12-month Major Adverse Cardiac Events Research Articles

Impact of aortic aneurysms in trans-catheter aortic valve replacement: A single center experience

BackgroundPatients who undergo trans-catheter aortic valve replacement (TAVR) may have concomitant aortic aneurysms. We sought to clarify the incidence of aortic aneurysms and its impact on clinical outcomes among patients undergoing TAVR. MethodsWe performed a retrospective analysis of patients with severe symptomatic aortic stenosis who underwent TAVR from January 2012 to June 2016. Multi-detector computer tomography (MDCT) was performed on all patients and images were reviewed to identify thoracic and abdominal aortic aneurysms (TAA and AAA). The incidence of vascular complications (VARC-2 definition), and in-hospital and 6-month major adverse cardiac events (MACE) defined as a composite of all-cause mortality, cardiac arrest, myocardial infarction, and stroke were recorded. ResultsAmong 232 patients included in the analysis, 22 patients (9.5%) had aortic aneurysms (11 had AAA, 8 had TAA, and 3 had both). Patients with aortic aneurysms had a higher, albeit statistically insignificant, rate of smoking history (63.6% vs. 42.9%, p = 0.062). Both groups of patient predominantly underwent TAVR via trans-femoral access (72.7% vs. 71.4%, p = 0.90). The incidence of vascular complications was similar between the two groups (9.1% vs. 10.5%, p = 1.0). Patients with aortic aneurysms had a similar in-hospital MACE (4.5% vs. 6.2%, p = 1.0) and 6-month MACE (9.1% vs. 9.0%, p = 1.0) compared to those without aneurysms. ConclusionsIn our patient cohort, 9.5% of patients who underwent TAVR had concomitant aortic aneurysms. Patients with aortic aneurysms had similar incidence of vascular complications as well as in-hospital and 6-month MACE compared to those without.

Efficacy and Safety of Polymer-Free Ultrathin Strut Sirolimus-Probucol Coated Drug-Eluting Stents for Chronic Total Occlusions: Insights from the Coroflex ISAR 2000 Worldwide Registry.

Objective Coronary revascularization in chronic total occlusion (CTO) is associated with improved clinical outcomes. The choice of the coronary stent is crucial in maintaining long-term vessel patency after CTO revascularization. We investigated the efficacy and safety of polymer-free ultrathin strut sirolimus-probucol coated drug-eluting stents (PF-SES) for CTO lesions. Methods Patients with CTO lesions treated with PF-SES were identified from the prospective multicenter international ISAR 2000 registry. The primary endpoint was clinically driven target lesion revascularization (TLR) at 9 months. Secondary endpoints were 9-month major adverse cardiac events (death, myocardial infarction, or TLR) (MACE) and the occurrence of stent thrombosis. Results A total of 111 patients with CTO lesions (n=127) were available for analysis. The 9-month clinical follow-up rate was 91%. The mean reference vessel diameter and lesion length were 2.76 mm ± 0.40 and 26.8 mm ± 13.1, respectively. The overall DAPT duration was 9.7 ± 2.8 months. Only one (1%) in-hospital MI was reported. The TLR and MACE rates at 9 months were 2% (2/101) and 5.9% (6/101), respectively. The 9-month accumulated rates of definite or probable stent thrombosis was 0% (0/101). Conclusion Revascularizations for CTO with PF-SES are associated with low rates of TLR and MACE at 9 months with no stent thrombosis. These initial findings need to be compared with results of other new generation DES of larger studies.

Coronary Flow Reserve in Non-Infarcted Myocardium Predicts Long-Term Clinical Outcomes in Patients Undergoing Percutaneous Coronary Intervention.

PurposeCoronary flow reserve (CFR) is recognized as an indicator of myocardial perfusion. The aim of this study was to assess the relationship between CFR in the non-infarcted myocardium and the incidence of major adverse cardiac events (MACEs).Materials and Methods100 consecutive patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) were enrolled in the present study, and divided into MACE and non-MACE groups according to the incidence of 12-month MACEs. Left ventricular function and CFR were analyzed using two-dimensional echocardiography and myocardial contrast echocardiography at one week after PCI. Cardiac troponin I levels were assayed to estimate peak concentrations thereof.ResultsThe MACE group was associated with lower CFR, compared to the non-MACE group (2.41 vs. 2.77, p<0.001). In the multivariable model, CFR in the non-infarcted myocardium was an independent predictor of 12-month MACE (hazard ratio: 0.093, 95% confidence interval: 0.020–0.426, p=0.002) after adjustment for baseline demographic and clinical characteristics.ConclusionCFR in the non-infarcted myocardium is a useful marker for predicting 12-month MACEs in patients with AMI undergoing primary PCI.

Safety and Efficacy of the Endeavor Resolute® Stent in Patients with Multivessel Disease: The HEART (Honam EndeAvor ResoluTe) Prospective, Multicenter Trial

The Endeavor Resolute® (ER) is a zotarolimus-eluting stent (ZES) with a biocompatible BioLinx polymer. This study prospectively compared the clinical outcomes of 2 versions of ZES, ER and Endeavor Sprint® (ES), in patients with multivessel disease. A total of 488 patients who underwent multivessel percutaneous coronary intervention (PCI) were divided into 2 groups the ER group (n=288) and the ES group (n=200). The primary endpoint was a composite of major adverse cardiac events (MACE) consisting of death, myocardial infarction, and target vessel revascularization after 12 months. In all patients, the prevalence of diabetes was higher in the ER group (42.7% vs. 31.0%, p=0.009). The rate of post-PCI Thrombolysis in Myocardial Infarction flow grade 3 was higher in the ER group (100.0% vs. 98.0%, p=0.028). There were no between-group differences in the in-hospital, 1-month and 12-month clinical outcomes. In the propensity score matched cohort (n=200 in each group), no differences were observed in the baseline and procedural characteristics. There were no statistical differences in the rates of in-hospital, 1-month and 12-month events (12-month MACE in the ER and ES groups: 6.0% vs. 3.5%, p=0.240, respectively). The safety and efficacy of both versions of ZES were comparable in patients with multivessel disease during a 12-month clinical follow-up.

Characteristics, management, and prognosis of patients under 35 years old with ST-segment elevation myocardial infarction: Insights from the multicenter prospective ORBI registry

Recent data regarding ST-segment Elevation Myocardial Infarction (STEMI) in young adults are limited. Currently, long-term prognosis is poorly described. Data from a prospective multicenter registry were analyzed. STEMI patients ≤ 35 years old were compared with their older counterparts. The primary endpoint was 1-year major adverse cardiac events (MACE), defined as the composite of cardiovascular-death, STEMI, non-STEMI, new revascularization procedure and stroke. Multivariable Cox regression was performed to assess the impact of age on 1-year MACEs while adjusting for confounders. Moreover, long-term MACEs rates among young patients were assessed. Hundred and three STEMI in patients ≤ 35 years old were compared with 1073 in patients > 35 years old with available 1-year follow-up data. Young adults were more likely current smokers (86% vs. 40%; P < 0.001). Other cardiovascular risk factors were more common among older patients. There were no significant differences in in-hospital STEMI management. One year MACEs rates were 8% and 10% in young and older patients respectively ( P < 0.001). After adjustment for confounders, age ≤ 35 years was not associated with lower 12-month MACEs rate (HR = 2.049 [95% CI 0.748–4.805, P = 0.124]). At a median 54 months follow-up, mortality rate was low (2.4%) but MACEs recurrence was frequent (24%) in young patients, who reported persistent smoking in 45% of cases. In the contemporary era of STEMI management, young and older patients have the same prognosis at 1 year post-STEMI. However, considering the high rate of morbidity after a premature STEMI, the importance of risk factors modification must be stressed.

Utility of the ACC/AHA lesion classification as a predictor of procedural, 30-day and 12-month outcomes in the contemporary percutaneous coronary intervention era.

Correlations between the ACC/AHA coronary lesion classification and clinical outcomes in the contemporary percutaneous coronary intervention (PCI) era are not well established. We analyzed clinical characteristics and outcomes according to ACC/AHA lesion classification (A, B1, B2, C) in 13,701 consecutive patients from the Melbourne Interventional Group (MIG) registry. Patients presenting with STEMI, cardiogenic shock and out-of-hospital cardiac arrest were excluded. The primary endpoints were 30-day and 12-month mortality. Secondary endpoints were procedural success as well as 30-day and 12-month major adverse cardiac events. Of the 13,701 patients treated, 1,246 (9.1%) had type A lesions, 5,519 (40.3%) had type B1 lesions, 4,449 (32.5%) had Type B2 lesions and 2,487 (18.2%) had Type C lesions. Patients with type C lesions were more likely to be older and have impaired renal function, diabetes, previous myocardial infarction, peripheral vascular disease and prior bypass graft surgery (all P < 0.01). They were also more likely to require rotational atherectomy, drug-eluting stents and longer stent lengths (all P < 0.01). Increasing lesion complexity was associated with lower procedural success (99.6% vs. 99.1% vs. 96.6% vs. 82.7%, P < 0.001) and worse 30-day (0.2% vs. 0.3% vs. 0.7% vs. 0.6%, P < 0.001) and 12-month mortality (2.2% vs. 2.0% vs. 3.2% vs. 2.9%, P <0.01). Kaplan Meier analysis showed complex lesions (type B2 and C) had lower survival at 12-months (P = 0.003). PCI to more complex lesions continues to be associated with lower procedural success rates as well as inferior medium-term clinical outcomes. Thus the ACC/AHA lesion classification should still be calculated preprocedure to predict acute PCI success and clinical outcomes.

Prognostic significance of non-chest pain symptoms in patients with non-ST-segment elevation myocardial infarction.

Background/AimsChest pain is an essential symptom in the diagnosis of acute coronary syndrome (ACS). One-third of patients with ACS present atypically, which can influence their receiving timely lifesaving therapy.MethodsA total of 617 NSTEMI patients from the Korea Acute MI Registry (KAMIR) and the Korea Working Group on MI (KorMI) databases were analyzed. The study population was divided into two groups by symptoms at presentation (typical symptoms group, 128; atypical symptoms groups, 128).ResultsIn this study population, 23% of patients presented without chest pain. After propensity score matching, the contact-to-device time (2,618 ± 381 minutes vs. 1,739 ± 241 minutes, p = 0.050), the symptoms-to-balloon time (3,426 ± 389 minutes vs. 2,366 ± 255 minutes, p = 0.024), and the door-to-balloon time (2,339 ± 380 minutes vs. 1,544 ± 244 minutes, p = 0.002) were significantly higher in the patients with atypical symptoms than in those with typical symptoms, respectively. Atypical symptoms were an independent predictor for 1-year mortality (hazard ratio, 2.820; 95% confidence interval, 1.058 to 7.515; p = 0.038). The Kaplan-Meier estimates showed higher risk for 12-month mortality in patients with atypical symptoms (p = 0.048) and no significant difference for 12-month major adverse cardiac events (p = 0.487).ConclusionsAcute myocardial infarction patients with atypical symptoms were not rare in clinical practice and showed a high risk of delayed reperfusion therapy. After imbalance between the groups was minimized by use of propensity score matching, patients who presented atypically had a high mortality rate.

Nonprimary PCI at hospitals without cardiac surgery on-site: Consistent outcomes for all?

The CPORT-E trial showed the noninferiority of nonprimary percutaneous coronary intervention (PCI) at hospitals without cardiac surgery on-site (SoS) compared with hospitals with SoS for 6-week mortality and 9-month major adverse cardiac events (MACE). However, target vessel revascularization (TVR) was increased at non-SoS hospitals. Therefore, we aimed to determine the consistency of the CPORT-E trial findings across the spectrum of enrolled patients. Post hoc subgroup analyses of 6-week mortality and 9-month MACE, defined as the composite of death, Q-wave myocardial infarction, or TVR, were performed. Patients with and without 9-month TVR and rates of related outcomes were compared. There was no interaction between SoS status and clinically relevant subgroups for 6-week mortality or 9-month MACE (P for any interaction=.421 and .062, respectively). In addition to increased 9-month rates of TVR and diagnostic catheterization at hospitals without SoS, non-TVR was also increased (2.7% vs 1.9%, P=.002); there was no difference in myocardial infarction-driven TVR, non-TVR, or diagnostic catheterization. Predictors of 9-month TVR included intra-aortic balloon pump use, any index PCI complication, and 3-vessel PCI, whereas predictors of freedom from TVR included SoS, discharge on a P2Y12 inhibitor, and stent implantation. The noninferiority of nonprimary PCI at non-SoS hospitals was consistent across clinically relevant subgroups. Elective PCI at an SoS hospital conferred a TVR benefit which may be related to a lower rate of referral for diagnostic catheterization for reasons other than myocardial infarction.

Optimized Prognosis Assessment in ST-Segment-Elevation Myocardial Infarction Using a Cardiac Magnetic Resonance Imaging Risk Score.

Cardiac magnetic resonance (CMR) demonstrated great potential for the prediction of major adverse cardiac events (MACE) in ST-segment-elevation myocardial infarction. The aim of this study was to develop and validate a CMR-based risk score for ST-segment-elevation myocardial infarction patients. The scoring model was developed and validated on ST-segment-elevation myocardial infarction cohorts from 2 independent randomized controlled trials (n=738 and n=458 patients, respectively) and included left ventricular (LV) ejection fraction, infarct size, and microvascular obstruction. Primary end point was the 12-month MACE rate consisting of death, reinfarction, and new congestive heart failure. In the derivation cohort, LV ejection fraction ≤47%, infarct size ≥19%LV, and microvascular obstruction ≥1.4%LV were identified as the best cutoff values for MACE prediction. According to the hazard ratios in multivariable regression analysis, the CMR risk score was created by attributing 1 point for LV ejection fraction ≤47%, 1 point for infarct size ≥19%LV, and 2 points for microvascular obstruction ≥1.4%LV. In the validation cohort, the score showed a good prediction of MACE (area under the curve: 0.76). Stratification into a low (0/1 point) and high-risk group (≥2 points) resulted in significantly higher MACE rates in high-risk patients (9.0% versus 2.2%; P=0.001). Inclusion of the CMR score in addition to a model of clinical risk factors led to a significant increase of C statistics from 0.74 to 0.83 (P=0.037), a net reclassification improvement of 0.18 (P=0.009), and an integrated discriminative improvement of 0.04 (P=0.010). Our approach integrates the prognostic information of CMR imaging into a simple risk score that showed incremental prognostic value over clinical risk factors in ST-segment-elevation myocardial infarction patients. URL: http://www.clinicaltrials.gov. Unique identifiers: NCT00712101 and NCT02158468.

Association of Troponin Trends and Cardiac Morbidity and Mortality After On-Pump Cardiac Surgery

Elevated, single-measure, postoperative troponin is associated with adverse events after cardiac surgery. We hypothesized that increases in troponin from the first to the second postoperative day are also associated with all-cause, 12-month mortality and major adverse cardiac events (MACE). This observational study included consecutive adults undergoing on-pump cardiac surgery with cardiac arrest. Troponin T was measured on the first andsecond postoperative day and was classified as "increasing" (>10%), "unchanged" (10% to -10%), or "decreasing" (<-10%). The primary endpoint was all-cause, 12-month mortality. Secondary endpoints were all-cause 12-month mortality or MACE and both outcomes at 30 days. Themain analysis was by multivariable Cox regression. Of 1,417 included patients, 99 (7.0%) died and 162 (11.4%) died or suffered MACE at 12 months. A significant interaction (p < 0.001) between first postoperative day troponin and the troponin trend from the first to the second postoperative day on 12-month, all-cause mortality precluded an analysis independent of first postoperative day troponin. Consequently, we stratified patients by their first postoperative day troponin (cutoff, 0.8 μg/L). Increasing troponin was associated with higher mortality in patients with first postoperative day troponin T ≥ 0.8 μg/L (hazard ratio, 1.98; 95% CI, 1.09 to 3.59; p=0.025). Troponin changes from the first to the second postoperative day should not be interpreted without consideration of the first postoperative day troponin concentration. For patients with a first postoperative day troponin ≥ 0.8 μg/L, an increase by more than 10% from the first to the second postoperative day was significantly associated with all-cause, 12-month mortality and other adverse events.

Biomarker for the Prediction of Major Adverse Cardiac Events in Patients with Non-ST-Segment Elevation Myocardial Infarction.

N-terminal pro-brain natriuretic peptide (NT-proBNP) is a well-known biomarker for the diagnosis and prognosis of heart failure, and is directly associated with myocardial dysfunction. We evaluated the prognostic value of NT-proBNP for major adverse cardiac events (MACEs) among patients with non-ST-segment elevation myocardial infarction (NSTEMI) from the Korea Acute Myocardial Infarction Registry during their mid-term follow-up period. In this paper, we analyzed NT-proBNP according to various MACE and level of NT-proBNP. We used multivariate logistic regression to determine the risk factors according to MACE type and NT-proBNP levels, and to identify the cutoff value for each MACE by using the receiver operating characteristic (ROC) curve. NT-proBNP was a significant variable among cardiac deaths (p = 0.016), myocardial infarction (p = 0.000), and coronary artery bypass grafting (CABG) (p = 0.000) in patients with MACE compared with those without MACE. Two-vessel coronary artery disease (CAD) (p = 0.037) and the maximum creatinine kinase (max-CK) (p = 0.031) produced significant results in repeat percutaneous coronary intervention. The area under the ROC curve was found to be statistically significant for cardiac death and CABG. NT-proBNP is a useful predictor for 12-month MACEs among patients with NSTEMI and in those with heart failure. We propose that a new index incorporating NT-proBNP, max-CK, and CAD vessel will be useful as a prognostic indicator of MACEs in the future.

Effects of statin therapy on clinical outcomes after acute myocardial infarction in patients with advanced renal dysfunction: A propensity score-matched analysis.

ObjectiveLipid lowering therapy is widely used for the prevention of cardiovascular complications after acute myocardial infarction (AMI). However, some studies show that this benefit is uncertain in patients with renal dysfunction, and the role of statins is based on the severity of renal dysfunction. In this study, we investigated the impact of statin therapy on major adverse cardiac events (MACEs) and all-cause mortality in patients with advanced renal dysfunction undergoing percutaneous coronary intervention (PCI) after AMI.MethodsThis study was based on the Korea Acute Myocardial Infarction Registry database. We included 861 patients with advanced renal dysfunction from among 33,205 patients who underwent PCI after AMI between November 2005 and July 2012. Patients were divided into two groups: a statin group (n = 537) and a no-statin group (n = 324). We investigated the 12-month MACEs (cardiac death, myocardial infarction, repeated PCI or coronary artery bypass grafting) and all-cause mortality of each group. Subsequently, a propensity score-matched analysis was performed.ResultsIn the total population studied, no significant differences were observed between the two groups with respect to the rate of recurrent MI, repeated PCI, coronary artery bypass grafting (CABG), or all-cause mortality. However, the cardiac death rate was significantly lower in the statin group (p = 0.009). Propensity score-matched analysis yielded 274 pairs demonstrating, results similar to those obtained from the total population. However, there was no significant difference in the cardiac death rate in the propensity score-matched population (p = 0.103). Cox-regression analysis revealed only left ventricular ejection fraction to be an independent predictor of 12-month MACEs (Hazard ratio [HR] of 0.979, 95% confidence interval [CI], 0962–0.996, p = 0.018).ConclusionsStatin therapy was not significantly associated with a reduction in the 12-month MACEs or all-cause mortality in patients with advanced renal dysfunction undergoing PCI after AMI.

Efficacy of a seal-wing paclitaxel-eluting balloon catheters in the treatment of bare metal stent restenosis

BackgroundOur study aimed to compare the efficacy of seal-wing paclitaxel-eluting balloon catheters (PEB) with iopromide-coated PEB and everolimus-eluting stents (EES) for treating bare metal stent restenosis (BMS-ISR).MethodsWe enrolled 64 patients with 69 BMS-ISR. The control group comprised patients from the iopromide-PEB and EES arms of a previous TIS study. The primary end-point was 12-month in-segment late lumen loss (LLL). Secondary end-points included incidence of binary in-stent restenosis and 12-month major adverse cardiac events (MACE).ResultsCompared to iopromide-coated PEB, seal-wing PEB was associated with significantly higher 12-month LLL (0.30 vs. 0.02 mm; p < 0.0001), repeated binary restenosis (28.12% vs. 8.7%; p = 0.012), 12-month MACE (26.98% vs. 10.29%; p = 0.003), and target vessel revascularization (TVR; 20.63% vs. 7.35%; p = 0.009).Compared to EES, no significant differences were found in the 12-month LLL (0.30 vs. 0.19 mm; p = 1.000), repeated binary restenosis (28.12% vs. 19.12%; p = 0.666), 12-month MACE (26.98% vs. 19.12%; p = 0.102) or TVR (20.63% vs. 16.18%; p = 0.360).ConclusionBMS-ISR treatment using seal-wing PEB led to significantly higher 12-month LLL, repeated binary restenosis, MACE, and TVR compared to iopromide-coated PEB. However, no significant differences were found in comparison with EES.Trial registrationClinicalTrials.gov; NCT01735825

Polymer-free sirolimus-eluting stents in a large-scale all-comers population

ObjectiveThe objective of this study was to assess the safety and efficacy of a polymer-free sirolimus coated, ultrathin strut drug-eluting stent (PF-SES) in an unselected patient population with a focus...

TCTAP A-014 Optimal Timing of Invasive Strategy in Stable Non-ST-segment Elevation Myocardial Infarction: Impact of Immediate Intervention

Background: The optimal timing of intervention in non-ST-elevation myocardial infarction (NSTEMI) remains controversial. We sought to assess impact of immediate percutaneous coronary intervention (PCI) for NSTEMI. Methods: 6,134 NSTEMI patients undergoing PCI from the Korea Acute Myocardial Infarction Registry were divided into group 1 (immediate PCI within 4 h, n = 1,132) and group 2 (deferred PCI after 4 h, n = 5,002). Patients with recurrent or refractory ischemia, systolic blood pressure Results: In all patients and propensity-matched cohort (n = 1,131 in each group), group 1 had higher peak troponin level, higher rate of pre-PCI Thrombolysis In Myocardial Infarction (TIMI) grade 0 or 1, higher use of glycoprotein IIb/IIIa inhibitor, and lower use of unfractionated heparin and nitrates. In all patients, 12-month rates of MI and death/MI were higher in group 1. No differences were observed in 12-month death and major adverse cardiac events (MACE: composite of death, MI, target-vessel revascularization, and coronary artery bypass graft surgery). In the propensity-matched cohort, no significant differences were observed in 12-month rates of death, MI, death/MI or MACE. However, group 1 had less major bleeding (0.8% vs. 3.0%, p = 0.024) and shorter hospital stay. In the propensity-matched cohort, the effect of PCI on 12-month outcome showed a U-shaped relationship with time to PCI: rates of MI and death/MI (≤4 h, 4-12 h, 12-24 h, 24-72 h, >72 h after arrival) were 2.7%, 1.3%, 1.1%, 1.9%, 2.2% and 6.5%, 4.2%, 3.9%, 5.2%, 6.1%, respectively. PCI 4-12 h and 12-24 h after arrival was associated with lower risk of 12-month MI (hazard ratio [HR]: 0.49, 95% confidence interval [CI]: 0.25 to 0.93, p = 0.03 and HR: 0.40, 95% CI: 0.22 to 0.72, p = 0.002) and death/MI (HR: 0.64, 95% CI: 0.44 to 0.93, p = 0.02 and HR: 0.60, 95% CI: 0.43 to 0.84, p = 0.003), respectively. Conclusions: Immediate PCI for stable NSTEMI did not confer an advantage with respect to hard clinical endpoints at 12 months. PCI within 4-24 h after arrival was associated with lower risk of adverse events.

Prognostic values of 4 risk scores in Chinese patients with chest pain

Four risk scores for stratifying patients with chest pain presenting to emergency departments (EDs) (namely Thrombolysis in myocardial infarction [TIMI], Global registry for acute coronary events [GRACE], Banach and HEART) have been developed in Western settings but have never been compared and validated in Chinese patients. We aimed to find out to the number of MACE within 7 days, 30 days, and 6 months after initial ED presentation, and also to compare the prognostic performance of these scores in Chinese patients with suspected cardiac chest pain (CCP) to predict 7-day, 30-day, and 6-month major adverse cardiac events (MACE).A prospective 2-center observational cohort study of consecutive patients presenting with chest pain to the EDs of 2 university hospitals in Guangdong and Hong Kong from 17 March 2012 to 14 August 2013 was conducted. Patients aged ≥18 years with suspected CCP but without ST-segment elevation myocardial infarction (STEMI) were recruited.Of 833 enrolled patients (mean age 65.1 years, SD14.5; 55.6% males), 121 (14.5%) experienced MACE within 6 months (4.8% with safety outcomes and 10.3% with effectiveness outcomes). The HEART score had the largest area under the receiver operating characteristic (ROC) curve for predicting MACE at 7-day, 30-day, and 6-month follow-up [area under curve (AUC) = 0.731, 0.726, and 0.747, respectively. The HEART score also had the largest AUC for predicting effectiveness outcome (AUC = 0.715, 0.704, and 0.721, respectively). However, there was no significant difference in AUC between HEART and TIMI scores. Banach had the largest AUC for predicting safety outcome (AUC = 0.856, 0.837, and 0.850, respectively).The HEART score performed better than the GRACE and Banach scores to predict total MACE and effectiveness outcome in Chinese patients with suspected CCP, whereas the Banach score best predicted safety outcomes.

β-blocker dosage and outcomes after acute coronary syndrome

Although β-blockers increase survival in acute coronary syndrome (ACS) patients, the doses used in trials were higher than doses used in practice, and recent data do not support an advantage of higher doses. We hypothesized that rates of major adverse cardiac events (MACE), all-cause death, myocardial infarction, and stroke are equivalent for patients on low-dose and high-dose β-blocker. Patients admitted to Intermountain Healthcare with ACS and diagnosed with ≥70% coronary stenosis between 1994 and 2013 were studied (N = 7,834). We classified low dose as ≤25% and high dose as ≥50% of an equivalent daily dose of 200 mg of metoprolol. Multivariate analyses were used to test association between low-dose versus high-dose β-blocker dosage and MACE at 0-6 months and 6-24 months. A total of 5,287 ACS subjects were discharged on β-blockers (87% low dose, 12% high dose, and 1% intermediate dose). The 6-month MACE outcomes rates for the β-blocker dosage (low versus high) were not equivalent (P = .18) (hazard ratio [HR] = 0.76; 95% CI, 0.52-1.10). However, subjects on low-dose β-blocker therapy did have a significantly decreased risk of myocardial infarction for 0-6 months (HR = 0.53; 95% CI, 0.33-0.86). The rates of MACE events during the 6-24 months after presentation with ACS were equivalent for the 2 doses (P = .009; HR = 1.03 [95% CI, 0.70-1.50]). In ACS patients, rates of MACE for high-dose and low-dose β-blocker doses are similar. These findings question the importance of achieving a high dose of β-blocker in ACS patients and highlight the need for further investigation of this clinical question.

Clinical impact of immediate invasive strategy in patients with non-ST-segment elevation myocardial infarction

BackgroundImmediate invasive approach for non-ST-segment elevation myocardial infarction (NSTEMI) may permit treatment of the underlying plaque rupture as early as possible with subsequent reduction of death and myocardial infarction (MI). We sought to assess clinical impact of immediate percutaneous coronary intervention (PCI) for NSTEMI. MethodsA total of 6134 NSTEMI patients undergoing PCI from the Korea Acute Myocardial Infarction Registry were divided into group 1 (immediate PCI within 4h, n=1132) and group 2 (non-immediate PCI after 4h, n=5002). Propensity-matched 12-month clinical outcome was compared. ResultsIn all patients and propensity-matched cohort (n=1131 in each group), group 1 had higher peak troponin level, higher rate of pre-PCI Thrombolysis In Myocardial Infarction (TIMI) grade 0 or 1, higher use of glycoprotein IIb/IIIa inhibitor, and lower use of unfractionated heparin and nitrates. In all patients, 12-month rates of MI and death/MI were higher in group 1. No differences were observed in 12-month death and major adverse cardiac events (MACE: composite of death, MI, target-vessel revascularization, and coronary artery bypass graft surgery). In propensity-matched cohort, no significant differences were observed in 12-month rates of death, MI, death/MI or MACE. However, group 1 had less major bleeding (0.8% vs. 3.0%, p=0.024) and shorter hospital stay. ConclusionsImmediate PCI for patients with NSTEMI was associated with lower pre-PCI culprit vessel patency and not with improved 12-month clinical outcome.

Results From the International Drug Coated Balloon Registry for the Treatment of Bifurcations. Can a Bifurcation Be Treated Without Stents?

This observational study assessed the 9-month clinical outcomes in patients with coronary bifurcation lesions suitable for drug-coated balloon (DCB) angioplasty. It was the intention to use DCB's without additional stenting (DCB-only strategy) in selected patients for this chosen strategy. Bail-out main branch (MB) and/or side branch (SB) stenting, however, were permissible when flow limiting dissections or excessive recoil occurred. A multitude of interventional strategies have been studied to treat bifurcation lesions. With the availability of DCB angioplasty, investigators have been using this interventional tool with the optional implantation of bare metal stents (BMS). This study is an international, prospective, multicenter registry enrolling patients with coronary bifurcation lesions including a side branch ≥2 mm in diameter. Patients with stable angina and documented ischemia or selected forms of unstable angina due to a culprit bifurcation lesion of any Medina classification type were recruited. The primary endpoint was clinically driven target-lesion revascularization (TLR) at 9 months. Secondary endpoints included 9-month major adverse cardiac events (death, myocardial infarction, or TLR), technical success, in-hospital outcomes and vessel thrombosis rates. A total 127 patients 66.1 ± 10.1 years of age were enrolled. Demographic characteristics were 80.3% (102/127) male gender, 31.5% (40/127) diabetes, 91.3% (116/127) hypertension, 7.1% (9/127) ST-elevation myocardial infarction (STEMI), and 9.4% (12/127) non ST-elevation myocardial infarction (NSTEMI). The 130 lesions were treated with 184 DCB's and 64 BMS. In 53.8% (70/130) of all lesions the DCB-only strategy could be used while 34.6% (45/130) of lesions had at least 1 stent (BMS) in the main branch, 8.5% (11/130) had at least 1 stent in the side branch and 3.1% (4/130) needed at least 1 stent in the main and side branch. 94.5% patients (121/127) were available for follow-up after 9.8 ± 2.0 months. The TLR rate was 4.6% in the absence of any thrombotic events in the treated vessels whereas the 9-month MACE rate was 6.2%. This observational study suggests that the DCB-only strategy is safe and effective to treat selected bifurcations while benefiting from a shortened dual antiplatelet therapy (DAPT).

Roles of High-Density Lipoprotein Cholesterol in Patients With Acute Myocardial Infarction.

Many observational studies showed hogh-density lipoprotein cholesterol (HDL-C) is a strong inverse predictor of cardiovascular (CV) outcome. However, recent large clinical trials evaluating therapies to raise HDL-C level in those already on statin therapy have been discouraging. This complexity is not well-known.A total of 28,357 acute myocardial infarction (AMI) patients were enrolled in the Korea Acute Myocardial Infarction Registry (KAMIR), which was a prospective, multicenter, nationwide, web-based database of AMI in Korea. From this registry, we evaluated 3574 patients with AMI who have follow-up HDL-C level to investigate its association with clinical outcomes. The primary endpoint was the relationship between follow-up change in HDL-C and a 12-month composite of major adverse cardiac events (MACEs).Patients with initial HDL-C ≥ 40 mg/dL showed significantly lower rates of 12-month MACEs, especially cardiac and all-cause mortalities (P < 0.001). When patients were stratified into 4 groups according to the change of HDL-C, patients with decreasing HDL-C showed significantly higher rates of 12-month MACEs as comparable with patients with increasing HLD-C. A multivariate analysis indicated that HDL-C level was a significant predictor of CV events (hazard ratio, 1.38; 95% confidence interval, 1.12–1.71) after correcting for confounding variables.The follow-up change in HDL-C level was significantly related with CV outcomes in patients with AMI.