Association of aortic stiffness with biomarkers of myocardial wall stress after myocardial infarction

Background

Aortic pulse wave velocity (PWV) was linked to LV-geometry and -function in patients with kidney disease and non-ischemic cardiomyopathy. The role of aortic compliance after acute STEMI is so far unknown. In the present study, we prospectively investigated the relationship of increased aortic stiffness with biomarkers of myocardial wall stress 4 months after STEMI.

Methods

48 STEMI patients who were reperfused by primary coronary angioplasty underwent cardiovascular magnetic resonance (CMR) at baseline and at 4-month follow-up. The CMR protocol comprised cine-CMR as well as gadolinium contrast-enhanced CMR. Aortic PWV was determined by velocity-encoded, phase-contrast CMR. Blood samples were routinely drawn at baseline and follow-up to determine N-terminal pro-B-type natriuretic peptide (NT-proBNP). In a subgroup of patients, mid-regional pro-adrenomedullin (MR-proADM) and mid-regional pro-A-type natriuretic peptide (MR-proANP) levels were determined.

Results

Patients with a PWV above median (> 7.0 m/s) had significantly higher NT-proBNP, MR-proADM and MR-proANP concentrations at 4-month follow-up than patients with a PWV below median (all p < 0.02). PWV showed moderate to good correlation with NT-proBNP, MR-proAMD and MR-proANP levels 4 months after STEMI (all p < 0.05). Multivariate analysis revealed PWV, beside myocardial infarct size, as an independent predictor of 4-month NT-proBNP levels after correction for age, creatinine and LV ejection fraction (model r: 0.781, p < 0.001).

Conclusion

Aortic stiffness is directly associated with biomarkers of myocardial wall stress 4 months after reperfused STEMI, suggesting a role for aortic stiffness in chronic LV-remodelling.     

Prevalence of acute cardiac disorders in patients with suspected ST-segment elevation myocardial infarction and non-significant coronary artery disease

Background and purpose

We aimed to study the prevalence of acute cardiac disorders in patients with suspected ST-segment elevation myocardial infarction (STEMI) and non-significant coronary artery disease (CAD).

Methods

From January to October 2012 we consecutively included patients admitted with suspected STEMI and non-significant CAD (coronary artery stenosis diameter < 50%). Patients were diagnosed with acute cardiac disorder in the presence of elevated cardiac biomarkers (troponin T > 50 ng/l or creatine kinase MB > 4 μg/l) or dynamic ECG changes (ST-segment changes or T-wave inversion).

Results

Of the 871 patients admitted with suspected STEMI, 11% (n = 95) had non-significant CAD. Of these, 67% (n = 64) had elevated cardiac biomarkers or dynamic ECG changes and were accordingly diagnosed with acute cardiac disorders. In the remaining 33% (n = 31) of patients, cardiac biomarkers were normal and ECG changes remained stationary.

Conclusions

Acute cardiac disorders were diagnosed in two thirds of patients with suspected STEMI and non-significant CAD.     

Cardiovascular magnetic resonance-derived intramyocardial hemorrhage after STEMI: Influence on long-term prognosis,adverse left ventricular remodeling and relationship with microvascular obstruction

Background

T2 weighted cardiovascular magnetic resonance (CMR) can detect intramyocardial hemorrhage (IMH) after ST-elevation myocardial infarction (STEMI). The long-term prognostic value of IMH beyond a comprehensive CMR assessment with late enhancement (LE) imaging including microvascular obstruction (MVO) is unclear. The value of CMR-derived IMH for predicting major adverse cardiac events (MACE) and adverse cardiac remodeling after STEMI and its relationship with MVO was analyzed.

Methods

CMR including LE and T2 sequences was performed in 304 patients 1 week after STEMI. Adverse remodeling was defined as dilated left ventricular end-systolic volume indexes (dLVESV) at 6 months CMR.

Results

During a median follow-up of 140 weeks, 47 MACE (10 cardiac deaths, 16 myocardial infarctions, 21 heart failure episodes) occurred. Predictors of MACE were ejection fraction (HR .95 95% CI [.93–.97], p = .001, per %) and IMH (HR 1.17 95% CI [1.03–1.33], p = .01, per segment). The extent of MVO and IMH significantly correlated (r = .951, p < .0001). dLVESV was present in 40% of patients. CMR predictors of dLVESV were: LVESV (OR 1.11 95% CI [1.07–1.15], p < .0001, per ml/m²), infarct size (OR 1.05 95% CI [1.01–1.09], p = .02, per %) and IMH (OR 1.54 95% CI [1.15–2.07], p = .004, per segment). Addition of T2 information did not improve the LE and cine CMR-model for predicting MACE (.744 95% CI [.659–.829] vs. .734 95% CI [.650–.818], p = .6) or dLVESV (.914 95% CI [.875–.952] vs. .913 95% CI [.875–.952], p = .9).

Conclusions

IMH after STEMI predicts MACE and adverse remodeling. Nevertheless, with a strong interrelation with MVO, the addition of T2 imaging does not improve the predictive value of LE-CMR.     

Comprehensive Prognosis Assessment by CMR Imaging After ST-Segment Elevation Myocardial Infarction

Background

Although the prognostic value of findings from cardiac magnetic resonance (CMR) imaging has been established in single-center center studies in patients with ST-segment elevation myocardial infarction (STEMI), a large multicenter investigation to evaluate the prognostic significance of myocardial damage and reperfusion injury is lacking.

Objectives

The aim of this study was to assess the prognostic impact of CMR in an adequately powered multicenter study and to evaluate the most potent CMR predictor of hard clinical events in a STEMI population treated by primary percutaneous coronary intervention (PCI).

Methods

We enrolled 738 STEMI patients in this CMR study at 8 centers. The patients were reperfused by primary PCI <12 h after symptom onset. Central core laboratory–masked analyses for quantified left ventricular (LV) function, infarct size (IS), microvascular obstruction (MO), and myocardial salvage were performed. The primary clinical endpoint of the study was the occurrence of major adverse cardiac events.

Results

Patients with cardiovascular events had significantly larger infarcts (p < 0.001), less myocardial salvage (p = 0.01), a larger extent of MO (p = 0.009), and more pronounced LV dysfunction (p < 0.001). In a multivariate model that included clinical and other established prognostic parameters, MO remained the only significant predictor in addition to the TIMI (Thrombolysis In Myocardial Infarction) risk score. IS and MO provided an incremental prognostic value above clinical risk assessment and LV ejection fraction (c-index increase from 0.761 to 0.801; p = 0.036).

Conclusions

In a large, multicenter STEMI population reperfused by primary PCI, CMR markers of myocardial damage (IS and especially MO) provide independent and incremental prognostic information in addition to clinical risk scores and LV ejection fraction. (Abciximab i.v. Versus i.c. in ST-elevation Myocardial Infarction [AIDA STEMI]; NCT00712101).     

Prognostic value of adenosine stress perfusion cardiac MRI with late gadolinium enhancement in an intermediate cardiovascular risk population

Background

The high diagnostic accuracy of adenosine stress cardiac magnetic resonance (AS-CMR) for detecting coronary artery stenoses, with high sensitivity and specificity, is well documented. Prognostic data, particularly in non-low risk study populations and for greater than 12 months of follow up, is however lacking or variable in its findings. We present prognostic data, in an intermediate cardiovascular risk cohort undergoing adenosine stress perfusion CMR, over approximately 2 years of follow up.

Methods

The study population comprised 362 patients referred for a clinically indicated stress CMR and included patients with proven coronary artery disease (CAD; n = 157) or unknown CAD status, yet an intermediate cardiovascular risk profile (n = 205). Perfusion imaging was performed at stress (adenosine 140 μg/kg/min) and rest on a 1.5 T system. Patient records and state-wide hospital databases were reviewed. Major adverse cardiac events — death, myocardial infarction, revascularisation or ischaemic hospitalisation — were evaluated over a median follow up of 22 months.

Results

Of the 362 cases, 90 had a stress perfusion CMR positive for ischaemia and experienced a MACE rate of 24%. Of the 272 negative CMR scans, 225 were also negative for late gadolinium enhancement, and in this group MACE was encountered in only 6 (2.7%) patients. Accordingly a negative stress CMR afforded a freedom from MACE of 97.3%. Freedom from death/myocardial infarction was 99.6%.

Conclusions

In patients with confirmed coronary artery disease or at intermediate risk for cardiovascular events, a negative stress perfusion CMR is associated with an excellent prognosis over nearly 2 years of follow up.     

ST-elevation myocardial infarction in the elderly — Temporal Trends in incidence,utilization of percutaneous coronary intervention and outcomes in the United States

Background

Elderly patients with ST-elevation myocardial infarction (STEMI) are often underrepresented in major percutaneous coronary intervention (PCI) trials. Use of PCI for STEMI, and associated outcomes in patients aged ≥ 65 years with STEMI needed further investigation.

Methods

We used the 2001–2010 United States Nationwide Inpatient Sample (NIS) database to examine the temporal trends in STEMI, use of PCI for STEMI, and outcomes among patients aged 65–79 and ≥ 80 years.

Results

During 2001–2010, of 4,017,367 patients aged ≥ 65 years with acute myocardial infarction (AMI), 1,434,579 (35.7%) had STEMI. Over this period, among patients aged 65–79 and ≥ 80 years, STEMI decreased by 16.4% and 19%, whereas the use of PCI for STEMI increased by 33.5% and 22%, respectively (P_trend < 0.001). There was a significant decrease in age-adjusted in-hospital mortality (per 1000) in patients aged ≥ 80 years (150 versus 116, P_trend = 0.02) but not in patients aged 65–79 years (63 versus 59, P_trend = 0.886). Stepwise logistic regression identified intra-aortic balloon pump use, acute renal failure, acute cerebrovascular disease, age ≥ 80 years, peripheral vascular disease, gastrointestinal bleeding, female gender, congestive heart failure, chronic lung disease, weekend admission and multivessel PCI as independent predictors of in-hospital mortality among all patients ≥ 65 years of age who underwent PCI for STEMI.

Conclusions

In this large, multi-institutional cohort of elderly patients, a decreasing trend in STEMI, an increasing trend in PCI utilization for STEMI, and reduction in in-hospital mortality were observed from 2001 to 2010.     

Prognostic value of neutrophil/lymphocyte ratio in patients with ST-elevated myocardial infarction undergoing primary coronary intervention: A prospective,multicenter study

Objective

The pre-procedural neutrophil to lymphocyte ratio (N/L) is associated with adverse outcomes among patients with coronary artery disease but its prognostic value in ST-segment elevation myocardial infarction (STEMI) has not been fully investigated. This study evaluated the relations between pre-procedural N/L ratio and the in-hospital and long-term outcomes in STEMI patients undergoing primary percutaneous coronary intervention (PCI).

Methods

A total of 682 STEMI patients presented within the first 6 h of symptom onset were enrolled and stratified according to tertiles of N/L ratio based on the blood samples obtained in the emergency room upon admission.

Results

The mean follow-up period was 43.3 months (1–131 months). In-hospital in-stent thrombosis, non-fatal myocardial infarction, and cardiovascular mortality increased as the N/L tertile ratio increased (p < 0.001, p < 0.001, p = 0.003, respectively). Long-term in-stent thrombosis, non-fatal myocardial infarction and cardiovascular mortality also increased as the N/L ratio increased (p < 0.001, p < 0.001, p = 0.002, respectively). On multivariate analysis, N/L ratio remained an independent predictor for both in-hospital (OR 1.189, 95% CI 1.000–1.339; p < 0.001) and long-term major (OR 1.228, 95% CI 1.136–1.328; p < 0.001) adverse cardiac events.

Conclusion

The N/L ratio was an independent predictor of both in-hospital and long-term adverse outcomes among STEMI patients undergoing primary PCI. Our findings suggest that this inexpensive, universally available hematological marker may be incorporated into the current established risk assessment model for STEMI.     

Electrocardiographic scores of severity and acuteness of myocardial ischemia predict myocardial salvage in patients with anterior ST-segment elevation myocardial infarction

Background

Terminal “QRS distortion” on the electrocardiogram (ECG) (based on Sclarovsky-Birnbaum's Grades of Ischemia Score) is a sign of severe ischemia, associated with adverse cardiovascular outcome in ST-segment elevation myocardial infarction (STEMI). In addition, ECG indices of the acuteness of ischemia (based on Anderson-Wilkins Acuteness Score) indicate myocardial salvage potential. We assessed whether severe ischemia with or without acute ischemia is predictive of infarct size (IS), myocardial salvage index (MSI) and left ventricular ejection fraction (LVEF) in anterior versus inferior infarct locations.

Left circumflex artery-related myocardial infarction: Does ST elevation matter? Results from the Euro Heart Survey PCI registry

Background/objectives

Little is known about angiographic and clinical differences in patients presenting with left circumflex artery (LCX)-related ST elevation myocardial infarction (STEMI) and non ST elevation myocardial infarction (NSTEMI). We sought to determine the clinical significance of ST elevations in patients with LCX-related myocardial infarction.

Methods and results

Between 2005 and 2008 10,503 consecutive patients with acute STEMI and NSTEMI undergoing percutaneous coronary intervention (PCI) were prospectively enrolled into the Euro Heart Survey PCI-Registry. For the present analysis patients with LCX-related STEMI (n = 1100, 54.7%) were compared to those with LCX-related NSTEMI (n = 910, 45.3%). NSTEMI-patients were older, more often female and had a higher incidence of prior cardiac events. Patients with STEMI more frequently presented with shock (8.0 versus 3.9%, P < 0.001) or had been resuscitated (8.5 versus 2.7%, P < 0.0001). TIMI 0–1 before PCI was much more often found among those with STEMI (58.2 versus 25.1%, P < 0.0001). In the univariate analysis there were no significant differences in hospital mortality (STEMI: 4.8%, NSTEMI: 3.5%, P = 0.17), however after adjustment for age, female gender, diabetes and chronic renal failure hospital mortality was significantly higher in STEMI patients (odds ratio 1.71, 95%-CI 1.08–2.72, P < 0.05).

Conclusions

Over 50% of the patients with LCX-related myocardial infarction treated with PCI had ST elevations in the initial electrocardiogram. STEMIs were more often associated with total vessel occlusions or haemodynamic instability. In-hospital mortality was significantly higher in patients with LCX-related STEMI.     

A mismatch index based on the difference between measured left ventricular ejection fraction and that estimated by infarct size at three months following reperfused acute myocardial infarction

Background and Aim

The reduction of left ventricular ejection fraction (LVEF) following ST-segment elevation myocardial infarction (STEMI) is a result of infarcted myocardium and may involve dysfunctional but viable myocardium. An index that may quantitatively determine whether LVEF is reduced beyond the expected value when considering only infarct size (IS) has previously been presented based on cardiac magnetic resonance (CMR). The purpose of this study was to introduce the index based on the electrocardiogram (ECG) and compare indices based on ECG and CMR.

Method and Results

In 55 patients ECG and CMR were obtained 3 months after STEMI treated with primary percutaneous coronary intervention. Significant, however moderate inverse relationships were found between measured LVEF and IS. Based on IS and LVEF an IS estimated LVEF was derived and an MI–LVEF mismatch index was calculated as the difference between measured LVEF and IS estimated LVEF. In 41 (74.5%) of the patients there was agreement between the ECG and CMR indices in regards to categorizing indices as > 10 or ≤ 10 and generally no significant difference was detected, mean difference of 1.26 percentage points (p = 0.53).

Conclusion

The study found an overall good agreement between MI–LVEF mismatch indices based on ECG and CMR. The MI–LVEF mismatch index may serve as a tool to identify patients with potentially reversible dysfunctional but viable myocardium, but future studies including both ECG and CMR are needed.     

Vitamin D and prognosis in acute myocardial infarction

Background

Vitamin D status (VDS) has been linked to mortality and incident acute myocardial infarction (AMI) in healthy cohorts. Associations with recurrent adverse cardiovascular events in those with cardiovascular disease are less clear. Our objective was to assess the prevalence and prognostic impact of VDS on patients presenting with AMI.

Methods

We measured plasma 25-(OH)D₃ and 25-(OH)D₂ using isotope dilution tandem mass spectrometry, in 1259 AMI patients (908 men, mean age 65.7 ± 12.8 years). The primary endpoint was major adverse events (MACE), a composite of death (n = 141), heart failure hospitalisation (n = 111) and recurrent AMI (n = 147) over median follow-up of 550 days (range 131–1095). Secondary endpoints were fatal and non-fatal MACE.

Results

Almost 74% of the patients were vitamin D deficient (< 20 ng/ml 25-(OH)D). Plasma 25-(OH)D existed mainly as 25-(OH)D₃ which varied with month of recruitment. Multivariable survival Cox regression models stratified by recruitment month (adjusted for age, gender, past history of AMI/angina, hypertension, diabetes, hypercholesterolaemia, ECG ST change, Killip class, eGFR, smoking, plasma NTproBNP), showed 25-(OH)D₃ quartile as an independent predictor of MACE(P < 0.001) and non-fatal MACE(P < 0.01), but not death. Using the lowest 25-(OH)D₃ quartile(< 7.3 ng/ml) as reference for MACE prediction, the 2nd, 3rd and 4th quartiles showed significantly lower hazard ratios (HR 0.59(P < 0.002), 0.58(P < 0.001), and 0.59(P < 0.003) respectively). For non-fatal MACE prediction, the 2nd, 3rd and 4th 25-(OH)D₃ quartiles were all significantly different from the lowest reference quartile (HR 0.69(P < 0.05), 0.54(P < 0.003) and 0.59(P < 0.014) respectively).

Conclusions

VDS is prognostic for MACE (predominantly non-fatal MACE) post-AMI, with approximate 40% risk reduction for 25-(OH)D₃ levels above 7.3 ng/ml.     

High post-clopidogrel platelet reactivity assessed by a point-of-care assay predicts long-term clinical outcomes in patients with ST-segment elevation myocardial infarction who underwent primary coronary stenting

Background

Recent studies have shown that post-clopidogrel high platelet reactivity (HPR), assessed by a point-of-care assay, is associated with a higher risk of adverse events after percutaneous coronary intervention (PCI). We assessed the clinical impact of HPR by the VerifyNow P2Y12 point-of-care assay in 181 patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary PCI with drug-eluting stents (DES) at 3 hospitals.

Methods

The primary endpoint of the study was the 12-month major adverse cardiovascular events (MACE), which comprised cardiovascular death, nonfatal MI and ischemic stroke. All patients received a single loading dose of 600 mg clopidogrel and 300 mg aspirin followed by a daily maintenance dose of 75 mg clopidogrel and 100 mg aspirin.

Results

A P2Y12 reaction unit (PRU) ≥ 282 (AUC 0.719, 95% CI 0.588–0.851, p = 0.004, sensitivity 68.8%, specificity 73.8%) was the optimal cut-off value in predicting 12-month MACE by receiver operating characteristic curve analysis. Occurrence of MACE was significantly more frequent in patients with HPR (PRU ≥ 282) compared to patients without HPR (20.4% vs. 3.9%, HR 6.24, 95% CI 2.05–18.99, p = 0.001). By multivariate analysis, HPR (HR 3.84, 95% CI 1.17–12.58, p = 0.026) and elderly patients above 80 years of age (HR: 8.13, 95% CI 1.79–37.03, p = 0.007) were found to be the significant predictors of 12-month MACE. The MACE-free survival rate was significantly lower in patients with HPR compared to patients without HPR (p < 0.001).

Conclusion

HPR assessed by a point-of-care assay was able to predict 12-month MACE in patients with STEMI who underwent primary PCI with DES.     

Prognostic implications of quantitative evaluation of baseline Q-wave width in ST-segment elevation myocardial infarction

Objectives

To evaluate quantitative relationships between baseline Q-wave width and 90-day outcomes in ST-segment elevation myocardial infarction (STEMI).

Background

Baseline Q-waves are useful in predicting clinical outcomes after MI.

Methods

3589 STEMI patients were assessed from a multi-centre study.

Results

1156 patients of the overall cohort had pathologic Q-waves. The 90-day mortality and the composite of mortality, congestive heart failure (CHF), or cardiogenic shock (p < 0.001 for both outcomes) rose as Q-wave width increased. After adapting a threshold ≥ 40 ms for inferior and ≥ 20 ms for lateral/apical MI in all patients (n = 3065) with any measureable Q-wave we found hazard ratios (HR) for mortality (HR: 2.44, 95% confidence interval (CI) (1.54–3.85), p < 0.001) and the composite (HR: 2.32, 95% CI (1.70–3.16), p < 0.001). This improved reclassification of patients experiencing the composite endpoint versus the conventional definition (net reclassification index (NRI): 0.23, 95% CI (0.09-0.36), p < 0.001) and universal MI definition (NRI: 0.15, 95% CI (0.02–0.29), p = 0.027).

Conclusions

The width of the baseline Q-wave in STEMI adds prognostic value in predicting 90-day clinical outcomes. A threshold of ≥ 40 ms in inferior and ≥ 20 ms for lateral/apical MI enhances prognostic insight beyond current criteria.     

Angiographic assessment of myocardial perfusion in Tako-Tsubo syndrome

Objectives

To angiographically assess myocardial perfusion in patients with Tako-Tsubo syndrome (TTS) in comparison with control individuals and patients with ST-elevation myocardial infarction (STEMI).

Background

Coronary microvascular dysfunction has been proposed as the pathophysiological mechanism underlying TTS.

Methods

We retrospectively selected consecutive TTS patients showing typical left ventricular (LV) apical dysfunction admitted to our Department in the period 2007–2011 (n = 25). We also enrolled an age and gender-matched control group showing normal coronary arteries (CTR, n = 25), patients with STEMI undergoing primary percutaneous intervention with myocardial reperfusion (SR, n = 25) or microvascular obstruction (SMVO, n = 25). TIMI flow, TIMI frame count (TFC) and both qualitative and quantitative myocardial blush grade in LV apex were assessed. Specifically, myocardial perfusion was quantitatively evaluated using ‘Quantitative Blush Evaluator’ (QuBE), an open source software previously validated in the setting of STEMI.

Results

In TTS, TIMI flow on the LAD was significantly lower and TFC significantly higher compared to CTR and SR (p = 0.008 for both), while it did not significantly differ compared to SMVO (p = 0.06). In TTS, MBG was significantly lower than that in CTR and SR (p = 0.001 for both), while it was significantly higher than that in SMVO (p < 0.001). In TTS, QuBE score was significantly lower than that in CTR and SR (p = 0.001 for both) and higher than in SMVO (p = 0.02).

Conclusions

Our data indicate that myocardial perfusion assessed during angiography is more impaired in patients with TTS than in patients with STEMI exhibiting myocardial reperfusion, while it is less impaired than in patients with STEMI exhibiting MVO.     

Safety and diagnostic accuracy of stress cardiac magnetic resonance imaging vs exercise tolerance testing early after acute ST elevation myocardial infarction

Objective

To determine the safety and diagnostic accuracy of adenosine‐stress cardiac magnetic resonance (CMR) perfusion imaging early after acute ST elevation myocardial infarction (STEMI) compared with standard exercise tolerance testing (ETT).

Design and setting

Cross sectional observational study in a university teaching hospital.

Patients

35 patients admitted with first acute STEMI.

Interventions

All patients underwent a CMR imaging protocol which included rest and adenosine‐stress perfusion, viability, and cardiac functional assessment. All patients also had an ETT (modified Bruce protocol) and x ray coronary angiography.

Main outcome measures

Safety and diagnostic accuracy of adenosine‐stress perfusion CMR vs ETT early after STEMI in identifying patients with significant coronary stenosis (⩾70%) and the need for coronary revascularisation. Also, to determine if CMR can distinguish between ischaemia in the peri‐infarct zone and ischaemia in remote myocardium.

Results

CMR imaging was well tolerated (all patients completed the protocol) and no complications occurred. CMR was more sensitive (86% vs 48%, p = 0.0074) and more specific than ETT (100% vs 50%, p<0.0001) for detecting significant coronary stenosis, and more sensitive for predicting revascularisation (94% vs 56%, p = 0.039). Inducible ischaemia in the infarct related artery territory was seen in 21 of 35 patients and was associated with smaller infarct size and less transmurality of infarction.

Conclusions

Adenosine‐stress CMR imaging is safe early after acute STEMI and identifies patients with significant coronary stenosis more accurately than ETT.     

Prognostic significance of elevated lipoprotein(a) in coronary artery revascularization patients

Background

Although lipoprotein(a) [Lp(a)] has been considered a cardiovascular risk factor for many years, there is a paucity of data in regard to the potential risk of elevated Lp(a) in symptomatic patients with CAD. Therefore, we sought to evaluate whether elevated Lp(a) is associated with worse outcome in symptomatic patients with coronary artery disease (CAD), and to clarify the prognostic value of Lp(a) in the era of coronary artery revascularization.

Methods

6252 consecutive subjects (59.2% male, mean age 61.2 ± 11.2 years) suspected of having CAD underwent coronary angiography. Laboratory values for lipid parameters including Lp(a) were obtained on the day of coronary angiography. Baseline risk factors, coronary angiographic findings, length of follow-up, and major adverse cardiovascular events (MACE), including cardiac death and non-fatal myocardial infarction were recorded.

Results

Over a mean follow-up period of 3.1 ± 2.2 years, there were 100 MACE (56 cardiac deaths and 44 non-fatal myocardial infarctions), with an event rate of 1.6%. In multivariate Cox regression analysis, elevated Lp(a) was a significant predictor of MACE [hazard ratio 1.773 (95% confidence interval 1.194–2.634, p = 0.005)], and the addition of this factor to the model significantly increased the global х² value over traditional risk factors and CAD (from 79.1 to 88.7, p = 0.003).

Conclusions

Elevated Lp(a) is an independent prognostic risk factor for cardiovascular events, and moreover, has incremental prognostic value in symptomatic patients with coronary artery revascularization.     

Fever after primary percutaneous coronary intervention in ST-segment elevation myocardial infarction is associated with adverse outcomes

Background

Fever is a common finding after primary percutaneous coronary intervention (PPCI) in patients with ST-segment elevation myocardial infarction (STEMI). However, its prognostic value is not validated yet.

Objectives

This study sought to evaluate the impact of fever after PPCI in STEMI on adverse clinical outcomes.

Methods

Five hundred fourteen consecutive patients who underwent PPCI due to STEMI were enrolled. Body temperature (BT) was checked every 6 h for 5 days after PPCI. Patients were divided into two groups according to the highest quartile of peak BT; peak BT ≤ 37.6 °C (control group) and peak BT > 37.6 °C (fever group). Rates of 1-year major adverse cardiovascular events (MACE; death, myocardial infarction, any revascularization) were compared.

Results

The prevalence of fever group (peak BT > 37.6 °C) was 24.7% (127/514). White blood cell count, highly sensitive C-reactive protein and serum cardiac troponin I level were higher in fever group than control group (12,162 ± 4199/μL vs. 10,614 ± 3773/μL, p < 0.001; 22.9 ± 49.4 mg/L vs. 7.4 ± 2.5 mg/L, p = 0.001, 16.7 ± 36.9 ng/dl vs. 8.70 ± 26.2 ng/dl, p = 0.027, respectively). The frequency of a history of previous myocardial infarction and left ventricular ejection fraction was lower in fever group (0.0% vs. 4.7%, p = 0.010; 47 ± 8 % vs. 49 ± 9 %, p = 0.002, respectively). There was no significant difference in angiographic characteristics between 2 groups. 1-year MACE rates were higher in fever group (11.0% vs. 4.7%, p = 0.010). Multivariate analysis revealed fever (OR 2.358, 95% CI 1.113–4.998, p = 0.025), diabetes mellitus as risk factor (2.227, 1.031–4.812, 0.042), and left anterior descending artery as infarct related artery (2.443, 1.114–5.361, 0.026) as independent predictors for 1-year MACE.

Conclusions

Fever after PPCI in patients with STEMI is frequently developed and it can predict adverse clinical outcome.     

Early eicosapentaenoic acid treatment after percutaneous coronary intervention reduces acute inflammatory responses and ventricular arrhythmias in patients with acute myocardial infarction: A randomized,controlled study

Objective

We examined whether early loading of eicosapentaenoic acid (EPA) reduces clinical adverse events by 1 month, accompanied by a decrease in C-reactive protein (CRP) values in patients with acute myocardial infarction (MI).

Background

Acute MI triggers an inflammatory reaction, which plays an important role in myocardial injury. EPA could attenuate the inflammatory response.

Methods

This prospective, open-label, blinded endpoint, randomized trial consisted of 115 patients with acute MI. They were randomly assigned to the EPA group (57 patients) and the control group (58 patients). After percutaneous coronary intervention (PCI), 1800 mg/day of EPA was initiated within 24 h. The primary endpoint was composite events, including cardiac death, stroke, re-infarction, ventricular arrhythmias, and paroxysmal atrial fibrillation within 1 month.

Results

Administration of EPA significantly reduced the primary endpoint within 1 month (10.5 vs 29.3%, p = 0.01), especially the incidence of ventricular arrhythmias (7.0 vs 20.6%, p = 0.03). Peak CRP values after PCI in the EPA group were significantly lower than those in the control group (median [interquartile range], 8.2 [5.6–10.2] mg/dl vs 9.7 [7.6–13.9] mg/dl, p < 0.01). Logistic regression analysis showed that EPA use was an independent factor related to ventricular arrhythmia until 1 month, with an odds ratio of 0.29 (95% confidence interval, 0.09 to 0.96, p = 0.04).

Conclusions

Early EPA treatment after PCI in the acute stage of MI reduces the incidence of ventricular arrhythmias, and lowers CRP values.     

Impact of intra-aortic balloon pump support initiated before versus after primary percutaneous coronary intervention in patients with cardiogenic shock from acute myocardial infarction

Background

Little evidence is available on the optimal sequence of intra-aortic balloon pump (IABP) support initiation and primary percutaneous coronary intervention (PCI) in patients who present with cardiogenic shock from ST-elevation myocardial infarction (STEMI). The aim of this study was to evaluate the order of IABP insertion and primary PCI and its association with infarct size and mortality.

Methods

A series of 173 consecutive patients admitted with cardiogenic shock from STEMI and treated with primary PCI and IABP between 2000 and 2009 were included. The order of IABP insertion and primary PCI was left at the discretion of the interventional cardiologist.

Results

All baseline characteristics were similar in patients who first received IABP (n = 87) and patients who received IABP directly after PCI (n = 86). In these two groups, cumulative 30-day mortality was 44% and 37% respectively (p = 0.39). Median peak serum creatine kinase (CK) concentrations were 5692 U/l and 4034 U/l respectively (p = 0.048). In multivariable analysis, IABP insertion before PCI was independently associated with higher CK levels (p = 0.046). In patients who survived 30 days, IABP insertion before PCI was not associated with late mortality evaluated at five years of follow-up (HR1.5, 95% CI 0.7–3.3; p = 0.34).

Conclusions

Early IABP insertion before primary PCI might be associated with higher peak CK levels, indicating a larger infarct size. A possible explanation may be the increased reperfusion delay. Our study suggests that early reperfusion could have priority over routine early IABP insertion in STEMI patients with cardiogenic shock. Randomized studies are needed to determine the optimal timing of IABP insertion relative to primary PCI.     

Usefulness of endothelin-1 assessment in acute myocardial infarction

Introduction and objectives

High endothelin-1 (ET-1) levels have been linked to poor clinical outcomes after ST-segment elevation myocardial infarction (STEMI). Vasoconstriction of the coronary microcirculation seems to be the underlying mechanism. The aim of the study was to assess the effect of ET-1 on microvascular integrity, infarct size, left ventricular ejection fraction (LVEF) and myocardial salvage in evolving myocardial infarction (MI).

Methods

We measured ET-1 levels acutely (6-24 h) in 127 patients presenting with their first STEMI. Contrast-enhanced cardiac magnetic resonance (ce-CMR) was performed in 94 patients within 1 week to assess microvascular obstruction (MO), infarct size and LVEF. A myocardial salvage index (MSI) was defined as the percentage of at-risk angiographic area without necrosis on the ce-CMR.

Results

Mean age was 60.9 ± 11.8 years and 98 (77%) were males. Median ET-1 level within the first 24 h was 6.8 pg/mL (25^th -75^th percentile range: 5.4-8.5 pg/mL). Patients with ET-1 concentrations over the median presented higher percentage of MO (77.7% for ET-1 > 6.8 pg/mL vs. 16.6% for ET-1 ≤ 6.8 pg/mL, P < .001) and lower MSI values (13.8 ± 26% for ET-1 > 6.8 pg/mL vs. 37.4 (26%) for ET-1 ≤ 6.8 pg/mL, P = .02). ET-1 levels did not show a significant association with infarct size (P = .11) and LVEF (P = .16). Multivariate analysis found ET-1 to be a significant predictor of MO (OR = 2.78; CI 95% 1.16-6.66; P = .021) and MSI ≤ Percentile 25 (OR = 1.69, CI 95% 1.01-2.81; P = .04).

Conclusions

High ET-1 levels after myocardial infarction are associated with the presence of microvascular obstruction and lower myocardial salvage index.Full English text available from: www.revespcardiol.org