Controlled Abciximab And Device Investigation To Lower Late Angioplasty Complications Research Articles

Association between the number of Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria and clinical outcomes in patients with acute coronary syndrome

BackgroundAcademic Research Consortium for High Bleeding Risk (ARC-HBR) criteria have been used to identify high-risk patients undergoing percutaneous coronary intervention (PCI) in current clinical practice. This study aimed to evaluate the association between the number of ARC-HBR criteria and clinical outcomes in patients with acute coronary syndrome (ACS) after an emergent PCI. MethodsWe assessed 338 consecutive patients with ACS who underwent successful emergent PCI between January 2017 and December 2020. The ARC-HBR score was calculated by assigning 1 point to each major criterion and 0.5 points to each minor criterion. The patients were classified into low (ARC-HBR score<1), intermediate (1≤ARC-HBR score<2), and high (ARC-HBR score≥2) bleeding risk groups. We investigated the association between the ARC-HBR score and major adverse cardiovascular events (MACEs), defined as a composite of all-cause death, non-fatal myocardial infarction, and non-fatal stroke. We also compared the diagnostic ability of the ARC-HBR score and Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) risk score. ResultsThe mean age of the patients was 67.6±12.4years, and 78.4% were men. During the median follow-up of 864 (557–1309) days, 70 patients developed MACEs. Kaplan–Meier curves showed that the cumulative incidence of MACE was significantly higher as the ARC-HBR score increased in a stepwise manner (log-rank p<0.001). There were no significant differences in the area under the receiver operating characteristic curve (AUC) for predicting MACE within two years after an emergent PCI between the ARC-HBR and CADILLAC risk scores (AUC: 0.763 vs. 0.777). ConclusionsARC-HBR score was independently associated with an increased risk of MACE in patients with ACS after an emergent PCI. Moreover, it had a similar diagnostic ability for predicting MACE within two years compared to the CADILLAC risk score.

Comparison of Different Risk Scores for Prediction of In-Hospital Mortality in STEMI Patients Treated with PPCI.

Several risk scores have been developed to predict and analyze in-hospital mortality and short- and long-term outcomes of ST-elevation myocardial infarction (STEMI) patients after primary percutaneous coronary intervention (PPCI); these can classify patients as having a high or low risk of death or complications. To compare the prognostic precision of four risk scores for predicting in-hospital mortality in patients with STEMI treated with PPCI. We performed a retrospective cohort analysis of patients with STEMI who underwent PPCI between 2012 and 2019 (N = 1346). GRACE (Global Registry of Acute Cardiac Events), CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications), Zwolle, and TIMI (Thrombolysis in Myocardial Infarction) risk scores were calculated for each patient according to different variables. We evaluated the predictive accuracy of these scores for in-hospital mortality using the C statistic, which was obtained using logistic regression and receiver operating characteristic curves. The GRACE, CADILLAC, Zwolle, and TIMI risk scores all had good predictive precision for in-hospital mortality, with C statistics ranging from 0.842 to 0.923. The GRACE and CADILLAC risk scores were found to be superior. All GRACE, CADILLAC, Zwolle, and TIMI risk scores showed a high predictive value for in-hospital mortality due to all causes in patients with STEMI treated with PPCI. The GRACE and CADILLAC risk scores revealed a better accuracy for predicting in-hospital mortality than the Zwolle and TIMI risk scores.

Impact of CADILLAC and GRACE risk scores on short- and long-term clinical outcomes in patients with acute myocardial infarction

BackgroundRecent guidelines recommend risk stratification using objective scoring systems in patients with acute coronary syndrome. In this context, the CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) and GRACE (Global Registry of Acute Coronary Events) risk scores were both originally established to predict short-term mortality. However, their impact on short- and long-term clinical outcomes in a contemporary cohort of patients with acute myocardial infarction (MI) is unclear. MethodsThis bi-center registry included 809 patients with acute MI undergoing primary percutaneous coronary intervention. Patients were divided into three groups according to the pre-defined thresholds and tertiles of the CADILLAC and GRACE scores. The study endpoints included all-cause death and major adverse cardiovascular events (MACE) during the index hospitalization and after discharge. ResultsOf 809 patients, 323 (39.9%) and 255 (31.5%) had high CADILLAC and GRACE risk scores. During the index hospitalization, 61 (7.5%) patients died and 262 (32.4%) had MACE. Both CADILLAC and GRACE risk scores were associated with in-hospital mortality and MACE rates. After discharge, out of 683 patients with available follow-up information who survived to discharge, 42 (6.1%) died and 123 (18.0%) had MACE during the median follow-up period of 632 days. Significantly higher incidence of MACE in higher CADILLAC and GRACE risk scores was observed in a stepwise manner. ConclusionBoth CADILLAC and GRACE risk scores were predictive for short- and long-term mortality and MACE rates in a contemporary cohort of acute MI patients undergoing primary percutaneous coronary intervention.

P845Comparison of the performance of the five validated risk scores in acute myocardial infarction patients undergoing primary PCI

Abstract Background Several risk scores have been developed to predict mortality of patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (pPCI), with limited data on the comparative prognostic value of these models. Purpose We aimed to compare the prognostic value of five validated risk scores for in-hospital and one-year mortality of patients with AMI undergoing pPCI. ume catheterization laboratory in a period from January 2009 to December 2017, a total of 3868 consecutive patients who underwent pPCI were available for analysis. For each patient, the Thrombolysis In Myocardial Infarction (TIMI), Controlled Abciximab and Device Investigation to Lower Late Angioplasty complications (CADILLAC), ACTION Registry-GWTG in-hospital mortality risk score (ACTION), Age, Creatinine, and Ejection Fraction (ACEF), and ZWOLLE risk scores were calculated using required clinical and angiographic characteristics. In-hospital and one-year mortality were assessed (follow-up available for 92% of pts). Calibration and discrimination of the three risk models were evaluated by the Hosmer-Lemeshow (H-L) goodness-of-fit test and C-statistic, respectively. Results Mortality rates for in-hospital and one-year mortality were 1.8% and 6.9% respectively. All five scores showed good model calibration as assessed by the H-L test and very good discriminative power for in-hospital and one-year mortality as assessed by C-statistics (Table 1 &amp; Figure 1): Table 1 Risk score H-L H-L p AUC in-hospital 95% CI Significant p AUC one-year 95% CI Significant p ZWOLLE 1.3 0.7 0.90 0.89–0.91 vs. CADILLAC &lt;0.05 0.75 0.74–0.77 vs. TIMI &lt;0.005 ACTION 13.1 0.1 0.87 0.86–0.88 vs. TIMI &lt;0.005 0.79 0.77–0.80 CADILLAC 5.5 0.2 0.85 0.84–0.86 vs. TIMI &lt;0.01 0.81 0.80–0.83 vs. ZWOLLE &lt;0.000 vs. TIMI &lt;0.000 ACEF 9.9 0.3 0.814 0.83–0.85 0.80 0.78–0.81 vs. ZWOLLE &lt;0.000 vs. TIMI &lt;0.05 TIMI 7.1 0.3 0.79 0.78–0.80 0.76 0.75–0.78 Figure 1 Conclusion Risk stratification of patients with AMI undergoing pPCI using the ZWOLLE, ACTION, CADILLAC, ACEF or TIMI risk scores enables accurate identification of high-risk patients for in-hospital and one-year mortality in an all-comers population. Among evaluated scores, ZWOLLE model was better fitted for prediction of in-hospital mortality while CADILLAC and ACEF better predicted late events.

Risk Scoring System to Assess Outcomes in Patients Treated with Contemporary Guideline-Adherent Optimal Therapies after Acute Myocardial Infarction.

Background and ObjectivesA risk prediction is needed even in the contemporary era of acute myocardial infarction (AMI). We sought to develop a risk scoring specific for patients with AMI being treated with guideline-adherent optimal therapies, including percutaneous coronary intervention and all 5 medications (aspirin, thienopyridine, β-blocker, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and statin).MethodsFrom registries, 12,174 AMI patients were evaluated. The primary outcome was 1-year all-cause death or AMI. The Korea Working Group in Myocardial Infarction (KorMI) system was compared with the Assessment of Pexelizumab in Acute Myocardial Infarction (APEX AMI), Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC), and Global Registry of Acute Coronary Events scores (GRACE) models.ResultsTen predictors were identified: left ventricular dysfunction (hazard ratio [HR], 2.3), bare-metal stent (HR, 2.0), Killip class ≥II (HR, 1.9), renal insufficiency (HR, 1.8), previous stroke (HR, 1.6), regional wall-motion- score >20 on echocardiography (HR, 1.5), body mass index ≤24 kg/m2 (HR, 1.4), age ≥70 years (HR, 1.4), prior coronary heart disease (HR, 1.4), and diabetes (HR, 1.4). Compared with the previous models, the KorMI system had good discrimination (time-dependent C statistic, 0.759) and showed reasonable goodness-of-fit by Hosmer-Lemeshow test (p=0.84). Moreover, the continuous-net reclassification improvement varied from −27.3% to −19.1%, the integrated discrimination index varied from −2.1% to −0.9%, and the median improvement in risk score was from −1.0% to −0.4%.ConclusionsThe KorMI system would be a useful tool for predicting outcomes in survivors treated with guideline-adherent optimal therapies after AMI.

Association Between Intraprocedural Thrombotic Events and Adverse Outcomes After Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction (a Harmonizing Outcomes With RevasculariZatiON and Stents in Acute Myocardial Infarction [HORIZONS-AMI] Substudy)

The present study sought to determine the extent to which adverse angiographic events encountered during percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI) are associated with adverse clinical outcomes. Patients with STEMI represent a cohort at particularly high risk of intraprocedural thrombotic events (IPTEs). The overall frequency and implications of IPTEs occurring in patients with STEMI have not been systematically quantified in previous studies. A total of 3,163 patients undergoing primary percutaneous coronary intervention with stent implantation for STEMI in the Harmonizing Outcomes with RevasculariZatiON and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial underwent detailed frame-by-frame core laboratory angiographic analysis to assess IPTEs. The clinical outcomes at 30 days were compared between the patients with and without IPTEs. IPTEs, defined as the development of new or increasing thrombus, abrupt vessel closure, no reflow, slow reflow, and distal embolization at any point during the procedure, occurred in 386 patients (12.2%). The independent predictors of IPTE were thrombus at baseline, lesion length, and randomization to bivalirudin; the patients with IPTEs were also more likely to receive bailout glycoprotein IIb/IIIa inhibitors and unplanned thrombectomy. Compared with patients without IPTEs, the patients with IPTEs had higher 30-day rates of composite major adverse cardiovascular events (death, myocardial infarction, ischemic target vessel revascularization, and stroke; 7.8% vs 4.2%, p = 0.002), major bleeding not related to coronary artery bypass grafting (11.8% vs 6.5%, p <0.001), and all-cause death (4.2% vs 1.8%, p = 0.002). On multivariate analysis, IPTEs were independently associated with 30-day major adverse cardiovascular events, major bleeding, and death. In conclusion, the development of IPTEs in patients undergoing primary percutaneous coronary intervention for STEMI was associated with subsequent adverse outcomes, including major adverse cardiovascular events, major bleeding, and death. Additional studies of strategies to decrease the occurrence of IPTEs are warranted.

Risk score comparison of outcomes in patients presenting with ST-elevation myocardial infarction treated with percutaneous coronary intervention

Accurate risk stratification is important in the management of acute coronary syndrome (ACS) patients. Several risk scores have been developed to stratify patients hospitalized with ACS. To compare the prognostic value of three risk scores used to determine the risk for secondary events in patients diagnosed with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). A retrospective analysis of patients with an ACS experiencing a STEMI treated with PCI presenting to a Kaiser Permanente Foundation Hospital in Northern California from January 2007 to January 2008 (n=186). For each patient, the Thrombolysis in Myocardial Infarction (TIMI), Controlled Abciximab and Device Investigation to Lower Late Angioplasty complications (CADILLAC), and Global Registry for Acute Coronary events (GRACE) risk scores were calculated and predictive ability was analysed using the area under the curve or C statistic method. The CADILLAC, TIMI, and GRACE risk scores all had high predictive accuracy for a major cardiac event in hospital, with C statistics ranging from 0.63 to 0.718 with the CADILLAC risk score superior. For non-major cardiac events in hospital, the three risk scores were similar in accuracy for predictability, with C statistics ranging from 0.62 to 0.66. Risk stratification of patients with STEMI undergoing primary percutaneous coronary intervention can be done using all three risk scores. In our analysis, the CADILLAC and GRACE score was more predictive for major cardiac events in hospital and CADILLAC and TIMI for major cardiac events at 1 year.

Comparison of the Prognostic Predictive Value of the TIMI, PAMI, CADILLAC, and GRACE Risk Scores in STEACS Undergoing Primary or Rescue PCI

Introduction and objectivesWe sought to compare the predictive value of the Thrombolysis In Myocardial Infarction (TIMI), Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC), Primary Angioplasty in Myocardial Infarction (PAMI), and Global Registry for Acute Coronary Events (GRACE) scores for the outcome of ST-segment elevation acute coronary syndrome undergoing urgent percutaneous coronary intervention. MethodsWe performed a retrospective analysis of a cohort composed of all consecutive patients with ST-segment elevation acute coronary syndrome treated by urgent percutaneous coronary intervention between 2006 and 2010 (n=1503). TIMI, PAMI, CADILLAC, and GRACE risk scores were calculated for each patient according to different clinical variables. We assessed the predictive accuracy of these scores for death, reinfarction, and target-vessel revascularization at 30 days and 1 year, using the C statistic, which was obtained by means of logistic regression and ROC curves. ResultsThe TIMI, PAMI, CADILLAC and GRACE showed an excellent predictive value for 30-day and 1-year mortality (C statistic range, 0.8-0.9), with superiority of the TIMI, CADILLAC, and GRACE risk models. The performance of these 4 scores was poor for both reinfarction and target-vessel revascularization (C statistic, 0.5-0.6). ConclusionsThe TIMI, PAMI, CADILLAC, and GRACE scores provide excellent information to stratify the risk of mortality in patients treated by percutaneous coronary intervention. The TIMI, CADILLAC, and GRACE models have higher predictive accuracy. The usefulness of these models for reinfarction and target-vessel revascularization prediction is questionable.

Comparación del valor predictivo pronóstico de los scores TIMI, PAMI, CADILLAC y GRACE en el SCACEST sometido a ICP primario o de rescate

Introduction and objectivesWe sought to compare the predictive value of the Thrombolysis In Myocardial Infarction (TIMI), Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC), Primary Angioplasty in Myocardial Infarction (PAMI), and Global Registry for Acute Coronary Events (GRACE) scores for the outcome of ST-segment elevation acute coronary syndrome undergoing urgent percutaneous coronary intervention. MethodsWe performed a retrospective analysis of a cohort composed of all consecutive patients with ST-segment elevation acute coronary syndrome treated by urgent percutaneous coronary intervention between 2006 and 2010 (n=1503). TIMI, PAMI, CADILLAC, and GRACE risk scores were calculated for each patient according to different clinical variables. We assessed the predictive accuracy of these scores for death, reinfarction, and target-vessel revascularization at 30 days and 1 year, using the C statistic, which was obtained by means of logistic regression and ROC curves. ResultsThe TIMI, PAMI, CADILLAC and GRACE showed an excellent predictive value for 30-day and 1-year mortality (C statistic range, 0.8-0.9), with superiority of the TIMI, CADILLAC, and GRACE risk models. The performance of these 4 scores was poor for both reinfarction and target-vessel revascularization (C statistic, 0.5-0.6). ConclusionsThe TIMI, PAMI, CADILLAC, and GRACE scores provide excellent information to stratify the risk of mortality in patients treated by percutaneous coronary intervention. The TIMI, CADILLAC, and GRACE models have higher predictive accuracy. The usefulness of these models for reinfarction and target-vessel revascularization prediction is questionable.

Predictors and Implications of Coronary Infarct Artery Patency at Initial Angiography in Patients With Acute Myocardial Infarction (from the CADILLAC and HORIZONS-AMI Trials)

Pre-percutaneous coronary intervention (PCI) Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow has been identified as a predictor of final TIMI grade 3 flow and better survival. Yet pharmacologic strategies increasing the rates of pre-PCI TIMI grade 3 flow resulted in more bleeding, without a benefit in survival. The aim of this study was to identify the predictors and implications of spontaneous reperfusion before primary PCI in patients with ST-segment elevation myocardial infarction. The Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) and Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trials were combined, and the predictors of core laboratory-determined baseline TIMI grade 3 flow and 1-year outcomes were analyzed according to baseline TIMI flow. Baseline TIMI grade 3 flow was present in 932 of 5,332 patients (17.5%). The independent predictors of baseline TIMI grade 3 flow were diabetes, longer delay to PCI, smoking, and more extensive coronary disease. Patients with compared to those without baseline TIMI grade 3 flow had significantly higher rates of post-PCI TIMI grade 3 flow (99.1% vs 91.4%, p <0.0001) and lower 1-year all-cause mortality (2.7% vs 4.3%, p = 0.02). By multivariate analysis, baseline TIMI grade 3 flow (hazard ratio 1.65, 95% confidence interval 1.01 to 2.71, p = 0.046) and final TIMI grade 3 flow (hazard ratio 3.67, 95% confidence interval 2.45 to 5.48, p <0.001) were significant independent predictors of 1-year survival. In conclusion, TIMI grade 3 flow is present in about 1 in every 6 patients before PCI and paradoxically is more common in patients with higher risk characteristics. TIMI grade 3 flow before as well as after PCI is an independent predictor of greater 1-year survival. These data should inform future trials of ST-segment elevation myocardial infarction with respect to improvement in outcomes.

When Is Door-to-Balloon Time Critical? Analysis From the HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) and CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) Trials

When Is Door-to-Balloon Time Critical? Analysis From the HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) and CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) Trials

Impact of Bivalirudin Therapy in High-Risk Patients With Acute Myocardial Infarction: 1-Year Results From the HORIZONS-AMI (Harmonizing Outcomes with RevasculariZatiON and Stents in Acute Myocardial Infarction) Trial

This study sought to assess the relationship between 1-year mortality and baseline patient risk in the HORIZONS-AMI (Harmonizing Outcomes with RevasculariZatiON and Stents in Acute Myocardial Infarction) trial. The HORIZONS-AMI trial showed that bivalirudin compared with unfractionated heparin (UFH) plus glycoprotein IIb/IIIa inhibitors (GPI) decreased major bleeding and 30-day and 1-year mortality in patients undergoing primary percutaneous intervention for acute myocardial infarction. Patients in the HORIZONS-AMI trial were classified as low, intermediate, and high risk according to the CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) risk score based on 7 clinical variables. Among 2,530 CADILLAC-score evaluable HORIZONS-AMI trial patients, 1,522 (60%) were classified as low risk, 531 (21%) as intermediate risk, and 477 (19%) as high risk. The mortality rates in the bivalirudin and UFH plus GPI arms, respectively, were 0.4% and 1.2% (p = 0.09) in the low-risk group, 4.2% and 4.1% (p = 0.99) in the intermediate-risk group, and 8.4% and 15.9% (p = 0.01) in the high-risk group. Among high-risk patients, there was also a decreased rate of recurrent myocardial infarction in patients randomized to bivalirudin as compared to UFH plus GPI (3.6% vs. 7.9%, p = 0.04). In high-risk patients undergoing primary percutaneous coronary intervention for acute myocardial infarction, bivalirudin compared with UFH plus GPI reduces 1-year mortality and recurrent myocardial infarction. (HORIZONS-AMI trial; NCT00433966).

When Is Door-to-Balloon Time Critical?: Analysis From the HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) and CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) Trials

Our objective was to evaluate the impact of door-to-balloon time (DBT) on mortality depending on clinical risk and time to presentation. DBT affects the mortality rate in ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention, but the impact may vary across subgroups. The CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) and HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trials evaluated stent and antithrombotic therapy in patients undergoing primary percutaneous coronary intervention. We studied the impact of DBT on mortality in 4,548 patients based on time to presentation and clinical risk. The 1-year mortality rate was lower in patients with short versus long DBT (< or = 90 min vs. >90 min, 3.1% vs. 4.3%, p = 0.045). Short DBTs were associated with a lower mortality rate in patients with early presentation (< or = 90 min: 1.9% vs. 3.8%, p = 0.029) but not those with later presentation (>90 min: 4.0% vs. 4.6%, p = 0.47). Short DBTs showed similar trends for a lower mortality rate in high-risk (5.7% vs. 7.4%, p = 0.12) and low-risk (1.1% vs. 1.6%, p = 0.25) patients. Short DBTs had similar relative risk reductions in patients with early presentation in high-risk (3.7% vs. 7.0%, p = 0.08) and low-risk (0.8% vs. 1.5%, p = 0.32) patients, although the absolute benefit was greatest in high-risk patients. Short DBTs (< or = 90 min) are associated with a lower mortality rate in patients with early presentation but have less impact on the mortality rate in patients presenting later. The absolute mortality rate reduction with short DBT is greatest in high-risk patients presenting early. These data may be helpful in designing triage strategies for reperfusion therapy in patients presenting to non-percutaneous coronary intervention hospitals.

Antiphospholipid Syndrome, Microalbuminuria, and Risk of Venous Thromboembolism

nary Events Investigators. Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med. 2003;163(19):2345-2353. 3. Halkin A, Singh M, Nikolsky E, et al. Prediction of mortality after primary percutaneous coronary intervention for acute myocardial infarction: the CADILLAC risk score. J Am Coll Cardiol. 2005;45(9):1397-1405. 4. Mehta RH, O’Neill WW, Harjai KJ, et al; Primary Angioplasty in Myocardial Infarction (PAMI) and the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) Investigators. Prediction of oneyear mortality among 30-day survivors after primary percutaneous coronary interventions. Am J Cardiol. 2006;97(6):817-822.

Prognostic Impact of Blood Transfusion After Primary Angioplasty for Acute Myocardial Infarction: Analysis From the CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) Trial

We sought to determine the relationship between red blood cell (RBC) transfusion and clinical outcomes in patients undergoing primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). The implications of RBC transfusion in patients undergoing primary PCI for AMI have not been evaluated. Clinical outcomes of patients from the prospective, randomized CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) trial were analyzed by administration of in-hospital RBC transfusion not related to coronary artery bypass surgery. Of 2,060 randomized patients, 82 (3.98%) received RBC transfusion during the index hospitalization, including 33 (1.60%) with moderate/severe bleeding and 49 (2.38%) without overt major bleeding. Transfusion was independently associated with baseline anemia (odds ratio [95% confidence interval]: 4.44 [2.60 to 7.58], p < 0.0001), older age (1.03 [1.01 to 1.06], p = 0.002), triple-vessel disease (2.54 [1.47 to 4.38], p = 0.0008), and female sex (1.04 [1.02 to 1.06], p = 0.0008). Patients transfused versus not transfused had significantly higher rates of 1-year mortality (23.9% vs. 3.4%), disabling stroke (2.5% vs. 0.5%), reinfarction (7.0% vs. 2.2%), and composite major adverse cardiac events (41.0% vs. 16.6%) (all p values < 0.01). After multivariable adjustment for potential confounders including transfusion propensity, RBC transfusion was independently associated with mortality at 30 days (hazards ratio: 4.71, p = 0.0005) and 1 year (hazards ratio: 3.16, p = 0.0005). An RBC transfusion after primary PCI in AMI may be harmful, which is consistent with the findings from other studies after PCI in the noninfarct setting. Alternatively, RBC transfusion may be a marker of markedly increased risk. Randomized studies are warranted to determine the optimal threshold for RBC transfusion in patients with AMI undergoing mechanical reperfusion therapy.

Comparison of the Predictive Value of Four Different Risk Scores for Outcomes of Patients With ST-Elevation Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Accurate risk stratification has an important role in the management of patients with acute coronary syndromes. Even in patients with ST-elevation acute myocardial infarction (STEMI), for whom early therapeutic options are well defined, risk stratification has an impact on early and late therapeutic decision making. We aimed to compare the prognostic value of 4 risk scores used to evaluate patients with STEMI. We conducted a prospective registry of all patients treated with primary percutaneous coronary intervention for STEMI from January 2001 to June 2006. Excluded were patients with cardiogenic shock. A total of 855 consecutive patients were included in the analysis (age 60.5 +/- 13 years, 19% women, 28% with diabetes, and 48% with anterior wall myocardial infarction). For each patient, the Thrombolysis In Myocardial Infarction (TIMI), Controlled Abciximab and Device Investigation to Lower Late Angioplasty complications (CADILLAC), Primary Angioplasty in Myocardial Infarction (PAMI), and Global Registry for Acute Coronary Events (GRACE) risk scores were calculated using specific clinical variables and angiographic characteristics. Thirty-day and 1-year clinical outcomes were assessed. The predictive accuracy of the 4 risk scores was evaluated using the area under the curve or C statistic method. The CADILLAC, TIMI, and PAMI risk scores all had relatively high predictive accuracy for 30-day and 1-year mortality (C statistic range 0.72 to 0.82), with slight superiority of the CADILLAC score. These 3 risk scores also performed well for prediction of reinfarction at 30 days (C statistic range 0.6 to 0.7). The GRACE score did not perform as well and had low predictive accuracy for mortality (C statistic 0.47). In conclusion, risk stratification of patients with STEMI undergoing primary percutaneous coronary intervention using the CADILLAC, TIMI, or PAMI risk scores provide important prognostic information and enables accurate identification of high-risk patients.

Stenting versus plain old angioplasty in patients with ST segment elevation myocardial infarction: Understanding of the randomized trials

In their recently published article De Luca and coworkers aimed to perform an updated meta-analysis to evaluate the benefits of coronary stenting for acute myocardial infarction (AMI) in terms of mortality, reinfarction, and target vessel revascularization (TVR), and whether these benefits correlated with the patient's risk profile [1]. In that meta-regression analysis, a total of 13 randomized trials were identified and analyzed involving 6922 patients (50% randomized to stent and 50% randomized to balloon). They found that among AMI patients undergoing primary percutaneous intervention (PCI), coronary stent implantation, when anatomically and technically feasible, may be considered, in addition to benefits in terms of TVR, to reduce mortality in high-risk patients, who may be identified by the use of validated risk scores [1]. Initial nonrandomized studies suggesting that primary stenting was more effective in ST segment elevation myocardial infarction (STEMI) than primary PTCA [2,3] were followed by randomized trials [4–7]. A 2005 metaanalysis evaluated 9 randomized trials with a total of 4433 patients [8]. In that meta-analysis stenting was shown to be associated with significant reductions in reinfarction (odds ratio [OR] 0.52, 95% CI 0.31–0.87 at 30 days, and OR 0.67, 95% CI 0.45–0.98 at 1 year) and TVR (OR 0.45, 95% CI 0.34–0.60 at 30 days, and OR 0.47, 95% CI 0.38–0.57 at 1 year). However, there was no significant difference in mortality (OR 1.06 at 1 year). The Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial randomly assigned 2082 patients with AMI to PTCA alone, PTCA and abciximab, stenting alone, or stenting and abciximab; clopidogrel or ticlopidine was given to all patients initially and then continued in those who received a stent [4]. Thus, CADILLAC examined 2 issues: stenting versus PTCA; and abciximab versus no therapy. The initial restoration of TIMI grade 3 blood flow was comparable in all groups (94.5 to 96.9%). At 6 months, the composite end point (death, reinfarction, disabling stroke, or ischemia-driven TVR) was significantly lower with stenting compared to PTCA alone (10.5 versus 18.0%). The benefit of stenting was entirely due to a significantly lower need for repeat ischemia-driven revascularization. There was no difference in mortality among groups. Stenting was associated with a lower rate of angiographic restenosis (22 versus 41%) and reocclusion of the infarct-related artery (5.7 versus 11%); these changes were independent of abciximab use. The Primary Angioplasty in Myocardial Infarction Study (Stent PAMI) trial randomly assigned 900 patients with an AMI to primary PTCA or implantation of a heparin-coated Palmaz–Schatz stent [5]. Angiographic success was high in both groups, but the minimum luminal diameter was significantly larger with stenting (2.56 versus 2.12 mm for PTCA). At 30 days, the composite end point (death, recurrent MI, stroke, or ischemia-driven target vessel revascularization) was similar in both groups (4.2 versus International Journal of Cardiology 133 (2009) 394–423 www.elsevier.com/locate/ijcard

Fetuin-A Is an Independent Predictor of Death after ST-Elevation Myocardial Infarction

Fetuin-A inhibits inflammation and has a protective effect against myocardial ischemia. Its deficiency has been found to be associated with cardiovascular death in patients with end-stage renal failure disease. We investigated the association between plasma fetuin-A and clinical outcome after ST-elevation acute myocardial infarction (STEMI). We measured fetuin-A in 284 consecutive patients with STEMI and correlated these data with the occurrence of death at 6 months (n = 25). We also measured fetuin-A in a control group and chose the 95th percentile as the cutoff to define abnormality. Patient mean (SD) age was 60 (14) years, and creatinine clearance was 83 (31) mL/min; 82% were men. Mean (SD) plasma fetuin-A concentrations at admission [188 (69) mg/L, P = 0.01] and at day 3 [163 (57) mg/L, P <0.0001] were lower in patients than in controls [219 (39) mg/L; 95th percentile 140 mg/L]. Fetuin-A <140 mg/L was observed in 20% of patients at admission vs 40% at day 3 (P <0.001). Fetuin-A concentrations did not correlate with peak cardiac troponin values but did correlate inversely with C-reactive protein (CRP) and NT-pro-brain natriuretic peptide (NT-proBNP). Fetuin-A <140 mg/L at admission (OR = 3.3, P = 0.03) and at day 3 (OR = 6.3, P = 0.002) was an independent correlate of death at 6 months, irrespective of NT-proBNP, CRP, or Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) risk score. Conversely, fetuin-A > or = 140 mg/L was associated with an excellent survival rate [negative predictive value (NPV) = 97% overall], even in high-risk populations with CADILLAC risk score > or = 6 (NPV = 90% in patients). Fetuin-A is an important predictor of death at 6 months in STEMI patients independent of NT-proBNP, CRP, and CADILLAC risk score.

Prognostic Implications of Creatine Kinase Elevation After Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction

We examined the prognostic implications of the absolute level and rate of increase of creatine kinase (CK) elevation after primary percutaneous coronary intervention (PCI). Peak creatine kinase (CK(peak)) and the rate of CK increase are related to reperfusion success and clinical outcomes after thrombolytic therapy for acute myocardial infarction (AMI). The utility of routine serial CK monitoring after primary PCI, in which normal antegrade blood flow is restored in most patients, is unknown. In the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial, 1,529 patients with AMI randomized to either stenting or balloon angioplasty, each with or without abciximab, had CK levels determined at baseline and at 8 +/- 1 h, 16 +/- 1 h, and 24 +/- 1 h after PCI. The CK(peak) occurred at baseline in 3.9% of patients, at 8 +/- 1 h in 69.6%, at 16 +/- 1 h in 20.0%, and at 24 +/- 1 h in 6.5%. The CK levels at all post-procedural time points were significantly higher in patients who died compared with the one-year survivors, as was CK(peak) (mean, 2,865 U/l vs. 1,885 U/l, respectively, p < or = 0.001). By multivariate analysis, CK(peak) was a significant predictor of one-year mortality (hazard ratio = 2.15, p = 0.0002), independent from post-PCI Thrombolysis In Myocardial Infarction (TIMI) flow. Both the improvement in left ventricular ejection fraction from baseline to seven months and its absolute level were inversely correlated with CK(peak) (p < 0.001 for both). In contrast, the time to CK(peak) was not an independent predictor of mortality or myocardial recovery. The CK(peak) after primary PCI is a powerful predictor of one-year mortality independent of other clinical and angiographic measures.

Gender Differences in Outcomes After Primary Angioplasty Versus Primary Stenting With and Without Abciximab for Acute Myocardial Infarction: Results of the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) Trial

Gender Differences in Outcomes After Primary Angioplasty Versus Primary Stenting With and Without Abciximab for Acute Myocardial Infarction: Results of the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) Trial