ST-segment resolution after primary percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction

Background: The association between ST-segment resolution and clinical outcome in patients with acute ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PPCI) remains unclear. Recent studies on the association between ST-segment resolution and mortality have given conflicting results. We undertook this study to assess whether ST-segment resolution in electrocardiograms recorded 90&#8211;120 min after initiation of PPCI predicts long-term mortality in patients with STEMI. Methods: The study included 900 patients with STEMI presenting within the first 24 h after symptom onset who were treated with PPCI. The ST-segment resolution was assessed in electrocardiograms recorded 90&#8211;120 min after the first balloon inflation. The ST-segment resolution was dichotomized as follows: < 30% (no resolution), 30% to &le; 70% (partial resolution) and > 70% (complete resolution). The primary endpoint was five-year mortality. Results: ST-segment resolution was < 30% in 263 (29.0%) patients, between 30% and &le; 70% in 356 (40.0%) patients and > 70% in 281 (31.0%) patients. There were 62 deaths during the follow-up. In patients with ST-segment resolution < 30%, 30 to &le; 70% and > 70%, the Kaplan-Meier estimates of mortality were 8.3% (n = 17 deaths), 11.5% (n = 29 deaths) and 6.8% (n = 16 deaths), respectively; unadjusted hazard ratio (HR) = 0.88, 95% confidence interval (CI) 0.46&#8211;1.67, p = 0.695 for ST-segment resolution > 70% vs < 30%; adjusted HR = 0.91, 95% CI 0.61&#8211;1.33; p = 0.607, for ST-segment resolution > 70% vs ST-segment resolution < 30%. Conclusions: In patients with STEMI undergoing PPCI, ST-segment resolution in electrocardiograms recorded 90&#8211;120 min after initiation of PPCI did not predict long-term mortality. (Cardiol J 2012; 19, 1: 61&#8211;69

Statin pretreatment and presentation patterns in patients with coronary artery disease

Background: Knowledge on the impact of pretreatment statin therapy on presentation of patients with coronary artery disease (CAD) is incomplete. The aim of this study was to investigate the impact of statin pretreatment on presentation patterns of patients with CAD. Methods: The study included 12,989 consecutive patients with CAD who underwent coronary angiography. The primary outcome was presentation as stable angina or acute coronary syndrome (ACS) according to statin pretreatment. Results: At the time of presentation, 8147 (62.7%) patients were receiving statins and 4842 (37.3%) patients were not receiving statins. Presentation pattern in patients receiving statins vs. those not receiving statins was: stable angina in 5939 (72.9%) vs. 2102 (43.4%) patients; odds ratio (OR) = 3.50, 95% confidence interval (CI) 3.25&#8211;3.78; p < 0.001; unstable angina in 1435 (17.6%) vs. 1011 (20.9%) patients; OR = 0.81, 95% CI 0.74&#8211;0.89; p < 0.001; non- -ST-segment elevation myocardial infarction (NSTEMI) in 463 (5.7%) vs. 505 (10.4%) patients; OR = 0.52, 95% CI 0.45&#8211;0.59; p < 0.001; and ST-segment elevation myocardial infarction (STEMI) in 310 (3.8%) vs. 1224 (25.3%) patients; OR = 0.11, 95% CI 0.10&#8211;0.13; p < 0.001. Gensini score (median [25th to 75th percentiles]) was significantly higher in patients on statins presenting with stable angina (26.5 [13.0&#8211;59.5] vs. 21.0 [10.5&#8211;47.4]; p < 0.001) or ACS (39.3 [17.5&#8211;77.0] vs. 37.0 [18.0&#8211;64.0]; p = 0.001). In multivariable analysis, statin therapy was an independent correlate of reduced presentation with ACS (adjusted OR = 0.35 [0.32&#8211;0.39]; p < 0.001) or STEMI (adjusted OR = 0.18 [0.16&#8211;0.22]; p < 0.001). Conclusions: Despite having a higher coronary atherosclerotic burden, patients with CAD on statin therapy have reduced odds for presentation with ACS and STEMI compared to patients not receiving statins

Predictors of Increased Left Ventricular Filling Pressure in Dialysis Patients with Preserved Left Ventricular Ejection Fraction

Aim To study the left and right ventricular function and to assess the predictors of increased left ventricular (LV) filling pressure in dialysis patients with preserved LV ejection fraction. Methods This study included 63 consecutive patients (age 57 ± 14 years, 57% women) with end-stage renal failure. Echocardiography, including tissue Doppler measurements, was performed in all patients. Based on the median value of the ratio of transmitral early diastolic velocity to early myocardial velocity (E/E’ ratio), patients were divided into 2 groups: the group with high filling pressure (E/E’>10.16) and the group with low filling pressure (E/ E’≤10.16). Results Compared with patients with low filling pressure, the group of patients with high filling pressure included a higher proportion of diabetic patients (41% vs 13%, P = 0.022) and had greater LV mass index (211 ± 77 vs 172 ± 71 g/m3, P = 0.04), lower LV lateral long axis amplitude (1.4 ± 0.3 vs 1.6 ± 0.3 cm, P = 0.01), lower E wave (84 ± 19 vs 64 ± 18cm/s, P < 0.001), lower systolic myocardial velocity (S’: 8.6 ± 1. 5 vs 7.0 ± 1.3 cm/s, P < 0.001), and lower diastolic myocardial velocities (E’: 6.3 ± 1.9 vs 9.5 ± 2.9 cm/s, P < 0.001; A’: 8.4 ± 1.9 vs 9.7 ± 2.5 cm/s, P = 0.018). Multivariate analysis identified LV systolic myocardial velocity – S’ wave (adjusted odds ratio, 1.909; 95% confidence interval, 1.060-3.439; P = 0.031) and age (1.053; 1.001-1.108; P = 0.048) as the only independent predictors of high LV filling pressure in dialysis patients. Conclusions In dialysis patients with preserved left ventricular ejection fraction, reduced systolic myocardial velocity and elderly age are independent predictors of increased left ventricular filling pressure

Periprocedural Bleeding and 1-Year Outcome After Percutaneous Coronary Interventions Appropriateness of Including Bleeding as a Component of a Quadruple End Point

ObjectivesThe aim of the study was to investigate the relationship between bleeding within the 30 days after percutaneous coronary interventions (PCI) and 1-year mortality and to assess the appropriateness of inclusion of the periprocedural bleeding in a quadruple composite end point to assess PCI outcome.BackgroundPeriprocedural bleeding is one of the most frequent complications of PCI.MethodsThis study included 5,384 patients from 4 randomized placebo-controlled trials on the value of abciximab after pre-treatment with 600 mg of clopidogrel: ISAR-REACT, -SWEET, -SMART-2, and –REACT-2. Bleeding—defined according to the Thrombolysis In Myocardial Infarction criteria—included all bleeding events within 30 days after enrollment. The primary end point was 1-year mortality.ResultsIn the 4 trials, within the first 30 days there were 42 deaths (0.8%), 314 myocardial infarctions (MIs) (5.8%), 52 urgent revascularizations (1.0%), and 215 bleeding complications (4.0%). Mortality at 1 year was 3.6% (n = 197). A Cox proportional hazards model revealed that the 30-day occurrence of bleeding (hazard ratio [HR] 2.96, 95% confidence interval [CI] 1.96 to 4.48; p < 0.001), MI (HR 2.29, 95% CI 1.52 to 3.46; p < 0.001) and urgent revascularization (HR 2.49, 95% CI 1.16 to 5.35; p = 0.019) independently predicted 1-year mortality. The c statistic was 0.79 for bleeding, 0.78 for MI, and 0.78 for urgent revascularization, demonstrating a comparable discriminatory power of these adverse events for predicting 1-year mortality.ConclusionsOur study demonstrates a strong relationship between the 30-day frequency of bleeding and 1-year mortality after PCI and supports the inclusion of periprocedural bleeding in a 30-day quadruple end point for the assessment of outcome after PCI

Longitudinal quantile regression in presence of informative drop-out through longitudinal-survival joint modeling

We propose a joint model for a time-to-event outcome and a quantile of a continuous response repeatedly measured over time. The quantile and survival processes are associated via shared latent and manifest variables. Our joint model provides a flexible approach to handle informative drop-out in quantile regression. A general Monte Carlo Expectation Maximization strategy based on importance sampling is proposed, which is directly applicable under any distributional assumption for the longitudinal outcome and random effects, and parametric and non-parametric assumptions for the baseline hazard. Model properties are illustrated through a simulation study and an application to an original data set about dilated cardiomyopathies

Statin effect on thrombin inhibitor effectiveness during percutaneous coronary intervention: a post-hoc analysis from the ISAR-REACT 3 trial

Objective: To determine whether statin therapy influences the efficacy of thrombin inhibitor bivalirudin or unfractionated heparin (UFH) during PCI. Setting and patients: The post-hoc analysis of the ISAR-REACT 3 Trial included 4,570 patients: 3,106 patients were on statin therapy and 1,464 patients were not on statin therapy at the time of PCI procedure. Main outcome measures: The primary outcome of this analysis was the 30-day composite of death, myocardial infarction, target vessel revascularization (TVR) or major bleeding. Results: The primary outcome occurred in 7.9% patients (n=246) in the statin group versus 9.8% (n=143) in the non-statin group (P=0.036). There was an interaction in univariate (P=0.028) and multivariable (P=0.026) analysis between pre-PCI statin therapy and the type of antithrombotic therapy regarding myocardial infarction. In the statin group, bivalirudin significantly reduced the incidence of major bleeding (2.6 vs. 4.3%, P=0.013) with no significant difference in the incidence of myocardial infarction (4.9 vs. 5.2%; P=0.73) compared with UFH. In the non-statin group, bivalirudin was inferior to UFH regarding the incidence of myocardial infarction (7.1 vs. 4.1%, P=0.013), yet major bleeding remained lower among bivalirudin-treated patients (4.0 vs. 5.2%, P=0.25). Conclusion: This post-hoc analysis suggests the existence of an interaction between statin therapy before PCI and antithrombotic therapy during PCI. Patients receiving bivalirudin therapy at the time of PCI showed less periprocedural myocardial infarction when on pre-PCI statin therapy which has to be investigated in further studie

Hotline sessions presented at the American College of Cardiology Congress 2009

The article summarizes the results of clinical trials in the field of cardiovascular medicine, which were presented during the Hotline Sessions at the annual meeting of the American College of Cardiology in Orlando, USA, from 28th March to 31st March 2009. The data were presented by leading experts in the field with relevant positions within the trials. Unpublished reports should be considered as preliminary data as the analysis may change in the final publications. The summaries presented in the manuscript were generated from the oral presentations and provide the readers with the comprehensive information on the results of the latest clinical trials in cardiovascular medicine

Liver enzymes are not directly involved in atrial fibrillation: a prospective cohort study

Background: Epidemiological evidence proposes the direct involvement of the liver enzymes in atrial fibrillation. These relationships are controversial and mechanistically unclear. As part of the British Regional Heart Study, we investigated whether change in liver enzymes over time associates with atrial fibrillation in men initially free of this heart condition. Materials and Methods: We prospectively investigated change (delta) in liver enzymes and new-onset atrial fibrillation in a representative sample of 1428 men aged 60-79 years. Results: Mean follow-up was 12.3 years, after which 108 new atrial fibrillation cases were identified. The liver enzymes did not differ at baseline or follow-up, except for gamma-glutamyl transferase which was higher at follow-up in men who developed atrial fibrillation compared to those who did not (P<0.0001). Change in GGT was greater in men who developed AF than those who did not (+6.12 vs. –2.60U/l, P=0.036). N-terminal pro-brain natriuretic peptide (baseline and follow-up, P<0.0001) and total bilirubin (follow-up only, P<0.0001) were also higher in men who developed atrial fibrillation while serum haemoglobin was similar at baseline and follow-up (P≥0.74). Atrial fibrillation was associated with change in gamma-glutamyl transferase (OR, 1.18; 95%CI, 1.01–1.37) after multiple adjustments and exclusions. However, after adjusting for baseline (P=0.088) or change (P=0.40) in N-terminal pro-brain natriuretic peptide, the association between atrial fibrillation and change in gamma-glutamyl transferase was lost. Conclusion: The direct relationship between atrial fibrillation and liver enzymes is absent and depends, at least in part, on the progression of heart failure as captured by N-terminal pro-brain natriuretic peptide