Incidence, Predictors and Associations Between In-Hospital Bleeding and Adverse Events in Patients with Acute Coronary Syndrome Above 75 Years of Age – The Real-World Scenario

Background: Bleeding events in patients with acute coronary syndrome (ACS) are associated with poor outcomes. Risk factors and their associations with in-hospital events in older patients with ACS are not fully understood, because older patients with ACS are often excluded from randomized controlled studies. Methods: We enrolled 962 patients with ACS above 75 years of age treated at our center between January 2012 and December 2016. The incidence and risk factors for in-hospital bleeding events, as well as their associations with in-hospital adverse events were evaluated. Results: Bleeding complications were observed in 38 patients (4.1%). The most common bleeding site was the gastrointestinal tract (52.6%). Anemia (P=0.007), renal insufficiency (P=0.019), use of positive inotropic medicines (P=0.006) and elevated leukocyte count (P=0.046) were independent predictors of in-hospital bleeding after adjustment for age, sex, atrial fibrillation history and hypertension history. In-hospital mortality (28.9% vs. 2.4%, P<0.001), stroke (5.3% vs. 0.5%, P<0.001) and the prevalence of heart failure (39.5% vs. 16.3%, P<0.001) were significantly higher in patients with than without bleeding. Conclusions: The incidence of in-hospital bleeding was 4.1% in patients with ACS above 75 years of age in this cohort. Independent risk factors for in-hospital bleeding events included anemia, renal insufficiency and elevated leucocyte count. Bleeding events were strongly associated with in-hospital adverse events

Proximal buddy in jail technique: A bail out technique to increase guide support

  Background: During percutaneous coronary intervention, “buddy-in-jail” technique is often used to facilitate stent delivery in complex coronary artery lesions. However, the safety and efficacy of this tech­nique when used with different jailed wire and applied in different target vessel lesions remain elusive. The aim of this retrospective study was to analyze the effectiveness of “buddy-in-jail” technique in the tortuous and rigid lesions of both the common and neighboring coronary arteries. The effectiveness between hydrophilic-coated and non-hydrophilic-coated guide wire as jailed wires was also compared. Methods: The “buddy-in-jail” technique was applied in 15 patients after failed balloon or stent delivery into the target vessel lesion from June 2014 to December 2016. The safety and effectiveness of the “bud­dy-in-jail” technique was compared in the tortuous and rigid lesions of both the common and neighbor­ing coronary arteries and between hydrophilic-coated and non-hydrophilic-coated “jailed” wires. Results: Stent delivery was successful in 13 (86.7%) patients with the use of “buddy-in-jail” technique. The success rate was similar to the group using the common artery (87.5%) as a “buddy” vessel and the group using a neighboring artery (85.7%) as a “buddy” vessel (p &gt; 0.05), and between hydrophilic- -coated (100%) and non-hydrophilic-coated “jailed” wire (77.8%) group (p &gt; 0.05). All wires were successfully extracted without complications. Conclusions: The “buddy-in-jail” technique offers a potential alternative approach for the distal stent delivery in both the common and neighboring coronary arteries. Also, both hydrophilic and non-hydro­philic-coated wire could be safely and effectively used as “jailed” wire.

Levosimendan in Europe and China: An Appraisal of Evidence and Context

The calcium sensitiser levosimendan (SIMDAX; Orion Pharma) has been in clinical use for the management of acute heart failure and a range of related syndromes in many countries around the world for two decades. More recently, levosimendan has become available in China. The authors have examined the profile of levosimendan in clinical trials conducted inside and outside China and grouped the findings under six headings: effects on haemodynamics, effects on natriuretic peptides, effect on symptoms of heart failure, renal effects, effect on survival, and safety profile. Their conclusions are that under each of these headings there are reasonable grounds to expect that the effects and clinical benefits established in trials and with wider clinical use in Europe and elsewhere will accrue also to Chinese patients. Therefore, the authors are confident that global experience with levosimendan provides a reliable guide to its optimal use and likely therapeutic effects in patients in China

Rosiglitazone Activates Renal Sodium-and Water-Reabsorptive Pathways and Lowers Blood Pressure in Normal Rats

ABSTRACT Synthetic agonists of the peroxisomal proliferator-activated receptor subtype ␥ (PPAR-␥) are highly beneficial in the treatment of type II diabetes. However, they are also associated with fluid retention and edema, potentially serious side effects of unknown origin. These studies were designed to test the hypothesis that rosiglitazone (RGZ, PPAR-␥ agonist) may activate sodium-and water-reabsorptive processes in the kidney, possibly in response to a drop in mean arterial blood pressure (MAP), as well as directly through PPAR-␥. Targeted proteomics of the major renal sodium and water transporters and channel proteins was used to identify potentially regulated sites of renal sodium and water reabsorption. RGZ (47 or 94 mg/kg diet) was fed to male, Sprague-Dawley rats (ϳ270g) for 3 days. MAP, measured by radiotelemetry, was decreased significantly in rats fed either level of RGZ, relative to control rats. Delta MAP from baseline was Ϫ3.2 Ϯ 1.2 mm Hg in rats fed high-dose RGZ versus ϩ 3.4 Ϯ 0.8 for rats fed control diet. RGZ did not affect feed or water intake, but rats treated with high-dose RGZ had decreased urine volume (by 22%), sodium excretion (44%), kidney weight (9%), and creatinine clearance (35%). RGZ increased whole kidney protein abundance of the ␣-1 subunit of Na-K-ATPase, the bumetanide-sensitive Na-K-2Cl cotransporter (NKCC2), the sodium hydrogen exchanger (NHE3), the aquaporins 2 and 3, and endothelial nitric-oxide synthase. We conclude that both increases in renal tubule transporter abundance and a decrease in glomerular filtration rate likely contribute to the RGZ-induced sodium retention

Association between Percentage of Neutrophils at Admission and in-Hospital Events in Patients ≥75 Years of Age with Acute Coronary Syndrome

Objective: The study aimed to evaluate the role of the neutrophil percentage (N%) at admission in predicting in-hospital major adverse cardiovascular events (MACE) in patients ≥75 years of age with acute coronary syndrome (ACS).Methods: A total of 1189 patients above 75 years of age with ACS hospitalized at the Second Xiangya Hospital between January 2013 and December 2017 were enrolled in this retrospective study. Receiver operator characteristic curve analysis was performed to calculate the optimal N% cut-off value for patient grouping. The in-hospital MACE consisted of acute left heart failure, stroke and any cause of death. Multivariable logistic analyses were used to assess the role of N% in predicting MACE in older patients with ACS.Results: The patients were divided into a high N% group (N% ≥74.17%, n=396) and low N% group (N%<74.17%, n=793) according to the N% cut-off value (N%=74.17%). The rate of MACEs during hospitalization was considerably higher in the high N% group than the low N% group (27.5% vs. 9.6%, P<0.001). After adjustment for other factors, high N% remained an independent risk factor for in-hospital MACE in older patients with ACS (odds ratio 1.779, 95% confidence interval 1.091–2.901, P=0.021).Conclusion: High N% at admission is an independent risk factor for in-hospital MACE in patients above 75 years of age with ACS

In-Hospital Cardiac Arrest after Emotional Stress in a Patient Hospitalized with Gastrointestinal Symptoms and Chronic Anxiety Disorder

Background: We report an acute emotional stress–induced in-hospital cardiac arrest in a patient admitted with gastrointestinal symptoms after experiencing chronic anxiety disorder. Case Presentation: The patient was admitted to the Second Xiangya Hospital, Central South University, with gastrointestinal symptoms and chronic anxiety disorder, and experienced cardiac arrest during hospitalization after acute emotional stress. Malignant ventricular tachycardia and cardiogenic shock were evidenced in this patient after the acute emotional stress. Severe and extensive coronary spasm was confirmed by emergency coronary angiography, and coronary spasm was relieved by intracoronary injection of nitroglycerin. The patient recovered from myocardial infarction with nonobstructive coronary arteries. However, the patient developed acute kidney dysfunction and severe pulmonary infection and eventually died of respiratory circulatory failure on the ninth day after the successful rescue. Conclusions: Acute emotional stress on top of chronic anxiety disorder in patients hospitalized for noncardiovascular reasons might lead to the development of life-threatening cardiovascular diseases, including coronary artery spasm and myocardial infarction with nonobstructive coronary arteries. Psychological management is of importance to improve the outcome of these patients. </p

Clinical Significance of Angiographically Detectable Neovascularity in Patients with Cardiac Myxoma

Background: Myxomas are the most common primary cardiac tumors. Angiographically detectable neovascularity (ADN) of myxoma is increasingly being reported as a result of the use of coronary angiography (CAG) to detect coronary artery disease. However, the clinical significance of these findings is not fully understood. Methods: We enrolled 59 patients with cardiac myxoma who also underwent CAG between January 2013 and October 2018. Patients were followed up for a mean of 28.9 months (range 1–69 months). The clinical features, echocardiography measurements, pathological examination findings, CAG results, and outcomes during follow-up were compared between patients with ADN and patients without ADN. Results: ADN was found in 25 patients (42.4%). The arteries feeding the ADN included the right coronary artery ( n=15), the left circumflex coronary artery ( n=7), and both arteries ( n=3). The patients with ADN had a higher proportion of eosinophils (3.2% vs. 2.2%, P=0.03) and higher low-density lipoprotein cholesterol level (2.7 mmol/L vs. 2.2 mmol/L, P=0.02). Myxoma pedicles were more likely to be located in the interatrial septum in patients with ADN (96% vs. 73.5%, P=0.02). No significant correlation was observed between the groups in clinical manifestations, atrial arrhythmia, myxoma size, cardiac chamber size, left ventricular ejection fraction, and the prevalence of complication with coronary artery disease [16% in the ADN group ( n=4) vs. 20.6% in the non-ADN group ( n=7), P=0.66]. However, patients with ADN tended to have a lower incidence of major adverse cardiac and cerebrovascular events on long-term follow-up (0% vs. 14.7%, P=0.07). Conclusion: CAG-detected ADN in patients with cardiac myxoma is associated with a borderline lower rate of major adverse cardiac and cerebrovascular events. </p

Association of Urine Albumin-to-Creatinine Ratio with Cardiovascular Outcomes in Patients with Type 2 Diabetes Mellitus

The urinary albumin-to-creatinine ratio (UACR) is a widely used indicator of albuminuria and has predictive value for adverse cardiovascular events.To evaluate the correlation between the UACR and the risk of developing major adverse cardiovascular events (MACEs) and total mortality in patients with type 2 diabetes mellitus (T2DM).This post-hoc analysis included 10,171 participants from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study and the ACCORD Follow-up study with baseline UACR data. The natural logarithm (ln) of each UACR measurement was calculated. Univariate and multivariate Cox proportional hazard regression analyses were conducted to examine the association between the UACR and the risk of MACEs and total mortality. The additional predictive value of UACR was further evaluated. Similar methods were used to analyze the correlation between the UACR and MACEs and total mortality within the normal range.During a median follow-up period of 8.83 years, 1808 (17.78%) participants experienced MACEs, and there were 1934 (19.01%) total mortality. After adjusting for traditional cardiovascular risk factors, the multivariate analysis revealed a significant association between the UACR and the risk of MACEs and total mortality. The inclusion of UACR in the conventional risk model enhanced the predictive efficacy for MACEs and total mortality.An elevated UACR is associated with a higher risk of MACEs and total mortality in patients with T2DM, even when it falls below the normal range. The UACR improves MACE and total mortality risk prediction in patients with T2DM.</p

Glycemic control, HbA1c variability, and major cardiovascular adverse outcomes in type 2 diabetes patients with elevated cardiovascular risk: insights from the ACCORD study

Abstract Background Although recent guidelines advocate for HbA1c target individualization, a comprehensive criterion for patient categorization remains absent. This study aimed to categorize HbA1c variability levels and explore the relationship between glycemic control, cardiovascular outcomes, and mortality across different degrees of variability. Methods Action to Control Cardiovascular Risk in Diabetes study data were used. HbA1c variability was measured using the HbA1c variability score (HVS) and standard deviation (SD). K-means and K-medians clustering were used to combine the HVS and SD. Results K-means clustering was the most stable algorithm with the lowest clustering similarities. In the low variability group, intensive glucose-lowering treatment significantly reduced the risk of adverse cardiovascular outcomes (HR: 0·78 [95% CI: 0·63, 0·97]) without increasing mortality risk (HR: 1·07 [0.81, 1·42]); the risk of adverse cardiovascular events (HR: 1·33 [1·14, 1·56]) and all-cause mortality (HR: 1·23 [1·01,1·51]) increased with increasing mean HbA1c. In the high variability group, treatment increased the risk of cardiovascular events (HR: 2.00 [1·54, 2·60]) and mortality (HR: 2·20 [1·66, 2·92]); a higher mean HbA1c (7·86%, [7·66%, 8·06%]) had the lowest mortality risk, when the mean HbA1c was < 7·86%, a higher mean HbA1c was associated with a lower mortality risk (HR: 0·63 [0·42, 0·95]). In the medium variability group, a mean HbA1c around 7·5% was associated with the lowest risk. Conclusions HbA1c variability can guide glycemic control targets for patients with type 2 diabetes. For patients with low variability, the lower the HbA1c, the lower the risk. For those with medium variability, controlling HbA1c at 7·5% provides the maximum benefit. For patients with high variability, a mean HbA1c of around 7·8% presents the lowest risk of all-cause mortality, a lower HbA1c did not provide cardiovascular benefits but instead increased the mortality risk. Further studies, especially those with patients that reflect the general population with type 2 diabetes undergoing the latest therapeutic approaches, are essential to validate the conclusions of this study