenosis, but also to a great percentage for indications for which no clear consensus exists in literature. Acute angiographic results and early clinical results are excellent, and the use of DEB is highly safe

Pharmacoinvasive strategy and its role in the management of patients with acute ST-segment elevation myocardial infarction

Učinkovita, rana i brza reperfuzijska terapija je najvažniji cilj u liječenju bolesnika s akutnim infarktom s elevacijom ST-segmenta (STEMI). Pravovremeno učinjena primarna perkutana koronarna intervencija (pPCI) je nesumnjivo strategija izbora u liječenju STEMI i u posljednjih desetak godina pPCI kao način revaskularizacijske strategije je zamijenila fibrinolitičku terapiju. Mnoga klinička istraživanja su pokazala da bolesnike liječene fibrinolizom treba rutinski premjestiti u invazivni kardiološki centar radi elektivne perkutane koronarne intervencije (PCI) unutar 24 sata te da ovakva rana invazivna strategija dovodi do stabilizacije ciljne lezije i manje pojavnosti rekurentne ishemije. Najnovije Smjernice Europskog kardiološkog društva za zbrinjavanje bolesnika sa STEMI farmakoinvazivnoj strategiji daju klasu I indikacija. U ovom preglednom članku su prikazana najvažnija klinička istraživanja o farmakoinvazivnoj strategiji i mjesto ovog načina liječenja STEMI. Ovakav način reperfuzije dovodi do značajnog smanjenja reinfarkta i rekurentne ishemije bez povišenog rizika od krvarenja te bi implementiranje ove strategije u regionalne protokole zbrinjavanja bolesnika sa STEMI povećalo broj bolesnika kojima je pružena pravilna i pravodobna primjena reperfuzijske terapije.Effective, early and rapid reperfusion therapy is the most important goal in the treatment of patients with acute ST-segment elevation myocardial infarction (STEMI). Timely performed primary percutaneous coronary intervention (pPCI) is undoubtedly the strategy of choice in the treatment of STEMI and in the last decade pPCI has replaced fibrinolytic therapy as a way revascularization strategy. Many clinical studies have shown that patients treated with fibrinolysis should be routinely moved to the invasive cardiology center for elective percutaneous coronary intervention (PCI) within 24 hours and that this early invasive strategy leads to a stabilization of the target lesion and lowers the incidence of recurrent ischemia. The latest European Society of Cardiology Guidelines for the management of patients with STEMI award the Class I indication to the pharmacoinvasive strategy. This review article presents the most important clinical research on pharmacoinvasive strategy and importance of this method of treatment of STEMI. This method of reperfusion leads to a significant reduction in reinfarction and recurrent ischemia without increased risk of bleeding and implementing this strategy in regional protocols for the management of patients with STEMI would increase the number of patients who are to receive proper and timely reperfusion therapy

Acute in-situ coronary thrombosis during elective coronary angiography

This report presented a case of in situ intracoronarythrombosis of the proximal left anteriordescending artery (LAD), causing significanttransient myocardial ischemia during electivecoronary angiography in a patient with knowncoronary artery disease (chronic occlusion ofthe circumflex artery, significant stable left mainstenosis) and a severe vasovagal reaction duringfemoral artery puncture. He was treated successfullywith local fibrinolytic therapy, whereasentire diagnostic procedure was completed successfully.There were no cardiac wall motionabnormalities after the procedure, and the rest ofthe hospitalization was uneventful

Relation of Lipoprotein(a) Levels to Incident Type 2 Diabetes and Modification by Alirocumab Treatment

none1691siOBJECTIVE: In observational data, lower levels of lipoprotein(a) have been associated with greater prevalence of type 2 diabetes. Whether pharmacologic lowering of lipoprotein(a) influences incident type 2 diabetes is unknown. We determined the relationship of lipoprotein(a) concentration with incident type 2 diabetes and effects of treatment with alirocumab, a PCSK9 inhibitor. RESEARCH DESIGN AND METHODS: In the ODYSSEY OUTCOMES trial alirocumab was compared with placebo in patients with acute coronary syndrome. Incident diabetes was determined from laboratory, medication, and adverse event data. RESULTS: Among 13,480 patients without diabetes at baseline, 1,324 developed type 2 diabetes over a median 2.7 years. Median baseline lipoprotein(a) was 21.9 mg/dL. With placebo, 10 mg/dL lower baseline lipoprotein(a) was associated with hazard ratio 1.04 (95% CI 1.02-1.06, P < 0.001) for incident type 2 diabetes. Alirocumab reduced lipoprotein(a) by a median 23.2% with greater absolute reductions from higher baseline levels and no overall effect on incident type 2 diabetes (hazard ratio 0.95, 95% CI 0.85-1.05). At low baseline lipoprotein(a) levels, alirocumab tended to reduce incident type 2 diabetes, while at high baseline lipoprotein(a) alirocumab tended to increase incident type 2 diabetes compared with placebo (treatment-baseline lipoprotein(a) interaction P = 0.006). In the alirocumab group, a 10 mg/dL decrease in lipoprotein(a) from baseline was associated with hazard ratio 1.07 (95% CI 1.03-1.12; P = 0.0002) for incident type 2 diabetes. CONCLUSIONS: In patients with acute coronary syndrome, baseline lipoprotein(a) concentration associated inversely with incident type 2 diabetes. Alirocumab had neutral overall effect on incident type 2 diabetes. However, treatment-related reductions in lipoprotein(a), more pronounced from high baseline levels, were associated with increased risk of incident type 2 diabetes. Whether these findings pertain to other therapies that reduce lipoprotein(a) is undetermined.restrictedSchwartz G.G.; Szarek M.; Bittner V.A.; Bhatt D.L.; Diaz R.; Goodman S.G.; Jukema J.W.; Loy M.; Manvelian G.; Pordy R.; White H.D.; Steg P.G. ODYSSEY OUTCOMES Committees and Investigators: Gregory G Schwartz, Philippe Gabriel Steg, Deepak L Bhatt, Vera A Bittner, Rafael Diaz, Shaun G Goodman, Robert A Harrington, J Wouter Jukema, Michael Szarek, Harvey D White, Andreas M Zeiher, Pierluigi Tricoci, Matthew T Roe, Kenneth W Mahaffey, Jay M Edelberg, Corinne Hanotin, Guillaume Lecorps, Angèle Moryusef, Robert Pordy, William J Sasiela, Jean-François Tamby, Philip E Aylward, Heinz Drexel, Peter Sinnaeve, Mirza Dilic, Renato D Lopes, Nina N Gotcheva, Juan-Carlos Prieto, Huo Yong, Patricio López-Jaramillo, Ivan Pećin, Zeljko Reiner, Petr Ostadal, Margus Viigimaa, Markku S Nieminen, Vakhtang Chumburidze, Nikolaus Marx, Nicolas Danchin, Evangelos Liberopoulos, Pablo Carlos Montenegro Valdovinos, Hung-Fat Tse, Robert Gabor Kiss, Denis Xavier, Doron Zahger, Marco Valgimigli, Takeshi Kimura, Hyo Soo Kim, Sang-Hyun Kim, Andrejs Erglis, Aleksandras Laucevicius, Sasko Kedev, Khalid Yusoff, Gabriel Arturo Ramos López, Marco Alings, Sigrun Halvorsen, Roger M Correa Flores, Andrzej Budaj, Joao Morais, Maria Dorobantu, Yuri Karpov, Arsen D Ristic, Terrance Chua, Jan Murin, Zlatko Fras, Anthony J Dalby, José Tuñón, H Asita de Silva, Emil Hagström, Ulf Landmesser, Chern-En Chiang, Piyamitr Sritara, Sema Guneri, Alexander Parkhomenko, Kausik K Ray, Patrick M Moriarty, Robert Vogel, Bernard Chaitman, Sheryl F Kelsey, Anders G Olsson, Jean-Lucien Rouleau, Maarten L Simoons, Karen Alexander, Chiara Meloni, Robert Rosenson, Eric J G Sijbrands, Pierluigi Tricoci, John H Alexander, Luciana Armaganijan, Akshay Bagai, Maria Cecilia Bahit, J Matthew Brennan, Shaun Clifton, Adam D DeVore, Shalonda Deloatch, Sheila Dickey, Keith Dombrowski, Grégory Ducrocq, Zubin Eapen, Patricia Endsley, Arleen Eppinger, Robert W Harrison, Connie Ng Hess, Mark A Hlatky, Joseph Dedrick Jordan, Joshua W Knowles, Bradley J Kolls, David F Kong, Sergio Leonardi, Linda Lillis, David J Maron, Jill Marcus, Robin Mathews, Rajendra H Mehta, Robert J Mentz, Humberto Graner Moreira, Chetan B Patel, Sabrina Bernardez-Pereira, Lynn Perkins, Thomas J Povsic, Etienne Puymirat, William Schuyler Jones, Bimal R Shah, Matthew W Sherwood, Kenya Stringfellow, Darin Sujjavanich, Mustafa Toma, Charlene Trotter, Sean Van Diepen, Matthew D Wilson, Andrew T Yan, Lilia B Schiavi, Marcelo Garrido, Andrés F Alvarisqueta, Sonia A Sassone, Anselmo P Bordonava, Alberto E Alves De Lima, Jorge M Schmidberg, Ernesto A Duronto, Orlando C Caruso, Leonardo P Novaretto, Miguel Angel Hominal, Oscar R Montaña, Alberto Caccavo, Oscar A Gomez Vilamajo, Alberto J Lorenzatti, Luis R Cartasegna, Gustavo A Paterlini, Ignacio J Mackinnon, Guillermo D Caime, Marcos Amuchastegui, Oscar Salomone, Oscar R Codutti, Horacio O Jure, Julio O E Bono, Adrian D Hrabar, Julio A Vallejos, Rodolfo A Ahuad Guerrero, Federico Novoa, Cristian A Patocchi, Cesar J Zaidman, Maria E Giuliano, Ricardo D Dran, Marisa L Vico, Gabriela S Carnero, Pablo N Guzman, Juan C Medrano Allende, Daniela F Garcia Brasca, Miguel H Bustamante Labarta, Sebastian Nani, Eduardo D S Blumberg, Hugo R Colombo, Alberto Liberman, Victorino Fuentealba, Hector L Luciardi, Gabriel D Waisman, Mario A Berli, Ruben O Garcia Duran, Horacio G Cestari, Hugo A Luquez, Jorge A Giordano, Silvia S Saavedra, Gerardo Zapata, Osvaldo Costamagna, Susana Llois, Jonathon H Waites, Nicholas Collins, Allan Soward, Chris L S Hii, James Shaw, Margaret A Arstall, John Horowitz, Daniel Ninio, James F Rogers, David Colquhoun, Romulo E Oqueli Flores, Philip Roberts-Thomson, Owen Raffel, Sam J Lehman, Constantine Aroney, Steven G M Coverdale, Paul J Garrahy, Gregory Starmer, Mark Sader, Patrick A Carroll, Ronald Dick, Robert Zweiker, Uta Hoppe, Kurt Huber, Rudolf Berger, Georg Delle-Karth, Bernhard Frey, Franz Weidinger, Dirk Faes, Kurt Hermans, Bruno Pirenne, Attilio Leone, Etienne Hoffer, Mathias C M Vrolix, Luc De Wolf, Bart Wollaert, Marc Castadot, Karl Dujardin, Christophe Beauloye, Geert Vervoort, Harry Striekwold, Carl Convens, John Roosen, Emanuele Barbato, Marc Claeys, Frank Cools, Ibrahim Terzic, Fahir Barakovic, Zlatko Midzic, Belma Pojskic, Emir Fazlibegovic, Mehmed Kulić, Azra Durak-Nalbantic, Dusko Vulic, Adis Muslibegovic, Boris Goronja, Gilmar Reis, Luciano Sousa, Jose C Nicolau, Flavio E Giorgeto, Ricardo P Silva, Lilia Nigro Maia, Rafael Rech, Paulo R F Rossi, Maria José A G Cerqueira, Norberto Duda, Renato Kalil, Adrian Kormann, José Antonio M Abrantes, Pedro Pimentel Filho, Ana Priscila Soggia, Mayler O N de Santos, Fernando Neuenschwander, Luiz C Bodanese, Yorghos L Michalaros, Freddy G Eliaschewitz, Maria H Vidotti, Paulo E Leaes, Roberto V Botelho, Sergio Kaiser, Euler Roberto Fernandes Manenti, Dalton B Precoma, Jose C Moura Jorge, Pedro G Silva, Jose A Silveira, Wladmir Saporito, Jose A Marin-Neto, Gilson S Feitosa, Luiz Eduardo F Ritt, Juliana A de Souza, Fernando Costa, Weimar K S B Souza, Helder J L Reis, Leandro Machado, José Carlos Aidar Ayoub, Georgi V Todorov, Fedya P Nikolov, Elena S Velcheva, Maria L Tzekova, Haralambi O Benov, Stanislav L Petranov, Haralin S Tumbev, Nina S Shehova-Yankova, Dimitar T Markov, Dimitar H Raev, Mihail N Mollov, Kostadin N Kichukov, Katya A Ilieva-Pandeva, Raya Ivanova, Maryana Gospodinov, Valentina M Mincheva, Petar V Lazov, Bojidar I Dimov, Manohara Senaratne, James Stone, Jan Kornder, Stephen Pearce, Danielle Dion, Daniel Savard, Yves Pesant, Amritanshu Pandey, Simon Robinson, Gilbert Gosselin, Saul Vizel, Gordon Hoag, Ronald Bourgeois, Anne Morisset, Eric Sabbah, Bruce Sussex, Simon Kouz, Paul MacDonald, Ariel Diaz, Nicolas Michaud, David Fell, Raymond Leung, Tycho Vuurmans, Christopher Lai, Frank Nigro, Richard Davies, Gustavo Nogareda, Ram Vijayaraghavan, John Ducas, Serge Lepage, Shamir Mehta, James Cha, Robert Dupuis, Peter Fong, Sohrab Lutchmedial, Josep Rodes-Cabau, Hussein Fadlallah, David Cleveland, Thao Huynh, Iqbal Bata, Adnan Hameed, Cristian Pincetti, Sergio Potthoff, Monica Acevedo, Arnoldo Aguirre, 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Irakli Khintibidze, Tamaz Shaburishvili, Zurab Pagava, Ramaz Ghlonti, Zaza Lominadze, George Khabeishvili, Rayyan Hemetsberger, Kemala Edward, Ursula Rauch-Kröhnert, Matthias Stratmann, Karl-Friedrich Appel, Ekkehard Schmidt, Heyder Omran, Christoph Stellbrink, Thomas Dorsel, Emmanouil Lianopoulos, Hans Friedrich Vöhringer, Roger Marx, Andreas Zirlik, Detlev Schellenberg, Thomas Heitzer, Ulrich Laufs, Christian Werner, Nikolaus Marx, Stephan Gielen, Sebastian Nuding, Bernhard Winkelmann, Steffen Behrens, Karsten Sydow, Mahir Karakas, Gregor Simonis, Thomas Muenzel, Nikos Werner, Stefan Leggewie, Dirk Böcker, Rüdiger Braun-Dullaeus, Nicole Toursarkissian, Michael Jeserich, Matthias Weißbrodt, Tim Schaeufele, Joachim Weil, Heinz Völler, Johannes Waltenberger, Mohammed Natour, Susanne Schmitt, Dirk Müller-Wieland, Stephan Steiner, Lothar Heidenreich, Elmar Offers, Uwe Gremmler, Holger Killat, Werner Rieker, Sotiris Patsilinakos, Athanasios Kartalis, Athanassios Manolis, Dimitrios Sionis, Geargios Chachalis, Ioannis Skoumas, Vasilios Athyros, Panagiotis Vardas, Frangkiskos Parthenakis, Dimitrios Alexopoulos, Georgios Hahalis, John Lekakis, Apostolos Hatzitolios, Sergio R Fausto Ovando, Juan L Arango Benecke, Edgar R Rodriguez De Leon, Bryan P Y Yan, David C W Siu, Tibor Turi, Bela Merkely, Imre Ungi, Geza Lupkovics, Lajos Nagy, András Katona, István Édes, Gábor Müller, Iván Horvath, Tibor Kapin, Zsolt Szigeti, József Faluközy, Mukund Kumbla, Manjinder Sandhu, Sharath Annam, Naveen Reddy Proddutur, Reddy Regella, Rajendra K Premchand, Ajaykumar Mahajan, Sudhir Pawar, Atul D Abhyanakar, Prafulla Kerkar, Ravishankar A Govinda, Abraham Oomman, Dhurjati Sinha, Sachin N Patil, Dhiman Kahali, Jitendra Sawhney, Abhijeet B Joshi, Sanjeev Chaudhary, Pankaj Harkut, Santanu Guha, Sanjay Porwal, Srimannarayana Jujjuru, Ramesh B Pothineni, Minguel R Monteiro, Aziz Khan, Shamanna S Iyengar, Jasprakash Singh Grewal, Manoj Chopda, Mahesh C Fulwani, Aparna Patange, Patil Sachin, Vijay K 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Valgimigli Marco, Giovanni Licciardello, Carla Auguadro, Filippo Scalise, Claudio Cuccia, Alessandro Salvioni, Giuseppe Musumeci, Michelle Senni, Paolo Calabrò, Salvatore Novo, Pompilio Faggiano, Marco Metra, Nicoletta B De Cesare, Sergio Berti, Claudio Cavallini, Enrico Puccioni, Marcello Galvani, Maurizio Tespili, Piermarco Piatti, Michela Palvarini, Giuseppe De Luca, Roberto Violini, Alessandro De Leo, Zoran Olivari, Pasquale Perrone Filardi, Maurizio Ferratini, Vittorio Racca, Kazuoki Dai, Yuji Shimatani, Haruo Kamiya, Kenji Ando, Yoshihiro Takeda, Yoshihiro Morino, Yoshiki Hata, Kazuo Kimura, Koichi Kishi, Ichiro Michishita, Hiroki Uehara, Toshinori Higashikata, Atsushi Hirayama, Keiji Hirooka, Yasuji Doi, Satoru Sakagami, Shuichi Taguchi, Akihiro Koike, Hiroyuki Fujinaga, Shinji Koba, Ken Kozuma, Tomohiro Kawasaki, Yujiro Ono, Masatoshi Shimizu, Yousuke Katsuda, Atsuyuki Wada, Toshiro Shinke, Takeshi Kimura, Junya Ako, Kenshi Fujii, Toshiyuki Takahashi, Tomohiro Sakamoto, Koichi 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Marcel J J A Bokern, Remco Nijmeijer, Ferry M R J Hersbach, Frank F Willems, Antonius T M Gosselink, Saman Rasoul, John Elliott, Gerard Wilkins, Raewyn Fisher, Douglas Scott, Hamish Hart, Ralph Stewart, Scott Harding, Ian Ternouth, Nicholas Fisher, Samuel Wilson, Denise Aitken, Russell Anscombe, Laura Davidson, Tadeusz Tomala, Ottar Nygård, Jon Arne Sparby, Kjell Andersen, Lars Gullestad, Jarle Jortveit, Peter S Munk, Erlend Gyllensten Singsaas, Ulf Hurtig, Jorge R Calderon Ticona, Julio R Durand Velasquez, Sandra A Negron Miguel, Enrique S Sanabria Perez, Jesus M Carrion Chambilla, Carlos A Chavez Ayala, Reynaldo P Castillo Leon, Rolando J Vargas Gonzales, Jose D Hernandez Zuniga, Luis A Camacho Cosavalente, Jorge E Bravo Mannucci, Javier Heredia Landeo, Nassip C Llerena Navarro, Yudy M Roldan Concha, Víctor E Rodriguez Chavez, Henry A Anchante Hernandez, Carlos A Zea Nunez, Walter Mogrovejo Ramos, Arthur Ferrolino, Rosa Allyn G Sy, Louie Tirador, Rody G Sy, Generoso Matiga, Raul Martin Coching, Alisa Bernan, Gregorio Rogelio, Dante D Morales, Edgar Tan, Dennis Jose Sulit, Adrian Wlodarczak, Krystyna Jaworska, Grzegorz Skonieczny, Lidia Pawlowicz, Pawel Wojewoda, Benita Busz-Papiez, Janusz Bednarski, Aleksander Goch, Pawel Staneta, Elzbieta Dulak, Krzysztof Saminski, Wlodzimierz Krasowski, Wanda Sudnik, Aleksander Zurakowski, Marcin Skorski, Beata Miklaszewicz, Jacek Kubica, Jan Andrzej Lipko, Edyta Kostarska-Srokosz, Marek Piepiorka, Anna Drzewiecka, Ryszard Sciborski, Arkadiusz Stasiewski, Tomasz Blicharski, Leszek Bystryk, Michal Szpajer, Marek Korol, Tomasz Czerski, Ewa Mirek-Bryniarska, Jacek Gniot, Andrzej Lubinski, Jerzy Gorny, Edward Franek, Grzegorz Raczak, Hanna Szwed, Pedro Monteiro, Jose Mesquita Bastos, Helder H Pereira, Dinis Martins, Filipe Seixo, Carlos Mendonça, Ana Botelho, Francisca Caetano, Bogdan Minescu, Octavian Istratoaie, Dan N Tesloianu, Gabriel Cristian, Silviu Dumitrescu, Cristian G C Podoleanu, Mircea C A Constantinescu, Cristina M Bengus, Constantin Militaru, Doina Rosu, Irinel R Parepa, Adrian V Matei, Tom M Alexandru, Mihaela Malis, Ioan Coman, Rodica Stanescu-Cioranu, Doina Dimulescu, Yury Shvarts, Olga Orlikova, Zhanna Kobalava, Olga L Barbarash, Valentin Markov, Nadezhda Lyamina, Alexander Gordienko, Konstantin Zrazhevsky, Alexander Y Vishnevsky, Victor Gurevich, Raisa Stryuk, Nikita V Lomakin, Igor Bokarev, Tatiana Khlevchuk, Sergey Shalaev, Larisa Khaisheva, Petr Chizhov, Inna Viktorova, Natalya Osokina, Vladimir Shchekotov, Evgenia Akatova, Galina Chumakova, Igor Libov, Mikhail I Voevoda, Tatyana V Tretyakova, Evgeny Baranov, Sergey Shustov, Sergey Yakushin, Ivan Gordeev, Niiaz Khasanov, Olga Reshetko, Tatiana Sotnikova, Olga Molchanova, Konstantin Nikolaev, Liudmila Gapon, Elena Baranova, Zaur Shogenov, Elena Kosmachova, Yuriy Karpov, Anton Povzun, Liudmila Egorova, Vadim V Tyrenko, Igor G Ivanov, Masterov Ilya, Sergey Kanorsky, Dragan Simic, Nikola Ivanovic, Goran Davidovic, Nebojsa Tasic, Milika R Asanin, Stevo Stojic, Svetlana R Apostolovic, Stevan Ilic, Biljana Putnikovic Tosic, Aleksandar Stankovic, Aleksandra Arandjelovic, Slavica Radovanovic, Branislava Todic, Jovan Balinovac, Dragan V Dincic, Petar Seferovic, Ana Karadzic, Slobodan Dodic, Sinisa Dimkovic, Tamara Jakimov, Kian-Keong Poh, Hean Yee Ong, Justin Tang I-Shing, Karol Micko, Jan Nociar, Daniel Pella, Peter Fulop, Marian Hranai, Juraj Palka, Juraj Mazur, Ivan Majercák, Andrej Dzupina, František Fazekas, Jozef Gonsorcik, Viliam Bugan, Juraj Selecky, Gabriel Kamensky, Jaroslava Strbova, Rudolf Smik, Andrej Dukat, Peter Olexa, Ivan Žuran, Janez Poklukar, Nataša Černič Šuligoj, Matija Cevc, Henry P Cyster, Naresh Ranjith, Clive Corbett, Junaid Bayat, Ellen Makoali Makotoko, Hendrik du Toit Theron, Ilse E Kapp, Matthys M de V Basson, Hanlie Lottering, Dina Van Aswegen, Louis J Van Zyl, Peter J Sebastian, Thayabran Pillay, Jan A Saaiman, Patrick J Commerford, Soraya Cassimjee, Garda Riaz, Iftikhar O Ebrahim, Mahomed Sarvan, Joseph H Mynhardt, Helmuth Reuter, Rajendran Moodley, Manuel Vida, Angel R Cequier Fillat, Vicente Bodí Peris, Francisco Fuentes Jimenez, Francisco Marín, Jose M Cruz Fernández, Rafael Jesus Hidalgo Urbano, Blas Gil-Extremera, Pablo Toledo, Fernando Worner Diz, David Garcia-Dorado, Andres Iñiguez, José Tuñón Fernández, Jose R Gonzalez-Juanatey, Javier Fernandez Portales, Fernando Civeira Murillo, Laia Matas Pericas, Jose Luis Zamorano, Manuel De Mora Martin, Jordi Bruguera Cortada, Joaquin J Alonso Martin, Jose Maria Serrano Antolin, José R De Berrazueta Fernández, José Antonio Vázquez de Prada, Jose Francisco Díaz Fernández, José Alberto García Lledó, Juan Cosín Sal

Lipoprotein(a) and Benefit of PCSK9 Inhibition in Patients With Nominally Controlled LDL Cholesterol

International audienceBackground: Guidelines recommend nonstatin lipid-lowering agents in patients at very high risk for major adverse cardiovascular events (MACE) if low-density lipoprotein cholesterol (LDL-C) remains ≥70 mg/dL on maximum tolerated statin treatment. It is uncertain if this approach benefits patients with LDL-C near 70 mg/dL. Lipoprotein(a) levels may influence residual risk.Objectives: In a post hoc analysis of the ODYSSEY Outcomes (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab) trial, the authors evaluated the benefit of adding the proprotein subtilisin/kexin type 9 inhibitor alirocumab to optimized statin treatment in patients with LDL-C levels near 70 mg/dL. Effects were evaluated according to concurrent lipoprotein(a) levels.Methods: ODYSSEY Outcomes compared alirocumab with placebo in 18,924 patients with recent acute coronary syndromes receiving optimized statin treatment. In 4,351 patients (23.0%), screening or randomization LDL-C was 13.7 mg/dL or ≤13.7 mg/dL; corresponding adjusted treatment hazard ratios were 0.82 (95% CI: 0.72-0.92) and 0.89 (95% CI: 0.75-1.06), with Pinteraction = 0.43.Conclusions: In patients with recent acute coronary syndromes and LDL-C near 70 mg/dL on optimized statin therapy, proprotein subtilisin/kexin type 9 inhibition provides incremental clinical benefit only when lipoprotein(a) concentration is at least mildly elevated. (ODYSSEY Outcomes: Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab; NCT01663402)