Cardiac Ischemic Complications Research Articles

Heme oxygenase-1 polymorphisms associate with ischemic cardiac complications and mortality in type 1 diabetes

Abstract Background/Introduction Heme oxygenase-1 (HO-1), encoded by the HMOX1 gene is a highly inducible enzyme with multiple cardiovascular protective properties. Polymorphisms of the HMOX1 gene, especially a guanine-thymine dinucleotide repeat polymorphism (GTn), affects its transcriptional activity and is associated with cardiovascular complications in the general population. Purpose We studied the association of HMOX1 polymorphisms and HO-1 plasma levels with cardiovascular complications in patients with type 1 diabetes (DM1). Methods The study population consists of patients with DM1 participating in the nationwide, multicenter Finnish Diabetic Nephropathy Study (FinnDiane). We genotyped the HMOX1 GTn repeat (n=3990), extracted from genome-wide genotyping data two single nucleotide polymorphisms (SNPs) (−413A/T upstream variant rs2071746, and +99G/C p.Asp7Asn missense variant rs2071747; n=4278), and measured the plasma HO-1 levels (n=861) from blood samples taken during a regular visit to the study center. The GTn repeats were divided into short (S) and long (L) alleles where the cutoff point was L>29 repeats. Results In men, LL genotype was associated with ischemic cardiac events (LL 22.9% vs. SS/SL 17.0%, p=0.001, see figure) and mortality (p=0.031, see figure). The association was detected also when analyzing all patients (LL 19.5% vs. SS/SL 16%, p=0.006, see figure) but not women alone (LL 15.7% vs. SS/SL 14.9%, p=0.657). For −413A/T SNP, men with AA genotype had higher odds for ischemic cardiac events (21.0% vs. 17.4%, p=0.044, see figure) but no differences in women or all together were found. There were no differences between different genotypes of +99G/C for cardiovascular complications. There was no difference in HO-1 plasma levels between different genotypes (GTn repeat, −413A/T or +99G/C). Men had significantly higher HO-1 plasma levels compared to women (3.12±1.23 ng/l vs. 2.64±1.04 ng/l, p<0.001). Interestingly, in women, higher HO-1 plasma levels were associated with cardiovascular complications and the need for antihypertensive and lipid lowering medications. Conclusions In men, but not in women LL genotype of the HMOX1 GTn repeat and AA genotype of −413A/T SNP were associated with ischemic cardiac complications and mortality. Thus, HMOX1 genotype may influence the development of cardiovascular complications in DM1 patients in a gender-dependent manner. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The Finnish Foundation for Cardiovascular ResearchFinnish State Funding for university-level research

CRISPR/Cas9-mediated inactivation of the phosphatase activity of soluble epoxide hydrolase prevents obesity and cardiac ischemic injury

IntroductionAlthough the physiological role of the C-terminal hydrolase domain of the soluble epoxide hydrolase (sEH-H) is well investigated, the function of its N-terminal phosphatase activity (sEH-P) remains unknown. ObjectivesThis study aimed to assess in vivo the physiological role of sEH-P. MethodsCRISPR/Cas9 was used to generate a novel knock-in (KI) rat line lacking the sEH-P activity. ResultsThe sEH-P KI rats has a decreased metabolism of lysophosphatidic acids to monoacyglycerols. KI rats grew almost normally but with less weight and fat mass gain while insulin sensitivity was increased compared to wild-type rats. This lean phenotype was more marked in males than in female KI rats and mainly due to decreased food consumption and enhanced energy expenditure. In fact, sEH-P KI rats had an increased lipolysis allowing to supply fatty acids as fuel to potentiate brown adipose thermogenesis under resting condition and upon cold exposure. The potentiation of thermogenesis was abolished when blocking PPARγ, a nuclear receptor activated by intracellular lysophosphatidic acids, but also when inhibiting simultaneously sEH-H, showing a functional interaction between the two domains. Furthermore, sEH-P KI rats fed a high-fat diet did not gain as much weight as the wild-type rats, did not have increased fat mass and did not develop insulin resistance or hepatic steatosis. In addition, sEH-P KI rats exhibited enhanced basal cardiac mitochondrial activity associated with an enhanced left ventricular contractility and were protected against cardiac ischemia–reperfusion injury. ConclusionOur study reveals that sEH-P is a key player in energy and fat metabolism and contributes together with sEH-H to the regulation of cardiometabolic homeostasis. The development of pharmacological inhibitors of sEH-P appears of crucial importance to evaluate the interest of this promising therapeutic strategy in the management of obesity and cardiac ischemic complications.

The Impact of Charlson Comorbidity Index on De Novo Cardiac Implantable Electronic Device Procedural Outcomes in the United States

ObjectiveTo investigate the utility of Charlson comorbidity index (CCI) as a measure of comorbidity burden to predict procedural outcomes after de novo cardiac implantable electronic device (CIED) implantation. MethodsAll de novo CIED implantations in the United States National Inpatient Sample between 2015 and 2018 were retrospectively analyzed, stratified by CCI score (0=no comorbidity burden, 1=mild, 2=moderate, ≥3=severe). Multivariable logistic regression models were performed to examine the association between unit CCI score (scale) and in-hospital outcomes (major adverse cerebrovascular and cardiovascular events [MACCE]: composite of all-cause mortality, acute ischemic stroke, thoracic and cardiac complications, and device-related complications; and MACCE individual components). ResultsOf 474,475 CIED procedures, the distribution of CCI score was as follows: CCI=0 (17.7%), CCI=1 (21.8%), CCI=2 (18.7%), and CCI=3+ (41.8%). Charlson comorbidity index score was associated with increased odds ratios of MACCE (1.10; 95% CI, 1.09 to 1.11), all-cause mortality (1.23; 95% CI, 1.21 to 1.25), and acute stroke (1.45; 95% CI, 1.44 to 1.46). This finding was consistent across all CIED groups except the cardiac resynchronization therapy groups in which CCI was not associated with increased risk of mortality. A higher CCI score was not associated with increased odds of procedural (thoracic and cardiac) and device-related complications. ConclusionIn a nationwide cohort of CIED procedures, higher comorbidity burden as measured by CCI score was associated with an increased risk of in-hospital mortality and acute ischemic stroke, but not procedure-related (thoracic and cardiac) or device-related complications. Objective assessment of comorbidity burden is important to risk-stratify patients undergoing CIED implantation for better prognostication of their in-hospital survival.

Perioperative baseline β-blockers: An independent protective factor for post-carotid endarterectomy hypertension.

Post-carotid endarterectomy hypertension is a well-recognized phenomenon closely related to surgical complications. This study aimed to determine whether different kinds of perioperative antihypertensive drugs had a protective effect on post-carotid endarterectomy hypertension and influence on intraoperative hemodynamics. We retrospectively investigated 102 carotid stenosis patients who underwent conventional endarterectomy with a perioperative baseline antihypertensive regimen. Post-carotid endarterectomy hypertension was defined as a postoperative peak systolic blood pressure ≥160 mmHg and/or a requirement for any additional antihypertensive therapies. We compared the clinical characteristics and types of baseline perioperative antihypertensive drugs between patients with and without post-carotid endarterectomy hypertension and then determined the significant independent effect of antihypertensive drugs on post-carotid endarterectomy hypertension through multivariate regression and detected their influence on intraoperative hypertension (induction-related systolic blood pressure and vasodilators consumption) and hemodynamic depression (intra-arterial systolic blood pressure ≤100 mmHg and/or heart rate ≤50beats/min). We also investigated adverse events such as stroke, death, myocardial infarction, and cerebral hyperperfusion syndrome during the postoperative hospitalization. A total of 52/102 (51.0%) patients were defined as having post-carotid endarterectomy hypertension during the first three days postoperative, including eight patients with a postoperative systolic blood pressure that exceeded 160 mmHg at least once, 31 patients requiring postoperative antihypertensive treatment in addition to their baseline regimen, and 13 patients with both. The incidence of stroke/death/myocardial infarction and cerebral hyperperfusion syndrome after conventional endarterectomy during hospitalization were both 1.9%. A significantly increased risk of composite postoperative complications (including cerebral hyperperfusion syndrome, hyperperfusion-related symptoms, transient ischemic attacks, stroke, death, and cardiac complications) was observed in patients with post-carotid endarterectomy hypertension than without (15.4% versus 2.0%, p = 0.032). Patients free of post-carotid endarterectomy hypertension had a higher incidence of perioperative baseline β-blocker use than patients who suffered from post-carotid endarterectomy hypertension (46.0% versus 21%, p = 0.008). In multivariate analysis, β-blocker use was a significant independent protective factor for post-carotid endarterectomy hypertension (OR = 0.356, 95% CI: 0.146-0.886, p = 0.028). Patients taking β-blockers had a lower postoperative peak systolic blood pressure than the β-blocker-naïve population (137.1 ± 12.1 mmHg versus 145.0 ± 11.2 mmHg, p = 0.008), but the postoperative mean systolic blood pressure showed no intergroup difference. However, the incidence of hemodynamic depression during conventional endarterectomy was higher in patients with perioperative β-blocker use than in those without (44.1% versus 25.0%, p = 0.050). The difference in intraoperative hemodynamic depression became more prominent between the β-blocker and non-β-blocker groups (81.8% versus 33.3%, p = 0.014) for whose preoperative baseline heart rate was equal to or lower than 70beats/min. The perioperative use of β-blockers is a protective factor for post-carotid endarterectomy hypertension and contributes to stabilizing the postoperative peak systolic blood pressure three days after conventional endarterectomy. However, β-blockers might also lead to intraoperative hemodynamic depression, especially for patients with a low baseline heart rate.

Postoperative Cardiac Ischemic Complications in Lung Cancer Patients

Background. Perioperative myocardial ischemia often complicates extracardiac surgery. The problems of its prediction, diagnostics, treatment and prevention are not solved. Frequency, structure and clinical features of cardiac ischemic complications of surgical treatment of lung cancer are not well understood.The aim of the study was to investigate the frequency of postoperative myocardial infarction and myocardial ischemia in the surgical treatment of patients with non-small cell lung cancer.Methods. The frequency (%) of myocardial infarction (MI) with and without ST segment elevation of electrocardiogram, acute myocardial ischemia in a complete sample of cancer patients (n = 2051) who underwent treatment for non-small cell lung cancer for the last 10 years was calculated. By comparing the relative indicators and calculating the Odds Ratio (OR), we studied the relationship between the cardiac ischemic events with age, type of surgery, prevalence and localization of the tumour. The clinical manifestations and pathomorphology of postoperative myocardial infarction were analysed.Results. Cardiac ischemic complications of thoracotomy for lung cancer occurred in 2.73 % (95% CI 1.98–3.48) cases. Myocardial infarction with ST segment elevation was recorded in 1.07 % (95% CI 0.58–1.57) patients, MI without ST segment elevation – in 0.54 % (95% CI 0.17–0.9), myocardial ischemia – in 1.12 % (95% CI 0.62–1.63). An increase in the frequency of ischemic events after pneumonectomy was observed compared with lobectomy (OR 6.5, 95% CI 3.5–12.2) and after right-sided pneumonectomy compared with left-sided one (OR 3.2, 95% CI 1.6–6.3), and also the age over 70. Hospital mortality from MI was 39.3 %. According to autopsies of patients who died of МI, coronary atherothrombosis was detected in 2 of 22 cases.Conclusion. In the surgical treatment of non-small cell lung cancer, cardiac ischemic events develop in 2.73 % of patients. The greatest risk is associated with right-sided pneumonectomy.

Coronary CTA for Preoperative Risk Assessment in Noncardiac Surgery

Risk assessment for ischemic cardiac complications post noncardiac surgery is not an exact science. This often prompts physicians to order investigations for further risk stratification. As a diagnostic text coronary CT angiography (CCTA)* could prove to be a useful adjunct in preoperative risk assessment and its utility in this setting will be considered. CCTA has been used to assess preoperative risk in several clinical studies, including the recent CTA VISION trial. CTA VISION suggested, in the cohort examined, that CCTA could lead to an exaggeration of preoperative risk. Whether this is true in other populations will be considered. In this review, the results from CTA VISION and the recently published Canadian Cardiovascular Society guidelines will be considered in the context of previous literature and current international guidelines.

A propensity-matched comparison of fenestrated endovascular aneurysm repair and open surgical repair of pararenal and paravisceral aortic aneurysms

ObjectiveThis study investigated the outcomes of a current series of patients treated with fenestrated and branched endovascular aneurysm repair (F-BEVAR) or open surgical repair (OSR) for pararenal abdominal aortic aneurysms (pr-AAAs), including juxtarenal, suprarenal, and type IV thoracoabdominal aneurysms. This study compares the outcomes of these procedures from two high-volume centers without the bias induced by a learning curve. MethodsAll patients with pr-AAAs undergoing repair at two centers between January 2010 and June 2016 were included in a prospective database. Patients undergoing F-BEVAR and OSR were propensity matched for age, sex, anatomic criteria (aortic clamp site), coronary artery disease, chronic obstructive pulmonary disease, diabetes, smoking, chronic kidney disease, aneurysm diameter, and previous aortic surgery. The primary end points were mortality and dialysis. Secondary end points included any myocardial ischemia, respiratory and early procedural complications, acute kidney injury (AKI) according to RIFLE criteria (Risk, Injury, Failure, Loss of kidney function, and End-stage renal failure), spinal cord ischemia, a composite of these complications, and postoperative intensive care unit length of stay. During follow-up, all-cause survival and freedom from reintervention were compared, as was the patency of stented vessels and renal and visceral bypasses. Late renal function deterioration was evaluated. ResultsIn this period, 157 F-BEVAR patients and 119 OSR patients were operated on. After 1:1 propensity matching, the study cohort consisted of 102 F-BEVARs and 102 OSRs. In the matched population, an average of 2.5 vessels were treated per patient. Univariate analysis demonstrated no significant difference in 30-day mortality (2.9% vs 2.0%; P = .68), dialysis (4.9% vs 3.9%; P = 1), cardiac ischemic complications (3.8% vs 5.9%; P = .52), pulmonary complications (5.9% vs 5.9%; P = 1), or any complications (28.4% vs 30.4%; P = .63) in the F-BEVAR and OSR groups, respectively. AKI was significantly lower in the F-BEVAR group than in the OSR group (19.6% vs 52%; P < .001), as was severe AKI (>50% decrease in glomerular filtration rate, 6.9% vs 16.7%; P = .03). There was no spinal cord ischemia. The median intensive care unit length of stay was 1 day in both groups (P = .33). During follow-up, we found occlusions of five stented vessels and three surgical bypasses. Late renal function deterioration was comparable between the two groups. According to Kaplan-Meier estimates, all-cause survival at 24, 48, and 72 months was 85.6%, 66.8%, and 55.8% after F-BEVAR and 90.5%, 82.9%, and 68.5% after OSR (P = .04). Rates of freedom from reintervention were 97.6% vs 97.5% at 24 months, 90.1% vs 93.4% at 48 months, and 63.9% vs 93.4% at 72 months in the F-BEVAR and OSR groups (P = .05), respectively. Thus, both all-cause survival and freedom from reintervention were lower in the F-BEVAR group. ConclusionsThis propensity score analysis in patients with pr-AAA undergoing F-BEVAR or OSR suggests no difference in terms of 30-day mortality, dialysis, or organ-specific postoperative complications, with the exception of AKI. Postoperative AKI was significantly higher after OSR, although most patients had recovered before discharge. Our data suggest similar outcomes after F-BEVAR or OSR for pr-AAA.

Peripheral arterial occlusive disease and perioperative risk.

Surgical procedures represent a risk for different complications which may appear during the perioperative period. Cardiac ischemic events and vascular complications are the most important causes of increased morbidity and mortality and they are much more frequent in patients with manifest cardiovascular disease. This is particularly seen in patients with peripheral arterial occlusive disease (PAD), which represents advanced atherosclerosis frequently accompanied by the presence of coronary artery disease. Therefore, patients with PAD need careful preoperative examination, including estimation of functional capacity and the presence of other co-existing atherosclerotic diseases. The perioperative risk of cardiac complications should be calculated by Apgar score. In patients with unstable coronary syndrome myocardial revascularization should be performed before vascular procedures, whereas in other coronary patients pharmacotherapy should be intensified. The latter includes beta-adrenergic receptor blockers, statin therapy, which significantly improves postoperative outcome and antiplatelet drugs, which do not significantly increase major bleeding complications but significantly reduce cardiovascular thromboembolic events. Postoperative strategy for prevention of complications should be focused particularly on identification of myocardial infarction which is frequently asymptomatic. Therefore, serial postoperative measurements of troponin levels allow close monitoring of postoperative myocardial damage and help to implement strategic choices for the treatment of postoperative adverse cardiac events.

Eptifibatide Bolus Dose During Elective Percutaneous Coronary Intervention.

BackgroundEptifibatide is a platelet glycoprotein IIb/IIIa receptor antagonist used for the prevention of cardiac ischemic complications of percutaneous coronary intervention (PCI). Eptifibatide has been used with bolus dose only or bolus plus infusion in patients undergoing PCI which have shown less complications, but the risk of bleeding has been increased. We aimed to compare the outcome and bleeding rate of bolus dose alone or plus infusion in elective PCI.MethodsIn this quasi-experimental study, we compared the outcome of elective PCI following single bolus dose intracoronary (41 patients) or bolus plus intravenous infusion (19 patients) of eptifibatide. In-hospital and follow-up major adverse cardiac events (MACEs) and bleeding rate were recorded and evaluated between groups.ResultsBoth groups were comparable regarding baseline findings. Bolus only compared to bolus plus infusion group had lower in-hospital (19.5% vs. 31.6%) and follow-up MACE (15.4% vs. 17.6%), lower bleeding in-hospital (14.6% vs. 21.1%) and follow-up (2.4% vs. 5.3%) as well as lower mortality rate in hospital (4.9% vs. 15.8%), but higher follow-up mortality (10.3% vs. 0), but the difference was not significant.ConclusionsWe observed no significant difference regarding bleeding or MACE between intracoronary bolus infusion and bolus plus intravenous infusion of eptifibatide. It seems intracoronary bolus infusion of eptifibatide due to use of lower doses is a better choice in elective PCI to prevent post-PCI MACE.

Efficacy and safety of eptifibatide versus tirofiban in acute coronary syndrome patients: A systematic review and meta-analysis.

Glycoprotein IIb/IIIa inhibitors were the strongest available antiplatelet therapy and have been shown to reduce cardiac ischemic complications in patients undergoing percutaneous coronary intervention. However, evidences are still lacking on the superiority of eptifibatide over tirofiban or vice versa in patients with acute coronary syndrome. To compare the efficacy and safety of eptifibatide and tirofiban used among patients with acute coronary syndrome by performing a systematic review and meta-analysis of randomized controlled trials. A systematic search was conducted in Pubmed, Ovid/Medline, Ovid/Embase, Clinicaltrials.gov, CBM and CNKI to identify randomized controlled trials comparing eptifibatide with tirofiban for acute coronary syndrome until November 2015. The methodological quality was assessed with the Cochrane bias risk assessment tool. 1256 patients from 9 randomized controlled trials were finally included. Compared with tirofiban, eptifibatide could reduce more risk of thrombolysis in myocardial infarction minor bleeding (RR 0.61, 95%CI 0.38, 0.98). However, no significant differences were observed for major adverse cardiac events (RR 0.41, 95%CI 0.15 to 1.12), major bleeding, thrombocytopenia in the two treatment groups. The relative treatment benefits were similar in subgroups of patients according to types of acute coronary syndrome, or undergoing percutaneous coronary intervention. Available evidence suggests that the safety of eptifibatide is slightly superior to tirofiban in patients with acute coronary syndrome, but no significant difference was observed on efficacy. Future studies should focus on the randomized controlled trials with larger sample, multi-center, long-term follow-up, high quality to compare the two drugs.

頚動脈内膜剝離術と冠動脈バイパス術の一期的手術の有用性

The purpose of this study was to evaluate the efficacy of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG). Between April 2006 and April 2014, a total of 57 patients with carotid artery stenosis underwent CEA in our institution. Among them, 7 patients (12.3%; 5 males, 2 females; mean age 74.9 ± 4.5 years) with significant coronary artery disease underwent combined CEA and CABG. Three patients had symptomatic stenosis, with mean degree of stenosis of 71 ± 20% according to the North American Symptomatic Carotid Endarterectomy Trial method. Although one patient (14%) developed postoperative recurrent nerve paralysis, and another patient (14%) died due to postoperative intra-thoracic hemorrhage, technical success had been obtained in all 7 patients without any peri-operative neurological or cardiac complications. It is well known that 30% to 40% of patients with carotid stenosis have coronary artery disease. When CABG is performed in cases of significant carotid stenosis, the risk of perioperative stroke increases. One of the approaches to solve this problem is combined CEA and CABG. Though it might a need longer time for surgery and carries a higher risk of surgical bleeding compared with a single surgery, it can decrease both neurological and cardiac ischemic complications. In our experience, combined CEA and CABG is a preferred surgical approach for high-risk patients.

Plasma CTGF is independently related to an increased risk of cardiovascular events and mortality in patients with atherosclerotic disease: the SMART study

Aims: Connective tissue growth factor (CTGF) plays a key role in tissue fibrogenesis and growing evidence indicates a pathogenic role in cardiovascular disease. Aim of this study is to investigate the association of connective tissue growth factor (CTGF/CCN2) with cardiovascular risk and mortality in patients with manifest vascular disease. Methods and results: Plasma CTGF was measured by ELISA in a prospective cohort study of 1227 patients with manifest vascular disease (mean age 59.0 ± 9.9 years). Linear regression analysis was performed to quantify the association between CTGF and cardiovascular risk factors. Results are expressed as beta (β) regression coefficients with 95% confidence intervals (CI). The relation between CTGF and the occurrence of new cardiovascular events and mortality was assessed with Cox proportional hazard analysis. Adjustments were made for potential confounding factors. Plasma CTGF was positively related to total cholesterol (β 0.040;95%CI 0.013–0.067) and LDL cholesterol (β 0.031;95%CI 0.000–0.062) and inversely to glomerular filtration rate (β −0.004;95%CI −0.005 to −0.002). CTGF was significantly lower in patients with cerebrovascular disease. During a median follow-up of 6.5 years (IQR 5.3–7.4) 131 subjects died, 92 experienced an ischemic cardiac complication and 45 an ischemic stroke. CTGF was associated with an increased risk of new vascular events (HR 1.21;95%CI 1.04–1.42), ischemic cardiac events (HR 1.41;95%CI 1.18–1.67) and all-cause mortality (HR 1.18;95%CI 1.00–1.38) for every 1 nmol/L increase in CTGF. No relation was observed between CTGF and the occurrence of ischemic stroke. Conclusions: In patients with manifest vascular disease, elevated plasma CTGF confers an increased risk of new cardiovascular events and all-cause mortality.

Cardiac Ischemic Complications Following Cardiac Surgery - Angiographic Findings and Predictors of In-hospital Mortality

Objective: To describe findings and predictors of in-hospital mortality in patients requiring repeated coronary angiogram for cardiac ischemic complications following heart surgery. Methods: Between January 2005 and January 2015, out of 10,759 (3.1%) 336 patients underwent postoperative coronary angiogram because clinical signs of cardiac ischemia occurred. Operative procedures included CABG in 294 patients, 84 valve and 14 aortic procedures. A logistic regression analysis was performed to identify significant risk factors for in-hospital mortality. Results: Graft failure including distal anastomotic stenosis, kinking or graft thrombosis was found in 121 angiograms (36%). A new native coronary artery occlusion was found in 96 patients (28.6%). A combination of graft-related and non-graft-related occlusions occurred in 36 patients (10.7%), while 83 patients (24.7%) had normal postoperative graft-related angiograms. Revision CABG and percutaneous coronary intervention was performed in 56 (16.7%) and 120 (35.7%) patients respectively. In hospital mortality was 15.8% (53 patients). After multivariate adjustment emergency admission (p< 0.0001; OR 5.3), absence of preoperative sinus rhythm (p = 0.006; OR 3.2), female sex (p = 0.007; OR 2.7), aortic valve surgery (p = 0.01; OR 2.8), aortic surgery (0.01; OR 2.8), history of decompensation (p = 0.02; OR 2.9) and surgery duration (p = 0.04; OR 1.004) turned out to be independent predictors of in hospital mortality. Conclusion: Postoperative ischemic heart complications with the need of re-coronary angiogram generally results in a notably bad outcome in terms of mortality. Patients with abovementioned risk factors for mortality deserve particular care and expertise to avoid ischemic complications.

Pre- and in-hospital antithrombotic management patterns and in-hospital outcomes in patients with acute coronary syndrome: data from the Turkish arm of the EPICOR study.

Objective:To evaluate the acute phase (pre- and in-hospital) antithrombotic management patterns (AMPs) and in-hospital outcomes for patients hospitalized with an acute coronary syndrome (ACS).Methods:In total, 1034 patients [514 patients with ST-segment elevation myocardial infarction (STEMI) and 520 with unstable angina/non-STEMI (UA/NSTEMI)] hospitalized for ACS within 24 h of symptom onset were included in this multicenter prospective registry study conducted at 34 hospitals across Turkey. Patient characteristics, index event description, pre- and in-hospital AMPs, and clinical outcomes were evaluated.Results:Majority (89.1%) of patients did not receive pre-hospital treatment. Overall 87.9% patients with STEMI and 55.6% patients with NSTEMI underwent percutaneous coronary intervention and dual antiplatelet therapy (DAPT) was based mainly on acetylsalicylic acid (ASA) and clopidogrel during hospitalization (99.8% and 98.2%, respectively). DAPT use at discharge was 98.4% and 86.8%, respectively. The percentage of patients with STEMI who received pre-hospital care, in-hospital cardiac catheterization, and pre and/or in-hospital triple antiplatelet therapy was higher than that of patients with UA/NSTEMI. In addition, higher rate of in-hospital hemorrhagic (2.3% vs. 0.8%) and cardiac ischemic (1.2% vs. 0.4% for MI and 1.6% vs. 0.8% for recurrent ischemia) complications and earlier induction of pre and/or in-hospital antiplatelet therapy and cardiac catheterization were also noted in patients with STEMI than in those with UA/NSTEMI.Conclusion:Our findings revealed in-hospital and at-discharge management to be mainly based on DAPT in patients with ACS. Interventional strategies were used in the majority of patients with STEMI, while the usage and timing of immediate pre-hospital ECG from symptom onset should be improved in these patients.

Hematopoietic Stem Cell Transplantation in Patients with Systolic Dysfunction: Can It Be Done?

Hematopoietic cell transplantation (HCT) is a potential cure for certain hematologic malignancies. However, because of risks of complications and mortality, this treatment option is limited to patients with minimal comorbidities. We performed a retrospective cohort study evaluating the impact of pre-HCT systolic dysfunction on outcomes. We identified 49 subjects with systolic dysfunction, defined as left ventricular ejection fraction (LVEF) < 50% and 49 controls (matched by age, gender, conditioning regimen, and HCT donor number; all with LVEF ≥ 50%) undergoing HCT at the University of Minnesota between 2002 and 2012. Treatment complications, use of beta-blockers and angiotensin-converting enzyme inhibitors, and overall survival (OS) after HCT out to 24 months were analyzed. The median LVEF was 45% (range, 27.5% to 49%) for the study group and 60% (range, 50% to 69%) for controls. The majority of patients in both groups (81.6%) received reduced-intensity conditioning (RIC). Treatment-related mortality (TRM) at day 100 was identical, with a cumulative incidence of 14% in the study (95% confidence interval [CI], 5% to 24%) versus 14% in controls (95% CI, 5% to 24%) (P = .89). Two-year OS was similar in the study group (53%; 95% CI, 38% to 66%) versus controls (61%; 95% CI, 46% to 73%) (P = .34). LVEF ≥ 43% was associated with improved OS at 1 year (hazard ratio [HR], .36; 95% CI, .15 to .87; P = .02). There was no significant difference in the incidence of non–life-threatening cardiac complications (12.2% in cases versus 8.2% in controls, P = .50) or serious (life-threatening or fatal) cardiac complications (4.1% in cases versus 2.0% in controls, P = .56). Pre-existing coronary artery disease was associated with increased TRM at 100 days (HR, 4.35; 95% CI, 1.24 to 15.32; P = .02). Cardiac medication use had no effect on TRM. Our study demonstrates that patients with asymptomatic borderline systolic dysfunction can safely undergo HCT with RIC. Coronary artery disease remains a risk factor for increased TRM. Patients with borderline systolic dysfunction can safely undergo HCT, but may need particular vigilance for potential hemodynamic or ischemic cardiac complications.

B-type Natriuretic Peptide (BNP) Predicts Early Ischemic Postoperative Cardiac Complications and Long-term Mortality after Elective Endovascular Treatment of AAAs

B-type Natriuretic Peptide (BNP) Predicts Early Ischemic Postoperative Cardiac Complications and Long-term Mortality after Elective Endovascular Treatment of AAAs

Brain volumes and risk of cardiovascular events and mortality. The SMART-MR study

Brain atrophy is a strong predictor for cognitive decline and dementia, and these are, in turn, associated with increased mortality in the general population. Patients with cardiovascular disease have more brain atrophy and a higher morbidity and mortality. We investigated if brain volumes on magnetic resonance imaging were associated with the risk of cardiovascular events and mortality in patients with manifest arterial disease (n = 1215; mean age 58 years). Automated brain segmentation was used to quantify intracranial volume, and volumes of total brain, sulcal cerebrospinal fluid, and ventricles. After a median follow-up of 8.3 years, 184 patients died, 49 patients had an ischemic stroke, and 100 patients had an ischemic cardiac complication. Smaller relative brain volumes increased the risk of all-cause death (hazard ratio [HR] per standard deviation decrease in total brain volume: 1.58, 95% confidence interval [95% CI]: 1.33–1.88), vascular death (HR 1.69, 95% CI: 1.35–2.13), and ischemic stroke (HR 1.96, 95% CI: 1.43–2.69), independent of cardiovascular risk factors. These results suggest that brain volumes are an important determinant of poor outcome in patients with high cardiovascular risk.

Surgical Treatment for Cervical Carotid Artery Stenosis in the Elderly: Importance of Perioperative Management of Ischemic Cardiac Complications

Ischemic cardiac complication is one of the major perioperative complications of surgical treatment for cervical carotid stenosis, carotid endarterectomy (CEA), and carotid artery stenting (CAS), and may greatly affect surgical outcome, especially in elderly patients aged ≥ 80 years. We retrospectively analyzed the records of 259 patients (34 patients aged ≥ 80 years) treated by CEA and 61 patients (12 patients aged ≥ 80 years) treated by CAS at Aizu Chuo Hospital from January 2000 to September 2010. Preoperative ischemic heart disease screening was performed in all patients. If high risk of coronary atherosclerotic stenosis was detected, treatment for coronary lesion was performed prior to CEA or CAS. There was no preoperative ischemic cardiac complication in both the CEA and CAS groups. Perioperative complications (morbidity + mortality) occurred in 2.9% of patients aged ≥ 80 years and 1.7% of patients aged ≤ 79 years in the CEA group, and 8.3% and 8.1% of patients, respectively, in the CAS group. There was no statistically significant difference by age in either group. CEA could be safely performed with tolerable complication rates even in elderly patients. However, the complication rate in the CAS group was relatively high. New ischemic lesion on diffusion-weighted magnetic resonance imaging, both symptomatic and asymptomatic, tended to occur at a higher rate in the CAS group, especially in the elderly patients. Thorough perioperative management may minimize ischemic cardiac complications even in elderly patients. Efforts must be continued to minimize surgical complications, especially for CAS. Noninvasive medical treatment should also be considered for elderly patients.

The key areas of medical therapy for ischemic stroke

The paper considers the main therapeutic and preventive areas of management of patients with stroke, which are relied on evidence-based medicine data. To treat stroke patients is a multistep and multidisciplinary problem that starts with the emergence of the first neurological symptoms and extends over the entire life. Each period, including factors, such as the pattern of prehospital first medical aid; the rate of patient delivery to hospital; further actions of medical staff; measures for the prevention of recurrent cerebral ischemic events, cardiac complications, and cognitive disorders, is of importance in itself and serves a common aim. All efforts must aim eventually to reduce death rates in acute stroke, patient functional dependence, and recurrent brain damage rates, to prevent and timely treat cognitive impairments, to strictly adhere to the principles of secondary treatment of cardiovascular events in order to increase life expectancy and quality.

Advances in antiplatelet technologies to improve cardiovascular disease morbidity and mortality: a review of ticagrelor.

Antiplatelet therapy is widely used with proven benefit for the prevention of further ischemic cardiac complications in patients with acute coronary syndrome. Treatment guidelines for acute coronary syndrome and percutaneous coronary intervention now recommend the use of oral antiplatelet agents including ticagrelor, prasugrel, or clopidogrel in combination with aspirin to comprise dual antiplatelet therapy for the prevention of recurrent ischemic events. The limitations of conventional antiplatelet therapy with clopidogrel or prasugrel include the potential for low response to clopidogrel identified through platelet reactivity or genetic testing, increased risk of bleeding with prasugrel, or slower return to normal platelet activity in patients who received either prasugrel or clopidogrel prior to emergent or planned surgical procedures. This review will discuss the pharmacokinetic and pharmacodynamic properties of ticagrelor in comparison to conventional P2Y12 receptor inhibitors and its utility in patients identified as low responders to clopidogrel. Completed clinical studies and substudies comparing ticagrelor to clopidogrel and ongoing clinical trials evaluating ticagrelor in acute coronary syndrome patients will also be reviewed.