Fifteen years trends of cardiogenic shock and mortality in patients with diabetes and acute coronary syndromes

PURPOSE: Our study was intended to examine time trends of management and mortality of acute coronary syndrome patients with associated diabetes mellitus. METHODS: We analyzed data from 5 nationwide registries established between 2001 and 2014, including consecutive acute coronary syndrome patients admitted to the Italian Intensive Cardiac Care Units. RESULTS: Of 28,225 participants, 8521 (30.2%) had diabetes: as compared with patients without diabetes, they were older and had significantly higher rates of prior myocardial infarction and comorbidities (all P < .0001). Prevalence of diabetes and comorbidities increased over time (P for trend < .0001). Cardiogenic shock rates were higher in patients with diabetes, as compared with those without diabetes (7.8% vs 2.8%, P < .0001), and decreased significantly over time only in patients without diabetes (P = .007). Revascularization rates increased over time in patients both with and without diabetes (both P for trend < .0001), although with persistingly lower rates in patients with diabetes. All-cause in-hospital mortality was higher in patients with diabetes (5.4 vs 2.5%, respectively, P < .0001) and decreased more consistently in patients without diabetes (P for trend = .007 and < .0001, respectively). At multivariable analysis, diabetes remains an independent predictor of both cardiogenic shock (odds ratio 2.03; 95% confidence interval, 1.77-2.32; P < .0001) and mortality (odds ratio 1.95; 95% confidence interval, 1.69-2.26; P < .0001). CONCLUSIONS: Despite significant mortality reductions observed over 15 years in acute coronary syndromes, patients with diabetes continue to show threefold higher rates of cardiogenic shock and lower revascularization rates as compared with patients without diabetes. These findings may explain the persistingly higher mortality of patients with diabetes and acute coronary syndromes

Protein quality control: the who’s who, the where’s and therapeutic escapes

In cells the quality of newly synthesized proteins is monitored in regard to proper folding and correct assembly in the early secretory pathway, the cytosol and the nucleoplasm. Proteins recognized as non-native in the ER will be removed and degraded by a process termed ERAD. ERAD of aberrant proteins is accompanied by various changes of cellular organelles and results in protein folding diseases. This review focuses on how the immunocytochemical labeling and electron microscopic analyses have helped to disclose the in situ subcellular distribution pattern of some of the key machinery proteins of the cellular protein quality control, the organelle changes due to the presence of misfolded proteins, and the efficiency of synthetic chaperones to rescue disease-causing trafficking defects of aberrant proteins

Assessment of internal mammary artery and saphenous vein graft patency and flow reserve using transthoracic Doppler echocardiography

OBJECTIVE—To investigate transthoracic Doppler echocardiography in the identification of coronary artery bypass graft (CABG) flow for assessing graft patency.
DESIGN—The initial study group comprised 45 consecutive patients with previous CABG undergoing elective cardiac catheterisation for recurrent ischaemia. The Doppler variables best correlated with angiographic graft patency were then tested prospectively in a further 84 patients (test group).
SETTING—Three tertiary referral centres.
INTERVENTIONS—Flow velocities in grafts were recorded at rest and during hyperaemia induced by dipyridamole (0.56 mg/kg/4 min), under the guidance of transthoracic colour Doppler flow mapping. Findings on transthoracic Doppler were compared with angiography.
MAIN OUTCOME MEASURES—Feasibility of identifying open grafts by Doppler and diagnostic accuracy for Doppler detection of significant (⩾ 70%) graft stenosis.
RESULTS—In the test group the identification rate for mammary artery grafts was 100%, for saphenous vein grafts to left anterior descending coronary artery 91%, for vein grafts to right coronary artery 96%, and for vein grafts to circumflex artery 90%. Coronary flow reserve (the ratio between peak diastolic velocity under hyperaemia and at baseline) of < 1.9 (95% confidence interval 1.83 to 2.08) had 100% sensitivity, 98% specificity, 87.5% positive predictive value, and 100% negative predictive value for mammary artery graft stenosis. Coronary flow reserve of < 1.6 (95% CI 1.51 to 1.73) had 91% sensitivity, 87% specificity, 85.4% positive predictive value, and 92.3% negative predictive value for significant vein graft stenosis.
CONCLUSIONS—Transthoracic Doppler can provide non-invasive assessment of CABG patency.


Keywords: blood flow; coronary artery disease; coronary artery bypass graft; echocardiograph

[Morpho-functional changes of left ventricle produced by sublingual nitroglycerin (author's transl)]

Two successive left ventriculargraphs [in basal conditions and after Nitroglycerin (TNG)] were performed with the same technical procedures in 20 patients before coronary arteriography. End-diastolic and end-systolic volumes and ejection fraction were studied following Greene's modified method. Diastolic and systolic ventricular projected images were divided into four zones and their variations were evaluated after TNG. Two patients did not show any significant abnormality (pseudoangor); two others suffered from cardiomyopathy (myocardosis) with mitral regurgitation and no coronary artery disease; two had restrictive cardiomyopathy. Fourteen had a coronary artery disease: seven of them had signs of end-systolic mitral regurgitation. End-diastolic and end-systolic volumes decreased and ejection fraction increased after TNG in all of these cases except in the two suffering from cardiomyopathy (ESV increased and EF decreased). Mitral regurgitation disappeared in all of them. In patients with coronary artery disease and mitral regurgitation the volume variations were slighter, and the increase of EF was larger than in the other cases. Finally, a decrease in asynergic and hypokinetc zones was observed, whereas no variations were seen in diskinetic zones. TNG can improve left ventricular kinetics by decreasing the pre-load, the after-load and myocardial oxygen consumption. Demonstration of this improvement could be of prognostic value

Percutaneous coronary interventions for stable ischemic heart disease in Italy

AimsAlthough the benefits of percutaneous coronary interventions (PCIs) in patients with stable chronic ischemic heart disease (SIHD) are controversial, a large number of PCIs are currently performed in SIHD patients, frequently after coronary angiography (ad-hoc procedures), without the use of fractional flow reserve (FFR) to identify patients most likely to benefit from PCI.MethodsAssessment of regional variations in PCI for SIHD performed in Italy in 2017 and correlation of the regional number of PCI per million inhabitants with the use of FFR were performed using the data reported in the registry of the Italian Society of Interventional Cardiology (SICI-GISE) registry for the year 2017.ResultsPCI for SIHD accounted for 44.5% of all PCI performed in Italy with large variations among the Italian regions. There was a significant and inverse relationship between the use of FFR and the PCI number per million inhabitants performed for SIHD in the various Italian regions (P = 0.01). In the Veneto region, where local authorities mandated Heart Team reports to select the most appropriate treatment choice in multivessel disease patients, the rate of ad-hoc procedures was significantly lower than the national average.ConclusionPCI for SIHD patients represent almost half of all procedures currently performed in Italy with regional variations inversely related to physiologic guidance use. The mandatory assessment by the Heart Team to select the most appropriate treatment choice in multivessel disease patients is associated with a significantly lower number of ad-hoc procedures