Higher Rates Of Major Adverse Cardiovascular Events Research Articles

Impact of Iron Deficiency on Peripheral Artery Disease After Endovascular Therapy.

Background: Despite advances in endovascular therapy (EVT), peripheral artery disease (PAD) is a public health problem associated with high cardiovascular mortality. Iron deficiency (ID) is associated with poor clinical outcome in patients with heart disease, but whether ID is associated with the severity and clinical outcome of PAD remains unclear. Methods and Results: A total of 449 patients with PAD who received EVT and who had iron and red blood cell measurement were enrolled. ID was defined as transferrin saturation (TSAT) <20%, based on a previous report. TSAT and hemoglobin decreased with deteriorating Fontaine class. During a median follow-up period of 1,064 days, 71 major adverse cardiovascular and leg events (MACLE) and 47 major adverse cardiovascular events (MACE) were noted. All patients were divided into 2 groups based on the presence of ID. On Kaplan-Meier analysis, patients with ID had higher rates of MACE and MACLE than those without. On multivariate Cox proportional hazard regression analysis, TSAT and hemoglobin were independently associated with MACLE. Addition of TSAT to the known risk factors significantly improved the net reclassification index and integrated discrimination improvement. Conclusions: ID, as assessed by TSAT, was associated with the severity and clinical outcome of PAD, indicating that it could be a therapeutic target.

One-Year Outcomes of Patients With Established Coronary Artery Disease Presenting With Acute Coronary Syndromes

The risk of major adverse cardiovascular events (MACE) remains high in patients with established coronary artery disease (CAD). The aim of this study was to assess the prognostic significance of established CAD in patients who present with acute coronary syndromes (ACS) using a large established multicenter registry. Consecutive patients from the Melbourne Interventional Group registry who presented with ACS and underwent percutaneous coronary intervention from 2005 to 2015 were included. Patients with a history of myocardial infarction, percutaneous coronary intervention, or coronary artery bypass graft surgery were included in the established CAD cohort. The primary end points were 12-month mortality and 12-month MACE. Of the 12,878 ACS patients included in our study, 3,542 (28%) patients had established CAD. Over the 10-year study period, the proportion of patients presenting with established CAD decreased (30.7% to 25.2%; p-for-overall-trend <0.001). Non-ST elevation myocardial infarction was the most prominent presentation in the established CAD cohort (45.1%) whereas ST-elevation myocardial infarction was the most prominent in the de novo CAD cohort (51%; p< 0.001). The patients in the established CAD cohort were older, had more co-morbidities and were more likely to present with high-risk features such as atrial fibrillation, left main disease, multivessel CAD and left ventricular dysfunction (all p < 0.001). Regarding revascularization in ST-elevation myocardial infarction presentations, symptom-to-door time was shorter, whereas door-to-balloon-time was longer in those with established CAD (p < 0.001). On multivariate analysis, established CAD was an independent risk factor for 12-month MACE (odds ratio 1.40, 95% confidence intervals 1.23 to 1.58, p < 0.001), but not for 12-month mortality (odds ratio 1.08, 95% confidence intervals 0.77 to 1.52, p = 0.66). In conclusion, patients with a history of myocardial infarction or previous revascularization have a higher rate of MACE at 12 months. Despite this they do not appear to suffer from higher mortality.

Radial versus femoral vascular access in ST-elevation myocardial infarction: Are the results of femoral operators unfairly represented in observational research?

Recent randomized controlled trials comparing femoral and radial access in primary percutaneous coronary intervention (PPCI) have shown conflicting results regarding the incidence of major adverse cardiovascular events (MACE) and major bleeding. Using data from the HEAT-PPCI trial, we compared the primary efficacy (all-cause mortality, stroke, new myocardial infarction or unplanned repeat revascularization) and safety (major bleeding BARC 3-5) outcomes at 28 days, by final access site used (radial or femoral) and by default operator type. We then assessed outcomes in femoral cases performed by both operator types. Radial access (RA) was associated with fewer MACE (91/1472 = 6.2% vs. 36/332 = 10.8% P = .003) and major bleeding events (38/1472 = 2.6% vs 22/332 = 6.6% P = .001) when compared to femoral access (FA). When analyzing outcomes by default operator type, there was a similar incidence of MACE (111/1575 = 7% vs 16/229 = 7% P = .97) and major bleeding events (49/1575 = 3.1% vs 11/229 = 4.8% P = .18). In cases where FA was performed by default radial operators, there was a higher rate of MACE (22/122 = 18% vs 14/210 = 6.7% P = .003) and major bleeding events (11/122 = 9% vs 11/210 = 5.2% P < .001), potentially explained by a higher risk profile in these cases. Default femoral operators achieved comparable outcomes when compared to default radial operators. The less favorable outcomes observed in FA cases may result from its selective use by radial operators in high risk cases.

Prognostic Value of Hemoglobin A1c Levels in Postmenopausal Diabetic Patients Undergoing Percutaneous Coronary Intervention (PCI) for Acute Coronary Syndrome.

BackgroundThe purpose of our study was to analyze the clinical value of glycosylated hemoglobin Alc (HbA1c) levels in postmenopausal women with acute coronary syndrome (ACS) and diabetes following percutaneous coronary intervention (PCI).Material/MethodsA total of 173 consecutive postmenopausal patients with comorbid diabetes underwent PCI for primary ACS were enrolled in this study. Serum HbA1c levels were measured prior to PCI, and baseline clinical characteristics of all patients were collected. All patients were followed up at regular intervals for major adverse cardiovascular events (MACEs) during the first year after PCI. MACEs included cardiac death, non-fatal myocardial infarction, and target vessel revascularization (TVR).ResultsAt the endpoint of this study, 29 (16.8%) patients out of all 173 patients had MACEs. According to the effect of glycemic control (as indicated by HbA1c levels), all patients were stratified into a well-controlled group (HbA1c ≤7.0%, N=72) and a poorly-controlled group (HbA1c >7.0%, N=101). The incidence rate of MACEs and TVR in poorly-controlled diabetics was prominently higher than that in well-controlled diabetics (10.8% vs. 21.8%, p=0.04). In multivariable COX regression analysis, after adjustment for potential confounders, HbA1c ≥7.0% remained an independent risk predictor of MACE (HR, 2.17; 95%CI, 1.13–5.65; p<0.01).ConclusionsIn postmenopausal ACS patients with comorbid diabetes, a high level of HbA1c is associated with a higher MACE rate after PCI, which is mainly driven by a higher rate of TVR.

Incidence and predictors of bleeding in ACS patients treated with PCI and prasugrel or ticagrelor: An analysis from the RENAMI registry

ObjectivesTo evaluate “real life” incidence and independent predictors of major bleeding defined in ACS patients treated with PCI and current standard antithrombotic therapy with prasugrel or ticagrelor. Methods and resultsThe RENAMI project is a multicenter retrospective observational registry enrolling 4424 patients with ACS treated with PCI and prasugrel or ticagrelor plus aspirin. Primary endpoint was MACE (major adverse cardiovascular events). Secondary endpoints included each component of MACE, cardiovascular death (CV death), recurrence of ACS (reACS) and stroke. Eighty three (1.8%) patients developed out of hospital major bleedings after 14.1 ± 6.2 months. These patients had higher rates of MACE (14.5% vs 4.4%; p = 0.001) and of all-cause death (11% vs 2.1%; p < 0.001). Independent predictors of major bleeding were age >75 years (OR 2.00; 95% CI 1.18–3.41; p = 0.010) and female sex (OR 1.66; 95% CI 1.02–2.70; p = 0.041). BARC 3–5 bleeding was independently associated with all-cause mortality (OR 3.46; 95% CI 1.64–7.31; p 0.001). ConclusionIn ACS patients treated with PCI and ticagrelor or prasugrel, BARC 3–5 bleedings despite being uncommon negatively impacted on prognosis. Old and female patients are at increased risk, offering clinical indications for tailoring dual antiplatelet therapy.

Circulating Surfactant Protein-D Is Associated With Clinical Outcomes in Peripheral Artery Disease Patients Following Endovascular Therapy.

Peripheral artery disease (PAD) is a risk factor for the development of cardiovascular disease and death. Surfactant protein-D (SP-D) is a 43-kDa protein secreted from type II pneumocytes in the lungs. Recent studies have demonstrated that circulating SP-D plays a key role in the development of atherosclerosis and is related to clinical outcomes in patients with ischemic heart disease. However, it remains unclear whether circulating SP-D is associated with clinical outcomes in patients with PAD.Methods and Results:We enrolled 364 patients with PAD who underwent endovascular therapy. We measured serum levels of SP-D and Krebs von den Lungen-6 (KL-6). During a median follow-up period of 974 days, there were 69 major adverse cardiovascular and leg events (MACLE), including 48 major adverse cardiovascular events (MACE). Kaplan-Meier analysis demonstrated that patients with high SP-D (≥110 ng/mL) had higher rates of MACE and MACLE than those with low SP-D. Multivariate Cox proportional hazard regression analysis demonstrated that SP-D, but not KL-6, was an independent predictor of MACE and MACLE. The addition of SP-D to known risk factors significantly improved the C index and net reclassification index. The circulating SP-D level was affected by sex, diabetes mellitus, and cilostazol prescription. Circulating SP-D was associated with clinical outcomes in patients with PAD, suggesting that it may be a new therapeutic target in these patients.

Treatment outcomes in diabetic patients with chronic limb-threatening ischemia

ObjectiveThere are conflicting reports about outcomes after infrainguinal bypass for chronic limb-threatening ischemia (CLTI) in patients with diabetes. We compared perioperative outcomes between patients with and patients without diabetes in the current era. MethodsThe National Surgical Quality Improvement Program vascular module, 2011 to 2014, was used to identify patients undergoing infrainguinal revascularization for CLTI. Patients with and without diabetes were compared in terms of presentation, comorbidities, operative approach, and 30-day outcomes. Major adverse limb events (MALEs) included 30-day major reintervention or amputation, and major adverse cardiovascular events (MACEs) included 30-day myocardial infarction, cardiac arrest, stroke, or death. Multivariable logistic regression was used to adjust for baseline differences. ResultsWe identified 8887 patients undergoing open (5744; 50% diabetic) or endovascular (3143; 62% diabetic) treatment for CLTI. Patients with diabetes were younger and more often nonwhite, nonsmokers, and obese. Patients with diabetes presented more often with tissue loss (71% vs 47%; P < .001) and were more likely to be treated with endovascular intervention (41% vs 29%; P < .001). The 30-day mortality was similar before (open, 3.1% vs 2.8% [P = .53]; endovascular, 2.6% vs 2.1% [P = .37]) and after adjustment for baseline differences (open: odds ratio [OR], 1.1 [95% confidence interval (CI), 0.7-1.5]; endovascular: OR, 1.2 [95% CI, 0.7-2.0]). Patients with diabetes had longer lengths of stay (open, 8 vs 6 days [P < .001]; endovascular, 3 vs 2 days [P < .001]) and higher 30-day readmission rates (open, 21% vs 18% [P < .01]; endovascular, 20% vs 15% [P < .01]); however, these differences were no longer significant after adjustment for baseline differences. Patients with diabetes had a higher rate of MACEs (7.0% vs 5.1%; P < .01) and lower rate of MALEs (8.1% vs 10%; P < .01) after bypass. After adjustment, patients with diabetes still had a lower rate of MALEs (OR, 0.7; 95% CI, 0.6-0.9) but no longer had a higher rate of MACEs (OR, 1.2; 95% CI, 0.9-1.6). ConclusionsCLTI patients with diabetes undergoing revascularization have similar 30-day outcomes compared with those without diabetes, although they appear to be at lower risk for MALEs after bypass. Prolonged length of stay and readmission in patients with diabetes is not due to underlying diabetic disease but likely secondary to other baseline comorbidities, such as higher rates of tissue loss. Concern for worse perioperative outcomes in patients with diabetes after lower extremity bypass is unsubstantiated and should not discourage a physician from performing an open bypass.

Use of High-Risk Coronary Atherosclerotic Plaque Detection for Risk Stratification of Patients With Stable Chest Pain

Coronary computed tomographic angiography (coronary CTA) can characterize coronary artery disease, including high-risk plaque. A noninvasive method of identifying high-risk plaque before major adverse cardiovascular events (MACE) could provide practice-changing optimizations in coronary artery disease care. To determine whether high-risk plaque detected by coronary CTA was associated with incident MACE independently of significant stenosis (SS) and cardiovascular risk factors. This prespecified nested observational cohort study was part of the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) trial. All stable, symptomatic outpatients in this trial who required noninvasive cardiovascular testing and received coronary CTA were included and followed up for a median of 25 months. Core laboratory assessment of coronary CTA for SS and high-risk plaque (eg, positive remodeling, low computed tomographic attenuation, or napkin-ring sign). The primary end point was an adjudicated composite of MACE (defined as death, myocardial infarction, or unstable angina). The study included 4415 patients, of whom 2296 (52%) were women, with a mean age of 60.5 years, a median atherosclerotic cardiovascular disease (ASCVD) risk score of 11, and a MACE rate of 3% (131 events). A total of 676 patients (15.3%) had high-risk plaques, and 276 (6.3%) had SS. The presence of high-risk plaque was associated with a higher MACE rate (6.4% vs 2.4%; hazard ratio, 2.73; 95% CI, 1.89-3.93). This association persisted after adjustment for ASCVD risk score and SS (adjusted hazard ratio [aHR], 1.72; 95% CI, 1.13-2.62). Adding high-risk plaque to the ASCVD risk score and SS assessment led to a significant continuous net reclassification improvement (0.34; 95% CI, 0.02-0.51). Presence of high-risk plaque increased MACE risk among patients with nonobstructive coronary artery disease relative to patients without high-risk plaque (aHR, 4.31 vs 2.64; 95% CI, 2.25-8.26 vs 1.49-4.69). There were no significant differences in MACE in patients with SS and high-risk plaque as opposed to those with SS but not high-risk plaque (aHR, 8.68 vs. 9.31; 95% CI, 4.25-17.73 vs 4.21-20.61). High-risk plaque was a stronger predictor of MACE in women (aHR, 2.41; 95% CI, 1.25-4.64) vs men (aHR, 1.40; 95% CI, 0.81-2.39) and younger patients (aHR, 2.33; 95% CI, 1.20-4.51) vs older ones (aHR, 1.36; 95% CI, 0.77-2.39). High-risk plaque found by coronary CTA was associated with a future MACE in a large US population of outpatients with stable chest pain. High-risk plaque may be an additional risk stratification tool, especially in patients with nonobstructive coronary artery disease, younger patients, and women. The importance of findings is limited by low absolute MACE rates and low positive predictive value of high-risk plaque. clinicaltrials.gov Indentifier: NCT01174550.

Abstract 21306: Impact of Insulin Treated Diabetes Mellitus on 1 Year Outcomes After Contemporary PCI

Background: Insulin treated diabetes mellitus (ITDM) is associated with more extensive atherosclerotic disease and worse cardiovascular prognosis compared to non-ITDM patients. Hypothesis: We sought to examine 1-year outcomes in ITDM and non-ITDM patients compared to non-DM patients following contemporary percutaneous coronary intervention (PCI). Methods: We followed consecutive patients undergoing PCI at a large tertiary center from 2009-2016. Prospectively collected data were retrospectively examined. Patients were grouped based on DM and treatment status at baseline. 1-year outcomes were analyzed in a time to event manner and adjusted using multivariable Cox regression methods. Major adverse cardiovascular events (MACE) were defined as a composite of death, myocardial infarction (MI) or target vessel revascularization (TVR). Results: During the study period, 16,889 patients underwent PCI including 13.7% (n=2313) ITDM, 34.0% non-ITDM (n=5737) and 52.3% non-DM (n=8839) patients. ITDM and non-ITDM patients were younger than non-DM patients, with greater prevalence of females and non-white patients, higher body mass index and greater prevalence of prior revascularization and chronic kidney disease. ITDM patients were more likely to present with stable angina compared to others. With respect to angiographic characteristics, the prevalence of B2/C type lesions was similar between the groups. At 1-year, both ITDM and non-ITDM patients had greater risk of 1-year MACE and MI compared to non-DM patients, however ITDM patients had significantly higher rates of MACE, death, MI, and TLR ( figure ). Conclusions: The negative prognostic effect of DM following contemporary PCI is heightened in the presence of insulin treatment, compared to non-DM patients, despite use of contemporary PCI techniques and use of new generation DES.

Relationship of glycated haemoglobin and reported hypoglycaemia to cardiovascular outcomes in patients with type 2 diabetes and recent acute coronary syndrome events: The EXAMINE trial.

AimsTo investigate relationships between glycated haemoglobin (HbA1c) and reported hypoglycaemia and risk of major adverse cardiovascular events (MACE).MethodsThe EXAMINE trial randomized 5380 patients with type 2 diabetes (T2DM) and a recent acute coronary syndrome (ACS) event, in 49 countries, to double‐blind treatment with alogliptin or placebo in addition to standard of care. We used Cox proportional hazards models to analyse relationships among MACE, HbA1c levels and hypoglycaemic events.ResultsPatients randomized to alogliptin achieved lower HbA1c levels than the placebo group in all baseline HbA1c categories without differences in hypoglycaemia rates. No systematic change was found in MACE rates according to baseline HbA1c (P interaction = 0.971) or HbA1c category at 1 month. Patients in the combined treatment groups (n = 5380) who experienced serious hypoglycaemia (n = 34) had higher MACE rates than those who did not (35.3% vs 11.4%, adjusted hazard ratio [HR] 2.42, 95% confidence interval [CI] 1.27–4.60; P = .007), although the association was less strong when analysing only events after the hypoglycaemic event (adjusted HR 1.60, 95% CI 0.80, 3.20).ConclusionsThere were no relationships between baseline HbA1c levels or HbA1c levels after 1 month of treatment and the risk of MACE. Alogliptin improved glycaemic control without increasing hypoglycaemia. Reported events of hypoglycaemia and serious hypoglycaemia were associated with MACE. These data underscore the safety of alogliptin in improving glycaemic control in T2DM post‐ACS. Further study of hypoglycaemia as an independent risk factor for MACE in patients with T2DM and coronary disease is needed.

Clinical outcome and correlates of coronary microvascular obstruction in latecomers after acute myocardial infarction

AimsMicrovascular obstruction (MVO) is associated with a worse prognosis in patients with ST-elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PCI). However, data about incidence, clinical outcome and correlates of MVO in latecomers after STEMI are still lacking. MethodsWe prospectively enrolled consecutive patients that were latecomers after STEMI (symptoms onset >12h) undergoing PCI. We performed an angiographic analysis to assess the occurrence of MVO [defined as TIMI flow grade ≤2 or 3 with a myocardial blush grade <2]. Moreover, we performed a clinical and echocardiographic follow-up to assess the occurrence of major adverse cardiovascular events (MACE), defined as the composite of cardiac death, myocardial infarction and rehospitalization for heart failure, and to evaluate left ventricle remodelling. ResultsSeventy-eight patients were enrolled [mean age 67.58±11.72years, 57 (73%) male; mean time of symptom onset 23.14±16.06h] with a mean follow-up time of 29.7±14.1months. MVO occurred in 39 (50%) patients. Patients with MVO had a higher rate of MACE [18 (46%) vs. 3 (8%), p<0.001] and LV remodelling [25 (64%) vs. 6 (15%), p<0.001] compared with patients without MVO. By multivariable Cox regression MVO and left anterior descending artery were independent predictors of MACE. ConclusionsLatecomers after STEMI have a high risk to develop MVO that is related to an adverse prognosis. Appropriate management and follow-up strategies should be implemented in such high-risk patients group.

Fractional Flow Reserve–Guided Deferred Versus Complete Revascularization in Patients With Diabetes Mellitus

To assess the safety and efficacy of deferred versus complete revascularization using a fractional flow reserve (FFR)-guided strategy in patients with diabetes mellitus (DM), we analyzed all DM patients who underwent FFR-guided revascularization from January 1, 2010, to December 12, 2013. Patients were divided into 2 groups: those with ≥1 remaining FFR-negative (>0.80) medically treated lesions [FFR(-)MT] and those with only FFR-positive lesions (≤0.80) who underwent complete revascularization [FFR(+)CR] and were followed until July 1, 2015. The primary end point was the incidence of major adverse cardiovascular events (MACE), a composite of death, myocardial infarction (MI), target lesion (FFR assessed) revascularization, and rehospitalization for acute coronary syndrome. A total of 294 patients, 205 (69.7%) versus 89 (30.3%) in FFR(-)MT and FFR(+)CR, respectively, were analyzed. At a mean follow-up of 32.6 ± 18.1months, FFR(-)MT was associated with higher MACE rate 44.0% versus 26.6% (log-rank p=0.02, Cox regression-adjusted hazard ratio [HR] 2.01, 95% confidence interval [CI] 1.21 to 3.33, p<0.01), anddriven by both safety and efficacy end points: death/MI (HR 2.02, 95% CI 1.06 to 3.86, p= 0.03), rehospitalization for acute coronary syndrome (HR 2.06, 95% CI 1.03 to 4.10, p= 0.04), and target lesion revascularization (HR 3.38, 95% CI 1.19 to 9.64, p= 0.02). Previous MI was a strong effect modifier within the FFR(-)MT group (HR 1.98, 95% CI 1.26 to 3.13, p <0.01), whereas this was not the case in the FFR(+)CR group (HR 0.66, 95% CI 0.27 to 1.62, p= 0.37). Significant interaction for MACE was present between FFR groups and previous MI (p= 0.03). In conclusion, in patients with DM, particularly thosewith previous MI, deferred revascularization is associated with poor medium-term outcomes. Combining FFR with imaging techniques may be required to guide our treatment strategy in these patients with high-risk, fast-progressing atherosclerosis.

Gender differences in risk factors and clinical outcomes in young patients with acute myocardial infarction

BackgroundThere are limited data on the influence of gender on risk factors and clinical outcomes in young patients with acute myocardial infarction (AMI).MethodsThis prospective study stratified outcomes according to gender...

Ticagrelor for Prevention of Ischemic Events After Myocardial Infarction in Patients With Peripheral Artery Disease

BackgroundPeripheral artery disease (PAD) is associated with heightened ischemic and bleeding risk in patients with prior myocardial infarction (MI). ObjectivesThis study evaluated the efficacy and safety of ticagrelor on major cardiovascular (CV) events and major adverse limb events in patients with PAD and a prior MI. MethodsPEGASUS-TIMI 54 (Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin—Thrombolysis In Myocardial Infarction 54) randomized 21,162 patients with prior MI (1 to 3 years) to ticagrelor 90 mg twice daily, ticagrelor 60 mg twice daily, or placebo, all on a background of low-dose aspirin. History of PAD was obtained at baseline. Occurrences of major adverse cardiovascular events (MACE) (defined as CV death, MI, or stroke) and major adverse limb events (MALE) (defined as acute limb ischemia or peripheral revascularization for ischemia) were recorded in follow-up. ResultsA total of 1,143 patients (5%) had known PAD. In the placebo arm, those with PAD (n = 404) had higher rates of MACE at 3 years than those without (n = 6,663; 19.3% vs. 8.4%; p < 0.001), which persisted after adjusting for baseline differences (adjusted hazard ratio: 1.60; 95% confidence interval: 1.20 to 2.13; p = 0.0013), and higher rates of acute limb ischemia (1.0% vs. 0.1%) and peripheral revascularization procedures (9.15% vs. 0.46%). Whereas the relative risk reduction in MACE with ticagrelor was consistent, regardless of PAD, patients with PAD had a greater absolute risk reduction of 4.1% (number needed to treat: 25) due to their higher absolute risk. The absolute excess of TIMI major bleeding was 0.12% (number needed to harm: 834). The 60-mg dose had particularly favorable outcomes for CV and all-cause mortality. Ticagrelor (pooled doses) reduced the risk of MALE (hazard ratio: 0.65; 95% confidence interval: 0.44 to 0.95; p = 0.026). ConclusionsAmong stable patients with prior MI, those with concomitant PAD have heightened ischemic risk. In these patients, ticagrelor reduced MACE, with a large absolute risk reduction, and MALE. (Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin [PEGASUS-TIMI 54]; NCT01225562)

Abstract 470: Statin Treatment in Patients with Acute Myocardial Infarction According to Left Ventricular Systolic Function

Aim: Statin decreases low density lipoprotein cholesterol level and prevents atherosclerosis. Although statin may be beneficial for patients with acute myocardial infarction (AMI) due to its direct anti-atherosclerotic effect, statin is not usually prescribed to all patients with AMI. This study was performed to identify different determinants of statin treatment and its prognostic impacts in patients with AMI according to their baseline LV systolic function. Methods: 12,988 patients with AMI were enrolled into nationwide registry database study. Patients were stratified into 2 groups according to their LV ejection fraction (LVEF): LVEF &lt; 40% vs ≥ 40%, and determinant factors for statin treatment and MACE were identified in each group. Major adverse cardiovascular events (MACE) within 12 months of AMI including death, nonfatal MI and revascularization were assessed. Results: 1,962 patients (15.1%) with LVEF &lt; 40% were older and had more un¬favorable cardiovascular risk factors than those with LVEF ≥ 40%. Statin treatment rate was significantly lower in group with LVEF &lt; 40% than those with LVEF ≥ 40 % (70.5% vs 76.2%, p=0.001). Mean LDL-C level of patients with LVEF &lt; 40% was lower than those with LVEF ≥ 40 %. MACE rate in patients with LVEF &lt; 40% was higher than those with LVEF ≥ 40% (26.8% vs 11.4%, P &lt; 0.001). Independent predictors for 12-month MACE in patients with LVEF ≥ 40% were history of previous myocardial infarction, high Killip stage, three vessel disease, and lower renal function, which are already known risk factors. Conclusions: The patients with LVEF &lt; 40% were less treated with statin and showed lower LDL-C level and higher MACE rate than those with LVEF ≥ 40 %. Statin treatment may be considered in patients with AMI and LVEF &lt; 40%.

Abstract 308: Percutaneous Coronary Intervention Outcomes in HIV+ and HIV- Patients

Background: Studies suggest HIV infected (HIV+) people have similar rates of major adverse cardiovascular events (MACE) after AMI and/or after percutaneous coronary interventions (PCI) compared to uninfected (HIV-) people. However, these studies were limited by a lack of CD4 cell count and/or stent type data. Low CD4 cell count and bare metal stents (BMS) are associated with higher MACE rates than high CD4 cell count and drug eluding stents (DES), respectively. Our study compared the rates and risk of MACE and mortality after PCI between HIV+ and HIV- stratified by stent type and CD4 cell count. Methods: We included 611 HIV+ and 1,564 HIV- from the Veterans Aging Cohort Study Virtual Cohort, a prospective, longitudinal, observational study of HIV+ and 1:2 matched HIV- who underwent PCI with stent placement between 1/2002-1/2010. 1-year incidence rates (IR) per 1000 person years and 95% confidence intervals (CI) for MACE and mortality were calculated by HIV and CD4 (&lt;200/≥200 cells/mm3) status and stent type (BMS vs. DES). To compare 1-year MACE and mortality between HIV+ with CD4 &lt;200 and ≥200 to HIV-, hazard ratios (HR) were generated from multivariate Cox proportional hazards models adjusted for age, gender, race/ethnicity, hypertension, diabetes, dyslipidemia, smoking, hepatitis C, renal disease, anemia, and substance use. MACE was defined as a composite of repeat PCI, CABG, AMI using ICD9 and ICD10 codes and all-cause mortality. Results: There were 594 MACE including 108 deaths after PCI. Percent receiving DES was similar by HIV status (57% in HIV+ vs. 56% in HIV-). MACE rates were higher among those who received BMS (429.0, 95% CI 383.8-479.5) compared to DES (318.7, 95% CI 285.5-355.9), p=0.004 and the pattern is similar by HIV status. MACE rates were similar between HIV+ with CD4≥200 and HIV- (p=0.8), but higher for HIV+ with CD4&lt;200 (p&lt;0.001 compared to both HIV+ with CD4≥200 and HIV-). Mortality was also similar between HIV+ with CD4≥200 and HIV- (p=0.2), but higher for HIV+ with CD4&lt;200 (p&lt;0.01 compared to both HIV+ with CD4≥200 and HIV-). Adjusted HRs are shown in the table. Conclusion: Stent type received did not vary by HIV status. HIV+ with CD4&lt;200 have worse outcomes post PCI with stent placement than both HIV- and HIV+ with CD4≥200. Management of HIV may be important for decreasing MACE and mortality after PCI.

Transcutaneous Oxygen Tension as a Potential Predictor of Cardiovascular Events in Type 2 Diabetes

OBJECTIVETranscutaneous oxygen tension (TcPO2) measures tissue perfusion and is important in the management of peripheral artery disease (PAD). Ankle brachial index (ABI) is used for the diagnosis of PAD and represents a predictor of major adverse cardiovascular events (MACE), even if in diabetes its diagnostic and predictive value seems to be reduced. No study has evaluated TcPO2 as a predictor of cardiovascular events. Aim of this longitudinal study was to assess whether TcPO2 is better than ABI at predicting MACE in type 2 diabetic patients.RESEARCH DESIGN AND METHODSAmong 361 consecutive patients with apparently uncomplicated diabetes, 67 MACE occurred during a follow-up period of 45.8 ± 23.2 months.RESULTSThe percentage of both subjects with low ABI (≤0.9) and subjects with low TcPO2 (≤46 mmHg as measured by a receiver operating characteristic curve) was significantly (<0.001) greater among patients with than among those without MACEs (ABI 64.2 vs. 40.8; TcPO2 58.2 vs. 34%). The Kaplan-Meier method showed that both low ABI (Mantel log-rank test, 4.087; P = 0.043) and low TcPO2 (Mantel log-rank test, 33.748; P > 0.0001) were associated with a higher rate of MACEs. Cox regression analysis showed that low TcPO2 (hazard ratio 1.78 [95% CI 1.44–2.23]; P < 0.001) was a significant predictor of MACE, while ABI did not enter the model.CONCLUSIONSThis longitudinal study showed that TcPO2 may be a potential predictor of MACE among patients with uncomplicated type 2 diabetes and that its predictive value seems to be greater than that of ABI.

Coronary Calcium Score as an Adjunct to Nuclear Myocardial Perfusion Imaging for Risk Stratification Before Noncardiac Surgery

The purpose of this study was to evaluate the added value of coronary artery calcium score (CACS) as an adjunct to myocardial perfusion imaging (MPI) with SPECT for cardiac risk stratification before noncardiac surgery. SPECT MPI is a well-established and widely used tool for preoperative risk stratification before noncardiac surgery. The potential added value of combining SPECT MPI with CACS is unknown. We included 326 consecutive patients who were referred for SPECT MPI for preoperative cardiac risk assessment before elective noncardiac surgery. All patients underwent an additional low-dose CT scan for CACS and SPECT MPI. Patients were followed up for 40 d after their index surgical procedure, and the occurrence of major adverse cardiovascular events (MACE), including death, myocardial infarction, revascularization, stroke, and sudden cardiac death, was registered. Postoperative MACE occurred in 30 patients (9%). Cumulative MACE rate was highest in patients with abnormal SPECT and high CACS (22%), defined by a cutoff value CACS of 1,314 or more, and lowest in patients with normal SPECT MPI findings and low CACS (5%) (CACS < 1,314). A CACS score of 1,314 or more was independently associated with a higher MACE rate in patients with normal (12% vs. 5%) or abnormal perfusion (22% vs. 12%, P < 0.05 for all intergroup comparisons). SPECT MPI findings and CACS are strong preoperative risk predictors. CACS allows further risk stratification, indicating very low risk when CACS less than 1,314 is associated with normal SPECT MPI findings. Conversely, in patients with abnormal SPECT MPI findings, a CACS of 1,314 or more confers an added value for predicting adverse outcomes.

Prognosis of patients suffering an acute coronary syndrome while already under chronic clopidogrel therapy

To assess the prognosis of patients presenting with an acute coronary syndrome (ACS) despite chronic clopidogrel therapy (CCT). CCT has been shown to be beneficial in decreasing the frequency of major adverse cardiovascular events (MACE) in patients after an ACS or drug-eluting stent (DES) implantation. Some patients, however, still suffer thrombotic events while on CCT. The outcome of this particular subgroup of patients is unknown. A cohort of 1,281 patients undergoing percutaneous coronary intervention (PCI) for an ACS was studied. They were divided according to their treatment prior to the ACS. The CCT group was composed of all patients who had been taking clopidogrel for >or=30 days before the onset of the ACS (n = 175) and the no CCT group of all patients not on clopidogrel before the ACS (n = 1,106). Rates of cardiovascular death and myocardial infarction at 6 months' follow-up were compared. Patients in the CCT group were older (66 +/- 11 vs. 63 +/- 13; P< 0.001), and more often diabetic (46.8 vs. 31.9%; P < 0.01). In-hospital outcomes were similar, including the rate of death and myocardial infarction (no CCT vs. CCT group: 4.2 vs. 2.3%; P = 0.2). At 6 months, patients already taking clopidogrel before the ACS had a higher rate of MACE than patients who were not (18.3 vs. 11.8%; P = 0.02). In multivariate analysis, CCT before the ACS was associated with a hazard ratio of 1.7 for MACE. This study suggests that patients suffering an ACS while under on CCT have a poor long-term prognosis, which could be linked to clopidogrel low-response.