Long Term Effects of Epoetin Alfa in Patients with ST- Elevation Myocardial Infarction

Purpose

The HEBE III trial showed that epoetin alfa administration in patients with a first ST-elevation myocardial infarction (STEMI) did not improve left ventricular function at 6 weeks after primary percutaneous coronary intervention (PCI). The long term effects of erythropoiesis- stimulating agents on cardiovascular morbidity and mortality are unknown, therefore we evaluated clinical events at 1 year after PCI.

Methods

A total of 529 patients with a first STEMI and successful primary PCI were randomized to standard optimal medical treatment (N?=?266) or an additional bolus of 60,000 IU epoetin alfa administered intravenously (N?=?263) within 3 h after PCI. Analyses were performed by intention to treat.

Results

At 1 year after STEMI, 485 patients had complete follow-up. The rate of the composite end point of all-cause mortality, re-infarction, target vessel revascularization, stroke and/or heart failure was 6.4 % (N?=?15) in the epoetin alfa group and 9.6 % (N?=?24) in the control group (p?=?0.18). Thromboembolic events were present in 1.3 % (N?=?3) of patients in the epoetin alfa group and 2.4 % (N?=?6) in the control group. There was no evidence of benefit from epoetin alfa administration in subgroups of patients.

Conclusions

Administration of a single bolus of epoetin alfa in patients with STEMI does not result in a reduction of cardiovascular events at 1 year after primary PCI. There was a comparable incidence of thromboembolic complications in both treatment groups, suggesting that epoetin alfa administration is safe at long term.     

Coronary Stent Thrombosis in the Current Era: Challenges and Opportunities for Treatment

The introduction of the drug-eluting stent has raised concerns regarding the occurrence of stent thrombosis (ST), particularly late (and very late) thrombosis. This renewed attention shows that ST remains a major concern after implantation of both bare metal and drug-eluting stents. Cardiologists should be aware of this dreadful complication, because it is associated with substantial morbidity and mortality. Numerous clinical, procedural, and angiographic risk factors have been identified. Moreover, the influence of novel determinants, such as high on-treatment reactivity, genetic predisposition, and the stent’s direct effects on the (healing of the) vessel wall, now are recognized. Consequently, the pathophysiology of ST has evolved into a complex multifactorial model. This broader understanding of the pathophysiology of ST enables cardiologists to perform extensive risk stratification to identify patients at higher risk and provides clues to important treatment options. The core of primary prevention after stent implantation, as well as secondary prevention after ST, should consist of a) the prevention of modifiable risk factors and b) optimal individualized treatment for each patient. Future developments, such as genetic bedside testing, point-of-care platelet testing, and sophisticated imaging modalities, might aid in this approach.     

Impaired bioavailability of clopidogrel in patients with a ST-segment elevation myocardial infarction

Recent data has indicated that interindividual variability of intestinal absorption is an important determinant of the wide response variability to clopidogrel. We hypothesised that the physiological state of STEMI influences the intestinal absorption of clopidogrel. To evaluate this, we determined the pharmacokinetic response to a high loading dose of clopidogrel and the absolute ADP induced change in aggregation from baseline in STEMI patients and healthy volunteers. We found a significantly impaired bioavailability in STEMI patients as compared to healthy volunteers and a strong correlation between the reduction in platelet aggregation and the maximal plasma concentration of the active metabolite of clopidogrel. Although large clinical trails have clearly demonstrated the effectiveness of clopidogrel in the setting of STEMI, this small observational study encourages further research based on clinical endpoints to define the optimal dosing of clopidogrel in STEMI patients.     

Atherosclerotic plaque characteristics on quantitative coronary computed tomography angiography associated with ischemia on positron emission tomography in diabetic patients

The International Journal of Cardiovascular Imaging - Patients with diabetes mellitus (DM) may show diffuse coronary artery atherosclerosis on coronary computed tomography angiography (CTA). The...