Índice de masa corporal y eficacia y seguridad del ticagrelor frente al prasugrel en pacientes con síndrome coronario agudo

Introduction and objectivesThe efficacy and safety of ticagrelor vs prasugrel in patients with acute coronary syndromes (ACS) according to body mass index (BMI) remain unstudied. We assessed the efficacy and safety of ticagrelor vs prasugrel in patients with ACS according to BMI.MethodsPatients (n = 3987) were grouped into 3 categories: normal weight (BMI < 25 kg/m²; n = 1084), overweight (BMI ≥ 25 to < 30 kg/m²; n = 1890), and obesity (BMI ≥ 30 kg/m²; n = 1013). The primary efficacy endpoint was the 1 year incidence of all-cause death, myocardial infarction, or stroke. The secondary safety endpoint was the 1 year incidence of Bleeding Academic Research Consortium type 3 to 5 bleeding.ResultsThe primary endpoint occurred in 63 patients assigned to ticagrelor and 39 patients assigned to prasugrel in the normal weight group (11.7% vs 7.5%; HR, 1.62; 95%CI, 1.09-2.42; P = .018), 78 patients assigned to ticagrelor and 58 patients assigned to prasugrel in the overweight group (8.3% vs 6.2%; HR, 1.36; 95%CI, 0.97-1.91; P = .076), and 43 patients assigned to ticagrelor and 37 patients assigned to prasugrel in the obesity group (8.6% vs 7.3%; HR, 1.18; 95%CI, 0.76-1.84; P = .451). The 1-year incidence of bleeding events did not differ between ticagrelor and prasugrel in patients with normal weight (6.5% vs 6.6%; P = .990), overweight (5.6% vs 5.0%; P = .566) or obesity (4.4% vs 2.8%; P = .219). There was no significant treatment arm-by-BMI interaction regarding the primary endpoint (P_int = .578) or secondary endpoint (P_int = .596).ConclusionsIn patients with ACS, BMI did not significantly impact the treatment effect of ticagrelor vs prasugrel in terms of efficacy or safety.Clinical Trial Registration: NCT01944800.     

The use of revascularization strategies in patients with acute coronary syndromes admitted to hospitals without catheterization facilities: Results from the ALERT-CZ registry

AimPercutaneous coronary intervention (PCI) became the standard of care for patients (pts) with acute coronary syndromes (ACS). Czech Republic is among European countries with well developed networks of PCI and non-PCI hospitals. Ample data about PCI-treated pts is available from many registries. Much less is known about treatments and outcomes of ACS pts admitted to hospitals without cath-lab. ALERT-CZ registry was designed specifically to analyze these pts presenting to local non-PCI hospitals. The aim was to see, whether the ESC guidelines are implemented in these local, small hospitals.Methods and resultsA total of 6265 pts with first hospital admission for ACS has been enrolled in 32 Czech community hospitals without cath-lab during a 3-year period (7/2008–6/2011). The mean age was 69.7±12.3 years, 39.5% were females, 35.4% had known diabetes mellitus, 76.0% hypertension, 28.3% previous myocardial infarction and 12.0% previous stroke. Twenty-five percent pts had signs of acute heart failure (Killip II in 19.0%, Killip III in 4.8% and Killip IV in 1.1%). The discharge diagnosis was ST-elevation myocardial infarction (STEMI) in 26.1%, non-STEMI in 53.1% and unstable angina pectoris (UAP) in 20.9%.Emergent interhospital transport to coronary angiography (CAG) and PCI within <12 h from symptom onset was indicated in 73.4% of STEMI pts, elective CAG was indicated in 15.9% of STEMI, CAG was not indicated in 9.9% of STEMI and 0.9% STEMI pts refused CAG. Among non-STE ACS pts CAG was performed within <24 h in 16.2%, between 24–72 h in 18.2%, later in 38.1%, not indicated in 22.7%, refused by pts in 4.8%. The median stay in the PCI center was 2.0 days and only 37% pts returned after CAG (±PCI) to the referring community hospital, the rest was discharged from PCI center directly to home.Among STEMI pts the median time intervals were: pain—first medical contact (FMC) 120 min, FMC—community hospital door 30 min, door-in–door-out for emergency transfer 23 min. Thrombolysis was used in 0.4% of STEMI—in rare situations when immediate transfer was logistically not possible.PCI was performed in 41.6% pts overall (65.9% STEMI, 35.8% non-STEMI and 26.4% UAP). CABG was performed in 2.9% pts overall (2.1%, 3.1% and 3.6% per diagnosis). Detailed pharmacotherapy data as well as indirect comparison with a separate PCI centers registry is beyond the space frame of this abstract and will be presented.The overall in-hospital mortality was 7.2%. Mortality per final diagnosis was 9.5% (STEMI), 8.7% (non-STEMI) and 0.5% (UAP). Mortality per age group was 16.2% (>80 years), 8.0% (70–80 years) and 2.4% (<70 years).ConclusionPatients presenting to non-PCI hospitals undergo revascularization procedures less frequently than those directly admitted to PCI centers. This may be related to baseline differences. The outcomes are influenced by these facts.     

Infarto de miocardio con elevación del segmento ST revascularizado. Tendencias temporales de los tratamientos contemporáneos y su impacto en los resultados

Introduction and objectivesTo assess, in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous intervention, the pace of introduction in clinical practice (2010-2017) of drug-eluting stents (DES), ticagrelor, prasugrel, and prolonged dual antiplatelet therapy (DAPT) duration, and their potential impact on the risk of 2-year outcomes.MethodsProspective and exhaustive community-wide cohort of 14 841 STEMI patients undergoing primary percutaneous intervention between 2010 and 2017. Index episodes were obtained from the Catalan Codi IAM Registry, events during follow-up from the Minimum Data Set and DAPT were defined by pharmacy dispensation. Follow-up was 24 months. The temporal trend for exposures and outcomes was assessed using regression models.ResultsAge > 65 years, diabetes, renal failure, previous heart failure, and need for anticoagulation at discharge were more frequent in later periods (P < .001). From 2010 to 2017, the use of DES increased from 31.1% to 69.8%, ticagrelor from 0.1% to 28.6%, prasugrel from 1.5% to 23.8%, and the median consecutive months on DAPT from 2 to 10 (P < .001 for all). Adjusted analysis showed a temporal trend to a lower risk of the main outcome over time: the composite of death, acute myocardial infarction, stroke and repeat revascularization (absolute odds reduction 0.005% each quarter; OR, 0.995; 95%CI, 0.99-0.999; P = .028). The odds of all individual components except stroke were reduced, although significance was only reached for revascularization.ConclusionsDespite a strong increase between 2010 and 2017 in the use and duration of DAPT and the use of ticagrelor, prasugrel and DES, there was no substantial reduction in major cardiovascular outcomes.Full English text available from:www.revespcardiol.org/en     

Comparison of peri-procedural platelet inhibition with prasugrel versus adjunctive cilostazol to dual anti-platelet therapy in patients with ST segment elevation myocardial infarction

BackgroundIt has been well known that the inhibition of platelet aggregation (IPA) by anti-platelet agents was important to reduce the thrombo-embolic events in patients with ST segment elevation myocardial infarction (STEMI). However, the peri-procedural IPA by anti-platelet agents was not well known.MethodsWe compared the peri-procedural IPA between prasugrel and adjunctive cilostazol to dual anti-platelet therapy (triple anti-platelet therapy; TAP) in patients with STEMI undergoing primary percutaneous coronary intervention (PCI). We prospectively randomized 70 consecutive clopidogrel-naive patients with STEMI planned PCI to either prasugrel [loading dose (LD) 60 mg; 37 patients] or TAP (LD aspirin 300 mg, clopidogrel 600 mg, and cilostazol 200 mg; 33 patients). Primary end points of the study were the platelet reactivity unit (PRU) or % inhibition by the VerifyNow P2Y₁₂ assay at pre-PCI and pre-discharge.ResultsThe drug loading to pre-PCI time was similar between prasugrel and TAP groups (25.4 ± 10.42 min vs. 25.5 ± 10.56 min, p = 0.957). PRU at pre-PCI was significantly lower in prasugrel than in TAP (269.1 ± 71.69 vs. 306.5 ± 48.67, p = 0.012). The lower PRU and greater % inhibition also observed in prasugrel than in TAP at pre-discharge (108.2 ± 60.51 vs. 238.1 ± 73.40; 63.6 ± 18.51% vs. 16.8 ± 17.91%, p < 0.001 respectively). No differences in in-hospital bleeding complications between the two groups were observed.ConclusionOur study demonstrates that prasugrel could produce a significantly greater peri-procedural as well as in-hospital IPA compared with TAP in patients with STEMI undergoing primary PCI.     

The impact of intra-aortic balloon counter-pulsation on in-hospital mortality in patients presenting with anterior ST-elevation myocardial infarction without cardiogenic shock

ObjectivesThis study aimed to determine whether the elective insertion of an intra-aortic balloon counter pulsation (IABP) device at the time of myocardial revascularization in patients presenting with an acute anterior ST-elevation myocardial infarction (STEMI) without cardiogenic shock has any impact on the in-hospital rate of cardiac mortality.BackgroundThe role of IABP in patients presenting with an acute MI without cardiogenic shock remains ill defined.MethodsThe present study comprised 605 consecutive patients who underwent primary percutaneous coronary intervention for an anterior STEMI without cardiogenic shock. Patients who received IABP at the time of their coronary revascularization (n = 105) were compared to those who had not (n = 500). Patients with stable angina, unstable angina, non-STEMI, non-anterior STEMI, and cardiogenic shock were excluded.ResultsThe two cohorts were well matched for the conventional risk factors for coronary artery disease. Although the left ventricular ejection fraction was significantly lower in the patients who received IABP (0.32 ± 0.11 vs. 0.39 ± 0.12; P < 0.001), the two cohorts were well matched for history of MI, coronary revascularization, and chronic renal impairment. Following propensity scoring, the in-hospital rate of cardiac death was similar between the two cohorts (5.6% vs. 0%; P = .12) as was the rate of vascular complications. Major bleeding was significantly greater in the IABP cohort (10.0% vs. 0%; P = .01) leading to a greater transfusion requirement (14.9% vs. 2.9%; P = .01).ConclusionThe adjunctive use of an IABP in patients presenting with an acute anterior STEMI without cardiogenic shock may not be associated with an in-hospital mortality benefit.     

Oral antiplatelet therapy and platelet inhibition: An experience from a tertiary care center

Aims and objectivesAlthough clopidogrel combined with aspirin is the most commonly used dual drug combination to avert thrombotic events in patients with coronary artery disease, the poor responsiveness to clopidogrel remains a concern. The objective of the current study is to assess the extent of resistance to clopidogrel, prasugrel, and ticagrelor in a real life set of patients with coronary artery disease who underwent percutaneous coronary intervention (PCI).Materials and methodsA total of 539 patients, who underwent PCI and were on aspirin and on any of the three drugs, namely, clopidogrel, prasugrel and ticagrelor, were followed up regularly in the outpatient department. After 24 h of initiation of antiplatelet medication, response to the treatment in all the patients was assessed using thrombelastography. The average percentage platelet inhibition was assessed along with the resistance and sensitivity to the drug in each patient. Sensitivity and resistance to the specific drug was defined as >50% and <50% of mean platelet inhibition, respectively.ResultsAbout 99.15% of the patients treated with ticagrelor were sensitive to the drug and the difference between ticagrelor, clopidogrel, and prasugrel groups for sensitivity was significant with a p value of 0.00001, in favor of ticagrelor. It was also found that ticagrelor was significantly (p value of 0.001) associated with least resistance as compared with the other drugs assessed in the study.ConclusionsUse of ticagrelor as dual therapy along with aspirin in patients with coronary artery disease (CAD) and undergoing PCI was associated with a significantly higher mean percentage platelet inhibition, higher sensitivity, and lower resistance as compared with the usage of clopidogrel or prasugrel.     

The mortality benefit seen with the newer more potent oral P2Y12 inhibitors prasugrel and ticagrelor over clopidogrel is dependent on the underlying risk: A class effect as suggested by a meta-regression analysis

BackgroundThe two newer oral P2Y₁₂ inhibitors prasugrel and ticagrelor have proven superior to clopidogrel in the treatment of acute coronary syndrome (ACS). The extent to which the reduction in mortality seen with ticagrelor is confined to this particular agent is hard to judge by simply looking at the overall study results as the study populations were composed of different cohorts at substantially different risk of death.MethodsA meta-regression technique was applied to 12 distinctive patient cohorts, six for each of prasugrel and ticagrelor, to investigate differential effects on mortality of P2Y₁₂ inhibitors.ResultsData for the analysis cohorts, totalling 37,372 patients, were extracted from publications and cover a widely comparable spectrum of patient types, defined by the type of ACS and treatment strategy. The meta-regression lines for cardiovascular mortality with prasugrel or ticagrelor (each versus clopidogrel), as well as for both agents pooled, indicate a linear relationship with increasing benefit seen with higher underlying risk (p = 0.007, 0.021 and 0.003, and R² = 0.87, 0.77 and 0.62, respectively).ConclusionsIn the ACS patients studied, we found a mortality benefit with the two newer oral P2Y₁₂ inhibitors prasugrel and ticagrelor when compared with clopidogrel, which increases progressively as the underlying risk of death increases. This appears to be a class effect for these two newer agents.     

Pronóstico a largo plazo de la extensión de la TAPD en una cohorte consecutiva de pacientes con IAMCEST

Introduction and objectivesDual antiplatelet therapy (DAPT) duration after ST-segment elevation myocardial infarction (STEMI) remains a matter of debate.MethodsWe analyzed the effect of DAPT on 5-year all-cause mortality, cardiovascular mortality, and cardiovascular readmission or mortality in a cohort of 1-year survivor STEMI patients.ResultsA total of 3107 patients with the diagnosis of STEMI were included: 93% of them were discharged on DAPT, a therapy that persisted in 275 high-risk patients at 5 years. Cardiovascular mortality in patients on single antiplatelet therapy vs DAPT at 5 years was 1.4% vs 3.6% (P < .01), respectively, whereas noncardiovascular mortality was 3.3% vs 5.8% (P = .049) at 5 years. Cardiovascular readmission or mortality in patients with single antiplatelet therapy vs DAPT was 11.4% vs 46.5% (P < .001). Extended DAPT was independently associated with worse 5-year all-cause mortality (HR, 2.16; 95%CI, 1.40-3.33), cardiovascular mortality (HR, 2.83; 95%CI, 1.37-5.84), and cardiovascular readmission or mortality (HR, 5.20; 95%CI, 3.96-6.82). These findings were confirmed in propensity score matching and inverse probability weighting analyses.ConclusionsOur results suggest the hypothesis that, in 1-year STEMI survivors, extending DAPT up to 5 years in high-risk patients does not improve their long-term prognosis.     

Angiographic and electrocardiographic parameters of myocardial reperfusion in angioplasty of patients with ST elevation acute myocardial infarction loaded with ticagrelor or clopidogrel (MICAMI—TICLO trial)

IntroductionTicagrelor has been shown to improve outcomes in patients with ACS. However, the effects of this drug on parameters of microvascular flow in patients presenting with ST-segment elevation myocardial infarction (STEMI) have not been completely evaluated.MethodsNinety-two patients presenting with STEMI where randomized to a loading dose of clopidogrel (600 mg) or ticagrelor (180 mg) before undergoing primary angioplasty. We assessed angiographic and electrocardiographic parameters of myocardial reperfusion. Blinded operators calculated angiographic corrected TIMI Frame count (cTFC) and myocardial blush grade (MBG) before and after stent implantation. ST segment resolution was also measured in all patients. Primary endpoint was cTFC after PCI. Secondary endpoints were cTFC prior to PCI, TIMI flow grade, MBG and the percentage of ST resolution.ResultsOf the 92 randomized patients, 70 patients were analyzed. Mean age of patients was 58.8 ± 10 years. Patients presented with a mean ischemic time of 4.4 ± 2.6 hours. There were no significant differences in the time between loading dose and stent deployment (35.2 ± 36.4 in ticagrelor and 42.7 ± 29.5 min in clopidogrel, p = 0.36). cTFC before angioplasty was significantly lower in ticagrelor than in clopidogrel (81.1 ± 29.4 vs. 95.1 ± 17.5 frames respectively, p = 0.01). After angioplasty there were no differences between ticagrelor and clopidogrel in cTFC (24.6 ± 9.3 vs. 27.0 ± 13.4 frames respectively, p = 0.62); MBG grade 3 was present in 76.4 vs. 69.4% of patients, respectively (p = 0.41). The percentage of ST resolution did not show any differences between groups (84.8 ± 23.4 in ticagrelor vs. 70.8 ± 33.7 in clopidogrel, p = 0.36).ConclusionCompared with clopidogrel, ticagrelor loading in patients presenting with STEMI is not associated with an improvement of angiographic and electrocardiographic parameters of myocardial reperfusion after angioplasty.     

Early phosphatemia changes in acute cardiac care patients

IntroductionThe significance of inorganic serum phosphate levels (Pi) in patients with acute coronary syndromes (ACS) in the reperfusion era is unknown, as well as its relation to biomarkers of myocardial necrosis. Our aim was to assess admission Pi and its dynamics in patients admitted to the intensive cardiac care unit (ICCU), with emphasis on patients with ST segment elevation myocardial infarction (STEMI).MethodsWe studied 192 patients admitted to the ICCU during a 4-month period. The first group included 92 patients with STEMI (STEMI group) treated by primary percutaneous coronary intervention (PCI). The second group consisted of 100 patients without ACS (non-ACS group). Normophosphatemia was defined as Pi 0.7–1.6 mmol/l. Phosphatemia was measured at admission and then 6 h and 12 h later as well as troponin I.ResultsAdmission phosphatemia was lower in the STEMI group as compared to the non-ACS group (Pi 0.95 mmol/l vs. 1.18 mmol/l, p<0.001). Admission hypophosphatemia (Pi<0.7 mmol/l) was more often present in the STEMI group than in the non-ACS group (21% vs. 4%, p=0.001). In all hypophosphatemic STEMI patients, serum Pi normalized itself within 6 h without substitution. Admission hyperphosphatemia (Pi>1.6 mmol/l) was more frequent in non-ACS group (6.5% STEMI pts. vs. 13% non-ACS pts.). In the STEMI group, admission phosphatemia did not correlate with peak troponin I.ConclusionWe conclude that patients with STEMI treated by primary PCI have lower Pi and more frequent transient hypophosphatemia at admission than acute cardiac care patients without acute coronary syndrome.     

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.     

Clinical and angiographic profiles and six months outcomes of smokers with acute ST segment elevation myocardial infarction undergoing primary percutaneous coronary angioplasty

BackgroundOutcomes of primary percutaneous coronary intervention (PCI) for acute STEMI (ST-segment elevation myocardial infarction) in smokers are expected to be better than non-smokers as for patients of acute STEMI with or without fibrinolytic therapy.ObjectivesThis comparative study was designed to evaluate the outcomes of primary PCI in patients with acute STEMI in smokers and non-smokers. Clinical and angiographic profile of the two groups was also compared.MethodsOver duration of two year, a total of 150 consecutive patients of acute STEMI eligible for primary PCI were enrolled and constituted the two groups [Smokers (n = 90), Non-smokers (n = 60)] of the study population. There was no difference in procedure in two groups.ResultsIn the present study of acute STEMI, current smokers were about a decade younger than non-smokers (p value = 0.0002), majority were male (98.9% vs 56.6%) were male with a higher prevalence of hypertension and diabetes mellitus (61.67% vs 32.28% and 46.67% vs 14.44%, p = 0.001) respectively. Smokers tended to have higher thrombus burden (p = 0.06) but less multi vessel disease (p = 0.028). Thirty day and six month mortality was non-significantly higher in smokers 4.66% vs 1.33% (p = 0.261) and 5.33% vs 2.66% (p = NS) respectively. Rate of quitting smoking among smokers was 80.90% at 6 months.ConclusionThe study documents that smokers with acute STEMI have similar outcomes as compared to non smokers with higher thrombus burden and lesser non culprit artery involvement. Smokers present at much younger age emphasizing the role of smoking cessation for prevention of myocardial infarction.     

Non-physician health workers for improving adherence to medications and healthy lifestyle following acute coronary syndrome: 24-month follow-up study

ObjectiveTo evaluate usefulness of non-physician health workers (NPHW) to improve adherence to medications and lifestyles following acute coronary syndrome (ACS).MethodsWe randomized 100 patients at hospital discharge following ACS to NPHW intervention (n = 50) or standard care (n = 50) in an open label study. NPHW was trained for interventions to improve adherence to medicines – antiplatelets, β-blockers, renin–angiotensin system (RAS) blockers and statins and healthy lifestyles. Intervention lasted 12 months with passive follow-up for another 12. Both groups were assessed for adherence using a standardized questionnaire.ResultsST elevation myocardial infarction (STEMI) was in 49 and non-STEMI in 51, mean age was 59.0 ± 11 years. 57% STEMI were thrombolyzed. On admission majority were physically inactive (71%), consumed unhealthy diets (high fat 77%, high salt 58%, low fiber 57%) and 21% were smokers/tobacco users. Coronary revascularization was performed in 90% (percutaneous intervention 79%, bypass surgery 11%). Drugs at discharge were antiplatelets 100%, β-blockers 71%, RAS blockers 71% and statins 99%. Intervention and control groups had similar characteristics. At 12 and 24 months, respectively, in intervention vs control groups adherence (>80%) was: anti platelets 92.0% vs 77.1% and 83.3% vs 40.9%, β blockers 97.2% vs 90.3% and 84.8% vs 45.0%), RAS blockers 95.1% vs 82.3% and 89.5% vs 46.1%, and statins 94.0% vs 70.8% and 87.5% vs 29.5%; smoking rates were 0.0% vs 12.5% and 4.2% vs 20.5%, regular physical activity 96.0% vs 50.0%, and 37.5% vs 34.1%, and healthy diet score 5.0 vs 3.0, and 4.0 vs 2.0 (p < 0.01 for all). Intervention vs standard group at 12 months had significantly lower mean systolic BP, heart rate, body mass index, waist:hip ratio, total cholesterol, triglyceride, and LDL cholesterol (p < 0.01).ConclusionsNPHW-led educational intervention for 12 months improved adherence to evidence based medicines and healthy lifestyles. Efficacy continued for 24 months with attrition.     

Impact of thrombus aspiration during primary percutaneous coronary intervention in cardiogenic shock complicating ST-segment elevation myocardial infarction

AimTo assess the impact on in-hospital and long-term survival of thrombus aspiration (TA) during primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS).Methods and ResultsFrom September 2001 to May 2010 we collected data from 155 patients affected with STEMI complicated by CS undergoing PPCI (12.4% of all PPCI) including 70 patients (45.2%) in TA group and 85 patients (54.8%) in conventional PCI group. Patients in TA group were more likely to have right ventricular infarction (24.3% vs 5.9%, p = 0.002), higher mean left ventricular ejection fraction (40% ± 9% vs 35% ± 7%, p < 0.0001) and lower left main coronary artery occlusion (2.8% vs 21.2%, p = 0.002). TA was associated with a lower rate of in-hospital and long-term mortality (31.4% vs 48.2%, p = 0.05 and 42.8% vs 64.7%, p = 0.01 respectively) at a mean follow-up time of 6.1 ± 2.1 years. At multivariate analysis the only independent predictor of in-hospital and long-term survival was the procedural success (HR 0.18 95% CI 0.025–0.31, p = 0.03 and HR 0.46 95% CI 0.09–0.74, p = 0.034 respectively).ConclusionsIn this retrospective study TA, performed during PPCI for STEMI complicated by CS, was not an independent predictor of in-hospital and long-term survival.     

Diferencias en mortalidad intrahospitalaria tras IAMCEST frente a IAMSEST por sexo. Tendencia durante once años en el Sistema Nacional de Salud

Introduction and objectivesConflicting results have been reported on the possible existence of sex differences in mortality after myocardial infarction (MI). There is also a scarcity of data on the impact of sex on outcomes after ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). The aim of this study was to analyze sex difference trends in sex-related differences in mortality for STEMI and NSTEMI.MethodsA retrospective analysis of 445 145 episodes of MI (2005-2015) was carried out using information from the Spanish National Health System. The incidence rates were expressed as events per 10 000 person-years. The denominators (age-specific groups) were obtained from the nationwide census. We calculated crude and adjusted (multilevel logistic regression) mortality. Poisson regression analysis was used to study temporal trends for in-hospital mortality.ResultsA total of 69.8% episodes occurred in men. The mean age in men was 66.1 ± 13.3 years, which was significantly younger than in women, 74.9 ± 12.1 (P < .001). A total of 272 407 (61.2%) episodes were STEMI, and 172 738 (38.8%) were NSTEMI. Women accounted for 28.8% of STEMI and 33.9% of NSTEMI episodes (P < .001). The effect of female sex on risk-adjusted models for in-hospital mortality was the opposite in STEMI (OR for women, 1.18; 95%CI, 1.14-1.22; P < .001) and NSTEMI (OR for women, 0.85; 95%CI, 0.81-0.89; P < .001). MI hospitalization rates were higher in men than in women for all age groups [20 vs 7.7 per 10 000 individuals aged 35-94 years (P < .001)], with a trend to diminish in both sexes.ConclusionsWomen had a slight but significantly increased risk of in-hospital mortality after MI, but the effect of sex depended on MI type, with women exhibiting higher mortality for STEMI and lower mortality for NSTEMI     

Transfer distance effect on reperfusion: timeline of ST-elevation patients transferred for primary percutaneous coronary intervention

ObjectivesThis study aims to establish if transfer distance impacts the outcome of ST-elevation myocardial infarction (STEMI) patients transferred to a percutaneous coronary intervention (PCI).BackgroundRegional emergency care systems were designed to decrease delays in reperfusion of patients but the effect of transfer distance on outcome is less established.MethodsWe compare the characteristics and outcomes of STEMI patients transferred from a distance > 25 miles (GT25) to those transferred from distances ≤ 25 miles (LT25) by utilizing data from a regional STEMI care network in the greater Washington DC area.ResultsWithin the transferred patients (n = 1065), 609 patients (57%) were transferred from GT25 (median distance 36 miles), while 456 (43%) were transferred from LT25 (median distance 13 miles). Most of the baseline characteristics between the groups were similar. Door-to-balloon (DTB) was defined as the time elapsed from the presentation to the center without PCI capability to flow restoration in the culprit artery. No differences were noted in the median DTB (GT25: 158 min [122–213] vs. 149 [118–219]; p = 0.5) or in in-hospital mortality (8% vs. 7.2%; p = 0.617). By implementing the regional STEMI care network, a constant decrease in DTB was noted throughout its years of operation.ConclusionsFor STEMI patients presenting to a non-PCI capable center, a network care system for PCI mitigates the distance factor on DTB time. This is turn translates into comparable outcomes.     

STEMI vs NSTEACS management trends in non-invasive hospital

ObjectivesTo compare the clinical features, management, and in-hospital outcomes of patients with ST elevation myocardial infarction (STEMI) and non-ST elevation acute coronary syndrome (NSTEACS), in the Western Region of Saudi Arabia.MethodsA total of 71 patients were enrolled in a longitudinal study at a tertiary hospital without cardiac catheterization facility. These data were collected from Saudi Project for Assessment of Coronary Events registry.ResultsTwenty-three patients with STEMI were compared to 48 patients with NSTEACS. Mean age for STEMI was younger, 57.4 ± 13.7 years compared to 63.2 ± 13.9 years respectively (p = 0.19). Forty-four percent arrived at the hospital by ambulance. History of hypertension and hyperlipidemia were more frequent in NSTEACS (p = 0.05), while both groups showed no difference in diabetes mellitus, 17% vs 22% and smoking, 30% vs 17%. In-hospital medications were: Aspirin (100%) both groups, Clopidogrel (91% vs 100%) (p = 0.03). There was more aggressive use of beta-blockers (74% vs 95%) (p = 0.01) and statins (87% vs 100%) (p = 0.01) in NSTEACS.In-hospital outcomes showed one recurrent myocardial infarction and one death in NSTEACS group (2%). Other outcome in the two groups showed recurrent ischemia (13% vs 29%) (p = 0.14) and cardiogenic shock (9% vs 2%) (p = 0.17). No stroke or major bleeding was reported in both groups.ConclusionNSTEACS patients in western province of KSA present at an older age are mostly males and have higher prevalence of hypertension and hyperlipidemia compared with STEMI patients. It is therefore important to identify patients with high-risk profile and put implement measures to reduce these factors.     

Why some patients with acute coronary syndrome hospitalized in a university tertiary centre do not undergo coronary angiography? Results from the AHEAD ACS registry

BackgroundTo evaluate in-hospital and long-term mortality of patients with acute coronary syndromes (ACS) not having selective coronary angiography (CAG) during hospitalization and to analyze the reasons for conservative approach.Methods and patientsA single-centre retrospective study using registry data. Over the period from January 2005 to April 2009, a total of 193 ACS patients did not have in-hospital CAG. Fifty-five (28.5%) patients had recent CAG (within the last 12 months) or the procedure was planned after discharge (invasive group “I”). In 138 (71.5%) patients, CAG was not considered at all (conservative approach, group “C”). These subgroups were compared in terms of in-hospital parameters and long-term mortality.ResultsST-segment elevation myocardial infarction (STEMI) was diagnosed in 50 (25.9%) patients. The most frequent reasons for not performing CAG included serious comorbidities affecting the prognosis (22%) and pharmacological stabilization in very old individuals with non-STEMI (21%). One in ten (11%) patients died before the CAG was performed, the same proportion of patients refused to have CAG or had a long ischaemia time (STEMI subgroup). A temporary contraindication to CAG was found in 8%, a recent CAG finding not suitable for revascularization in 8%, while a limiting neurological disease was present in 6% of patients. In-hospital mortality was 30.1%, being higher in Group C (34.1% vs. 20.0%; p = 0.049), 6-year mortality was as high as 78.8%, also with higher rates in Group C (86.2% vs. 60.2%; p < 0.001). Patients receiving conservative therapy were older, with a higher proportion of limiting comorbidities that contraindicated CAG, and had a more serious course of hospitalization.ConclusionThe most common reasons for not performing CAG in ACS patients included advanced age, serious and often extra-cardiac comorbidities, and a complicated hospitalization course. The short- and long-term mortality rates in these patients are high.     

Particularities in coronary revascularization in elderly patients presenting with ST segment elevation acute myocardial infarction (STEMI)

Nowadays, ST elevation acute myocardial infarction (STEMI) is seen with greater incidence in older patients. Current guidelines recommend an immediate invasive evaluation and eventually primary percutaneous coronary intervention (PCI) in all STEMI patients regardless of age. Nevertheless, data in literature show a significant underuse of interventional treatment in older patients with STEMI.Our objective is to assess the in-hospital outcome of the elderly STEMI patients compared to the younger ones in the setting of systematic interventional management. We also discussed some particular aspects which we considered as significant concerning the management of elderly patients with STEMI.We evaluated 975 consecutive STEMI patients admitted to a single centre between January 2012 to July 2013. There were 203 (20.8%) patients ≥75 years old.Compared to the younger group, in the older group there were more women (47. 2% vs 22.7%; p < 0.001), an increased prevalence of hypertension (78.8% vs 65.0%; p < 0.001) but a decreased prevalence of smoking (13.7% vs 48.8%; p < 0.001) and dyslipidemia (54.7% vs 41.3%; p = 0.03). The ≥75 years group had more cardiovascular comorbidities: stroke (11.8% vs 4.1%; p < 0.001), atrial fibrillation (23.6% vs 53.9%; p < 0.001) and severe valvulopathies (6.8% vs 1.2%; p < 0.001). Elderly patients presented more frequently with signs of heart failure (Killip class > 1: 21.1% vs 7.2%; p < 0.001). Both groups had similar ischaemia time with 54.1% vs 55.1% presenting within 6 h.There were fewer PCIs performed in the elderly group (74.3% vs 85.7%; p = 0.02). The extension of coronary lesions was not significantly different between the two groups, except for left main disease in favour of the elderly (12.2% vs 5.1%; p < 0.001). There were no significant differences between the two groups regarding the in-hospital treatment (dual antiplatelet, anticoagulation, beta-blockers, ACEI/ARB and statin). The in-hospital mortality for our entire study group was 4.41%, with a rate of 11.3% in the older group and 2.59% in the <75 years group (p < 0.001).In-hospital outcome in older patients with STEMI is worse, with an increased mortality rate, especially when associated with heart failure on admission. Fewer PCI were performed in the older patients, although there was no difference in the pharmacological treatment. A strategy based on urgent coronary angiography and, if necessary, primary PCI, should be applied in all eligible patients irrespective of age.