Major Adverse Cardiac Events Hazard Ratio Research Articles

Association between trimethylamine N-oxide and prognosis of patients with acute myocardial infarction and heart failure.

This study aimed to investigate the association between trimethylamine N-oxide (TMAO) and the prognosis and association between high-sensitivity C-reactive protein (hsCRP) and TMAO-associated cardiovascular risk in patients with acute myocardial infarction (AMI) complicated by heart failure (HF). A total of 985 patients presenting with AMI and HF were consecutively enrolled at the Fuwai Hospital between March 2017 and January 2020. Patients were stratified into groups according to tertiles of TMAO levels and the median hsCRP levels. The primary endpoint was major adverse cardiac events (MACE), including all-cause death, recurrence of myocardial infarction, and rehospitalization due to HF. During a median follow-up of 716days, 138 (14.0%) patients experienced MACE. Cox regression analyses showed that the adjusted hazard ratio (HR) for MACE was higher in patients in tertile 3 [TMAO>9.52μmol/L, HR: 1.85, 95% confidence interval (CI): 1.18-2.89; P=0.007] than in tertile 1 (TMAO<4.74μmol/L), whereas no significant differences were detected between the patients in tertiles 1 and 2 (TMAO=4.74-9.52μmol/L, HR: 0.96, 95% CI: 0.59-1.58; P=0.874). Restricted cubic spline regression depicted an S-shaped association between TMAO and MACE (P for nonlinearity=0.012). In the setting of hsCRP above the median level (6.68mg/L), per unit increase of TMAO was associated with a 20% increase of MACE risk (HR: 1.20, 95% CI: 1.05-1.37, P=0.009); increasing tertiles of TMAO were significantly associated with a higher risk of MACE (adjusted P=0.007 for interaction; P<0.001 for trend across tertiles). The Kaplan-Meier analysis indicated that patients in tertile 3 had a significantly lower event-free survival (P=0.001) when the hsCRP level was above the median level. No similar association between TMAO and MACE was observed when the hsCRP level was below the median level. High plasma TMAO levels were independently correlated with poor prognosis in patients with AMI complicated by HF, especially in those with higher hsCRP levels. There was an S-shaped relationship between TMAO and HR for MACE.

Prognostic value of computed tomography derived fractional flow reserve for predicting cardiac events and mortality in kidney transplant candidates

BackgroundCardiac screening using coronary computed tomography angiography (CCTA) in kidney transplant candidates before transplantation yields both diagnostic and prognostic information. Whether CT-derived fractional flow reserve (FFRCT) analysis provides prognostic information is unknown.This study aimed to assess the prognostic value of FFRCT for predicting major adverse cardiac events (MACE) and all-cause mortality in kidney transplant candidates. MethodsAmong 553 consecutive kidney transplant candidates, 340 CCTA scans (61%) were evaluated with FFRCT analysis. Patients were categorized into groups based on lowest distal FFRCT; normal >0.80, intermediate 0.80–0.76, and low ≤0.75. In patients with ≥50% stenosis, a lesion-specific FFRCT was defined as; normal >0.80 and abnormal ≤0.80.The primary endpoint was MACE (cardiac death, resuscitated cardiac arrest, myocardial infarction or revascularization). The secondary endpoint was all-cause mortality. ResultsMedian follow-up was 3.3 years [2.0–5.1]. MACE occurred in 28 patients (8.2%), 29 patients (8.5%) died.When adjusting for risk factors and transplantation during follow-up, MACE occurred more frequently in patients with distal FFRCT ≤0.75 compared to patients with distal FFRCT >0.80: Hazard Ratio (HR): 3.8 (95%CI: 1.5–9.7), p ​< ​0.01.In the lesion-specific analysis with <50% stenosis as reference, patients with lesion-specific FFRCT >0.80 had a HR for MACE of 1.5 (95%CI: 0.4–4.8), p ​= ​0.55 while patients with lesion-specific FFRCT ≤0.80 had a HR of 6.0 (95%CI: 2.5–14.4), p ​< ​0.01.Abnormal FFRCT values were not associated with increased mortality. ConclusionIn kidney transplant candidates, abnormal FFRCT values were associated with increased MACE but not mortality. Use of FFRCT may improve cardiac evaluation prior to transplantation.

Prognostic value of coronary flow reserve in patients with suspected or known coronary artery disease referred to PET myocardial perfusion imaging: A meta-analysis

BackgroundWe performed a meta-meta-analysis to evaluate the prognostic value of coronary flow reserve (CFR) assessed by cardiac positron emission tomography (PET) imaging in patients with suspected or known coronary artery disease (CAD). MethodsStudies published until April 2019 were identified by database search. We included studies if they evaluated CFR by PET providing data on adjusted hazard ratio (HR) for the occurrence of adverse events. Annualized event rates were calculated and the incidence rate ratios with 95% confidence interval (CI) were estimated to compare patients with impaired and preserved CFR. ResultsWe identified 13 eligible articles including 11,867 patients with a follow-up ranging from 0.6 to 7.1 years. The HR for the occurrence of major adverse cardiac events (MACE) was reported in 11 studies and pooled HR was 1.93 (95% CI 1.65-2.27). The HR for the occurrence of hard events was reported in 5 studies and pooled HR was 3.11 (95% CI 1.88-5.14). Six studies reported data useful to calculate separately the incidence rate of MACE in patients with preserved and impaired CFR and pooled IRR was 2.26 (CI 95% 1.79-2.85). Three studies reported data useful to calculate separately the incidence rate of hard events in patients with preserved and impaired CFR and pooled IRR was 4.12 (CI 95% 3.08-5.51). At meta-regression analysis, we found an association between HR for MACE and gender, diabetes and hypertension, while no significant association was found between HR for hard events and demographic and clinical variables. ConclusionIn patients with suspected or known CAD, an impaired CFR is associated with adverse cardiovascular events. However, the large heterogeneity in study population underlines the need for further investigations to maximize the prognostic role of CFR.

Cardiovascular outcomes after percutaneous coronary intervention on bifurcation lesions with moderate to severe coronary calcium: A single-center registry study.

Both target vessel calcification and target vessel bifurcation are associated with worse outcomes following percutaneous coronary intervention (PCI). Whether these entities in combination interact to influence outcomes after PCI of complex coronary disease is not known. This study evaluated the association of target vessel bifurcation and target vessel calcification, alone and in combination, with adverse events following PCI. Registry data from 21,165 patients who underwent PCI with drug-eluting stents (DES) between January 2009 and December 2017 were analyzed. Patients were divided into four groups according to the presence or absence of target vessel bifurcation and presence of none/mild or moderate/severe target vessel calcification on angiography. Associations between lesion groups and 1 year major adverse cardiac events (MACE) were examined using Cox regression analysis. At 1 year, unadjusted rates of MACE, death, myocardial infarction (MI), as well as stent thrombosis were highest in the group with both bifurcation lesion and moderate/severe calcification. After adjusting for confounders such as age, renal disease, and smoking, hazard ratios for MACE were 1.14 (95%CI 0.99-1.33) for bifurcation with none/mild calcification, 1.21 (95%CI 1.06-1.38) for no bifurcation and moderate/severe calcification, and 1.37 (95%CI 1.14-1.64) for bifurcation and moderate severe calcification, compared to patients with no bifurcation and none/mild calcification. The presence of a bifurcating target vessel with moderate/severe calcification is associated with a higher risk of adverse outcomes than either attribute alone. New approaches are needed to improve outcomes in this subset of patients with complex coronary artery disease.

Impact of new-onset diabetes on clinical outcomes after ST segment-elevated myocardial infarction

Objective. Patients with diabetes have higher mortality rate than patients without diabetes after ST-segment elevated myocardial infarction (STEMI). Prognosis of patients with new onset diabetes (NOD) after STEMI remains unclear. The aim of this study was to evaluate the prognosis of patients with NOD compared to that of patients without NOD after STEMI. Design. This study was a retrospective observational study. We enrolled 901 STEMI patients. Patients were divided into diabetic and non-diabetic groups at index admission. Non-diabetic group was divided into NOD and non-NOD groups. Kaplan-Meier analysis and Cox's proportional hazard regression models were used to compare major adverse cardiac events (MACE) free survival rate and hazard ratio for MACE between NOD and non-NOD groups. Results. Mean follow-up period was 59 ± 28 months. Diabetes group had higher MACE than non-diabetes group (p = .038). However, MACE was not different between NOD and non-NOD groups (p = 1.000). After 1:2 propensity score matching, incidence of MACE was not different between the two groups. In Kaplan-Meier survival curves, MACE-free survival rates were not statistically different between NOD and non-NOD groups either (p = .244). Adjusted hazard ratios of NOD for MACE, all-cause of death, recurrent myocardial infarction, and target vessel revascularization were 0.697 (95% confidence interval [CI]: 0.362–1.345, p = .282), 0.625 (95% CI: 0.179–2.183, p = .461), 0.794 (95% CI: 0.223–2.835, p = .723), and 0.506 (95% CI: 0.196–1.303, p = .158), respectively. Conclusion. This retrospective observational study with a limited statistical power did not show a different prognosis in patients with and without NOD.

Age at Menarche and Risk of Cardiovascular Disease Outcomes: Findings From the National Heart Lung and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation.

BackgroundPrevious studies have reported an association between the timing of menarche and cardiovascular disease (CVD). However, emerging studies have not examined the timing of menarche in relation to role of estrogen over a lifetime and major adverse cardiac events (MACE).Methods and ResultsA total of 648 women without surgical menopause undergoing coronary angiography for suspected ischemia in the WISE (Women's Ischemia Syndrome Evaluation) study were evaluated at baseline and followed for 6 years (median) to assess major adverse CVD outcomes. MACE was defined as the first occurrence of all‐cause death, nonfatal myocardial infarction, nonfatal stroke, or heart failure hospitalization. Age at menarche was self‐reported and categorized (≤10, 11, 12, 13, 14, ≥15 years) with age 12 as reference. Total estrogen time and supra–total estrogen time were calculated. Cox regression analysis was performed adjusting for CVD risk factors. Baseline age was 57.9 ± 12 years (mean ± SD), body mass index was 29.5 ± 6.5 kg/m2, total estrogen time was 32.2 ± 8.9 years, and supra–total estrogen time was 41.4 ± 8.8 years. MACE occurred in 172 (27%), and its adjusted regression model was J‐shaped. Compared with women with menarche at age 12 years, the adjusted MACE hazard ratio for menarche at ≤10 years was 4.53 (95% CI 2.13‐9.63); and at ≥15 years risk for MACE was 2.58 (95% CI, 1.28‐5.21).ConclusionsHistory of early or late menarche was associated with a higher risk for adverse CVD outcomes. These findings highlight age at menarche as a potential screening tool for women at risk of adverse CVD events.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000554.

PC128. Serum Resistin Is Associated With Impaired Endothelial Function and Poor Outcomes in Patients With Peripheral Artery Disease

Resistin is a hormone secreted by adipocytes that has been associated with metabolic syndrome and cardiovascular disease. However, less is known on the role of resistin in patients with peripheral artery disease (PAD). The present study seeks to understand the relationship of serum resistin with endothelial function and cardiovascular outcomes in patients with PAD. We hypothesize that increased serum resistin is associated with worse endothelial function and an increased rate of major adverse cardiac events (MACE). One-hundred six patients who presented to clinic with complaints of claudication and an ankle-brachial index of <0.9 or history of revascularization for symptomatic PAD were recruited between 2011 and 2016. Patients were excluded if they had acute illness, renal or hepatic disease, or were taking immunosuppressants. Resistin was assayed using commercially available ELISA kits. Endothelial function was measured via brachial artery flow-mediated vasodilation (FMD) at baseline. Incident MACE were identified by subsequent chart review and defined as a composite end point of myocardial infarction, coronary revascularization, stroke, or death from a cardiac cause. Cox proportional hazards models were used to calculate hazard ratios for MACE. At baseline, despite similar Rutherford scores, medical comorbidities, and medication use, FMD was significantly lower with increasing resistin quartile (I, 9.1 ± 3.3%; II, 7.1 ± 3.5%; III, 5.8 ± 4.0%; IV, 5.6 ± 3.5%; P = .002; Fig 1). A univariate linear regression demonstrated that increasing resistin quartiles predicted lower FMD (II, −1.99 [95% confidence interval (CI), −3.96 to -0.02; P = .05]; III, −3.34 [95% CI, −5.29 to −1.39; P = .001]; IV, −3.52 [95% CI, −5.48 to -1.55; P = .001]). In multivariate linear regression, resistin quartiles III and IV predicted lower FMD relative to the first quartile after adjusting for age, race, body mass index, diabetes mellitus, hypertension, estimated glomerular filtration rate, C-reactive protein, and beta-blocker and angiotensin converting enzyme inhibitor use (III, −2.26 [95% CI, −4.51 to −0.01; P = .05]; IV, -2.53 [95% CI, −4.87 to -0.20; P = .03]). During a median follow-up period of 36 months (interquartile range, 29-45), 21 patients experienced the primary end point. In a Cox proportional hazards model adjusted for smoking status, coronary artery disease, and age, resistin was independently associated with an increased rate of MACE (HR, 1.10; 95% CI, 1.00-1.20; P = .04; Fig 2). Resistin is associated with impaired endothelial function and an increased rate of MACE in patients with PAD. Further research is needed to determine the potential mechanism by which resistin may increase MACE, and prospective studies should determine whether decreasing resistin has therapeutic benefit in patients with PAD.Fig 2: Kaplan-Meier estimate of freedom from major adverse cardiac event (MACE) in the lowest and highest resistin quartiles.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Prevalence, Impact, and Predictive Value of Detecting Subclinical Coronary and Carotid Atherosclerosis in Asymptomatic Adults: The BioImage Study

BackgroundAlthough recent studies suggest that measuring coronary artery calcification (CAC) may be superior to indirect atherosclerotic markers in predicting cardiac risk, there are limited data evaluating imaging-based biomarkers that directly quantify atherosclerosis in different vascular beds performed in a single cohort. ObjectivesThe BioImage Study (A Clinical Study of Burden of Atherosclerotic Disease in an At-Risk Population) sought to identify imaging biomarkers that predict near-term (3-year) atherothrombotic events. MethodsThe BioImage Study enrolled 5,808 asymptomatic U.S. adults (mean age: 69 years, 56.5% female) in a prospective cohort evaluating the role of vascular imaging on cardiovascular risk prediction. All patients were evaluated by CAC and novel 3-dimensional carotid ultrasound. Plaque areas from both carotid arteries were summed as the carotid plaque burden (cPB). The primary endpoint was the composite of major adverse cardiac events (MACE) (cardiovascular death, myocardial infarction, and ischemic stroke). A broader secondary MACE endpoint also included all-cause death, unstable angina, and coronary revascularization. ResultsOver a median follow-up of 2.7 years, MACE occurred in 216 patients (4.2%), of which 82 (1.5%) were primary events. After adjustment for risk factors, and compared with individuals without any cPB, hazard ratios for MACE were 0.78 (95% confidence interval [CI]: 0.31 to 1.91), 1.45 (95% CI: 0.67 to 3.14), and 2.36 (95% CI: 1.13 to 4.92) with increasing cPB tertile, with similar results for CAC. Net reclassification significantly improved with either cPB (0.23) or CAC (0.25). MACE rates increased simultaneously with higher levels of both cPB and CAC. ConclusionsDetection of subclinical carotid or coronary atherosclerosis improves risk predictions and reclassification compared with conventional risk factors, with comparable results for either modality. Cost-effective analyses are warranted to define the optimal roles of these complementary techniques. (BioImage Study: A Clinical Study of Burden of Atherosclerotic Disease in an At-Risk Population; NCT00738725)

Abstract 11539: Impact of Adipose Tissue Composition on Cardiovascular Risk Assessment

Background: Visceral adipose tissue (VAT) , unlike subcutaneous adipose tissue (SAT), has been shown to be highly correlated with cardiovascular risk factors. The aim of this study was to evaluate the predictive value of adipose tissue composition measured by computed tomography for cardiovascular outcome. Method: 369 consecutive patients without history of cardiovascular disease who underwent 64-slice computed tomography angiography (CTA) were recruited. The ratio of visceral adipose tissue to the total adipose tissue (%VAT) was calculated as VAT/ (VAT + SAT) х 100. Patients were divided into three groups in accordance with tertiles of %VAT (tertile1, &lt;35.1%; tertile2, 35.1 to 45.0%; tertile3, 45.1%≤). The investigated risk factors were hypertension, hyperglycemia, and dyslipidemia. We analyzed the incidence of major adverse cardiac events (MACE), including cardiovascular death, myocardial infarction, and any revascularization. Result: The rate of patients who have two or more concomitant risk factors was significantly increased across tertiles of %VAT (p=0.001). During the median follow-up of 1973 days, 96 events occurred. Event-free survival was significantly associated with %VAT tertiles, with worse event-free survival in tertile 3 (log-rank p=0.001). In Cox analysis, the hazard ratio (HR) of %VAT (per tertile) for MACE was 1.39 (95% confident interval [CI] 1.05-1.82, p=0.02). Among patients with tertile 3, HR for MACE was 1.81 (95% CI 1.01-3.23, p=0.045) compared to tertile 1 after adjustment for confounding factors. Conclusion: %VAT is independently associated with MACE, indicating that adipose tissue composition is a useful predictor of cardiovascular outcome.

Meta-analysis of drug-eluting versus bare metal stents in patients with indications for oral anticoagulation undergoing coronary stenting

Background Current expert consensus recommends the use of bare metal stent (BMS) for patients with an indication for oral anticoagulation (OAC) undergoing coronary stenting. The use of drug-eluting stents (DES) should be limited. However, there is a lack of evidence to support these recommendations. We performed a meta-analysis to compare the efficacy and safety of DES to BMS in these patients.Methods We searched PubMed, Embase, the Cochrane library, and relevant journals. Studies comparing the efficacy and safety of DES to BMS in patients with an indication for OAC undergoing coronary stenting were included. End points included major adverse cardiac events (MACE), death, bleeding complications, and stroke. The outcome assessments were measured by hazard ratio (HR) and its 95% confidence interval.Results We yielded 453 studies by primary searching. According to the inclusion criteria, four studies enrolling 1,522 patients were finally included. A pooled estimate of HR for MACE, all-cause mortality, myocardial infarction, and bleeding complications showed no significant differences between patients treated with DES and BMS. The risk of target vessel revascularization (TVR) was significantly decreased in the DES implanted patients in comparison with patients with a BMS implantation.Conclusion For patients with an indication for OAC undergoing coronary stenting, DES might a DES can be as safely used as a BMS, and is superior in reducing the risk of TVR.

Low high-density lipoprotein cholesterol is a residual risk factor associated with long-term clinical outcomes in diabetic patients with stable coronary artery disease who achieve optimal control of low-density lipoprotein cholesterol

Diabetes mellitus is recognized an independent risk factor for coronary artery disease (CAD) and mortality. Clinical trials have shown that statins significantly reduce cardiovascular events in diabetic patients. However, residual cardiovascular risk persists despite the achievement of target low-density lipoprotein cholesterol (LDL-C) levels with statin. High-density lipoprotein cholesterol (HDL-C) is an established coronary risk factor that is independent of LDL-C levels. We evaluated the impact of HDL-C on long-term mortality in diabetic patients with stable CAD who achieved optimal LDL-C. We enrolled 438 consecutive diabetic patients who were scheduled for percutaneous coronary intervention between 2004 and 2007 at our institution. We identified 165 patients who achieved target LDL-C <100 mg/dl. Patients were stratified into two groups according to HDL-C levels (low HDL-C group, baseline HDL-C <40 mg/dl; high HDL-C group, ≥40 mg/dl). Major adverse cardiac events (MACE) that included all-cause death, acute coronary syndrome, and target lesion revascularization were evaluated between the two groups. The median follow-up period was 946 days. The rate of MACE was significantly higher in diabetic patients with low-HDL-C who achieved optimal LDL-C (6.9 vs 17.9 %, log-rank P = 0.030). Multivariate Cox regression analysis showed that HDL-C is significantly associated with clinical outcomes (adjusted hazard ratio for MACE 1.33, 95 % confidence interval 1.01-1.75, P = 0.042). Low HDL-C is a residual risk factor that is significantly associated with long-term clinical outcomes among diabetic patients with stable CAD who achieve optimal LDL-C levels.

Individual and summed effects of high-risk genetic polymorphisms on recurrent cardiovascular events following ischemic heart disease

AimsHigh-risk single nucleotide polymorphisms (SNPs) have been recently identified as risk factors for ischemic heart disease in large epidemiological and genome-wide association studies. However, their influence on prognosis remains uncertain. The aim of the study was to investigate the impact of previously identified SNPs and their joint effects in a genetic score (GS) on Major Adverse Cardiac Events (MACEs). Methods and resultsHigh-throughput genotyping for 48 high-risk SNPs was performed in 498 patients (432 males; 57.4 ± 8.3 years) who were followed-up for 6.9 ± 3.4 years. First MACE-coronary-related death, nonfatal myocardial infarction, or myocardial revascularization- was the endpoint taken into consideration. A GS was obtained by summing the number of significant high-risk alleles associated to MACEs.One-hundred and nineteen patients (24%) had a MACE. The hazard ratio (HR) for SNPs with a significant difference in cumulative survival were: APOC3 -482C > T (HR = 1.7, 95% CI 1.01–3.0), MTHFR (HR = 1.5, 95% CI 1.02–2.2), NADHPH oxidase- p22-PHOX C242T (HR = 1.9, 95% CI 1.2–2.8), PON-2 (HR = 0.2, 95% CI 0.1–0.8), and SELP (HR = 0.6, 95% CI 0.4–0.8). The resulting GS predicted a 25% risk for MACEs per risk allele (HR = 1.25, 95% CI 1.1–1.4, p = 0.001). The highest HR for MACEs was found in patients in the top tertile (HR = 3.0, 95% CI 1.4–6.7, p = 0.0005) of the GS compared with those in the bottom tertile. ConclusionOur findings show that high-risk SNPs may be used to create a useful GS that predicts MACEs in a secondary prevention setting, which in turn allows a better risk stratification.

Associations among chronic kidney disease, high total p-cresylsulfate and major adverse cardiac events

Cardiovascular disease is prevalent among patients with chronic kidney disease (CKD). Patients with CKD have elevated levels of p-cresylsulfate (PCS), which has been linked with cardiovascular mortality in this population. The aim of this study was to evaluate the clinical significance of CKD in coronary artery disease (CAD) patients and to investigate whether a significant correlation exists between CKD, total PCS and poor clinical outcomes in CAD patients. We assessed the occurrence of major adverse cardiac events (MACEs) among 340 consecutive CAD patients who enrolled in a disease management program after the patients were discharged from the hospital. CKD was defined as an estimated glomerular filtration rate (eGFR) of <60 ml/min per 1.73 m(2). Kaplan-Meier analysis revealed that CKD and high total PCS levels (>1.66 mg/L) were significantly associated with the occurrence of MACE. A multivariate Cox hazard regression model revealed that the predictive independent risk factor for the occurrence of MACE was high total PCS level (relative risk = 1.387). We divided the patients with or without CKD and high or low total PCS levels into 4 groups according to their eGFR and total PCS levels, respectively. The hazard ratio for MACE in the group with both CKD and high total PCS level was 1.721, relative to the group without CKD that had low total PCS level (p=0.005). A high serum level of total PCS may be a predictor of elevated risk of MACE in CAD patients with low eGFR.

Myeloperoxidase Improves Risk Stratification in Patients with Ischemia and Normal Cardiac Troponin I Concentrations

We assessed the ability of myeloperoxidase (MPO) to identify the risk for major adverse cardiac events (MACE) in patients who present with ischemic symptoms suggestive of acute coronary syndrome and have a normal cardiac troponin I (cTnI) value. We used Siemens (n = 400) and Abbott (n = 350) assays to measure MPO and cTnI in plasma samples from 400 patients. Event rates (myocardial infarction, cardiac death, percutaneous coronary intervention, coronary artery bypass grafting) were estimated by the Kaplan-Meier method and compared with the log-rank statistic. At the 30-day follow-up, the adjusted hazard ratios for MACE were 3.9 (P < 0.001) for increased cTnI and 2.7 (P = 0.006) for increased MPO for the Siemens assays and were 5.5 (P < 0.001) for increased cTnI and 2.9 (P = 0.001) for increased MPO for the Abbott assays. Similar findings were observed with 6 months of follow-up. Patients who initially had a normal cTnI value and an increased Siemens MPO value demonstrated a higher rate of MACE at 30 days than those in whom both values were normal (16.1% vs 3.6%, P = 0.002) and 6 months (18.1% vs 5.0%, P = 0.002). Similarly, patients who had an increased Abbott MPO result demonstrated a higher MACE rate at 30 days (12.3% vs 3.9%, P = 0.03) and at 6 months (16.2% vs 5.1%, P = 0.01) than those with normal values. A combination of MPO and cTnI allowed the identification of a greater proportion of patients at risk for MACE than the use of cTnI alone. Increased MPO values remained predictive of future cardiac events even when the cTnI value was normal.

Comparison of Five-Year Outcome of Octogenarians Undergoing Percutaneous Coronary Intervention With Drug-Eluting Versus Bare-Metal Stents (from the RESEARCH and T-SEARCH Registries)

Although octogenarians are increasingly referred for percutaneous coronary intervention (PCI), data are lacking on long-term safety and efficacy of drug-eluting stents in this high-risk subpopulation. The aim of this study was to evaluate 5-year clinical outcome of octogenarians who underwent PCI using sirolimus-eluting stents (SESs) or paclitaxel-eluting stents (PESs) compared to bare-metal stents (BMSs). From January 2000 to December 2005, 319 consecutive octogenarian patients who underwent PCI with BMSs (n = 93, January 2000 to April 2002), SESs (n = 52, April 2002 to February 2003), or PESs (n = 174, February 2003 to December 2005) were included prospectively. Primary study end points were all-cause mortality and major adverse cardiac events (MACEs), defined as all-cause death, any myocardial infarction, or any revascularization. Mean age of the study population was 83 ± 2 years and 51% of patients were men. Median follow-up duration was 5.4 years (range 3 to 9). Five-year mortality rates in the BMS, SES, and PES cohorts were similar (41%, 42%, and 41%, respectively). Cumulative 5-year MACE-free survival in the BMS, SES, and PES cohorts were 44%, 52%, and 48%, respectively. Compared to the BMS cohort, adjusted hazard ratios for MACEs in the SES and PES cohorts were 0.5 (95% confidence interval [CI] 0.3 to 0.9, p <0.05) and 0.5 (95% CI 0.2 to 1.4, p = 0.2), respectively. Overall, use of drug-eluting stents was associated with fewer MACEs (adjusted hazard ratio 0.5, 95% CI 0.3 to 0.9, p <0.05) and a trend toward less target vessel revascularization (adjusted hazard ratio 0.5, 95% CI 0.2 to 1.2, p = 0.1). In conclusion, PCI with drug-eluting stents in octogenarians was found to be safe and more effective compared to PCI with BMSs.

Relation of Proton Pump Inhibitor Use After Percutaneous Coronary Intervention With Drug-Eluting Stents to Outcomes

Recent evidence has shown that clopidogrel and proton pump inhibitors (PPIs) are metabolized by the same pathway and that patients taking both drugs have greater levels of platelet reactivity and more adverse outcomes than patients taking only clopidogrel. We sought to examine the effect of a PPI at discharge from the hospital after percutaneous coronary intervention with drug-eluting stents on the incidence of major adverse cardiac events (MACE) at 1 year. We compared 502 patients who were not prescribed a PPI at discharge and 318 patients who were prescribed a PPI. All patients were taking clopidogrel. We followed patients for 1 year with regard to MACE, including death, Q-wave myocardial infarction, target vessel revascularization, and stent thrombosis. We performed multivariate Cox regression to adjust for confounding variables, including compliance with clopidogrel, to assess the effect of a PPI at discharge on the 1-year outcomes. The baseline characteristics of patients discharged with a PPI were similar to those of patients discharged without a PPI. Univariate survival analysis of the outcomes showed a greater rate of MACE (13.8% vs 8.0%, p = 0.008) and overall mortality (4.7% vs 1.8%, p = 0.02) in the PPI group. After multivariate analysis, the adjusted MACE hazard ratio for PPI at discharge was 1.8 (95% confidence interval 1.1 to 2.7, p = 0.01). In conclusion, in patients undergoing percutaneous coronary intervention with drug-eluting stents and receiving clopidogrel, the prescription of a PPI at discharge was associated with a greater rate of MACE at 1 year.

The synergistic combined effect of anemia with high plasma levels of B-type natriuretic peptide significantly predicts an enhanced risk for major adverse cardiac events

The prevalence of anemia in patients with heart failure (HF) increases according to disease severity as a consequence of renal insufficiency, cytokine production, plasma volume expansion, and/or malnutrition. B-type natriuretic peptide (BNP) has been recognized as a biochemical marker of ventricular dysfunction. The aim of this study was to evaluate the clinical significance of anemia in HF patients and furthermore, to investigate whether a significant correlation exists between anemia, BNP, and poor clinical outcomes in HF patients. We studied 185 consecutive HF patients. We assessed the occurrence of major adverse cardiac events (MACE) post hospital discharge. Anemia was defined as Hb concentrations <12.9 g/dl in men and <11.3 g/dl in women, respectively. Kaplan-Meier analysis revealed that anemia and high BNP levels (>259 pg/ml) were significantly associated with the occurrence of MACE. Multiple logistic analysis revealed that the most predictive independent risk factor for the occurrence of MACE was high BNP levels, followed by anemia (relative risk [RR] = 2.803 and 2.241, respectively). We divided the patients with or without anemia and high or low BNP levels into four groups according to their respective Hb and BNP levels. The hazard ratio for MACE in the group with anemia and high BNP levels was 10.3 in comparison to the group without anemia and with low BNP levels (P = 0.0002). Both anemia and high plasma levels of BNP are significantly and independently associated with the occurrence of MACE in HF patients; furthermore, the synergistic effect of anemia combined with high BNP levels significantly predicts an enhanced risk for MACE.

Impact of Impaired Renal Function and Diabetes on Long-Term Prognosis in Patients Undergoing Primary Angioplasty for Acute Coronary Syndrome

We sought to determine the effect of impaired renal function (IRF) and diabetes on the long-term outcome in patients undergoing primary angioplasty for acute coronary syndrome (ACS). Background Diabetes and IRF occur frequently in patients presenting with ACS. However, the prognostic importance of IRF in comparison with diabetes after primary angioplasty has not been specifically studied. A total of 742 patients with ACS treated by primary angioplasty were evaluated. Study endpoints were major adverse cardiac events (MACE), a composite of all-cause mortality, ACS, and target vessel revascularization (TVR). During an average follow-up period of 6.8 years, we documented 13 cardiovascular deaths, 27 non-cardiovascular deaths, 12 incidents of ACS, and 165 incidences of TVR. Six-year rates of MACE were significantly higher in diabetics with IRF (47.6%), nondiabetics with IRF (36.4%), and diabetics without IRF (36.0%) than in nondiabetics without IRF (28.4%, Log-rank test: p=0.0057). Nondiabetics with IRF, diabetics without IRF, and diabetics with IRF had a relative hazard ratio for MACE of 1.63 (95% confidence interval (CI) 1.04 to 2.54, p=0.033), 1.47 (95% CI, 1.03 to 2.11; p=0.036), and 1.97 (95% CI, 1.12 to 3.48; p=0.019), respectively, compared with nondiabetics without IRF. IRF has an important association with MACE after primary angioplasty in patients with ACS and may be nearly as predictive of long-term outcome as is diabetes.