Major Adverse Coronary Events Research Articles

Utility of Lipoprotein-Associated Phospholipase A2 for Prediction of 30-day Major Adverse Coronary Event in Patients with the First Anterior ST-Segment Elevation Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention

Lipoprotein-associated phospholipase A2 (Lp-PLA2) has been suggested as an inflammatory marker of cardiovascular risk. The predictive value of Lp-PLA2 in ST-segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PCI) has not been established. The aim of this study was to determine whether plasma Lp-PLA2 is a predictor of a major adverse cardiac event (MACE) in patients with the first anterior STEMI treated by primary PCI. This study consisted of 100 consecutive patients with first anterior STEMI who underwent primary PCI within 6 hours of the symptom onset. Plasma Lp-PLA2 level was measured on admission using a turbidimetric immunoassay (diaDexus, Inc., USA). The Receiver Operating Characteristic analysis was performed to identify the most useful Lp-PLA2 cut-off level for the prediction of MACE. The patients were divided into two groups according to the cut-off Lp-PLA2 level: high Lp-PLA2 group (> or = 463 ng/mL, n = 33) and low Lp-PLA2 group (< 463 ng/mL, n = 67). MACE was defined as cardiac death, non-fatal reinfarction, and target vessel revascularization. Patients in the high Lp-PLA2 group had significantly higher total-, LDL-cholesterol, apolipoprotein B levels, and significantly lower estimated glomerular filtration rates compared with the low Lp-PLA2 group. The incidence of 30-day mortality was 18.2% (6/33) in high Lp-PLA2 group, while in the low Lp-PLA2 group no patient died (p < 0.001). The 30-day MACE occurred in 24.2% of the high Lp-PLA2 group and 3% of the low Lp-PLA2 group (p = 0.001). Multiple logistic regression analysis identified the plasma Lp-PLA2 level as an independent predictor of MACE (OR 1.011, 95%CI 1.001 - 1.013, p = 0.037). In patients with first anterior STEMI treated by primary PCI, the plasma Lp-PLA2 level is an independent predictor of 30-day MACE.

Incremental Prognostic Value of Different Components of Coronary Atherosclerotic Plaque at Cardiac CT Angiography beyond Coronary Calcification in Patients with Acute Chest Pain: Nance JW Jr, Schlett CL, Schoepf UJ, et al. Radiology 2012;264:679–90.

In this single-centered, retrospective cohort study of 458 low-to-intermediate-risk patients presenting with acute onset chest pain and without acute coronary syndrome or non-cardiac etiology of their symptoms on initial work-up, the authors investigated the value of coronary artery calcium (CAC) score and cardiac computed tomography (CT) angiography in predicting the risk for major adverse coronary events (MACE). Of the 458 patients included in the analysis, 70 (15%) had a MACE during the 24-month follow-up period.

Outcomes of Coronary Revascularization (Percutaneous or Bypass) in Patients With Diabetes Mellitus and Multivessel Coronary Disease

Clinical outcomes in patients with diabetes mellitus and multivessel disease (MVD) undergoing coronary revascularization have not been extensively evaluated, we sought to examine outcomes in a diabetic cohort of 195 consecutive patients with MVD characterized by SYNTAX scores (SSs) undergoing nonrandomized revascularization, 102 (52%) by percutaneous intervention (PCI) and 93 (48%) by coronary artery bypass grafting (CABG) at Liverpool Hospital (Sydney, Australia) from June 2006 to March 2010. Clinical outcomes were assessed at a median term of 14 months. The overall median SS was 44, with significantly higher SSs in CABG- than PCI-treated patients (48 vs 39, p <0.0001). There was a similar incidence of all-cause death, nonfatal myocardial infarction and stroke in PCI- and CABG-treated patients (6.1% vs 8.3%, p = 0.383; 12% vs 4.9%, p = 0.152; 3.1% vs 3.5%, p = 0.680 respectively). However, the rates of target vessel revascularization and major adverse coronary and cerebral event were significantly higher in PCI-treated patients than in those undergoing CABG (20% vs 1.2%, p <0.0001; 29% vs 15%, p = 0.034). Despite a much higher SS, patients who underwent PCI achieved comparable outcomes at 1 year to those with diabetes mellitus and a SS ≥ 33 as reported in the SYNTAX trial. In conclusion, in this single-center nonrandomized observational study, coronary revascularization by PCI is associated with increased major adverse coronary and cerebral events at 1-year follow-up, predominantly driven by a high rate of target vessel revascularization. Thus, CABG should remain the revascularization procedure of choice for diabetic patients with MVD and high SSs.

High on-treatment platelet reactivity by ADP and increased risk of MACE in good clopidogrel metabolizers

High on-treatment platelet reactivity (HPR) by ADP, which primarily reflects the effect of thienopyridines, has been found to be an independent predictor of ischemic events in patients with acute coronary syndrome (ACS) on dual antiplatelet therapy. CYP2C19*2 is associated with HPR by ADP. The aim of our study was to evaluate if high on-clopidogrel platelet reactivity (HPR) by ADP is associated with an increased risk of major adverse coronary events (MACE) after ACS independent of CYP2C19*2 allele, i.e. whether genotyping patients for CYP2C19*2 polymorphism is sufficient to identify those to be switched to novel antiplatelets. A total of 1187 patients were included (CYP2C19 *1/*1 n = 892; *1/*2 n = 264; *2/*2 n = 31); 76 MACE (CV death and non-fatal MI) were recorded in non-carriers of CYP2C19*2 (8.5%) and 39 in carriers of CYP2C19*2 (13.2%). At the landmark analysis in the first 6 months, HPR by ADP and CYP2C19*2 allele were both significantly and independently associated with MACE [HPR by ADP: HR = 2.0 (95% CI 1.2–3.4), p = 0.01; CYP2C19*2 allele: HR = 2.3 (95% CI 1.3–3.9), p = 0.003]. At the land mark analysis from 7 to 12 months, only HPR by ADP remained significantly associated with the risk of MACE [HPR by ADP: HR = 2.7 (95% CI 1.4–5.3), p = 0.003; CYP2C19*2: HR = 0.8 (95% CI 0.2–1.1), p = ns]. CYP2C19*2 allele and HPR by ADP are both independently associated with an increased risk of MACE in the first 6 months after ACS. HPR by ADP is associated with an increased risk until 12 months of follow-up. Therefore, both phenotype and genotype are clinically relevant for the evaluation of the antiplatelet effect of clopidogrel and for the prognostic stratification of ACS patients.

Long‐term results of cephalad arteries percutanoeus transluminal angioplasty with stent implantation (The CAPTAS registry)

Carotid artery stenting (CAS) has become an alternative to carotid endarterectomy. Moreover, percutaneous transluminal angioplasty (PTA) allows other cephalad arteries revascularization. The aim of this study was to evaluate late outcomes of cephalad arteries PTA. This is an international multicenter registry of 434 consecutive patients in which 497 PTAs were performed. Patients with symptomatic >50% stenosis or asymptomatic >70% stenosis were enrolled. Stenting of 577 internal carotid arteries (ICA) and 13 common carotid arteries was performed, 20.7% procedures were complex in which bilateral carotid stenoses or carotid and vertebral arteries stenoses were revascularized at one stage. In 15.9% patients, one-stage coronary intervention was carried out. Distal protection devices were used in 69.6% of cases. PTAs were divided into high (n = 330) and low (n = 167) risk of major adverse coronary and cerebral events (MACCE). At 30 days, there were 15 (3.5%) cases of MACCE [0.9% deaths, 2.1% strokes, and 0.9% myocardial infarction (MI)]. TIAs were observed in 15 (3.9%) patients. There was no significant difference in stroke incidence between procedures with or without neuroprotection (1.8 vs. 3%; P = 0.66) as well as in MACCE occurrence between high and low-risk groups (4.3 vs. 2%; P = 0.34). Bilateral stenoses increased while hypertension decreased the risk of MACCE. Left ICA lesions increased the risk of cerebrovascular accidents (CVA). At 4 years (1-11 years), the mortality rate was 11.5%, 6% of patients had stroke, and 3% MIs. Restenosis occurred in 3%. There was a trend toward higher mortality rate (13.3 vs. 6.9%; P = 0.07) and MACCE risk in high-risk group (23.5 vs.14.7% P = 0.06). Age > 65 y.o. and stent length < 24 mm increased, while the statin therapy on admission decreased the risk of long-term death. Structural valve disease and stent length <30 mm increased the risk of MACCE, while implantation of Acculink stent decreased the risk of CVA. CAS is safe and successful procedure with low early and long-term adverse events. Special attention should be put on patients with bilateral and left ICA stenoses. If possible, longer stents should be applied.

Coronary stent management in elective genitourinary surgery

What's known on the subject? and What does the study add? Withdrawal of dual antiplatelet therapy before the recommended, 12 months for drug-eluting stents and 1 month for bare-metal stents increases the rate of major adverse coronary events and mortality. However, in those undergoing surgery the risk of bleeding is increased substantially for those on antiplatelet agents. Successful management in patients with coronary stents who must undergo elective or non-elective urological surgery should be a multidisciplinary decision. This article reviews the literature and recommends a protocol for clinical management of patients undergoing urological procedures after coronary stent placement. To review the literature on coronary stents and genitourinary surgery and provide a protocol for perioperative. The keywords, 'elective surgery', 'aspirin', 'clopidogrel', 'guidelines for percutaneous coronary intervention', and 'antiplatelet therapy after coronary stent placement' were used to search PubMed for any relevant articles relating to coronary stents. Recommendations were made based on the whether the procedures patients were exposed to placed them at low-, moderate- or high-bleeding risk based on the extent of the procedure. All elective procedures should be delayed for 1 month after bare-metal stent placement and 1 year after drug-eluting stent placement. In patients classified as low risk (endoscopy and laser prostatectomy), aspirin should be continued throughout the perioperative period and dual antiplatelet therapy should continue 24-48 h postoperatively, if there is no concern for active bleeding. In those classified as moderate risk (scrotal procedures, transurethral resection of bladder tumours, transurethral resection of the prostate, urinary sphincter placement) dual antiplatelet therapy should be discontinued 5-7 days before the procedure and continued within 7 days after procedure, if there is no concern for active bleeding, in consultation with cardiology. In high-risk procedures (cystectomy, nephrectomy, prostatectomy, penile prosthesis placement) dual antiplatelet therapy should be discontinued 10 days before the procedure and continued postoperatively within 7-10 days of the procedure, when there is no longer a concern for active bleeding with the assistance of a cardiologist. Coronary artery disease is becoming more prominent in our society, increasing the use of coronary stents and antiplatelet agents. With the proposed protocol, it is safe to proceed with surgical intervention in those that have adequate stent endothelialisation.

Comprehensive Intravascular Ultrasound Assessment of Stent Area and Its Impact on Restenosis and Adverse Cardiac Events in 403 Patients With Unprotected Left Main Disease

We assessed the optimal intravascular ultrasound (IVUS) stent area to predict angiographic in-stent restenosis (ISR) after sirolimus-eluting stent implantation for unprotected left main coronary artery (LM) disease. A total of 403 patients treated with single- or 2-stent strategies (crushing and T-stent) had immediate poststenting IVUS and 9-month follow-up angiography. Poststenting minimal stent area (MSA) was measured in each of 4 segments: ostial left anterior descending (LAD), ostial left circumflex (LCX) polygon of confluence (POC, confluence zone of LAD and LCX), and proximal LM above the POC. Overall, 46 (11.4%) showed angiographic restenosis at 9 months: 3 of 67 (4.5%) nonbifurcation lesions treated with a single-stent, 14 of 222 (6.3%) bifurcation lesions treated with single-stent crossover, and 29 of 114 (25.4%) of bifurcation lesions treated with 2 stents. The MSA cutoffs that best predicted ISR on a segmental basis were 5.0 mm(2) (ostial LCX ISR), 6.3 mm(2) (ostial LAD ISR), 7.2 mm(2) (ISR within the POC), and 8.2 mm(2) (ISR within the LM above the POC). Using these criteria, 133 (33.8%) had underexpansion of at least 1 segment. Angiographic ISR (at any location) was more frequent in lesions with underexpansion of at least 1 segment versus lesions with no underexpansion (24.1% versus 5.4%, P<0.001). Two-year major adverse coronary event-free survival rate was significantly lower in patients with underexpansion of at least 1 segment versus lesions with no underexpansion (90±3% versus 98±1%, log-rank P<0.001), and poststenting underexpansion was an independent predictor for major adverse cardiac events (adjusted hazard ratio, 5.56; 95% confidence interval, 1.99-15.49; P=0.001). With these criteria, IVUS optimization during LMCA stenting procedures may improve clinical outcomes.

The Role of Serotonin in Depression and Clotting in the Coronary Artery Disease Population

Despite the strong evidence that depression is an independent risk factor for coronary artery disease (CAD), the underlying physiological mechanisms linking depression and CAD remain poorly understood. This review of the literature focuses on the current understanding of the physiological effects of serotonin on depression and clotting as well as its role in CAD. Articles for this review were identified using CINAHL, PsychINFO, and MEDLINE searches. Results revealed that depression is an independent risk factor for CAD. Although the physiological mechanisms underlying depression and related increases in acute coronary events remain unclear, serotonin plays an important role in depression and CAD. Elevated platelet serotonin levels promote clotting, which may be a potential underlying mechanism linking depression with CAD. This review of the literature suggests that elevated platelet serotonin levels may be associated with depression and the occurrence of major adverse coronary events. Future research should investigate if platelet serotonin levels contribute at least in part to the acute coronary events seen in patients with CAD who have elevated levels of platelet serotonin when depressed.

Value of the SYNTAX score in patients treated by primary percutaneous coronary intervention for acute ST-elevation myocardial infarction: The MI SYNTAXscore study

The aims of this study were to evaluate the SYNTAX score (SXscore) calculated at 2 stages during a primary percutaneous intervention (PPCI), that is, SXscore I (diagnostic) and SXscore II (postwiring), and assess its additional value to standard clinical risk scores in acute myocardial infarction. SXscores I and II were applied to 736 consecutive acute ST-elevation myocardial infarction patients referred for PPCI between November 2006 and February 2008. SXscore changed significantly before (I: 16, interquartile range 9.5-23) and after wiring (II: 11, interquartile range 6-19), P < .001. Kaplan-Meier methods were used to compare the primary end point major adverse coronary events (MACE; composite of repeat MI, target vessel revascularization [TVR], and mortality) and secondary end point mortality at 1.5 years in tertiles of SXscore I and SXscore II. Major adverse coronary event was highest in the higher SXscore I tertile (11% vs 15% vs 23%, log-rank <0.01), driven primarily by increased rate of mortality (9% vs 11% vs 17%, log-rank 0.02). Major adverse coronary event was also highest in SXscore II tertile, by a combination of increased mortality and also TVR (TVR rate 2% vs 3% vs 9%, log-rank <0.01). Predictive Cox regression models for mortality and MACE were significantly and similarly improved by the addition of either SXscore I or SXscore II (hazard ratio 1.63, 95% CI 1.18-2.26, P < .01 for MACE) with respective c indices of 0.61 and 0.63 for MACE and 0.60 and 0.61 for mortality. SXscore during PPCI is a useful tool that provides additional risk stratification to known risk factors of long-term mortality and MACE in patients with ST-elevation myocardial infarction.

MR and CT: When to Use Each

Coronary CT angiography (CCTA) and cardiovascular magnetic resonance (CMR) have evolved as quite useful techniques in chronic/acute coronary artery disease evaluation. The calcium score measurement quantifies coronary artery calcium and classifies the patients into low, intermediate, and high risk of major adverse coronary events. The CCTA value resides in the high accuracy to exclude the presence of coronary artery disease. CMR allows the acquisition of images throughout the body in any tomographic plane without limitations imposed by body habitus; also, it allows to characterize cardiovascular anatomy and structure, tissue composition, right and left ventricular function, and visualize and quantify myocardial perfusion along with viability. Since the acquisition is performed with cardiac gating in both methods, the left and right ventricular function can be calculated along with valvular characterization. Both techniques provide high-value anatomical/functional information that finally will impact on the patient’s treatment and survival.

Performance of adenosine “stress-only” perfusion MRI in patients without a history of myocardial infarction: a clinical outcome study

To assess the diagnostic value of adenosine “stress-only” myocardial perfusion MR for ischemia detection as an indicator for coronary angiography in patients without a prior myocardial infarction and a necessity to exclude ischemia. Adenosine perfusion MRI was performed at 1.5 T in 139 patients with a suspicion of ischemia and no prior myocardial infarction. After 3 min of adenosine infusion a perfusion sequence was started. Patients with a perfusion defect were referred to coronary angiography (CAG). Patients with a normal perfusion were enrolled in follow-up. Fourteen out of 139 patients (10.1%) had a perfusion defect indicative of ischemia. These patients underwent a coronary angiogram, which showed complete agreement with the perfusion images. 125 patients with a normal myocardial perfusion entered follow-up (median 672 days, range 333–1287 days). In the first year of follow-up one Major Adverse Coronary Event (MACE) occurred and one patient had new onset chest pain with a confirmed coronary stenosis. Reaching a negative predictive value for MACE of 99.2% and for any coronary event of 98.4%. At 2 year follow-up no additional MACE occurred. Sensitivity of adenosine perfusion MR for MACE is 93.3% and specificity and positive predictive value are 100%. Adenosine myocardial perfusion MR for the detection of myocardial ischemia in a “stress-only” protocol in patients without prior myocardial infarctions, has a high diagnostic accuracy. This fast examination can play an important role in the evaluation of patients without prior myocardial infarctions and a necessity to exclude ischemia.

Relation of Aspirin Failure to Clinical Outcome and to Platelet Response to Aspirin in Patients With Acute Myocardial Infarction

Aspirin failure, defined as occurrence of an acute coronary syndrome despite aspirin use, has been associated with a higher cardiovascular risk profile and worse prognosis. Whether this phenomenon is a manifestation of patient characteristics or failure of adequate platelet inhibition by aspirin has never been studied. We evaluated 174 consecutive patients with acute myocardial infarction. Of them, 118 (68%) were aspirin naive and 56 (32%) were regarded as having aspirin failure. Platelet function was analyzed after ≥72 hours of aspirin therapy in all patients. Platelet reactivity was studied by light-transmitted aggregometry and under flow conditions. Six-month incidence of major adverse coronary events (death, recurrent acute coronary syndrome, and/or stroke) was determined. Those with aspirin failure were older (p = 0.002), more hypertensive (p <0.001), more hyperlipidemic (p <0.001), and more likely to have had a previous cardiovascular event and/or procedure (p <0.001). Cumulative 6-month major adverse coronary events were higher in the aspirin-failure group (14.3% vs 2.5% p <0.01). Patients with aspirin failure had lower arachidonic acid-induced platelet aggregation (32 ± 24 vs 45 ± 30, p = 0.003) after aspirin therapy compared to their aspirin-naive counterparts. However, this was not significant after adjusting for differences in baseline characteristics (p = 0.82). Similarly, there were no significant differences in adenosine diphosphate-induced platelet aggregation and platelet deposition under flow conditions. In conclusion, our results suggest that aspirin failure is merely a marker of higher-risk patient profiles and not a manifestation of inadequate platelet response to aspirin therapy.

Do we reach target lipid levels in diabetic and non-diabetic patients with previous myocardial infarction?

Considering that dyslipidaemia is an important factor for cardiovascular diseases, target lipid levels are rarely reached in everyday clinical practice. The objective of this study was to evaluate how often we achieve the treatment goals for the lipid parameters in the diabetic and non-diabetic patients after the previous myocardial infarction (MI). The survey included 118 patients (84 males and 34 females), mean age 59.38 +/- 9.86 years, 34 (28.8%) of them diabetics, with the history of MI in the previous 3 years. The patients were selected from the database of multicentre prospective interventional study "Secondary prevention of coronary heart disease and cerebrovascular diseases", conducted in 2005 on 1,189 patients in Serbia. The patients were further followed in the period from 18 (5th visit) and 36 months (6th visit) after inclusion into the study from 2005-2008. Their lipid status, the use of lipid-lowering drugs, and the independent prognostic factors for major adverse coronary events were identified. In the beginning of the study, all patients were informed about the importance of lifestyle change and active approach to treatment. The accomplishment of secondary preventive measures was estimated on the basis of the European guidelines on secondary prevention of the coronary heart disease. Three years after introduction of the preventive measures, diabetics had a higher prevalence of the target levels of the total cholesterol (21.2% vs. 7.6%) and HDL-cholesterol than non-diabetics (100% vs. 87.3%) (p < 0.05). Non-diabetics had significantly higher prevalence of the target levels of LDL-cholesterol than diabetics (19% vs. 3%) (p < 0.05). No significant differences were found in the prevalence of the treatment goals of triglycerides in diabetic (42.4%) and non-diabetic patients (60.8%) (p > 0.05). At the end of the study, after applying secondary prevention measures, 27.3% of diabetics did not use lipid-lowering drugs. The percentage of non-diabetics using no lipid-lowering drugs was lower (20.3%), but the difference was not statistically significant (p > 0.05). By using the method Enter Cox regression multivariant analysis, the change in the level of triglycerides, total and LDL-cholesterol were singled out as independent prognostic factors for major adverse coronary events. Our study has shown high prevalence of increased plasma concentrations in the total, LDL-cholesterol and triglycerides and low plasma concentrations of HDL-cholesterol, as well as the insufficient use of lipid-lowering drugs in diabetic and non-diabetic patients with previous MI. Decreasing the total cholesterol and increasing the HDL-cholesterol are significant, decreasing of triglycerides and LDL-cholesterol does not suffice. Therefore, secondary prevention measures of cardiovascular events should be intensified, especially in patients with diabetes.

Relationship between major adverse cardiac events and angiographic findings in dialysis patients

In dialysis patients, coronary angiography (CA) predicts major adverse coronary events (MACE) better than non-invasive tests. The aim of this study was to investigate in such patients the relationship between coronary atherosclerotic damage shown by angiography and MACE, during an average follow-up period of more than 5 years. Coronary angiography was performed in 63 dialysis patients (mean age 56 ± 12 years, 49 men); 37 subjects awaiting kidney transplantation had no history of cardiac disease, whereas the remaining 26 patients had clinical evidence of coronary artery disease (CAD). During a follow-up period of 62 ± 20 months (range 12-109), all the MACE were recorded. Statistical analysis was carried out by dividing the patients into two groups, those who had MACE (MACE group) and those who were free of cardiac events (FCE group). Severe CAD on CA was defined as luminal stenosis ≥ 75% in at least one vessel. Logistic regression analysis and Cox regression analysis were carried out in order to evaluate which variable was associated with MACE. At the end of follow-up, 17 subjects had MACE and severe CAD was shown in the epicardial arteries of 31 patients (49%). Compared to the FCE group, the MACE group had older age (65 ± 10 vs 53 ± 11 years, P = 0.002), lower diastolic blood pressure (79 ± 7 vs 85 ± 7 mmHg, P = 0.0037), higher prevalence of CAD (82 vs 30%, P = 0.0002) and cerebrovascular disease (41 vs 15%, P = 0.0278). Coronary artery damage was higher in the MACE group than in the FCE group. Logistic and Cox regression analyses showed that age was the only variable independently associated with MACE (OR 1.109 95% CI 1.022-1.204, P = 0.0133, hazard ratio 1.066 95% CI 1.010-1.125, P = 0.02, respectively). After removal of age from the model, MACE were independently associated with haemodynamic stenosis of coronary arteries (OR 7.429 95% CI 1.829-30.173, P = 0.005, hazard ratio 5.992 95% CI 1.655-21.698, P = 0.006, respectively). Event-free survival was much better in the 37 renal transplant candidates with no history of CAD than in the 26 patients who had clinical evidence of CAD. This observational study confirms that in dialysis patients coronary atherosclerotic damage shown by angiography is strongly related to MACE and that age and severe CAD are major risk factors for MACE.

Lower Homocysteine Levels in Renal Transplant Recipients Treated With Everolimus: A Possible Link With A Decreased Cardiovascular Risk?

Cardiovascular disease (CVD) is the main cause of morbidity and mortality in renal transplant recipients. The incidence of CVD in this setting is approximately 5-fold greater than in age- and and gender-matched subjects. This excess cardiovascular risk is not completely explained by traditional cardiac risk factors. It has been well documented that these patients show greatly increased prevalence of both fasting and postmethionine-loading hyperhomocysteinemia (hHcy) compared with the general population. An immunosuppressive therapy based on everolimus has been demonstrated to reduce the incidence major adverse coronary events at 4 years compared with azathioprine among heart transplant recipients. In contrast, scarce data are available on the impact of everolimus on emerging risk factors, such as homocysteine (Hcy), in renal transplant recipients. The aim of this study was to evaluate the possibile impact of everolimus compared with other immunosuppressive regimes among 132 stable recipients, including 91 men and 41 women who were at least 1 year after transplant with stable renal function and no clinical evidence of acute or chronic renal graft rejections. We compared 31 subjects on everolimus immunosuppressive therapy (group A) versus 101 on immunosuppressive therapy based on cyclosporine, steroids, and mycophenolate. The Hcy levels were significantly lower among group A patients compared with group B: 16.5 ± 5 μmol/L vs 21.2 ± 11 μmol/L; P < .005. Hyper-Hcy, defined as Hcy levels >15 μmol/L, was diagnosed in 18 out of 31 patients (51%) of group A and in 82 out of 101 patients (81%) of group B. This preliminary study demonstrates a favorable impact of everolimus on a marker of atherothrombosis which is associated with a worse vascular prognosis.

The risk of myocardial infarction in patients with atrial fibrillation: an unresolved issue

Atrial fibrillation (AF) is the most common sustained dysrhythmia encountered in clinical practice in North America and Europe, accounting for approximately onethird of all hospitalizations for a cardiac rhythm abnormality [1]. The presence of AF markedly increases the patient’s risk for developing arterial embolism and stroke, depending on the presence of other clinical conditions, such as hypertension and diabetes [2]. AF is associated with a fivefold increased risk for stroke, and is estimated to cause 15% of all strokes. The rate of ischemic stroke among patients with non-valvular AF averages 5% per year, 2–7 times that of people without AF. Additionally, when transient ischemic attacks (TIAs) and clinically ‘‘silent’’ strokes are considered, the rate of brain ischemia accompanying non-valvular AF exceeds 7% per year. Patients with AF frequently have several risk factors for atherosclerosis, including hypertension, diabetes, and dyslipidemia [3, 4]. Accordingly, systemic signs of atherosclerosis can be detected in AF patients, and these likely account for an enhanced risk of coronary heart disease (CHD). In addition to cerebrovascular disease, patients with AF may suffer from coronary events including myocardial infarction (MI), but the rate of MI in AF patients seems to be variable, but often underestimated. Surprisingly few studies with antithrombotic drug therapy include MI as an end-point. We reasoned that analysis of the MI rate in AF could be useful for future interventional trials with anti-thrombotic drugs. Thus, we evaluated the rate of MI in the clinical trials where this clinical end-point was taken into account, and tried to relate it with the common atherosclerotic risk factors. Searches were conducted in computerized publication database (Medline) with hand searches of publications from January 1995 to September 2008. Bibliographies of all selected articles and review articles were reviewed for other relevant articles. We used search terms including ‘‘atrial fibrillation’’ and ‘‘cardiovascular risk’’, ‘‘atrial fibrillation’’ and ‘‘myocardial infarction’’, ‘‘atrial fibrillation’’ and ‘‘coronary heart disease’’, ‘‘atrial fibrillation’’ and ‘‘mortality’’, ‘‘atrial fibrillation’’ and ‘‘cardiovascular events’’. The search was confined to human studies and English language restricted. We obtained 278 articles. A trial was included if the overall study population included AF patients, it was published in a peer-reviewed journal, and major adverse coronary events (MACE) were recorded through the follow-up. A trial was excluded from our analysis if the AF population was lower than 150 subjects. Thus, 13 studies were selected according to the above-mentioned inclusion and exclusion criteria [5–17] (Table 1). In only two of these, MACE were included as primary end-points [5, 6] (Table 1A). In the first study, a very high incidence of new MACE was found in AF patients (74% during a mean follow-up of 30 months) compared with patients with a sinus rhythm (42%) or a supraventricular tachycardia (43%) [5]. These patients had a mean age of 81 years, and a clinical history complicated by CHD in [50% of cases. After controlling L. Polimeni and L. Perri equally contributed to the study.

Impact and Clinical Management of Depression in Patients with Coronary Artery Disease

The rates of major adverse coronary events, including recurrent ischemic events and death, in patients with coronary artery disease (CAD) have been shown to be significantly increased in patients with depression. In addition, health care costs are higher and health-related quality of life is lower in depressed patients with CAD. Several pathophysiologic mechanisms have been proposed for the association of increased events seen in this population. Studies have focused on antidepressants (specifically, selective serotonin reuptake inhibitors and mirtazapine), psychotherapy (cognitive behavioral therapy and interpersonal psychotherapy), and a wide range of other nonpharmacologic interventions. Pharmacologic and nonpharmacologic treatments are known to improve depressive symptoms in patients with CAD, but their effects on outcomes such as mortality and hospital admissions remain controversial. If treatment of depression is warranted, strategies should include sertraline or citalopram, with or without cognitive behavioral therapy, based on the known efficacy and safety of the drugs in this population. Nonpharmacologic therapy such as aerobic exercise has been shown to improve not only depression but also cardiovascular health. When selecting an appropriate antidepressant, clinicians should consider their patients' comorbid conditions and the potential for drug interactions, and treatment should be frequently monitored. Screening for depression in patients with cardiac disease should be instituted on a routine basis by using either case-finding or symptom-triggered approaches. Based on the high prevalence of depression and its known adverse effects in patients with CAD, future research is needed to help determine the role of antidepressants and nonpharmacologic strategies in improving outcomes in patients with both comorbidities.

Safety of drug eluting stents in patients on chronic anticoagulation using long‐term single antiplatelet treatment with clopidogrel

Use of triple therapy with aspirin, clopidogrel, and anticoagulants significantly increases bleeding, thus drug eluting stents (DES) are usually avoided in patients requiring anticoagulation. We tested use of DES vs. BMS using a long-term therapy with clopidogrel only and anticoagulants in this group of patients. We enrolled 165 consecutive patients, 79 receiving DES (age 67 +/- 9 years, 84% with atrial fibrillation) and 86 receiving bare metal stents (BMS) (age 70 +/- 11 years, 71% with atrial fibrillation). All patients received aspirin + clopidogrel + oral anticoagulants for 4 weeks, then aspirin was stopped and clopidogrel was continued during the 12-month follow-up. Primary end point was the combined incidence of major adverse coronary events and major bleedings. Incidence of the primary endpoint was 10.1% in patients with DES and 26.7% in patients with BMS (P = 0.01). There was a large difference in incidence of target vessel revascularization (8.1% for DES, 23.3% for BMS, P = 0.01), whereas incidence of myocardial infarction (3.8% in DES vs. 8.1% in BMS) and major bleeding (1.3% vs. 2.3%, respectively) were not significantly different. There were no cases of stent thrombosis. On multivariate Cox regression analysis, the only factor associated with a reduced risk of the primary endpoint was use of DES (hazard ratio 0.35 with 95% confidence interval 0.14-0.85, P = 0.02). Results of our cohort study suggest that use of DES associated with a treatment with clopidogrel only may be safe and significantly reduce the need for new revascularization in patients requiring chronic anticoagulation.

Remote ischaemic conditioning before hospital admission, as a complement to angioplasty, and effect on myocardial salvage in patients with acute myocardial infarction: a randomised trial

Remote ischaemic preconditioning attenuates cardiac injury at elective surgery and angioplasty. We tested the hypothesis that remote ischaemic conditioning during evolving ST-elevation myocardial infarction, and done before primary percutaneous coronary intervention, increases myocardial salvage. 333 consecutive adult patients with a suspected first acute myocardial infarction were randomly assigned in a 1:1 ratio by computerised block randomisation to receive primary percutaneous coronary intervention with (n=166 patients) versus without (n=167) remote conditioning (intermittent arm ischaemia through four cycles of 5-min inflation and 5-min deflation of a blood-pressure cuff). Allocation was concealed with opaque sealed envelopes. Patients received remote conditioning during transport to hospital, and primary percutaneous coronary intervention in hospital. The primary endpoint was myocardial salvage index at 30 days after primary percutaneous coronary intervention, measured by myocardial perfusion imaging as the proportion of the area at risk salvaged by treatment; analysis was per protocol. This study is registered with ClinicalTrials.gov, number NCT00435266. 82 patients were excluded on arrival at hospital because they did not meet inclusion criteria, 32 were lost to follow-up, and 77 did not complete the follow-up with data for salvage index. Median salvage index was 0.75 (IQR 0.50-0.93, n=73) in the remote conditioning group versus 0.55 (0.35-0.88, n=69) in the control group, with median difference of 0.10 (95% CI 0.01-0.22; p=0.0333); mean salvage index was 0.69 (SD 0.27) versus 0.57 (0.26), with mean difference of 0.12 (95% CI 0.01-0.21; p=0.0333). Major adverse coronary events were death (n=3 per group), reinfarction (n=1 per group), and heart failure (n=3 per group). Remote ischaemic conditioning before hospital admission increases myocardial salvage, and has a favourable safety profile. Our findings merit a larger trial to establish the effect of remote conditioning on clinical outcomes. Fondation Leducq.

041 Percutaneous coronary intervention of unprotected left main coronary artery for cardiogenic shock

Primary coronary angioplasty (PCA) of unprotected left main coronary artery (LM) in patients (pts) with cardiogenic shock (CS) is a high-risk procedure, carrying a high morbi-mortality. Accordingly we aimed to assess the prevalence, clinical presentation, therapeutic workout and in-hospital and long-term prognosis of pts presenting with CS due to TIMI flow 0-1 LM thrombosis. Over a 6-years period, and out of a prospective cath-lab database of 6062 files, 17 cases of CS secondary to LM thrombosis were identified and confirmed by reanalysis of angiograms. Therapeutic management and in-hospital outcome were obtained from medical files and prospective follow-up was obtained. The study population consisted in 13 men (76%) with a mean age of 64±16 years, corresponding to a prevalence of 0.28% of pts proposed for coronary procedure. Clinical presentation was an ACS with and without persistent ST-elevation in 11 (65%) and 6 cases (35%) respectively. Five patients (29%) received pre-hospital thromboysis, which failed to achieved reperfusion in all cases. Twelve patients (71%) undergone mechanical support (intra-aortic balloon pumping alone in 55%, extracorporeal life support alone in 5%, and both in 45%). The majority of PCA were performed with bare metal stent (n=14, 82%), under GPIIbIIIa antagonists in 8 cases, and instrumental thrombectomy in 3 cases. In-hospital death occurred in 5 pts (29%). At mean follow-up of 23 months (100% completed) survival rate was 53% for entire cohort and 75% among discharged pts. Most patients were in NYHA class I (7/9), with averaged left ventricular ejection fraction of 50+17%. One pts was implanted with a Thoratec device and is awaiting heart transplantation, and one is in terminal heart failure. LM occlusion with CS has a very high mortality rate. However, PCA in such setting with use of aggressive mechanical life support carries an acceptable level of major adverse coronary event at medium and long-term prognosis.