Decreasing hospital mortality between 1994 and 1998 in patients with acute myocardial infarction treated with primary angioplasty but not in patients treated with intravenous thrombolysis Results from the pooled data of the maximal individual therapy in acute myocardial infarction (MITRA) registry and the myocardial infarction registry (MIR)

AbstractOBJECTIVESWe investigated changes in the clinical outcome of primary angioplasty and thrombolysis for the treatment of acute myocardial infarction (AMI) from 1994 to 1998.BACKGROUNDPrimary angioplasty for the treatment of AMI is a sophisticated technical procedure that requires experienced personnel and optimized hospital logistics. Growing experience with primary angioplasty in clinical routine and new adjunctive therapies may have improved the outcome over the years.METHODSThe pooled data of two German AMI registries: the Maximal Individual Therapy in AMI (MITRA) study and the Myocardial Infarction Registry (MIR) were analyzed.RESULTSOf 10,118 lytic eligible patients with AMI, 1,385 (13.7%) were treated with primary angioplasty, and 8,733 (86.3%) received intravenous thrombolysis. Patients characteristics were quite balanced between the two treatment groups, but there was a higher proportion of patients with a prehospital delay of >6 h in those treated with primary angioplasty. The proportion of an in-hospital delay of more than 90 min significantly decreased in patients treated with primary angioplasty over the years (p for trend = 0.015, multivariate odds ratio [OR] for each year of the observation period = 0.84, 95% confidence interval [CI]: 0.73– 0.96) but did not change significantly in patients treated with thrombolysis. Hospital mortality decreased significantly in the primary angioplasty group (p = 0.003 for trend; multivariate OR for each year = 0.73, 95% CI: 0.58– 0.93). However, for patients treated with thrombolysis, hospital mortality did not change significantly (p for trend 0.175, multivariate OR for each year: 1.02, 95% CI: 0.94– 1.11).CONCLUSIONSCompared with thrombolysis the clinical results of primary angioplasty for the treatment of AMI improved from 1994 to 1998. This indicates a beneficial effect of the growing experience and optimized hospital logistics of this technique over the years

Management of acute coronary syndromes with fondaparinux

Harm Wienbergen, Uwe ZeymerHerzzentrum Ludwigshafen, Medizinische Klinik B, GermanyAbstract: Fondaparinux is the first selective inhibitor of the coagulation factor Xa which is commercially avaliable for clinical use. It has been approved for the prevention of venous thromboembolism in patients undergoing orthopedic surgery and for the initial therapy of venous thromboembolism. In randomized clinical trials the value of fondaparinux in the treatment of ST-elevation myocardial infarction (STEMI) has been investigated. The PENTALYSE study showed that fondaparinux was at least as effective and safe as unfractionated heparin in 333 patients with STEMI undergoing fibrinolysis with t-PA. In the recent large OASIS-6 trial with 12,092 patients the treatment with 2.5 mg fondaparinux daily significantly reduced death and reinfarctions until day 30 compared with guideline recommended usual care and compared with unfractionated heparin (9.7% vs 11.2%, p = 0.008) without increasing major bleedings (1.0% vs 1.3%, p = 0.13). This advantage was predominantly seen in the subgroups of patients with fibrinolysis and without early reperfusion therapy. However, in the subgroup of primary percutaneous coronary interventions (PCIs) no clinical benefit of fondaparinux was found, but there were more catheter thrombosis and acute thrombotic complications. In summary, fondaparinux is a new antithrombin that is an efficient, safe, and easy to use in treatment for STEMI patients, particularly those not undergoing primary PCI.Keywords: selective factor Xa inhibition, fondaparinux, acute ST-elevation myocardial infarction, antithrombin therap

Comments on the 2021 European Society of Cardiology (ESC) Guidelines on cardiovascular disease prevention in clinical practice

Gielen S, Wienbergen H, Reibis R, Koenig W, Weil J, Landmesser U. Kommentar zu den neuen Leitlinien (2021) der Europäischen Gesellschaft für Kardiologie (ESC) zur kardiovaskulären Prävention. Kardiologie. 2022.The new ESC guidelines on cardiovascular disease prevention in clinical practice have introduced a number of new features into the guidelines: 1. The new SCORE2 system was developed based on recent European cohort studies with a total of 677,684 participants, a significant update compared to the old SCORE system, which was based on studies dating back to the 1970s and 1980s. For the first time SCORE2-OP enables the calculation of the individual risk in people> 69 years of age. SCORE2 also marks a change in the risk definition: instead of mortality risk it now provides an estimate of morbidity and mortality risks for cardiovascular diseases. 2. The thresholds for risk categorization based on SCORE2 are now dynamic with age: below 50 years of age individuals with a SCORE2 risk of >= 7.5% are very high-risk, while those between 50 and 69 years need to surpass >= 10% and those >= 70 years should be above 15% SCORE2 risk to be classified as very high risk. This change was made to reflect the lifetime exposure, which is greater at a younger age. 3. The novel 2-step approach separates a general recommendation for prevention for all from the final prevention goals that should be reached in selected patients based on life years gained, comorbidities, frailty and patient wishes. There is a certain danger that this may dilute the prevention goals because many patients and physicians may not go beyond step 1. Not all effects of the new SCORE2 system and the readjusted risk thresholds have yet become clear. A close monitoring of how the new guidelines affect the number of patients in whom, e.g. statin treatment is recommended, is warranted in the different risk regions. Additionally, the freedom of choice with respect to prevention intensity remains a potential threat to optimal guideline implementation. Therefore, implementation studies are needed to continue the virtuous cycle of guideline development.Die bedeutendste Veränderung in den neuen ESC-Leitlinien zur kardiovaskulären Prävention von 2021 betrifft die Risikoevaluation gesunder Menschen: Durch die Einführung von SCORE2 wird eine neue epidemiologische Studienbasis für die Risikoeinschätzung eingeführt, die erstmals die Berechnung der kardiovaskulären Erkrankungswahrscheinlichkeit und der kardiovaskulären Mortalität erlaubt. Zudem ermöglicht SCORE2 OP nun auch eine zuverlässige Risikobestimmung bei Menschen oberhalb des 65. Lebensjahres bis in die 9. Lebensdekade. Die Altersdynamisierung der Risikoschwellen für hohes und sehr hohes kardiovaskuläres Risiko trägt dem Gedanken der Lebenszeitexposition Rechnung, führt aber evtl. zu einer höheren Zahl behandlungspflichtiger Patienten. Mit dem 2‑Step-Approach empfiehlt die ESC eine pragmatische Herangehensweise an die Risikofaktoreinstellung: Während in Step 1 basale Präventionsziele für alle Patienten vorgegeben werden, soll der Arzt im Gespräch mit dem Patienten in Abhängigkeit von 10-Jahres-Risiko, Lebenszeitnutzen, Begleiterkrankungen und Patientenwunsch die optimalen Präventionsziele besprechen und anschließend anstreben. Leider werden in den Leitlinien die Kriterien, wer für die optimalen Präventionsziele geeignet ist, nicht klar definiert. Damit besteht die Gefahr einer subjektiven Fehleinschätzung seitens der behandelnden Ärzte, die möglicherweise vielen Patienten den Nutzen einer optimalen kardiovaskulären Prävention vorenthält. Der von den Autoren der Leitlinie hervorgehobene Gedanke des „Freedom of Choice“ könnte insofern zum Bumerang werden und zur Verwässerung der Implementierung einer optimalen Prävention führen. Hierzu und zu möglichen Verschiebungen beim Anteil behandlungsbedürftiger Patienten in der Primär- und Sekundärprävention sind in den nächsten Jahren Längsschnittstudien erforderlich, um Umsetzungsqualität und Prognosewirksamkeit zu objektivieren