Clinical,Angiographic Characteristics and In-Hospital Outcomes of Smoker and Nonsmoker Patients After Primary Percutaneous Coronary Intervention

BackgroundSmoking is a well-established cardiac risk factor there is dearth of Local data regarding clinical and angiographic characteristics of smoker patients.ObjectivesThis study was planned to assess the differences in the clinical characteristics, angiographic characteristics, and in-hospital outcomes of smokers and nonsmokers after primary percutaneous coronary intervention at a tertiary care hospital in Karachi, Pakistan.MethodsWe included patients between 40 and 80 years of age diagnosed with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention from July 1, 2017, to March 31, 2018. Clinical and angiographic characteristics and in-hospital outcomes were obtained from the cases submitted to the National Cardiovascular Data Registry's CathPCI (Catheterization–Percutaneous Coronary Intervention) Registry from our site.ResultsA total of 3,255 patients were included in this study. Smokers consist of 25.1% (817) of the total sample. A high majority of smokers were male, 98.8% (807), and smokers were relatively younger as compared to nonsmokers with a mean age of 52.89 ± 10.59 versus 55.98 ± 11.24 years; p < 0.001. Smokers had higher post-procedure TIMI (Thrombolysis In Myocardial Infarction) flow grade III: 97.8% (794) versus 95.53% (2,329); p = 0.037, and they had a relatively low mortality rate: 2.69% (22) versus 3.16% (77); p = 0.502.ConclusionsSmokers were predominantly male and around 3 years younger than nonsmokers. Diabetes mellitus and hypertension were less common among smokers and single-vessel disease was the more common angiographic finding for smokers as compared to 3-vessel disease for nonsmokers. No statistically significant differences in in-hospital outcomes were observed. ST-segment elevation myocardial infarction in smokers despite younger age and the low atherosclerotic risk profile, in our region, emphasize the need for nicotine addiction management and smoking cessation campaigns at large and for pre-discharge counseling.     

National Prevalence of Self-Reported Coronary Heart Disease and Chronic Stable Angina Pectoris: Factor Analysis of the Underlying Cardiometabolic Risk Factors in the SuRFNCD-2011

Background

Coronary heart disease (CHD) is one of the most common causes of mortality worldwide. The national prevalence remains unclear in most of the developing countries.

Peripheral Arterial Disease in Women: an Overview of Risk Factor Profile,Clinical Features,and Outcomes

Purpose of Review

Peripheral arterial disease (PAD) is the third most common manifestation of cardiovascular disease (CVD), following coronary artery disease (CAD) and stroke. PAD remains underdiagnosed and under-treated in women.

Recent Findings

Women with PAD experience more atypical symptoms and poorer overall health status. The prevalence of PAD in women increases with age, such that more women than men have PAD after the age of 40 years. There is under-representation of PAD patients in clinical trials in general and women in particular. In this article, we address the lack of women participants in PAD trials. We then present a comprehensive overview of the epidemiology/risk factor profile, clinical features, treatment, and outcomes.

Summary

PAD is prevalent in women and its global burden is on the rise despite a decline in global age-standardized death rate from CVD. The importance of this issue has been underlined by the American Heart Association’s (AHA) “Call to Action” scientific statement on PAD in women. Large-scale campaigns are needed to increase awareness among physicians and the general public. Furthermore, effective treatment strategies must be implemented.

     

Incidence and Outcomes of Acute Coronary Syndrome After Transcatheter Aortic Valve Replacement

ObjectivesThis study sought to address a knowledge gap by examining the incidence, timing, and predictors of acute coronary syndrome (ACS) after transcatheter aortic valve replacement (TAVR) in Medicare beneficiaries.BackgroundEvidence about incidence and outcomes of ACS after TAVR is scarce.MethodsWe identified Medicare patients who underwent TAVR from 2012 to 2017 and were admitted with ACS during follow-up. We compared outcomes based on the type of ACS: ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina. In patients with non–ST-segment elevation ACS, we compared outcomes based on the treatment strategy (invasive vs. conservative) using inverse probability weighting analysis.ResultsOut of 142,845 patients with TAVR, 6,741 patients (4.7%) were admitted with ACS after a median time of 297 days (interquartile range: 85 to 662 days), with 48% of admissions occurring within 6 months. The most common presentation was NSTEMI. Predictors of ACS were history of coronary artery disease, prior revascularization, diabetes, valve-in-TAVR, and acute kidney injury. STEMI was associated with higher 30-day and 1-year mortality compared with NSTEMI (31.4% vs. 15.5% and 51.2% vs. 41.3%, respectively; p < 0.01). Overall, 30.3% of patients with non–ST-segment elevation ACS were treated with invasive approach. On inverse probability weighting analysis, invasive approach was associated with lower adjusted long-term mortality (adjusted hazard ratio: 0.69; 95% confidence interval: 0.66 to 0.73; p < 0.01) and higher risk of repeat revascularization (adjusted hazard ratio: 1.29; 95% confidence interval: 1.16 to 1.43; p < 0.001).ConclusionsAfter TAVR, ACS is infrequent (<5%), and the most common presentation is NSTEMI. Occurrence of STEMI after TAVR is associated with a high mortality with nearly one-third of patients dying within 30 days. Optimization of care is needed for post-TAVR ACS patients and if feasible, invasive approach should be considered in these high-risk patients.     

Cardiovascular Risk Profile,Presentation and Management Outcomes of Patients with Acute Coronary Syndromes after Coronary Artery Bypass Grafting

Background: Coronary artery bypass (CABG) is an important revascularization procedure with excellent long-term results. However, bypass grafts, particularly venous grafts, develop structural changes and atherosclerotic plaques that may cause angina or even acute coronary syndromes (ACS). Here we aimed to study patients with previous CABG presenting with an ACS and evaluated their cardiovascular (CV) risk profile, clinical presentations, angiographic findings, management strategies and short and long term outcomes. Patients and methods: This represents an observational retrospective cross sectional single center study including all consecutive patients with previous CABG presenting with ACS at the University Heart Center of the University Hospital Zurich, Switzerland between January 1, 2000 and December 31, 2016. Mean age was 76.4 years and 83.1% were males, 60.2% were diabetics and 58.6% obese, 43.5% hypertensives and 37.8% had hyperlipidemia. Major adverse cardiovascular and cerebrovascular events (MACCE) at 1-year and long-term follow up were analyzed using Kaplan Meyer survival analysis. Results: We included 510 patients with ACS and prior CABG. 73% (n=372) presented as unstable angina (UA), 22.5% as NSTEMI (n=115) and only 4.5% as STEMI (n=23). Acute events during the index hospitalization occurred in 4.9% (n=25) before discharge, in 4.9% (n=25) within the first year and in 90.2% (n=460) thereafter. Most patients (92.2%; n=470) had stenosed or occluded venous bypass grafts at presentation, while a minority (7.8%; n=40) had significantly narrowed or occluded arterial grafts. CV risk profiles were similar in both groups. However, arterial graft disease occurred earlier after CABG and more likely presented as NSTEMI rather than UA compared to the SVG group. In 54.7% (n=279) primary PCI of the saphenous graft, and in 13.5% (n=69) of the native coronary arteries was performed, while 6.5% (n=33) underwent redo CABG and 25.3% (n=129) received medical treatment only. MACE at 1 year occurred in 12.2% (n=62) with repeated revascularization as the most common event (7.2%; n=37) followed by cardiac death (2.4%; n=12), MI (1.2%; n=6), cerebrovascular infarction (1.2%; n=6) and major bleeding (0.2%; n=1). Hypertensive and obese patients, those with myocardial infarction or an ACS before discharge or during the first year after CABG had higher MACCE. In patients undergoing pPCI the rate of cardiac death and MI at 1 year was lower with an intervention in the native coronary arteries and with redo CABG compared to pPCI of bypass grafts. Conclusion: Thus, patients with ACS and prior CABG typically present as UA and much less frequently as NSTEMI-ACS and rarely as STEMI. Most events occur after one year, particularly with SVG. The 1 year MACCE rate is comparable to those with native coronary artery ACS. Hypertensive and obese patients, those with MI or with an ACS before discharge had higher MACCE rates.     

Accuracy of the Global Registry of Acute Coronary Events (GRACE) Risk Score in Contemporary Treatment of Patients With Acute Coronary Syndrome

Background

Global Registry of Acute Coronary Events (GRACE) score has been routinely used for risk stratification in acute coronary syndromes (ACS). We aimed to investigate whether the GRACE score has remained relevant with contemporary treatment of patients with ACS.

Acute Decline in Renal Function,Inflammation, and Cardiovascular Risk after an Acute Coronary Syndrome

Background and objectives: Chronic kidney disease is associated with a higher risk of cardiovascular outcomes. The prognostic significance of worsening renal function has also been shown in various cohorts of cardiac disease; however, the predictors of worsening renal function and the contribution of inflammation remains to be established.Design, setting, participants, & measurements: Worsening renal function was defined as a 25% or more decrease in estimated GFR (eGFR) over a 1-mo period in patients after a non-ST or ST elevation acute coronary syndromes participating in the Aggrastat-to-Zocor Trial; this occurred in 5% of the 3795 participants.Results: A baseline C-reactive protein (CRP) in the fourth quartile was a significant predictor of developing worsening renal function (odds ratio, 2.48; 95% confidence interval, 1.49, 4.14). After adjusting for baseline CRP and eGFR, worsening renal function remained a strong multivariate predictor for the combined cardiovascular composite of CV death, recurrent myocardial infarction (MI), heart failure or stroke (hazard ratio, 1.6; 95% confidence interval, 1.1, 2.3).Conclusions: Patients with an early decline in renal function after an acute coronary syndrome are at a significant increased risk for recurrent cardiovascular events. CRP is an independent predictor for subsequent decline in renal function and reinforces the idea that inflammation may be related to the pathophysiology of progressive renal disease.Impaired renal function has consistently been shown to be an independent risk factor for cardiovascular outcomes across a broad spectrum of patients including population-based studies of patients with cardiovascular disease (1,2), acute coronary syndromes (3–6), chronic heart failure with either impaired or preserved ventricular systolic function (7), and after coronary artery bypass grafting (8). Worsening renal function (WRF), defined by small increases in creatinine or decreases in GFR, has also been independently associated with adverse cardiovascular outcomes and mortality in patients after an acute MI (9), cardiac surgery (10,11), and in patients with heart failure (12–14).Serum C-reactive protein (CRP), a marker of inflammation, has been associated with WRF in a population of nondiabetics (15), as well as in those after an MI (15,16). The predictors and prognostic significance of WRF in a cohort of patients after an acute coronary syndrome (ACS) is not well defined. Furthermore, the contribution of inflammatory markers to WRF in this cohort is unknown. We analyzed subjects from the phase Z of the A-Z trial (Early Intensive versus Delayed Conservative Simvastatin Strategy in Patients with Acute Coronary Syndromes), who had both measurements of serum creatinine and thus estimates of GFR (eGFR), at baseline and 1 mo. We have previously reported that both baseline CRP and eGFR were important prognostic markers after an ACS and that the increased cardiovascular hazard associated with a reduction in eGFR was independent and additive to baseline markers of inflammation (6). The objectives of this subsequent analysis was to determine clinical factors associated with an early decline in eGFR after an ACS and second to evaluate the cardiovascular prognostic importance of an early decline in eGFR in this patient population.     

Educational Inequalities in Cardiovascular Risk Factor and Blood Pressure Control in the Elderly: Comparison of MESA Cohort and Chilean NHS Survey Outcome Measures

Background

Social determinants differ between countries, which is not always considered when adapting health policies and interventions to face inequalities in noncommunicable diseases and their risk factors.

Optical Coherence Tomography Fractional Flow Reserve and Cardiovascular Outcomes in Patients With Acute Coronary Syndrome

BackgroundOptical coherence tomography–derived fractional flow reserve (OCT-FFR) correlates strongly with wire-based FFR; however, its clinical significance remains uncertain.ObjectivesThis study sought to investigate the relationship between post–percutaneous coronary intervention (PCI) OCT-FFR and long-term clinical outcomes in acute coronary syndrome (ACS).MethodsThis retrospective, multicenter, observational cohort study included consecutive patients with ACS who underwent OCT-guided emergency PCI. We analyzed post-PCI OCT images and calculated OCT-FFR to identify independent factors associated with target vessel failure (TVF) after PCI.ResultsAmong 364 enrolled patients, 54 experienced TVF during a median follow-up of 36 (IQR: 26-48) months. Vessel-level OCT-FFR was significantly lower in the TVF group than in the non-TVF group (0.87 vs 0.94; P < 0.001). In the multivariable Cox regression analysis, low vessel-level OCT-FFR (HR per 0.1 increase: 0.38; 95% CI: 0.29-0.49; P < 0.001) and thin-cap fibroatheroma in the nonculprit lesion were independently associated with TVF. The TVF rate of vessels with both low vessel-level OCT-FFR (<0.90) and thin-cap fibroatheroma in the nonculprit lesion was 8.1 times higher than that of all other vessels (69.3% vs 12.4%; HR: 8.13; 95% CI: 4.33-15.25; log-rank P < 0.001). Furthermore, adding vessel-level OCT-FFR to baseline characteristics and post-PCI OCT findings improved discriminatory and reclassification ability in identifying patients with subsequent TVF.ConclusionsVessel-level OCT-FFR was an independent factor associated with TVF after PCI in patients with ACS. Adding the OCT-FFR measurement to post-PCI OCT findings may enable better discrimination of patients with subsequent TVF after PCI for ACS. (Relationship between Intracoronary Optical Coherence Tomography Derived Virtual Fractional Flow Reserve and cardiovascular outcome on Acute coronary syndrome; UMIN000043858)     

核素心肌显像在急性冠状动脉综合征中的临床应用进展

随着核素心肌显像 (MPI)技术的发展及新的显像剂的出现 ,MPI在ACS患者的诊断、危险度分层、治疗方案选择和出院安排等方面的应用越来越广泛。最新的ACC/AHA的AMI指南、不稳定型心绞痛 /非ST段抬高型心肌梗死指南 ,以及核心脏病学指南均充分肯定了MPI的上述应用价值。