Worse Killip Class Research Articles

Prognostic value of arterial lactate index in ST-elevation myocardial infarction treated with primary percutaneous coronary intervention: a prospective cohort study.

Aim: Limited knowledge exists on the pathophysiological cascade beyond serum lactate's association with myocardial injury. Method: Assessed the prognostic value of lactate index on periprocedural variables and its impact on 30-day major adverse cardiovascular events (MACE)in 300 prospective ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI). Results: Significant correlations were observed between admission lactate and Killip class, periprocedural time intervals, postprocedure thrombolysis in myocardial infarction (TIMI) flow and myocardial blush grade (MBG;p<0.01). Lactate levels correlated with diminished ST-deviation resolution, cardiac enzymes (CK-MB, troponin;p<0.001; 0.004), and lower ejection fraction (p<0.001). This relationship impacted 30-day MACE (p<0.001). Conclusion: Hyperlactatemia in STEMI patients undergoing pPCI is associated with worse Killip class, unsatisfactory TIMI flow, MBG, larger infarct size and higher 30-day MACE. Serum lactate aids risk stratification in pPCI for STEMI patients.

Serum fibrinogen-to-albumin ratio predicts new-onset atrial fibrillation risk during hospitalization in patients with acute myocardial infarction after percutaneous coronary intervention: a retrospective study

BackgroundNew-onset atrial fibrillation (NOAF) is a common adverse outcome of percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI) and is closely correlated with hospital stay and prognosis. In recent years, serum fibrinogen-to-albumin ratio (FAR), a novel biomarker for inflammation and thrombosis, has been used to predict the severity and prognosis of coronary artery disease. Our study aimed to investigate the relationship between FAR and NOAF during hospitalization after PCI in patients with AMI.MethodsWe retrospectively analyzed the incidence of NOAF during hospitalization and follow-up in 670 patients with AMI after PCI. Data were collected on patient age, sex, body mass index, medical history, current medication, heart failure, laboratory tests, culprit blood vessels, echocardiographic characteristics, and AMI type. The enrolled patients were divided into NOAF and non-NOAF groups. The baseline characteristics of patients in the two groups were compared, and the predictive correlation between FAR and NOAF was evaluated using logistic regression analysis and the receiver operating characteristic curve.ResultsFifty-three (7.9%) patients developed NOAF during hospitalization. The occurrence of NOAF was found to be independently associated with higher FAR besides older age, higher neutrophil count, greater left atrial size, worse Killip class upon admission, lower body mass index, lower platelet count, lower left ventricle ejection fraction, and target left circumflex artery disease. FAR exhibited a better predictive value for the occurrence of NOAF during hospitalization (area under the curve, 0.732; 95% confidence interval, 0.659–0.808).ConclusionsFAR is a robust tool for predicting NOAF risk during hospitalization in patients with AMI after PCI and has a better predictive value than serum fibrin and serum albumin levels alone.

Nutritional Status as a Risk Factor for New-Onset Atrial Fibrillation in Acute Myocardial Infarction.

Our study aimed to identify new-onset atrial fibrillation (NOAF) risk factors in acute myocardial infarction (AMI) patients after treatment with percutaneous coronary intervention (PCI) and investigate whether their nutritional status can be a predicting factor of NOAF. We analyzed 662 AMI patients after PCI for NOAF occurrence during follow-up hospitalization and divided them into an NOAF and non-NOAF group. The patients' nutritional status was assessed using the controlling nutritional status (CONUT) score and geriatric nutritional risk index (GNRI). The Kaplan‒Meier analysis was used to assess NOAF-free survival in varying degrees of malnutrition. Cox proportional hazards models were used to identify the risk factors for NOAF. Eighty-four (12.7%) patients developed NOAF during hospitalization. There was a statistically significant difference in the occurrence of NOAF among different categories of nutritional status. The CONUT score and GNRI classifications were independent predictors of NOAF. NOAF occurrence was associated with older age, higher uric acid levels, higher N-terminal pro-B-type natriuretic peptide levels, greater left atrial size, and worse Killip class upon admission. The nutritional status can affect NOAF occurrence in AMI patients after PCI. The CONUT score and GNRI are ideal tools for evaluating the nutritional status of AMI patients, with an excellent predictive effect on NOAF.

Intravenous antiplatelet therapy with cangrelor vs. tirofiban in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

Abstract Background Intravenous antiplatelet drugs provide rapid and sustained inhibition of platelet aggregation and can mitigate the ischemic risk of patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). However, there are few real-world studies comparing cangrelor to tirofiban in this patient population. Purpose The aim of this study was to evaluate the effectiveness and the safety of cangrelor compared to tirofiban in a real-world population of STEMI patients undergoing pPCI. Methods This was a prospective, multicenter, observational study including consecutive STEMI patients who received either cangrelor or tirofiban during pPCI at six Italian high-volume pPCI centers from January 2020 to January 2022. The study population was divided into two groups according the antiplatelet treatment received (cangrelor or tirofiban). The primary study outcome was impaired myocardial revascularization assessed by post-procedural Thrombolysis in Myocardial Infarction (TIMI) flow grade &amp;lt;3. The secondary outcome measures were major bleeding, defined as Bleeding Academic Research Consortium (BARC) type 3 or 5, and all-cause mortality during the hospitalization. Results A total of 478 STEMI patients received intravenous antiplatelet therapy during pPCI. Of them, 16 patients were excluded since they received both cangrelor and tirofiban as bailout strategy. Thus, the final study population included 462 patients (mean age 63.9±11.8 years; 79.7% males): 223 patients received cangrelor (48.3%), and 239 tirofiban (51.7%). Patients treated with tirofiban had higher prevalence of prior myocardial infarction (p=0.016) and prior PCI (p=0.048) than patients receiving cangrelor (Table 1); also, they showed higher SYNTAX score (p=0.038) than patients receiving cangrelor, and a higher proportion of stent thrombosis as culprit lesion (p=0.047; Table 2). Conversely, patients treated with cangrelor had worse Killip class (p&amp;lt;0.001), and underwent more frequently pPCI via femoral access. Post-procedural TIMI flow&amp;lt;3 was reported in 114 (24.7%) patients. At propensity score adjusted regression analysis, the use of cangrelor was associated with a lower probability of post-procedural TIMI flow&amp;lt;3 (aOR: 0.530; 95% CI: 0.313–0.900; p=0.019) than tirofiban. Major bleeding and all-cause death occurred in 28 (6.1%) and 19 (4.1%) patients. There was no difference in the risk of major bleeding (aOR: 1.626; 95% CI: 0.618–4.279; p=0.324) and death (aOR: 2.724; 95% CI: 0.719–10.318; p=0.140) between groups. Conclusions In this real-world population of STEMI patients undergoing pPCI, periprocedural use of cangrelor was associated with improved myocardial reperfusion compared to tirofiban, but with no differences in terms of major bleeding or death during the hospitalization. Funding Acknowledgement Type of funding sources: None.

Symptoms at NSTEMI presentation - do they predict the outcome?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The most common clinical presentation of non-ST-segment elevation myocardial infarction (NSTEMI) is angina pectoris. However, some groups of patients such as elderly, women and patients with diabetes or chronic renal disease,may have atypical symptoms, like isolated dyspnea or syncope. Aim The aim of this study was to identify the outcomes of NSTEMI patients with different types of presenting symptoms and to verify if these presentations were independent predictors of the studied outcomes. Methods We studied patients &amp;gt;18 year-old admitted with NSTEMI between October 2010 and September 2019. Data was collected from a national multicentric registry. From an initial pool of 13739 patients, a total of 4726 were included (the main exclusion criterion was lack of follow-up registry). The patients were divided into 3 groups according to the main presentation symptom: group 1 – chest pain; group 2 – dyspnea/fatigue; group 3 – syncope. The primary endpoint was 1-year death from any cause. Results The most common presentation sympton was chest pain (91.3%; n=4313), followed by dyspnea/fatigue (7%; n=332) and syncope (1.7%; n=81). Seventy-one percent (n=3352) of patients were male and 29.1% (n=1374) female. Mean age was 68±13 years. Patients presenting with dyspnea/fatigue were older (75±11 vs 68±13 [group 1] vs 74±13 [group 3], p&amp;lt;0.001), more commonly women (41.9% vs 29.1% [group 1] vs 37% [group 3], p&amp;lt;0.001), with hypertension (89.5% vs 74.8% [group 1] vs 75% [group 3], p&amp;lt;0.001), diabetes mellitus (54.6% vs 33.7% [group 1] vs 38.3% [group 3], p&amp;lt;0.001), chronic kidney disease (18.1% vs 6.8% [group 1] vs 11.5% [group 3], p&amp;lt;0.001, and chronic obstructive pulmonary disease [COPD] (15.5% vs 5.9% [group 1] vs 10.3% [group 3], p&amp;lt;0.001). They also had worse Killip class at admission (KK&amp;gt; 1 80% vs 9.9% [group 1] vs 23.5% [group 3], p&amp;lt;0.001). One-year survival rate was lowest patients presenting with dyspnea/fatigue (75.7% vs 93.5% [group 1] vs 92.1 [group 3], p&amp;lt;0.001) and 1-year free from cardiovascular rehospitalization was also lowest in this group (75.6% vs 85% [group 1] vs 83.3% [group 3], p&amp;lt;0.001). However, after multivariate analysis, the different presenting symptoms were not significant independent predictors of the primary endpoint; identified independent predictors included age (HR 3.37, 95% CI 2.111 to 3.815, p&amp;lt;0.001), COPD (HR 2.508, 95% CI 1.584 to 3.969, p&amp;lt;0.001), LVEF &amp;lt; 50% (HR 2.350, 95% CI 1.642 to 3.365, p&amp;lt;0.001), and major bleeding (HR 4.66, 95% CI 2.118 to 10.254, p&amp;lt;0.001). Conclusion This study reveals that patients with dyspnea/fatigue at presentation have an overall worse prognosis than those who present with chest pain or syncope. The former patients were more commonly women, older and had more comorbidities; also, they presented with worse Killip class. However, symptoms themselves were not independent predictors of 1-year mortality.

Baseline CHA 2 DS 2 ‐VASc score and prognosis in octogenarians with non‐ST segment elevation acute coronary syndrome

CHA2 DS2 -VASc Score is widely used to predict thromboembolic risk in patients with Atrial Fibrillation (AF). We sought to study if this score predicts outcomes in elderly patients with Non-ST segment Elevation Acute Coronary Syndromes (NSTEACS). The multicenter LONGEVO-SCA prospective registry included 532 unselected patients with NSTEACS aged ≥80 years. Data to calculate CHA2DS2-VASc Score were available in 523 patients (98.3%). They were classified according to CHA2DS2-VASc Score: group 1 (score ≤4), and 2 (5-9). We studied outcomes in terms of mortality or readmission at 6 months follow-up. A total of 266 patients (51%) had a high CHA2DS2-VASc Score (group 2). They were more often women, with more cardiovascular risk factors like hypertension or diabetes mellitus, and history of previous stroke and cardiovascular disease and heart failure (all, p=0.001). Geriatric syndromes (Barthel Index, Lawton Brody, cognitive impairment and frailty) and Charlson index were worse in this group (all, p=0.001). They had poorer clinical status on admission, with worse Killip class and lower left ventricle ejection fraction (all, p=0.001), and developed new onset AF more often during admission (12.4% vs. 6.6%, p=0,024). At six months follow-up, patients in group 2 had higher reinfarction, all-cause mortality, and mortality or readmission rates. A CHA2DS2-VASc Score >4 was associated with mortality or readmission at 6 months (HR 2.07, p<0.001). However, after adjusting for potential confounders, this last association was not significant (p=0.175). A CHA2DS2-VASc score >4 is present in half of octogenarians with NSTEACS and is associated with poorer outcomes. However, it is not an independent predictor of events and should not replace recommended tools for risk prediction in this setting.

Clinical Implication of Hypoxic Liver Injury for Predicting Hypoxic Hepatitis and In-Hospital Mortality in ST Elevation Myocardial Infarction Patients.

PurposeIn this study, we aimed to determine the value of hypoxic liver injury (HLI) in the emergency room (ER) for predicting hypoxic hepatitis (HH) and in-hospital mortality in ST elevation myocardial infarction (STEMI) patients.Materials and Methods1537 consecutive STEMI patients were enrolled. HLI in the ER was defined as a ≥2-fold increase in serum aspartate transaminase (AST). HH was defined as a ≥20-fold increase in peak serum transaminase. Patients were divided into four groups according to HLI and HH status (group 1, no HLI or HH; group 2, HLI, but no HH; group 3, no HLI, but HH; group 4, both HLI and HH).ResultsThe incidences of HLI and HH in the ER were 22% and 2%, respectively. In-hospital mortality rates were 3.1%, 11.8%, 28.6%, and 47.1% for groups 1, 2, 3, and 4, respectively. Patients with HLI and/or HH had worse Killip class, higher cardiac biomarker elevations, and lower left ventricular ejection fraction. Multivariate logistic regression analysis showed that HLI in the ER was an independent predictor of HH [odds ratio 2.572, 95% confidence interval (CI) 1.166–5.675, p=0.019]. The predictive value of HLI in the ER for the development of HH during hospitalization was favorable [area under the curve (AUC) 0.737, 95% CI 0.643–0.830, sensitivity 0.548, specificity 0.805, for cut-off value AST >80]. Furthermore, in terms of in-hospital mortality, predictive values of HLI in the ER and HH during hospitalization were comparable (AUC 0.701 for HLI at ER and AUC 0.674 for HH).ConclusionAmong STEMI patients, HLI in the ER is a significant predictor for the development of HH and mortality during hospitalization (INTERSTELLAR ClinicalTrials.gov number, NCT02800421).

P1563CHA2DS2-VASc score predicts mortality and readmission in octogenarian patients with non-ST-segment elevation myocardial infarction

Abstract Background CHA2DS2-VASc Score is widely used to predict thromboembolic risk in patients with Atrial Fibrillation (AF). We ought to study if this score predicts outcomes in elderly patients with Non ST-segment Elevation Myocardial Infarction (NSTEMI). Methods The multicenter LONGEVO-SCA prospective registry included 532 unselected patients with NSTEMI aged ≥80 years. Data to calculate CHA2DS2-VASc Score were available in 523 patients (98.3%). They were classified according to CHA2DS2-VASc Score: group 1 (score 0–4), and 2 (5–9). We studied outcomes in terms of mortality or readmission at 6 months follow-up. Results A total of 266 patients (51%) had a high CHA2DS2-VASc Score (group 2). They were more often women, with more cardiovascular risk factors like hypertension or diabetes mellitus, and history of previous stroke and cardiovascular disease and heart failure (all, p=0.001). Geriatric syndromes (Barthel Index, Lawton Brody, cognitive impairment and frailty) and Charlson index were worse in this group (all, p=0.001). They had poorer clinical status on admission, with worse Killip class and lower left ventricle ejection fraction (all, p=0.001), and developed new onset AF more often during admission (12.4% vs. 6.6%, p=0,024). At six months follow-up, patients in group 2 had higher reinfarction, all cause mortality, and mortality or readmission rates (all, p=0.001). (Table) A CHA2DS2-VASc Score &gt;4 predicted mortality (HR 2,60 [95% CI 1,48–4,55], p&lt;0,001) (Figure 1) and was associated with mortality or readmission at 6 months (HR 2.07 [CI 95% 1.51–2.84], p&lt;0.001). CHADS VASC2 0–4 (n=257) CHADS &gt;4 (n=266) p Geriatric syndromes Barthel Index 94 (13) 85 (22) 0.001 Lawton brody 6.2 (2) 4.9 (3) 0.001 Charlson Index 1.5 (1) 3.3 (2) 0.001 Cognitive impairment 0.001 No 201 (79.1) 155 (58.7) Mild 49 (19.3) 100 (37.9) Severe 4 (1.6) 9 (3.4) Nutritional risk (MNA-SF*) 122 (48) 149 (57.1) 0.040 Frailty (FRAIL scale) 0.001 Non-frail 111 (43.2) 69 (25.9) Prefrail 102 (39.7) 101 (38) Frail 44 (17.1) 96 (36.1) Outcomes at 6 months Reinfarction 26 (6.9) 16 (13.9) 0.018 Mortality or readmission 111 (28.9) 60 (50.4) 0.001 All cause mortality 38 (9.9) 24 (20.2) 0.003 Conclusions A CHA2DS2-VASc sore&gt;4 is present in half of octogenarians with NSTEMI and is associated with a poor outcome.

P6264Mitral regurgitation and prognosis after non-ST-segment elevation myocardial infarction in very old patients

Abstract Background Mitral regurgitation (MR) after acute coronary syndromes is associated with adverse prognosis. However, the prognostic impact of MR in older patients with Non ST-segment Elevation Myocardial Infarction (NSTEMI) has not been well addressed. Methods The multicenter LONGEVO-SCA prospective registry included 532 unselected patients with NSTEMI aged ≥80 years. Echocardiography performed during admission quantified mitral valve parameters in 497 patients, who were classified according to mitral regurgitation (MR) status in two groups: significant (moderate or severe) or no significant MR (absent or mild). We evaluated the impact of MR status on mortality or readmission at 6-months. Results Mean age was 84.3±4.1 years, 308 (61.9%) were males. A total of 108 patients (21.7%) had significant MR. Compared with patients without significant MR these patients had lower systolic blood pressure (132±28 vs 141±27 mmHg), higher heart rate (82±21 vs 74±17 bpm), worse Killip class (≥II 49.5% vs 22.5%), lower ejection fraction (47±14% vs 55±11%), higher pulmonary pressure (42±15 vs 35±11 mmHg), as well as more frequent new onset atrial fibrillation (16.4% vs 7.2%) (all p values=0.001). Patients with significant MR also had higher in-hospital mortality (4.6% vs 1.3%, p=0.04) and longer hospital stay (median 8 [5–12] vs 6 [4–10] days, p=0.002),and higher mortality/readmission at 6 months (HR 1,54, 95% CI 1.09–2.18). However, after adjusting for potential confounders, this last association was not significant. Conclusions Significant MR is seen in about one fifth of octogenarians with NSTEMI. Patients with significant MR have a poor prognosis, which is mainly determined by their clinical characteristics.

Mitral Regurgitation and Prognosis After Non-ST-Segment Elevation Myocardial Infarction in Very Old Patients.

Mitral regurgitation (MR)after an acute coronary syndrome is associated with a poor prognosis. However,the prognostic impact of MR in elderly patients with non-ST-segment elevation myocardialinfarction (NSTEMI) has not been well addressed. Prospective registry. The multicenter LONGEVO-SCA prospective registry included 532 unselected NSTEMI patients aged ≥80 years. MR was quantified using echocardiography during admission in 497 patients. They were classified in two groups: significant (moderate or severe) or not significant MR (absent or mild). We evaluated the impact of MR status on mortality or readmission at 6 months. Mean age was 84.3±4.1 years, and 308 (61.9%) were males. A total of 108 patients (21.7%) had significant MR. Compared with those without significant MR, they were older and showed worse baseline clinical status, with higher frailty, disability, and risk of malnutrition. They also had lower systolic blood pressure, higher heart rate, worse Killip class, lower left ventricular ejection fraction, and higher pulmonary pressure on admission, as well as more often new onset atrial fibrillation (all p values = 0.001). Patients with significant MR also had higher in-hospital mortality (4.6% vs. 1.3%, p = 0.04), longer hospital stay (median 8 [5-12] vs. 6 [4-10] days, p = 0.002), and higher mortality/readmission at 6 months (hazard ratio 1.54, 95% confidence interval 1.09-2.18, p = 0.015). However, after adjusting for potential confounders, this last association was not significant. Significant MR is seen in one fifth of octogenarians with NSTEMI. Patients with significant MR have a poor prognosis, mainly determined by their baseline clinical characteristics. J Am Geriatr Soc 67:1641-1648, 2019.

Central Sleep Apnoea Is Related to the Severity and Short-Term Prognosis of Acute Coronary Syndrome.

ObjectiveTo evaluate the relation of central sleep apnoea (CSA) to the severity and short-term prognosis of patients who experience acute coronary syndrome (ACS).MethodsObservational study with cross-sectional and longitudinal analyses. Patients acutely admitted to participating hospitals because of ACS underwent respiratory polygraphy during the first 24 to 72 h. CSA was defined as an apnoea-hypopnoea index (AHI) >15 events•h-1 (>50% of central apnoeas). ACS severity (Killip class, ejection fraction, number of diseased vessels and peak plasma troponin) was evaluated at baseline, and short-term prognosis (length of hospitalization, complications and mortality) was evaluated at discharge.ResultsA total of 68 CSA patients (AHI 31±18 events•h−1, 64±12 years, 87% males) and 92 controls (AHI 7±5 events•h−1, 62±12 years, 84% males) were included in the analyses. After adjusting for age, body mass index, hypertension and smoking status, patients diagnosed with CSA spent more days in the coronary unit compared with controls (3.7±2.9 vs. 1.5±1.7; p<0.001) and had a worse Killip class (Killip I: 16% vs. 96%; p<0.001). No differences were observed in ejection fraction estimates.ConclusionsCSA patients exhibited increased ACS severity as indicated by their Killip classification. These patients had a worse prognosis, with longer lengths of stay in the coronary care units. Our results highlight the relevance of CSA in patients suffering ACS episodes and suggest that diagnosing CSA may be a useful strategy to improve the management of certain ACS patients.

Pre-hospital physical activity status affects in-hospital course of elderly patients with acute myocardial infarction.

The clinical course of elderly patients with acute myocardial infarction (AMI) can sometimes unexpectedly result in an adverse outcome even when therapy appears to be successful. We suspect that specific factors may characterize this worsening of status during hospitalization. This study examines whether the pre-hospital physical activity status of the elderly treated with percutaneous coronary intervention (PCI) for AMI affects their in-hospital course. We studied 110 consecutive patients, aged 80 or older, who had undergone emergent PCI for AMI. Patients were divided into two groups based on clinical presentation: Better Killip class (Killip classes I and II) and Worse Killip class (Killip classes III and IV). Patients were also divided into two groups based on pre-hospital physical activity status, determined retrospectively by review of medical records: Good physical activity (n=57) comprising those able to go out alone independently and Poor physical activity comprising those mainly confined to home (n=53). The overall in-hospital mortality rate was 9.1% for the study population. The Worse Killip class group had a higher in-hospital mortality rate than the Better Killip class group (27.8% vs 5.4%, respectively; p=0.0102). In addition, the Poor physical activity group had a higher in-hospital mortality rate than the Good physical activity group (15.1% vs. 3.5%, respectively; p=0.047). These data suggest that pre-hospital physical activity status in elderly patients with AMI may affect in-hospital mortality as well as Killip class.

Effect of age on efficacy and safety of vorapaxar in patients with non–ST-segment elevation acute coronary syndrome: Insights from the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) trial

Antithrombotic therapy plays an important role in the treatment of non-ST-segment elevation acute coronary syndromes (NSTE ACS) but is associated with bleeding risk. Advanced age may modify the relationship between efficacy and safety. Efficacy and safety of vorapaxar (a protease-activated receptor 1 antagonist) was analyzed across ages as a continuous and a categorical variable in the 12,944 patients with NSTE ACS enrolled in the TRACER trial. To evaluate the effect of age, Cox regression models were developed to estimate hazard ratios (HRs) with the adjustment of other baseline characteristics and randomized treatment for the primary efficacy composite of cardiovascular death, myocardial infarction (MI), stroke, recurrent ischemia with rehospitalization, or urgent coronary revascularization, and the primary safety composite of moderate or severe Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) bleeding. The median age of the population was 64years (25th, 75th percentiles = 58, 71). Also, 1,791 patients (13.8%) were ≤54years of age, 4,968 (38.4%) were between 55 and 64 years, 3,979 (30.7%) were between 65 and 74 years, and 2,206 (17.1%) were 75years or older. Older patients had higher rates of hypertension, renal insufficiency, and previous stroke and worse Killip class. The oldest age group (≥75years) had substantially higher 2-year rates of the composite ischemic end point and moderate or severe GUSTO bleeding compared with the youngest age group (≤54years). The relationships between treatment assignment (vorapaxar vs placebo) and efficacy outcomes did not vary by age. For the primary efficacy end point, the HRs (95% CIs) comparing vorapaxar and placebo in the 4 age groups were as follows: 1.12 (0.88-1.43), 0.88 (0.76-1.02), 0.89 (0.76-1.04), and 0.88 (0.74-1.06), respectively (P value for interaction = .435). Similar to what was observed for efficacy outcomes, we did not observe any interaction between vorapaxar and age on bleeding outcomes. For the composite of moderate or severe bleeding according to the GUSTO classification, the HRs (95% CIs) comparing vorapaxar and placebo in the 4 age groups were 1.73 (0.89-3.34), 1.39 (1.04-1.86), 1.10 (0.85-1.42), and 1.73 (1.29-2.33), respectively (P value for interaction = .574). Older patients had a greater risk for ischemic and bleeding events; however, the efficacy and safety of vorapaxar in NSTE ACS were not significantly influenced by age.

Efficacy of Early Invasive Management After Fibrinolysis for ST-Segment Elevation Myocardial Infarction in Relation to Initial Troponin Status

BackgroundWe examined whether the efficacy of an early invasive strategy after fibrinolysis in ST-segment elevation myocardial infarction (STEMI) differs in relation to the initial troponin status. MethodsIn the Trial of Routine Angioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI), patients with STEMI presenting to a non-percutaneous coronary intervention (PCI)-capable hospital who received fibrinolysis were randomized to either a pharmacoinvasive or standard strategy for subsequent angiography and PCI. In this post hoc subgroup analysis, we compared the efficacy of these strategies in relation to the initial troponin status at hospital presentation for the primary composite end point of mortality, reinfarction, recurrent ischemia, heart failure, and cardiogenic shock at 30 days. We assessed the heterogeneity of treatment effect with initial troponin status using the Breslow-Day test and tested for interaction after adjustment for baseline Global Registry of Acute Coronary Events (GRACE) risk score. ResultsAmong 1059 patients, those with abnormal initial troponin levels (n = 514 [48.5%]) were older with worse Killip class, had a longer time from symptom onset to fibrinolysis, and had higher GRACE and Thrombolysis In Myocardial Infarction risk scores. Patients with abnormal troponin levels had higher rates of the primary end point (17.5% vs 10.8%; P = 0.002) and cumulative mortality or reinfarction at 1 year (14.0% vs 8.1%; P = 0.003). In stratified analyses, pharmacoinvasive management reduced the primary end point only among patients with normal initial troponin status. However, there was no significant treatment heterogeneity (all P ≥ 0.10) and no interaction between initial troponin status and treatment assignment after adjusting for GRACE risk score. ConclusionsPatients with STEMI and abnormal initial troponin levels had worse short-term and long-term outcomes. Accounting for overall baseline risk with the GRACE risk score, troponin status did not modulate the efficacy of pharmacoinvasive management.

Clinical Characteristics, Management, and Outcomes of Acute Coronary Syndrome in Patients With Right Bundle Branch Block on Presentation

We examined the relations between right bundle branch block (RBBB) and clinical characteristics, management, and outcomes among a broad spectrum of patients with acute coronary syndrome (ACS). Admission electrocardiograms of patients enrolled in the Global Registry of Acute Coronary Events (GRACE) electrocardiogram substudy and the Canadian ACS Registry I were analyzed independently at a blinded core laboratory. We performed multivariable logistic regression analysis to assess the independent prognostic significance of admission RBBB on in-hospital and 6-month mortality. Of 11,830 eligible patients with ACS (mean age 65; 66% non-ST-elevation ACS), 5% had RBBB. RBBB on admission was associated with older age, male sex, more cardiovascular risk factors, worse Killip class, and higher GRACE risk score (all p <0.01). Patients with RBBB less frequently received in-hospital cardiac catheterization, coronary revascularization, or reperfusion therapy (all p <0.05). The RBBB group had higher unadjusted in-hospital (8.8% vs 3.8%, p <0.001) and 6-month mortality rates (15.1% vs 7.6%, p <0.001). After adjusting for established prognostic factors in the GRACE risk score, RBBB was a significant independent predictor of in-hospital death (odds ratio 1.45, 95% CI 1.02 to 2.07, p = 0.039), but not cumulative 6-month mortality (odds ratio 1.29, 95% CI 0.95 to 1.74, p = 0.098). There was no significant interaction between RBBB and the type of ACS for either in-hospital or 6-month mortality (both p >0.50). In conclusion, across a spectrum of ACS, RBBB was associated with preexisting cardiovascular disease, high-risk clinical features, fewer cardiac interventions, and worse unadjusted outcomes. After adjusting for components of the GRACE risk score, RBBB was a significant independent predictor of early mortality.

PP.LB03.24

Objective: Obesity is a risk factor for cardiovascular disease and mortality, however several studies have been reported that patients with obesity who have admitted with acute myocardial infarction or have undergone percutaneous coronary intervention (PCI) have better clinical outcomes than their normal weight counterparts. The impact of body mass index (BMI) on myocardial perfusion and early clinical outcomes in ST-segment elevation myocardial infarction (STEMI) patients revascularized totally with manual thrombus aspiration remains unclear. Design and method: The study included 94 consecutive patients who underwent thrombus aspiration and stent-based primary PCI for STEMI between the years 2009 and 2013. Revascularization success was achieved in 83 patients with STEMI. These patients were divided into two groups according to BMI as normal weight (BMI < 25) or overweight (BMI > 25). At least 50% resolution of ST-segment up to 90 minutes after the procedure was defined as electrocardiographic good flow. Results: Among the 83 patients, 80% were overweight. While good flow observed in 79% of the patients, electrocardiographic perfusion success rates were similar in both groups. Overweight patients had better Killip class and higher initial left ventricular ejection fraction than normal weight patients. Angiographic characteristics were similar between the two groups except for the stent diameter which was higher in normal weight patients(Table 1). The usage of Glycoprotein IIb-IIIa antagonists was similar between the groups. In hospital and 30 day period, major adverse cardiac events (MACE) were not significantly different among the BMI categories.Conclusions: In the study, we demonstrated that despite similar myocardial reperfusion, patients with normal BMI had lower initial left ventricular ejection fraction and worse Killip class. The better results in overweight patients might indicate the presence of the phenomenon “obesity paradox” in patients who underwent thrombus aspiration in stent-based primary PCI for STEMI.

IN-HOSPITAL MANAGEMENT AND OUTCOMES OF ACUTE CORONARY SYNDROMES IN RELATION TO PRIOR HISTORY OF HEART FAILURE

Acute heart failure (HF) complicating acute coronary syndromes (ACS) portends an ominous outcome. Previous history of HF is a predictor of acute decompensated HF in ACS, but the incremental prognostic significance of previous HF has not been well studied. Accordingly, we evaluated the baseline characteristics, management patterns, and clinical outcomes in relation to prior history of HF across a broad spectrum of ACS patients. Our study population consisted of ACS patients from 53 Canadian sites in the Global Registry of Acute Coronary Events (GRACE), the subsequently expanded GRACE2, and Canadian Registry of Acute Coronary Events (CANRACE) between 1999 and 2008. Patients were stratified into two groups based on history of prior HF. Multivariable logistic regression analysis was performed to assess the impact of prior history of heart failure on in-hospital mortality, adjusting for the components of the GRACE risk model. Of the 13937 eligible patients (mean age 66±13 years, 33% female, and 28.3% with ST-elevation MI), 1498 (10.7%) patients had a history of HF. Those with prior HF tended to be older, female, with higher prevalence of diabetes and previous myocardial infarction; they also had lower systolic blood pressure, higher heart rate, worse Killip class, higher creatinine, and higher GRACE risk score on presentation (all p<0.001). Previous HF was also associated with significantly worse left ventricular systolic function (p<0.001). The table summarizes the in-hospital management and outcomes. After adjusting for components of the GRACE risk model including Killip class on presentation, prior HF remained an independent predictor of in-hospital mortality (OR 1.48, 95% CI 1.08-2.03, p=0.02). Prior HF was associated with other high risk features in ACS including HF on presentation, and other adverse outcomes in hospital. After adjusting for other prognosticators, prior HF remained an independent predictor of in-hospital mortality. However, patients with prior HF were less likely to receive evidence-based medical and invasive therapies, suggesting an opportunity for more intensive treatment to improve outcomes.

Clinical characteristics and outcomes of acute coronary syndrome patients with left anterior hemiblock

ObjectiveWe aimed to study the relationships between left anterior hemiblock (LAHB) and the patient characteristics, management, and clinical outcomes in the setting of acute coronary syndromes (ACS).MethodsAdmission ECGs of patients...

Aspiration Thrombectomy in Patients With ST Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention (from the Acute Coronary Syndrome Israeli Survey 2010)

We assessed the impact of aspiration thrombectomy (AT) in patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention (PPCI) on major adverse cardiac events at 30 days and 1-year mortality in 517 consecutive patients who were included in the prospective, nationwide, multicenter, observational Acute Coronary Syndrome Israeli Survey in 2010. Two hundred seventeen patients (42%) underwent AT (AT-PPCI) and 300 patients conventional (C) PPCI. Both groups had similar infarct-related artery distribution and ostial or proximal culprit lesion. Patients in AT-PPCI versus C-PPCI had lower systolic blood pressure and worse Killip class on admission, more frequent Thrombolysis In Myocardial Infarction flow 0 or 1 before PPCI (80% vs 56%), less frequent restoration of flow after indwelling a guidewire in the infarct-related artery (32% vs 52%), and more use of IIb/IIIa glycoprotein inhibitors (69% vs 49%), respectively (p ≤0.05 for all comparisons). Thirty-day major adverse cardiac events was similar in the AT-PPCI and C-PPCI groups, 10.6% versus 9.7%, p = 0.73; adjusted odds ratio 0.97, 95% confidence interval 0.45 to 2.10, p = 0.95. One-year mortality was lower in the AT-PPCI versus C-PPCI group, 3.7% versus 6.7%, p = 0.13; adjusted hazard ratio 0.31, 95% confidence interval 0.10 to 0.96, p = 0.042. In conclusion, this study of consecutive patients with ST elevation myocardial infarction undergoing PPCI demonstrates that AT was an independent predictor of reduced 1-year mortality.

Prognosis of different types of atrial fibrillation in the primary angioplasty era

Atrial fibrillation (AF) has been associated with a poor prognosis in patients with ST-segment elevation myocardial infarction. There is considerable controversy regarding the prognostic implications of different types of AF. We analyzed 913 patients consecutively admitted to our center with ST-segment elevation myocardial infarction undergoing a primary percutaneous coronary intervention. Clinical, ECG, and angiographic data were collected. We carried out univariate and multivariate analysis, using a combined endpoint of death, reinfarction, stroke, and clinically relevant bleeding. AF was documented in 117 patients. Among them, 25 presented AF at admission (previous AF) and 92 developed new-onset AF (66% transient, 13% persistent). Patients with AF were older, more frequently men, and had a worse Killip class, and a poorer left-ventricular ejection fraction. When analyzing the different types of AF, patients with new-onset AF (persistent and transient) had a higher Killip class and a worse left-ventricular ejection fraction. AF was associated with significantly higher in-hospital mortality and with a greater incidence of in-hospital adverse events. An increase in in-hospital mortality was recorded both for previous and for new-persistent AF, but after adjusting for confounding factors, only persistent AF was found to carry a worse short-term prognosis. In patients undergoing primary angioplasty in the stent era, AF is associated with a poor prognosis. This risk appears to be particularly high among patients with persistent AF.