Impacto del bloqueo del sistema renina-angiotensina en el pronóstico del síndrome coronario agudo en función de la fracción de eyección

Introduction and objectivesFor patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI), it is unclear whether angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) are associated with reduced mortality, particularly with preserved left ventricular ejection fraction (LVEF). The goal of this study was to determine the association between ACEI/ARB and mortality in ACS patients undergoing PCI, with and without reduced LVEF.MethodsData from the BleeMACS registry were used. The endpoint was 1-year all-cause mortality. The prognostic value of ACEI/ARB was tested after weighting by survival-time inverse probability and after adjustment by Cox regression, propensity score, and instrumental variable analysis.ResultsAmong 15 401 ACS patients who underwent PCI, ACEI/ARB were prescribed in 75.2%. There were 569 deaths (3.7%) during the first year after hospital discharge. After multivariable adjustment, ACEI/ARB were associated with lower 1-year mortality, ≤ 40% (HR, 0.62; 95%CI, 0.43-0.90; P = .012). The relative risk reduction of ACEI/ARB in mortality was 46.1% in patients with LVEF ≤ 40%, and 15.7% in patients with LVEF > 40% (P value for treatment-by-LVEF interaction = .008). For patients with LVEF > 40%, ACEI/ARB was associated with lower mortality only in ST-segment elevation myocardial infarction (HR, 0.44; 95%CI, 0.21-0.93; P = .031).ConclusionThe benefit of ACEI/ARB in decreasing mortality after an ACS in patients undergoing PCI is concentrated in patients with LVEF ≤ 40%, and in those with LVEF > 40% and ST-segment elevation myocardial infarction. In non–ST-segment elevation-ACS patients with LVEF > 40%, further studies are needed to assess the prognostic impact of ACEI/ARB.     

Evaluation of the impact of chronic kidney disease on the survival of octogenarian patients submitted to percutaneous coronary intervention

ObjectiveTo evaluate the impact of chronic kidney disease on the survival of patients – 80 years of age undergoing percutaneous coronary intervention (PCI) in the long term.Methods273 subjects who underwent PCI between January 2010 and January 2016 were divided into four categories: (1) stable angina (SA) and creatinine clearance – 30 (n = 24); (2) patients with SA and CrCl <30 (n = 70); (3) patients with acute coronary syndrome (ACS) and CrCl – 30 (n = 51); (4) patients with ACS and ICC <30 (n = 128). Mortality curves were evaluated using the Kaplan-Meier method and differences between groups were compared by log-rank statistic. Multivariate analysis was performed using the Cox proportional hazards method. The 4 groups were compared and the survival between the groups was evaluated.ResultsOctogenarian patients with CrCl <30 with SA and ACS have lower long-term survival (p < 0.0001).ConclusionCKD has a worse long-term prognosis for patients undergoing PCI.     

Angioplastie coronaire dans les syndromes coronariens aigus en Côte d’Ivoire : difficultés et résultats

AimAssess the challenges and outcomes of percutaneous coronary intervention (PCI) in the management of ACS at Abidjan Heart Institute.Patients and methodsProspective survey carried out from April, 1st, 2010 to April, 29th, 2016. Whole patients aged 18-year-old, admitted at Abidjan Heart Institute for ACS, and who underwent PCI were included in the Registre prospectif des actes de cardiologie interventionnelle de l’institut de cardiologie d’Abidjan (REPACI). Indications and outcomes of PCI were analyzed.ResultsSeven hundred and forty-nine patients were admitted for ACS, of which 165 underwent PCI. Ratio PCI/ACS was 0.22. Mean age was 55.6 ± 9.8 years. Male were predominant (sex-ratio = 12.7). Main clinical presentation was ST-elevation myocardial infarction (STEMI) in 75.1% of cases. One-vessel disease was predominant in STEMI (52.4%), and multi-vessel disease in non-ST-segment elevation acute coronary syndromes (NSTE-ACS) (51.2%). Most of patients (86.7%) underwent PCI with stent implantation. PCI was performed successfully in 97.0% of cases. Main non-fatal complications were hematoma (2.4%). In-hospital mortality-rate was 1.2%, and one-year mortality-rate was 1.6%.ConclusionPCI is performed in Subsaharan Africa with safety, despite encountered difficulties in its implementation.     

Impact of admission glycemia and glycosylated hemoglobin A1c on long-term clinical outcomes of non-diabetic patients with acute coronary syndrome

BackgroundAdmission glucose levels have proven to be a predictor in patients with acute myocardial infarction and elevated glycosylated hemoglobin A1c (HbA1c) is associated with an increased risk of cardiovascular disease, even in patients without diabetes. However, the effect of both admission glucose and HbA1c levels on clinical outcomes in non-diabetic patients with acute coronary syndrome (ACS) has not been fully elucidated. We evaluated the combined effect of admission glucose and HbA1c values on long-term clinical outcomes in non-diabetic patients with ACS treated with percutaneous coronary intervention (PCI).Methods and resultsThis was an observational study of 452 consecutive non-diabetic patients with ACS who underwent PCI between January 1997 and December 2006. The patients were assigned to four groups according to the median values of admission glucose and HbA1c. The primary endpoint comprising a composite of all-cause death and non-fatal MI was compared among the four groups. The primary endpoint occurred in 13.3% of the participants during a median follow-up period of 4.7 years. The cumulative incidence rate of primary endpoint significantly differed among the groups (p = 0.048). Multivariable Cox regression analysis showed that the combination of elevated admission glucose and HbA1c was independently associated with long-term clinical outcomes.ConclusionsCombined admission glucose and HbA1c values were independently associated with clinical outcomes in non-diabetic patients with ACS treated with PCI.     

Remote ischemic preconditioning for prevention of contrast induced nephropathy—Insights from an Indian study

ObjectivesTo study if four cycles of remote ischemic preconditioning (RIPC) could offer protection against contrast induced nephropathy (CIN) and post procedural renal dysfunction in high risk patients undergoing percutaneous coronary intervention (PCI).MethodsThis was a prospective single blind randomized sham controlled trial where patients undergoing coronary angioplasty with stage III chronic kidney disease were randomized into sham preconditioning and remote ischemic preconditioning. The primary outcome was the reduction in the incidence of CIN. The secondary outcomes were the maximum improvement in eGFR, maximum reduction in serum creatinine and composite of requirement of hemodialysis, death and rehospitalization for heart failure up to 6 weeks after PCI.ResultsEleven out of fifty patients in the study group developed CIN (22%) compared to eighteen out of the fifty control patients (36%) (p = 0.123). There was a statistically significant improvement in the post procedure creatinine values at 24 h (p = 0.013), 48 h (p = 0.015), 2 weeks (p = 0.003), 6 weeks (p = 0.003) and post procedure glomerular filtration rate (eGFR) values at 24 h (p = 0.026), 48 h (p = 0.044), 2 weeks (p = 0.015) and 6 weeks (p = 0.011) in study group compared to control group. The secondary outcome composite of requirement of hemodialysis, death and rehospitalization for heart failure was not statistically significant (p: 0.646).ConclusionRIPC does not result in significant reduction of CIN. However RIPC helps in the prevention of post procedural worsening in eGFR and serum creatinine even up to 6 weeks.     

Preloading with atorvastatin before percutaneous coronary intervention in statin-naïve Asian patients with non-ST elevation acute coronary syndromes: A randomized study

BackgroundData on atorvastatin pretreatment in Asian patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) are limited. However, there have been studies in other populations in Asia which demonstrated that statins can reduce the risk of periprocedural myocardial infarction (MI).Methods and resultsStatin-naïve patients with non-ST-segment-elevation (NSTE)-ACS scheduled for PCI were randomized to usual care or atorvastatin preloading groups. All patients received usual care including atorvastatin 40 mg/day. The atorvastatin group received atorvastatin 80 mg 12 h and 40 mg 2 h pre-PCI. Of 499 patients randomized, 247 were assigned to atorvastatin preloading. Following coronary angiography, 335 patients (163 atorvastatin) received PCI. During the 30 days post-PCI, major adverse cardiac events (death, MI, and target vessel revascularization) occurred in 24 (15%) atorvastatin and 27 (16%) usual care patients (p = NS). Post hoc analyses showed that at 8 h post-PCI, 3.82% of the atorvastatin group and 7.22% of the usual care group had a post-procedural creatine kinase-myocardial band (CK-MB) above 3 times the upper limit of normal (p = 0.27) and at 24 h post-PCI, the rate was 7.64% versus 9.47% (p = 1.0). Safety profile suggests that high-dose atorvastatin (40 mg) for up to 1 month, in conjunction with usual care, is relatively safe and well tolerated.ConclusionsThis study of statin-naïve Korean and Chinese patients with NSTE-ACS who received additional atorvastatin loading doses of 80 mg at 12 h, and 40 mg at 2 h, pre-PCI did not find a beneficial effect compared with usual post-PCI atorvastatin 40 mg/day treatment. Atorvastatin was found to be well tolerated in Asian patients with NSTE-ACS undergoing PCI. Results of the current study merit further investigation of the early use of statins in patients with NSTE-ACS to delineate patient subgroups who may benefit from this therapy.     

Trends in epidemiology and the treatment of acute coronary syndromes in the Czech Republic: Comparison of the CZECH-1 and CZECH-2 registries

BackgroundThe clinical spectrum of acute coronary syndrome (ACS) has changed due to a progressively ageing population over the last two decades.AimWe analysed the changes in the epidemiological and treatment strategies between two large registries that were performed in 2005 and 2012 in well-defined populations of the Czech Republic.Methods and resultsThe CZECH-1 and CZECH-2 registries enrolled all consecutive hospitalized patients with an initial diagnosis of ACS during a 1 or 2-month period, respectively. Thirty-six and 32 hospitals participated in the CZECH-1 and CZECH-2 registries, respectively. A total of 1921 patients were enrolled in the CZECH-1 registry and 1221 patients participated in the CZECH-2 registry. Patients enrolled in the CZECH-2 registry were older than those in CZECH-1 (68 ± 12 vs. 66 ± 12 years; p < 0.001). ACS was not confirmed during hospitalization in 30.5 and 30.1% (p > 0.05) of the patients in the CZECH-1 and CZECH-2 registries, respectively. Urgent angiography in patients with ST segment elevation myocardial infarction (STEMI) was performed in 92 and 94% of the patients (p > 0.05), respectively; of these, 87 and 89% subsequently underwent primary PCI. There were no signifiant differences in in-hospital (4.2 vs. 4.4%, p=0.805) or in the mortality of patients with a final diagnosis of Q-myocardial (10.3 vs. 10.7%; p = 0.870) or non-Q-myocardial infarction (4.7 vs. 3.8%; p = 0.497) between the two registries. The estimated incidence of confirmed ACS and STEMI in a representative population from both registries was 3248 and 661 cases/million individuals/year in the CZECH-1 registry and 2149 and 652 cases/million individuals/year in the CZECH-2 registry. The fall in ACS incidence was almost exclusively due to a significant decrease in the incidence of unstable angina as the final diagnosis. At discharge, the patients with confirmed ACS were administered the following medications: aspirin (95 vs. 94%; p > 0.05), clopidogrel (60 vs. 76.4%; p < 0.001), beta-blockers (78 vs. 78%; p > 0.05), angiotensin-converting enzyme (ACE) inhibitors (50 vs. 78%; p = <0.001) and statins (75 vs. 90%; p < 0.001) in the CZECH-1 and CZECH-2 registries, respectively.ConclusionIn the Czech Republic, the age of the patients hospitalized with ACS increased between 2005 and 2012. Invasive reperfusion strategy for patients with STEMI was very high in both registries. The overall outcome in patients with confirmed ACS did not change between 2005 and 2012. The estimated incidence of ACS decreased due to the fall in unstable angina pectoris.     

Comparación de seguridad y efectividad entre los accesos radiales derecho e izquierdo en la intervención coronaria percutánea

Introduction and objectivesThere is a paucity of data comparing the left radial approach (LRA) and right radial approach (RRA) for percutaneous coronary intervention (PCI) in all-comers populations and performed by operators with different experience levels. Thus, we sought to compare the safety and clinical outcomes of the RRA and LRA during PCI in “real-world” patients with either stable angina or acute coronary syndrome (ACS).MethodsTo overcome the possible impact of the nonrandomized design, a propensity score was calculated to compare the 2 radial approaches. The study group comprised 18 716 matched pairs with stable angina and 46 241 with ACS treated with PCI and stent implantation between 2014 and 2017 in 151 tertiary invasive cardiology centers in Poland (the ORPKI Polish National Registry).ResultsThe rates of death and periprocedural complications were similar for the RRA and LRA in stable angina patients. A higher radiation dose was observed with PCI via the LRA in both clinical presentations (stable angina: 1067.0 ± 947.1 mGy vs 1007.4 ± 983.5 mGy, P = .001; ACS: 1212.7 ± 1005.5 mGy vs 1053.5 ± 1029.7 mGy, P = .001). More contrast was used in LRA procedures but only in ACS patients (174.2 ± 75.4 mL vs 167.2 ± 72.1 mL, P = .001). Furthermore, periprocedural complications such as coronary artery dissection (0.16% vs 0.09%, P = .008), no-reflow phenomenon (0.65% vs 0.49%, P = .005), and puncture site bleeding (0.09% vs 0.05%, P = .04) were more frequently observed with the LRA in ACS patients. There was no difference in mortality between the 2 groups (P = .90).ConclusionsOur finding of poorer outcomes with the LRA may be related to lower operator experience with this approach. While both the LRA and RRA are safe in the setting of stable angina, the LRA was associated with a higher rate of periprocedural complications during PCI in ACS patients.Full English text available from:www.revespcardiol.org/en     

Resultados intrahospitalarios tras tratamiento percutáneo frente a quirúrgico en pacientes con estenosis aórtica y enfermedad arterial coronaria concomitante

Introduction and objectivesConcomitant coronary artery disease (CAD) is prevalent among aortic stenosis patients; however the optimal therapeutic strategy remains debated. We investigated periprocedural outcomes among patients undergoing transcatheter aortic valve implantation with percutaneous coronary intervention (TAVI/PCI) vs surgical aortic valve replacement with coronary artery bypass grafting (SAVR/CABG) for aortic stenosis with CAD.MethodsUsing discharge data from the Spanish National Health System, we identified 6194 patients (5217 SAVR/CABG and 977 TAVI/PCI) between 2016 and 2019. Propensity score matching was adjusted for baseline characteristics. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were in-hospital complications and 30-day cardiovascular readmission.ResultsMatching resulted in 774 pairs. In-hospital all-cause mortality was more common in the SAVR/CABG group (3.4% vs 9.4%, P < .001) as was periprocedural stroke (0.9% vs 2.2%; P = .004), acute kidney injury (4.3% vs 16.0%, P < .001), blood transfusion (9.6% vs 21.1%, P < .001), and hospital-acquired pneumonia (0.1% vs 1.7%, P = .001). Permanent pacemaker implantation was higher for matched TAVI/PCI (12.0% vs 5.7%, P < .001). Lower volume centers (< 130 procedures/y) had higher in-hospital all-cause mortality for both procedures: TAVI/PCI (3.6% vs 2.9%, P < .001) and SAVR/CABG (8.3 vs 6.8%, P < .001). Thirty-day cardiovascular readmission did not differ between groups.ConclusionsIn this large contemporary nationwide study, percutaneous management of aortic stenosis and CAD with TAVI/PCI had lower in-hospital mortality and morbidity than surgical intervention. Higher volume centers had less in-hospital mortality in both groups. Dedicated national high-volume heart centers warrant further investigation.     

Hyperuricemia in acute heart failure. More than a simple spectator?

BackgroundHyperuricemia is a prevalent condition in chronic heart failure (CHF), describing increased oxidative stress and inflammation. Although there is evidence that serum uric acid (UA) predicts mortality in CHF, its role as a prognostic biomarker in acute heart failure (AHF) has not yet been well assessed. The aim of this study was to determine if UA levels predict all-cause mortality. Additionally, as a secondary endpoint we sought the clinical predictors of UA serum level in this population.MethodsWe analyzed 560 consecutive patients with AHF admitted in a single university center. UA (mg/dl) was measured during early hospitalization. Patient survival status was followed up after discharge (median follow-up: 330 days). The independent association of UA level with all-cause mortality was analyzed using Cox regression analysis.ResultsDuring follow-up 165 (29.5%) deaths were identified. Patients with UA levels above the median value (≥ 7.7 mg/dl) exhibited higher mortality rates (21.1 vs. 37.9%; p < 0.001). In multivariable analysis, after adjusting for recognized prognostic factors and potential confounders, UA ≥ 7.7 mg/dl and per change in 1 mg/dl of UA was associated with an increased risk of mortality (HR 1.45, CI 95% = 1.03–2.44; p = 0.03 and HR 1.08, CI 95% = 1.01–1.15; p = 0.03, respectively).ConclusionUA serum levels is an independent predictor of all-cause mortality in an unselected patients admitted with AHF.     

Eficacia de la tromboaspiración en pacientes con shock cardiogénico secundario a infarto agudo de miocardio y alta carga trombótica

Introduction and objectivesCurrent guidelines do not recommend routine thrombus aspiration in acute myocardial infarction (AMI) because no benefits were observed in previous randomized trials. However, there are limited data in cardiogenic shock (CS) complicating AMI.MethodsWe included 575 patients with AMI complicated by CS. The participants were stratified into the TA and no-TA groups based on use of TA. The primary outcome was a composite of 6-month all-cause death or heart failure rehospitalization. The efficacy of TA was additionally assessed based on thrombus burden (grade I-IV vs V).ResultsNo significant difference was found in in-hospital death (28.9% vs 33.5%; P = .28), or 6-month death, or heart failure rehospitalization (32.4% vs 39.4%; HR_adj: 0.80; 95%CI, 0.59-1.09; P = .16) between the TA and no-TA groups. However, in 368 patients with a higher thrombus burden (grade V), the TA group had a significantly lower risk of 6-month all-cause death or heart failure rehospitalization than the no-TA group (33.4% vs 46.3%; HR_adj: 0.59; 95%CI, 0.41-0.85; P = .004), with significant interaction between thrombus burden and use of TA for primary outcome (adjusted P_int = .03).ConclusionsRoutine use of TA did not reduce short- and mid-term adverse clinical outcomes in patients with AMI complicated by CS. However, in select patients with a high thrombus burden, the use of TA might be associated with improved clinical outcomes. The study was registered at ClinicalTrials.gov (Identifier: NCT02985008).     

Comparison effectiveness of acute coronary syndrome treatments on geriatric function

ObjectivesThe study objectives were to compare short time complications, mortality, and effectiveness of primary Percutaneous Coronary Intervention (PCI) with optimal medical therapy in older adults with acute coronary syndromes (ACS).MethodsA prospective cohort study, which patients 60 years old and over with ACS were collecting by face to face interview and assessment of the electronic document, in two educational hospitals of Tehran medical university from May 2018 to Jan. 2019. Patients were evaluated in two groups (primary PCI and medical) in terms of complications, mortality and effectiveness, 24 hours and 30 days after treatment. Initially, 312 patients were enrolled in the study that 192 were excluded for different reasons. In the final, 120 patients have met all inclusion criteria.ResultsOne hundred and twenty patients were collected with mean age 71.2 ± 8.2 years old. In both groups every 1 point increase in Instrumental Activity Daily Living (IADL), the Major Adverse Cardiac Effect (MACE) was significantly reduced up to 88% (P = 0.007). Short-term mortality was significantly higher in the optimal medical therapy group (P = 0.006). In comparison complications 24 hours between two groups, atrial fibrillation was significantly higher in the medical group which risk increased 11 times (OR = 10.93, CI 95% = 1.38–87.04, P = 0.02).ConclusionsNotwithstanding, primary PCI reduced poor outcomes, and improve quality of life, but a lesser option for older adult patients. Primary PCI in older adult patients could maintain independence in functional daily living that results in reduced mortality and MACE considerably.     

Impact of diabetes on hospital adverse cardiovascular outcomes in acute coronary syndrome patients: Data from the Saudi project of acute coronary events

BackgroundDiabetes mellitus (DM) is a major public health problem in Saudi Arabia. DM patients who present with acute coronary syndrome (ACS) have worse cardiovascular outcomes. We characterized clinical features and hospital outcomes of diabetic patients with ACS in Saudi Arabia.MethodsACS patients enrolled in the Saudi Project for Assessment of Acute Coronary Syndrome (SPACE) study from December 2005 to December 2007, either with DM or newly diagnosed during hospitalization were eligible. Baseline demographics, clinical presentation, therapies, and in-hospital outcomes were compared with non-diabetic patients.ResultsOf the 5055 ACS patients enrolled in SPACE, 2929 (58.1%) had DM (mean age 60.2 ± 11.5, 71.6% male, and 87.6% Saudi nationals). Diabetic patients had higher risk-factor (e.g., hypertension, hyperlipidemia) prevalences and were more likely to present with non–ST-elevation myocardial infarction (40.2% vs. 31.4%, p < 0.001), heart failure (25.4% vs. 13.9%, p < 0.001), significant left ventricular systolic dysfunction and multi-vessel disease. Diabetic patients had higher in-hospital heart failure, cardiogenic shock, and re-infarction rates. Adjusted odds ratio for in-hospital mortality in diabetic patients was 1.83 (95% CI, 1.02–3.30, p = 0.042).ConclusionsA substantial proportion of Saudi patients presenting with ACS have DM and a significantly worse prognosis. These data highlight the importance of cardiovascular preventative interventions in the general population.     

Short- and Long-Term Outcomes in Patients With New-Onset Persistent Left Bundle Branch Block After Transcatheter Aortic Valve Replacement

BackgroundThe impact of new-onset persistent left bundle branch block (LBBB) after transcatheter aortic valve replacement (TAVR) on all-cause mortality has been controversial.MethodsWe conducted a systematic review and meta-analysis of eleven studies (7398 patients) comparing the short- and long- outcomes in patients who had new-onset LBBB after TAVR vs. those who did not.ResultsDuring a mean follow-up of 20.5 ± 14 months, patients who had new-onset persistent LBBB after TAVR had a higher incidence of all-cause mortality (29.7% vs. 23.6%; OR 1.28 (1.04–1.58), p = 0.02), rehospitalization for heart failure (HF) (19.5% vs. 17.3%; OR 1.4 (1.13–1.73), p = 0.002), and permanent pacemaker implantation (PPMi) (19.7% vs. 7.1%; OR 2.4 (1.64–3.52), p < 0.001) compared with those who did not. Five studies (4180 patients) reported adjusted hazard ratios (HR) for all-cause mortality; new LBBB remained associated with a higher risk of mortality (adjusted HR 1.43 (1.08–1.9), p < 0.01, I² = 81%).ConclusionPost-TAVR persistent LBBB is associated with higher PPMi, HF hospitalizations, and all-cause mortality. While efforts to identify patients who need post-procedural PPMi are warranted, more studies are required to evaluate the best follow-up and treatment strategies, including the type of pacing device if required, to improve long-term outcomes in these patients.     

Spectrum of acute coronary syndrome in North Eastern India – A study from a major center

AimSpectrum of acute coronary syndrome (ACS) has not been reported from North Eastern India. The present study was undertaken to study the clinical spectrum of ACS.MethodsWe prospectively collected data of 704 ACS patients from February 2011 to August 2012 in Gauhati Medical College, a tertiary care center. We evaluated data on clinical characteristic, treatment, and outcome in ACS patients.ResultsOf the 704 ACS patients, 72.4% presented with STEMI and 27.6% presented with NSTEMI/UA. Mean age of presentation was 56.5 years. Mean time to presentation was 11.42 h and was higher in NSTEMI/UA than STEMI (12.86 h vs. 9.98 h, p < 0.001). Treatment for STEMI did not differ much from NSTEMI/UA with ≥90% of patients in both groups receiving antiplatelets, statin, and anticoagulants. 39% of STEMI received thrombolytic therapy and percutaneous coronary intervention (PCI) rates were higher in STEMI. The 30-day mortality was found to be 10.22%, with STEMI having higher mortality than NSTEM/UA (11.76% vs. 6.18%, p = 0.03).ConclusionThese data represent the first reported study on spectrum of ACS in North Eastern India and has noted few key differences from the national registry CREATE, with greater percentage of STEMI patients, greater delay in seeking treatment, greater 30-day mortality, and lesser percentage of patients receiving reperfusion therapy.     

Cardiovascular risk factors profile in patients with acute coronary syndrome with particular reference to left ventricular ejection fraction

BackgroundAcute coronary syndrome (ACS) remains a leading cause of death in the United States. Numerous studies have shown that the degree of LV systolic dysfunction is a major if not the most important determinant of long-term outcome in ACS.ObjectivesTo identify the most important risk factors and other clinical predictors which might have impact on left ventricular ejection fraction in patients with ACS.ResultsThe total patients (299) admitted to our center from July, 2015 till December, 2015; with established diagnosis of ACS were classified in to two groups: Group I: 193 patients with impaired LVEF < 40% (64.5%), Group II: 106 patients with LVEF equal or > 40% (35.5%). The patients of group I were significant elderly compared to those of group II (60.9 ± 11.2 vs 56.9 ± 10.6; p = 0.002), had significant history of DM and CKD (66.3% and 31.1% VS 49.1% and 19.8%; p = 0.004 and 0.036 respectively), presented mainly with STEMI- ACS (51.3% VS 28.3% respectively; p < 0.001) with +v cardiac biomarker (troponin) (90.2% VS 66.0%; p < 0.001). Moreover, patients of group I had more significant ischemic MR compared to the patients of group II (24.9% VS 3.8% respectively; p < 0.001) with higher rate of LV thrombus discovered by echocardiography (25.4% VS 1.9%; p < 0.001). Extensive significant CAD disease was observed to be higher among patients of group I (69.4% VS 57.5%; p = 0.039) and those patients treated mainly with PCI revascularization therapy (68.9% VS 52.8%; p = 0.002) compared to patients of group II who mainly treated medically (34.9% VS 17.6 %; p < 0.001). Multiple logistic regression analysis demonstrated that DM (odd ratio (OR): 2.64, 95% confidence interval (CI): 1.45-4.79, P = 0.01), presence of significant ischemic MR (OR: 13.7, 95% CI:2.84-66.1, p = 0.001)and presence of significantly diseased coronary vessels (odd ratio (OR): 5.06, 95% confidence interval (CI): 1.14-22.6, P = 0.033,) all were independent predictors for significant LV dysfunction (LVEF < 40%) which predict poor outcome in ACS patients.ConclusionWe concluded that DM, presence of significant ischemic MR, and increased number, severity of diseased coronaries all were independent predictors of LV dysfunction (LVEF < 40%) which is known to predict poor outcome. Identification of those risk predictors upon patient evaluation could be helpful to identify high risk-patients, in need of particular care, aggressive therapy and close follow-up to improve their poor outcome.     

Angiographic predictors of success in antegrade approach of Chronic Total Occlusion interventions in a South Indian population in the contemporary era

Chronic Total Occlusion (CTO) intervention is a challenging area in interventional cardiology. Presently about 70% of CTO interventions are successful.Materials and methodsThis was a single center prospective study of a cohort of all patients undergoing percutaneous coronary intervention (PCI) as elective or adhoc procedure for CTO from August 2014 to June 2015. Only antegrade CTO interventions were included. In all patients the following data were recorded.ResultsA total of 210 (8.9% of total PCI (2353) during the study period) CTO patients were followed up. The mean age was 56.54 ± 8.9. In the study sixty nine patients (32.9%) presented with chronic stable angina and rest of the patients had history of acute coronary syndrome of which 22.9% (n = 48) had unstable angina (UA) or non ST elevation myocardial infarction (NSTEMI) and 44.2% (n = 93) had ST Elevation Myocardial Infarction (STEMI). In those with history of ACS, 64.78% (n = 92) had ACS during the previous year and remaining 35.22% (n = 49) had ACS prior to that. Single vessel CTO was seen in 89.5% (n = 188) and two vessel CTO in 10.5% (n = 22). LAD was involved in 36.7% (n = 77), RCA in 48.1% (n = 101), and LCX in 15.2% (n = 32). Procedural success in the first attempt was 68.1% (n = 143), which increased to 71.42% (n = 150) after the second attempt. CTO interventions were more frequently successful when the calcium was absent or minimal (p-0.05), CTO length was <10 mm (p < 0.01) and good distal reformation (p < 0.01).     

Outcomes of patients hospitalized for suspected acute coronary syndrome,in whom the diagnosis was not confirmed: Results from the CZECH-1 and CZECH-2 registries

BackgroundSuspicion of acute coronary syndrome (ACS) is one of the most common reasons for hospital admission. However, ACS is not confirmed in a high proportion of these patients during hospitalization. Very few details exist about these patients.AimTo evaluate the clinical characteristics and outcomes of hospitalized patients with a suspicion for ACS that has not been confirmed and compare these results with patients with confirmed ACS.Methods and resultsData were used from the CZECH-1 and CZECH-2 registries, collected in November 2005 and October–November 2012. Both registries contain data from all consecutive patients who have been hospitalized with an initial diagnosis of ACS. ACS was not confirmed during hospitalization in 578 of 1921 patients (30.1%) in the CZECH-1 registry and in 372 of 1221 (30.5%) in the CZECH-2 registry. In both registries, higher proportions of females (52 vs. 36%; p < 0.001 and 46 vs. 33%; p < 0.01, respectively) were observed between patients with unconfirmed ACS compared to those with confirmed ACS. A history of myocardial infarction was known in 25% of the patients with unconfirmed ACS in both registries. On admission, atrial fibrillation or other non-sinus rhythm on ECG was present in 17% of patients with unconfirmed ACS, bundle branch block in 18%, ST depression in 8%, and ST elevation in 3.6%. Coronary angiography was performed on 36% of these patients in CZECH-1 and 27% of patients in CZECH-2 (p < 0.01). In-hospital mortality of the ACS unconfirmed patients was 1.2% in the CZECH-1 registry and 2.1% in the CZECH-2 registry (p = NS). 30-day and 1-year mortality in patients with unconfirmed ACS in the CZECH-2 registry were significantly lower compared to patients with confirmed ACS (3.5 vs. 6.6%; p < 0.05 and 6.5 vs. 13%; p < 0.05, respectively). Musculoskeletal pain and acute heart failure were the most common discharge diagnosis in patients with unconfirmed ACS.ConclusionHospitalized patients in whom the suspicion of ACS had not been confirmed were more often female and a high proportion had abnormal ECG on admission. In-hospital mortality was very low, and the 1-year mortality was significantly lower compared to patients with confirmed ACS.     

Multi-vessel versus culprit-vessel and staged percutaneous coronary intervention in STEMI patients with multivessel disease: a meta-analysis of randomized controlled trials

IntroductionPercutaneous coronary intervention (PCI) is preferred in patients with acute ST-elevation myocardial infarction (STEMI). In patients with acute STEMI with multivessel disease (MVD), the guidelines recommend culprit vessel PCI (CV-PCI) in the absence of hemodynamic instability. We performed a meta-analysis of all randomized controlled trials (RCTs) comparing multi-vessel PCI (MV-PCI) with CV-PCI or staged PCI (S-PCI) in patients with acute STEMI and MVD.MethodsPubMed, EMBASE and CENTRAL were searched for publications since inception to December 2013. Random effects model was used to compute summary effects.ResultsFour RCTs (840 patients) were identified. MV-PCI compared to CV-PCI significantly reduced the risks of major adverse cardiac events (MACE)—a composite of MI, revascularization and all-cause mortality (RR: 0.46, 95% CI: 0.35–0.60, P < 0.00001) by reducing the risks of MI (0.35, 0.17–0.71, P = 0.004) and revascularization (0.35, 0.24–0.52, P < 0.00001). The risk of all-cause mortality was not different (0.69, 0.39–1.21, P = 0.19). S-PCI and MV-PCI had similar risks of MACE (0.96, 0.59–1.57, P = 0.87), MI (0.60, 0.20–1.78, P = 0.36), revascularization (0.86, 0.47–1.54, P = 0.60) and all-cause mortality (1.50, 0.44–5.07, P = 0.57).ConclusionsMV-PCI compared to CV-PCI resulted in lower risks of MACE driven by lower MI and revascularization in patients with STEMI and multi-vessel disease.     

Obesity,Brain Natriuretic Peptide Levels and Mortality in Patients Hospitalized With Heart Failure and Preserved Left Ventricular Systolic Function

BackgroundAn inverse relationship between brain natriuretic peptide (BNP) levels and body mass index (BMI) has been described for patients with left ventricular (LV) systolic dysfunction. In this study, the association of BMI, BNP levels and mortality in patients hospitalized for heart failure with preserved LV systolic function (HFpLVF) was investigated.MethodsOne hundred fifty consecutive patients (98% men) who were hospitalized with HFpLVF and had BNP levels measured on admission were analyzed. Patients were divided into categories of BMI: normal (BMI < 25 kg/m²), overweight (BMI 25–29.9 kg/m²) and obese (BMI ≥ 30 kg/m²). Relevant clinical and echocardiographic characteristics and all-cause mortality were obtained through chart review.ResultsBNP levels were significantly lower in obese (median = 227 pg/mL) and overweight (median = 396 pg/mL) patients compared with those with normal BMI (median = 608 pg/mL, P = 0.003). Higher BMI predicted BNP levels of <100 pg/mL. Compared with patients with normal BMI, overweight and obese patients had a significantly lower risk of total mortality, even after adjusting for other clinical characteristics, including log-transformed BNP levels, atrial fibrillation, the use of beta-blockers at discharge, age, hemoglobin levels and the presence of pulmonary congestion on admission. Higher BNP levels also independently predicted mortality.ConclusionsAn inverse relationship between BMI and BNP levels exists in patients hospitalized with HFpLVF. Higher BMI is associated with lower mortality, whereas higher BNP levels predict higher mortality in male patients with HFpLVF. These findings should be confirmed in a larger multicenter setting.