Major Acute Cardiac Events Research Articles

Leptin as predictor of cardiovascular events and high platelet reactivity in patients undergoing percutaneous coronary intervention

Leptin is a hormone involved in the regulation of food intake. Previous studies suggested an interplay between leptin, platelet aggregation, and cardiovascular outcome but this issue was not investigated invivo in patients treated with percutaneous coronary intervention (PCI). We designed a study to evaluate the possible relation between leptin, cardiovascular outcome, and platelet reactivity (PR) in patients undergoing PCI. 155 PCI patients had preprocedural measurements of PR and leptin plasma levels. The latter were assessed by ELISA. Hyperleptinemia was defined as leptin levels ≥14ng/ml. PR was evaluated by the VerifyNowP2Y12 assay and expressed as P2Y12 reaction units (PRU). Patients were divided into three groups based on PR values and defined as low (LPR), normal (NPR), and high (HPR). Patients were followed for up 8 years. The primary endpoint was the incidence of Major Acute Cardiac Events (MACE) at long-term follow-up according to leptin groups. Secondary endpoints were the evaluation of leptin levels according to PR groups and the incidence of periprocedural myocardial infarction (PMI) according to leptin groups. Long-term follow-up was completed in 140 patients. Patients with hyperleptinemia experienced a higher MACE rate than the normoleptinemic group (HR 2.3; CI 95% 1.14-4.6, P=0.02). These results remained unchanged after adjusting for Body Mass Index, hypertension, and gender. Leptin levels were significantly different among groups of PR (P=0.047). Leptin levels were higher in the HPR group (12.61±16.58ng/ml) compared to the LPR group (7.83±8.87ng/ml, P=0.044) and NPR group (7.04±7.03ng/ml, P=0.01). The rate of PMI was higher in hyperleptinemia patients (15.1% vs. 6.5%, P=0.22). This study suggests that high leptin levels are associated with a worse clinical outcome in patients undergoing PCI and with HPR. Further studies are needed to define better the pathophysiological pathways underlying this association.

Prognostic significance of serum potassium level for major adverse cardiac events and death in patients with coronary atherosclerotic disease

Introduction: Serum potassium levels have been shown in some animal studies to be associated with the process of atherosclerosis. We decided to assess the correlation of serum potassium level in ischemic heart disease patients with disease severity and its relationship with prognosis in terms of major acute cardiac events (MACE). Material and methods: This was a cross-sectional cohort study carried out at cardiology department of Rehman Medical Institute, from July 2016 to 31st Aug. 2018 a period of 26 months. 622 patients were included in the study. Clinical and angiographic characteristics were assessed based on the serum potassium level. Correlation of serum potassium level with Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) and Gensini scores was also evaluated. Follow up for MACE was carried out after one year. Results: Mean serum potassium level was 3.93 ± 0.95 (mEq/l) in coronary artery disease patients. Serum potassium level showed negative correlation with SYNTAX score (r = –0.60, p < 0.05) and Gensini score (r = –0.64, p < 0.05). There was also a significant difference between low and high potassium level in relation to the multi-vessel disease on coronary angiography (p < 0.05). Low potassium level was a good predictor of adverse outcomes as shown by Kaplan-Meier analysis. Multivariate Cox regression analysis showed that serum potassium level and diabetes were independent predictors of MACE (p < 0.05). Conclusion: Low serum potassium level is correlated with more severe coronary atherosclerosis. Low potassium levels are associated with significantly poor outcomes.

The Role of Residual Stenosis of the Coronary Arteries in the Dynamics Systolicdiastolic Left Ventricular Function after Acute Coronary Syndrome

The aim of the research under consideration was to study the dynamics of a local systolic-diastolic function of patients with various ischemic heart disease (IHD) progressions after survival of an acute coronary syndrome (ACS) provided there are residual stenoses of coronary arteries. There were 112 patients suffering from ACS who took part in the research. The diagnosis was verified (acute myocardial infarction or unstable angina) in accordance with the recommendations of European Society of Cardiology (ESC). All patients were divided into two groups depending on the occurrence of major acute cardiac events (MACE): 59 patients with aggravated IHD progression and 152 patients with non-aggravated course. Echo-cardiography was performed on a scanner Philips iE33 (the Netherlands) with a consideration to systolic and diastolic functions parameters of a left ventricle. Quantitative analysis of the left ventricle was executed in the mode of Tissue Doppler Imaging (TDI) and according to the method of tracing the patches of the ultra-sound image gray scale (ST). In the course of the aggravated IHD a decrease in systolic-diastolic function of left ventricle has been discovered. It has been found out that the amount of the systolic peak of longitudinal strain of the left ventricle anteroseptal wall less than 12% is associated with a greater extent of coronary atherosclerosis and aggravated progression of IHD. TDI and ST methods have enabled to reveal that in the course of non-aggravated IHD the contractility and the diastolic function of the left ventricle anteroseptal wall improve in combination with the increase in the contractility of the left ventricle inferolateral wall. During an aggravated IHD progression the contractility and diastolic function of the left ventricle anteresoptal wall decreases without an increase in contractility and diastolic function of the inferior and inferolateral walls of the left ventricle. The reason for such results might be a progressing myocardial ischemia of the left ventricle anteroseptal wall despite the sufficient anterior interventricular artery stenting. The presence of the relevant residual stenoses of the circumflex and right coronary arteries increases the possibility of the aggravated IHD progressing especially by the end of the fourth year of observation. The disbalance of the local contractility of anterior, inferior and inferolateral left ventricle walls in the course of aggravated IHD is connected with the CA residual stenoses presence and forwards the decrease in global systolic-diastolic function of the left ventricle. The final results can serve as a foundation for optimization of recommendations for performing PCI on the patients with multivessel disease of CA.

The effect of anesthetic technique on mortality and major morbidity after hip fracture surgery: a retrospective, propensity-score matched-pairs cohort study

IntroductionSpinal anesthesia (SA) has physiological benefits over general anesthesia (GA), but there is insufficient evidence regarding a mortality benefit. We performed a retrospective propensity score-matched cohort study to evaluate the...

Downregulation of the Complement Cascade In Vitro, in Mice and in Patients with Cardiovascular Disease by the BET Protein Inhibitor Apabetalone (RVX-208)

Apabetalone (RVX-208) is an epigenetic regulator developed to treat cardiovascular disease (CVD) that targets BET proteins. Through transcriptional regulation RVX-208 modulates pathways that underlie CVD including reverse cholesterol transport, vascular inflammation, coagulation, and complement. Using transcriptomics and proteomics we show that complement is one of the top pathways downregulated by RVX-208 in primary human hepatocytes (PHH) and in plasma from CVD patients. RVX-208 reduces basal and cytokine-driven expression of complement factors in PHH and in chimeric mice with humanized livers. Plasma proteomics of CVD patients shows that RVX-208 decreases complement proteins and regulators, including complement activators SAP and CRP. Circulating activated fragments C5a, C3b, and C5b-C6 are reduced by 51, 32, and 10%, respectively, indicating decreased activity of complement in patients. As complement components are linked to CVD and metabolic syndrome, including major acute cardiac events, modulating their levels and activity by RVX-208 may alleviate risks associated with these diseases.

Efficacy and safety of alcohol septal ablation in patients over 65 years old with obstructive hypertrophic cardiomyopathy.

BackgroundThe performance of alcohol septal ablation (ASA) in elderly symptomatic patients with drug-refractory obstructive hypertrophic cardiomyopathy is still to be confirmed. The objective of this study was to compare the efficacy and safety of ASA in patients under and over 65 years old.Methods and resultsFifty-one consecutive patients with obstructive hypertrophic cardio-myopathy who underwent ASA were retrospectively included and reviewed for in-hospital major acute cardiac events and follow-up. Twenty-eight patients were over 65 years old. Left ventricular outflow tract obstruction at rest, use of diuretic and average dose of diuretic were higher in patients over 65 years old. There was no difference in hospital stay between patients under and over 65 years old. Among patients over 65 years old, 2 (7%) died before being discharged. Major acute cardiac events were more frequent in patients over 65 years old in comparison with younger patients (43% versus 9%, respectively, P=0.007). The average follow-up duration was 16±15 months. There was no difference between patients under and over 65 years old regarding the efficacy of the procedure with a decrease of the New York Heart Association class of 1.3±0.6 and 1.4±0.7 (P=0.510) and the maximum left ventricular outflow tract gradient of 86±57 and 81±36 mmHg (P=0.733), respectively.ConclusionElderly patients have the same benefits as younger patients after ASA but have more complications including mortality events.

Long-term prognostic impact of CT-Leaman score in patients with non-obstructive CAD: Results from the COronary CT Angiography EvaluatioN For Clinical Outcomes InteRnational Multicenter (CONFIRM) study

BackgroundNon-obstructive coronary artery disease (CAD) identified by coronary computed tomography angiography (CCTA) demonstrated prognostic value. CT-adapted Leaman score (CT-LeSc) showed to improve the prognostic stratification. Aim of the study was to evaluate the capability of CT-LeSc to assess long-term prognosis of patients with non-obstructive (CAD). MethodsFrom 17 centers, we enrolled 2402 patients without prior CAD history who underwent CCTA that showed non-obstructive CAD and provided complete information on plaque composition. Patients were divided into a group without CAD and a group with non-obstructive CAD (<50% stenosis). Segment-involvement score (SIS) and CT-LeSc were calculated. Outcomes were non-fatal myocardial infarction (MI) and the combined end-point of MI and all-cause mortality. ResultsPatient mean age was 56±12years. At follow-up (mean 59.8±13.9months), 183 events occurred (53 MI, 99 all-cause deaths and 31 late revascularizations). CT-LeSc was the only multivariate predictor of MI (HRs 2.84 and 2.98 in two models with Framingham and risk factors, respectively) and of MI plus all-cause mortality (HR 2.48 and 1.94 in two models with Framingham and risk factors, respectively). This was confirmed by a net reclassification analysis confirming that the CT-LeSc was able to correctly reclassify a significant proportion of patients (cNRI 0.28 and 0.23 for MI and MI plus all-cause mortality, respectively) vs. baseline model, whereas SIS did not. ConclusionCT-LeSc is an independent predictor of major acute cardiac events, improving prognostic stratification of patients with non-obstructive CAD.

Patterns of coronary artery ectasia and short-term outcome in acute myocardial infarction

Objective. To assess the relationship between hematological inflammatory signs, cardiovascular risk (CV) factors and prognosis in patients presenting with acute myocardial infarction (AMI) and coronary artery ectasia (CAE). Design. We investigated 3321 AMI patients who required urgent primary percutaneous intervention in two centres in the United Kingdom between January 2009 and August 2012. Thirty patients with CAE were compared with 60 age- and gender-matched controls. Blood was collected within 2 h of the onset of chest pain. CV risk factors were assessed from the records. Major acute cardiac events and/or mortality (MACE) over 2 years were documented. Results. CAE occurred in 2.7% and more often affected the right (RCA) (p = 0.001) and left circumflex artery (LCx) (0.0001). Culprit lesions were more frequently related to atherosclerosis in non-CAE patients (p = 0.001). Yet, CV risk factors failed to differentiate between the groups, except diabetes, which was less frequent in CAE (p = 0.02). CRP was higher in CAE (p = 0.006), whereas total leucocyte, neutrophil counts and neutrophil/lymphocyte ratio (N/L ratio) were lower (p = 0.002, 0.002 and 0.032, respectively) than among non-CAE. This also was the case in diffuse versus localised CAE (p = 0.02, 0.008 and 0.03, respectively). The MACE incidence did not differ between CAE and non-CAE (p = 0.083) patients, and clinical management and MACE were unrelated to the inflammatory markers. Conclusion. In AMI, patients with CAE commonly have aneurysmal changes in RCA and LCx, and their inflammatory responses differ from those with non-CAE. These differences did not have prognostic relevance, and do not suggest different management.

Does Quantifying Epicardial and Intrathoracic Fat With Noncontrast Computed Tomography Improve Risk Stratification Beyond Calcium Scoring Alone?

Noncontrast cardiac computed tomography allows calculation of coronary artery calcium score (CACS) and measurement of epicardial adipose tissue (EATv) and intrathoracic fat (ITFv) volumes. It is unclear whether fat volume information contributes to risk stratification. Cardiac computed tomography was performed in 760 consecutive patients with acute chest pain admitted thorough the emergency department. None had prior coronary artery disease. CACS was calculated using the Agatston method. EATv and ITFv were semiautomatically calculated. Median patient follow-up was 3.3 years. Mean patient age was 54.4±13.7 years and Framingham risk score 8.2±8.2. The 45 patients (5.9%) with major acute cardiac events (MACE) were older (64.8±13.9 versus 53.7±13.4 years), more frequently male (60% versus 40%), and had a higher median Framingham risk score (16 versus 4) and CACS (268 versus 0) versus those without events (all P<0.01). The MACE group had a higher median of EATv (154 versus 116 mL) and ITFv (330 versus 223 mL), and a higher prevalence of EATv >125 mL (67% versus 44%) and ITFv >250 mL (64% versus 42%) (all P<0.01). CACS, EATv, and ITFv were all independently associated with MACE. CACS was associated with MACE after adjustment for fat volumes (P<0.0001), whereas EATv and ITFv improved the risk model only in patients with CACS >400. CACS and fat volumes are independently associated with MACE in acute chest pain patients and beyond that provided by clinical information alone. Although fat volumes may add prognostic value in patients with CACS >400, CACS is most strongly correlated with outcome.

Safety of provocative tests of coronary artery spasm and prediction of long-term outcome: need for an innovative clinical research strategy

Takagi et al ,1 have reported the findings of a nationwide multicentre Japanese registry on the arrhythmic risk of provocative tests of coronary artery spasm (CAS) in all comers with angiographically documented vasospastic angina (VSA). They recruited a total of 1246 patients who, after the test, were followed for a median period of 32 months in order to quantify major acute cardiac events (MACEs). Although largely retrospective and with an incomplete clinical characterization of patients (no information on onset, duration, and severity of symptoms in patients with focal, diffuse, or microvascular constriction), this study has two major practical clinical implications and suggests that continuing to consider only the most common features of the ‘average’ patient with VSA is unlikely to produce relevant additional novel information; thus the time has come to implement novel clinical research strategies. This report proves the following conclusively, in agreement with previous smaller, single-centre studies: (i) In an unselected spectrum of patients with VSA, the global acute arrhythmogenic risk of provocative tests for CAS was quite low, comparable with that observed during spontaneous anginal episodes [with or without pain or electrocardiogam (ECG) changes]; moreover, the risk of life-threatening events was quite small and unpredictable, on the basis of the descriptors tested. (ii) In the broad range of patients studied, the risk of MACEs during a median follow-up of nearly 3 years was also quite low, and the predictive value of available descriptors for MACEs appears poor. Therefore, innovative clinical research strategies must be developed in order to identify: (i) new, more specific, and more accurate combined predictors of life-threatening events, in carefully characterized subgroups of patients, rather than in all comers; and (ii) the various underlying causal mechanisms of spasm and their specific diagnostic and therapeutic targets. The examination of the composition of the 6.8% …

THIS MONTH IN Anesthesiology

In-training examination scores and three other factors were predictive. See the accompanying Editorial View on page 6 Spinal fentanyl concentration did not predict speed of onset or duration of labor analgesia.How should surgical patients be managed based on the available evidence?Prolonged prone positioning increases intraocular pressure.Naloxone and alternative nonopioid antagonists are discussed.Although perioperative β-blockade decreases cardiac events, it also increases perioperative stroke and mortality. In this retrospective study, the records of all noncardiac, nontransplant surgical patients over 1 yr were retrieved to investigate if β-blockade limits the cardiac reserve to compensate for acute surgical anemia. Of 4,387 patients, 26% received β-blockers within the first 24 hr of surgery. Major acute cardiac events (MACE) were defined as myocardial infarction, nonfatal cardiac arrest, and in-hospital mortality. MACE occurred approximately two times more frequently in β-blocked patients compared with β-blocker naive patients. This difference was restricted to those patients with hemoglobin decreases exceeding 35% of the baseline value. β-blocked patients do not appear to tolerate acute surgical anemia. See the accompanying Editorial View on page 12 Administration of oral amiodarone reduces atrial fibrillation (AF) after cardiac surgery; however, the hemodynamic safety and efficacy have not been studied in the absence of a preoperative loading dose. In this single-center, double-blind, double-dummy, randomized controlled trial, patients undergoing valvular surgery received either an intravenous loading dose of 300 mg of amiodarone or placebo in the operating room, followed by an infusion of 15 mg/kg per 24 hr for 2 days. Overall AF occurred more frequently in the perioperative intravenous amiodarone group compared with placebo and was associated with older age, recent myocardial infarction, preoperative angina, and use of a calcium channel blocker preoperatively. In patients undergoing cardiac valvular surgery, intravenous amiodarone increased the risk of AF during cardiac valvular surgery.A common cause of chronic pain and disability is neck pain and facet joint arthropathy accounts for the majority of cases. Diagnostic blocks of the nerves that innervate the cervical facet joint pain may result in false-positive results. The objective of this randomized, double-blind study was to evaluate the accuracy of medial branch blocks and effect of varying injectate volumes. All patients (n = 24) received cervical medial branch blocks (0.5 or 0.25 ml of bupivacaine and contrast). Aberrant spread was observed more frequently in patients in the 0.5-ml group and was most commonly observed (57%) when an injection at C3 engulfed the third occipital nerve. Among the 86 nerve blocks, foraminal spread occurred in 5 instances using 0.5 ml and in 2 cases with 0.25 ml. No significant difference in any outcome measure was observed between the prone and lateral positions. Reducing the volume during cervical medial branch blocks may improve precision and accuracy.

The threshold of admission glycemia as a predictor of adverse events in diabetic and non-diabetic patients with acute coronary syndrome.

Recent studies indicated a high prevalence of hyperglycemia in non-diabetic patients presenting with acute coronary syndrome (ACS). However, the threshold of admission glucose (AG) as a predictor of adverse events in ACS is unclear. The aim of this study was to assess the threshold of admission glucose (AG) as a predictor of adverse events including Major Acute Cardiac Events (MACE) and mortality, during the first week of admitting patients presenting with ACS. The data of 551 patients with ACS were extracted and evaluated. Patients were stratified according to their blood glucose on admission into three groups: group 1: </=7 mmol/L (n = 200, 36.3%) and group 2: >7 mmol/L and <15 mmol/L (n = 178, 32.3%) and group 3: >/=15 mmol/L (n = 173, 31.4%). Stress hyperglycemia was arbitrarily defined as AG levels > 7 mmol/L (group 2 and 3). Patients with ACS were sub-divided into two groups: patients with unstable angina (UA, n = 285) and those with ST segment elevation myocardial Infarction (STEMI, n = 266) and data were analyzed separately using multiple regression analysis. The mean age of patients was 59.7 +/- 14.8 years and 63% were males. The overall mortality in the population was 8.5% (5.4% in STEMI and 3.1% in UA) patients. In STEMI patients, the odds ratio of stress hyperglycemia as predictor of mortality in group 3 compared with group 1 was 3.3 (CI 0.99-10.98, P < 0.05), while in group 2 compared with group 1 was 2.4 (CI: 0.75-8.07, P = 0.065) after adjustment for age and sex. Similarly, in UA patients, the odds ratio of stress hyperglycemia in group 3 compared with group 1 was 2.7 (CI 0.37-18.98, P < 0.05), while in group 2 compared with group 1 was 2.4 (CI: 0.4-15.2, P = 0.344) after adjustment for age and sex. The incidence of more than 2 MACE in both STEMI and UA patients was higher in group 3 compared with the other two groups. Regression analysis showed that history of DM, high level of LDL cholesterol, high level of HbA1c, and anterior infarction were significant predictors of adverse events while other risk factors such as BMI, history of hypertension and smoking were of no significance. This study indicates that the stress hyperglycemia on admission is a powerful predictor of increased major adverse events and hospital mortality in patients with acute coronary syndrome.

Abstract 4337: Best Outcome Predictor Post Myocardial Infarction: Can Blood Glucose Defeat Left Ventricular Ejection Fraction?

Introduction: Ventricular dysfunction in acute myocardial infarction (AMI) is a recognized predictor of in-hospital and post-discharge morbidity and mortality. Recently, admission hyperglycaemia has also been considered an important marker of poor prognosis in this patient population. Aim: To compare the predictive value of left ventricular dysfunction with admission glycaemia (GLY) on prognosis of AMI patients and to identify independent predictors of 1-year major acute cardiac events (MACE) and mortality. Population and methods: Retrospective analysis of 583 consecutive patients admitted to a single coronary care unit for AMI. Patients were followed during twelve months after AMI. Re-hospitalization by worsening heart failure, non programmed revascularization, new ACS and death were considered as MACE. Results: After multivariate analysis, age, previous diabetes, necrosis markers, and low ejection fraction (EF) were independent predictors of 1-year mortality, while PCI performance and admission GLY, in addition to parameters listed before were independent predictors of MACE at 1-year of follow-up. We then compared, by multivariate regression analysis, the predictive value of admission GLY and EF in this population. The receiver-operator curves showed that both parameters were equally predictive of both short and long-term MACE and mortality. Conclusion: In this population, admission GLY was as predictive of outcome as EF, a well recognized and strong prognosis determinant post-AMI. This fact, never before described, underlies the importance of metabolic abnormalities and its control in the prognosis of AMI patients.

Chest pain after recent stress test: Is there a warranty?

Study objectives: Emergency physicians often incorporate recent stress test results into their decisionmaking process for the evaluation and disposition of chest pain patients, which is based on studies of prognosis after stress testing. However, the subset of patients who present to an emergency department (ED) with chest pain and a history of a normal stress test is not adequately addressed in the literature. We seek to determine whether a history of a recent normal stress test result in patients presenting with chest pain to the ED is associated with a low risk (<1%) of major acute cardiac events. Methods: Patients presenting to our ED with a chief complaint of chest discomfort between January 1, 1998, and September 30, 2002, and who had undergone a stress test at our institution within 2 years were included. The primary endpoint was acute myocardial infarction on ED visit or death within 30 days. The diagnosis of acute myocardial infarction was based on cardiac marker elevation or ECG. All ECGs were reread for the purpose of this study by an investigator blinded to all other clinical data. Previous stress tests included treadmill studies without imaging, treadmill studies with imaging, and pharmacologic imaging studies. Treadmill study results were considered normal if there were no ST-segment changes and no abnormalities of functional capacity or heart rate dynamics during or after exercise. Imaging study results were considered normal if there was no evidence of myocardial ischemia or scar. Results: There were 1,857 eligible patients, of whom 283 had treadmill tests without imaging (79 or 27% were normal), 750 had treadmill tests with imaging (235 or 31% were normal), and 824 had pharmacologic tests (448 or 54% were normal). There were 190 patients (10%) who had the primary endpoint; only 2 patients died within 30 days. The history of a normal stress test was associated with a lower risk of the primary endpoint (50/762 or 7% versus 140/1095 or 13%, odds ratio 0.48, 95% confidence interval [CI] 0.34 to 0.67, <i>P</i><.0001). Among 449 patients who had a normal stress test result and on initial presentation had a nondiagnostic ECG and normal biomarkers, only 9 (2.0%, 95% CI 1.1% to 3.8%) had the primary endpoint. Among 508 patients who, on initial presentation, had a nondiagnostic ECG and normal biomarkers but had a history of an abnormal stress test result, 16 (3.2%, 95% CI 2.0% to 5.1%) had the primary endpoint. Conclusion: Among patients presenting with chest pain to the ED and a history of stress testing within the past 2 years, a normal stress test result was associated with a markedly reduced risk of having a major cardiac endpoint. However, with the possible exception of patients presenting with initially normal biomarkers and ECG findings, the absolute risk of 7% was not reassuringly low enough to justify early discharge.

Prognostic significance of an elevated creatine kinase in the absence of an elevated troponin I during an acute coronary syndrome

In patients with troponin-negative acute coronary syndromes, creatine kinase (CK)-MB elevation predicts a significantly higher risk of death and major acute cardiac events compared with CK-MB negative patients. This risk is accentuated in troponin-negative, CK-MB positive patients who do not demonstrate ST elevation by electrocardiogram.