Incidence Of Ischemic Events Research Articles

Cardiovascular disease risk in diabetes patients aged 40 years old and above in China

Objective: To evaluate the incidence of cardiovascular disease (CVD), ischemic and hemorrhagic cardiovascular events among Chinese diabetic patients aged 40 years and above with different CVD risk levels. Methods: This study enrolled participants aged 40 years and above in 15 provinces from a prospective cohort study, the China-PAR project (Prediction for Atherosclerotic Cardiovascular Disease Risk in China). Participants were categorized into two groups according to the presence or absence of diabetes at baseline. Individuals were further classified into low (0-4.9%), moderate (5%-9.9%) and high risk groups (≥10%), based on predicted ten-year CVD risk using the China-PAR equations. Two followed-up surveys were conducted between 2007 and 2015 to identify CVD events, which were defined as nonfatal acute myocardial infarction, or death due to coronary heart disease, or stroke. Ischemic cardiovascular events included nonfatal acute myocardial infarction, or death due to coronary heart disease, or ischemic stroke. Hemorrhagic cardiovascular events included subarachnoid hemorrhage and intracerebral hemorrhage. The incidences of CVD, ischemic and hemorrhagic cardiovascular events were compared in diabetes and non-diabetes population with different CVD risk levels. Results: This study included 89 209 participants aged 40 years and above, the average follow-up period was 8.5 years. The age was (54.8±9.4) years, and 36 794 (41.2%) were men, and 5 730 (6.4%) were diabetic patients. In diabetes patients aged 40 years and above, 53.7% (3 075/5 730) were at high risk of CVD. Age-and sex-adjusted incidence of CVD, ischemic and hemorrhagic cardiovascular events (1 066.93/100 000 person-years, 824.23/100 000 person-years, and 211.56/100 000 person-years) were significantly lower in diabetes patients than those in non-diabetes population with high CVD risk (1 773.73/100 000 person-years, 1 228.18/100 000 person-years, and 446.49/100 000 person-years) (all P<0.001). Among high CVD risk populations, incidence of ischemic events was significantly higher in diabetic patients than in non-diabetes population (1 638.47/100 000 person-years vs. 1 228.18/100 000 person-years, P<0.001), but incidence of hemorrhagic events tended to be lower in diabetic patients than in non-diabetes population (415.70/100 000 person-years vs. 446.49/100 000 person-years, P=0.635). Incidence of ischemic and hemorrhagic events were similar between diabetes patients and non-diabetes population at low or moderate CVD risk groups (all P>0.05). Conclusions: More than half of diabetes patients aged 40 years and above in China have high CVD risk. The incidence of CVD, ischemic and hemorrhagic cardiovascular events are different in diabetic patients with different CVD risk levels.

Relationship between symptom-onset-to-balloon time and outcomes in patients with acute myocardial infarction treated with primary percutaneous coronary intervention

Abstract Background Time delay is an important prognostic factor and indicator of quality of care for patients with AMI indicated for primary percutaneous coronary intervention (PCI). Purpose Assessment of total ischaemia time and its relationship to catheterization findings and the incidence of ischaemic events within 1 year in patients treated with primary PCI. Method The analysis included 1230 patients with AIM and primary PCI randomized in the Prague-18 study (prasugrel vs. ticagrelor). We evaluated the total ischaemia time and two the intermediate intervals: A - from the symptom onset to the arrival to the hospital and B - from the entry the hospital to balloon time. We assessed the time delay in relation to patient characteristics, PCI results and ischaemic endpoints (death, reIM, stroke) within 30 days and 1 year. Results Median total ischaemia time was 3.2 hours. Its prolongation resulted in more frequent incidence of TIMI flow &amp;lt;2 before PCI (p=0.029), TIMI flow &amp;lt;3 after PCI (p=0.004) and suboptimal PCI (p=0.018). The interval A was significantly prolonged in women (p=0.001) and obese patients with BMI ≥30 kg / m2 (p=0.001). The interval B &amp;lt;30 min was achieved in 70% of patients, only 5.3% had interval &amp;gt;90 min. In 717 (61,6%) patients with increased risk (at least 1 criterion: age &amp;gt;70 years, STEMI anterior wall or LBBB, Killip II-IV, history of MI and CABG, SBP &amp;lt;100 mmHG and HR &amp;gt;100 / min), the prolongation of total ischaemia time (≤2 vs. 2.1–4 vs. 4.1–6 vs. &amp;gt;6 hours) resulted in a more frequent incidence of combined ischaemic endpoints within 1 year (p=0.034) and left ventricular systolic dysfunction (p=0.028). Conclusion The extension of total ischaemia time in patients treated with primary PCI resulted in a more frequent suboptimal result with TIMI flow &amp;lt;3. Female gender, older age and obesity in women were associated with an increase in total ischaemia time. In patients with increased risk, time delay resulted in a higher incidence of combined ischaemic endpoints within 1 year and left ventricular systolic dysfunction. Funding Acknowledgement Type of funding source: None

Related factors and the long-term outcome after percutaneous coronary intervention of premature acute myocardial infarction

Objective: To explore the related factors of premature acute myocardial infarction(AMI), and to compare the the long-term outcomes in patients with and without premature AMI after percutaneous coronary intervention (PCI). Methods: This study was a prospective cohort study.From January 2013 to December 2013, 10 724 consecutive patients with coronary heart disease undergoing PCI in Fuwai Hospital were enrolled. Among them 1 920 patients with the diagnosis of AMI were divided into two groups: premature AMI (man≤50 years old, woman≤60 years old) and non-premature AMI. The baseline characteristics were collected, and multivariate logistic regression was uesed to analysis the related factors of premature AMI. The clinical outcomes, including the major adverse cardiovascular and cerebrovascular events(MACCE) which was the composite of cardiac death, myocardial infarction, revascularization, stroke and stent thrombosis, as well as bleeding events, during hospitalization, at 2 years and 5 years follow-up were analyzed. Results: A total of 1 920 AMI patiens were included(age was (56.5±11.3) years old)，with 1 612(84.0%) males. There were statistically significant differences between the two groups in gender, body mass index, blood lipid, complications, inflammatory markers, etc (all P<0.05). Multivariate logistic regression analysis showed body mass index(OR=1.06, 95%CI 1.01-1.10, P<0.01), triglyceride(OR=1.47, 95%CI 1.14-1.90, P<0.01), serum uric acid level(OR=1.02, 95%CI 1.01-1.04, P<0.01), high density lipoprotein cholesterol level(OR=0.33, 95%CI 0.14-0.78, P=0.01) and history of hypertension(OR=0.72, 95%CI 0.56-0.93, P=0.01) were independent related factors of premature AMI. The incidence of all-cause death and cardiac death were lower during hospitalization, at 2 years and 5 years follow-up in the premature AMI group than in non-premature AMI group(all P<0.05). In the premature AMI group, the incidence of MACCE and stroke was lower, with more bleeding events in 5 years follow-up(all P<0.05). Conclusions: Metabolic abnormalities, including high BMI, high triglyceride level and high serum uric acid, low high-density lipoprotein cholesterol level are the related factor of premature AMI. The incidence of ischemic events in patients with premature AMI is lower, while the incidence of bleeding events is higher than non-premature AMI patients.

Predicting ischaemic events using platelet reactivity in patients receiving clopidogrel: Indirect meta-comparison among VerifyNow, light transmission aggregometry and thromboelastography.

The present study compared performances of the three major methods used for assessing platelet reactivity (PR)-VerifyNow, light transmission aggregometry (LTA) and thromboelastography (TEG)-to predict ischaemic events in patients receiving clopidogrel. PubMed, EMBASE and the Cochrane Library were searched from their inception to April 2019 for prospective studies that examined PR using VerifyNow, LTA or TEG and the incidence of ischaemic events. The investigated diagnostic indices include sensitivity, specificity, positive (PLR) and negative likelihood ratio (NLR), diagnostic odds ratio and area under the receiver operating characteristic curves (AUC) of VerifyNow, LTA and TEG, respectively. A total of 26 prospective studies involving 22185 patients were included in the analysis. The pooled AUC was 0.71 (95% CI: 0.67-0.75) for VerifyNow, 0.60 (95% CI: 0.55-0.64) for LTA and 0.81 (95% CI: 0.77-0.84) for TEG. Results of indirect comparisons indicated the AUC of VerifyNow was higher than that of LTA (1.18, 95% CI: 1.08-1.30) and lower than that of TEG (0.88, 95% CI: 0.82-0.94). TEG outperformed the other two methods for assessing PR in all predictive measures, including sensitivity, specificity, PLR and NLR. Despite a lack of studies that directly compared the three methods, our findings suggest that TEG should be recommended.

Comparison of Efficacy between Clopidogrel and Ticagrelor in Patients with Acute Coronary Syndrome after Interventional Treatment and Their Effects on IL-6

We aimed to compare the efficacy between clopidogrel and ticagrelor in patients with acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI) and their effects on IL-6. A retrospective analysis and collection of 200 ACS patients diagnosed by the Department of Cardiology, Affiliated Hospital of Qingdao University, Qingdao, China in 2016 were performed. Patients were randomly divided into clopidogrel group and ticagrelor group. Data of left ventricular ejection fraction and ACS clinical classification before PCI, PCI treatment, IL-6, platelet aggregation status, maximum platelet aggregation rate (MPAR), P2Y12 response unit (PRU) and adverse reaction of patients were collected. After PCI, patients were followed up for 1 year to compare the ischemia after treatment between clopidogrel group and tigravilol group. MPAR and PRU after PCI of clopidogrel group were significantly higher than those of ticagrelor group (P<0.05). The expression of IL-6 in two groups peaked at 1 day after PCI and then decreased. That of ticagrelor group was consistently lower than that of clopidogrel group (P<0.05). The incidence of ischemic events after treatment in clopidogrel group was significantly higher than that in ticagrelor group (P<0.001). Compared with clopidogrel, tigerrilol had more significant inhibition of platelet aggregation after PCI in ACS patients, and tigerrilol had better effect after interventional treatment in ACS patients. In addition, compared with clopidogrel, tegrel can significantly inhibit the expression of IL-6 in patients with ACS and better alleviate the inflammatory response after PCI.

P1307HEMORRHAGIC VERSUS ISCHEMIC RISK IN PATIENTS WITH ATRIAL FIBRILLATION ON HEMODIALYSIS

Abstract Background and Aims Patients with renal replacement therapy and atrial fibrillation (AF) have a particularly high risk of both stroke and bleeding, but no high-quality evidence-based recommendations exist to properly manage these patients. Therefore, we aim to evaluate the ischaemic versus the haemorrhagic risk in a hemodialysis (HD) population. Method We selected patients that started hemodialysis in our hospital between 2011 and 2015. Only incident patients that were on regular hemodialysis treatment for more than 3 months were considered. Both patients that already had AF before HD, or developed AF during the follow-up, were included. At the time of AF diagnosis or beginning of HD, the risk factors were analyzed based on CHA2 DS2 -VASC and HAS-BLED scores. The outcomes were hemorrhagic events (only the events that needed hospitalization were taken into account), ischaemic events (i.e. that result from embolic arterial ischaemia) and death related to any of these events. Results From 302 incident patients on hemodialysis, 46 (15.23 %) were included. Mainly man (65%), with a mean age of 75 ± 10 years old. Most of the patients (63%) already had AF when they started hemodialysis. There was no significant difference between the incidence of ischaemic and haemorrhagic events (p=0.219). Three patients died of an ischemic event and two of haemorrhagic shock.Twenty one patients (45.6%) started oral anticoagulation. No difference was found between the proportion of haemorrhagic events between patients with oral anticoagulation and patients with no anticoagulation (p=0.157). Similarly, oral anticoagulation was not associated with any effect on the incidence of ischaemic events (p=0.366). The results after adjustment for the risk factors included in the HAS-BLED and CHA2 DS2-VASC scores were the same. Previous stroke, transient ischaemic attack or thromboembolic event significantly increased the risk of an ischaemic event, when adjusted to oral anticoagulation, age, diabetes, vascular disease and hypertension (OR 6.78, C.I 95% 1.236-37.278, p=0.028). This risk factor was not associated with an increase of haemorrhagic events. No other risk factor included in the scores was associated with any significant effect in the outcomes. Conclusion As we know, AF increases the risk of ischaemic events in general population. However, in hemodialysis patients, we didn’t observe any difference between the incidence of ischaemic and haemorrhagic events. Therefore, the benefit of oral anticoagulation in such patients remains questionable. It is worth noting that patients with previous stroke, transient ischemic attack or thromboembolic event seem to have higher risk of new ischaemic events. In these patients, there may be some advantage in oral anticoagulation. Since this is a single center, retrospective, observational study, these results should be interpreted with caution.

Duration of dual antiplatelet therapy after percutaneous coronary intervention with implantation of second-generation drug-eluting stent: A meta-analysis of randomized controlled trials.

Objective: The optimal duration of dual antiplatelet therapy (DAPT) in patients after PCI with implantation of a drugeluting stent is still controversial. We conducted a meta-analysis to compare the efficacy and safety of short term DAPT (≤ 3 months) followed by P2Y12 inhibitor monotherapy and standard DAPT (12 months) after PCI. Method: Relevant studies published in Medline, Embase, CoChrane Library were searched for randomized controlled trials (RCTs) until November 2019. Studies were screened by selection criteria then quality assessed through the Cochrane Collaboration's tool. Data were extracted from the included studies and statistically analyzed by RevMan 5.3 software. Results: Five RCTs (n=18,357) were included. Compared with standard DAPT, the short term DAPT was associated with a significant decrease in the major bleeding [odds ratio (OR)=0.43, 95% Confidence Interval (CI):0.32-0.58, P <0.00001] and any bleeding [OR=0.56, 95%CI:0.47-0.66, P<0.00001]. There were no significant differences in all-cause death [OR=0.91, 95%CI:0.71-1.16, P =0.45], major adverse cardiac and cerebrovascular event [OR=1.01, 95%CI:0.87-1.17, P =0.91] and stent thrombosis [OR=0.97, 95%CI:0.61-1.54, P =0.91] between with the short term DAPT group and the standard DAPT group. Conclusions: Short term DAPT followed by P2Y12 monotherapy could reduce the risk of bleeding without increasing the incidence of ischemic events after PCI with implantation of second-generation DES compared with standard DAPT. Therefore, short term DAPT may be a promising strategy to balance ischemic events and bleeding complications in patients after PCI.

Study of Utilization of Antiplatelet Agents in Coronary Heart Disease Patients in Private Hospital in Surabaya

ABSTRACT Antiplatelet is the most commonly drug used as secondary prevention for Coronary Heart Disease (CHD). The aim of this study was to determine the profile of the use of antiplatelet related with its efficacy and side effects. Observational methods with cross sectional approach for 3 months follow up was used, a descriptive analysis carried out at the private hospital in Surabaya. Results from this study: aspirin 80 mg was the most prescribed antiplatelet in patients with the incidence of ischemic events 9%. Higher ischemic events also seen in patients with hypertension, dyslipidemia, and Diabetes Mellitus. Bleeding and gastrointestinal disturbance as side effects occurred in 4 patients who used aspirin as antiplatelet, and based for Naranjo scale can be concluded as possible adverse drug reaction. Keywords: Coronary Heart Disease, Antiplatelet , Ischemic events, Bleeding

P2539Impact of sex (female vs male) in the ischemic-bleeding profile after hospital discharge for acute coronary syndrome during treatment with dual antiplatelet therapy

Abstract Introduction Sex-specific differences exist in the presentation, pathophysiological mechanisms, and outcomes in patients with acute myocardial infarction. These differences could condition the treatment and prognosis of women compared to men with Acute Coronary Syndrome (ACS). The aim of our study was to determine, after matching the baseline characteristics of patients according to gender, the prognosis of women versus men during treatment with Dual Antiplatelet Therapy (DAPT), after an ACS undergoing Percutaneous Coronary Intervention (PCI). Methods The data analyzed in this study were obtained from the fusion of 3 clinical registries of ACS patients: BleeMACS (2004–2013), CardioCHUVI/ARRITXACA (2010–2016) and RENAMI (2013–2016). All 3 registries include consecutive patients discharged after an ACS with DAPT and undergoing PCI. The merged data set contain 26,076 patients. A propensity-matched analysis was performed to match the baseline characteristics of patients according to gender (female vs male). The impact of gender in the ischemic and bleeding risk was assessed by a competitive risk analysis, using a Fine and Gray regression model, with death being the competitive event. For ischemic risk we have considered a new acute myocardial infarction, whereas for bleeding risk we have considered major bleeding defined as bleeding requiring hospital admission. Follow-up time was censored by DAPT suspension/withdrawal. Results From the 26,076 ACS patients, 6,091 were women PAD (23.4%). During a mean follow-up of 12.2±4.8 months, 964 patients died (3.7%), 640 had myocardial infarction (2.5%) and 685 had major bleeding (2.6%). After propensity-score matching, we obtained two matched groups (according gender) of 5,341 patients. In comparison with male, female had similar risk of myocardial infarction (sHR 1.14, 95% CI 0.91–1.44, p=0.001) with lower risk of major bleeding (sHR 0.75, 95% CI 0.61–0.92, p=0.006). The cumulative incidence of myocardial infarction was 26 and 30 per 1,000 patients/year in men and women, respectively, during DAPT. And the cumulative incidence of major bleeding was 43 and 32 per 1,000 patients/year in men and women, respectively. The difference between myocardial infarction rate and major bleeding rate was −17 in male (more bleeding than ischemic event rates; p&lt;0.05) and +3 in women (similar bleeding and ischemic event rates; p&gt;0.05), per 1,000 patient-years (Figure). Figure 1 Conclusions After an ACS underwent PCI, during DAPT, the ischemic-bleeding balance is different between women and men. In women, the annual incidence of ischemic events was similar to the incidence of bleeding events. However, in men, the incidence of bleeding events is higher than the incidence of ischemic events,

Five-Year Risk of Major Ischemic and Hemorrhagic Events After Intracerebral Hemorrhage.

Background and Purpose- We aimed to determine incidences and predictors of major vascular events in intracerebral hemorrhage (ICH) survivors. Methods- We did a prospective observational cohort study in patients with spontaneous ICH from the Prognosis of Intracerebral Hemorrhage cohort in Lille, France. We studied incidences and predictors of long-term vascular events (cerebral and extracerebral, ischemic and hemorrhagic) in patients alive at 30 days with a prespecified subgroup analysis according to ICH location. We performed multivariable analyses (competing risk analyses, with death during follow-up as a competing event). Results- From the 560 patients with spontaneous ICH enrolled between November 2004 and March 2009, we included 310 patients (median age, 70 years). Eighty-two patients presented at least 1 major vascular event leading to an incidence rate of 20.0% (95% CI, 15.7-24.7) at 5 years after ICH. In the overall cohort, ischemic events were more frequent than hemorrhagic events. However, the incidence strikingly differed according to ICH location: deep ICH was associated with future ischemic events (subhazard ratio, 1.85; 95% CI, 1.01-3.40), whereas lobar ICH with hemorrhagic events (subhazard ratio, 2.38; 95% CI, 1.17-4.86). In deep ICH, the incidence of ischemic events at 5 years was 6× higher than the incidence of hemorrhagic events. Conclusions- ICH survivors are at high risk of both cerebral and extracerebral vascular events. The ischemic or hemorrhagic risk profile varies according to the index ICH location with a stronger ischemic risk in deep ICH. Secondary prevention, tailored on ICH location, should target not only cerebral recurrences but also extracerebral vascular events.

Blood Transfusion and Increased Perioperative Risk in Coronary Artery Bypass Grafts.

ObjectiveTo correlate blood transfusions and clinical outcomes during hospitalization in coronary artery bypass grafting surgery (CABG).MethodsTransfusion, clinical and hematological data were collected for 1,378 patients undergoing isolated or combined CABG between January 2011 and December 2012. The effect of blood transfusions was evaluated through multivariate analysis to predict three co-primary outcomes: composite ischemic events, composite infectious complications and hospital mortality. Because higher risk patients receive more transfusions, the hospital mortality outcome was also tested on a stratum of low-risk patients to isolate the effect of preoperative risk on the results.ResultsThe transfusion rate was 63.9%. The use of blood products was associated with a higher incidence of the three coprimary outcomes: composite infectious complications (OR 2.67, 95% CI 1.70 to 4.19; P<0.001), composite ischemic events (OR 2.42, 95% CI 1.70 to 3.46; P<0.001) and hospital mortality (OR 3.07, 95% CI 1.53 to 6.13; P<0.001). When only patients with logistic EuroSCORE ≤ 2% were evaluated, i.e., low-risk individuals, the mortality rate and the incidence of ischemic events and infectious complications composites remained higher among the transfused patients [6% vs. 0.4% (P<0.001), 11.7% vs. 24,3% (P<0.001) and 6.5% vs. 12.7% (P=0.002), respectively].ConclusionThe use of blood components in patients undergoing CABG was associated with ischemic events, infectious complications and hospital mortality, even in low-risk patients.

The impact of residual platelet activity and CYP2C19 polymorphism on the prognosis of acute coronary syndrome patients

Objective To evaluate the correlation between RPA or the polymorphism of CYP2C19 and the incidence of ischemic events and the influence on the clinical prognosis. Methods A case-control study was used. A total of 202 patients [male 66%, (63±11) years] with ACS on aspirin and clopidogrel treatment were recruited, whose RPA were measured by whole blood aggregometry (WBA), and their CYP2C19 polymorphism were also tested. Their clinical ischemic events were recorded in the mean follow-up period of 16 months. The RPA cut-off values for antiplatelet low-responsiveness were defined by the receiver operator characteristic curve (ROC); the relationships of clinical outcomes with RPA and CYP2C19 were assessed by the Kaplan-Meier survival analysis. Results CYP2C19*2 (681G>A) present in 52.5% of recruited patients and*3 (636G>A) present in12.9%. RPA induced by adenosine diphosphate (ADP) showed significant difference among CYP2C19*2 or *3 heterozygotes, CYP2C19*2 or *3 homozygotes and noncarriers (χ2=9.318, P=0.009); whereas, RPA induced by arachidonic acid (AA) (χ2=2.441, P=0.295) and the incidence of ischemic events (χ2=0.513, P=0.774) were not. During follow-up, 18 (9%) patients experienced clinical ischemic episodes, and their RPA were higher than patients without ischemic episodes [(8.6±4.8) Ω vs (5.2±3.7) Ω, P=0.013; (8.6±6.8) Ω vs (1.6±3.7) Ω, P<0.001]. Moreover, employing 6.5 Ω (induced by ADP) and 2.5 Ω (induced by AA) as cutoff values, RPA showed optimal negative predictive values (97%, 96%) and poor positive predictive values (16%, 29%). Survival analysis showed, statistically, patients with clopidogrel low-responsiveness had higher risk of ischemic episodes than patients with clopidogrel responsiveness (HR=2.86, χ2=11.27, P=0.0008); however, patients with aspirin low responsiveness (HR=1.77, χ2=1.74, P=0.19) or patients with CYP2C19*2 or *3 (HR=0.89, χ2=0.12, P=0.73) did not. Conclusion Clopidogrel low responsiveness is associated with the occurrence of clinical ischemic events; however, patients with CYP2C19 function reduced genetypes do not show higher risk of ischemic episodes though it presented slighly higher RPA. (Chin J Lab Med, 2016, 39: 911-916) Key words: Acute coronary syndrome; Platelet activation; Platelet function tests

Bivalirudin in percutaneous coronary intervention, is it the anticoagulant of choice?

For decades, unfractionated heparin (UFH) has been widely used in catheterization laboratories for anticoagulation for percutaneous coronary intervention (PCI). The direct thrombin inhibitors, bivalirudin, has emerged as an alternative to UFH for PCI procedures, due to its lower bleeding risk. More recently, randomized trials and meta-analyses questioned the efficacy of bivalirudin, and demonstrated that bivalirudin might be associated with a higher incidence of ischemic events and in particular stent thrombosis. In this review, we discuss the pharmacology of bivalirudin along with the clinical evidence comparing bivalirudin versus UFH in patients undergoing PCI for various indications.

Abstract O.65: Long-term Outcome of Patients with Giant Coronary Aneurysms caused by Kawasaki Disease: A 30-year Experience in a Single Center in Taiwan

Background: Patients with coronary artery aneurysms are at risk for thrombotic and stenotic complications later in their lives. The longitudinal changes of giant coronary aneurysms caused by Kawasaki disease (KD) and their long-term outcome are still unclear in Taiwan. Methods: By retrospective chart review of patients diagnosed with Kawasaki disease complicated by giant coronary aneurysms, we analyze incidence of ischemic event, survival rates, and related risk factors. Results: Between 1984 and 2012, 28 patients (24 male and 4 female) developed giant aneurysms. The mean age at onset and observe period was 3.8 years (range from 0.41 - 10.3 years) and 12 years (0 to 36.8 years), respectively. The initial median coronary Z-score was +5.75 (+0.62 to +19.06) in left main coronary artery, +4.49 (-0.18 to +11.19) in left anterior descending artery, +6.71 (+1.79 to +14.46) in right coronary artery. None of the giant aneurysms regressed during follow-up. The 5- and 35-year survival rates were 0.92 and 0.69, respectively. Except the three deaths, four additional male patients were diagnosed with acute myocardial infarction (AMI), and 2 of these diagnoses occurred within 1 year of KD onset. The incidence of AMI or death in patients with giant aneurysms was 26%, and 67% of the AMI occurred within the first year of KD onset. Clinical evidence of ischemia as documented in nuclear medicine studies was also noted in a further 9 patients (33%), and only one was female. AMI/death-free survival rates were 76% and 69% at 10 and 20 years after KD onset, respectively. Ischemia event-free survival rates were 63% and 36% at 10 and 20 years after disease onset. Men tended to have AMI and ischemia, and only one ischemia patient was female. The hazard ratio of gender on the ischemia events was 2.70 (95% CI: 0.33 - 21.73, P = 0.38). Conclusions: The long-term survival of KD patients with giant coronary aneurysms is guarded. Ischemic heart disease is the major cause of morbidity and mortality. Male KD patients, once they had giant aneurysms, tend to have ischemic events. Other risk factors need to be validated in a larger cohort.

Abstract 63: Three-month Outcomes in Japanese Stroke /TIA Patients With Non-valvular Atrial Fibrillation After Initiating Oral Anticoagulants: The SAMURAI-NVAF Study

Backgound and Purpose: Recently, three non-vitamin K antagonist oral anticoagulants (NOACs) became available for patients with nonvalvular atrial fibrillation (NVAF) in Japan. We aimed to determine 3-month outcomes in ischemic stroke/TIA patients receiving NOACs or warfarin from a multicenter prospective registry (SAMURAI-NVAF registry, NCT01581502). Methods: Among 1,191 acute ischemic stroke /TIA patients enrolled between September 2011 and March 2014, we studied 916 patients (389 women, 77±10 y) who took oral anticoagulants (OACs) after index stroke and completed 3-month follow-up survey. Primary outcome measures were ischemic events, including recurrent stroke/TIA and thromboembolism, and major bleedings events, such as fatal bleeding and/or symptomatic bleeding in a critical area or organ according to the International Society on Thrombosis and Haemostasis statement. We assessed the incidence and clinical factors associated with primary outcomes within 90 days after initiating OACs. Results: NOACs were given for 370 patients (126 women, 74±9 y; dabigatran 168, rivaroxaban 183 and apixaban 19) and warfarin for 546 (263 women, 79±10 y). NOAC users had lower scores of CHADS2 (median 3 in NOAC, 4 in warfarin, p&lt;0.001) and HAS-BLED (3, 3, p&lt;0.001) than warfarin users. Ischemic events occurred in 14 NOAC users (3.8%; 2 women, 76±6 y, including 8 lower dose users between two approved dose for each NOAC) and 25 warfarin users (4.6%; 13 women, 81±9 y). Of these, 13 NOAC users (3.5%) and 16 warfarin users (2.9%) developed ischemic stroke/TIA. Among NOAC users, patients with ischemic events had lower body weights (53±11 vs 60±11kg, p= 0.017), more frequently had congestive heart failure (36 vs 10%, p = 0.003) and intracardiac thrombus (27 vs 4%, p &lt; 0.001) than those without. Major bleeding events occurred in 5 NOAC users (1.4%, all using lower dose), and 14 warfarin users (2.6%). Of these, one NOAC user (0.3%) and 4 warfarin users (0.7%) developed intracranial hemorrhage. Conclusion: The 3-month incidence of ischemic events in stroke/TIA patients with NVAF was approximately 4% in both NOAC and warfarin users. Intracranial hemorrhage was relatively infrequent in NOAC users.

Stroke/Thromboembolism and Intracranial Hemorrhage in a Real-world Atrial Fibrillation Population: The Complications of Atrial Fibrillation in the Bologna Area (CAFBO) Study

Ischemic events (IEs) and intracranial hemorrhages (ICHs) are feared complications of atrial fibrillation (AF) and of antithrombotic treatment in patients with these conditions. Patients with AF admitted to the EDs of the Bologna, Italy, area with acute IE or ICH were prospectively recorded over 6 months. A total of 178 patients (60 male patients; median age: 85 years) presented with acute IE. Antithrombotic therapy was as follows: (1) vitamin K antagonists (VKAs) in 31 patients (17.4%), with international normalized ratio (INR) at admission of < 2.0 in 16 patients, 2.0 to 3.0 in 13 patients, and > 3.0 in two patients; (2) aspirin (acetylsalicylic acid) (ASA) in 107 patients (60.1%); and (3) no treatment in 40 patients (22.5%), mainly because AF was not diagnosed. Twenty patients (eight male patients; median age: 82 years) presented with acute ICH: 13 (65%) received VKAs (INR, 2.0-3.0 in 11 patients and > 3.0 in two patients), while six (30%) received ASA. Most IEs (88%) and ICHs (95%) occurred in patients aged > 70 years. A modeling analysis of patients aged > 70 years was used to estimate annual incidence in subjects anticoagulated with VKAs in our Network of Anticoagulation Centers (NACs), or those expected to have AF but not included in NACs. The expected incidence of IE was 12.0%/y (95% CI, 10.7-13.3) in non-NACs and 0.57%/y (95% CI, 0.42-0.76) in NACs (absolute risk reduction [ARR], 11.4%/y; relative risk reduction [RRR], 95%; P < .0001). The incidence of ICH was 0.63%/y (95% CI, 0.34-1.04) and 0.30%/y (95% CI, 0.19-0.44), respectively (ARR, 0.33%/y; RRR, 52.4%/y; P = .04). IEs occurred mainly in elderly patients who received ASA or no treatment. One-half of patients with IEs receiving anticoagulant treatment had subtherapeutic INRs. Therapeutic approaches to elderly subjects with AF require an effective anticoagulant treatment strategy.

Evidence of platelet sensitization to ADP following discontinuation of clopidogrel therapy in patients with stable coronary artery disease

Epidemiological studies have linked clopidogrel discontinuation with an increased incidence of ischemic events. This has led to the hypothesis that clopidogrel discontinuation may result in a pharmacological rebound. We evaluated the impact of clopidogrel discontinuation on platelet function. Platelet aggregation was measured by light transmission aggregometry (LTA) in response to adenosine diphosphate (ADP) 0.5, 1, 1.5, 2.5, 5 and 10 µM and by VerifyNow® P2Y12, in 37 clinically stable coronary artery disease (CAD) patients scheduled to discontinue clopidogrel treatment, and 37 clinically stable CAD patients not taking clopidogrel. Platelet function was assessed the day before clopidogrel cessation and 1, 3, 7, 14, 21 and 28 days after. Clopidogrel had been initiated a median of 555 days (ranging from 200 to 2280 days) before the treating cardiologist recommended its discontinuation. All participants were taking aspirin, most commonly 80 mg daily although a minority was prescribed 325 mg daily. Following clopidogrel discontinuation, VerifyNow® P2Y12 did not detect any rebound platelet activity, but ADP-induced LTA showed platelet sensitization to ADP, particularly at low ADP levels. Increased platelet activity was detectable seven days after clopidogrel cessation and remained higher than in controls 28 days after discontinuation. No clinical event occurred in any of the participants during the 28 days following clopidogrel cessation. In conclusion, platelet sensitization to ADP as a consequence of chronic clopidogrel administration may partially explain the recrudescence of ischemic events following clopidogrel discontinuation in otherwise stable coronary artery patients.

Therapeutic inertia in hypercholesterolaemia is associated with ischaemic events in primary care patients. A case-control study

The frequency of therapeutic inertia (TI) is very high in the management of vascular risk factors, although its impact on the incidence of ischaemic events is not well-established. Our aim was to investigate the relationship between TI in the treatment of hypercholesterolaemia and the appearance of ischaemic events. An observational, multicentre, case-control study was conducted in 70 primary care centres in Spain. Case subjects (n=235) were high-risk hypercholesterolaemic patients (both genders, ≥18years) who had had a first event in the 12months prior to recruitment. They were matched with 235 controls (by vascular risk, age and gender). The observation period was 18months prior to the onset of a first event (cases) or to date of recruitment (control subjects). The TI in the basal visit (an average of 7.8months before the event) was slightly higher in cases than in controls (39.7% vs. 34.8%, NS). However, the accumulated TI was similar in both groups (70.7% for cases and 73.95% for controls, NS). The multivariate analysis, taking ischaemic events as the dependent variable, showed that the TI at baseline visit was significantly associated with the development of the event [OR 2.18 (95% CI 1.04-4.51), p<0.05]. Other variables also associated with the ischaemic event were a family history of premature vascular disease [OR 3.38 (95% CI 1.35-8.49), p<0.05] and uncontrolled hypertension [OR 2.35 (95% CI 1.02-5.43), p<0.05]. The TI in high-risk hypercholesterolaemic patients in primary prevention in Spanish primary care centres doubled the risk of an ischaemic event in the short term.

Tratamiento quirúrgico de la enfermedad valvular cardiaca de predominio izquierdo, en un hospital de referencia nacional de Lima, Perú

To describe the preoperative, intraoperative and postoperative characteristics of patients with left-sided heart valve disease treated in the thoracic and cardiovascular surgery service of a national reference hospital; as well as to describe the occurrence of thromboembolic and bleeding events in these patients. A retrospective longitudinal study was carried out, which included 185 patients who underwert surgery between 1999 and 2006 at the Hospital Nacional Dos de Mayo (Lima, Peru). The patients were divided into 4 groups: patients with mitral commissurotomy; with aortic valve replacement; with mitral valve replacement and with double valve replacement. T-student test, Chi-square test, analysis of variance and Bonferroni test were used. The survival analysis took into account the severe thromboembolic and bleeding events and a follow-up period of 7 years was set. The average durations of disease was 4.6 years. The most frequent etiology was rheumatic valve disease (74.6%). Hospital mortality was 3.8%, the most frequent cause of death was low cardiac output syndrome associated to multiple organ failure. The incidence of ischemic events (thrombosis or embolization) in patients who had a long-term valve replacement (more than 6 months) was 3.2%, and the incidence of bleeding events was 4.3%. The results of surgical treatment for left-sided heart valve disease in Peru are favorable. The rate of complications and hospital mortality rate, as well as the long-term thromboembolic and bleeding events are comparable to those reported in the world literature.

Thrombozytenaggregationshemmer: Was sind die Risiken?

The most common risks related to platelet inhibitor therapy are bleeding, drug-drug interactions and therapeutic failure. The new substances prasugrel and ticagrelor are more potent platelet inhibitiors than clopidogrel. This reduces the incidence of ischemic events, but also potentially increases the bleeding risk. Clopidogrel therapy has up to 20% non-response rates, which can partially be explained by genetic polymorphisms and drug-drug interactions. Currently no evidence exists that ticagrelor or prasugrel efficacy is affected by genetic polymorphisms. The therapy in patients at risk still has to be carefully adapted to minimize adverse events. Patients older than 75 years and/or weighing less than 60 kg should receive a reduced dose of prasugrel. The combination of ticagrelor with strong cytochrome-P450-3A4 inhibitors is contraindicated.