Management of octogenarians hospitalized for heart failure in Euro Heart Failure Survey I

Aims Here, the aim is to study the management of octogenarianshospitalized for heart failure in Euro Heart Failure SurveyI. Heart Failure (HF) is common in older people and associatedwith poor outcome. Methods and results We compared clinical characteristics, treatment,and short-term outcomes in 2780 octogenarians (group A, medianage 85 years) and in 7912 younger patients (group B, medianage 69 years) enrolled in the Euro Heart Failure Survey I. There were 37% males in group A vs. 59% in group B (P < 0.001).Co-morbidities were more common in group A. Ejection fractionwas measured only in 38% in group A vs. 65% in group B (P <0.001) and when measured was preserved in 50 vs. 40% (P <0.001). In-hospital and 12 weeks follow-up mortality were, respectively,13 vs. 5% (P < 0.001) and 12 vs. 6% (P < 0.001) in groupsA and B. Acute cardiac conditions and co-morbidity predictedmortality, whereas the use of angiotensin-converting enzymeinhibitor (ACE-I) and beta-blockers was associated with a betteroutcome. ACE-I and beta-blockers were used in 50 vs. 66% (P< 0.001) and 24 vs. 42% (P < 0.001) in groups A and B,respectively, whereas diuretics, digitalis, and nitrates weremore commonly used in octogenarians. Conclusion Preserved systolic function, multiple co-morbidities,and high mortality are observed in octogenarians with HF. Inthese patients, cardiac function is assessed in only a minorityand treatments known to improve prognosis in younger patientsunder-utilized. Overall, the management of octogenarians withHF does not follow international guidelines.     

Infarct Size Reduction and Attenuation of Global Left Ventricular Remodeling with the CorCap<Superscript>TM</Superscript> Cardiac Support Device Following Acute Myocardial Infarction in Sheep

Background:Whether mechanical restraint of the left ventricle (LV) can influence remodeling following myocardial infarction (MI) remains poorly understood. The following discussion details three studies examining the effects of surgically placing a cardiac support device (CSD) over the entire epicardial surface, on infarct expansion, global cardiac function and myocyte geometry and function post-MI. Methods: The effects of passive constraint on infarct expansion and global cardiac function/myocardial energetics were investigated in 10 sheep (5 MI only; 5 MI + CSD) using pressure-volume analysis and magnetic resonance imaging (MRI). Additionally, 11 sheep (5 MI only; 6 MI + CSD) were used to study the effects of passive restraint on myocyte geometry and function post-MI, with 10 additional uninstrumented sheep serving as controls. Baseline data was collected followed by the creation of an anterior infarct. 1 week post-infarct the animals underwent a second set of data collection studies followed by placement of the CSD in the experimental groups. Additional data was collected at 2 and 3 months post-MI. The animals in the myocyte function group underwent additional studies immediately following the 3 month time point. Results: Infarct expansion was diminished as a result of the CSD. At 1 week post-MI the akinetic area was similar in both groups. At the terminal time-point, the akinetic area in the control group was similar to the 1-week time-point whereas, in the CSD group, the area of akinesis decreased (P = 0.001). A comparison of the two groups at the terminal time-point demonstrates a significantly diminished area of akinesis in the CSD group (P = 0.004). The relative area of akinesis followed a similar pattern. The CSD group also exhibited a decrease in end-diastolic volume (control 110.3 ± 19.8 mL vs. CSD 67.6 ± 4.7 mL, P = .006) and an improved ejection fraction (control 15.5% ± 5.7% vs. CSD 29.46% ± 4.42%, P = .008) relative to the control group. Myocardial energetics were also enhanced in the CSD group as evidenced by significant improvements in potential energy (control 2015 ± 503 mL ⋅ mm Hg/beat vs. CSD 885 ± 220 mL ⋅ Hg/beat, P = .006), efficiency (control 39.4% ± 13.6% vs. CSD 59.8% ± 8.5%, P = .044), and oxygen consumption (control 0.072 ± 0.013 mL O₂/beat vs. CSD 0.052 ± 0.007 mL O₂/beat, P = .034). Isolated LV myocyte shortening velocity was reduced by 35% from control values (P < 0.05) in both MI groups. LV myocyte β-adrenergic response was reduced with MI, but normalized in the MI + CSD group. Relative collagen content was increased and matrix metalloproteinase-9 was decreased within the MI border region of the CSD group. Conclusions:The CorCap cardiac support device retarded infarct expansion, improved global and regional cardiac function and beneficially modified LV and myocyte remodeling post-MI. These findings provide evidence that non-pharmacological strategies can interrupt adverse LV remodeling post-MI.     

Metoprolol CR/XL in postmyocardial infarction patients with chronic heart failure: experiences from MERIT-HF

Background

The benefit of β-blockers post-myocardial infarction (MI) was established in the late 1970s. Major advances in the treatment of MI have since occurred. However, patients with chronic heart failure (CHF) were excluded from those trials. The purpose of this study was to assess the effect of β-blockers in post-MI patients with CHF receiving contemporary management.

Methods

This was a prespecified subgroup analysis of a double-blind, randomized trial: the Metoprolol CR/XL Randomized Intervention Trial in Heart Failure (MERIT-HF). Patients with CHF in New York Heart Association class II to IV with an ejection fraction (EF) ≤0.40 and a history of being hospitalized for an acute MI (n = 1926) were randomized to metoprolol succinate controlled release/extended release (CR/XL) versus placebo. Mean EF was 0.28, and the mean follow-up was 1 year.

Results

Metoprolol CR/XL reduced total mortality by 40% (95% CI 0.20-0.55, P = .0004), and sudden death by 50% (95% CI 0.26-0.66, P = .0004). The combined end point of all-cause mortality/hospitalization for worsening CHF was reduced by 31% (95% CI 0.16-0.44, P < .0001), and cardiac death/nonfatal acute MI by 45% (95% CI 0.26-0.58, P < .0001). A post-hoc analysis showed that the outcome in patients with earlier revascularization (44%) and outcome in those with more severe CHF (20%) was similar to the entire post-MI population.

Conclusions

In post-MI patients with symptomatic CHF, β-blockade continues to exert a profound reduction in mortality and morbidity in the presence of contemporary management that includes early and late revascularization, angiotensin-converting enzyme inhibitors, aspirin, and statins.     

Self-reported depressive symptoms,diagnosed clinical depression and cardiac morbidity and mortality after myocardial infarction

Background

Self-reported depressive symptoms and clinical depression after myocardial infarction (MI) are both associated with poor cardiac prognosis. It is important to distinguish between the two when assessing cardiac prognosis, but few studies have done so. The present article evaluates the independent prognostic impact of self-reported depressive symptoms and clinical depression on cardiac outcomes after MI.

Methods

2704 MI-patients were administered the Beck Depression Inventory (BDI) and underwent the Composite International Diagnostic Interview at 3 months post-MI. All-cause mortality, cardiac mortality and cardiovascular readmissions were evaluated up till 10 years post-MI (mean: 6 years), representing 16,783 persons-years of follow-up. Event-free survival was evaluated using Cox regression analysis.

Results

Analyses on mortality and cardiovascular readmissions included 2493 and 2434 patients respectively. Compared to patients scoring < 5 on the BDI, those scoring ≥ 19 had age- and sex-adjusted HR's (95% CI) of 3.20 (2.16–4.74, p < 0.001) for all-cause mortality, 3.97 (2.06–7.65, p < 0.001) for cardiac mortality, and 1.45 (1.08–1.95, p < 0.05) for cardiovascular readmissions. Cardiac disease severity and cardiac risk factors explained one third to half of the relationship. The presence of clinical depression was associated with all-cause (HR: 1.72 (1.29–2.30, p < 0.001)) and cardiac mortality (HR: 1.67 (1.01–2.77, p < 0.05)). However, adjusting for BDI-scores decreased these HR's with 53% and 72% respectively, rendering them non-significant. Dichotomized BDI-scores remained to predict cardiac prognosis independently from the presence of clinical depression.

Conclusions

After MI, self-reported depressive symptoms are a more accurate predictor of cardiac morbidity and mortality than clinical depression. This association is confounded largely by cardiac disease severity.     

Prognostic significance of silent myocardial ischaemia during maximal exercise testing after a first acute myocardial infarction

Clinical, exercise, and angiographic variables, and long-termfollow-up were compared in patients, who, during maximal Bruceexercise testing after a first acute myocardial infarction (AMI),had positive responses to exercise testing (n = 116, 38% of303) with (n % 23, group I) or without (n = 93, group II) angina.Group I patients more often (52 vs 19%, P < 0.001) had ahistory of pre-infarction angina. Group II had a greater proportion(75 vs 52%, P < 0.05) of inferior wall AMI, whereas groupI had a greater proportion (30 vs 19%, P < 0.01) of non-Qwave AMI. Total exercise duration was significantly (P <0.01) longer in group II (7.6 ± 3.2 vs 5.5 ± 3.1min). Maximal exercise heart rate (144 ± 22 vs 133 ±21, beats . min^–1 P < 0.05 was also higher in groupII. A greater proportion of group II patients (37 vs 9%, P <0.05) had single-vessel disease, whereas multivessel diseasewas more common (91 vs 63% P < 0.03) in group I. Left ventricularfunction was similar in both groups. During follow-up (48 ±22 months) the incidence of cardiac death (group I, 3.3%, groupII, 4.8%), of recurrent infarction (group I, 4.8%, group II3.3%), and of revascularization procedures (group I, 28.5%,group II, 19.8%) were similar in both groups. Although asymptomaticexercise-induced ischaemia was associated with better exerciseperformance and less extensive coronary disease than symptomaticischaemia, it had the same long-term prognostic implications.     

Non-rheumatic annular mitral stenosis: prevalence and characteristics

Aims: To define the prevalence and characteristics of non-rheumaticannular mitral stenosis (AMS) in a general population as comparedwith rheumatic mitral stenosis (RMS). Methods and results: Clinical and echocardiographical variables were assessed in70 patients with mitral stenosis. AMS and RMS patients wereage- and gender-matched for the comparison of echocardiographicvariables. Thirteen patients (18.5%) had AMS. Arterial hypertensionand hypercholesterolemia were more prevalent in AMS (77 vs.36% and 75 vs. 27%, respectively, P < 0.05). Mitral annuluscalcification severity score (2.2 vs. 1.3, P < 0.05) andleft ventricular mass (276 ± 73 vs. 209 ± 57 g,P < 0.05) were significantly higher in AMS. Mitral valvearea (MVA) was higher and mean gradient was lower (2.25 ±0.6 vs.1.9 ± 0.6 cm², 4 ± 1.2 vs. 5.6 ±3.5 mmHg, P = ns) in AMS. Pressure half-time (PHT) MVA and planimetryMVA had a better correlation in RMS than in AMS patients (r= 0.98 vs. 0.71, P < 0.05). Conclusion: AMS is more frequent than that is assumed and is associatedwith risk factors for coronary artery disease. AMS is generallymild and PHT may be less accurate for MVA calculation than inRMS.     

Effects of adrenaline on ventricular function and coronary haemodynamics in relation to catecholamine handling in transplanted human hearts

We investigated cardiovascular and coronary responses to intravenousinfusions of adrenaline, which raised arterial concentrationsin a stepwise fashion from basal to about 5–6 nmol. l^–1,in 11 non-rejecting heart transplanted patients, and in eightintact innervated subjects. Cardiac adrenaline extraction andnoradrenaline release rate were also measured. The transplanted patients showed larger increases in heart rate(36±11% vs 16±6%, P<0.0001 and cardiac index(80±30% vs 56±19%, P<0.05), while stroke volumeincrements were similar in the two groups (32±17% vs35±13%). The study groups did not differ with respectto changes in arterial pressure, cardiac work or peripheralresistances. Coronary sinus blood flow increased to a greaterextent in the transplanted group (75±35% vs 48±31%,P <0.05) and myocardial oxygen consumption also tended toincrease more in these patients (78±42% vs 48±34%,NS). Myocardial adrenaline extraction was greatly reduced inthe transplant patients (–6±25% vs 64±18%,P<0.001), while forearm adrenaline extraction was similarin the two groups (41±22% vs 40±23%, NS). Cardiacnoradrenaline overflow tended to be lower in the transplantedgroup (12±62 vs 48±43 pmol. min^–1, NS).There was a wide range of noradrenaline overflow values (–64to 147 pmol. min^–1) and definite high values in threepatients. Cardiac noradrenaline overflow was not correlatedto heart rate responsiveness to adrenaline. We conclude that patients with cardiac transplantation respondto adrenaline with exaggerated increases in heart rate and thusin cardiac output. High values of cardiac noradrenaline overfloware seen in some transplant recipients and may suggest reinnervation.Signs of reinnervation are not associated with consistentlylower heart rate responses to ß-adrenergic stimulation.     

Increased cardiac sympathetic nervous activity in patients with unstable coronary heart disease

We have evaluated overall and cardiac sympathetic activity in47 patients undergoing coronary angiography, 27 with stableangina of at least 3 months duration, and 20 with unstable ischaemicsymptoms within this period. Cardiac and overall sympatheticactivity were assessed using radiotracer noradrenaline kinetictechniques to measure cardiac and total noradrenaline spilloverto plasma. Overall sympathetic activity (whole body noradrenaline spillover)was similar in the two groups, whereas cardiac sympathetic activity(cardiac noradrenaline spillover) was strikingly increased inthe patients with unstable ischaemic symptoms (102 ±23 pmol . min^–1 vs 34 ± 4 pmol . min^–1, P< 0.001), as was the cardiac to whole body noradrenalinespillover ratio (0.043 ± 0.008 vs 0.021± 0.005,P < 0.01). Coronary sinus bloodflow (50 ± 4 ml . min^–1vs 38 ± 4 ml . min^–1 P < 0.05) and coronarysinus noradrenaline concentration (2.60±0.38 nmol . 1^–1vs 1.41±0.17 nmol . 1^–1, P<0.01) were also increasedin the patients with unstable ischaemic syndromes. Left ventricularejection fraction was similar in the two groups (63 ±2% vs 62 ± 2%). Patients with unstable ischaemic symptoms within the previousthree months have increased cardiac sympathetic nervous activitycompared to patients with stable angina. This may in part explainwhy patients with unstable ischaemic syndromes are at increasedrisk of sudden cardiac death.     

Long-term remission of Philadelphia chromosome-positive acute lymphoblastic leukemia after allogeneic hematopoietic cell transplantation from matched sibling donors: a 20-year experience with the fractionated total body irradiation-etoposide regimen

Allogeneic hematopoietic cell transplantation (HCT) is the only known curative modality for patients with Philadelphia chromosome–positive acute lymphoblastic leukemia (Ph⁺ ALL). Sixty-seven patients with HLA-matched sibling donors received fractionated total body irradiation (FTBI) and high-dose VP16, whereas 11 patients received FTBI/VP16/cyclophosphamide, and 1 patient received FTBI/VP16/busulfan. The median age was 36 years. At the time of HCT, 49 patients (62%) were in first complete remission (CR1) and 30 patients (38%) were beyond CR1 (> CR1). The median follow-up was 75 months (range, 14-245 months). The 10-year overall survival for the CR1 and beyond CR1 patients was 54% and 29% (P = .01), respectively, and event-free survival was 48% and 26% (P = .02), respectively. There was no significant difference in relapse incidence (28% vs 41%, P = .28), but nonrelapse mortality was significantly higher in the beyond CR1 patients, (31% vs 54%, P = .03, respectively). By univariate analysis, factors affecting event-free and overall survival were white blood cell count at diagnosis (< 30 x 10⁹/L vs > 30 x 10⁹/L) and disease status (CR1 vs > CR1). The median time to relapse for CR1 and for beyond CR1 patients was 12 months and 9 months, respectively. Our results indicate that FTBI/VP16 with or without cyclophosphamide confers long-term survival in Ph⁺ ALL patients and that disease status at the time of HCT is an important predictor of outcome.     

Relationship of Serial High-Sensitivity C-Reactive Protein Changes to Long-term Clinical Outcomes in Stabilised Patients After Myocardial Infarction

BackgroundLittle is known about the association between serial high-sensitivity C-reactive protein (hsCRP) measurements and long-term outcomes in post–myocardial infarction (MI) patients. We aimed to investigate the usefulness of serial hsCRP measurements for risk stratification in stabilised post-MI patients after percutaneous coronary intervention (PCI).MethodsA total of 1018 patients who had hsCRP values at both baseline and 1 year after MI were included. High inflammatory status was defined as hsCRP > 2 mg/L. Patients were classified into 4 groups: persistently low, falling (first high then low hsCRP), rising (first low then high hsCRP), and persistently high hsCRP. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE: a composite of all-cause of death, MI, and cerebrovascular accident) within 4 years after the second hsCRP measurement.ResultsAt 1 year after MI, the numbers of patients in the persistently low, falling, rising, and persistently high hsCRP groups were 394 (38.7%), 358 (35.2%), 69 (6.8%), and 197 (19.4%), respectively. The incidence of MACCE was progressively elevated from the persistently low to the falling, rising, and persistently high hsCRP groups (4.8%, 8.1%, 10.1%, and 13.2%, respectively; P = 0.004). Persistently high hsCRP was an independent predictor of MACCE (adjusted hazard ratio 2.55; 95% confidence interval 1.35-4.81; P = 0.004) and provided incremental prognostic value beyond that of the baseline clinical risk model (net reclassification improvement = 0.397; integrated discrimination improvement = 0.025; all P < 0.001).ConclusionsAmong stabilised post-MI patients who underwent PCI, persistently high hsCRP was frequently seen 1 year after MI and was strongly associated with long-term adverse clinical outcomes. Serial measurements of hsCRP during clinical follow-up after MI may help to identify patients at higher risk for mortality and morbidity.     

Evolution of electrocardiographic and echocardiographic abnormalities during the 4 years following first acute myocardial infarction

Therapies aimed at salvaging jeopardized myocardium in patientswith acute myocardial infarction (MI) are now routine. The successof these therapies must often be estimated by non-invasive tests,such as the 12-lead electrocardiogram (ECG) or two-dimensionalechocardiography. To monitor QRS changes and left ventricular(LV) function over time in patients who have received therapiesaimed at myocardial salvage, it is important to know the ‘spontaneous’evolution of these estimates. Consecutive MI survivors admitted in the pre-thrombolytic erawith their first MI were re-studied at 4 years. Patients wereexcluded if they had experienced reinfarction, coronary revascularizationor bundle branch block in the acute or follow-up period A standardECG and a two-dimensional echocardiogram were obtained priorto discharge and at follow-up. The quantitative ECG analysiswas performed according to the Selvester QRS scoring method.During the two-dimensional echocardiogram each of the 20 segmentsof the LV were assessed to provide a wall motion score. Eighty patients with a median age of 64 years (range 40–79)were included in the study. Thirty-two had anterior and 48 inferiorMI. A significant decrement in median QRS score-estimated AMIsize occurred between pre-discharge and follow-up ECGs in theentire group (18•3% vs 10•5%; P<0•00001).This difference occurred in both anterior (21•6% vs 10•5%;P<0•00001) and inferior-posterior (16•5% vs 10•5%;P<0•00001) MI locations. In the anterior MI group therewas a trend towards a greater total decrease of QRS points thanin the inferior-posterior MI group (42% vs 27%; P=0•10).Within the anterior MI group, more QRS points awarded in theanteroseptal leads (V₁–V₃) remained at follow-up thanin the anterosuperior and apical leads (I, aVL and V₄–V₆)(80% vs 49%; P=0•03). Within the inferior-posterior MIgroup there were no significant differences in QRS point resolutionbetween lead groups. The comparison between pre-discharge andfollow-up two-dimensional echocardiograms demonstrated a significantdecrease in wall motion score in the population as a whole (median9•4 vs 7•6, P=0•01). The same trend was foundfor both anterior (median 16•4 vs 14•8, P=0•057)and inferior-posterior MI (7•5 vs 5•5, P=0•11).There was a significant correlation between the resolution ofQRS score and the improvement in wall motion score (P=0•04). In MI patients not treated with reperfusion therapies, withoutre-infarction or revascularization during 4 years follow-up,a significant and parallel improvement in ECG and two-dimensionalechocardiographic indices of MI size occurs. These results canprovide control data for evaluating the long-term benefits ofthrombolytic therapy.     

Clinical outcome and echocardiographic findings of native and prosthetic valve endocarditis in the 1990s

Prosthetic valve endocarditis is considered to be associatedwith a more severe prognosis than native valve endocarditis.Among other factors, inappropriate visualization of vegetationsin prosthetic valve endocarditis by transthoracic echocardiographyis responsible for this observation. Since the introductionof transoesophageal echocardiography into clinical practicethe diagnostic sensitivity and specificity of the detectionof vegetations located on prosthetic valves have been enhanced.Therefore we aimed to determine and compare the prognosis ofprosthetic valve endocarditis and native valve endocarditisin the era of this improved diagnostic approach. One hundred and six episodes of infective endocarditis in 104patients were seen at our institution between 1989 and 1993.Eighty patients (77%) had native valve endocarditis and 24 (23%)had late prosthetic valve endocarditis. In the latter grouptwo patients had recurrent infective endocarditis. Patientswith prosthetic valve endocarditis were older (mean age 64 vs54 years in native valve endocarditis; P<0.00l) and the majoritywas female (62% vs 38% in native valve endocarditis; P<0.001In prosthetic valve endocarditis, infection of a valve in themitral position predominated (65% vs 30% in native valve endocarditis;P<0.0l), whereas in native valve endocarditis more than halfthe cases had isolated aortic valve endocarditis (51% vs 27%in prosthetic valve endocarditis; P<0.01). In prostheticvalve endocarditis more cases were caused by Staphylococcusaureus (31% vs 14% in native valve endocarditis; P<0.08),whereas in native valve endocarditis the most frequent organismswere streptococci (29% vs l9% in prosthetic valve endocarditis;P<0.12). Differences in the clinical features of native valveendocarditis and prosthetic valve endocarditis could not befound except for a higher rate of embolism in native valve endocarditis(40% vs l9% in prosthetic valve endocarditis; P<0.05). Vegetationscould be detected by transthoracic echocardiography more frequentlyin native valve endocarditis (71% vs 15% in prosthetic valveendocarditis; P<0.0001). Transoesophageal echocardiographyvisualized vegetations in 95% of the episodes of native valveendocarditis and in 80% of the episodes of prosthetic valveendocarditis (P<0.09). Thus, the diagnostic gain by transoesophagealechocardiography was greatest in prosthetic valve endocarditis.Patients with native valve endocarditis had significantly largervegetations than patients with prosthetic valve endocarditis(P<0.05 for length, P<0.00l for width). The median timeto diagnosis was similar in native valve endocarditis and prostheticvalve endocarditis (31 vs 28 days). Surgery was performed in 74% of patients with native valve endocarditisand in 58% of those with prosthetic valve endocarditis; themedian time delay between the diagnosis of infective endocarditisand surgery tended to be shorter in prosthetic valve endocarditisthan in native valve endocarditis (45 vs 60 days). The in-hospitalmortality and the mortality during a follow-up of 22±10 months did not significantly differ between native valveendocarditis and prosthetic valve endocarditis (21% vs 17% 28%vs 25%). In summary in the era of transoesophageal echocardiography,late prosthetic valve endocarditis does not seem to carry aworse prognosis than native valve endocarditis. This can beattributed in part to the improved diagnostic accuracy achievedby transoesophageal echocardiography leading to comparable diagnosticlatency periods in both patient groups. Finally, better characterizationof vegetations on prosthetic valves by transoesophageal echocardiographyallows early lifesaving surgery in patients with prostheticvalve endocarditis.     

Cancer Patients Have a Higher Risk of Thrombotic and Ischemic Events After Percutaneous Coronary Intervention

ObjectivesThis study sought to define the risk of stent thrombosis (ST) and myocardial infarction (MI) in cancer patients compared with noncancer patients after percutaneous coronary intervention (PCI).BackgroundCancer patients are considered to be at high thrombotic risk, but data on whether this is the case after PCI remain inconclusive.MethodsCancer patients undergoing PCI at Mayo Clinic Rochester from January 1, 2003, to December 31, 2013, were identified by cross-linking institutional cancer and PCI databases and by propensity score matching to noncancer patients. The combined primary endpoint was all-cause mortality, MI, and revascularization rate at 5-year follow-up. Secondary endpoints were the individual primary endpoint components, cause of mortality, ST, and Bleeding Academic Research Consortium 2+ bleeding.ResultsThe primary endpoint occurred in 48.6% of 416 cancer and in 33.0% of 768 noncancer patients (p < 0.001). In competing risk analyses, cancer patients had a higher rate of noncardiac death (24.0% vs. 10.5%; p < 0.001) and a lower rate of cardiac death (5.0% vs. 11.7%; p < 0.001). Cancer patients had a higher rate of MI (16.1% vs. 8.0%; p < 0.001), ST (6.0% vs. 2.3%; p < 0.001), repeat revascularization (21.2% vs. 10.0%; p < 0.001), and bleeding (6.7% vs. 3.9%; p = 0.03). The most critical period for ST in cancer patients was in the first year after PCI. The dual antiplatelet therapy score was predictive of thrombotic and ischemic events in both groups.ConclusionsCancer patients have a higher risk of thrombotic and ischemic events after PCI, identifiable by a high dual antiplatelet therapy score. These findings have important implications for antiplatelet therapy decisions.     

5-year results of a comprehensive rehabilitation programme after myocardial infarction

A comprehensive cardiac rehabilitation programme has been offeredto a non-selected consecutive group of patients who have survivedan acute myocardial infarction (MI). The programme includesfollow-up at a post-MI clinic, physical training in outpatientgroups, the provision of information on smoking and diet, andpsychological support to patients and their families. The interventiongroup, consisting of the 147 patients participating in the programmehas been compared with a nonselected consecutive reference groupof 158 patients receiving standard care. During the five-year follow-up there was no difference in cardiacmortality between the groups, but the recurrence rate of non-fatalMl (17.3 vs 33.3%. P = 0.02) and the rate of total cardiac eventswas lower in the intervention group (39.5 vs 53.2%, P = 0.05).There was an alteration of risk factors, as there were fewersmokers and uncontrolled hypertensives in the intervention group.Patients in the reference group used more sedatives and long-actingnitroglycerine ami had a lower return-to-work rate during thestudy period. The programme proved to be particularly effective in the agegroup below 55 years, where a significantly lower rate of totalcardiac events was observed and more patients returned to workthan in the reference group. It is concluded that the combined effect of the comprehensiveprogramme has contributed to the long-term results, and thatthe programme offers an effective and safe method of secondaryprevention after MI.     

Patients with peripheral arterial disease in the CHARISMA trial

Aims: The aim of this study was to determine whether clopidogrel plusaspirin provides greater protection against major cardiovascularevents than aspirin alone in patients with peripheral arterialdisease (PAD). Methods and results: This is a post hoc analysis of the 3096 patients with symptomatic(2838) or asymptomatic (258) PAD from the CHARISMA trial. Therate of cardiovascular death, myocardial infarction (MI), orstroke (primary endpoint) was higher in patients with PAD thanin those without PAD: 8.2% vs. 6.8% [hazard ratio (HR), 1.25;95% CI 1.08, 1.44; P = 0.002]. Among the patients with PAD,the primary endpoint occurred in 7.6% in the clopidogrel plusaspirin group and 8.9% in the placebo plus aspirin group (HR,0.85; 95% CI, 0.66–1.08; P = 0.18). In these patients,the rate of MI was lower in the dual antiplatelet arm than theaspirin alone arm: 2.3% vs. 3.7% (HR, 0.63; 95% CI, 0.42–0.96;P = 0.029), as was the rate of hospitalization for ischaemicevents: 16.5% vs. 20.1% (HR, 0.81; 95% CI, 0.68–0.95;P = 0.011). The rates of severe, fatal, or moderate bleedingdid not differ between the groups, whereas minor bleeding wasincreased with clopidogrel: 34.4% vs. 20.8% (odds ratio, 1.99;95% CI, 1.69–2.34; P < 0.001). Conclusion: Dual therapy provided some benefit over aspirin alone in PADpatients for the rate of MI and the rate of hospitalizationfor ischaemic events, at the cost of an increase in minor bleeding.     

Heart Failure in Post-MI Patients With Persistent IRA Occlusion: Prevalence,Risk Factors,and the Long-Term Effect of PCI in the Occluded Artery Trial (OAT)

BackgroundThe incidence and predictors of heart failure (HF) after myocardial infarction (MI) with modern post-MI treatment have not been well characterized.Methods and ResultsA total of 2,201 stable patients with persistent infarct-related artery occlusion >24 hours after MI with left ventricular ejection fraction <50% and/or proximal coronary artery occlusion were randomized to percutaneous intervention plus optimal medical therapy (PCI) or optimal medical therapy (MED) alone. Centrally adjudicated HF hospitalizations for New York Heart Association (NYHA) III/IV HF and mortality were determined in patients with and without baseline HF, defined as a history of HF, Killip Class >I at index MI, rales, S3 gallop, NYHA II at randomization, or NYHA >I before index MI. Long-term follow-up data were used to determine 7-year life-table estimated event rates and hazard ratios. There were 150 adjudicated HF hospitalizations during a mean follow-up of 6 years with no difference between the randomized groups (7.4% PCI vs. 7.5% MED, P = .97). Adjudicated HF hospitalization was associated with subsequent death (44.0% vs. 13.1%, HR 3.31, 99% CI 2.21–4.92, P < .001). Baseline HF (present in 32% of patients) increased the risk of adjudicated HF hospitalization (13.6% vs. 4.7%, HR 3.43, 99% CI 2.23–5.26, P < .001) and death (24.7% vs. 10.8%, HR 2.31, 99% CI 1.71–3.10, P < .001).ConclusionsIn the overall Occluded Artery Trial (OAT) population, adjudicated HF hospitalizations occurred in 7.5% of subjects and were associated with increased risk of subsequent death. Baseline or prior HF was common in the OAT population and was associated with increased risk of hospitalization and death.     

Comparative Analysis of Patient Characteristics in Cardiogenic Shock Studies: Differences Between Trials and Registries

ObjectivesThis study sought to evaluate the differences in cardiogenic shock patient characteristics in trial patients and real-life patients.BackgroundCardiogenic shock (CS) is a leading cause of mortality in patients presenting with acute myocardial infarction (AMI). However, the enrollment of patients into clinical trials is challenging and may not be representative of real-world patients.MethodsWe performed a systematic review of studies in patients presenting with AMI-related CS and compared patient characteristics of those enrolled into randomized controlled trials (RCTs) with those in registries.ResultsWe included 14 RCTs (n = 2,154) and 12 registries (n = 133,617). RCTs included more men (73% vs 67.7%, P < 0.001) compared with registries. Patients enrolled in RCTs had fewer comorbidities, including less hypertension (61.6% vs 65.9%, P < 0.001), dyslipidemia (36.4% vs 53.6%, P < 0.001), a history of stroke or transient ischemic attack (7.1% vs 10.7%, P < 0.001), and prior coronary artery bypass graft surgery (5.4% vs 7.5%, P < 0.001). Patients enrolled in RCTs also had lower lactate levels (4.7 ± 2.3 mmol/L vs 5.9 ± 1.9 mmol/L, P < 0.001) and higher mean arterial pressure (73.0 ± 8.8 mm Hg vs 62.5 ± 12.2 mm Hg, P < 0.001). Percutaneous coronary intervention (97.5% vs 58.4%, P < 0.001) and extracorporeal membrane oxygenation (11.6% vs 3.4%, P < 0.001) were used more often in RCTs. The in-hospital mortality (23.9% vs 38.4%, P < 0.001) and 30-day mortality (39.9% vs 45.9%, P < 0.001) were lower in RCT patients.ConclusionsRCTs in AMI-related CS tend to enroll fewer women and lower-risk patients compared with registries. Patients enrolled in RCTs are more likely to receive aggressive treatment with percutaneous coronary intervention and extracorporeal membrane oxygenation and have lower in-hospital and 30-day mortality.     

以提高肾脏病整体预后工作组诊断标准分析脓毒症相关急性肾损伤患者的临床特点

  目的 以提高肾脏病整体预后工作组（KDIGO）诊断标准分析重症监护病房（ICU）内脓毒症相关急性肾损伤（AKI）患者的临床特征和预后。方法 应用KDIGO推荐的AKI诊断标准,收集2007年6月—2012年6月江苏省无锡市人民医院ICU收治的符合入选标准的AKI患者资料,回顾性分析脓毒症相关AKI患者的临床特征、预后和影响患者死亡的主要危险因素。结果 在收治的703例AKI患者中,脓毒症相关AKI 395例（56.2%）,脓毒症是发生AKI最主要的原因。脓毒症相关AKI患者中,AKI Ⅰ期146例（37.0%）,Ⅱ期154例（39.0%）,Ⅲ期95例（24.1%）。与非脓毒症相关AKI患者比较,脓毒症相关AKI组急性生理与慢性健康评分Ⅱ（APACHEⅡ）、序贯器官衰竭评分（SOFA）更高(25.1±4.9比20.5±6.4,12.9±2.6比10.4±4.5;P值均<0.05)。两组基础血肌酐值差异无统计学意义［(82.9±22.2)μmol/L比(83.1±30.0)μmol/L,P>0.05］,但ICU期间脓毒症相关AKI组血肌酐更高［(143.5±21.6)μmol/L比(96.2±15.5) μmol/L,P<0.05］,进展为AKI Ⅱ期和Ⅲ期的比例更高（63.0%比33.1%,P<0.05）,接受肾脏替代治疗的比例更高（22.3%比6.2%,P<0.05）,而肾功能完全恢复的患者比例更少(74.4%比82.8%,P值均<0.05)。脓毒症相关AKI患者90 d病死率高于非脓毒症相关AKI患者(52.2%比34.1%,P<0.05)。随着KDIGO分期的增加,脓毒症相关AKI患者病死率增加。Logistic回归分析显示APACHEⅡ(OR=5.451,95%CI：3.095~9.416)、SOFA(OR=2.166,95%CI：1.964~4.515)和肾脏替代治疗(OR=4.021,95%CI：2.975~6.324)均是脓毒症相关AKI患者死亡的独立危险因素。结论 脓毒症相关AKI 患者全身疾病严重程度高、肾功能差、病死率高。APACHEⅡ、SOFA和肾脏替代治疗是脓毒症相关AKI患者死亡的独立危险因素。        

Impact of delirium on patients hospitalized for myocardial infarction: A propensity score analysis of the National Inpatient Sample

Background

Delirium is associated with worse outcomes in critically ill patients. In the subset of patients with myocardial infarction (MI), the impact on clinical outcomes of delirium is not as well elucidated.

Hypothesis

Delirium is associated with increased mortality in patients hospitalized for MI.

Methods

The study used data from the National Inpatient Sample 2012 to 2014, Healthcare Cost and Utilization Project. We included discharges associated with the primary diagnosis of MI using the relevant International Classification of Diseases, Ninth Revision, Clinical Modification codes. The outcome was inpatient mortality between the delirium group and propensity score–matched controls without delirium.

Results

The study included 1 330 020 weighted discharges with MI as the principal diagnosis. Within this cohort, 18 685 discharges (1.4%) had delirium. Delirium was associated with older age, lower rates of percutaneous coronary intervention, and increased comorbid conditions. The delirium group had higher mortality (10.5% vs 2.6%, P < 0.001). Propensity score–matching analysis showed increased mortality in the delirium group (10.5% vs 7.6%, relative risk: 1.39 [95% confidence interval: 1.2–1.6, P < 0.001) using nearest neighbor 1:1 matching.

Conclusions

In individuals with MI, delirium was associated with increased inpatient mortality.