Myocardial Infarction Coronary Revascularization Research Articles

Is staging for cardiac damage in aortic stenosis associated with MACE in cancer patients with prior radiotherapy or chemotherapy that underwent transcatheter aortic valve replacement?

Abstract Background Staging classification for severe aortic stenosis (AS) based on the extent of cardiac damage has been correlated with outcomes in the general population. This is categorized based on the following echocardiographic findings: stage 1 (increase in the left ventricular mass index; E/e’>14; and left ventricular ejection fraction <50%); stage 2 (left atrial volume index >34ml/m2; moderate to severe mitral regurgitation and atrial fibrillation), stage 3 (systolic pulmonary hypertension> 60mmHg and moderate to severe tricuspid regurgitation) and stage 4 (moderate to severe right ventricular dysfunction); its applicability in a cancer population exposed to chemo+/- radiotherapy and its correlation with MACE has not been explored. Purpose To evaluate if this staging system predicts MACE (cardiovascular death, myocardial infarction, coronary revascularization, stroke, and hospitalization for heart failure) at 18 months after TAVR in cancer patients who were previously exposed to cardiotoxic therapies. Methods We retrieved data of patients that underwent TAVR from 2013 to 2021. 544 patients were included in this study and divided in 3 groups: 187 patients with prior chest Radiotherapy and Chemotherapy (RT/CT), 155 with CT only, and 202 cancer patients not exposed to CT or RT control group. This was further subdivided in two groups based on the staging system in: stage ≤ 2 and ≥3. Fisher's exact test or chi-square was used to compare categorical variables and clinical outcomes among groups and ANOVA for continuous variables. Echocardiographic findings and correlation with the outcome were evaluated by a multivariable Cox model analysis and assessed by a proportional hazards model for time to event. Kaplan–Meier curves were performed to determine the event-free survival rate. Significance was considered as a p<0.05. Results RT/CT had a higher prevalence of moderate to severe mitral regurgitation (11.8%) p <0.001 and tricuspid regurgitation (13.9%) p=0.02. Stage ≥3 was (24.1%) in the RT/CT, (9.4%) in CT, and (16.1%) in controls p= 0.004. Additionally, stage ≥3 was a predictor of MACE at 18 months: RT/CT group HR 6.43 (3.06 – 13.1) p<0.001, CT HR 4.49 CI (2.27 – 8.89) p<0.001 and control HR 2.20 CI (1.13 – 4.26) p=0.02 (Table 1). MACE at 18 months for stage ≥3 was higher for all groups vs. stage ≤ 2. MACE at 18 months after TAVR was significantly higher in stage >3 for RT/CT (57.4%) and CT only (61.2%) vs. CL (27.2%) p<0.001 (Figure 1B). Conclusions In addition to predicting aortic stenosis risk in cancer patients before TAVR, cardiac damage staging is a strong predictor of MACE at 18 months in patients post-RT/CT and CT and suggests that these patients may benefit from earlier stratification for TAVR prior to reaching stage 3. Future studies with longer follow-up should be explored to evaluate its usefulness in this complex population.

P831Effect of high-dose statin pretreatment in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: meta-analysis of randomized controlled trials

Abstract Introduction Current guidelines recommend the use of high doses of statins in patients with acute coronary syndrome. However, up to now, there is not enough evidence about the time of its onset in patients with acute myocardial infarction with ST elevation (STEMI) undergoing primary angioplasty. We conducted a systematic review and meta-analysis with the aim of evaluating the efficacy of pre-treatment with statins in high doses in the short term in patients with STEMI treated with primary angioplasty. Methods A systematic search was carried out in Pubmed, EMBASE, Scopus and Cochrane database, LILACS, and references of relevant articles were searched manually. We included randomized clinical trials (RCTs) comparing pretreatment with high doses of statins (rosuvastatin/atorvastatin) with low doses or without treatment published until April 2018. We evaluated the incidence of MACE (death, spontaneous myocardial infarction, coronary revascularization and stroke) at 30 days. In addition the presence of final TIMI III flow, TIMI blush grade, CPK peak, stent thrombosis and death from any cause during follow-up were evaluated. The data were combined as relative risk (RR) or difference of means (DM) with their 95% confidence interval (CI), using RevMan software. The meta-analysis was performed with the fixed effects model or random effects according to the heterogeneity. Results Six RCTs met the inclusion criteria with a total of 1454 patients. The pretreatment with statins in high doses was associated with a decrease in MACE (RR 0.52 CI 95% 0.37–0.77, I2=0%, P=0.001). The pretreatment was not associated with a reduction of the final TIMI III flow (RR 1.03 CI 95% 0.98–1.09, I2=0%, P=0.1), CPK peak (MD 13.99 CI95% −12.68 to 40.6; I2=0%; P=0.3), or stent thrombosis (RR 0.54 CI95% 0.1–2.85; I2 = 0%; P=0.46), neither death in the follow-up (RR 0.52 CI95% 0.16–1.68, I2=0%, P=0.27). In addition, an improvement in the degree of myocardial blush TIMI was observed (MD 0.36 CI95% 0.20–0.52, I=0%, P<0.0001), Conclusion In this meta-analysis, treatment with high doses of statins prior to primary angioplasty in STEMI significantly reduced adverse cardiac events at 30 days. In addition, an improvement in the degree of myocardial blush was observed in the pretreatment group with high-dose statins. Therefore, the findings of this meta-analysis can help guide medical decision making regarding the time of onset of statins in STEMI.

The prognostic value of regadenoson SPECT myocardial perfusion imaging in patients with end-stage renal disease

BackgroundThe prognostic value of regadenoson SPECT myocardial perfusion imaging (MPI) has not been specifically studied in patients with end-stage renal disease (ESRD). Methods and ResultsWe prospectively followed ESRD patients enrolled in the ASSUAGE and ASSUAGE-CKD trials in which they received regadenoson-stress 99mTc-tetrofosmin SPECT-MPI. Images were semiquantitatively analyzed by an investigator blinded to clinical and outcome data. Patients were followed for cardiac death, myocardial infarction (MI), and coronary revascularization (CR). Revascularizations occurring >90 days post-MPI were considered “late” events. Survival analysis was performed using Cox regression models, adjusting for age, gender, diabetes, dyslipidemia, smoking, and known coronary artery disease. We analyzed 303 patients (mean age 54 years; 64% men), who were followed for 35 ± 10 months. Adjusting for clinical covariates, abnormal regadenoson-stress MPI (SSS ≥ 4) was associated with increased risk of the composite of cardiac death or MI (23.9% vs 14.4%; HR 1.88; CI 1.04-3.41; P = .037) and the composite of cardiac death, MI, or late CR (27.3% vs 16.7%; HR 1.80; CI 1.03-3.14; P = .039). Adjusting for clinical covariates, regadenoson-induced myocardial ischemia (SDS ≥ 2) was associated with increased rate of the composite endpoint of cardiac death, MI, or CR (33.3% vs 16.9%; HR 1.97; CI 1.19-3.27; P = .008). ConclusionRegadenoson-stress SPECT-MPI provides a significant prognostic value in patients with ESRD. ESRD patients with normal SPECT-MPI have relatively high adverse event rates.

Influenza vaccination in secondary prevention from coronary ischaemic events in coronary artery disease: FLUCAD study

To evaluate the effect of influenza vaccination on the coronary events in patients with confirmed coronary artery disease (CAD). Randomized, double-blind, placebo controlled study. We included 658 optimally treated CAD patients; 477 men, mean age 59.9+/-10.3 years. Three hundred and twenty-five patients received the influenza vaccine, and 333 patients placebo. Median follow-up was 298 (interquartile range 263-317) days. Primary endpoint was the cardiovascular death. Its estimated 12-month cumulative event rate was 0.63% in the vaccine vs. 0.76% in controls (HR 1.06 95% CI: 0.15-7.56, P = 0.95). There were two secondary composite endpoints: (i) the MACE (cardiovascular death, myocardial infarction, coronary revascularization) tended to occur less frequently in the vaccine group vs. placebo with the event rate 3.00 and 5.87%, respectively (HR 0.54;95% CI: 0.24-1.21, P = 0.13). (ii) Coronary ischaemic event (MACE or hospitalization for myocardial ischaemia) estimated 12-month event rate was significantly lower in the vaccine group 6.02 vs. 9.97% in controls (HR 0.54; 95% CI: 0.29-0.99, P = 0.047). In optimally treated CAD patients influenza vaccination improves the clinical course of CAD and reduces the frequency of coronary ischaemic events. Large-scale studies are warranted to evaluate the effect of influenza vaccination on cardiovascular mortality. (ClinicalTrials.gov: NCT 00371098).