Comparison of C‐reactive Protein and Albumin Excretion as Prognostic Markers for 10‐Year Mortality After Myocardial Infarction

Background

C‐reactive protein (CRP) is an established prognostic marker in the setting of acute coronary syndromes. Recently, albumin excretion rate also has been found to be associated with adverse outcomes in this clinical setting. Our aim was to compare the prognostic power of CRP and albumin excretion rate for long‐term mortality following acute myocardial infarction (AMI).

Hypothesis

To determine whether albumin excretion rate is a better predictor of long‐term outcome than CRP in post‐AMI patients.

Methods

We prospectively studied 220 unselected patients with definite AMI (median [interquartile] age 67 [60–74] y, female 26%, heart failure 39%). CRP and albumin‐to‐creatinine ratio (ACR) were measured on day 1, day 3, and day 7 after admission in 24‐hour urine samples. Follow‐up duration was 10 years for all patients.

Results

At survival analysis, both CRP and ACR were associated with increased risk of 10‐year all‐cause mortality, also after adjusting for age, hypertension, diabetes mellitus, prehospital time delay, creatine kinase‐MB isoenzyme peak, heart failure, and creatinine clearance. CRP and ACR were associated with nonsudden cardiovascular (non‐SCV) mortality but not with sudden death (SD) or noncardiovascular (non‐CV) death. CRP was not associated with long‐term mortality, while ACR was independently associated with outcome both in short‐ and long‐term analyses. At C‐statistic analysis, CRP did not improve the baseline prediction model for all‐cause mortality, while it did for short‐term non‐SCV mortality. ACR improved all‐cause and non‐SCV mortality prediction, both in the short and long term.

Conclusions

ACR was a better predictor of long‐term mortality after AMI than CRP. Copyright © 2010 Wiley Periodicals, Inc. This work was supported by grants from the University of Padova, Padova, Italy, for the collection, management, and analysis of the data. The authors have no other funding, finan‐ cial relationships, or conflicts of interest to disclose.     

The Significance of Heart Rate Turbulence in Predicting Major Cardiovascular Events in Patients after Myocardial Infarction Treated Invasively

Introduction: The role of heart rate turbulence (HRT) related to baroreflex sensitivity in predicting mortality after myocardial infarction (MI) has been confirmed by several investigators. However, the significance of HRT in predicting major adverse cardiovascular events (MACE) following acute MI is unknown. Purpose: To analyze the prognostic value of HRT and other independent risk factors associated with autonomic regulation of MACE. Methods: HRT was assessed based on 24‐hour Holter recordings in 500 patients (pts) with acute MI treated invasively (352 M, aged 60.58 years). Turbulence onset (TO,%), slope (TS, ms/RR interval) and timing (TT) were calculated. TO ≥ 0, TS ≤ 2.5 and TT ≥ 10 were considered abnormal; classic and own categories were defined. Time domain heart rate variability (HRV) parameters were also calculated. Within 30.1 ± 15.1 months of follow‐up, MACE occurred in 116 pts. Results: Abnormal TO, TS, and TT were significantly more frequent in patients with MACE (P < 0.05 for each parameter, classic and own categories). In long‐term follow‐up, the largest differences in MACE were observed in patients with own category comprising abnormal TO, TS, and TT. Combining HRT parameters with SDNN (total HRV index) augmented their predictive value. Independent risk factors for MACE were TT, SDNN and rMSSD (a parasympathetic activity index) (HR 2.44, 1.71 and 1.69 respectively; P < 0.05). Conclusion: Abnormal HRT distinguishes patients at risk of MACE after MI. Own category encompassing three abnormal HRT parameters best differentiates patients at risk of MACE. Turbulence timing is a strong independent risk factor for MACE following MI.     

Prediction of 1‐year mortality and impact of bivalirudin therapy according to level of baseline risk: A patient‐level pooled analysis from three randomized trials

Objectives : We aimed to construct a predictive model for one‐year mortality in patients undergoing invasive coronary evaluation and to examine the impact of bivalirudin on survival according to the level of baseline risk. Background : Compared to heparin plus GP IIb/IIIa inhibitors (HEP/GPI), bivalirudin decreases bleeding complications in a range of clinical presentations. The impact of preprocedural risk assessment on survival and whether this is modified by bivalirudin, has not been investigated in detail. Methods : We examined patient‐level data from the REPLACE‐2, ACUITY, and HORIZONS‐AMI trials (n = 18,819) to construct a risk‐adjusted mortality model using baseline clinical variables. Results : One‐year mortality occurred in 287 patients (3.1%) assigned to bivalirudin and 336 patients (3.6%) assigned to HEP/GPI (HR 0.85; 95% CI, 0.73–1.00; P = 0.048). Using 11 highly significant predictors of mortality, we developed an integer‐risk score to classify patients into risk tertiles. High‐risk patients had a rate of 1‐year mortality over 9‐fold greater than low‐risk patients. Consequently, the absolute mortality reduction attributed to bivalirudin was more marked in high‐risk patients: 3.1% (?0.8% to 7.0%) in the overall cohort, 4.8% (0.5% to 9.2%) in the PCI cohort (P‐interaction versus intermediate and low risk categories, 0.09 and P = 0.02, respectively). Conclusions : In patients undergoing invasive coronary evaluation, 1‐year mortality can be predicted using baseline variables. Bivalirudin treatment (versus HEP/GPI) conferred a survival benefit. © 2015 Wiley Periodicals, Inc.     

Impact of diabetes and gender on survival after acute myocardial infarction in the Province of Quebec,Canada—a population‐based study

Aims To examine the impact of diabetes, gender and their interaction on 30‐day, 1‐year and 5‐year post‐acute myocardial infarction (AMI) mortality in three age groups (20–64, 65–74 and ≥ 75 years). Methods Retrospective analysis including 23 700 patients aged ≥ 20 years (22% with diabetes) admitted to hospital for a first AMI in any hospital in the Province of Quebec, Canada, between April 1995 and March 1997. Administrative databases were used to identify patients and assess outcomes. Results Regarding 30‐day mortality, there was non‐significant interaction between diabetes and gender. Women aged < 75 years had, independently of diabetes status, at least a 38% (P < 0.05) higher mortality than their male counterparts after adjustment for socio‐economic status and co‐morbid conditions. Gender difference disappeared, however, after controlling for in‐hospital complications. Regarding 1‐year mortality (31–365 days), there was no significant gender disparity for all age groups. During the 5‐year follow‐up, no gender differences were seen in any age group, except for younger (< 65 years) women with diabetes, who had a 52% (P = 0.004) higher mortality than men after controlling for co‐variables. This female disadvantage was demonstrated by a significant interaction between diabetes and gender in patients aged < 65 years (P = 0.009). Conclusions The higher 30‐day mortality post‐AMI in younger (20–64 years) and middle‐aged (65–74 years) women compared with men was not influenced by diabetes status. However, during the 5‐year follow‐up, the similar gender mortality observed in patients without diabetes seemed to disappear in younger patients with diabetes, which may be explained by the deleterious, long‐term, post‐AMI impact of diabetes in younger women.     

Comparison of 4.5‐Year Outcomes of Bare‐Metal and Zotarolimus‐Eluting Stents in New York

Background

Both bare‐metal stents (BMS; the first‐generation coronary stent) and zotarolimus‐eluting stents (ZES; a second‐generation drug‐eluting stent [DES]) have been widely utilized to treat coronary heart disease. However, the long‐term comparative effectiveness of BMS and ZES remains unclear. The purpose of this study was to evaluate long‐term comparative effectiveness of BMS versus ZES.

Methods

We created a longitudinal database by linking the New York State (NYS) cardiac registries, statewide hospital discharge data, the National Death Index (NDI), and the U.S. Census file (2010) for patients receiving either BMS or ZES during the 2008–2009 period. We examined the rates of all‐cause mortality, acute myocardial infarction (AMI), target‐lesion PCI (TLPCI), and target‐vessel coronary artery bypass graft (TVCABG) surgery for a follow‐up period of 4.5 years. A total of 10,443 propensity score matched pairs were compared using the Kaplan–Meier method and Cox proportional hazards regression adjusting for patient risk factors.

Results

We found that patients receiving ZES had a lower rate of 4.5‐year mortality (adjusted hazard ratio AHR: 0.68, 95% confidence interval CI: 0.63–0.73), AMI (AHR: 0.89, 95% CI: 0.80–0.98), and TVCABG (AHR: 0.84, 95% CI: 0.71–0.99) but a similar rate of TLPCI (AHR: 1.02, 95% CI: 0.93–1.12). For “off‐label” and “high‐risk” subgroups, ZES was associated with improved mortality and generally better or non‐inferior AMI, TLPCI, and TVCABG outcomes relative to BMS.

Conclusions

Compared with BMS, ZES was associated with lower long‐term mortality, AMI and TVCABG. (J Interven Cardiol 2016;29:265–274)

     

Heart rate turbulence can predict cardiac mortality following myocardial infarction in patients with diabetes mellitus

Heart Rate Turbulence in Post‐MI Patients With DM. Background: Previous studies have described the clinical utility of heart rate turbulence (HRT) as an autonomic predictor in risk‐stratifying patients after myocardial infarction (MI). Some reports showed that diabetes mellitus (DM) affects the prognostic value of autonomic markers. We assessed the utility of HRT as a risk marker in post‐MI patients with DM and without DM. Methods: We prospectively enrolled 231 consecutive DM patients and 300 non‐DM patients after acute MI. HRT was measured using an algorithm based on 24‐hour Holter electrocardiograms (ECGs), assessing 2 parameters: turbulence onset (TO) and turbulence slope (TS). HRT was considered positive when both TO ≥0% and TS ≤2.5 ms/R‐R interval were met. The endpoint was defined as cardiac mortality. Results: Of patients with DM, 9 patients (4%) were not utilized for HRT assessment because of frequent ventricular contractions or presence of atrial fibrillation. Forty‐two of 222 patients (19%) were HRT positive. During follow‐up of 876 ± 424 days, 26 patients (22%) reached the endpoint. Several factors including left ventricular ejection fraction (LVEF), renal dysfunction, documentation of nonsustained ventricular tachycardia (VT), and a HRT‐positive outcome had significant association with the endpoint. Multivariate analysis determined that renal dysfunction and a positive HRT outcome had significant value with a hazard ratio (HR) of 4.7 (95%CI, 1.9–11.5; P = 0.0008) and 3.5 (95%CI, 1.4–8.8; P = 0.007), respectively. In non‐DM patients, only a positive HRT outcome had significant value. Conclusions: This study reveals that HRT detected by 24‐hour Holter ECG can predict cardiac mortality in post‐MI patients whether DM is present or not. (J Cardiovasc Electrophysiol, Vol. 22, pp. 1135‐1140, October 2011)     

Five-year mortality in patients with acute chest pain in relation to smoking habits

BACKGROUND: Smoking is one of the major risk indicators for development of coronary artery disease, and smokers develop acute myocardial infarction (AMI) approximately a decade earlier than nonsmokers. In smokers with established coronary artery disease, quitting smoking has been associated with a more favorable prognosis. However, most of these studies comprised younger patients, the majority of whom were males. HYPOTHESIS: The purpose of the study was to determine mortality, mode of death, and risk indicators of death in relation to smoking habits among consecutive patients admitted to the emergency department with acute chest pain. METHODS: In all, 4,553 patients admitted with acute chest pain to the emergency department at Sahlgrenska University Hospital during a period of 21 months were included in the analyses and were prospectively followed for 5 years. RESULTS: Of these patients, 36% admitted current smoking. They were younger and had a lower prevalence of previous cardiovascular diseases than did nonsmokers. The 5-year mortality was 19.4% among smokers and 24.9% among non-smokers (p < 0.0001). However, when adjusting for difference in age, smoking was associated with an increased risk [relative risk (RR) 1.51; 95% confidence interval (CI) 1.32-1.74; p < 0.0001]. Among patients presenting originally with chest pain, the increased mortality for smokers was more pronounced in patients with non-acute than acute myocardial infarction (AMI). Among patients who died, death in smokers was less frequently associated with new-onset myocardial infarction (MI) and congestive heart failure. Among those who smoked at onset of symptoms and were alive 1 year later, 25% had stopped smoking. Patients with a confirmed AMI who continued smoking 1 year after onset of symptoms had a higher mortality (28.4%) during the subsequent 4 years than patients who stopped smoking (15.2%; p = 0.049). CONCLUSION: In consecutive patients admitted to the emergency department with acute chest pain, current smoking was significantly associated with an increased risk of death during 5 years of follow-up. Among patients who died, death in smokers was less frequently associated with new-onset MI and congestive heart failure than was death in nonsmokers.     

Impact of Scheduled Angiographic Follow‐Up in Patients Treated With Primary Percutaneous Coronary Intervention for ST‐Segment Elevation Myocardial Infarction

Routine scheduled angiographic follow‐up (SAF) after percutaneous coronary intervention (PCI) has been associated with a higher rate of target vessel revascularization (TVR). Its benefits are not known. SAF at 13 months after ST‐segment elevation myocardial infarction (STEMI) was planned in the first 1,800 successfully stented patients enrolled in the Harmonizing Outcomes with RevascularIZatiON and Stents in Acute Myocardial Infarction (HORIZONS‐AMI) trial. We compared the outcomes of patients with and without SAF at 1 year (before SAF) and at 3 years (after SAF). There were 1,197 patients (66.5% of expected) with and 2,207 patients without SAF. Prior to SAF, the 1‐year composite rate of death or myocardial infarction (MI) was not significantly different between the 2 groups (2.7% vs. 3.9%, respectively, P = 0.06), although the rate of death was lower (0.1% vs. 2.2%, P < 0.0001), nor were there differences in the 1‐year rates of TVR, stent thrombosis or major adverse cardiac and cerebral events). At 3 years, death or MI rates were again similar between the groups (8.3% vs. 9.5%, P = 0.22), but TVR was more common in the SAF group (17.0% vs. 8.6%, P < 0.0001), due to an increase in TVR at time of SAF. In the SAF group, patients in whom TVR was performed before or after the 13‐month SAF window had markedly higher 3‐year rates of MI and stent thrombosis than patients in whom TVR was performed during SAF or not at all. In conclusion, SAF after primary PCI in STEMI is associated with doubling of the rate of revascularization without an improvement in death or MI, and therefore cannot be recommended.

     

Prognostic Value of Standard Electrocardiographic Parameters for Predicting Major Adverse Cardiac Events after Acute Myocardial Infarction

Background: The prognostic value of electrocardiographic (ECG) variables in predicting major adverse cardiac events (MACEs) after acute myocardial infarction (AMI) in the era of modern therapy is unclear. This study was conducted to evaluate the prognostic significance of ECG parameters in predicting 1‐year MACEs for AMI patients. Methods: Between January 2006 and January 2008, 529 AMI patients were included. ECG variables were analyzed from the ECG taken on discharge day. The 1‐year MACEs were defined as death, nonfatal MI, and revascularization including repeat percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Mean follow‐up duration was 360 ± 119 days. Results: Of these patients, 497 (94%) patients provided complete follow‐up data (355 males; 67 ± 12 years old). The rate of 1‐year MACEs was 16%. In univariate analysis, heart rate, corrected QT interval, left ventricular (LV) hypertrophy, voltage (SV₁+ RV₅), lateral ST‐depression (V_5–6 or I, aVL), pathologic Q wave (V_1–4, V_5–6), ST‐elevation (V_1–4, V_5–6 or I, aVL), and T‐wave inversion (V_1–4, V_5–6, or I, aVL) had a significant association with 1‐year MACEs. In the Cox regression hazard model, lateral ST‐depression (hazard ratio [HR] 2.260, 95% confidence interval [CI] 1.204 to 4.241, P = 0.011) and corrected QT interval (HR 1.007, 95% CI 1.002 to 1.011, P = 0.004) were independent predictors of 1‐year MACEs. After adjustment for all risk variables, lateral ST‐depression (HR 3.781, 95% CI 1.047 to 13.656, P = 0.042) was the only ECG variable that independently predicted 1‐year MACEs. Conclusion: Lateral ST‐depression on discharge day ECG is an independent predictor of 1‐year MACEs after AMI. Ann Noninvasive Electrocardiol 2011;16(1):56–63     

Long‐term survival in young and middle‐aged Hodgkin lymphoma patients in Sweden 1992–2009—trends in cure proportions by clinical characteristics

Trends in Hodgkin lymphoma (HL) survival among patients treated outside of clinical trials provide real‐world benchmark estimates of prognosis and help identify patient subgroups for targeted trials. In a Swedish population‐based cohort of 1947 HL patients diagnosed in 1992–2009 at ages 18–59 years, we estimated relative survival (RS), cure proportions (CP), and median survival times using flexible parametric cure models. Overall, the CP was 89% (95% CI: 0.87–0.91) and median survival of the uncured was 4.6 years (95% CI: 3.0–6.3). For patients aged 18–50 years diagnosed after the year 2000, CP was high and stable, whereas for patients of 50–59 years, cure was not reached. The survival of relapse‐free patients was similar to that of the general population (RS_5‐year: 0.99; 95% CI: 0.98–0.99, RS_15‐year: 0.95; 95% CI: 0.92–0.97). The excess mortality of relapsing patients was 19 times (95% CI: 12–31) that of relapse‐free patients. Despite modern treatments, patients with adverse prognostic factors (e.g., advanced stage) still had markedly worse outcomes [CP _{stage: IIIB} 0.82 (95% CI: 0.73–0.89); CP _{stage: IVB} 0.72, (95% CI: 0.60–0.81)] and patients with international prognostic score (IPS) ≥3 had 2.7 times higher excess mortality (95% CI: 1.0–7.0, p = 0.04) than patients with IPS <3. High‐risk patients selected for 6–8 courses of BEACOPP (bleomycin, etoposide, doxorubicin, cyclofosphamide, vincristine, procarbazine, prednisone)‐chemotherapy had a 15‐year relative survival of 87%, (95% CI: 0.80–0.92), whereas the corresponding estimate for patients selected for 6–8 courses of ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) was 93% (95% CI: 0.88–0.97). These population‐based results indicate limited fatal side‐effects in the 15‐year perspective with contemporary treatments, while the unmet need of effective relapse treatment remains of concern. BEACOPP‐chemotherapy was still not sufficient in high‐risk HL patients. Am. J. Hematol. 90:1128–1134, 2015. © 2015 Wiley Periodicals, Inc.     

Development and validation of a prognostic index for 2‐year mortality in Chinese older residents living in nursing homes

Aim: There is no mortality prediction index for Chinese nursing home older residents. The objective of this study was to derive and validate a 2‐year mortality prognostic index for them. Methods: We carried out a prospective cohort study on 1120 older residents from 12 nursing homes of Hong Kong. We obtained potential predictors of mortality and carried out updated functional assessment. Each risk factor associated independently with 2‐year mortality in a derivation cohort was assigned a score based on the odds ratio, and risk scores were calculated for each participant by adding the points of risk factors present. Similar analysis was carried out on the validation cohort. Results: Independent predictors of mortality included: aged 86–90 years (3 points); aged ≥91 years (4 points); Charlson comorbidity index ≥4 (6 points); Barthel Index 5–60 (5 points); Barthel Index 0 (10 points); number of hospitalizations in the preceding year (Adbefore) 1 (4 points); Adbefore 2 (5 points) and Adbefore ≥3 (6 points). In the derivation cohort, 2‐year mortality was 10.8% in the low‐risk group (≤4 points) and 59.9% in the high‐risk group (≥14 points). In the validation cohort, 2‐year mortality was 11.8% in the low‐risk group and 60.4% in the high‐risk group. The receiver–operator characteristic curve area was 0.761 for the derivation cohort and 0.742 for the validation cohort. Conclusions: Our prognostic index had satisfactory discrimination and calibration in an independent sample of Chinese nursing home older residents. It can be used to identify older residents with a high risk for poor outcomes, who need a different level of care. Geriatr Gerontol Int 2012; 12: 555–562.     

Long-Term Prognostic Implications of Previous Silent Myocardial Infarction in Patients Presenting With Acute Myocardial Infarction

Objectives

This study investigated the prevalence of silent myocardial infarction (MI) in patients presenting with first acute myocardial infarction (AMI), and its relation with mortality and major adverse cardiovascular events (MACE) at long-term follow-up.

Survival analysis within one year of first acute myocardial infarction: comparison between non-Q and Q wave myocardial infarction.

BACKGROUND: Non-Q wave Myocardial Infarction (non-Q AMI) is related pathophysiologically to Q wave AMI, as each represents different stages of plaque rupture and thrombosis. Post-hospital re-infarction and recurrent angina are more frequent in non-Q AMI than in Q wave AMI, offsetting the higher early risk with Q wave AMI, with one-year survival rates similar in the two types of MI. OBJECTIVES: 1--Evaluation of early (< or = 28 days) and one-year total mortality from first non-Q AMI in comparison to QMI. 2--Analysis of recurrent acute ischaemic events (non-fatal reinfarction and unstable angina) in both types of MI in the same periods of time. POPULATION AND METHODS: A retrospective study of 1146 patients, mean age 65 +/- 13 years, 65% male, admitted at CCU with a first MI, from January 1988 to December 1997 (minimum follow-up period of one year, mean follow-up 42 +/- 37 months). We compared the baseline demographics and clinical characteristics (coronary risk factors, previous angina, MI evolution, recurrent cardiac events, 28 day mortality and one year mortality) of patients with non-Q AMI (NQ group = 239) and Q wave AMI (Q group = 907). RESULTS: The NQ group patients were significantly older (mean age: 67 +/- 12.6 vs 65 +/- 12.5 years; p < 0.05), included fewer smokers (29% vs 43%; p < 0.001) and were more symptomatic before the index infarction (stable angina: 40% vs 30%; p < 0.05; unstable angina: 16% vs 6%; p < 0.001), when compared to the Q group patients. There were no significant differences in MI evolution, in Killip-Kimbal class > or = 2, recurrent angina and in-hospital mortality (Q-12% vs NQ-9%; ns), although there was a higher combined risk of arrhythmias and AV conduction disturbances in patients with QMI (Q-34% vs NQ-26%; p < 0.05). The combined risk of unstable angina and reinfarction at one year was significantly higher in group NQ (NQ-13% vs Q-8.1%; p < 0.05). The NQ group showed no significant difference in 28 day total mortality (NQ-14% vs Q-17%; ns) or at one year follow-up (NQ-24% vs Q-26%; ns) when compared to the Q group. CONCLUSION: 1--Despite a lower severity of non-Q AMI in the acute phase, 28 day and one year total mortality were similar in the two groups. 2--Patients with non-Q AMI showed a higher incidence of recurrent ischemic events at one year follow-up.     

Ventricular Late Potentials and Degree of Reperfusion of the Infarct‐Related Artery

Background: Patency of the infarct‐related artery is known to be a powerful determinant of the prognosis after AMI. Most studies have reported a lower incidence of late potentials from patients treated with thrombolytic agents than patients not so treated. The purpose of this study was to evaluate the use of ventricular late potentials in the first week after AM1 to differentiate patients according to the TIMI flow in the infarct‐related artery. Material and Methods: In 106 patients with AMI, we recorded three determinations of late potentials with filters of 25, 40, and 80‐250 Hz, at 24, 72, and 144 hours after the onset of symptoms. Classification was based on the angiography study: group I with TIM1 0‐1 and group I1 with TIMI 2‐3. Results: We found a low positive predictive power in TIMI 0‐1 (around 50%) for all records and filters. The negative predictive value was high (72%‐93%) and increased with time from the AM1 and frequency of the filter. The most sensitive filter was 80‐250 Hz and the most specific was 25‐250 Hz. The duration of the QRSf and LAS40 was longer and the RAMS were lower in the patients with diminished TIMI flow. Conclusion: The absence of late potentials is associated with a better TIMI flow in the artery.     

Vectorcardiography Risk Stratifies Emergency Department Chest Pain Patients with Left Ventricular Hypertrophy on the Initial 12‐Lead ECG

Background: Vectorcardiographic (VCG) measurements of ST‐vector magnitude (VM) and QRS‐vector difference (VD) have been demonstrated to be independent predictors of adverse outcome (AO) and acute myocardial infarction (AMI) in emergency department (ED) chest pain patients with absence of bundle branch block or left ventricular hypertrophy (LVH) on the initial 12‐lead electrocardiogram (ECG). The prognostic value of ST‐VM and QRS‐VD in ED chest pain patients with LVH on the initial 12‐lead ECG has not been previously investigated. Methods: A prospective observational study was performed in 196 consecutive ED chest pain patients with suspected AMI and presence of voltage criteria for LVH on initial ECG who underwent continuous VCG monitoring during the initial evaluation. The optimal baseline ST‐VM value and 2‐hour QRS‐VD value were defined as the most accurate value on the receiver operator characteristic curve (value with lowest false‐negative and false‐positive rate). Thirty‐day AO was defined as AMI, percutaneous coronary intervention, coronary artery bypass grafting (CABG), or cardiac death occurring within 30 days of initial ED visit. Results: Fourteen patients (7.1%) were diagnosed as 24‐hour AMI and 28 patients (14.3%) experienced 30‐day AO. The optimal cut‐off value for predicting 30‐day AO was >124 μV for ST‐VM and >21.7 μV for QRS‐VD. Patients with either a positive ST‐VM or a positive QRS‐VD had 8.8 times increased odds of AMI (95% confidence interval, CI, 1.9–40.3; P = 0.003); 4.3 times increased odds of 30‐day PTCA/CABG (95% CI 1.3–13.8; P = 0.019); and 3.8 times increased odds of 30‐day AO (95% CI 1.6–9.3; P = 0.003). Conclusions: Baseline ST‐VM and 2‐hour QRS‐VD risk stratifies ED chest pain patients with LVH voltage criteria on the initial 12‐lead ECG.     

Doppler Echocardiographic Predictors of Mortality in Female Rats After Myocardial Infarction

BackgroundDoppler echocardiogram is useful for the evaluation of anatomical and functional changes in late myocardial infarction (MI) in rats. However, no studies have evaluated the prognostic value of echocardiographic parameters 1 week after MI.Methods and ResultsDoppler echocardiogram was performed in 84 female Wistar rats 1 week after MI to determine infarction size, left chambers dimensions, fractional area change (FAC) of the left ventricle (LV), mitral inflow and tissue Doppler, myocardial performance index (MPI), and signs of pulmonary hypertension. The 365-day follow-up showed 53.6% mortality rate. Nonsurvivors showed larger (P < .05) MI size and cavity dimensions, poorer diastolic and systolic function, and higher frequency of pulmonary hypertension. Parameters at early stage of MI associated with higher mortality risk by Cox multivariate regression model were FAC ≤37% (relative risk [RR] 3.78, 95% CI, 1.50–9.53), MPI ≥0.60 (RR 3.49, 95% CI, 1.80–6.76), LV systolic area ≥0.26 cm² (RR 4.38, 95% CI, 1.88–10.21), E/E' ratio ≥20.3 (RR 2.12, 95% CI, 1.15–4.34), and E/A ratio associated with FAC (RR 2.99, 95% CI, 1.44–6.18).ConclusionSome diastolic and systolic Doppler echocardiographic parameters in rats may be able to predict late mortality risk after MI.     

Comparison of 2‐year outcomes between zotarolimus‐eluting and everolimus‐eluting new‐generation cobalt–chromium alloy stents in real‐world diabetic patients

Background : To date, it remains unknown whether different types of new‐generation drug‐eluting stents have a differential impact on long‐term outcomes in diabetic patients. Methods and Results : In this historical cohort study (two Italian centers), we analyzed 400 diabetic patients with 553 coronary lesions treated with new‐generation CoCr zotarolimus‐eluting stents (R‐ZES: 136 patients, 196 lesions) or everolimus‐eluting stents (EES: 264 patients, 357 lesions) between October 2006 and August 2012. Primary endpoint was the occurrence of major adverse cardiac events (MACE) over a 2‐year follow‐up period. MACE was defined as all‐cause mortality, any myocardial infarction (MI) and/or target lesion revascularization (TLR). Multivessel revascularization, intervention for restenotic lesion and use of intravascular ultrasound were significantly higher in the R‐ZES group, whereas small stent (≤2.5 mm) deployment was significantly higher in the EES group. At 2‐year follow‐up, there was no significant difference in occurrence of MACE (R‐ZES vs EES: 22.8% vs 18.9%, P = 0.39). Similarly, no significant differences were observed in the composite endpoint of all‐cause mortality/MI (10.0% vs 10.3%, P = 0.86) or TLR (12.4% vs 7.4%, P = 0.11). Adjustment for confounders and baseline propensity‐score matching did not alter the aforementioned associations. Conclusion : After 2 years of follow up similar outcomes (MACE, all‐cause mortality/MI, TLR) were observed in real‐world diabetic patients, including those with complex lesions and patient characteristics, treated with R‐ZES and EES. © 2015 Wiley Periodicals, Inc.     

Five‐year clinical outcomes of sirolimus‐eluting versus paclitaxel‐eluting stents in high‐risk patients

Objectives and Background : First generation drug‐eluting stents have shown differential efficacy in high‐risk patient subsets at one year. It is unclear whether these differences endure over the medium‐ to long‐term. We compared the five‐year clinical efficacy and safety of sirolimus‐eluting stents (SES) and paclitaxel‐eluting stents (PES) in a population of high‐risk patients. Methods : The patient cohorts of the ISAR‐DESIRE, ISAR‐DIABETES, and ISAR‐SMART‐3 randomized trials were followed up for five years and data were pooled. The primary efficacy endpoint of the analysis was the need for target lesion revascularization (TLR) during a five‐year follow‐up period. The primary safety endpoint was the combination of death or myocardial infarction (MI) after five years. Results : A total of 810 patients (405 patients in the SES group and 405 patients in the PES group) was included. Over five years TLR was reduced by 39% with SES compared with PES stent (hazard ratio [HR] 0.61; 95% confidence interval [CI] 0.44–0.85; P = 0.004). No difference was observed according to death or MI rates between the two groups (HR 1.10; 95% CI 0.80–1.50; P = 0.57). Definite stent thrombosis occurred in 0.2% (n = 1) in the SES group and in 1.6% (n = 6) in the PES group (HR 0.16; 95% CI 0.02–1.34; P = 0.12). Conclusions : In high‐risk patient subsets the lower rate of 12‐month TLR observed with SES in comparison PES is maintained out to five years. In terms of safety, although there was no difference in the overall incidence of death or MI, there was a trend towards more frequent stent thromboses with PES. © 2011 Wiley‐Liss, Inc.     

Long‐term follow‐up after nonurgent percutaneous coronary intervention in unprotected left main coronary arteries

Objectives : To evaluate the long‐term outcomes of the selected patients by the local Heart Team to undergo percutaneous coronary intervention (PCI) of unprotected left main coronary artery (ULMCA) stenosis and to compare patients considered at low surgical risk versus at high surgical risk for coronary artery bypass grafting (CABG). Background : CABG is recommended in patients with ULMCA stenosis according to the AHA/ACC and ESC guidelines, and there are limited data on the long‐term outcomes in patients selected by the local Heart Team to undergo PCI. Methods : Between 1996 and 2007, 227 patients underwent PCI for ULMCA stenosis based on decision of the local Heart Team and patient's and/or physician's preference. All patients were contacted at 1 year and in November 2008. Results : Long‐term follow‐up was up to 8 years with a mean of 3.9 ± 2.6 years. Overall, the Kaplan–Meier estimate of the composite of cardiac death, myocardial infarction (MI), or target lesion revascularization (TLR) was 14.8% at 1 year, 18.3% at 3 years, and 20.9% at 5 years with no events occurring thereafter. Patients considered at low surgical risk for CABG had a significantly lower incidence of cardiac death or MI compared to patients considered at high surgical risk at 8 years (1.4 vs. 16.8%; 1.4 vs. 14.8%, respectively); however, no significant difference was observed for cardiac death, MI, or TLR (18.6 vs. 24.4%). Conclusions : PCI of ULMCA stenosis in patients selected by the Heart Team resulted in good long‐term clinical outcomes with most events occurring within the 1st year. Patients considered at low surgical risk for CABG have a significantly better long‐term survival than patients at high risk for surgery. © 2010 Wiley‐Liss, Inc.     

Blood Transfusion and In‐hospital Outcomes in Anemic Patients with Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Studies have shown poor prognostic implications of anemia in patients with myocardial infarction (MI) and in patients undergoing percutaneous coronary intervention (PCI). The impact of blood transfusion in these populations remains controversial. The objective of this study was to examine the effect of transfusion on in‐hospital mortality in anemic patients undergoing PCI for MI. Data from 67,051 PCIs (June 1, 1997 to January 31, 2004) were prospectively collected in a multicenter registry (Blue Cross Blue Shield of Michigan Cardiovascular Consortium). Of these, 4,623 patients who were classified as anemic according to the World Health Organization criteria underwent PCI within 7 days of presentation with acute MI. A propensity score for being transfused was estimated for each patient, and propensity matching and a prediction model for in‐hospital death were developed. The average age was 67.8 years, 57.7% of patients were men, and 22.3% of patients received a transfusion during hospitalization. Transfused patients, compared to nontransfused patients, were more likely to be older, female, have lower preprocedure hemoglobin levels, more comorbidities, and a higher unadjusted in‐hospital mortality rate (14.52% vs. 3.01%, p < 0.0001). After adjustment for comorbidities and propensity for transfusion, blood transfusion was associated with a higher risk of in‐hospital mortality (adjusted odds ratio = 2.02, 95% confidence interval 1.47–2.79, p < 0.0001). In anemic patients undergoing PCI for MI, transfusion was associated with an increased crude and adjusted rate of in‐hospital mortality. A randomized controlled trial is needed to determine the value of transfusion and the ideal transfusion criteria. Copyright © 2007 Wiley Periodicals, Inc.