Higher Incidence Of Major Adverse Cardiac Events Research Articles

Relation of C-Reactive Protein to Coronary Plaque Characteristics on Grayscale, Radiofrequency Intravascular Ultrasound, and Cardiovascular Outcome in Patients With Acute Coronary Syndrome or Stable Angina Pectoris (from the ATHEROREMO-IVUS Study)

The relation between C-reactive protein (CRP) and coronary atherosclerosis is not fully understood. This study aims to investigate the associations among high-sensitivity CRP, coronary plaque burden, and the presence of high-risk coronary lesions as measured by intravascular ultrasound (IVUS) and 1-year cardiovascular outcome. Between 2008 and 2011, grayscale and virtual histology IVUS imaging of a nonculprit coronary artery was performed in 581 patients who underwent coronary angiography for acute coronary syndrome (ACS) or stable angina pectoris. Primary end point consisted of 1-year major adverse cardiac events (MACEs), defined as all-cause mortality, ACS, or unplanned coronary revascularization. After adjustment for established cardiac risk factors, baseline CRP levels were independently associated with higher coronary plaque burden (p = 0.002) and plaque volume (p = 0.002) in the imaged coronary segment. CRP was also independently associated with the presence of large lesions (plaque burden ≥70%; p = 0.030) but not with the presence of stenotic lesions (minimal luminal area ≤4.0 mm(2); p = 0.62) or IVUS virtual histology-derived thin-cap fibroatheroma lesions (p = 0.36). Cumulative incidence of 1-year MACE was 9.7%. CRP levels >3 mg/L were independently associated with a higher incidence of MACE (hazard ratio 2.17, 95% confidence interval [CI] 1.01 to 4.67, p = 0.046) and of all-cause mortality and ACS only (hazard ratio 3.58, 95% CI 1.04 to 13.0, p = 0.043), compared with CRP levels <1 mg/L. In conclusion, in patients who underwent coronary angiography, high-sensitivity CRP is a marker of coronary plaque burden but is not related to the presence of virtual histology-derived thin-cap fibroatheroma lesions and stenotic lesions. CRP levels >3 mg/L are predictive for adverse cardiovascular outcome at 1 year.

The effect of low FT3 levels on coronary artery calcification and MACE in outpatients with suspected coronary artery disease

Considerable evidence suggests that thyroid dysfunction, especially hypothyroidism, may lead to coronary artery disease (CAD). The aim of this study is to investigate the effect of low serum levels of free triiodothyronine (FT3) on coronary artery calcification in outpatients with suspected CAD and the occurrence rate of major adverse cardiac events (MACE) in these patients. A total of 588 outpatients with suspected CAD were enrolled in this study. The patients' blood samples were assayed for FT3, free thyroxine, thyroid stimulating hormone and serum lipids. On the basis of FT3 levels, these patients were divided into low FT3 (FT3<3.5 pmol/l; n=127) and normal FT3 (≥3.5 pmol/l; n=461) groups. Coronary artery calcification scores (CACS) were measured using dual-source computed tomography. The occurrence of MACE was recorded during the follow-up period (8-29 months) and their relationship with FT3 levels was investigated. Patients with low FT3 levels had higher CACS (337.52±339.36 vs. 194.89±347.29, P<0.001) and a higher incidence of MACE (7.9 vs. 2.2%, P=0.002) compared with those with normal FT3 levels (≥3.5 pmol/l). Logistic regression analysis showed that the FT3 levels are inversely associated with CACS (odds ratio=0.463, 95% confidence interval=0.282-0.761, P=0.002) and patients with CACS greater than 100 have lower FT3 levels than those with lower CACS (P<0.001). Kaplan-Meier analysis showed that patients with low FT3 levels have a higher incidence of MACE. FT3 levels were inversely associated with CACS and the incidence of MACE in patients with suspected CAD. A low FT3 level was an important predictor of the occurrence of MACE.

Long-Term Predictors of Clinical Events after Off-Label Use of Drug-Eluting Stent beyond 1 Year

Background and ObjectivesWe evaluated the long-term outcomes and predictors of clinical events after off-label use of drug-eluting stents (DES) beyond 1 year after procedure.Subjects and MethodsA total of 518 patients who underwent DES implantation for off-label indications and did not have any major adverse cardiac events (MACE) during the first year were analyzed. The occurrence of MACE, including cardiac death, myocardial infarction (MI), stent thrombosis and target vessel revascularization, were evaluated for a median 1179 days (interquartile range 769-1541) after the first year.ResultsMajor adverse cardiac events occurred in 43 patients (8.3%) including 8 cases (1.5%) of cardiac death, 9 cases (1.7%) of MI, 24 cases (4.6%) of target vessel revascularization, and 11 cases (2.1%) of stent thrombosis. Patients with MACE had a higher serum creatinine level, higher incidence of in-stent restenosis lesion, more overlapping stents, a greater number of stents, and longer stents than did patients without MACE. Multivariate analysis revealed that serum creatinine level >1.5 mg/dL {hazard ratio (HR) 2.3, p=0.019}, stent length >33 mm (HR 2.4, p=0.035), and in-stent restenosis lesions (HR 2.4, p=0.040) were independent risk factors for MACE. Patients with DES length >33 mm had a higher incidence of MACE than those with DES length ≤33 mm (HR 2.7, log rank p=0.002).ConclusionThe risk of stent thrombosis and target vessel revascularization persisted in patients undergoing off-label DES implantation beyond 1-year follow-up. A total DES length >33 mm was a significant procedural predictor associated with the incidence of MACE.

110 THE pre-operative 12 lead ECG; can it predict post-operative cardiac complications?: Abstract 110 Table 1

<h3>Introduction</h3> The 12 lead electrocardiogram (ECG) is a standard pre-operative investigation for patients undergoing major surgery. A number of recent publications have questioned the predictive value for post-operative cardiac risk. The aim of this study is to investigate the correlation between an abnormal ECG and a post-operative major adverse cardiac event (MACE) and mortality. <h3>Methods</h3> A prospective single centre observational cohort study of 345 patients undergoing major non-cardiac surgery between January 2004 and August 2006 was performed. Patients underwent standard pre-operative assessment including an ECG. Screening for post-operative events was carried out with serial ECG and troponin measurement. Primary end-points were MACE (cardiac death and non-fatal myocardial infarction) and all-cause mortality. <h3>Results</h3> Three hundred and forty-five patients were included in the study, performed between January 2004 and August 2006. 276 (80.0%) patients underwent a vascular procedure (aortic surgery 25.8%, lower limb bypass 29.8% and amputation 25.2%) and 69 (20.0%) patients underwent laparotomy. An abnormal ECG (Abstract 110 Table 1) was present in 141 (40.9%) patients. MACE was observed in 46 (13.3) patients, and 27 (7.8%) patients died in the post-operative period. Patients with an abnormal ECG had a higher incidence of MACE (22.0% vs 7.4%, p&lt;0.001), and higher mortality rate (12.1% vs 9.8%, p=0.015). Univariate analysis shows that AF, strain and prolonged QTc interval predict post-operative events. Multivariate analysis of clinical variables and ECG abnormalities showed that strain, prolonged QTc and hypertension independently predicted post-operative MACE. <h3>Conclusion</h3> This study shows that ECG abnormalities were more predictive than traditional clinical variables for post-operative MACE, and therefore confirms that an ECG remains a useful adjunct in pre-operative assessment before surgery. An abnormal ECG confers a threefold increase risk of post-operative MACE. This may allow improved pre-operative optimisation and enhanced peri-operative care to reduce the event rates.

Resultados clínicos de pacientes com reestenose intrastent não tratada com novo procedimento de revascularização

INTRODUCAO: A reestenose clinica apos o implante de stent coronario costuma ser tratada com revascularizacao da lesao-alvo (RLA). Nosso objetivo foi relatar o perfil clinico e os desfechos de pacientes com reestenose intrastent (RIS) sintomatica que nao foram submetidos a nova RLA. METODO: Identificamos pacientes que apresentaram reestenose clinica apos colocacao de stent coronario entre janeiro de 1997 e dezembro de 2001. As caracteristicas clinicas e angiograficas e os desfechos clinicos dos pacientes que nao passaram por nova revascularizacao (grupo sem RLA) foram comparados aos de pacientes revascularizados (grupo com RLA). Todos os pacientes tiveram acompanhamento de pelo menos dois anos apos implante do stent para ocorrencia de eventos cardiacos adversos maiores (ECAM). RESULTADOS: No periodo do estudo, 1.221 stents foram implantados em 1.149 pacientes. Observou-se RIS em 135 pacientes (12%), dos quais 104 tiveram acompanhamento clinico e angiografico completo, 23 no grupo sem RLA e 81 no grupo com RLA. O periodo medio de acompanhamento apos a colocacao de stent coronario foi de 30,8 ± 7,5 meses. Pacientes do grupo sem RLA tiveram porcentual significativamente mais alto de doenca de um vaso (82% vs. 47%; P < 0,01). Pacientes do grupo sem RLA apresentaram taxa de ECAM de longo prazo de 21,7% (5 pacientes: 2 obitos, 3 infartos do miocardio), enquanto nos pacientes do grupo com RLA a taxa de ECAM foi de 9,8% (8 pacientes: 1 obito, 4 infartos do miocardio, 3 cirurgias de revascularizacao miocardica; P = 0,11). CONCLUSAO: Pacientes com RIS clinica nao tratados com RLA apresentaram doenca de um vaso com maior frequencia e tendencia para maior incidencia de ECAM em comparacao com pacientes tratados com nova RLA.

Long-Term Prognostic Value of 13N-Ammonia Myocardial Perfusion Positron Emission Tomography: Added Value of Coronary Flow Reserve

The goal of this study was to assess the predictive value of myocardial perfusion imaging with (13)N-ammonia positron emission tomography (PET) and coronary flow reserve (CFR) on long-term prognosis in patients with suspected myocardial ischemia. No prognostic data exist on the predictive value of CFR and (13)N-ammonia PET. Perfusion and CFR were assessed in 256 patients using (13)N-ammonia PET, and follow-up was obtained in 245 (96%) patients. Sixteen early revascularized patients were excluded and 229 were assigned to normal versus abnormal perfusion or normal versus abnormal CFR (<2.0). Major adverse cardiac events (MACE) (cardiac death, nonfatal myocardial infarction, late revascularization, or hospitalization for cardiac reasons) were assessed using the Kaplan-Meier method. Cox proportional hazard regression was used to identify independent predictors for cardiac events. During follow-up (5.4 +/- 2.2 years), 78 patients had at least 1 cardiac event, including 29 cardiac deaths. Abnormal perfusion (n = 126) was associated with a higher incidence of MACE (p < 0.001) and cardiac death (p < 0.05). In patients with normal perfusion, abnormal CFR was independently associated with a higher annual event rate over 3 years compared with normal CFR for MACE (1.4% vs. 6.3%; p < 0.05) and cardiac death (0.5% vs. 3.1%; p < 0.05). In abnormal perfusion, CFR remained predictive throughout the 10-year follow-up (p < 0.001). Perfusion findings in (13)N-ammonia PET and CFR are strong outcome predictors. CFR allows further risk stratification, suggesting a "warranty" period of 3 years if normal CFR is associated with normal perfusion. Conversely, in patients with abnormal perfusion, an impaired CFR has added value for predicting adverse outcomes.

Response of high-sensitivity C-reactive protein to percutaneous coronary intervention in patients with acute coronary syndrome

Percutaneous coronary intervention (PCI) provokes an inflammatory reaction, as shown by increased concentrations of plasma C-reactive protein (CRP) after PCI. However, the changes of CRP levels after PCI in patients with acute coronary syndrome (ACS) have not been well evaluated. We evaluated the characteristics of the patients with elevated CRP response after PCI and whether an increase in CRP after PCI predicts long-term prognosis in patients with ACS. We studied consecutive 360 patients with ACS who underwent elective coronary stenting. Inflammatory response to PCI was calculated as the difference between the peak postprocedural hsCRP level and the preprocedural hsCRP level (DeltaCRP). Twelve months follow-up data were obtained and clinical outcomes were compared with DeltaCRP. In receiver operating characteristics analyses, the cutoff point of DeltaCRP for major adverse cardiac events (MACE) was 3.0 mg/l, which yielded sensitivity of 61.7% and specificity of 69.7%. The patients with DeltaCRP > 3 mg/l revealed higher incidence of myocardial infarction (37.7 vs 14.6%, P < 0.001), and ACC/AHA type B2/C lesion (81.5 vs 68.7%, P = 0.006) than in patients with low DeltaCRP. White blood cell count, low-density lipoprotein cholesterol, peak creatinine kinase-MB, and peak troponin T were significantly elevated in patients with DeltaCRP > 3 mg/l than in those with < or =3 mg/l. There was significant correlation between DeltaCRP and the changes in troponin T after PCI (r = 0.210, P < 0.001). An increase in hsCRP > 3 mg/l after PCI had a higher predictive value for the occurrence of MACE than low hsCRP elevation (hazard ratio 2.1, P = 0.005). In multivariate analysis, DeltaCRP and peak troponin T were independent predictors of MACE (P < 0.001 and P = 0.013, respectively). In conclusion, postprocedural hsCRP elevation >3 mg/l was associated with higher incidence of MACE in patients with ACS. DeltaCRP determinations may be of value for risk stratification after PCI.

Long-term outcome of patients of over 85 years old with acute coronary syndrome undergoing percutaneous coronary stenting: a comparison of bare metal stent and drug eluting stent

Patients aged over 85 years have been under-represented in percutaneous coronary intervention (PCI) trials despite an increase in referrals for PCI. The long-term safety and efficacy of percutaneous coronary stenting in patients aged over 85 years with acute coronary syndrome (ACS) remain unclear. Moreover it is unknown whether there are differences between bare metal stent (BMS) and drug eluting stent (DES) in this special population. A total of 80 patients with ACS aged over 85 years undergoing stenting (BMS group n = 21 vs DES group n = 59) were retrospectively studied. In-hospital, one year and overall clinical follow-up (12 - 36 months) of major adverse cardiac events (MACEs) including cardiac deaths, myocardial infarction, target lesion revascularization (TLR) and target vessel revascularization (TVR) as well as stroke and other major bleeding were compared between the two groups. In the entire cohort, the procedure success rate was 93.8% with TIMI-3 coronary flow post-PCI in 93.8% of the vessels and the procedure related complication was 17.5%. The incidence of in-hospital MACEs in BMS group was higher (14.3% vs 6.8%, P = 0.30). The 1-year incidence of MACEs in DES group was 7.0% while there was no MACE in the BMS group. Clinical follow-up for 12 - 36 months showed that the overall survival free from MACE was 82.9% and the incidence of MACE in the BMS group was lower (5.3% vs 21.1%, P = 0.20). Multivariate regression analysis showed that the creatinine level (OR: 1.013; 95% CI: 1.006 - 1.020; P = 0.004) and hypertension (OR: 3.201; 95% CI: 1.000 - 10.663; P = 0.04) are two major factors affecting the long-term MACE. Percutaneous coronary stenting in patients aged over 85 years is safe and provides good short and long-term efficacy. Patients with renal dysfunction and hypertension may have a relatively high incidence of MACE.

Impact of Sirolimus-Eluting and Paclitaxel-Eluting Stents on Outcome in Patients With Diabetes Mellitus and Stenting in More Than One Coronary Artery

Randomized trials have shown that implantation of sirolimus-eluting stents (SESs) and paclitaxel-eluting stents (PESs) reduce the incidence of major adverse cardiac events (MACEs) compared with bare metal stents. We compared the impact of SESs and PESs on clinical outcome in medically treated diabetic patients with multivessel stents. In this study, the in-hospital and 9-month clinical outcomes of 260 consecutive diabetic patients who underwent implantation of SESs (147 patients) or PESs (113 patients) were compared. MACEs were defined as death, nonfatal myocardial infarction, and clinically driven target vessel revascularization. The baseline demographic and angiographic characteristics were well matched. An average of 3.0 +/- 1.3 versus 2.8 +/- 1.2 lesions were treated in the SES and PES groups, respectively (p = 0.34), with a mean stented length per patient of 73 +/- 43 versus 61 +/- 36 mm (p = 0.08). No significant difference was observed between the SES and PES groups for in-hospital (6.1% vs 3.5%, p = 0.34) or 9-month MACE (24.5% vs 19.5%, p = 0.34) rates or for subacute (1.4% vs 0.9%, p = 0.72) or late (0.7% vs 0.9%, p = 0.85) stent thrombosis. Insulin-requiring diabetic patients treated with SESs and PESs also had similar demographic and angiographic characteristics and rates of in-hospital (4.7% vs 7.7%, p = 0.57) and 9-month (28.0% vs 38.4%, p = 0.44) MACEs. Insulin-dependent diabetes was the only independent predictor of MACEs (odds ratio 2.68, 95% confidence interval 1.46 to 4.89, p = 0.001). In conclusion, our results demonstrated a relatively high incidence of MACEs in a diabetic population with multivessel disease, despite treatment with drug-eluting stents. In addition, we could not find any clear advantage of 1 type of stent versus the other.