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This study evaluated the relation between baseline fibrinogen and 6-month major adverse cardiovascular events (MACE) and bleeding after percutaneous coronary intervention (PCI). Three hundred eighty-seven subjects (65.6 ± 16.1 years, 69.5% men, 26.9% acute coronary syndrome [ACS]) who underwent PCI with baseline fibrinogen and platelet reactivity (VerifyNow P2Y12 assay, Accumetrics, San Diego, California) measured were enrolled. Fibrinogen (368.8 ± 144.1 vs 316.8 ± 114.3 mg/dl; p = 0.001), total stent length (TSL; 44.5 ± 25.0 vs 32.2 ± 20.1 mm; p <0.001), and ACS presentation (40.6% vs 23.9%; p = 0.005) were independently associated with 6-month MACE rates (17.8%: myocardial infarction 9.8%, rehospitalization for ACS 3.6%, urgent revascularization 3.6%, stroke 0.5%, and death 0.3%). Measures of platelet reactivity were not associated with 6-month MACE. After multivariate analysis, fibrinogen ≥280 mg/dl (odds ratio [OR] 2.60, 95% CI 1.33 to 5.11, p = 0.005), TSL ≥32 mm (OR 3.21, 95% CI 1.82 to 5.64, p <0.001), and ACS presentation (OR 2.58, 95% CI 1.45 to 4.61, p = 0.001) were associated with higher 6-month MACE. In 271 subjects receiving chronic P2Y12 inhibitor therapy, 6-month Thrombolysis In Myocardial Infarction bleeding after PCI was 7.0%, but no difference in fibrinogen level (338.3 ± 109.7 vs 324.3 ± 113.8 mg/dl, p = 0.60) stratified by Thrombolysis In Myocardial Infarction bleeding was observed. In conclusion, elevated serum fibrinogen, ACS presentation, and longer TSL are independently associated with higher 6-month MACE after PCI, whereas no association with on-thienopyridine platelet reactivity and 6-month MACE was observed. Post-PCI bleeding was not associated with lower fibrinogen level. [ABSTRACT FROM AUTHOR]

The transradial approach is increasingly used for percutaneous coronary intervention (PCI), and we therefore aimed to compare the clinical outcomes after transradial intervention (TRI) and transfemoral intervention (TFI) in all patients undergoing PCI. Among 6,973 patients enrolled in a nationwide, prospective, multicenter registry (February 2013 to September 2013), 1,860 underwent TRI (n = 1,445, 77.7%) and TFI (n = 415, 22.3%). Bleeding and major adverse cardiac events (MACE; death, myocardial infarction, revascularization, or stent thrombosis) were compared. Bleeding occurred in 42 patients (2.3%) and was significantly less likely in the TRI versus TFI group (overall cohort: 1.5% vs 4.8%, p = 0.001; propensity score-matched: n = 728, 2.7% vs 5.2%, p = 0.048). Multivariate regression revealed that TRI was negatively associated with bleeding (odds ratio 0.42, 95% CI 0.21 to 0.83, p = 0.013). MACE occurred in 152 patients (8.2%). Kaplan-Meier estimates showed higher MACE-free survival rates in the TRI versus TFI group (overall cohort: 93.3% vs 86.7%, log-rank p = 0.026; propensity score-matched: 91.8% vs 86.5%, log-rank p = 0.04). Cox proportional analysis demonstrated that TRI independently predicted improved MACE (hazard ratio 0.64, 95% CI 0.43 to 0.91, p = 0.024). In conclusion, TRI is associated with reduced bleeding rates and better clinical outcomes than TFI in all patients undergoing PCI. [ABSTRACT FROM AUTHOR]

Stent thrombosis (ST) remains a catastrophic problem in patients undergoing percutaneous coronary intervention (PCI). However, a paucity of data exist regarding the incidence, implications, and predictors of ST in patients with acute myocardial infarction (AMI). We consecutively enrolled patients with AMI in the CardiOvascular Risk and idEntificAtion of potential high-risk population in AMI registry who underwent PCI from January 2004 to December 2009 and analyzed definite or probable ST according to Academic Research Consortium definitions. The median follow-up duration was 41.9 months. Definite or probable ST occurred in 136 patients (3.7%), including 44 with early ST (1.0%), 38 with late ST (0.9%), and 54 with very late ST (2.0%). The annual incidence of very late ST ranged from 0.5% to 0.6%. The all-cause mortality rate after ST was 29%, which was higher than that for patients without ST (17%; p <0.001). The independent predictors of ST were no-reflow phenomenon (hazard ratio [HR] 1.96, 95% confidence interval [CI] 1.28 to 3.03), decreased left ventricular ejection fraction (HR 1.70, 95% CI 1.21 to 2.40), anemia (HR 1.54, 95% CI 1.09 to 2.18), and a mean stent diameter <3.0 mm (HR 1.53, 95% CI 1.04 to 2.27). ST is not uncommon in patients with AMI and continues to occur beyond 1 year after PCI, irrespective of the stent type or clinical presentation. Patients with ST are associated with higher mortality than patients without ST. No reflow, decreased left ventricular ejection fraction, anemia, and a mean stent diameter <3.0 mm are independent predictors of ST. [ABSTRACT FROM AUTHOR]

Coronary artery calcium score (CACS) is a strong predictor of adverse cardiovascular events in the general population. Recent data confirm the prognostic utility of single-photon emission computed tomographic (SPECT) imaging in end-stage renal disease, but whether performing CACS as part of hybrid imaging improves risk prediction in this population is unclear. Consecutive patients (n = 284) were identified after referral to a university hospital for cardiovascular risk stratification in assessment for renal transplantation. Participants underwent technetium-99m SPECT imaging after exercise or standard adenosine stress in those unable to achieve 85% maximal heart rate; multislice CACS was also performed (Siemens Symbia T16, Siemens, Erlangen, Germany). Subjects with known coronary artery disease (n = 88) and those who underwent early revascularization (n = 2) were excluded. The primary outcome was a composite of death or first myocardial infarction. An abnormal SPECT perfusion result was seen in 22% (43 of 194) of subjects, whereas 45% (87 of 194) had at least moderate CACS (>100 U). The frequency of abnormal perfusion (summed stress score ≥4) increased with increasing CACS severity (p = 0.049). There were a total of 15 events (8 deaths, and 7 myocardial infarctions) after a median duration of 18 months (maximum follow-up 3.4 years). Univariate analysis showed diabetes mellitus (Hazard ratio [HR] 3.30, 95% CI 1.14 to 9.54; p = 0.028), abnormal perfusion on SPECT (HR 5.32, 95% CI 1.84 to 15.35; p = 0.002), and moderate-to-severe CACS (HR 3.55, 95% CI 1.11 to 11.35; p = 0.032) were all associated with the primary outcome. In a multivariate model, abnormal perfusion on SPECT (HR 4.18, 95% CI 1.43 to 12.27; p = 0.009), but not moderate-to-severe CACS (HR 2.50, 95% CI 0.76 to 8.20; p = 0.130), independently predicted all-cause death or myocardial infarction. The prognostic value of CACS was not incremental to clinical and SPECT perfusion data (global chi-square change = 2.52, p = 0.112). In conclusion, a perfusion defect on SPECT is an independent predictor of adverse outcome in potential renal transplant candidates regardless of the CACS. The use of CACS as an adjunct to SPECT perfusion data does not provide incremental prognostic utility for the prediction of mortality and nonfatal myocardial infarction in end-stage renal disease. [ABSTRACT FROM AUTHOR]

Although cocaine is a well-recognized risk factor for coronary disease, detailed information is lacking regarding related behavioral and clinical features of cocaine-associated ST-segment elevation myocardial infarction (STEMI), particularly in socioeconomically disadvantaged urban settings. Nor are systematic or extended follow-up data available on outcomes for cocaine-associated STEMI in the contemporary era of percutaneous coronary intervention. We leveraged a prospective STEMI registry from a large health system serving an inner-city community to characterize the clinical features, acute management, and middle-term outcomes of cocaine-related versus cocaine-unrelated STEMI. Of the 1,003 patients included, 60% were black or Hispanic. Compared with cocaine-unrelated STEMI, cocaine-related STEMI (n = 58) was associated with younger age, male gender, lower socioeconomic score, current smoking, high alcohol consumption, and human immunodeficiency virus seropositivity but less commonly with diabetes or hypertension. Cocaine users less often received drug-eluting stents or β blockers at discharge. During median follow-up of 2.7 years, rates of death, death or any rehospitalization, and death or cardiovascular rehospitalization did not differ significantly between cocaine users and nonusers but were especially high for death or any hospitalization in the 2 groups (31.4 vs 32.4 per 100 person-years, p = 0.887). Adjusted hazard ratios for outcomes were likewise not significantly different. In conclusion, in this low-income community, cocaine use occurred in a substantial fraction of STEMI cases, who were younger than their nonuser counterparts but had more prevalent high-risk habits and exhibited similarly high rates of adverse outcomes. These data suggest that programs targeting cocaine abuse and related behaviors could contribute importantly to disease prevention in disadvantaged communities. [ABSTRACT FROM AUTHOR]

Vorapaxar is a first-in-class protease-activated receptor-1 antagonist indicated for secondary prevention in stable patients with previous myocardial infarction (MI) or peripheral artery disease and no cerebrovascular disease. Vorapaxar is not recommended for initiation in the acute phase of acute coronary syndromes (ACS) because of an unfavorable balance between bleeding and efficacy when started in that setting. The aim of this analysis was to investigate outcomes in patients who experienced a new ACS while receiving vorapaxar for long-term secondary prevention. Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic ischemic Events-Thrombolysis In Myocardial Infarction 50 was a randomized, double-blind, placebo-controlled trial of vorapaxar (n = 26,449). We evaluated bleeding and ischemic events during the acute care of patients with a new ACS during the trial. During a median follow-up of 30 months, 799 patients (8.9%) randomized to vorapaxar and 913 (10.0%) to placebo had a new ACS event (p = 0.003); 87% and 86%, respectively, were on study therapy at the time of the event. In a landmark analysis through 7 days after ACS, the rates of Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) severe bleeding were 0.8% versus 0.8% (hazard ratio [HR] 0.99, 95% CI 0.33 to 2.94) and GUSTO moderate/severe bleeding were 2.5% versus 1.6% (HR 1.59, 95% CI 0.78 to 3.24) with vorapaxar versus placebo. The effect of vorapaxar on cardiovascular death, MI, or stroke (2.4% vs 4.4%; HR 0.54, 95% CI 0.31 to 0.93; p = 0.027) was consistent with the overall trial result. In conclusion, in patients who experience a new ACS event while receiving vorapaxar for secondary prevention, continuing therapy was associated with favorable efficacy without excess severe bleeding during the period of acute ACS management. [ABSTRACT FROM AUTHOR]

Patients hospitalized with sepsis may be predisposed to acute myocardial infarction (AMI). The incidence, treatment, and outcomes of AMI in sepsis have not been studied. We analyzed data from the National Inpatient Sample from 2002 to 2011 for patients with a diagnosis of sepsis. The incidence of AMI as a nonprimary diagnosis was evaluated. Propensity score matching was used to identify a cohort of patients with secondary AMI and sepsis with similar baseline characteristics who were managed invasively (defined as cardiac catheterization, percutaneous coronary intervention [PCI], or coronary artery bypass graft [CABG] surgery) or conservatively. The primary outcome was in-hospital all-cause mortality. A total of 2,602,854 patients had a diagnosis of sepsis. AMI was diagnosed in 118,183 patients (4.5%), the majority with non-ST elevation AMI (71.4%). In-hospital mortality was higher in patients with AMI and sepsis than those with sepsis alone (35.8% vs 16.8%, p <0.0001; adjusted odds ratio 1.24, 95% CI 1.22 to 1.26). In patients with AMI, 11,899 patients (10.1%) underwent an invasive management strategy, in which 4,668 patients (39.2%) underwent revascularization. PCI was performed in 3,413 patients (73.1%), CABG in 1,165 (25.0%), and both CABG and PCI in 90 patients (1.9%). In a propensity-matched cohort of 23,708 patients with AMI, invasive management was associated with a lower mortality than conservative management (19.0% vs 33.4%, p <0.001; odds ratio 0.47, 95% CI 0.44 to 0.50). In subgroups that underwent revascularization, the odds of mortality were consistently lower than corresponding matched subjects from the conservative group. In conclusion, myocardial infarction not infrequently complicates sepsis and is associated with a significant increase in in-hospital mortality. Patients managed invasively had a lower mortality than those managed conservatively. [ABSTRACT FROM AUTHOR]

Clinical trials studying the efficacy of n-3 polyunsaturated fatty acids (PUFA) in reducing adverse events after acute myocardial infarction (AMI) have yielded conflicting results, and data regarding the influence of n-3 PUFA treatment after AMI in routine clinical practice are scarce. We conducted a retrospective observational cohort study including patients from 5 Italian Local Health Units who were discharged from the hospital with a primary diagnosis of AMI from January 1, 2010, to December 31, 2011. Using unique patient identifiers, patients were linked across governmental hospital discharge, medication prescription, and mortality databases and followed for 12-months post-index discharge. Patient characteristics and risk of all-cause mortality and repeat AMI were compared by n-3 PUFA prescription after discharge (for outcome analyses, defined as ≥ 2 prescriptions) at a presumed dose of 1 g/day. Overall, 11,269 patients met inclusion criteria, of which 2,425 patients (21.5%) were prescribed n-3 PUFA during follow-up. Patients treated with n-3 PUFA tended to be younger, men, and carry a diagnosis of diabetes and were more likely to be receiving guideline-recommended post-AMI medical therapy, including β blockers, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, statins, and antiplatelet therapy (all p <0.001). After adjusting for patient characteristics and concurrent therapies, n-3 PUFA treatment was associated with reduced all-cause mortality (hazard ratio 0.76, 95% CI 0.59 to 0.97) and recurrent AMI (hazard ratio 0.65, 95% CI 0.49 to 0.87) through 12-month follow-up. In conclusion, in this large, contemporary, observational study of "real-world" Italian patients hospitalized for AMI, the use of n-3 PUFA was independently associated with a robust reduction in all-cause mortality and recurrent AMI. These data support further randomized controlled trials with n-3 PUFA therapy in the post-AMI setting. [ABSTRACT FROM AUTHOR]

Thiazide-type diuretics have been recommended for initial treatment of hypertension in most patients, but should this recommendation differ for patients with and without coronary heart disease (CHD)? The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was a randomized, double-blind hypertension treatment trial in 42,418 participants with high risk of combined cardiovascular disease (CVD) (25% with preexisting CHD). This post hoc analysis compares long-term major clinical outcomes in those assigned amlodipine (n = 9048) or lisinopril (n = 9,054) with those assigned chlorthalidone (n = 15,255), stratified by CHD status. After 4 to 8 years, randomized treatment was discontinued. Total follow-up (active treatment + passive surveillance using national databases for deaths and hospitalizations) was 8 to 13 years. For most CVD outcomes, end-stage renal disease, and total mortality, there were no differences across randomized treatment arms regardless of baseline CHD status. In-trial rates of CVD were significantly higher for lisinopril compared with chlorthalidone, and rates of heart failure were significantly higher for amlodipine compared with chlorthalidone in those with and without CHD (overall hazard ratios [HRs] 1.10, p <0.001, and 1.38, p <0.001, respectively). During extended follow-up, significant outcomes according to CHD status interactions (p = 0.012) were noted in amlodipine versus chlorthalidone comparison for CVD and CHD mortality (HR 0.88, p = 0.04, and 0.84, p = 0.04, respectively) in those with CHD at baseline (HR 1.06, p = 0.15, and 1.08, p = 0.17) and in those without. The results of the overall increased stroke mortality in lisinopril compared with chlorthalidone (HR 1.2; p = 0.03) and hospitalized heart failure in amlodipine compared with chlorthalidone (HR 1.12; p = 0.01) during extended follow-up did not differ by baseline CHD status. In conclusion, these results provide no reason to alter our previous recommendation to include a properly dosed diuretic (such as chlorthalidone 12.5 to 25 mg/day) in the initial antihypertensive regimen for most hypertensive patients. [ABSTRACT FROM AUTHOR]

Percutaneous ventricular assist devices (PVADs) and intraaortic balloon pump (IABP) are used to provide mechanical circulatory support (MCS) for high-risk percutaneous coronary intervention (PCI). Contemporary trends in their utilization and impact on in-hospital mortality are not known. Using the National Inpatient Sample (2004 to 2012), we identified 5,031 patients who received a PVAD and 122,333 who received an IABP on the same day as PCI using International Classification of Diseases, Ninth Edition codes. Utilization of MCS increased from 1.3% of all PCIs in 2004 to 3.4% in 2012 (p trend <0.001), with increase in the use of both PVAD (<1/10,000 PCIs [2004 to 2007] to 38/10,000 [2012]) and IABP (132/10,000 PCIs [2004] to 299/10,000[2012] p <0.0001 for both). PVAD recipients were older (69 vs 65 years), more likely to have heart failure (68% vs 41%), chronic kidney disease (27% vs 11%, p <0.001 for all), and be admitted electively (30% vs 11%), but less likely to have acute myocardial infarction (52% vs 90%), cardiogenic shock (23% vs 50%), or need mechanical ventilation (16% vs 29%) compared with IABP recipients. Unadjusted in-hospital mortality was lower in PVAD compared with IABP recipients (12.8% vs 20.9%, p <0.001). However, in propensity-matched analyses (1:2), in-hospital mortality was similar in both groups (odds ratio 0.88, 95% confidence interval 0.70 to 1.09). In conclusion, there has been a marked increase in the utilization of MCS in patients undergoing PCI. Unadjusted mortality using PVADs is lower than IABP but may be due to their selective use in patients at lower risk. Randomized trials are necessary to establish their effectiveness in supporting high-risk PCI. [ABSTRACT FROM AUTHOR]

Left ventricular hypertrophy (LVH) is significantly related to adverse clinical outcomes in patients at high risk of cardiovascular events. In patients with atrial fibrillation (AF), data on LVH, that is, prevalence and determinants, are inconsistent mainly because of different definitions and heterogeneity of study populations. We determined echocardiographic-based LVH prevalence and clinical factors independently associated with its development in a prospective cohort of patients with non-valvular (NV) AF. From the "Atrial Fibrillation Registry for Ankle-brachial Index Prevalence Assessment: Collaborative Italian Study" (ARAPACIS) population, 1,184 patients with NVAF (mean age 72 ± 11 years; 56% men) with complete data to define LVH were selected. ARAPACIS is a multicenter, observational, prospective, longitudinal on-going study designed to estimate prevalence of peripheral artery disease in patients with NVAF. We found a high prevalence of LVH (52%) in patients with NVAF. Compared to those without LVH, patients with AF with LVH were older and had a higher prevalence of hypertension, diabetes, and previous myocardial infarction (MI). A higher prevalence of ankle-brachial index =0.90 was seen in patients with LVH (22 vs 17%, p = 0.0392). Patients with LVH were at significantly higher thromboembolic risk, with CHA2DS2-VASc =2 seen in 93% of LVH and in 73% of patients without LVH (p <0.05). Women with LVH had a higher prevalence of concentric hypertrophy than men (46% vs 29%, p = 0.0003). Logistic regression analysis demonstrated that female gender (odds ratio [OR] 2.80, p <0.0001), age (OR 1.03 per year, p <0.001), hypertension (OR 2.30, p <0.001), diabetes (OR 1.62, p = 0.004), and previous MI (OR 1.96, p = 0.001) were independently associated with LVH. In conclusion, patients with NVAF have a high prevalence of LVH, which is related to female gender, older age, hypertension, and previous MI. These patients are at high thromboembolic risk and deserve a holistic approach to cardiovascular prevention. [ABSTRACT FROM AUTHOR]

Contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) is frequent and associated with long-term renal impairment and mortality. Early markers of CIN are needed to improve risk stratification. We aimed to assess whether N-terminal fragment of pro B-type natriuretic peptide (Nt-proBNP) could be associated with CIN. From the French regional RICO survey, all the consecutive patients who underwent primary PCI for STEMI, from January 1, 2001, to December 3, 2013, were included. Nt-proBNP circulating levels were assessed on admission. CIN was defined as an increase in serum creatinine >26.5 µmol/L or >50% within 48 to 72 hours after PCI (KDIGO criteria). Of the 1,243 patients included, CIN occurred in 130 patients (10.4%). Nt-proBNP levels were 5 times greater in patients who developed CIN than without CIN (1,275 [435 to 4,022] vs 247 [79 to 986] pg/mL, p <0.001). Hospital mortality rate was markedly higher in patients with CIN (6.9% vs 1.1%, p <0.001). Nt-proBNP levels were univariate predictors for CIN as were age, hypertension, diabetes, smoking, previous stroke, heart rate, impaired left ventricular ejection fraction C-reactive protein, history of renal failure, anemia, and estimated glomerular filtration rate <30 ml/min/1.73 m2 at baseline. Nt-proBNP levels remained strongly associated with the occurrence of CIN even after adjustment for risk factors, treatments, clinical and biological variables (odds ratio 1.99, 95% confidence interval 1.49 to 2.66). Net reclassification improvement was achieved by the addition of Nt-proBNP to the risk model (p = 0.003). In conclusion, from this large contemporary prospective study in nonselected population, our work suggests that Nt-proBNP levels at admission could help to identify patients at risk of CIN beyond traditional risk factors. [ABSTRACT FROM AUTHOR]

The long-term risk associated with different coronary artery disease (CAD) presentations in women undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES) is poorly characterized. We pooled patient-level data for women enrolled in 26 randomized clinical trials. Of 11,577 women included in the pooled database, 10,133 with known clinical presentation received a DES. Of them, 5,760 (57%) had stable angina pectoris (SAP), 3,594 (35%) had unstable angina pectoris (UAP) or non-ST-segment-elevation myocardial infarction (NSTEMI), and 779 (8%) had ST-segment-elevation myocardial infarction (STEMI) as clinical presentation. A stepwise increase in 3-year crude cumulative mortality was observed in the transition from SAP to STEMI (4.9% vs 6.1% vs 9.4%; p <0.01). Conversely, no differences in crude mortality rates were observed between 1 and 3 years across clinical presentations. After multivariable adjustment, STEMI was independently associated with greater risk of 3-year mortality (hazard ratio [HR] 3.45; 95% confidence interval [CI] 1.99 to 5.98; p <0.01), whereas no differences were observed between UAP or NSTEMI and SAP (HR 0.99; 95% CI 0.73 to 1.34; p = 0.94). In women with ACS, use of new-generation DES was associated with reduced risk of major adverse cardiac events (HR 0.58; 95% CI 0.34 to 0.98). The magnitude and direction of the effect with new-generation DES was uniform between women with or without ACS (pinteraction = 0.66). In conclusion, in women across the clinical spectrum of CAD, STEMI was associated with a greater risk of long-term mortality. Conversely, the adjusted risk of mortality between UAP or NSTEMI and SAP was similar. New-generation DESs provide improved long-term clinical outcomes irrespective of the clinical presentation in women. [ABSTRACT FROM AUTHOR]

Myocardial Infarction with normal coronary arteries (MINCA) is common with a prevalence of 1% to 12% of all myocardial infarctions. The pathogenic mechanisms of MINCA are still unknown, but endothelial dysfunction has been suggested as a possible cause. To investigate risk factors and markers for MINCA, we conducted a case-control study. Considering the reported low prevalence of classical risk factors for coronary heart disease (CHD) in some but not all studies, our hypothesis was that endothelial function and intima-media thickness (IMT) were better, respectively lower, than CHD controls. One hundred patients with MINCA fulfilling diagnostic criteria according to the European Society of Cardiology/American Collage of Cardiology/American Heart Association universal definition of myocardial infarction with myocarditis excluded by cardiac magnetic resonance imaging were investigated. Risk factors, endothelial function (EndoPAT), and IMT were compared to gender- and age-matched patients with myocardial infarction and CHD, respectively healthy controls. Smoking, hypertension, impaired glucose tolerance and diabetes mellitus, inflammatory disease, and psychiatric disorders were more common in patients with MINCA than in healthy controls. In contrast to patients with CHD, the lipid profile was antiatherogenic with low low-density lipoprotein and high high-density lipoprotein cholesterol. There were no major differences between the groups regarding endothelial function and IMT that were in the normal range. In conclusion, the present study showed that MINCA was associated with many established cardiovascular risk factors without major differences in atherosclerosis markers. MINCA patients recalled a high prevalence of emotional stress before admission that together with previous psychiatric vulnerability and female gender speaks strongly in favor of Takotsubo syndrome being an important cause of MINCA. [ABSTRACT FROM AUTHOR]

Newer oral P2Y12 inhibitors are more potent and have faster onset of action than clopidogrel. However, the efficacy and safety in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) are not well studied. A systemic search of MEDLINE and EMBASE databases was performed to identify randomized clinical trials comparing newer oral P2Y12 inhibitors (prasugrel or ticagrelor) to clopidogrel in patients with NSTE-ACS. The primary outcome was a composite of cardiovascular death, myocardial infarction (MI), and stroke (major cardiovascular events [MACE]). Secondary outcomes were individual components of the primary outcome, all-cause mortality, and Thrombolysis In Myocardial Infarction (TIMI) major and minor bleeding. A total of 31,470 patients with NSTE-ACS from 4 randomized clinical trials were included (newer oral P2Y12 inhibitors: 15,951; clopidogrel: 15,519). Newer oral P2Y12 inhibitors significantly decreased MACE (relative risk [RR] 0.87, 95% confidence interval [CI] 0.80 to 0.95) and MI (RR 0.85, 95% CI 0.75 to 0.96) and showed a trend toward reduction of cardiovascular death (RR 0.89, 95% CI 0.71 to 1.01). There was a significant increase in TIMI major bleeding (RR 1.27, 95% CI 1.07 to 1.50) and TIMI major or minor bleeding (RR 1.20, 95% CI 1.02 to 1.42). Results were largely similar when stratified by ticagrelor versus prasugrel (pinteraction >0.05) except for increased TIMI major/minor bleeding with prasugrel than ticagrelor (pinteraction = 0.01). In conclusion, in patients with NSTE-ACS, newer oral P2Y12 inhibitors decrease MACE and MI at the expense of a significant increase in the risk of bleeding. Treatment of 1,000 patients with newer oral P2Y12 inhibitors will prevent 16 MACE and 13 MIs at the expense of increase in 6 major bleeding events. [ABSTRACT FROM AUTHOR]

This study evaluates the prognostic value of stress echocardiography (Secho) in short-term (10 years) and lifetime atherosclerotic cardiovascular disease risk-defined groups according to the American College of Cardiology/American Heart Association 2013 cardiovascular risk calculator. The ideal risk assessment and management of patients with low-to-intermediate or high short-term versus low (<39%) or high (=39%) lifetime CV risk is unclear. The purpose of this study was to evaluate the prognostic value of Secho in short-term and lifetime CV risk-defined groups. We evaluated 4,566 patients (60 ± 13 years; 46% men) who underwent Secho (41% treadmill and 59% dobutamine) with low-intermediate short-term (<20%) risk divided into low (<39%, n = 368) or high (=39%, n = 661) lifetime CV risk and third group with high short-term risk (=20%, n = 3,537). Follow-up (3.2 ± 1.5 years) for nonfatal myocardial infarction (n = 102) and cardiac death (n = 140) were obtained. By univariate analysis, age (p <0.001) and =3 new ischemic wall motion abnormalities (WMAs, p <0.001) were significant predictors of cardiac events. Cumulative survival in patients was significantly worse in patients with =3 WMA versus <3 WMA in low-intermediate short-term and low (3.3% vs 0.3% per year, p <0.001) or high (2.0% vs 0% per year, p <0.001) lifetime risk and also in those with high short-term CV risk group (3.5% vs 1.0% per year, p <0.001). Multivariate Cox proportional hazards analysis identified =3 new ischemic WMAs as the strongest predictor of cardiac events (hazard ratio 3.0, 95% confidence interval 2.3 to 3.9, p <0.001). In conclusion, Secho results (absence or presence of =3 new ischemic segments) can further refine risk assessment in patients with low-intermediate or high short-term versus low or high lifetime cardiovascular risk. Event rate with normal Secho is low (=1% per year) but higher in patients with high short-term CV risk by the American College of Cardiology/American Heart Association 2013 cardiovascular risk calculator. [ABSTRACT FROM AUTHOR]

As it is controversial whether metabolic syndrome (MetS) affects cardiovascular outcomes in patients who underwent percutaneous coronary intervention (PCI), we investigated the impact of MetS on clinical outcomes in patients who underwent PCI with everolimus-eluting stents (EESs). Patients who underwent PCI with EESs from 2009 to 2013 were included in this single-center, prospective cohort study. A composite event consisted of repeat revascularization, nonfatal myocardial infarction, and cardiac death. Of 903 patients observed for 4.9 years (median 1.8 years), 570 were diagnosed with MetS. The MetS group displayed more severe coronary artery disease and underwent more extensive PCIs than did the non-MetS group. The overall composite event rate was not significantly different between the MetS and the non-MetS group (11.9% vs 13.2%, p = 0.572). Kaplan-Meier survival analysis showed no significant difference in the event-free survival of the composite event between the 2 groups (p = 0.700). A multivariable Cox regression analysis showed that MetS was not associated with the composite event, whereas total stent length, decreased renal function, diabetes, and the absence of abdominal obesity were associated with the composite event. Abdominal obesity was associated with decreased risk of the composite event, alleviating unfavorable clinical outcomes of patients with diabetes in the MetS group. In conclusion, MetS has no impact on the clinical outcomes of patients who underwent PCI with EESs, although the MetS group exhibited more severe coronary artery disease and underwent more extensive PCIs. The paradoxical association between obesity and favorable clinical outcomes may explain this result. [ABSTRACT FROM AUTHOR]

Objective of this study was to assess the clinical performance of bioresorbable vascular scaffold (BVS) compared to everolimus-eluting stent (EES) in subjects with ST-segment elevation myocardial infarction (STEMI). We included all consecutive patients with STEMI who underwent percutaneous coronary intervention (PCI) with BVS implantation in centers participating to the Italian ABSORB Prospective Registry (BVS-RAI) and PCI with EES in the same centers during the same period. The 2 groups were compared. The primary end point was patient-oriented composite end point (POCE) including cardiac death, myocardial infarction, and target lesion revascularization (TLR) at the longest available follow-up. BVS or EES thrombosis at follow-up was also evaluated. Of the 563 patients with STEMI included, 122 received BVS and 441 EES. Procedural success was obtained in 549 (97.5%) cases without significant differences between the 2 groups (BVS 99.3% vs EES 97.0%, p = 0.2). At a median of 220-day (interquartile range 178 to 369) follow-up, no significant differences were observed in terms of POCE (BVS 4.9% vs EES 7.0%, p = 0.4); death (BVS 0.8%, EES 2.0%, p = 0.4), MI (BVS 4.1%, EES 2.0%, p = 0.2), TLR (BVS 4.1%, EES 4.5%, p = 0.8), device thrombosis (BVS 2.5%, EES 1.4%, p = 0.4). All TLR cases were successfully managed with re-PCI in both groups. A propensity matching of the study populations showed no significant differences regarding POCE at the longest available follow-up (odds ratio 0.53, 0.1 to 4.3). In conclusion, in this direct prospective comparison, BVS was associated with similar clinical results compared to EES in the STEMI setting. Larger and adequately powered randomized trials are needed to fully assess the potential clinical benefit of BVS versus the current standard of care in patients with STEM. [ABSTRACT FROM AUTHOR]

Contrast-induced nephropathy (CIN) after primary percutaneous coronary intervention (PPCI) is associated with adverse short- and long-term outcomes. The aim of this study was to evaluate the predictive value of gamma-glutamyl transferase (GGT) for risk of CIN in patients with ST-segment elevation myocardial infarction who underwent PPCI. A total of 473 patients were enrolled in the study. A relative increase in serum creatinine =25%, or an absolute increase =0.5 mg/dl, from the baseline within 72 hours of contrast exposure was defined as CIN. Patients were divided into 3 groups according to GGT tertiles (tertile 1, GGT <19 U/L; tertile 2, GGT 19 to 33 U/L; and tertile 3, GGT >33 U/L) on admission. Demographics, clinical risk factors, laboratory parameters, CIN incidence, and other inhospital clinical outcomes were compared among GGT tertiles. CIN incidence was significantly higher in tertile 3 (29%) compared with tertiles 1 (11%) and 2 (11%, p <0.001). Inhospital death incidence was significantly increased across tertiles (from tertile 1 to tertiles 2 and 3, 1%, 4%, and 5%, respectively, p <0.05). In receiver operating characteristic analysis, a threshold value of GGT >26.5 U/L had 70% sensitivity and 60% specificity for CIN. After including variables found significant in univariate analysis, the presence of diabetes mellitus (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.22 to 2.31, p <0.001), C-reactive protein (for each 1 mg/L increase; OR 1.01, 95% CI 1.00 to 1.02, p = 0.007), contrast volume (for each 1-ml increase; OR 1.01, 95% CI 1.00 to 1.02, p = 0.012), and GGT >26.5 U/L (OR 2.59, 95% CI 1.48 to 4.53, p <0.001) were found as independent associates of CIN in multivariate regression analysis. Each 1 U/L increase in GGT was also associated with CIN risk (OR 1.04, 95% CI 1.03 to 1.06, p <0.001). In conclusion, GGT on admission was a significant and independent predictor of CIN after PPCI in patients with ST-segment elevation myocardial infarction. [ABSTRACT FROM AUTHOR]

We aimed to assess the risk factors and outcome of ventricular fibrillation (VF) before and during primary percutaneous coronary intervention (PPCI) in patients with ST-segment elevation myocardial infarction. From 1999 to 2012, we consecutively enrolled 5,373 patients with ST-segment elevation myocardial infarction. In total, 410 of the patients had VF before and 88 had VF during PPCI. During a mean follow-up of 4.2 years, 1,196 subjects died. A logistic regression model identified younger age, anterior infarct, Killip class >I at admission, and a preprocedural Thrombolysis In Myocardial Infarction flow grade of 0 to I to be significantly associated with VF before PPCI, whereas inferior infarct, a preprocedural Thrombolysis In Myocardial Infarction flow grade of 0 to I, and Killip class >I at admission were significantly associated with VF during PPCI. All-cause mortality was evaluated using the Cox regression model. Compared with the patients without VF, those with VF before or during PPCI had a significantly increased 30-day mortality, with an adjusted hazard ratio = 3.40 (95% confidence interval 1.70 to 6.70) and 4.20 (95% confidence interval 1.30 to 13.30), respectively. Importantly, there was no tendency of 30-day mortality difference between VF before and during PPCI (p = 0.170). In patients with VF before or during PPCI who survived for at least 30 days, there was no increase in the long-term mortality. In conclusion, our data suggest that 30-day mortality is the same for patients with VF before PPCI compared with VF during PPCI, and the occurrence of VF before or during PPCI was associated with increased 30-day mortality but not with long-term mortality. [ABSTRACT FROM AUTHOR]

Although randomized studies have shown optimal medical therapy (OMT) to be as efficacious as revascularization in stable coronary heart disease (CHD), the application of OMT in routine practice is suboptimal. We sought to understand the predictors of receiving OMT in stable CHD and its impact on clinical outcomes. All patients with stable CHD based on coronary angiography from October 2008 to September 2011 were identified in Ontario, Canada. OMT was defined as concurrent use of β blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and statin. Aspirin use was not part of the OMT definition because of database limitations. Multivariable hierarchical logistic models identified predictors of OMT in the 12 months after angiography. Cox proportional hazard models with time-varying covariates for OMT and revascularization status examined differences in death and nonfatal myocardial infarction (MI). In these models, patients transitioned among 4 mutually exclusive treatment groups: no OMT and no revascularization, no OMT and revascularization, OMT and no revascularization, OMT and revascularization. Our cohort had 20,663 patients. Over a mean period of 2.5 years, 8.7% had died. Only 61% received OMT within 12 months. The strongest predictor of receiving OMT at 12 months was OMT before the angiogram (odds ratio 14.40, 95% confidence interval [CI] 13.17 to 15.75, p <0.001). Relative to no OMT and nonrevascularized patients, patients on OMT and revascularized had the greatest reduction in mortality (hazard ratio 0.52, 95% CI 0.45 to 0.60, p <0.001) and nonfatal MI (hazard ratio 0.74, 95% CI 0.64 to 0.84, p <0.001). In conclusion, our study highlights the low rate of OMT in stable CHD. Patients who received both OMT and revascularization achieved the greatest reduction in mortality and nonfatal MI. [ABSTRACT FROM AUTHOR]

There is a paucity of evidence on the impact of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) on long-term outcomes in patients with ejection fraction (EF) >40% after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI). We compared long-term all-cause mortality between patients with left ventricular ejection fraction (LVEF) >40% discharged on ACEi/ARB with patients who were discharged on neither of these agents. Patients discharged after percutaneous intervention for STEMI from our catheterization laboratories from January 2002 to December 2011 were considered for inclusion. Patients were excluded if they had LVEF <40% or chronic kidney disease or hypotension (systolic blood pressure <90 mm Hg any time after the procedure). Long-term mortality and discharge medications were determined using the Social Security Death Index and electronic medical record review, respectively. A total of 988 patients were included. The median follow-up duration was 4.6 years. Kaplan-Meier analysis showed no significant difference in long-term all-cause mortality in patients discharged on ACEi/ARB compared with those who were not discharged on these medications. The number needed to treat to prevent 1 death at 1 year was 714. In addition, multivariable Cox proportional hazard modeling failed to demonstrate any beneficial effect of ACEi/ARB similar to Kaplan-Meir analysis (hazard ratio 0.88, 95% confidence interval 0.57 to 1.36). In conclusion, we found no significant benefit in long-term mortality using ACEi/ARB in patients with LVEF >40% after primary percutaneous coronary intervention for STEMI. [ABSTRACT FROM AUTHOR]

There are limited population-based data available describing trends in the long-term prognosis of patients discharged from the hospital after an initial acute myocardial infarction (AMI). Our objectives were to describe multidecade trends in post-discharge mortality and their association with hospital management practices in patients discharged from all medical centers in Central Massachusetts after a first AMI. Residents of the Worcester, Massachusetts, metropolitan area discharged from all hospitals in Central Massachusetts after a first AMI from 1975 to 2009 comprised the study population (n = 8,728). Multivariable-adjusted logistic regression analyses were used to examine the association between year of hospitalization and 1-year post-discharge mortality. The average age of this population was 66 years, and 40% were women. Patients hospitalized in 1999 to 2009, compared with those discharged in 1975 to 1984, were older, more likely to be women, and have multiple previously diagnosed co-morbidities. Hospital use of invasive cardiac interventions and medications increased markedly over time. Unadjusted 1-year mortality rates were 12.9%, 12.5%, and 15.8% for patients discharged during 1975 to 1984, 1986 to 1997, and 1999 to 2009, respectively. After adjusting for several demographic characteristics, clinical factors, and inhospital complications, there were no significant differences in the odds of dying at 1-year post-discharge during the years under study. After further adjustment for hospital treatment practices, the odds of dying at 1 year post-discharge was 2.43 (95% confidence interval = 1.83 to 3.23) times higher in patients hospitalized in 1999 to 2009 than in 1975 to 1984. In conclusion, the increased use of invasive cardiac interventions and pharmacotherapies was associated with enhanced long-term survival in patients hospitalized for a first AMI. [ABSTRACT FROM AUTHOR]

The aim of this study was to compare the prognoses of patients with ST-segment elevation myocardial infarction (STEMI) and those with non-ST-segment elevation myocardial infarction (NSTEMI) without obstructive coronary artery disease (CAD) and the risk associated with gender for future cardiovascular events. The study population was selected from 95,849 patients who underwent coronary angiography for myocardial infarction from 2005 to 2010 and registered in the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). Outcome analyses, including all-cause death, myocardial infarction, congestive heart failure, stroke, and revascularization, were performed in 2,268 patients with STEMI and 10,904 with NSTEMI without obstructive CAD (<50% stenosis). Hazard ratios and 95% confidence intervals comparing women with men were calculated for events, adjusting for cardiovascular risk factors and age. Nonobstructive CAD was found in 7% of patients with STEMI (6% men, 10% women) and in 17% of those with NSTEMI (11% men, 28% women). During a median follow-up of 2.6 years, 8% of patients with STEMI and 5% of those with NSTEMI died. Gender-associated differences in risk were observed in patients with NSTEMI, with adjusted hazard ratios lower in women than men for mortality (hazard ratio 0.90, 95% confidence interval 0.50 to 0.73) and congestive heart failure (hazard ratio 0.61, 95% confidence interval 0.52 to 0.72). In the 2 groups, women underwent less revascularization. In conclusion, nonobstructive CAD was more common in patients with NSTEMI than those with STEMI, as well as in women compared with men. Long-term mortality in patients with nonobstructive CAD was higher after STEMI than NSTEMI. The gender differences in outcomes suggest gender differences in the underlying pathogenesis of myocardial infarction without obstructive CAD. [ABSTRACT FROM AUTHOR]

The relation between left anterior descending coronary artery (LAD) anatomic features and clinical outcomes in patients with anterior ST-segment elevation myocardial infarction has not been fully investigated. The Intracoronary Abciximab and Aspiration Thrombectomy in Patients With Large Anterior Myocardial Infarction (INFUSE-AMI) trial randomized 452 patients with anterior ST-segment elevation myocardial infarctions who underwent mechanical revascularization to intralesional abciximab versus no abciximab and to manual thrombus aspiration versus no aspiration. The primary end point was infarct size (percentage left ventricular mass) on contrast magnetic resonance imaging at 30 days. "Wraparound LAD" was defined as an LAD reaching the apex and supplying the apical inferior aspect of the heart. Among complete data available in 338 patients, 258 (76.3%) had wraparound LADs. Global infarct size (17.4% vs 16.1%, p=0.64) and the left ventricular ejection fraction (49.7% vs 48.7%, p = 0.98) by contrast magnetic resonance imaging at 30 days were comparable between patients with and those without wraparound LADs. Regional apical anterior infarct size was comparable (59.5% vs 55.8%, p=0.559) between the groups; however, apical septal (61.3% vs 48.9%, p = 0.005), apical inferior (19.0% vs 3.7%, p <0.0001), and apical lateral (12.2% vs 4.8%, p = 0.0584) infarct sizes were larger in patients with wraparound LADs compared with those with nonwraparound LADs. The incidence of new-onset severe heart failure at 1 year was significantly higher in patients with compared with those without wraparound LADs (6.3% vs 0%, p = 0.02). In conclusion, in patients with anterior ST-segment elevation myocardial infarctions, as compared with the LAD not supplying the inferior aspect of the heart, a wraparound LAD was associated with a larger left ventricular apex infarct size, resulting in worse adverse events at 1 year. [ABSTRACT FROM AUTHOR]

Although the traditional Agatston coronary artery calcium (CAC) score is a powerful predictor of mortality, it is unknown if the regional distribution of CAC further improves cardiovascular risk prediction. We retrospectively studied 23,058 patients referred for Agatston CAC scoring, of whom 61% had CAC (n = 14,084). CAC distribution was defined as the number of vessels with CAC (0 to 4, including left main). For multivessel CAC, "diffuse" CAC was defined by decreasing percentage of CAC in the single most affected vessel and by ≤75% total Agatston CAC score in the most calcified vessel. All-cause mortality was ascertained through the social security death index. The mean age was 55 ± 11 years, with 69% men. There were 584 deaths (2.5%) over 6.6 ± 1.7 years. Considerable heterogeneity existed between the Agatston CAC score group and the number of vessels with CAC. In each CAC group, increasing number of vessels with CAC was associated with an increased mortality rate. After adjusting for age, gender, Agatston CAC score, and cardiovascular risk factors, increasing number of vessels with CAC was associated with higher mortality risk compared with single-vessel CAC (2-vessel: HR 1.61 [95% CI 1.14 to 2.25], 3-vessel: 1.99 [1.44 to 2.77], and 4-vessel: 2.22 [1.53 to 3.23]). "Diffuse" CAC was associated with a higher mortality rate in the CAC 101 to 400 and >400 groups. Left main CAC was associated with increased mortality risk. In conclusion, increasing number of vessels with CAC and left main CAC predict increased all-cause mortality and improve the prognostic power of the traditional Agatston CAC score. [ABSTRACT FROM AUTHOR]

The impact of preoperative stable angina pectoris on postoperative cardiovascular outcomes in patients with previous myocardial infarction (MI) who underwent major noncardiac surgery is not well studied. We studied patients with previous MI who underwent elective major noncardiac surgeries within the American College of Surgeons-National Surgical Quality Improvement Program (2005 to 2011). Primary outcome was occurrence of an adverse cardiac event (MI and/or cardiac arrest). Multivariable logistic regression models evaluated the impact of stable angina on outcomes. Of 1,568 patients (median age 70 years; 35% women) with previous MI who underwent major noncardiac surgery, 5.5% had postoperative MI and/or cardiac arrest. Patients with history of preoperative angina had significantly greater incidence of primary outcome compared to those without anginal symptoms (8.4% vs 5%, p = 0.035). In secondary outcomes, reintervention rates (22.5% vs 11%, p <0.001) and length of stay (median 6-days vs 5-days; p <0.001) were also higher in patients with preoperative angina. In multivariable analyses, preoperative angina was a significant predictor for postoperative MI (odds ratio 2.49 [1.20 to 5.58]) and reintervention (odds ratio 2.40 [1.44 to 3.82]). In conclusion, our study indicates that preoperative angina is an independent predictor for adverse outcomes in patients with previous MI who underwent major noncardiac surgery, and cautions against overreliance on predictive tools, for example, the Revised Cardiac Risk Index, in these patients, which does not treat stable angina and previous MI as independent risk factors during risk prognostication. [ABSTRACT FROM AUTHOR]

The article focuses on study related to analysis of bypass angioplasty revascularization investigation trials outcomes using multistate model of clinical outcomes. Topics discussed include use of cardiovascular clinical trials in detection of treatment effect and composite outcomes, diagnosis of nonfatal Q-wave myocardial infarction in patients and use of regression analysis during the study.

Even in the era of contemporary drug-eluting stents, it is not clear whether percutaneous coronary intervention (PCI) for nonculprit lesions can improve long-term outcomes in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) with multivessel coronary disease. Relevant studies published through August 2014 were searched and identified in the electronic databases. Summary estimates were obtained using a random-effects model. From 368 initial citations, 8 observational studies with 8,425 patients (3,227 multivessel and 5,198 culprit-only PCI) were included. Mean follow-up duration was 18 months. There were no significant differences in all-cause mortality (odds ratios [ORs] 0.85, 95% confidence interval [CI] 0.70 to 1.04) and myocardial infarction (OR 0.86, 95% CI 0.55 to 1.35). However, multivessel PCI was associated with a significantly lower rate of repeat revascularization (OR 0.75, 95% CI 0.56 to 1.00). Comparison of multivessel versus culprit-only PCI disclosed OR for major adverse cardiac events of 0.74 (95% CI 0.57 to 0.97). In conclusion, multivessel PCI reduced repeat revascularization without significant benefits in terms of mortality or myocardial infarction at the long-term follow-up in patients with NSTE-ACS and multivessel coronary disease. Future randomized studies that examine the safety and efficacy of multivessel PCI in NSTE-ACS are warranted. [ABSTRACT FROM AUTHOR]

Pretreatment with antiP2Y12 agents before angiography in acute coronary syndrome (ACS) is associated with a reduction in thrombotic events. However, recent evidences have questioned the benefits of upstream antiP2Y12, reporting a higher incidence of bleeding. We analyzed the prognostic impact of clopidogrel pretreatment in a large cohort of invasively managed patients with ACS. In hospital, safety and efficacy of clopidogrel pretreatment were retrospectively analyzed in patients included in the ARIAM-Andalucía Registry (Analysis of Delay in Acute Myocardial Infarction). Propensity score and inverse probability of treatment weighting analysis were performed to control treatment selection bias. Results were stratified by ACS type. Sensitivity analyses were used to explore stability of the overall treatment effect. Of 9,621 patients managed invasively, 69% received clopidogrel before coronary angiography. In the ST-elevation myocardial infarction group, pretreatment was associated with a significant reduction in reinfarction (odds ratio 0.53, 95% confidence interval [CI] 0.27 to 0.96; p = 0.027), stent thrombosis (odds ratio 0.15, 95% CI 0.06 to 0.38; p <0.0001), and mortality (odds ratio 0.67, 95% CI 0.48 to 0.94; p = 0.020), with an increase in minor bleeding but remained as a net clinical benefit strategy. Those benefits were not present in patients without ST elevation (non-ST elevation ACS). The weighting and propensity analysis confirmed the same results. An interaction between pretreatment duration and bleeding was observed. In conclusion, pretreatment with clopidogrel reduced the occurrence of death and thrombotic outcomes at the cost of minor bleeding. Those benefits exclusively affected ST-elevation myocardial infarction cases. The potential benefit of routine upstream pretreatment in patients with non-ST-elevation ACS should be reappraised at the present. [ABSTRACT FROM AUTHOR]

The article focuses on a study related to assessment of efficacy and safety an early invasive strategy post fibrinolysis in patients with STelevation myocardial infarction (STEMI). Topics discussed include clinical benefits of the Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI) in patients of STEMI, tenecteplase received by patients for treatment of STEMI and use of Mann-Whitney U test during the study.

Circulating suppression of tumorigenicity 2 (ST2) predicts cardiovascular outcomes and mortality in ischemic heart disease (IHD). ST2 does not correlate with traditional risk indicators as closely as N-terminal pro--brain natriuretic peptide (NT-proBNP) and is only weakly correlated with other biomarkers, indicating distinct pathways for stimulus and release. Although of little diagnostic utility in IHD, ST2 does offer prognostic information. In ST elevation myocardial infarction, ST2 levels increase to peak above the normal reference range (within 6 to 18 hours of symptom onset) in about half of patients. Levels in the upper quartile observed in IHD independently predict cardiovascular death and heart failure with an approximate doubling of risk. Similar but weaker associations have been reported in non--ST elevation myocardial infarction, in which ST2 predicts short-term (30-day) and long-term (>1-year) death and heart failure independent of clinical indicators, but these relations are lost if Global Registry of Acute Coronary Events (GRACE) score and NT-proBNP are added to multivariate models. Early postinfarction levels of ST2 (i.e., <24 hours after admission) have the greatest prognostic utility. Early postinfarction ST2 levels and change over 24 weeks are related to infarct extent and remodeling to a similar extent as NT-proBNP and aldosterone, and ST2 may have a significant pathophysiological role in these postinfarction processes. In long-term follow-up of stable IHD, ST2 is predictive of all-cause and cardiovascular mortality independent of accepted clinical indicators and other biomarkers, including NT-proBNP, high-sensitivity C-reactive protein, interleukin-6, high-sensitivitiy cardiac troponin T, and galectin-3. In conclusion, ST2 in combination with NT-proBNP consistently improves risk stratification compared with either marker alone. [ABSTRACT FROM AUTHOR]

We undertook this systematic review to determine the prognostic significance of adrenomedullin (ADM) in patients with heart failure and acute myocardial infarction (AMI). Given the difficulty in measuring mature ADM, its surrogate, midregional proadrenomedullin (MRproADM) has been used in most studies. Systematic search of original published studies through MEDLINE and the Cochrane Collaboration databases restricted to reports in English from January 1, 1993, to June 30, 2014, in humans was undertaken. Heterogeneity of studies prohibited a meta-analysis. In patients with heart failure, the area under the curve for prediction of mortality by MRproADM ranged from 0.68 to 0.81 (95% confidence intervals [CI] 0.63 to 0.91) across studies. One nmol/l increase in MRproADM was associated with hazard ratios (HRs) ranging from 1.77 to 2.79 (95% CI 1.29 to 5.95) for death in patients with heart failure. In patients with AMI, the area under the curve for MRproADM predicting MACE ranged from 0.64 to 0.80 (CI 0.51 to 0.87) across studies and death 0.79 to 0.84 (CI 0.73 to 0.90). One nmol/l increase in MRproADM was associated with HR for MACE ranging from 1.78 to 4.10 (CI 1.20 to 10.12), whereas log10 of MRproADM had HRs of 3.63 to 9.75 (CI 1.48 to 26.16) for MACE and 4.86 to 16.68 (CI 4.56 to 60.99) for death across studies in patients with AMI. In conclusion, adrenomedullin is an independent predictor of death in patients with heart failure and of MACE and death in patients who have suffered an AMI. Quantification of this peptide might contribute to improved risk stratification in settings of heart failure and myocardial infarction. [ABSTRACT FROM AUTHOR]

Assessment of Dual Antiplatelet Therapy With Drug-Eluting Stents (ADAPT-DES) was a prospective, multicenter registry of 8,582 consecutive stable and unstable patients who underwent percutaneous coronary intervention using a drug-eluting stent. We sought to identify key morphologic features leading to ST-segment elevation myocardial infarction (STEMI) versus non-STEMI (NSTEMI) or unstable angina pectoris (UA) versus stable coronary artery disease (CAD) presentation. In the prespecified grayscale and virtual histology (VH) substudy of ADAPT-DES, preintervention imaging identified 676 patients with a single culprit lesion. The relation between lesion morphology and clinical presentation was compared among patients with (1) STEMI, (2) NSTEMI or UA, and (3) stable CAD. Intravascular ultrasound identified more plaque rupture and VH thin-cap fibroatheroma (TCFA) in STEMI lesions compared with NSTEMI/UA or stable CAD lesions; conversely, fibroatheromas appeared more often calcified with a thick fibrous cap in stable CAD. Minimum lumen cross-sectional area (MLA) was smaller with larger plaque burden and positive remodeling in STEMI lesions. Lesions with plaque rupture versus those without plaque rupture showed higher prevalence of VH-TCFA and larger plaque burden with positive remodeling, especially in patients with STEMI. Multivariate analysis showed that in the lesions with plaque rupture, plaque burden at the MLA site was the only independent predictor for STEMI (cutoff of plaque burden = 85%) and in lesions without plaque rupture, MLA was the only independent predictor for STEMI (cutoff of MLA = 2.3 mm²). In conclusion, culprit lesions causing STEMI have smaller lumen areas, greater plaque burden, and more plaque rupture or VH-TCFA compared with NSTEMI/UA or stable CAD; in lesions with plaque rupture, only plaque burden predicted STEMI, and in lesions without plaque rupture, only MLA area predicted STEMI. [ABSTRACT FROM AUTHOR]

The Killip classification of acute heart failure was developed decades ago to predict shortterm mortality in patients with acute myocardial infarction (AMI). The aim of this study was to determine the long-term prognosis of acute heart failure graded according to the Killip classification in 15,235 unselected patients hospitalized for AMI from 2000 to 2005. Vital status for each patient was ascertained, through to March 1, 2012, from linkage with national death records. A stepwise gradient in the adjusted hazard ratio (HR) for 12-year mortality was observed with increasing Killip class: class I (n = 10,123), HR 1.00 (reference group); class II (n = 2,913), HR 1.13 (95% confidence interval [CI] 1.06 to 1.21); class III (n = 1,217) HR 1.49 (95% CI 1.37 to 1.62); and class IV (n = 898), HR 2.80 (95% CI 2.53 to 3.10). Unexpectedly, in a landmark analysis excluding deaths <30 days after admission, patients in Killip class IV had lower adjusted long-term mortality than those in class III. The adjusted HR for 12-year mortality comparing Killip class IV with Killip class III in patients <60 years of age was 1.71 (95% CI 1.33 to 2.19, p <0.001) and in patients >60 years of age was 2.30 (95% CI 2.07 to 2.56, p <0.001). In conclusion, on the basis of simple clinical features, the Killip classification robustly predicted 12-year mortality after AMI. The heterogeneity in early versus late risk in patients with Killip class IV heart failure underscores the importance of appropriate early treatment in cardiogenic shock. [ABSTRACT FROM AUTHOR]

Given the vicissitudes of percutaneous coronary intervention (PCI) technology, epidemiology, and mode of practice, the aim of this study was to define contemporary outcome predictors in a very large consecutive patient cohort. Data from 11,441 consecutive patients who underwent PCI at a tertiary medical center from April 2004 to September 2013 are presented. A comprehensive database was built using various data sources, with outcome end points defined as all-cause mortality and as a composite of death or nonfatal myocardial infarction during follow-up. Candidate variables to influence outcome were chosen a priori and were tested using multivariate time-dependent models to estimate each interaction. Mean follow-up was 5.5 years (range 3 months to 9.5 years). The cohort consisted of 75% men, 42% patients with diabetes, and 61% patients who underwent PCI in acute coronary syndrome settings and 7.8% for ST-elevation myocardial infarction. Drug-eluting stents were used in 43.4% of patients, bare-metal stents in 52%, and balloon angioplasty alone in 4.6%. In multivariate analysis, in addition to already well-recognized predictors of death or myocardial infarction such as advanced age (hazard ratio [HR] 1.031, p <0.001), female gender (HR 1.23, p <0.001), urgent setting (HR 1.23, p <0.001) and diabetes mellitus (HR 1.28, p <0.001), we particularly noted previous anemia (HR 1.55 p <0.001), previous chronic kidney injury (HR 1.93, p <0.001) and previous moderate to severe left ventricular dysfunction (HR 2.29, p <0.001). Drug-eluting stent placement was associated with better outcomes (HR 0.70, p <0.001). In conclusion, this analysis confirms the effect of some known predictors of PCI outcomes. However, the extent of their effect is modest, while other predictors may have a greater influence on outcomes. Risk stratification of PCI patients should take into account kidney injury, anemia, and left ventricular function. Drug-eluting stents provide sustained benefit. [ABSTRACT FROM AUTHOR]

Despite advances in cardiopulmonary resuscitation (CPR), survival remains low after out-of-hospital cardiac arrest (OOHCA). Acute coronary ischemia is the predominating precipitant, and prompt delivery of patients to dedicated facilities may improve outcomes. Since 2011, all patients experiencing OOHCA in London,where a cardiac etiology is suspected, are systematically brought to heart attack centers (HACs). We determined the predictors for survival and favorable functional outcomes in this setting. We analyzed 174 consecutive patients experiencing OOHCA from 2011 to 2013 brought to Harefield Hospital—a designated HAC in London. Weanalyzed (1) all-cause mortality and (2) functional status using amodified Rankin scale (mRS 0 to 6, wheremRS0-3+ = favorable functional status). The overall survival rates were 66.7% (30 days) and 62.1% (1 year); and 54.5% had mRS0-3+ at discharge. Patients with mRS0-3+ had reduced mortality compared to mRS0-3-: 30 days (1.2% vs 72.2%, p <0.001) and 1 year (5.3% vs 77.2%, p <0.001). Multivariate analyses identified lower patient comorbidity, absence of cardiogenic shock, bystander CPR, ventricular tachycardia/ ventricullar fibrillation as initial rhythm, shorter duration of resuscitation, prehospital advanced airway, absence of adrenaline and inotrope use, and intra-aortic balloon pump use as predictors of mRS0-3+. Consistent predictors of increased mortality were the presence of cardiogenic shock, advanced airway use, increased duration of resuscitation, and absence of therapeutic hypothermia. A streamlined delivery of patients experiencing OOHCA to dedicated facilities is associated with improved functional status and survival. Our study supports the standardization of care for such patients with the widespread adoption of HACs. [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluate the influence of a home-based walking program on erectile function and the relation between functional capacity and erectile dysfunction (ED) in patients with recent myocardial infarctions. Patients with acute myocardial infarctions deemed to be at low cardiovascular risk were randomized into 2 groups: (1) a home-based walking group (n = 41), instructed to participate in a progressive outdoor walking program, and (2) a control group (n = 45), receiving usual care. Functional capacity was determined by the 6-minute walk test and evaluation of sexual function by the International Index of Erectile Function questionnaire; the 2 tests were performed at hospital discharge and 30 days later. In the overall cohort, 84% of patients reported previous ED at hospital discharge. After 30 days, ED had increased by 9% in the control group in relation to baseline (p = 0.08). However, the home-based walking group had a significant decrease of 71% in reported ED (p <0.0001). The 6-minute walk distance was statistically significant higher in the home-based walking group compared with the control group (p = 0.01). There was a significant negative correlation between 6-minute walk distance and ED 30 days after hospital discharge (r = -0.71, p <0.01). In conclusion, an unsupervised home-based progressive walking program led to significant improvements in functional capacity in men at low cardiovascular risk after recent acute myocardial infarctions. In addition, this intervention demonstrated a link between functional capacity and exercise training and erectile function improvement. [ABSTRACT FROM AUTHOR]

Infarct size after ST-segment elevation myocardial infarction (STEMI) is associated with long-term clinical outcomes. However, there is insufficient information correlating creatine kinase-MB (CK-MB) or troponin levels to infarct size and infarct location in first-time occurrence of STEMI. We, therefore, assessed the utility of CK-MB measurements after primary percutaneous coronary intervention of a first anterior STEMI using bivalirudin anticoagulation in patients who were randomized to intralesion abciximab versus no abciximab and to manual thrombus aspiration versus no aspiration. Infarct size (as a percentage of total left ventricular [LV] mass) and LV ejection fraction (LVEF) were evaluated by cardiac magnetic resonance imaging at 30 days and correlated to peak CK-MB. Peak CK-MB (median 240 IU/L; interquartile range 126 to 414) was significantly associated with infarct size and with LVEF (r = 0.67, p <0.001; r = -0.56, p <0.001, respectively). A large infarct size (greater than or equal the median, defined as 17% of total LV mass) and LVEF ≤40% were more common in the highest peak CK-MB tertile group than in the other tertiles (87.6% vs 49.5% vs 9.1%, p <0.001; 43.2% vs 14.0% vs 4.6%, p <0.001, respectively). Peak CK-MB of at least 300 IU/L predicted with moderate accuracy both a large infarct size (area under the curve 0.88) and an LVEF ≤40% (area under the curve 0.78). Furthermore, CK-MB was an independent predictor of 1-year major adverse cardiac events (hazard ratio 1.42 per each additional 100 IU/L [1.20 to 1.67], p <0.001). In conclusion, CK-MB measurement is useful in estimating infarct size and LVEF and in predicting 1-year clinical outcomes after primary percutaneous coronary intervention for first anterior STEMI. [ABSTRACT FROM AUTHOR]

The Italian Elderly ACS study was the first randomized controlled trial comparing an early aggressive with an initially conservative strategy in patients with non-ST-segment elevation acute coronary syndromes aged = 75 years, with the results showing no significant benefit of early aggressive therapy. The aim of this study was to evaluate the outcomes of trial patients, according to the treatment actually received during hospitalization. The trial enrolled 313 patients. The primary end point was the composite of death, myocardial infarction (MI), disabling stroke, and repeat hospital stay for cardiovascular causes or bleeding within 1 year. All patients in whom coronary angiography was performed during initial hospitalization were defined as having undergone invasive treatment (182 patients), whereas all patients who did not undergo coronary angiography were classified as medically managed (conservative treatment [CT] group, 131 patients). The primary end point occurred in 53 patients (40.5%) in the CT group and 45 patients (24.7%) in the invasive treatment group (hazard ratio 0.56, 95% confidence interval 0.37 to 0.83, p = 0.003). The invasive treatment group showed significantly lower rates of MI (6% vs 13% in the CT group; hazard ratio 0.43, 95% confidence interval 0.20 to 0.92, p = 0.034) and the aggregate of death and MI (14.3% vs 27.5% CT group; hazard ratio 0.48, 95% confidence interval 0.29 to 0.81, p = 0.004). In conclusion, elderly patients with non-ST-segment elevation acute coronary syndromes treated invasively experienced significantly better survival free from the composite of all-cause mortality, nonfatal MI, disabling stroke, and repeat hospitalization for cardiovascular causes or bleeding. [ABSTRACT FROM AUTHOR]

Intermediate coronary artery stenosis (≥50% and <90%) on coronary computed tomography angiography (CTA) is usually considered as a significant lesion. However, anatomical diagnosis is not well correlated with the functional significance of myocardial ischemia. We investigated whether functional testing in addition to coronary CTA improves outcomes of patients with intermediate stenosis, compared with the 1-step CTA-aloneebased strategy. From 2006 to 2011, we consecutively enrolled 335 patients with chest pain with intermediate stenosis detected by an initially performed coronary CTA. Of these, 159 patients followed the 1-step strategy, whereas 176 followed the 2-step strategy with confirmatory functional tests. One-year follow-up data were obtained for all patients. The primary end point was a composite of cardiovascular death, nonfatal myocardial infarction, and repeated or delayed revascularization (major adverse cardiac event) within a year. Baseline clinical parameters were comparable between patients of the 2 different strategies. The rate of invasive catheterization or percutaneous intervention was 75.5% in the 1-step group and 35.2% in the 2-step group (p <0.001). Consequently, more patients in the 2-step group were medically treated without unnecessary revascularization compared with patients in the 1-step group (71.0% vs 40.9%, p <0.001). Only 2.5% of the patients who received medical treatment in the 2-step group finally received delayed revascularization, whereas 14% in the 1-step group did. Overall, the primary end point occurred in 11.3% in the 1-step group and 4.0% in the 2-step group (p = 0.011). In conclusion, confirmatory functional testing reduces invasive catheterization and coronary intervention and improves clinical outcomes in patients with intermediate stenosis on coronary CTA. [ABSTRACT FROM AUTHOR]

Current guidelines recommend shorter door-to-balloon times (DBTs) (<90 minutes) for patients with ST-elevation myocardial infarction (STEMI). Clinical factors, including patient or hospital characteristics, associated with prolonged DBT have been identified, but angiographic variables such as culprit lesion location have not been thoroughly investigated. We aimed to evaluate the effect of culprit artery location on DBT of patients with STEMI who underwent percutaneous coronary intervention (PCI). Data were analyzed from 1,725 patients with STEMI who underwent PCI from August 2008 to March 2014 at 16 Japanese hospitals. Patients were divided into 3 groups according to culprit artery location, right coronary artery (RCA), left anterior descending artery (LAD), and left circumflex artery (LC), and associations with DBT were assessed. The LC group had a trend toward a longer DBT among the 3 groups (97.1 [RCA] vs 98.1 [LAD] vs 105.1 [LC] minutes; p [ 0.058). In-hospital mortality was also significantly higher in patients with a left coronary artery lesion (3.5% [RCA] vs 6.3% [LAD] vs 5.4% [LC]; p [ 0.041). Inhospital mortality for patients with DBT >90 minutes was significantly higher compared with patients with DBT ≤ 90 minutes (6.5% vs 3.6%; p [ 0.006). Multivariate logistic regression analysis revealed that the LC location was an independent predictor for DBT >90 minutes (odds ratio, 1.45; 95% confidence interval, 1.04 to 2.01; p [ 0.028). In conclusion, LC location was an independent predictor of longer DBT. The difficulties in diagnosing LC-related STEMI need further evaluation. [ABSTRACT FROM AUTHOR]

Lipoprotein levels are currently recognized as independent risk factors for long-term cardiovascular events after acute myocardial infarction (AMI). During the acutephase reaction after AMI, previous studies have reported trends of decreased low-density lipoprotein cholesterol (LDL-C), increased triglycerides, and variable high-density lipoprotein cholesterol (HDL-C) levels. However, the association between LDL-C and HDL-C levels and in-hospital mortality has not been well established following AMI. The relationship between lipid levels and in-hospital all-cause mortality in 115,492 patients hospitalized for AMI (July 2002 to December 2006), registered in the National Registry of Myocardial Infarction (NRMI) 4be5, was evaluated using multivariable-adjusted logistic regression models. Mean LDL-C was 104 ± 38, HDL-C was 41 ± 14, and triglycerides 143 ± 83 mg/dl. Compared with the lowest quartile of LDL-C (<77 mg/dl), the risk of in-hospital mortality in the second to fourth quartiles was decreased (adjusted odds ratio 0.79, 0.80, and 0.85, respectively). For HDL-C, only those in the lowest quartile (<31 mg/dl) had higher risk of in-hospital mortality (odds ratio 1.20) compared with the highest quartile (≥47 mg/dl). Results from NRMI 4be5 suggest a lipid paradox, with lower LDL-C levels associated with increased risk of in-hospital mortality, contrary to findings outside the acute setting. Consistent with previous analyses, lowest HDL-C levels were associated with increased in-hospital mortality. In conclusion, further explorations of the relationship between very low levels of LDL-C, myocardial necrosis, and subsequent adverse cardiovascular events are warranted. [ABSTRACT FROM AUTHOR]

Statin therapy moderately increases high-density lipoprotein cholesterol (HDL-C) levels. Contrary to this expectation, a paradoxical decrease in HDL-C levels after statin therapy is seen in some patients. We evaluated 724 patients who newly started treatment with statins after acute myocardial infarction (AMI). These patients were divided into 2 groups according to change in HDL-C levels between baseline and 6 to 9 months after initial AMI (DHDL). In total, 620 patients had increased HDL-C levels and 104 patients had decreased HDL-C levels. Both groups achieved follow-up low-density lipoprotein cholesterol levels <100 mg/dl. Adverse cardiovascular events (a composite of all-cause death, myocardial infarction, and stroke) have more frequently occurred in the decreased HDL group compared with the increased HDL group (15.4% vs 7.1%, p = 0.01). Multivariate analysis showed that decreased HDL, onset to balloon time, and multivessel disease were the independent predictors of adverse cardiovascular events (hazard ratio [HR] 1.95, 95% confidence interval [CI] 1.08 to 3.52; HR 1.05, 95% CI 1.01 to 1.09; and HR 2.08, 95% CI 1.22 to 3.56, respectively). In conclusion, a paradoxical decrease in serum HDL-C levels after statin therapy might be an independent predictor of long-term adverse cardiovascular events in patients with AMI. [ABSTRACT FROM AUTHOR]

Ventricular fibrillation (VF) during reperfusion (rVF) in ST-segment elevation myocardial infarction (STEMI) is an infrequent but serious event that complicates coronary interventions. The aim of this study was to analyze clinical predictors of rVF in an unselected population of patients with STEMI treated with percutaneous coronary intervention (PCI). Consecutive patients with STEMI admitted to a tertiary care hospital for primary PCI from 2007 to 2012 were retrospectively assessed for the presence of rVF. Admission electrocardiograms, stored in a digital format, were analyzed for a maximal ST-segment elevation in a single lead and the sum of ST-segment deviations in all leads. Clinical, electrocardiographic, and angiographic characteristics were tested for associations with rVF using logistic regression analysis. Among 3,724 patients with STEMI admitted from 2007 to 2012, 71 (1.9%) had rVF. In univariate analysis, history of myocardial infarction, aspirin and α-blocker use, VF before PCI, left main coronary artery disease, inferior myocardial infarction localization, symptom-to-balloon time <360 minutes, maximal ST-segment elevation in a single lead >300 µV, and sum of ST-segment deviations in all leads >1,500 µV were associated with increased risk for rVF. In a multivariate analysis, sum of ST-segment deviations in all leads >1500 µV (odds ratio 3.7, 95% confidence interval 1.45 to 9.41, p = 0.006) before PCI remained an independent predictor of rVF. In-hospital mortality was 18.3% in the rVF group and 3.3% in the group without VF (p <0.001), but rVF was not an independent predictor of in-hospital death. In conclusion, the magnitude of ST-segment elevation before PCI for STEMI independently predicts rVF and should be considered in periprocedural arrhythmic risk assessment. Despite higher in-hospital mortality in patients with rVF, rVF itself has no independent prognostic value for prognosis. [ABSTRACT FROM AUTHOR]

Smoke-free ordinance implementation and advances in smoking cessation (SC) treatment have occurred in the past decade; however, little is known about their impact on SC in patients with coronary artery disease. We conducted a retrospective cohort study of 2,306 consecutive patients from Olmsted County, Minnesota, who underwent their first percutaneous coronary intervention (PCI) from 1999 to 2009, and assessed the trends and predictors of SC after PCI. Smoking status was ascertained by structured telephone survey 6 and 12 months after PCI (ending in 2010). The prevalence of smoking in patients who underwent PCI increased nonsignificantly from 20% in 1999 to 2001 to 24% in 2007 to 2009 (p = 0.14), whereas SC at 6 months after PCI decreased nonsignificantly from 50% (1999 to 2001) to 49% (2007 to 2009), p = 0.82. The 12-month quit rate did not change significantly (48% in 1999 to 2001 vs 56% in 2007 to 2009, p = 0.38), even during the time periods after the enactment of smoke-free policies. The strongest predictor of SC at 6 months after PCI was participation in cardiac rehabilitation (odds ratio [OR] 3.17,95% confidence interval [CI] 2.05 to 4.91, p <0.001), older age (OR 1.42 per decade, 95% CI 1.16 to 1.73, p <0.001), and concurrent myocardial infarction at the time of PCI (OR 1.77,95% CI 1.18 to 2.65, p = 0.006). One-year mortality was lower in the group of smokers compared with never smokers (3% vs 7%, p <0.001). In conclusion, SC rates have not improved after PCI over the past decade in our cohort, despite the presence of smoke-free ordinances and improved treatment strategies. Improvements in delivery of systematic services aimed at promoting SC (such as cardiac rehabilitation) should be part of future efforts to improve SC rates after PCI. [ABSTRACT FROM AUTHOR]

The safety of early enrollment (<2 weeks after hospital discharge) into cardiac rehabilitation (CR) after recent coronary artery bypass graft (CABG) surgery or heart valve surgery (HVS) has not previously been assessed and has important policy implications. Consequently, we performed a detailed review of all clinical adverse events within 6 months of hospital discharge. We compared early and late attendees for patients undergoing CABG surgery or HVS and included patients with myocardial infarction (MI) as an additional control group. We analyzed 112 patients undergoing CABG surgery, 69 patients undergoing HVS, and 59 patients with MI. Median time (interquartile range) from hospital discharge to CR enrollment was 10.5 (8 to 15), 12 (8.5 to 21), and 9 days (7 to 14), respectively. There was no difference in major event rates between early and late enrollees (17% vs 17%, respectively, log-rank p = 0.98) or by diagnosis (15%, 16%, and 22% for CABG surgery, HVS, and MI, respectively; log-rank p = 0.50). Sternal instability and wound infection rates were similar. CR-related adverse events trended toward increased event rates in surgical and early enrollees, but of 44 events, only 3 were exercise related, none resulted in permanent harm, and 41 (93%) were managed in CR without need for emergency services. In conclusion, it appears that a policy of encouraging early enrollment into CR in patients with a recent open heart surgery seems unlikely to harm patients when careful individualized assessment and exercise prescription take place within the bounds of an established CR program. [ABSTRACT FROM AUTHOR]

The accuracy of the 12-lead electrocardiogram in detecting coronary artery occlusion is limited. We sought to determine the incidence, distribution, and outcomes of patients who have total occlusion of the culprit artery but present with non--ST-segment elevation myocardial infarction (NSTEMI). The randomized Acute Catheterization and Urgent Intervention Triage Strategy trial enrolled 13,819 patients presenting with non--ST-segment elevation acute coronary syndromes who underwent an early invasive strategy. The present study includes 1,319 patients with baseline biomarker elevation (NSTEMI) and no history of coronary artery bypass graft who underwent percutaneous coronary intervention of a single culprit vessel. We compared the baseline characteristics and outcomes according to whether the culprit vessel was occluded (baseline Thrombolysis In Myocardial Infarction [TIMI] 0 to 1) or patent (TIMI 2 to 3 flow) by angiographic core laboratory assessment. TIMI 0 to 1 flow in the culprit artery was present in 262 of 1,319 (19.9%) patients. The incidence of coronary occlusion was 28.4%, 19.3%, and 12.6% in patients with NSTEMI because of right coronary, left circumflex, and left anterior descending artery disease, respectively. Patients with an occluded culprit artery were more commonly men and had ST-segment deviation ≥1 mm. One-year outcomes, including death (3.5% vs 3.0%, p = 0.68) and myocardial infarction (8.4% vs 9.6%, p = 0.47), did not differ significantly between patients with versus without occluded culprit arteries, respectively. In conclusion, the present study demonstrates that the culprit artery is totally occluded in approximately 1 in 5 patients presenting with NSTEMI and single-vessel disease; however, the presence of total occlusion in NSTEMI was not associated with an incremental hazard of death or reinfarction at 1 year. [ABSTRACT FROM AUTHOR]

severity of coronary artery stenosis and to stratify which lesions should be subjected to intervention (percutaneous coronary intervention [PCI]). A systematic review was performed in MEDLINE and EMBASE including studies indexed until November 2013 that used FFR for deferral or performance of PCI. Outcomes of interest were death, acute myocardial infarction (AMI), and new revascularization (RV). Nineteen studies were included, totaling 3,097 patients (3,796 lesions). Mean follow-up was 21.2 months. In indirect comparisons, FFR-PCI and FFR-defer groups had similar death (2.2% vs 2.0%, respectively, p[0.86) and AMI rates (1.9% vs 1.9%, respectively, p[1.00). RV rates were higher in the FFR-PCI group (14.0% vs 4.4%, p = 0.002). Direct comparisons (2-arm trials) also showed no differences in death (odds ratio [OR] 1.86 [95% CI 0.81 to 4.27], I2=11.5, p=0.14) and AMI rates (OR 0.75 [95% CI 0.21 to 2.69], I2=47.1, p=0.66); RV rates were again higher in the FFR-PCI (OR 3.10 [95% CI 1.25 to 7.70], I2 = 72.2, p = 0.015). Meta-regression suggests influence of male gender on RV rates (β = 0.058, p = 0.026). In conclusion, deferral of PCI based on FFR is a safe strategy. Considerable heterogeneity was observed, however. [ABSTRACT FROM AUTHOR]

Two pilot studies of interleukin-1 (IL-1) blockade in ST-segment elevation myocardial infarction (STEMI) showed blunted acute inflammatory response and overall favorable outcomes at 3 months follow-up. We hereby present a patient-level pooled analysis with extended follow-up of 40 patients with clinically stable STEMI randomized to anakinra, a recombinant IL-1 receptor antagonist, 100 mg/day for 14 days or placebo in a doubleblinded fashion. End points included death, cardiac death, recurrent acute myocardial infarction (AMI), stroke, unstable angina, and symptomatic heart failure. Median follow-up was 28 (interquartile range 3 to 38) months. Sixteen patients (40%) had a total of 22 adverse cardiovascular events: 1 cardiac death, 4 recurrent AMI, 5 episodes of unstable angina pectoris requiring hospitalization and/or urgent revascularization, and 11 new diagnoses of heart failure. Treatment with anakinra was associated with a hazard ratio of 1.08 (95% confidence interval 0.31 to 3.74, p [ 0.90) for the combined end point of death, recurrent AMI, unstable angina pectoris, or stroke and a hazard ratio of 0.16 (95% confidence interval 0.03 to 0.76, p [ 0.008) for death or heart failure. In conclusion, IL-1 blockade with anakinra for 2 weeks appears, therefore, to have a neutral effect on recurrent ischemic events, whereas it may prevent new-onset heart failure long term after STEMI. [ABSTRACT FROM AUTHOR]