Higher Incidence Of Cardiac Death Research Articles

Hospital complications in patients with acute kidney injury after coronary artery bypass grafting

The aim was to assess the incidence of hospital complications in patients with acute kidney injury (AKI) after coronary artery bypass grafting (CABG).Patients and Methods. The study included 77 patients with stable angina who underwent CABG, aged 65 (61-69) years, 77,9 % men. The number of patients with arterial hypertension was 96,1 %, with carbohydrate metabolism disorders 45,5 %, with chronic kidney disease (CKD) 22,1 %, and with myocardial infarction (MI) 57,1 %. CABG on the working heart was performed in 28,6 %, bimammary CABG in 49,4 %. The duration of artificial circulation was 64 (55-82) minutes; the number of shunts implanted was 2,7+0,7 units. CKD was diagnosed when the glomerular filtration rate was less than 60 ml/min. The development of AKI was assessed according to the KDIGO criteria (2012).Results. CABG related AKI was detected in 10 (13 %) patients, of which grade 1 in 9 (11,7 %), grade 2 in 1 (1,3 %). The indicators associated with AKI after CABG were more severe initial CKD (stages 3b and 4 CKD – 20 % vs 1,5 %, p=0,043), a higher incidence of acute heart failure (in terms of adrenaline requirement – 30 % vs 5,9 %, p=0,043), more occluded coronary arteries (in the groups with and without CABG: one occlusion 70 % and 52,2 %, two occlusions 0 % and 13,4 %, three occlusions 10 % and 0 %, respectively, p=0,028). More severe CKD (stages 3b and 4) statistically significantly increased the relative risk of AKI after CABG by an average of 2,9 times. Among patients with AKI compared to patients without AKI after CABG, there was a higher incidence of cardiac death (20 % vs 0 %, p=0,015), intraoperative MI (60 % vs 8,9 %, p=0,001), acute heart failure (30 % vs 5,9 %, p=0,043).Conclusion. The incidence of AKI following CABG was 13 %. The development of AKI was associated with more severe initial CKD. Patients with postoperative AKI had a poor hospital prognosis.

Time to presentation and mortality outcomes among patients with diabetes and acute myocardial infarction.

Due to limited real-world evidence on the association between time to presentation (T2P) and outcomes following acute myocardial infarction and diabetes (AMI-DM), we investigated the characteristics of patients with AMI-DM and their outcomes based on their T2P. 4,455 patients with AMI-DM from a Korean nationwide observational cohort (2011-2015) were divided into early and late presenters according to symptom-to-door time. The effects of T2P on three-year all-cause mortality were estimated using inverse probability of treatment weighting (IPTW) and survival analysis. The incidence of all-cause mortality was consistently higher in late presenters than in early presenters (11.4 vs. 17.2%; p < 0.001). In the IPTW-adjusted dataset, the incidence of all-cause mortality was numerically higher in late presenters than in early presenters (9.1 vs. 12.4%; p = 0.072). In the survival analysis, the cumulative incidence of all-cause mortality was significantly higher in late presenters than in early presenters before and after IPTW. In the subgroup with ST-elevation myocardial infarction, late presenters had a higher incidence of cardiac death than early presenters before (4.8 vs. 10.5%; p < 0.001) and after IPTW (4.2 vs. 9.7%; p = 0.034). In the initial glycated hemoglobin (HbA1c)-stratified analysis, these effects were attenuated in patients with HbA1c ≥ 9.0% before (adjusted hazard ratio [HR]: 1.45, 95% confidence interval [CI]: 0.80-2.64) and after IPTW (adjusted HR: 0.82, 95% CI: 0.40-1.67). Late presentation was associated with higher mortality in patients with AMI-DM; therefore, multifaceted and systematic interventions are needed to decrease pre-hospital delays.

Cardio–Splenic Relationship in Patients Receiving Trans-Catheter Aortic Valve Replacement

Background: The spleen seems to be a significant buffer of the effective circulating blood volume by changing its size dramatically according to hemodynamics. The cardio–splenic relationship has been recently proposed in the literature regarding heart failure cohorts, and the splenic size has been proposed as a prognostic factor in these cohorts. However, the clinical implication of the splenic size in patients receiving trans-catheter aortic valve replacement (TAVR) remains unknown. Methods: Patients who underwent TAVR at our institute between 2015 and 2022 were eligible. Of these, the patients whose abdominal computed tomography imaging was obtained before TAVR were included. The volume of the spleen was measured in all the participants. The prognostic impact of the indexed splenic volume (SVI) on the 2-year cardiac death or heart failure readmissions was evaluated. Results: A total of 343 patients (86 years, 98 males) were included. The median value of the peak velocity at the aortic valve was 4.4 (4.0, 4.8) m/s and the median SVI was 65.5 (48.9, 86.9) mL/m2. A lower SVI tended to be associated with a lower cardiac output, whereas a higher SVI was associated with a higher plasma volume. The SVI was independently associated with the 2-year cardiac death or heart failure readmission after TAVR with a hazard ratio of 1.09 (95% confidence interval 1.01–1.18, p = 0.041), adjusted for potential confounders. A calculated cutoff of SVI was 70.2 mL/m2, which significantly stratified the cumulative incidence of the primary outcome (10% versus 4%, p = 0.033). Conclusion: A high baseline SVI, which was associated with systemic congestion, was associated with a higher incidence of cardiac death or heart failure readmission after TAVR. Further studies are warranted to clarify the detailed cardio–splenic relationship and implication of measuring the SVI in this cohort.

Changes in left ventricular systolic function for 1 year in patients with acute heart failure &amp;lt;50 years of age

Abstract Funding Acknowledgements Type of funding sources: None. Background Though old age is an important risk factor for cardiovascular disease including heart failure (HF), HF can develop in young patients and can have a greater impact on a quality of life because they are active individuals. Purpose We evaluated the clinical characteristics and prognosis according to change of left ventricular (LV) function in younger patients with acute HF. Methods Study data were obtained from a multicenter cohort that included patients hospitalized for acute HF. Patients who were under 50 years of age and had available data regarding baseline and one-year follow-up left ventricular ejection fraction (LVEF) were included in this analysis. Patient were classified into two groups according changes in LVEF: the improved or stationary group whose LVEF improved or maintained at one-year follow-up; the aggravated LVEF group whose LVEF deteriorated at one-year follow-up. Results Among 437 patients, 14.6% of patients had experienced worsening of LVEF at the one-year follow-up. The patients in aggravated LVEF group had a worse clinical profile than patients with improved or stationary LVEF. During follow-up (median 1946 days), a total of 56 patients (12.8%) died. Among them, the aggravated LVEF group had higher incidence of all-cause death (32.8% vs. 9.4%, p &amp;lt; 0.001). The aggravated LVEF group showed significant lower cumulative all-cause death free survival rate than improved or stationary LVEF group (Figure). In addition, the aggravated LVEF group had significantly higher incidence of cardiac death (14.1% vs. 2.9%, p &amp;lt; 0.001), readmission (76.6% vs. 55.5%, p = 0.002), readmission due to cardiac cause (57.8% vs.30.8%, p &amp;lt; 0.001), and HF readmission (51.6% vs. 26.0%, p &amp;lt; 0.001). After adjusting for confounding factors, Cox regression analysis showed that use of angiotensin converting enzyme inhibitors at discharge was independently associated with 63% reduced risk of aggravated LVEF (Odds ratio 0.37, 95% confidence interval 0.168–0.791, p = 0.001). Conclusions Poor clinical prognosis is expected if LVEF worsens after 1 year in young patients with HF. Clinicians need to be aware of the deteriorating characteristics of young HF patients and provide delicate treatment.

Associations of cardiovascular and diabetes-related risk factors with myocardial perfusion reserve assessed by 201Tl/99mTc-tetrofosmin single-photon emission computed tomography in patients with diabetes mellitus and stable coronary artery disease.

We aimed to examine the associations of cardiovascular risk factors with myocardial perfusion reserve (MPR) in patients with type 2 diabetes and stable coronary artery disease. The study patients were retrospectively identified from a database of patients with diabetes and stable coronary artery disease at Asan Medical Center (Seoul, Republic of Korea), covering the period from 2017 to 2019. The primary outcome variable was MPR assessed by dynamic stress 201Tl/rest 99mTc-tetrofosmin SPECT. Univariable and stepwise multivariable analyses were performed to assess the associations of cardiovascular risk factors with MPR. A total of 276 patients (236 men and 40 women) were included. The median global MPR was 2.4 (interquartile range 1.9-3.0). Seventy-five (27.2%) patients had an MPR < 2.0. Multivariable linear regression showed that smoking (ß = - 0.44, 95% confidence interval - 0.68 to - 0.21, P < 0.001), hypertension (ß = - 0.24, 95% confidence interval - 0.47 to - 0.02, P = 0.033), and summed difference score (ß = - 0.05, 95% confidence interval - 0.07 to - 0.03, P < 0.001) were independently associated with MPR. Abnormal MPR (< 2.0) was associated with a higher incidence of cardiac death or myocardial infarction (P = 0.034). MPR assessed by dynamic stress 201Tl/rest 99mTc-tetrofosmin SPECT was impaired in a large cohort of patients with diabetes. After adjusting for risk variables, including standard myocardial perfusion imaging characteristics, smoking, and hypertension were associated with MPR. Our results may aid in identifying patients with impaired MPR and stratifying patients with type 2 diabetes.

Clinical implications of severe sarcopenia in Japanese patients with acute heart failure.

Sarcopenia is a geriatric condition characterized by progressive loss of skeletal muscle mass and function. The definition and diagnosis of sarcopenia is inconsistent between different populations and is still evolving. Herein, we investigated the prevalence and clinical implications of severe sarcopenia using the Asian Working Group for Sarcopenia (AWGS) 2019 criteria in Japanese patients with acute heart failure (HF). Overall, 272 patients admitted for acute HF were evaluated for sarcopenia using the AWGS 2019 criteria. There were 46 patients with severe sarcopenia, accounting for approximately 75% of patients who were diagnosed as having sarcopenia. A Kaplan-Meier analysis showed that patients with severe sarcopenia had a higher incidence of cardiac death or rehospitalization for HF 1 year post-discharge than those with non-severe sarcopenia or without sarcopenia (log-rank P= 0.006). A multivariate Cox regression analysis showed that severe sarcopenia was independently correlated with the occurrence of cardiac death or rehospitalization for HF after adjusting for other prognostic factors (hazard ratio 2.580, 95% confidence interval: 1.404-4.740, P= 0.002). Severe sarcopenia constituted most sarcopenia diagnoses using the AWGS 2019 cut-off values, and was independently associated with 1-year incidence of cardiac death or rehospitalization for HF post-discharge in Japanese patients with acute HF. The assessment of sarcopenia may provide useful information for HF management. Geriatr Gerontol Int 2022; 22: 477-482.

Six-month Outcome after Early Invasive Versus Delayed Ischaemia Driven Percutaneous Coronary Intervention in Non-ST Elevated Myocardial Infarction

Background: Optimal timing of PCI and comparative outcome between early invasive strategy and ischaemia guided delayed invasive strategy is still in debate in reducing long-term cardiovascular complications in NSTEMI.&#x0D; Objective: The aim of the study was to assess the impact of an early invasive strategy or ischaemia guided delayed invasive strategy on six months clinical outcomes in NSTEMI patients undergoing PCI, from a Bangladesh health service perspective.&#x0D; Materials and Method: It was an observational cross-sectional comparative study conducted in cardiology department of BSMMU from November 2019 to February 2021. Study procedure: This study enrolled 389 adult patients of NSTEMI who underwent PCI which met inclusion and exclusion criteria. Study subjects were divided into two groups: early and delayed groups. This study considered an early invasive strategy as - revascularization within 72h for patients presented with NSTEMI with high-risk features defined by a GRACE score &gt; 140 and for those at lower risk with GRACE score &lt;140; delayed ischaemia driven strategy as - revascularization after 72h, reserved for refractory, recurrent or severe exercise-induced ischaemia. Coronary angiogram (CAG) and PCI were performed by respective consultant according to current practice guidelines. After index PCI, patients were followed up at 06 months for MACEs (Myocardial re-infarction, target vessel revascularization, stroke, hospitalization due to ischaemic causes and cardiac death) and findings of 2 groups were compared.&#x0D; Results: At 6 months after index PCI, patients in the early group despite having worse initial presentation and higher GRACE score had better outcome in comparison with the delayed group who had a statistically significant higher incidence of cardiac death, MI, and target vessel revascularization (p=0.002, p=0.004 and p=0.031). However, incidence of stroke, major bleeding and hospitalization due to ischemia were not significantly different between the groups (p&gt;0.05).&#x0D; Conclusion: Adoption of an early invasive strategy in NSTEMI patients undergoing PCI may be beneficial in reducing the risk of MACEs and associated with improved clinical outcome after PCI at 6 months follow-up.&#x0D; University Heart Journal 2022; 18(1): 22-28

Working Against the Clock: A Model for Rural STEMI Triage.

Residents in rural communities have a higher incidence of cardiac death and risk factors associated with cardiac disease. Living in a rural region can add precious time that amplifies cardiac death during an ST-elevated myocardial infarction (STEMI) episode. The consensus is that improved efficiencies can increase myocardial salvage and decrease STEMI mortality rates. This article identifies issues that may impact pre-hospital STEMI triage of patients in a rural region of the United States (U.S.). A qualitative research design was chosen to gain insight into emergency personnel perceptions of pre-hospital STEMI triage. The participants (n = 18) were obtained from a convenience sample in rural Northeast Texas, U.S. Data were gathered by individual and group semi-structured interviews. Themes were identified, synthesized, and oriented to offer a basis for understanding opportunities to improve the delivery of rural STEMI care. This study demonstrated that quality improvement initiatives aimed at achieving pre-hospital STEMI triage efficiencies have dependencies on teamwork, technology, and training in the context of 3 stages (a) pre-transport, (b) door-to-door, and (c) post-transport. A pre-hospital STEMI triage model is offered based on the findings. By incorporating this model, emergency medical coordinators in rural communities have a better opportunity to facilitate timely reperfusion therapy for this high-risk population.

Achilles tendon thickening is associated with higher incidence of adverse cardiovascular event in patients with coronary artery disease.

Achilles tendon thickening (ATT) is a marker of high risk for coronary artery disease (CAD). However, the association between the presence of ATT and the incidence of cardiovascular events in patients with CAD is unclear. A total of 406 consecutive patients who underwent percutaneous coronary intervention (PCI) and ATT assessment were analyzed. ATT was defined as the Achilles tendon thickness of 9mm or more on radiography. The incidence of major adverse cardiovascular events (MACE) at 1-year was compared between patients with ATT and those without ATT. MACE included cardiac death, non-fatal myocardial infarction, stroke, target vessel revascularization (TVR), and non-TVR. ATT was found in 67 patients (16.5%). The incidence of cardiac death (3.2 vs. 0.0%, p = 0.001), TVR (12.7 vs. 4.0%, p = 0.005) and MACE (20.6 vs. 9.6%, p = 0.011) was significantly higher in the ATT group than the no ATT group. Patients with ATT had significantly higher incidence of cardiac death (5.6 vs. 0%, p < 0.001) than those without ATT even if they did not meet the diagnostic criteria of familial hypercholesterolemia. A multivariate model demonstrated that ATT was independently associated with the MACE at 1-year (Hazard ratio, 2.09; 95% Confidence Interval, 1.09-4.00, p = 0.026). The presence of ATT was independently associated with 1-year recurrence of cardiovascular events in patients with CAD undergoing PCI. Assessment of ATT might be useful for risk stratification of secondary cardiovascular events.

Impact of unprotected left main percutaneous coronary intervention on long-term clinical outcomes: a large single-center study.

With the advancements of percutaneous coronary interventions (PCI), it is not clear whether unprotected left main (ULM) coronary artery disease (CAD) remains an independent predictor of adverse outcomes after PCI therapy. We have therefore carried out a large cohort study to investigate the impact of ULM disease on 2-year clinical outcomes in Chinese patients undergoing contemporary PCI treatment. From January 2013 to December 2013, 10 724 consecutive patients undergoing PCI were prospectively collected. Two-year clinical outcomes were compared for patients undergoing ULM PCI and non-ULM PCI. Among the 10 724 patients, 272 (2.5%) patients underwent ULM PCI. Overall, these patients had higher baseline clinical risks of CAD and more extensive CAD compared with non-ULM PCI patients. During the 2-year follow-up, patients who underwent ULM PCI experienced higher incidence of cardiac death (2.2 vs. 0.7%; log-rank P=0.002), myocardial infarction (7.0 vs. 1.9%; log-rank P<0.001), stroke (2.9 vs. 1.3%; log-rank P=0.02), and definite and probable stent thrombosis (3.3 vs. 0.5%; log-rank P<0.001), than patients who underwent non-ULM PCI. However, the rates of revascularization (7.4 vs. 8.7%; log-rank P=0.48), target vessel revascularization (5.5 vs. 5.0%; log-rank P=0.66), and major adverse cardiac and cerebrovascular events (15.1 vs. 12.0%; log-rank P=0.11) were not significantly different between the groups. When performing adjusted Cox regression after propensity score matching, ULM PCI was not an independent risk factor of any clinical events (all P>0.05). In this large cohort of patients who underwent modern PCI, ULM PCI patients had higher baseline clinical risks and poorer prognosis during 2-year follow-up. However, after multivariate analysis, ULM PCI was not an independent risk factor of any clinical adverse events.

Influence of marital status in patients undergoing transcatheter aortic valve implantation.

Marital status has been described to affect outcome in cardiovascular diseases, however its impact on patients undergoing transcatheter aortic valve implantation (TAVI) is unknown. We therefore aimed to assess the impact of marital status in patients undergoing TAVI. Between 2011 and 2015, 779 patients undergoing transfemoral TAVI with known marital status were included in the analysis. The primary endpoint of the study was the composite of cardiac death and readmission for congestive heart failure (CHF) at one year. Mean age was 80.7±5.9 years, 47.8% were female and median logistic EuroScore was 12.7% (8.13-19.39%). Forty-three point three percent of patients were not married. Compared to married patients, unmarried patients were older (82.4±5.5 vs. 79.5±5.8 years; P<0.001), more often female (73.3% vs. 28.3%; P<0.001), presented with a higher logistic EuroScore [13.1% (9.5-21.5%) vs. 11.7% (7.0-18.5%); P<0.001], and more symptomatic with New York Heart Association functional class III/IV (69.7% vs. 60.6%; P=0.009). At one year the incidence of the primary endpoint was higher in unmarried patients (18.7% vs. 12.0%; P=0.011) which was mainly driven by more admissions for CHF (14.1% vs. 7.8%; P=0.007). After multivariable adjustment, marital status was borderline significant regarding CHF (HR 0.61, 95% CI: 0.37-1.02; P=0.06) but not the primary endpoint. Unmarried patients undergoing TAVI showed a higher incidence of cardiac death or CHF at one year. Hence, marital status should be taken into account in patients with aortic stenosis subjected to TAVI. Whether closer monitoring and intensified medical follow-up improves outcomes remains to be investigated in future studies.

Impact of left ventricular hypertrophy on long-term clinical outcomes in hypertensive patients who underwent successful percutaneous coronary intervention with drug-eluting stents.

Left ventricular hypertrophy (LVH) is associated with increased risk for vascular events and mortality. This study investigated 8-year clinical outcomes of hypertensive patients with LVH who underwent percutaneous coronary intervention (PCI) with drug-eluting stents (DES) compared with hypertensive patients without LVH.A total of 1704 consecutive hypertensive patients who underwent PCI from 2004 to 2014 were enrolled. We classified them into either the LVH group (n = 406) or the control group (without LVH, n = 1298). LVH was defined by LV mass index > 115 g/m2 in men and > 95 g/m2 in women. After propensity score matched (PSM) analysis, 2 PSM groups (366 pairs, n = 732, c-statistic = 0.629) were generated.For up to 8 years, the LVH group showed a higher incidence of cardiac death (4.4% vs 1.2%, log-rank P = .023, hazard ratio: 3.371, 95% confidence interval: 1.109–10.25; P = .032) compared with the control group. However, there were no significant differences between the 2 groups in the incidence of total death, myocardial infarction, revascularization, and major adverse cardiac events up to 8 years.LVH in hypertensive patients who underwent successful PCI with DES was associated with higher incidence of cardiac death up to 8 years of follow-up. More careful managements and clinical follow-up are needed and treatment strategies should specifically focus to target prevention and reversal of LVH in hypertensive patients.

Early administration of tolvaptan preserves renal function in elderly patients with acute decompensated heart failure

BackgroundLoop diuretics used in the treatment of heart failure often induce renal impairment. This study was conducted in order to evaluate the renal protective effect of adding tolvaptan (TLV), compared to increasing the furosemide (FRM) dose, for the treatment of acute decompensated heart failure (ADHF) in a real-world elderly patient population. MethodsThis randomized controlled trial enrolled 52 consecutive hospitalized patients (age 83.4±9.6 years) with ADHF. The patients were assigned alternately to either the TLV group (TLV plus conventional treatment, n=26) or the FRM group (increasing the dose of FRM, n=26). TLV was administered within 24h from admission. ResultsThe incidence of worsening renal function (WRF) within 7 days from admission was significantly lower in the TLV group (26.9% vs. 57.7%, p=0.025). Furthermore, the rates of occurrence of persistent and late-onset (≥5 days from admission) WRF were significantly lower in the TLV group. Persistent and late-onset WRF were significantly associated with a higher incidence of cardiac death or readmission for worsening heart failure in the 90 days following discharge, compared to transient and early-onset WRF, respectively. ConclusionsEarly administration of TLV, compared to increased FRM dosage, reduces the incidence of WRF in real-world elderly ADHF patients. In addition, it reduces the occurrence of ‘worse’ WRF—persistent and late-onset WRF—which are associated with increased rates of cardiac death or readmission for worsening heart failure in the 90 days after discharge.

Abstract 17492: Extent and Pattern of Late Gadolinium Enhancement Predict Arrhythmic Events in Patients With Nonischemic Dilated Cardiomyopathy

Background: Late gadolinium enhancement (LGE) by cardiac MR (CMR) has been related to adverse clinical outcomes in patients with nonischemic dilated cardiomyopathy (NIDC). But, a statistically significant association between LGE and arrhythmic risk in NIDC has not been demonstrated consistently. This study evaluated the impact of the presence, location and pattern of LGE on arrhythmic risk prediction in NICM. Methods: This study included 365 patients (54±15years) with NICM who underwent CMR. The extent, location and pattern of LGE were categorized. We analyzed for the primary outcome of ventricular arrhythmia (VA) including sustained or nonsustained ventricular tachycardia (VT), appropriate implantable cardioverter-defibrillator (ICD) intervention and ventricular fibrillation (VF). Cardiac death and hospitalization for heart failure (HF) were evaluated as secondary outcomes. Results: LGE was seen in 267 (73 %) patients. During median follow-up of 44±36 months, patients with LGE had higher incidence of cardiac death (15 % vs. 2 %, p&lt;0.001), hospitalization for HF (40 % vs. 15 %, p&lt;0.001) and VA (14% vs. 6%, p=0.03). In multivariable analysis, the presence of LGE (HR 2.78; 95% CI 1.10-7.02; p=0.03) was the independent predictor of arrhythmias. Patients with extensive LGE had higher VA (32% vs. 10%, p&lt;0.001) with lower cumulative survival free of VA than those without extensive LGE (p=0.001). The frequent LGE location was as follows: LV septum 64%, LV-RV junction 42% and inferior 10%. VA was lower in patients with than without localized LGE limited to LV-RV junction (21% vs. 46%, p=0.005). Interestingly, while the incidence of ventricular arrhythmia was higher in patients with transmural LGE (29% vs. 10%, p=0.003), it was lower in those with patch LGE (2% vs. 16%, p=0.02) than the other patients. Conclusions: In patients with NICM, the LGE was an independent prognostic predictor of VA. Extensive LGE and specific location of LGE was related with the arrhythmic events.

Clinical outcomes of multiple chronic total occlusions in coronary arteries according to three therapeutic strategies: Bypass surgery, percutaneous intervention and medication

BackgroundLimited data exist regarding clinical outcomes of multiple chronic total occlusions (CTOs) according to therapeutic strategies, coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), and medical treatment (MT). MethodsFrom March 2003 to February 2012, a total of 2024 patients with at least one CTO were enrolled in retrospective, single-center registry. 393 patients with at least two CTOs were categorized based on the intention-to-treat principle. Propensity-score matching was performed. The primary outcome was major adverse cardiac and cerebral events (MACCE). ResultsOf 393 patients with multiple CTOs, 169 patients (43%) were referred for CABG, 130 (33%) for PCI, and 94 (24%) for MT. Median overall follow-up duration was 46.5 (interquartile range 22.7 to 74.6) months. After propensity-score matching analysis, CABG had lower rates of MACCE when compared with PCI (HR=0.43, 0.21–0.85, P=0.01) and MT (HR=0.10, 0.04–0.27, P<0.01). Rates of repeat revascularization was significantly lower in CABG, compared with PCI (HR=0.05, 0.01–0.40, P<0.01) and MT (HR=0.01, 0.00–0.54, P=0.02). CABG had similar rates of cardiac death compared with PCI group (HR=0.97, 0.37–2.53, P=0.95), but had significantly lower rates of cardiac death compared with MT (HR=0.24, 0.08–0.75, P=0.01). ConclusionsFor management of multiple CTOs, MT alone was associated with higher incidence of cardiac death and MACCE compared with CABG. PCI was associated with higher incidence of MACCE, as driven by higher repeat revascularization rate. These findings suggest that CABG might be associated with better clinical outcome and considered as the preferred treatment strategy in patients with multiple CTOs.

QT Peak Prolongation Predicts Cardiac Death Following Stroke

Cardiac death has been linked in many populations to prolongation of the QT interval (QTe). However, basic science research suggested that the best estimate of the time point when begins is near the T-wave peak. We found QT peak (QTp) was longer in hypertensive subjects with LVH. A prolonged depolarisation phase, rather than repolarisation (T peak to T end) might therefore account for the higher incidence of cardiac death linked to long QT. Hypothesis: We have tested the hypothesis that QT peak (QTp) prolongation predicts cardiac death in stroke survivors. Methods and Results: ECGs were recorded from 296 stroke survivors (152 male), mean age 67.2 (SD 11.6) approximately 1 year after the event. Their mean blood pressure was 152/88 mmHg (SD 29/15mmHg). These ECGs were digitised by one observer who was blinded to patient outcome. The patients were followed up for a median of 3.3 years. The primary endpoint was cardiac death. A prolonged heart rate corrected QT peak (QTpc) of lead I carried the highest relative risk of death from all cause as well as cardiac death, when compared with the other more conventional QT indices. In multivariate analyses, when adjusted for conventional risk factors of atherosclerosis, a prolonged QTpc of lead I was still associated with a 3-fold increased risk of cardiac death. (adjusted relative risk 3.0 (95% CI 1.1 - 8.5), p=0.037). Conclusion: QT peak prolongation in lead I predicts cardiac death after stroke.

Dual Antiplatelet Therapy Over 6 Months Increases the Risk of Bleeding after Biodegradable Polymer‐Coated Sirolimus Eluting Stents Implantation: Insights from the CREATE Study

BackgroundThe optimal duration of dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation remains controversial. The primary aim of our study was to evaluate the impact of optimal DAPT duration on bleeding events between 6 and 12 months after biodegradable polymer-coated DES implantation. The secondary aim is to determine the predictors and prognostic implications of bleeding.MethodsThis study is a post hoc analysis of the Multi-Center Registry of EXCEL Biodegradable Polymer Drug Eluting Stents (CREATE) study population. A total of 2,040 patients surviving at 6 months were studied, including 1,639 (80.3%) who had received 6-month DAPT and 401 (19.7%) who had received DAPT greater than 6 months. Bleeding events were defined according to the bleeding academic research consortium (BARC) definitions as described previously and were classified as major/minor (BARC 2–5) and minimal (BARC 1). A left censored method with a landmark at 6 months was used to determine the incidence, predictors, and impact of bleeding on clinical prognosis between 6 and 12 months.ResultsAt 1-year follow-up, patients who received prolonged DAPT longer than 6 months had a significantly higher incidence of overall (3.0% vs. 5.5%, P = 0.021) and major/minor bleeding (1.1% vs. 2.5%, P = 0.050) compared to the patients who received 6-month DAPT. Multivariate analysis showed that being elderly (OR = 1.882, 95% CI: 1.109–3.193, P = 0.019), having diabetes (OR = 1.735, 95% CI: 1.020–2.952, P = 0.042), having a history of coronary artery disease (OR = 2.163, 95% CI: 1.097–4.266, P = 0.026), and duration of DAPT longer than 6 months (OR = 1.814, 95% CI: 1.064–3.091, P = 0.029) were independent predictors of bleeding. Patients with bleeding events had a significantly higher incidence of cardiac death, myocardial infarction, target lesion revascularization, and stent thrombosis.ConclusionsProlonged DAPT (greater than 6 months) after biodegradable polymer-coated DES increases the risk of bleeding, and is associated with adverse cardiac events at 1-year follow-up.

Differential Prognostic Impact of Treatment Strategy Among Patients With Left Main Versus Non–Left Main Bifurcation Lesions Undergoing Percutaneous Coronary Intervention: Results From the COBIS (Coronary Bifurcation Stenting) Registry II

The authors sought to investigate whether the impact of treatment strategies on clinical outcomes differed between patients with left main (LM) bifurcation lesions and those with non-LM bifurcation lesions. Few studies have considered anatomic location when comparing 1- and 2-stent strategies for bifurcation lesions. We compared the prognostic impact of treatment strategies on clinical outcomes in 2,044 patients with non-LM bifurcation lesions and 853 with LM bifurcation lesions. The primary outcome was target lesion failure (TLF) defined as a composite of cardiac death, myocardial infarction (MI), and target lesion revascularization. The 2-stent strategy was used more frequently in the LM bifurcation group than in the non-LM bifurcation group (40.3% vs. 20.8%, p < 0.01). During a median follow-up of 36 months, the 2-stent strategy was not associated with a higher incidence of cardiac death (hazard ratio [HR]: 1.24; 95% confidence interval [CI]: 0.72 to 2.14; p= 0.44), cardiac death or MI (HR: 1.12; 95% CI: 0.58 to 2.19; p=0.73), or TLF (HR: 1.39; 95% CI: 0.99 to 1.94; p= 0.06) in the non-LM bifurcation group. In contrast, in patients with LM bifurcation lesions, the 2-stent strategy was associated with a higher incidence of cardiac death (HR: 2.43; 95% CI: 1.05 to 5.59; p= 0.04), cardiac death or MI (HR: 2.09; 95% CI: 1.08 to 4.04; p= 0.03), as well as TLF (HR: 2.38; 95% CI: 1.60 to 3.55; p < 0.01). Significant interactions were present between treatment strategies and bifurcation lesion locations for TLF (p= 0.01). The 1-stent strategy, if possible, should initially be considered the preferred approach for the treatment of coronary bifurcation lesions, especially LM bifurcation lesions. (Korean Coronary Bifurcation Stenting [COBIS] Registry II; NCT01642992).

Cytochrome c release in acute myocardial infarction predicts poor prognosis and myocardial reperfusion on contrast-enhanced magnetic resonance imaging

Myocardial ischemia and reperfusion injury in ST-segment elevation myocardial infarction (STEMI) can trigger no-flow, resulting in myocardial necrosis and apoptosis, even a poor prognosis. Cytochrome c can induce an apoptotic process. The aim of our study was to assess the relationship between systemic cytochrome c levels and the occurrence of no-reflow in STEMI. One hundred and sixty patients with STEMI undergoing a primary percutaneous coronary intervention (PPCI) were randomly chosen. Patients were divided into two groups defined by the mean cytochrome c peak level after PPCI. No-reflow was assessed using three different methods after PPCI: myocardial blush grade, electrocardiographic ST-resolution, and microvascular obstruction (MO) assessed by cardiovascular magnetic resonance imaging. The primary clinical end points were major adverse cardiovascular events (defined as cardiac death, reinfarction, or new congestive heart failure). Clinical follow-up was carried out for 1 year. Patients with a cytochrome c level of at least the mean peak level had a greater creatine kinase-MB isoenzyme peak level (P=0.044), a lower left ventricular ejection fraction (P=0.029), a significantly higher occurrence of early MO (P=0.008), and a significantly larger extent of early MO (P=0.020). The cytochrome c peak level was elevated in patients with early MO (P=0.025), myocardial blush grade 0-1 (P=0.002), and ST-resolution less than 30% (P=0.003) after PPCI. A higher incidence of cardiac death at the 1-year follow-up was found in the patients with cytochrome c levels of at least the mean peak level (log rank, P=0.029). Cytochrome c levels above the mean peak level were related to no-reflow and mortality in patients with STEMI.

Myocardial fibrosis and QTc are reduced following treatment with spironolactone or amiloride in stroke survivors: A randomised placebo-controlled cross-over trial

IntroductionMyocardial fibrosis is dysrhythmogenic and may contribute to the high incidence of cardiac death in stroke survivors, especially if they have long QTc. We tested the hypothesis that procollagen-1-carboxy terminal peptide (P1CP), a biomarker of myocardial fibrosis, might be improved following treatment with spironolactone or amiloride in stroke survivors. We also tested the hypothesis that both drugs would shorten QTc. MethodsStudy design: randomised, double-blinded, placebo-controlled, cross-over trial (spironolactone vs. amiloride vs. placebo).Duration of Study: 3months (1month per drug).Primary endpoints: P1CP, QTc Results11 stroke survivors (5 female), aged 71+4, BP 139/81mmHg+20/11mmHg, completed the study. Both spironolactone and amiloride significantly reduced P1CP [Spironolactone–Placebo=−24 ug/L, 95% CI=−40 to −6.9; Amiloride–Placebo=−28 ug/L, 95% CI=−44 to −11]. Spironolactone and amiloride both shortened QTc [Spironolactone vs. Placebo=−18ms1/2, 95% CI=−36 to −0.55; Amiloride vs Placebo=−25ms1/2, 95% CI=−42 to −7.5]. ConclusionsProcollagen-1-carboxy terminal peptide was reduced following treatment with spironolactone within a month. Further, this is the first study demonstrating amiloride could also improve myocardial fibrosis. The beneficial effects of both drugs on myocardial fibrosis, coupled with their effects on raising potassium translated to a shortening of QTc. Future studies should test the hypothesis that these drugs might reduce the risk of sudden cardiac death in stroke survivors.