Acute Coronary Disease Research Articles

Prasugrel versus ticagrelor nas síndromes coronárias agudas

Acute coronary syndromes are common situations in medical practice, with high morbidity and mortality. Consequent to its relevance, its clinical management has always been subject of discussion and controversy. Since the past decade, the dual antiplatelet regimen has been the main therapeutic option used in its passivation, whereas percutaneous interventions have become the most common therapeutic option. Clopidogrel, the drug initially used in combination with aspirin, is effective and safe; however, it has disadvantages that led to the development of a new generation of more efficient antiplatelet drugs, such as prasugrel and ticagrelor. In large comparative clinical trials, these two drugs proved superior to clopidogrel in reducing major combined cardiac events. Hence the main guidelines currently support the two new agents, which are considered first-line drugs. Due to the clear differences between the protocols of clinical trials corroborating their inclusion in clinical practice, it is not possible to make direct comparison without the risk of generating hasty impressions. More recently, a large prospective, randomized clinical trial provided an appropriate head-to-head comparison between prasugrel and ticagrelor in cases of acute coronary disease, in a population submitted to invasive treatment. The study demonstrated a significant advantage of prasugrel. In this review, we discuss the primary details of these more contemporary drugs and the most relevant clinical trials related to them, identifying the advantages and disadvantages of each agent. At the end, we state our view on their current prescription.

Trimethyllysine, vascular risk factors and outcome in acute ischemic stroke (MARK-STROKE).

Trimethyllysine (TML) is involved in the generation of the pro-atherogenic metabolite trimethylamine-N-oxide (TMAO) by gut microbiota. In clinical studies, elevated TML levels predicted major adverse cardiovascular events (MACE) in patients with acute or stable coronary artery disease (CAD). In contrast to cardiovascular patients, the role of TML in patients with acute cerebral ischemia is unknown. Here, we evaluated circulating TML levels in 374 stroke patients from the prospective biomarkers in stroke (MARK-STROKE) study. Compared with 167 matched healthy controls, acute ischemic stroke patients had lower median TML plasma concentrations, i.e. 0.71 vs. 0.47µmol/L (p < 0.001) and this difference persisted after adjusting for age and sex. TML plasma concentrations were associated with age, serum creatinine, glucose, cholesterol and lysine. Patients with prevalent arterial hypertension, atrial fibrillation or a history of myocardial infarction had increased TML levels, but this observation was not independent of age, sex and GFR. In 274 patients, follow-up data were available. During a median follow-up of 284 [25th-75th percentile: 198, 431] days, TML was not associated with incident MACE (stroke, myocardial infarction, death). In summary, our data suggests a different role of TML in acute ischemic stroke compared with CAD patients.

A machine learning approach to predict healthcare-associated infections at intensive care unit admission: findings from the SPIN-UTI project

Identifying patients at higher risk of healthcare-associated infections (HAIs) in intensive care units (ICUs) represents a major challenge for public health. Machine learning could improve patient risk stratification and lead to targeted infection prevention and control interventions. To evaluate the performance of the Simplified Acute Physiology Score (SAPS) II for HAI risk prediction in ICUs, using both traditional statistical and machine learning approaches. Data for 7827 patients from the 'Italian Nosocomial Infections Surveillance in Intensive Care Units' project were used in this study. The Support Vector Machines (SVM) algorithm was applied to classify patients according to sex, patient origin, non-surgical treatment for acute coronary disease, surgical intervention, SAPS II at admission, presence of invasive devices, trauma, impaired immunity, and antibiotic therapy in 48 h preceding ICU admission. The performance of SAPS II for predicting HAI risk provides a receiver operating characteristic curve with an area under the curve of 0.612 (P<0.001) and accuracy of 56%. Considering SAPS II along with other characteristics at ICU admission, the SVM classifier was found to have accuracy of 88% and an AUC of 0.90 (P<0.001) for the test set. The predictive ability was lower when considering the same SVM model but with the SAPS II variable removed (accuracy 78%, AUC 0.66). This study suggested that the SVM model is a useful tool for early prediction of patients at higher risk of HAIs at ICU admission.

Early Prediction of Seven-Day Mortality in Intensive Care Unit Using a Machine Learning Model: Results from the SPIN-UTI Project.

Patients in intensive care units (ICUs) were at higher risk of worsen prognosis and mortality. Here, we aimed to evaluate the ability of the Simplified Acute Physiology Score (SAPS II) to predict the risk of 7-day mortality, and to test a machine learning algorithm which combines the SAPS II with additional patients’ characteristics at ICU admission. We used data from the “Italian Nosocomial Infections Surveillance in Intensive Care Units” network. Support Vector Machines (SVM) algorithm was used to classify 3782 patients according to sex, patient’s origin, type of ICU admission, non-surgical treatment for acute coronary disease, surgical intervention, SAPS II, presence of invasive devices, trauma, impaired immunity, antibiotic therapy and onset of HAI. The accuracy of SAPS II for predicting patients who died from those who did not was 69.3%, with an Area Under the Curve (AUC) of 0.678. Using the SVM algorithm, instead, we achieved an accuracy of 83.5% and AUC of 0.896. Notably, SAPS II was the variable that weighted more on the model and its removal resulted in an AUC of 0.653 and an accuracy of 68.4%. Overall, these findings suggest the present SVM model as a useful tool to early predict patients at higher risk of death at ICU admission.

Percutaneous coronary intervention in acute unprotected left main coronary artery disease: Provisional strategy or two-stent technique?

Background: Primary percutaneous coronary intervention in acute unprotected left main coronary artery disease, however, tends to be a complex procedure as it lasts longer, requires more expertise, and frequently involves critical bifurcation and often results in more than one stent. Here we present a retrospective analysis of a specific group of patients treated with percutaneous coronary intervention in our center. Methods: Retrospectively 55 patients with unprotected left main coronary artery lesions and acute coronary syndrome diagnosis treated with per cutaneous coronary intervention were identified: The two-stent technique was applied in 28 cases, and provisional stenting (PS) was applied in 27 cases. Results: Current smoking (82.1% vs. 48.1%, p=0.007), prior myocardial infarction (35.7% vs. 7.4%, p=0.010) and prior coronary stent implantation history (28.6% vs. 3.7%, p=0.012) were more common in the two-stent technique group. While procedure duration was higher in the two-stent technique group compared to PS (58.21 vs. 33.15, p<0.001), door-balloon time was lower (29.7 vs. 42.1, p=0.006). However, creatinine levels 48-72 hours post-procedure (1.08 vs. 1.33, p=0.422) and in-hospital mortality rates were similar between the two groups (28.6% vs. 14.8%, p=0.229). Conclusion: In the treatment of acute unprotected left main coronary artery with percutaneous coronary intervention, two-stent technique is a viable, effective and safe strategy as it has similar contrast-induced nephropathy and mortality rates compared to provisional strategy.

Comparative cardiotoxicity of the novel hormonal agents abiraterone and enzalutamide in metastatic castration-resistant prostate cancer using real-world data.

62 Background: Novel hormonal agents (NHAs) such abiraterone (ABI) and enzalutamide (ENZA) have demonstrated similar survival benefits against placebo groups in their respective clinical trials leading to their regulatory approval in both the pre- and post-chemotherapy settings in metastatic castration-resistant prostate cancer (mCRPC). Despite the overall tolerable risk profile, certain signals of cardiovascular toxicity were reported for these agents in clinical trials but little is known about their incidence in clinical practice. The objective was to assess the comparative cardiovascular safety of ABI and ENZA in patients with mCRPC in the real-world. Methods: A retrospective population-based cohort was extracted from Quebec public healthcare administrative databases. Patients were selected on the basis of having received androgen deprivation therapy prior to initiating a novel hormonal agent (ABI or ENZA) between 2012 and 2016. The primary outcome of interest was cardiovascular-related hospitalization (composite outcome that included acute coronary disease, cerebrovascular disease, heart failure, arrhythmia and other cardiovascular causes). Inverse probability of treatment weighting (IPTW) with the propensity score was used to adjust for measured baseline confounders including pre-existing cardiovascular disease. Results: The cohort comprises 2,183 patients, with 1,773 (81.2%) in the ABI group and 410 (18.8%) in the ENZA group. Before IPTW, mean age of the ENZA group was higher than the ABI group (78 vs 76). There were more ENZA patients with pre-existing arrythmia (ABI: 10.7%, ENZA: 15.1%) and diabetes (ABI: 21.5%, ENZA: 25.1%). Crude incidence rates of cardiovascular-related hospitalization were of 10 events per 100 person-years (PYs) and of 7 events per 100 PYs for the ABI and ENZA groups, respectively. After applying IPTW, all baseline variables were well balanced across both groups with standardized differences &lt; 0.05. The ABI group was at greater risk of cardiovascular-related hospitalization compared to the ENZA group (IPTW-hazard ratio (HR): 1.79, 95% confidence interval (95%CI): 1.04-3.09). The risk of hospitalization for heart failure was greater in ABI (IPTW-HR: 3.02, 95%CI: 1.17-7.78). Conclusions: In our study population, there was a greater risk of cardiovascular-related hospitalizations for ABI users relative to ENZA users, in particular for hospitalization for heart failure. Given the lack of evidence from randomized head-to-head comparisons of both agents, these results provide clinicians with additional insight on the cardiovascular risks of mCRPC patients treated with NHAs in the real-world and further large studies are required to corroborate these findings.

Coronary, aortic and carotid artery inflammation by 18F-fluorodeoxyglucose positron emission tomography in acute and chronic coronary artery disease

Abstract Funding Acknowledgements Type of funding sources: None. Background 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) can detect arterial inflammation in individuals with atherosclerosis, but the associations among different vascular territories for 18F-FDG uptake are not known. Purpose We explored any possible correlation between arterial inflammation quantified by 18F-FDG PET in the aorta, carotid arteries, and coronary arteries in patients presenting with acute coronary syndrome (ACS), or chronic coronary artery disease (CAD). Methods Prospectively, we performed hybrid computed tomography angiography and 18F-FDG PET in 43 patients (26 ACS and 17 chronic CAD) at 6.6 ± 5.7 days following invasive coronary angiography. 18F-FDG PET was performed 90 minutes after injection of 302.2 ± 28.4 MBq 18F-FDG. Arterial 18F-FDG uptake was measured in the thoracic aorta, carotid arteries, and coronary arteries, and expressed as the target-to-background ratio (TBR; the ratio between arterial maximal standardized uptake value normalized to blood pool mean standardized uptake value) in the whole artery, and in the most diseased segment (MDS). Results Mean age was 64.9 ± 9.1 years, 90.7% males. The whole artery 18F-FDG uptake was higher in the aorta than in the carotid arteries (median TBR 2.23, interquartile range [0.36] vs. 1.88 [0.42], p &amp;lt; 0.001); whereas uptake in the coronary arteries was lower than in the aorta or carotid arteries (1.13 [0.23], p &amp;lt; 0.001 both). Similarly, 18F-FDG uptake in the aortic MDS was higher than in the carotid MDS (2.75 [0.62] vs. 2.25 [0.63], p &amp;lt; 0.001); whereas 18F-FDG uptake in the coronary MDS was the lowest (1.40 [0.33], p &amp;lt; 0.001 both). These findings were consistent in both ACS and chronic CAD patients. The whole artery 18F-FDG uptake of the aorta and carotid arteries correlated in patients with ACS (r = 0.58, p = 0.002), but not in patients with chronic CAD (r = 0.21, p = 0.3). There was no correlation between the whole artery 18F-FDG uptake in the coronary arteries and either the aorta or carotid arteries in the whole cohort (r=-0.16, p = 0.2, r = 0.01, p = 0.9, respectively), in patients with ACS (r = 0.06, p = 0.7, r=-0.01, p = 0.9, respectively), or in those with chronic CAD (r=-0.4, p = 0.1, r=-0.09, p = 0.7, respectively). Conclusions In patients with ACS or chronic CAD, large arteries had higher 18F-FDG uptake than the coronary arteries. The intensity of 18F-FDG uptake in the coronary arteries did not correlate with that in the carotid arteries or the aorta, indicating that disease activity differs between large arteries and coronary arteries.

Long-Term Antithrombotic Therapy and Clinical Outcomes in Patients with Acute Coronary Syndrome and Renal Impairment: Insights from EPICOR and EPICOR Asia.

BackgroundInformation is lacking on long-term management of patients with acute coronary syndrome (ACS) and chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m2).ObjectivesOur objectives were to describe antithrombotic management patterns and outcomes in patients with ACS with varying renal function from the EPICOR (long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients; NCT01171404) and EPICOR Asia (NCT01361386) studies.MethodsEPICOR and EPICOR Asia were prospective observational studies of patients who survived hospitalization for ACS and were enrolled at discharge in 28 countries across Europe, Latin America, and Asia. The studies were conducted from 2010 to 2013 and from 2011 to 2014, respectively. This analysis evaluated patient characteristics and oral antithrombotic management patterns and outcomes up to 2 years post-discharge according to admission eGFR: ≥ 90, 60–89, 30–59, or < 30 mL/min/1.73 m2.ResultsAmong 22,380 patients with available data, eGFR < 60 mL/min/1.73 m2 was observed in 16.7%. Patients with poorer renal function were older, were at greater cardiovascular risk, and had more prior cardiovascular disease and bleeding. Patients with CKD underwent fewer cardiovascular interventions and had more in-hospital cardiovascular and bleeding events. Dual antiplatelet therapy was less likely at discharge in patients with eGFR < 30 (82.3%) than in those with ≥ 90 (91.3%) mL/min/1.73 m2 and declined more sharply during follow-up in patients with low eGFR (p < 0.0001). An adjusted proportional hazards model showed that patients with lower eGFR levels had a higher risk of cardiovascular events and bleeding.ConclusionsThe presence of CKD in patients with ACS was associated with less aggressive cardiovascular management and an increased risk of cardiovascular events.Supplementary informationThe online version of this article (10.1007/s40256-020-00447-5) contains supplementary material, which is available to authorized users.

Prognostic significance of diastolic blood pressure in patients with heart failure with preserved ejection fraction

Although systolic blood pressure (SBP) is routinely considered when treating acute heart failure (HF), diastolic blood pressure (DBP) is hardly been assessed in the situation. There are no previous studies regarding the predictive value of DBP in elderly patients with HF with preserved ejection fraction (HFpEF) in Japan. This study aimed to investigate the prognostic significance of DBP in patients with acute decompensated HFpEF. We analyzed data of all HFpEF patients admitted to Shinonoi General Hospital for HF treatment between July 2016 and December 2018. We excluded patients with acute coronary syndrome and severe valvular disease. Patients were divided into two groups according to their median DBP; the low DBP group (DBP ≤ 77 mmHg, n = 106) and the high DBP group (DBP > 77 mmHg, n = 100). The primary outcome was HF readmission. In 206 enrolled patients (median 86 years), during a median follow-up of 302 days, the primary outcome occurred in 48 patients. The incidence of HF readmission was significantly higher in the low DBP group (33.0% vs 18.5%, p = 0.024). In Kaplan–Meier analysis, low DBP predicted HF readmission (Log-rank test, p = 0.013). In Cox proportional hazard analysis, low DBP was an independent predictor of HF readmission after adjustment for age, sex, SBP, hemoglobin, serum albumin, serum creatinine, B-type natriuretic peptide, renin-angiotensin system inhibitors, calcium channel blockers, left ventricular ejection fraction, coronary artery disease, and whether they live alone (hazard ratio, 2.229; 95% confidence interval, 1.021–4.867; p = 0.044). Low DBP predicted HF readmission in patients with HFpEF.

Complex Percutaneous Coronary Intervention Salvages a Patient with Recurrent Acute Coronary Syndrome and Ischaemic Heart Failure with Multiple Life Threatening Co-morbidities: A Case Report

More than 422 million people are suffering from Diabetes Mellitus (DM) worldwide. Majority of the affected population resides in lower and middle income countries. This chronic, metabolic disease gradually does serious damage to heart, blood vessels, eyes, kidneys and nerves; eventually causing cardiovascular diseases, peripheral vascular diseases, retinopathy, nephropathy and neuropathy. Here, a rare case of a 58-year-old male was present who had history of uncontrolled DM with dry gangrene in right forefoot, acute kidney injury and Coronary Artery Disease (CAD) involving Left Main (LM) bifurcation presented with recurrent acute coronary syndrome with heart failure. Patient in view of multiple co-morbidities was unfit for Coronary Artery Bypass Grafting (CABG) was managed successfully with complex coronary intervention involving LM bifurcation.

Cardio-Cerebral Infarction Syndrome (CCIS): Definition, Diagnosis, Pathophysiology and Treatment

Acute ischemic stroke (AIS) and coronary artery disease are the major causes of death in Palestine and in the world. Ischemic stroke and acute coronary syndrome have similar vascular risk factors and may evolve as a complication of the respective other disease. The prevalence of coronary artery disease has been reported in one fifth of stroke patients. high incidence rate of acute myocardial infarction (AMI) after recent ischemic stroke and the high risk of acute ischemic stroke after recent myocardial infarction has been reported in several clinical or observational studies. Patients are at increased risk of ischemic stroke following recent myocardial infarction, and aggressive treatment of AMI, including use of reperfusion therapy, decreases the risk of AIS. For patients presenting with AIS in the setting of a recent MI, treatment with alteplase, an intravenous tissue plasminogen activator, can be given, but may be harmful in many conditions. It is important for clinicians to recognize that troponin elevations can occur in the setting of AIS as well as other clinical scenarios and that this may have implications for short- and long-term mortality. So that acute or recent problem in the heart or brain that could result in an acute infarction of the other. In this review we describe the definition and new classification of the cardio-cerebral infarction syndrome with 3 subtypes that reflect the definition, pathophysiology and treatment options.

Smoking, ulcerated coronary plaques, and smoker’s paradox: A new hypothesis

Smoking accelerates the onset of acute coronary disease. Smoker’s paradox is the term applied to the observations that the short-term prognosis following an acute myocardial infarction is better in the smoker than in the nonsmoker. Efforts to explain these surprising observations have not been successful. The approach used in this study was to compare the pathologic findings in the coronary arteries following a complete histologic examination of the major branches of the epicardial coronary tree in smokers and nonsmokers. I found many ulcerated plaques in both smokers and nonsmokers, often without associated luminal stenosis or luminal thrombosis. These ulcerated plaques were discovered only on histologic examination and were consistently associated with dense foci of adventitial inflammatory cells. Based on these findings, the following hypothesis is proposed: Smoking injures the coronary artery endothelium, causing erosions, ulcerations, and a chronic inflammatory response in the arterial adventitia. These ulcerated plaques persist as chronically active, open ulcerations, constantly exposed to flowing blood, leading to increasing luminal stenosis as long as smoking continues. These ulcerated plaques eventually form the substrate for occlusive thrombosis and acute coronary events and are components of active, progressive, inflammatory, atherosclerotic disease. Premature acute coronary disease in the young smoker is due to accelerated plaque ulceration, luminal stenosis, and occlusive thrombosis. Smoker’s paradox can be explained by rapid resolution and healing of these potentially unstable ulcerated plaques when the patient is required to stop smoking during hospitalization for the acute myocardial infarction event.

Study of trace elements (Serum Copper and Zinc) in patients of coronary artery diseases

Introduction: Previous studies suggest a protective role of the essential trace elements against cardiovascular disease, whereas wistful epidemiological data remains controversial. We aimed to investigate the alteration in concentration of zinc (Zn) and copper (Cu) in patients presented with coronary artery disease. Materials and Methods: In this case control study 100 normal healthy controls and 100 patients diagnosed with acute coronary artery diseases were enrolled. Serum copper and serum zinc concentration were measured in both the groups. Results and Observations: Serum copper concentration was significantly higher in patient of acute coronary artery disease (141.0±15.2) compared to controls (97.0±10.8). Serum zinc concentration was significantly lower in patient of acute coronary artery disease (70.0±8.8) compared to controls (100.0±13.2). And the ratio of serum Cu: Zn almost double in patient of acute coronary artery disease patients compared to normal healthy individuals. Conclusion: From the present study, it is concluded that decreased serum zinc and increased serum copper levels are associated with coronary artery disease. Moreover, results demonstrate that increased serum Cu: Zn ratio can diagnose occurrence of vascular events even in CAD patients. Keywords: Coronary artery disease, Serum copper, Serum zinc.

A study of Serum Soluble CD40 Ligand level and its correlation with serum CK-MB and lipid profile in patients with acutecoronary syndrome

Introduction: Coronary heart disease is an impairment of heart function due to inadequate blood flow to the heart. It is the most common cause of death worldwide. Serum sCD40L is an inflammatory marker. It is released from the platelets as soon as the onset of the chest pain. It is a strong predictor of cardio vascular risk factor. Objectives: To estimate Serum sCD40Ligand, Serum CK-MB, Serum Lipid Parameters, Serum LDH, and Serum AST levels in patients with ACS. Materials and Methods:Study group comprised of 50 subjects were admitted in ICCU with ACS. 50 healthy sex and age matched subjects were taken as control groups. Venous blood samples were collected. Serum Soluble CD40Ligand was estimated by ELISA technique, Serum CK-MB estimated by Immunoinhibition method, Serum Lipid profile by enzymatic assay methods. Serum LDH by DKGC method, Serum AST by Modified IFCC method. Results:There was significant increase in Serum sCD40L(psignificant decrease in the Sr. HDL-C levels in the ACS patients compared to control group. There was no significant change in Sr. LDH levels and Sr. AST levels in ACS patients compared to control group. There was a significant positive correlation between Serum sCD40L and Serum CK-MB, Serum TC, Serum TGL, Serum LDL-C, Serum VLDL and a negative correlation between Serum sCD40L and Serum HDL-C while no significant correlation was found between Serum sCD40L with Serum LDH and Serum AST levels. Conclusion:Serum sCD40L can be used as a marker in individuals with Acute Coronary Artery disease. Keywords: sCD40L, ACS, MI, CK-MB, Lipid Parameters

Aortic Aneurysm and Dissection in Pregnancy: Report of a Rare Case in a Marfan with Bicuspid Aortic Valve

Abstract Background Type A aortic dissection is an emergency with high morbidity and mortality when surgery is not performed. Few cases are described in the literature about aortic dissection during pregnancy. A correlation between pregnancy and aortic dissection is mainly reported in patients with family history and connective tissue disorders, such as Marfan’s syndrome (MS), Loeys–Dietz’s syndrome, and Ehlers–Danlos’s syndromes, and patients with bicuspid aortic valve (BAV); exceptional cases are also described in patients without risk factors. Case presentation A 22-year-old young woman with MS, ascending aorta dilation, and BAV became pregnant. During labor, she experienced a short-term chest pain with spontaneous resolution. The electrocardiogram (ECG) and cardiac biomarkers were negative for acute coronary artery disease, but no transthoracic echocardiogram (TTE) was performed. A caesarean section was performed without complications. After 1 month, a routine TTE showed a chronic ascending aortic dissection involving the aortic arch and supra-aortic vessels. Due to a normally functioning aortic valve, the David operation was performed (sparing aortic valve) with the replacement of the aortic arch and supra-aortic vessels. Conclusions Aortic dissection is a rare cardiovascular complication that can occur during pregnancy and is associated with very high-risk mortality. We have reported a rare case of undiagnosed type A aortic dissection involving the aortic arch during unplanned pregnancy in patients with BAV and MS, subsequently treated with the David surgery and replacement of ascending aortic arch and supra-aortic vessels. A closer clinical and instrumental follow-up is necessary in this particular group of patients at risk. Awareness of all physicians involved is mandatory.

PCV26 Budget IMPACT Analysis of Antiplatelet Therapy with Cangrelor in Patients with ACUTE Coronary Artery Disease Undergoing Percutaneous Coronary Intervention in Germany

Cangrelor is a novel, potent, intravenous, fast onset P2Y12 receptor antagonist that blocks adenosine diphosphate-induced platelet activation and aggregation. Co-administered with acetylsalicylic acid, it is indicated for reducing thrombotic cardiovascular events in patients with coronary artery disease (CAD) undergoing PCI who have not received an oral P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor) prior to PCI and in whom oral therapy is not feasible or desirable. Our purpose was to assess the economic consequences of incorporating cangrelor into the hospital formulary for the acute care of CAD patients undergoing PCI in Germany. A budget impact model (BIM) was developed. The 3-year pharmacological and clinical event costs of two hypothetical scenarios, without and with cangrelor for the primary PCI population in Germany were compared. Epidemiological, efficacy (stent thrombosis, myocardial infarction (MI), ischaemia-driven revascularization, death), safety (Thrombolysis in Myocardial Infarction (TIMI) bleeding criteria) and costs (€, 2019) data were based on clinical trials, meta-analyses and on German registries. Only the costs of pre-treatment (pre-loading) with oral P2Y12 inhibitors and bail-out with glycoprotein IIb-IIIa inhibitors (GPI) were considered. One-way sensitivity analysis established the effect of uncertainty on BIM results. The model assumes that the three-year primary PCI population is 240,539 (85% are STEMI patients). The uptake of cangrelor changes from 0.40% to 0.90% in the same period. Considering current antithrombotics use and PCI management costs in Germany, the three-year budget impact of adding cangrelor into the hospital formulary for the primary PCI population represents less than 5 hundred thousand €. Results are most sensible to GPI bail-out use. Under BIM assumptions, introducing cangrelor for the acute care of CAD patients undergoing primary PCI represents a consistently affordable option in Germany. Cangrelor is particularly valuable when oral pre-treatment and adequate control of thrombosis cannot be guaranteed.

Acute Coronary Disease in very Young Patient: A Reality!

Introduction Acute cardiovascular events such as acute myocardial infarction (AMI) are uncommon in young individuals. Additionally, it is known that different factors may be involved in the occurrence of AMI. Here, we report a case of acute myocardial infarction due to severe coronary lesion in a very young patient. […] Acute Coronary Disease in very Young Patient: A Reality!

Incidence and risk factors for major bleeding among patients undergoing percutaneous coronary intervention: findings from the Norwegian coronary stent trial (NORSTENT)

Abstract Introduction Bleeding is a concern after percutaneous coronary intervention (PCI) and subsequent dual antiplatelet therapy (DAPT). Purpose We herein report the incidence and risk factors for major bleeding in the Norwegian Coronary Stent Trial (NORSTENT). Materials and methods NORSTENT was a randomized, double blind, pragmatic randomized trial among patients with acute coronary syndrome or stable coronary disease undergoing PCI during 2008–11. The patients (N=9,013) were randomized to receive either a drug eluting stent or a bare metal stent, and were treated with at least 9 months of DAPT. The patients were followed for a median of five years, with BARC 3–5 major bleeding as one of the safety endpoints. We estimated cumulative incidence by a competing risks model and risk factors through cause-specific Cox models. Results The 12-month cumulative incidence of major bleeding was 2.3%. Independent risk factors for major bleeding were chronic kidney disease (CKD), underweight (&amp;lt;60 kilograms), diabetes mellitus, and advanced age (&amp;gt;80 years). A myocardial infarction (MI) or PCI during follow-up increased the risk of major bleeding (HR = 1.7, 95% CI 1–3-2.2). Conclusions The 12-month cumulative incidence of major bleeding in NORSTENT was higher than reported in previous, explanatory trials. This analysis strengthens the role of CKD, advanced age, and underweight as risk factors for major bleeding among patients receiving DAPT after PCI. The presence of diabetes mellitus or recurrent MI among patients is furthermore a signal of increased bleeding risk. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Northern Norway Regional Health Authority (Helse Nord RHF)

Edoxaban in atrial fibrillation with PCI by ACS or stable CAD presentation: a pre-specified analysis of the ENTRUST-AF PCI trial

Abstract Aim We aimed to compare the safety and efficacy of edoxaban in combination with P2Y12 inhibition in the setting of percutaneous coronary intervention (PCI) in patients with atrial fibrillation (AF) presenting with an acute coronary syndrome (ACS) or stable coronary artery disease (SCAD). Methods and results This is a pre-specified sub-analysis of the ENTRUST-AF PCI trial. Participants were randomly assigned 1:1 to an edoxaban or vitamin K antagonist (VKA) based strategy and randomisation was stratified by ACS (edoxaban n=388, vitamin K n=389) vs. SCAD (edoxaban n=363, vitamin K=366). Participants received edoxaban 60mg once daily plus a P2Y12 inhibitor for 12 months; or VKA in combination with a P2Y12 inhibitor and aspirin 100mg (for 1–12 months). The primary bleeding endpoint, a composite of International Society on Thrombosis and Haemostasis (ISTH) major or clinical relevant non-major bleeding, at 12 months occurred in 59 (18.52%/year) vs 79 (26.21%/year) ACS patients (Hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.591–1.018, P=0.0631), and in 69 (23.11%/year) vs 73 (25.02%/year) SCAD patients (HR 0.94, 95% CI 0.676–1.305, P=0.7082) with edoxaban and VKA based therapies, respectively (P for interaction [P-int]=0.2741). The main efficacy endpoint (composite of cardiovascular death, myocardial infarction, stroke, systemic embolism, or definite stent thrombosis) occurred in 33 (9.59%/year) vs 28 (8.21%/year) ACS-patients (HR 1.16, 95% CI 0.697–1.916) compared with 16 (4.84%/year) vs 18 (5.47%/year) SCAD-patients (HR 0.91, 95% CI 0.465–1.781) with edoxaban and VKA based therapy, respectively (P-int=0.5573). Conclusions An antithrombotic regimen consisting of edoxaban and a P2Y12-inhibitor without aspirin provides equal safety and similar efficacy for ischaemic events in patients with AF regardless of their clinical presentation with ACS or SCAD. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH

Platelet reactivity among patients with acute coronary syndromes and multivessel coronary artery disease

Abstract Background Patients with multivessel or complex coronary artery disease (CAD) are at increased risk of atherothrombotic events. It has been suggested that these patients may derive an incremental benefit with more intense antiplatelet strategies, according to prior subgroup analyses from randomized clinical trials. However, whether there is any association between the presence and extension of multivessel CAD and platelet aggregability (PA) in patients with acute coronary syndromes (ACS) is unknown. Purpose To analyze the independent association between PA and presence of multivessel CAD in patients with ACS. Methods Patients with ACS on dual antiplatelet therapy (aspirin plus clopidogrel) were included in this study. Multivessel CAD was defined as the presence of significant ≥50% stenosis at two or more major epicardic vessels. Platelet aggregability was assessed by VerifyNow P2Y12 assay expressed in P2Y12 Reactivity Units (PRU) on the day of discharge from the coronary care unit. High On-treatment platelet reactivity (HPR) was defined as PRU ≥208. Stepwise linear and logistic regression models were applied to adjust for confounders. Models were adjusted for: age, sex, race, diabetes, hypertension, smoking, dyslipidemia, prior MI, prior PCI, prior CABG, prior HF, prior stroke and ACS phenotype (STEMI vs. Non-ST-segment elevation ACS). Results A total of 237 patients were included, among whom 143 (60.3%) had multivessel CAD at the coronary angiogram and 175 (73.8%) were submitted to PCI during index hospitalization. Patients with multivessel disease were older (mean age 64.8±12.1 vs. 58.9±11.2 years; p&amp;lt;0.001) and more likely to have a history of diabetes (47.6% vs. 29.8%; p=0.006) and non-ST-segment elevation ACS as the index event (55.2% vs. 28.7%; p&amp;lt;0.001), compared to patients without multivessel CAD. After adjustments, presence of multivessel CAD was associated with higher PA (mean 161.4±74 PRU in patients with versus 140.3±70.9 PRU in patients without multivessel CAD; adjusted mean difference 23.7 PRU; 95% CI 4.8 to 42.5; p=0.014). Additionally, there was an incremental of 12.5 PRU (95% CI 2.8 to 22.3; adj p=0.012) for each diseased vessel and of 4.67 PRU (95% CI 0.11 to 9.22; adj p=0.045) for each diseased coronary segment. Compared to patients with single-vessel disease, patients with three-vessel disease had higher rates of HPR. (Figure). Conclusion In patients with ACS, the presence and extension of multivessel CAD were associated with higher levels of platelet aggregability and higher rates of high on-treatment platelet reactivity with clopidogrel. This finding may explain the incremental benefit with more intense antiplatelet therapies seen in this particular subgroup in prior clinical trials. Prevalence of HPR and extension of CAD Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Sao Paulo Research Foundation (FAPESP)