Short-term Major Adverse Cardiac Events Research Articles

The Role of Using HEART Score to Risk Stratify Chest Pain Among Emergency Department High Utilizers.

The HEART score is used to effectively risk stratify undifferentiated chest pain patients in the Emergency Department (ED). It is unclear whether such risk stratification can be applied among ED high utilizers. We aim to determine the efficacy and safety of using the HEART score to predict 30-day short-term major adverse cardiac events (MACE) in ED high utilizers. We conducted a retrospective, observational study in which ED high utilizers were defined as patients who had four or more ED visits within the past 12 months. ED high utilizers presenting at the study ED with chest pain were enrolled. Patients in which the HEART score was utilized were placed in the HEART group and patients with no HEART scores documented were placed to the usual care group. Hospital admissions and cardiac stress tests performed during the index hospitalizations, and 30-day MACE rates were analyzed and compared between the HEART and usual care groups. From January 1, 2017 to December 31, 2019, a total of 8,315 patient visits from ED high utilizers were enrolled. In the HEART group, 49% of ED visits were admitted with 20% receiving stress tests. A 30-day MACE outcome occurred among 1.4% of visits. In the usual care group, 44% of ED visits were admitted, with only 9% receiving index stress tests and a 1.5% of 30-day MACE occurrence (p=0.727). The study showed that similar short-term MACE outcomes occurred between patients using HEART scores and usual care to risk stratify chest pain among ED high utilizers.

Leukocyte telomere length: a potential biomarker for the prognosis of coronary artery disease.

Aim: This study aimed to explore the prognostic value of leukocyte telomere length (LTL) in patients with coronary artery disease (CAD). Materials & methods: We enrolled 366 CAD patients and 76 healthy subjects in this study. LTL was measured. All subjects were followedup for 6months for further analysis regarding major adverse cardiac events (MACEs). Results: CAD patients had a significantly shortened LTL compared with healthy subjects (p<0.05). The area under the curve for LTL prediction of MACEs was 0.769 (p<0.001), with a shorter LTL being an independent predictor of MACEs (Cox proportional hazards regression, hazard ratio: 2.866; p<0.001). Conclusion: LTL could be considered as an independent predictor of short-term MACEs in CAD.

A Network-Based “Phenomics” Approach for Discovering Patient Subtypes From High-Throughput Cardiac Imaging Data

ObjectivesThe authors present a method that focuses on cohort matching algorithms for performing patient-to-patient comparisons along multiple echocardiographic parameters for predicting meaningful patient subgroups. BackgroundRecent efforts in collecting multiomics data open numerous opportunities for comprehensive integration of highly heterogenous data to classify a patient's cardiovascular state, eventually leading to tailored therapies. MethodsA total of 42 echocardiography features, including 2-dimensional and Doppler measurements, left ventricular (LV) and atrial speckle-tracking, and vector flow mapping data, were obtained in 297 patients. A similarity network was developed to delineate distinct patient phenotypes, and then neural network models were trained for discriminating the phenotypic presentations. ResultsThe patient similarity model identified 4 clusters (I to IV), with patients in each cluster showed distinctive clinical presentations based on American College of Cardiology/American Heart Association heart failure stage and the occurrence of short-term major adverse cardiac and cerebrovascular events. Compared with other clusters, cluster IV had a higher prevalence of stage C or D heart failure (78%; p < 0.001), New York Heart Association functional classes III or IV (61%; p < 0.001), and a higher incidence of major adverse cardiac and cerebrovascular events (p < 0.001). The neural network model showed robust prediction of patient clusters, with area under the receiver-operating characteristic curve ranging from 0.82 to 0.99 for the independent hold-out validation set. ConclusionsAutomated computational methods for phenotyping can be an effective strategy to fuse multidimensional parameters of LV structure and function. It can identify distinct cardiac phenogroups in terms of clinical characteristics, cardiac structure and function, hemodynamics, and outcomes.

Leukocyte Telomere Length: A Potential Biomarker for the Prognosis of Coronary Artery Disease

Background: Coronary artery disease(CAD) is a worldwide disease with high morbidity and mortality. There are many risk factors to predict the prognosis of CAD. We aimed to demonstrate the difference of leukocyte telomere length (LTL) between different types of CAD and illustrate the predictive value of LTL on the prognosis in patients with CAD. Methods: 366 patients hospitalized for coronary angiography were divided into three groups according to the CAD criteria and clinical manifestation: 98 stable angina pectoris (SAP), 144 unstable angina pectoris (UAP) and 124 acute myocardial infarction (AMI). Patients with a normal coronary artery diagnosed by coronary computed tomography angiography were chosen as the normal control (NC) group. LTL was measured using quantitative real-time polymerase chain reaction (qRT-PCR). All patients were followed-up for 6 months to analysis major adverse cardiac events (MACEs). Findings: CAD patients had significantly shortened LTL comparing with NC group (p < 0.05). LTL in AMI patients were significantly shorter compared with the SAP and UAP group (p < 0.05). Area under the curve values of LTL for predicting MACEs was 0.769 (p < 0.001). Cox proportional hazards regression analysis revealed shorter LTL was an independent predictor of MACEs. Kaplan-Meier analysis suggested that a trend toward poorer event free survival rate was observed in shorter LTL group (p < 0.001). Interpretations: LTL was independently correlated with short-term MACEs and can be used for risk stratification of CAD patients. Funding Statement: Supported by Traditional Chinese Medicine Science and Technology Development Plan Project of Shandong Province (No. 2019-0891). Declaration of Interests: The authors declare no conflict of interest. Ethics Approval Statement: The study was approved by the Medical Ethics Committee of Liaocheng People's Hospital. All procedures were in accordance with principles of Helsinki Declaration. Informed consent was obtained from all subjects.

Meta-analysis of preoperative high-sensitivity cardiac troponin measurement in non-cardiac surgical patients at risk of cardiovascular complications.

Patients undergoing major non-cardiac surgery are at risk of cardiovascular complications. Raised levels of high-sensitivity troponin are frequently detected before operation among these patients. However, the prognostic value of high-sensitivity troponin in predicting postoperative outcomes remains unclear. A systematic search of PubMed, Embase and Science Citation Index Expanded was undertaken for observational studies published before March 2018 that reported associations between raised preoperative levels of high-sensitivity troponin and postoperative major adverse cardiac events and/or mortality after non-cardiac surgery. Meta-analyses were performed, where possible, using random-effects models. Seven cohort studies with a total of 4836 patients were included. A raised preoperative high-sensitivity troponin level was associated with a higher risk of short-term major adverse cardiac events (risk ratio (RR) 2·92, 95 per cent c.i. 1·96 to 4·37; I2 =82·6 per cent), short-term mortality (RR 5·39, 3·21 to 9·06; I2 =0 per cent) and long-term mortality (RR 2·90, 1·83 to 4·59, I2 =74·2 per cent). The addition of preoperative high-sensitivity troponin measurement provided improvements in cardiovascular risk discrimination (increase in C-index ranged from 0·058 to 0·109) and classification (quantified by continuous net reclassification improvement) compared with Lee's Revised Cardiac Risk Index alone. There was substantial heterogeneity and inadequate risk stratification analysis in the included studies. Raised preoperative levels of high-sensitivity troponin appear to represent a risk for postoperative major adverse cardiac events and mortality. Further study is required before high-sensitivity troponin can be used to predict risk stratification in routine clinical practice.

Predicting Major Adverse Events in Patients With Acute Myocardial Infarction

BackgroundEarly and accurate detection of short-term major adverse cardiac events (MACE) in patients with suspected acute myocardial infarction (AMI) is an unmet clinical need. ObjectivesThe goal of this study was to test the hypothesis that adding clinical judgment and electrocardiogram findings to the European Society of Cardiology (ESC) high-sensitivity cardiac troponin (hs-cTn) measurement at presentation and after 1 h (ESC hs-cTn 0/1 h algorithm) would further improve its performance to predict MACE. MethodsPatients presenting to an emergency department with suspected AMI were enrolled in a prospective, multicenter diagnostic study. The primary endpoint was MACE, including all-cause death, cardiac arrest, AMI, cardiogenic shock, sustained ventricular arrhythmia, and high-grade atrioventricular block within 30 days including index events. The secondary endpoint was MACE + unstable angina (UA) receiving early (≤24 h) revascularization. ResultsAmong 3,123 patients, the ESC hs-cTnT 0/1 h algorithm triaged significantly more patients toward rule-out compared with the extended algorithm (60%; 95% CI: 59% to 62% vs. 45%; 95% CI: 43% to 46%; p < 0.001), while maintaining similar 30-day MACE rates (0.6%; 95% CI: 0.3% to 1.1% vs. 0.4%; 95% CI: 0.1% to 0.9%; p = 0.429), resulting in a similar negative predictive value (99.4%; 95% CI: 98.9% to 99.6% vs. 99.6%; 95% CI: 99.2% to 99.8%; p = 0.097). The ESC hs-cTnT 0/1 h algorithm ruled-in fewer patients (16%; 95% CI: 14.9% to 17.5% vs. 26%; 95% CI: 24.2% to 27.2%; p < 0.001) compared with the extended algorithm, albeit with a higher positive predictive value (76.6%; 95% CI: 72.8% to 80.1% vs. 59%; 95% CI: 55.5% to 62.3%; p < 0.001). For 30-day MACE + UA, the ESC hs-cTnT 0/1 h algorithm had a higher positive predictive value for rule-in, whereas the extended algorithm had a higher negative predictive value for the rule-out. Similar findings emerged when using hs-cTnI. ConclusionsThe ESC hs-cTn 0/1 h algorithm better balanced efficacy and safety in the prediction of MACE, whereas the extended algorithm is the preferred option for the rule-out of 30-day MACE + UA. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE]; NCT00470587).

Admission blood glucose as a prognostic indicator in patients with acute myocardial infarction

Objective: To investigate the utility of admission blood glucose for predicting major adverse cardiac events (MACE) during hospitalisation and 6 months’ postdischarge in acute myocardial infarction (AMI) patients. Methods and results: This study recruited 2878 AMI patients admitted to the Coronary Care Unit at R. K. Khan Hospital, Durban, South Africa, from 2002 - 2014. Demographic and clinical data stored in an electronic database were obtained from all patients. Admission blood glucose levels were sub-divided into 3 groups; low (<7.8), medium (7.8-10.9) and high (≥11) mmol/l. The mean age of the study population was 57.18 ± 7 years of whom 65% were males. Self-reported diabetes was found in 59%, while 377 patients were diagnosed with diabetes based on HbA1c levels ≥6.5%, increasing the overall prevalence to 72% (n=2070). More patients were in the low admission blood glucose group (49%), medium group (16%), and high group (35%). The highest prevalence of MACE was seen in the high group (42%) compared to either the medium (39%) or low groups (26%; p<0.001), particularly for cardiogenic shock (p<0.001), cardiac failure (p<0.001) and death (p<0.001). Following multivariable logistic regression analyses of clinical and laboratory parameters associated with mortality, high admission blood glucose conferred a significantly increased odds of mortality (p=0.001). The optimal cut-off admission blood glucose value as determined via the receiver operating characteristic curve for predicting in hospital and 6 months’ mortality was 8.5mmol/l (AUC of 0.63) and 8.1mmol/l (AUC of 0.61) for MACE. Conclusions: This study shows that patients have multiple risk factors for AMI with diabetes playing a central role. Although elevated admission blood glucose is an important predictor for in hospital and shortterm MACE, the cut-off value for predicting MACE and mortality has only modest predictability and further research is required to improve the performance of these measures for routine clinical use.

Prognostic efficacy of high-sensitivity C-reactive protein to albumin ratio in patients with acute coronary syndrome.

Aim: The present study aimed to examine the correlation between high-sensitivity CRP to albumin ratio (CAR) and in-hospital and short-term major adverse cardiac events (MACEs) in patients with acute coronary syndrome (ACS). Materials & methods: We analyzed 652 consecutive patients who had been hospitalized for ACS. The MACEs were defined as cardiogenic shock, reinfarction, acute heart failure and all-cause death. Results: The incidence rate of MACEs was significantly higher in the high CAR (≥0.114) group than in the low CAR (<0.114) group. Multivariate analysis revealed that CAR, hs-CRP and albumin were independent predictors for increased risk for MACEs. Conclusion:The CAR was independently correlated with in-hospital and short-term MACEs and can be used for risk stratification in patients with ACS.

Efficacy Evaluation of High-Dose Atorvastatin Pretreatment in Patients with Acute Coronary Syndrome: A Meta-Analysis of Randomized Controlled Trials.

BackgroundIt is unclear whether high-dose atorvastatin pretreatment benefits acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). To clarify this issue, we performed a meta-analysis of the published literature.Material/MethodsRandomized controlled trials (RCTs) assessing high-dose atorvastatin pretreatment in ACS patients undergoing PCI were enrolled. Short-term major adverse cardiac events (MACEs), changes in serum high-sensitivity C-reactive protein (hs-CRP), peak creatine kinase-myocardial band (CK-MB) level, and thrombolysis in myocardial infarction (TIMI) grade 3 flow after PCI were studied as clinical outcomes.ResultsSeventeen RCTs including 10 072 patients were retrieved. High-dose atorvastatin showed greater benefits in reducing the incidence of short-term MACEs (OR 0.72; 95% CI: 0.56 to 0.94; P=0.01) and hs-CRP level (SMD −1.59; 95% CI: −2.38 to −0.80; P<0.0001) among ACS patients after PCI. No significant difference was found between the 2 groups in terms of peak CK-MB (SMD −0.34; 95% CI: −0.79 to 0.10; P=0.13) or final TIMI flow grade 3 (OR 1.31; 95% CI: 0.73 to 2.36; P=0.36) after PCI. High-dose atorvastatin therapy also was not associated with alanine aminotransferase (ALT) elevation (OR 1.95; 95% CI: 0.95 to 4.03; P=0.07).ConclusionsThe results of this meta-analysis suggest that high-dose atorvastatin pretreatment reduces the incidence of short-term MACEs and hs-CRP level without increasing drug-induced hepatotoxicity in ACS patients after PCI.

Prognostic Accuracy of the HEART Score for Prediction of Major Adverse Cardiac Events in Patients Presenting With Chest Pain: A Systematic Review and Meta-analysis.

The HEART score has been proposed for emergency department (ED) prediction of major adverse cardiac events (MACE). We sought to summarize all studies assessing the prognostic accuracy of the HEART score for prediction of MACE in adult ED patients presenting with chest pain. We searched MEDLINE, PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews from inception through May 2018 and included studies using the HEART score for the prediction of short-term MACE in adult patients presenting to the ED with chest pain. The main outcome was short-term (i.e., 30-day or 6-week) incidence of MACE. We secondarily evaluated the prognostic accuracy of the HEART score for prediction of mortality and myocardial infarction (MI). Where available, accuracy of the Thrombolysis in Myocardial Infarction (TIMI) score was determined. We included 30 studies (n = 44,202) in analysis. A HEART score above the low-risk threshold (≥4) had a sensitivity of 95.9% (95% confidence interval [CI]= 93.3%-97.5%) and specificity of 44.6% (95% CI= 38.8%-50.5%) for MACE. A high-risk HEART score (≥7) had a sensitivity of 39.5% (95% CI= 31.6%-48.1%) and specificity of 95.0% (95% CI= 92.6%-96.6%) for MACE, whereas a TIMI score above the low-risk threshold (≥2) had a sensitivity of 87.8% (95% CI= 80.2%-92.8%) and specificity of 48.1% (95% CI= 38.9%-57.5%) for MACE. A high-risk TIMI score (≥6) was 2.8% sensitive (95% CI= 0.8%-9.6%), but 99.6% (95% CI= 98.5%-99.9%) specific for MACE. A HEART score ≥ 4 had a sensitivity of 95.0% (95% CI= 87.2%-98.2%) for prediction of mortality and 97.5% (95% CI= 93.7%-99.0%) for prediction of MI. The HEART score has excellent performance for prediction of MACE (particularly mortality and MI) in chest pain patients and should be the primary clinical decision instrument used for the risk stratification of this patient population.

Association of pre-operative troponin levels with major adverse cardiac events and mortality after noncardiac surgery: A systematic review and meta-analysis.

Circulating cardiac troponin levels are powerful predictors of prognosis in many clinical settings, but their association with outcomes after noncardiac surgery is unclear. The aim of this systematic review was to summarise current evidence on the association of pre-operative troponin elevation with postoperative major adverse cardiac events (MACE) and mortality in patients undergoing noncardiac surgery. Systematic review of observational studies with meta-analysis. PubMed, EMBASE and Science Citation Index Expanded (ISI Web of Science) from their inception to 1 October 2017. Observational studies reporting the associations between pre-operative troponin levels and MACE and all-cause mortality after noncardiac surgeries were included. Ten studies met the eligibility criteria. The entire body of evidence addressing the research question was based on a total of 10 371 patients: 4.7 to 68.3% (median 23.8%) of patients had elevated troponin levels before surgery. Elevated pre-operative troponin was significantly associated with short-term MACE (seven studies, 5180 patients: odds ratio (OR) 6.92, 95% confidence interval (CI) 3.85 to 12.42), short-term mortality (five studies, 6103 patients: OR 4.23, 95% CI 2.27 to 7.89) and long-term mortality (two studies, 760 patients: OR 2.51, 95% CI 1.47 to 4.29). The associations remained significant when only multivariate-adjusted results were analysed. Overall, the reviewers' certainty about the summary estimates of the associations was very low. Current evidence suggests that pre-operative high troponin levels are significantly associated with adverse cardiac events and mortality after noncardiac surgery. This systematic review was registered in the International Prospective Register of Systematic Reviews (Centre for Reviews and Dissemination 42017077837).

Timing of revascularization in patients with transient ST-segment elevation myocardial infarction: a randomized clinical trial.

Patients with acute coronary syndrome who present initially with ST-elevation on the electrocardiogram but, subsequently, show complete normalization of the ST-segment and relief of symptoms before reperfusion therapy are referred to as transient ST-segment elevation myocardial infarction (STEMI) and pose a therapeutic challenge. It is unclear what the optimal timing of revascularization is for these patients and whether they should be treated with a STEMI-like or a non-ST-segment elevation myocardial infarction (NSTEMI)-like invasive approach. The aim of the study is to determine the effect of an immediate vs. a delayed invasive strategy on infarct size measured by cardiac magnetic resonance imaging (CMR). In a randomized clinical trial, 142 patients with transient STEMI with symptoms of any duration were randomized to an immediate (STEMI-like) [0.3 h; interquartile range (IQR) 0.2-0.7 h] or a delayed (NSTEMI-like) invasive strategy (22.7 h; IQR 18.2-27.3 h). Infarct size as percentage of the left ventricular myocardial mass measured by CMR at day four was generally small and not different between the immediate and the delayed invasive group (1.3%; IQR 0.0-3.5% vs. 1.5% IQR 0.0-4.1%, P = 0.48). By intention to treat, there was no difference in major adverse cardiac events (MACE), defined as death, reinfarction, or target vessel revascularization at 30 days (2.9% vs. 2.8%, P = 1.00). However, four additional patients (5.6%) in the delayed invasive strategy required urgent intervention due to signs and symptoms of reinfarction while awaiting angiography. Overall, infarct size in transient STEMI is small and is not influenced by an immediate or delayed invasive strategy. In addition, short-term MACE was low and not different between the treatment groups.

Patient-Centered Decision-Making of Revascularization Strategy for Left Main or Multivessel Coronary Artery Disease

Patient preference plays an important role in daily practice; however, its implication has not been well investigated regarding treatment strategy for complex coronary artery disease. We prospectively evaluated a trend of patient-centered decision-making of revascularization strategy in patients with multivessel or unprotected left main coronary artery disease. A standardized protocol that favors coronary artery bypass graft surgery (CABG) as the primary treatment of choice, rather than percutaneous coronary intervention, was adopted. According to the protocol, patients decided whether or not they received CABG. Among the 763 consecutively enrolled patients, 293 patients (38%) consented to receive CABG. Fifty-six percent of patients with a high Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score chose CABG. SYNTAX score was independently correlated with consent to receive CABG in each patient SYNTAX score stratum. In-stent restenosis was an independent predictor of choosing CABG in patients with low and intermediate SYNTAX scores. Unprotected left main coronary artery disease was negatively correlated with the decision to choose CABG in patients with intermediate SYNTAX score. Reasons for declining CABG included refusal of open-heart surgery in 318 patients (68%), mild presentation of angina symptoms in 132 patients (28%), low self-confidence to expect long-term survival in 120 patients (26%), and economic factors in 10 patients (2%). Short-term major adverse cardiac and cerebrovascular events occurred in about 1% of patients without significant differences between the 2 groups. In conclusion, despite the preferred use of the CABG protocol, more than half of the patients declined CABG. Patient-centered decision-making as well as heart team approach should be considered in real-world practice situations.

Prognostic value of N-Terminal Pro-B-Type Natriuretic Peptide in Takotsubo syndrome.

Takotsubo syndrome (TTS), a form of acute transient heart failure, has been associated with severe complications and considerable mortality rates. N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP) might serve as a marker to identify high-risk patients but has not yet been investigated regarding prognostic implications in TTS. Aim of this study was to determine the short- and long-term prognostic utility of NT-proBNP in patients with TTS. The predictive value of admission NT-proBNP was assessed in an international, multicenter study including 177 consecutive TTS patients. Predefined endpoints were 30-day major adverse cardiac events (MACE) consisting of all-cause death, cardiogenic shock, and pulmonary edema as well as long-term mortality in median 2.3years after the acute event. Stratification according to median admission NT-proBNP (4511pg/ml) resulted in significantly higher 30-day MACE [22.5 versus 9.1%; odds ratio (OR) 2.90, 95% confidence interval (CI) 1.20-6.99 p = 0.015] and long-term mortality rates [16.3 versus 9.4%; hazard ratio (HR) 2.72, 95% CI 1.13-6.56 p = 0.021] in patients > median. The best admission NT-proBNP cutoffs to predict 30-day MACE and long-term mortality were determined at 5560 and 8178pg/ml respectively, with subsequent improved risk stratification for short-term MACE (OR 3.61, 95% CI 1.49-8.72; p = 0.003) and long-term mortality (HR 4.40; 95% CI 1.85-10.44, p < 0.001). Multivariate regression analysis identified admission NT-proBNP as an independent predictor of 30-day MACE (p < 0.001) and long-term mortality (p = 0.012). Admission NT-proBNP is an independent predictor for short- and long-term adverse events in TTS patients and, therefore, a useful marker for risk stratification immediately at presentation.

Intracoronary Glycoprotein IIb/IIIa Inhibitors Improve Short-Term Mortality and Reinfarction in East Asian Patients with ST-Segment Elevation Myocardial Infarction after Thrombus Aspiration: A Meta-Analysis.

Objective Intracoronary (IC) glycoprotein IIb/IIIa inhibitors (GPIs) after thrombus aspiration (TA) for patients with ST-segment elevation myocardial infarction (STEMI), as compared with percutaneous coronary interventions (PCI) alone, is still on debate. To address this issue, we performed a meta-analysis of results from prospective or randomized controlled trials on the topic. Methods We searched electronic and printed sources (up to June 20, 2016) according to the selection criteria. Data were abstraction and meta-analysis was performed using RevMan 5.3 software. Results The cohorts involved 14 articles describing 1,918 participants were included. The incidence of the short-term major adverse cardiac events (MACE) was significantly reduced with intracoronary GPIs after TA (odds ratio [OR]: 0.29; 95% confidence interval [CI]: 0.13 to 0.65, p=0.003). Benefits were noted for short-term mortality (OR: 0.31; 95% CI: 0.17 to 0.57, p=0.0002) and reinfarction (OR: 0.28; 95% CI: 0.10 to 0.78, p=0.01) in subjects who received intracoronary GPIs after TA. Moreover, the Thrombolysis in Myocardial Infarction (TIMI) trial grade 3 postprocedure (OR: 2.29; 95% CI: 1.72 to 3.04, P<0.00001) and complete ST-segment resolution (STR) rate (OR: 2.68; 95% CI: 1.85 to 3.87, P<0.00001) were both improved with intracoronary GPIs after TA. As a result, left ventricular ejection fraction (LVEF) at short-term follow-up showed a significant difference (OR: 7.33; 95% CI: 5.60 to 9.06, p<0.0001) in favor of the TA and intracoronary GPIs administration. Conclusions Our study demonstrates that intracoronary GPIs may have a synergistic effect with thrombus aspiration on short-term mortality, reinfarction, and cardiac functional recovery.

Meta-Analysis of Randomized Trials of Intracoronary Versus Intravenous Glycoprotein IIb/IIIa Inhibitors in Patients With ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

The efficacy and safety of glycoprotein IIb/IIIa inhibitors via intracoronary (IC) route versus the intravenous (IV) route are not well known. We conducted this meta-analysis of randomized trials evaluating the role of IC versus IV glycoprotein IIb/IIIa in patients undergoing primary percutaneous coronary intervention. The analysis included 14 trials with a total of 3,754 patients. The primary outcome of major adverse cardiac events (MACE) had no statistically significant difference between the IC and the IV groups (relative risk [RR] 0.74, 95% confidence interval [CI] 0.51 to 1.10). Subgroup analysis showed that short-term MACE (i.e., ≤3 months) was reduced in the IC compared with the IV group; however, long-term MACE (>3 months) was not. IC group was superior in achievement of post-procedural Thrombolysis In Myocardial Infarction 3 flow (RR 1.06, 95% CI 1.01 to 1.11), myocardial blush grade II to III (RR 1.15, 95% CI 1.08 to 1.23), ST-segment resolution rates (RR 1.15, 95% CI 1.03 to 1.29; p = 0.01), and improvement of left ventricular ejection fraction (standardized mean difference = 4.32, 95% CI 0.91 to 7.74). There was a trend for lower stent thrombosis with IC route (RR 0.50, 95% CI 0.24 to 1.03). There was no significant difference between the 2 groups in all-cause mortality, re-infarction, and major bleeding. In conclusion, despite lack of significant difference in overall MACE outcome, IC glycoprotein IIb/IIIa inhibitors may improve short -term MACE, Thrombolysis In Myocardial Infarction 3 flow, myocardial blush grade II- to III rates, ST-segment resolution, and left ventricular ejection fraction compared with the IV route.

Impact of periprocedural myocardial necrosis on short term clinical outcome

BackgroundNo reliable data whether periprocedural myocardial necrosis (PPN) has same poor prognostic value as periprocedural myocardial infarction (PMI) or not. We aimed to assess the impact of PPN on short term clinical outcome. Methods100 patients admitted with non ST elevation acute coronary syndrome and underwent PCI were enrolled. Patients were grouped according to the occurrence of PPN into 2 groups, and were followed for 3months. Patients with PMI were excluded. Results30 patients (30%) had PPN and were associated with higher risks of major adverse cardiac events (MACE) during the hospital and 3months follow up (43.3% and 66.7% vs. 12.9% and 14.3% respectively; p<0.001). PPN was more likely to occur in older, diabetic, previously infracted, and heart failure patients (p value: <0.05), in addition to patients who had lengthy and more complex lesions (p value 0.006 and <0.001 respectively). Each unit increase in Modified Gensini Score (MGS) increased odds of procedural complications 1.2 times, (P value 0.046), which in turn increased odds of short term MACE 5.7 times, (P value 0.003). ConclusionsPPN are associated with poor short term prognosis. PPN occurs more in diabetic, heart failure, infracted patients and those who have complex lesions.

Comparison of in-hospital glycemic variability and admission blood glucose in predicting short-term outcomes in non-diabetes patients with ST elevation myocardial infarction underwent percutaneous coronary intervention

AimsAdmission hyperglycemia is associated with increased mortality and major adverse cardiac events (MACE) in patients with or without diabetes mellitus after acute myocardial infarction (AMI). However, effects of glycemic variability (GV) on outcomes of non-diabetes patients with AMI still remains unclear. The aim of this study is to compare the prognostic value of in-hospital GV with admission blood glucose (ABG) for 3-month MACE in non-diabetes patients with ST elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI).MethodsWe analyzed 256 non-diabetes patients with STEMI in study. The GV accessed by mean amplitude of glycemic excursions (MAGE) was calculated from blood glucose profiles of continuous glucose monitoring system (CGMS) during hospitalization. ABG was measured on admission. Main endpoints were 3-month MACE; secondary endpoints were GRACE scores and enzymatic infarct size. Predictive effects of MAGE and ABG on the MACE in patients were analyzed.ResultsIn all participants, MAGE level was associated with ABG level (r = 0.242, p < 0.001). Both elevated MAGE levels (p = 0.001) and elevated ABG (p = 0.046) were associated with incidences of short-term MACE. Patients with a higher MAGE level had a significantly higher cardiac mortality (5.8 vs. 0.6%, p = 0.017) and incidence of acute heart failure (12.8 vs. 2.4%, p = 0.001) during 3 months follow-up. In multivariable analysis, high MAGE level (HR 2.165, p = 0.023) was significantly associated with incidence of short-term MACE, but ABG (HR 1.632, p = 0.184) was not. The area under the receiver-operating characteristic curve for MAGE (0.690, p < 0.001) was superior to that for ABG (0.581, p = 0.076).ConclusionsTo compare with ABG, in-hospital GV may be a more important predictor of short-term MACE and mortality in non-diabetes patients with STEMI treated with PCI.

Leptin predicts short-term major adverse cardiac events in patients with coronary artery disease

Introduction: Leptin is an adipose tissue-derived hormone associated with cardiovascular risk factors. We examined whether leptin predicts major adverse cardiac events (MACE) in coronary artery disease (CAD) patients.Methods: Fasting plasma leptin levels were measured in 1327 male and 619 female CAD patients. The patients were followed up for two years. The primary endpoint (MACE) was the composite of a hospitalisation for congestive heart failure (CHF) or a cardiac death. The secondary endpoint was the composite of an acute coronary syndrome (ACS) or a stroke.Results: In regression analysis including established risk variables, high leptin levels were associated with a significantly increased risk of MACE (HR 3.37; 95%CI 1.64–6.90; p = 0.001) and ACS or stroke (HR 1.95; 95%CI 1.29–2.96; p = 0.002). Adding leptin to the risk model for MACE increased the C-index from 0.78 (95%CI 0.71–0.85) to 0.81 (0.74–0.88) and improved classification (NRI 0.36; 95%CI 0.13–0.60; p = 0.002) and discrimination of the patients (IDI 0.016; 95%CI 0.001–0.030; p = 0.031).Conclusions: High plasma leptin levels predict short-term occurrence of CHF or cardiac death and ACS or stroke in patients with CAD independently of established risk factors. The possible harmful effects of leptin should be thoroughly investigated.Key messagesLeptin is a peptide hormone secreted mainly by adipose tissue. It has been associated with several cardiovascular risk factors.High leptin levels predict the short-term occurrence of congestive heart failure or cardiac death and ACS or stroke in patients with CAD independently of established risk factors.The possible detrimental effects of leptin on the cardiovascular system should be thoroughly investigated.

Comparing the adverse clinical outcomes in patients with non-insulin treated type 2 diabetes mellitus and patients without type 2 diabetes mellitus following percutaneous coronary intervention: a systematic review and meta-analysis.

BackgroundSeveral studies showed Type 2 Diabetes Mellitus (T2DM) to be associated with worse adverse clinical outcomes compared to non-T2DM (NDM) following Percutaneous Coronary Intervention (PCI). In addition, patients with insulin-treated T2DM (ITDM) showed worse clinical outcomes compared to patients with non-insulin treated T2DM (NITDM). Since NITDM and NDM have seldom been systematically analyzed, this study aimed to compare the short and long term adverse clinical outcomes observed in patients with NITDM and patients without T2DM following PCI.MethodsMedline/PubMed, EMBASE and the Cochrane library were searched for Randomized Controlled Trials (RCTs) and observational studies comparing patients with (including ITDM and NITDM) and without T2DM following PCI. Endpoints included adverse clinical outcomes reported during a short and a long term follow up period. Odd Ratios (OR) and 95% Confidence Intervals (CI) in accordance with either a fixed or a random effects model appropriately, were calculated and the pooled analyses were performed with RevMan 5.3.ResultsTwelve studies consisting of a total number of 52,451 patients (14,863 NITDM and 37,588 NDM) were included. Patients with NITDM were found to have significantly higher short-term Major Adverse Cardiac Events (MACEs) and mortality with OR: 1.63, 95% CI (1.17, 2.27); P = 0.004 and OR: 1.71, 95% CI (1.40, 2.10), P < 0.00001 respectively and higher long-term MACEs and mortality with OR: 1.25, 95% CI (1.12, 1.40), P = 0.0001 and OR: 1.32, 95% CI (1.19, 1.47), P < 0.00001 respectively compared to NDM following PCI. In addition, compared to NDM, long-term Target Vessel Revascularization (TVR) and Target Lesion Revascularization (TLR) were significantly higher in the NITDM group with OR: 1.36, 95% CI (1.18, 1.56), P < 0.0001 and OR: 1.32, 95% CI (1.10, 1.59), P = 0.003 respectively. However, even if an increased long-term stent thrombosis was observed in the NITDM group with OR: 1.13; 95% CI (0.91, 1.40), P = 0.28, the result was insignificant.ConclusionShort and long term MACEs and mortality were significantly higher in patients with NITDM compared to patients without diabetes following PCI. Revascularization also significantly favored patients without T2DM. However, stent thrombosis was not significantly different.