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Background: The efficacy and safety of a reduced dose of prasugrel versus a standard dose of ticagrelor in elderly patients or those with a low body weight presenting with an acute coronary syndrome (ACS) are unknown.Objective: To investigate the effect of an age- and weight-adapted dose of prasugrel versus a standard dose of ticagrelor in patients with ACS. (ClinicalTrials.gov: NCT01944800).Design: Prespecified analysis of the multicenter, randomized ISAR-REACT 5 trial.Setting: 23 centers in Germany and Italy.Patients: 3997 patients with ACS planned for invasive management.Intervention: Participants were randomly assigned to receive a standard dose of ticagrelor or prasugrel (reduced dose in the elderly or low-weight group and standard dose in the neither elderly nor low-weight group).Measurements: The efficacy end point was a composite of death, myocardial infarction, or stroke, and the safety end point was bleeding, both at 12 months.Results: In the elderly or low-weight group, the efficacy end point occurred in 12.7% of patients assigned to receive prasugrel and 14.6% of those assigned to receive ticagrelor (hazard ratio [HR], 0.82 [95% CI, 0.60 to 1.14]); in the neither elderly nor low-weight group, the efficacy end point occurred in 4.8% of patients assigned to receive prasugrel and 7.3% of those assigned to receive ticagrelor (HR, 0.65 [CI, 0.48 to 0.88]; P for interaction > 0.2). In the elderly or low-weight group, Bleeding Academic Research Consortium type 3 to 5 bleeding occurred in 8.1% of patients assigned to receive prasugrel and 10.6% of those assigned to receive ticagrelor (HR, 0.72 [0.46 to 1.12]), and in 3.7% and 3.8%, respectively, of patients in the neither elderly nor low-weight group (HR, 0.98 [CI, 0.65 to 1.47]; P for interaction > 0.2).Limitation: The study is a subgroup analysis.Conclusion: In elderly or low-weight patients with ACS, a reduced dose of prasugrel compared with the standard dose of ticagrelor is associated with maintained anti-ischemic efficacy while protecting these patients against the excess risk for bleeding.Primary Funding Source: German Center for Cardiovascular Research and Deutsches Herzzentrum München. [ABSTRACT FROM AUTHOR]

Background: The prognostic value of high-sensitivity troponin T (hs-TnT) elevation after elective percutaneous coronary intervention (PCI) in patients with or without raised baseline hs-TnT levels is unclear.Objectives: The goal of this study was to assess whether the prognostic value of post-procedural hs-TnT level after elective PCI depends on the baseline hs-TnT level.Methods: This study included 5,626 patients undergoing elective PCI who had baseline and peak post-procedural hs-TnT measurements available. The primary outcome was 3-year mortality (with risk estimates calculated per SD increase of the log hs-TnT scale).Results: Patients were divided into 4 groups: nonelevated baseline and post-procedural hs-TnT levels (hs-TnT ≤0.014 μg/l; n = 742); nonelevated baseline but elevated post-procedural hs-TnT levels (peak post-procedural hs-TnT >0.014 μg/l; n = 2,721); elevated baseline hs-TnT levels (hs-TnT >0.014 μg/l) with no further rise post-procedure (n = 516); and elevated baseline hs-TnT levels with a further rise post-procedure (n = 1,647). A total of 265 deaths occurred: 6 (1.6%) in patients with nonelevated baseline and post-procedural hs-TnT levels; 54 (3.8%) in patients with nonelevated baseline but elevated post-procedural hs-TnT levels; 50 (16.0%) in patients with elevated baseline hs-TnT levels with no further rise post-procedure; and 155 (18.2%) in patients with elevated baseline hs-TnT levels with a further rise post-procedure (p < 0.001). After adjustment, baseline hs-TnT levels (hazard ratio [HR]: 1.22; 95% confidence interval [CI]: 1.09 to 1.38; p < 0.001) but not peak post-procedural hs-TnT levels (HR: 1.04; 95% CI: 0.85 to 1.28; p = 0.679) were associated with an increased risk of mortality. Peak post-procedural hs-TnT findings were not associated with mortality in patients with nonelevated (HR: 0.93; 95% CI: 0.69 to 1.25; p = 0.653) or elevated (HR: 1.24; 95% CI: 0.91 to 1.69; p = 0.165) baseline hs-TnT levels.Conclusions: In patients with coronary artery disease undergoing elective PCI, an increase in post-procedural hs-TnT level did not offer prognostic information beyond that provided by the baseline level of the biomarker. [ABSTRACT FROM AUTHOR]

Despite dual antiplatelet therapy patients undergoing percutaneous coronary intervention (PCI) continue to experience periprocedural ischemic events. In addition, all currently used antithrombotic drugs increase the bleeding risk. Thus, there is an unmet clinical need for antithrombotic strategies with improved efficacy and no increase in bleeding. Revacept is a novel, lesion-directed antithrombotic drug that does not interfere with the function of circulating platelets. This dimeric fusion protein of the extracellular domain of glycoprotein VI (the major platelet collagen receptor) and the human Fc-fragment inhibits collagen-mediated platelet adhesion and subsequent aggregation at the site of vascular injury. The randomized, double-blinded, phase II ISAR-PLASTER trial is based on extensive preclinical evaluation of Revacept and a favorable first-in-man trial. A total of 332 patients with stable coronary artery disease undergoing elective PCI will be randomized to either Revacept 160 mg, Revacept 80 mg, or placebo administered as single intravenous infusion directly before the intervention, on top of standard dual antiplatelet therapy and either heparin or bivalirudin, based on local practice and current guidelines. The primary endpoint is the composite of death or myocardial injury (defined as increase in high sensitivity troponin T ≥ 5 times the upper limit of normal) at 48 hours. The safety endpoint is bleeding of class 2 or higher according to the Bleeding Academic Research Consortium at 30 days. This phase II randomized, double blind trial will assess for the first time the efficacy and safety of Revacept-a lesion-directed inhibitor of platelet adhesion-in patients undergoing elective PCI., Competing Interests: S.S. has received the Else Kröner-Memorial grant from the Else Kröner-Fresenius-Stiftung. D.S. reports grants from Roche Diagnostics and Daiichi Sankyo; and personal fees from Bayer AG, Daiichi Sankyo, Eli Lilly, Roche Diagnostics, MSD, Pfizer, Sanofi, and AstraZeneca. S.M. received research grants from Roche (Tropical ACS trial) and Pfizer/BMS (APPROACH-ACS AF trial). S.M. also reports grants from Deutsches Zentrum für Herz-Kreislaufforschung, during the conduct of the study; grants from Pfizer, from Roche, outside the submitted work. D.S. reports grants from Roche Diagnostics, grants from Daiichi Sankyo, personal fees from Bayer, personal fees from Astra Zeneca, personal fees from Daiichi Sankyo, personal fees from Eli Lilly, personal fees from MSD, personal fees from Pfizer, and personal fees from Sanofi, outside the submitted work. The other coauthors report no conflicts of interest related to this study., (Georg Thieme Verlag KG Stuttgart · New York.)

The relationship between central pulse pressure (CPP) measured at the time of primary percutaneous coronary intervention (PPCI) and long-term prognosis after ST-segment elevation myocardial infarction (STEMI) has not been investigated. CPP measurements were performed in 1348 patients with STEMI (327 women; mean age 62.5 ± 12.1 years) undergoing PPCI. Aortic systolic and diastolic blood pressure was measured before intervention. The primary outcome was 8-year all-cause mortality. The median [25-75th percentile] CPP value was 55.0 [43.0-70.0] mmHg. CPP correlated negatively with heart rate (P < 0.001), body mass index (P = 0.007), Killip class (P < 0.001) and initial area at risk (P < 0.001) and positively with age (P < 0.001), female sex (P < 0.001), diabetes (P = 0.012), arterial hypertension (P < 0.001) and glomerular filtration rate (P = 0.004). There were 181 deaths over the follow-up. In patients with CPP within the 1st, 2nd and 3rd tertiles, the Kaplan-Meier estimates of mortality were 17.3%, 10.8% and 24.2%, respectively; univariable hazard ratio [HR] =1.52, 95% confidence interval [CI] 0.99 to 2.32; P = 0.055 for tertile 1 vs. tertile 2 and HR =2.09 [1.36-3.21]; P < 0.001 for tertile 3 vs. tertile 2. For CPP values lower than 35 mmHg and higher than 71 mmHg, the association between CPP and all-cause mortality was significant (HR =1.276 [1.004-1.621] for the 35 mmHg value and HR =1.289 [1.003-1.657] for the 71 mmHg value) compared with the CPP reference value (54 mmHg). After adjustment, the association between CPP and all-cause mortality was attenuated (P = 0.304). In patients with STEMI undergoing PPCI there is a U-shaped association between CPP and mortality up to 8 years after PPCI.

Background: Whether there are sex differences in the outcome of patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) remains controversial. We undertook this study to assess whether there are sex-related differences in the long-term mortality in a large series of patients with CAD after PCI., Methods: The study included 18,334 patients (4735 women and 13,599 men) with CAD treated with PCI. Propensity matching was performed to obtain a group of patients (3000 women and 3000 men) matched for all characteristics available in database. The primary outcome was a composite of cardiac mortality, myocardial infarction or stroke at 3 years of follow-up., Results: The primary outcome occurred in 660 women and 1440 men (Kaplan-Meier [KM] estimates, 15.2% in women and 11.6% in men, unadjusted hazard ratio [HR] = 1.35, 95% confidence interval [CI] 1.24 to 1.49; P < 0.001). Women were at higher risk of all-cause mortality (15.4% vs. 12.3%; P < 0.001), cardiac mortality (10.2% vs. 7.6%; P < 0.001) and stroke (2.6% vs. 1.4%; P < 0.001) than men. In matched patients, the primary outcome occurred in 371 women and 322 men (KM estimates, 13.4% vs. 11.6%, HR = 1.18 [1.01-1.36], P = 0.033). Women were at higher risk of myocardial infarction (4.2% vs. 3.1%; P = 0.044) but not cardiac (8.7% vs. 8.2%; P = 0.306) or all-cause death (12.5% vs. 12.9%; P = 0.991) or stroke (1.9% vs. 1.6%; P = 0.550) than men., Conclusions: After propensity matching, women remained at a higher risk of a composite of cardiac mortality, myocardial infarction or stroke up to 3 years after PCI than men., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The magnitude of prognostically relevant myocardial injury after percutaneous coronary interventions remains poorly defined. The Society for Cardiovascular Angiography and Interventions (SCAI) proposed marked biomarker elevations to define periprocedural myocardial infarction (PMI). These consensus-based thresholds have not been validated in the era of high-sensitivity cardiac troponins. We sought to assess the prognostic impact of SCAI-defined PMI and explore optimal prognostic thresholds of high-sensitivity cardiac troponin T (hs-cTnT) after elective percutaneous coronary interventions., Methods and Results: We evaluated patients who underwent elective percutaneous coronary interventions at 2 tertiary care centers with serial hs-cTnT measurements. PMI was defined as peak postprocedural hs-cTnT >70× upper reference limit (URL) in patients with nonelevated (≤1× URL) baseline levels; or incremental increase >70× URL in patients with elevated baseline levels. The primary outcome was 1-year all-cause mortality. Of 8140 patients, 220 (2.7%) died within 1 year. In multivariable analyses, patients with SCAI-defined PMI (n=140; 1.7%) had a higher risk of 1-year mortality (12.9% versus 2.5%, adjusted hazard ratio 4.10, 95% CI 2.51-6.68; P<0.001) as well as cardiac mortality (11.4% versus 2.1%, adjusted hazard ratio 4.21, 95% CI 2.50-7.11; P<0.001). Based on receiver operating characteristics analysis, the optimal prognostic threshold of hs-cTnT was >10×URL, observed in 14.6% of patients. This threshold showed lower specificity (85.7% versus 98.4%) but higher sensitivity (25.4% versus 8.2%) and better overall performance for prediction of 1-year mortality compared with the SCAI-defined cutoff value of troponin., Conclusions: In patients undergoing elective percutaneous coronary interventions, SCAI-defined PMI emerged as an independent, highly specific, but insensitive predictor of 1-year mortality. Optimal trade-off between sensitivity and specificity was observed at a lower threshold of hs-cTnT (10× URL) in this cohort.

Thrombolysis in Myocardial Infarction (TIMI) flow, myocardial perfusion grade (MPG), and infarct size are established markers of reperfusion in patients with ST-segment elevation myocardial infarction. Whether these markers provide long-term prognostic information remains unknown. This study included 1,406 patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention. Postreperfusion TIMI flow, MPG, and infarct size (evaluated by scintigraphy at 7 to 14 days) were measured. The primary outcome was 8-year mortality. Overall there were 190 deaths. The Kaplan-Meier estimates of mortality were 22.6% (37 deaths) and 16.8% (153 deaths) according to TIMI flow ≤2 and TIMI flow 3 (adjusted hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.66 to 1.00, p = 0.058 for 1 grade increment), 21.6% (106 deaths) and 14.5% (84 deaths) according to MPG ≤2 and MPG 3 (adjusted HR 0.87 [0.77 to 0.98], p = 0.020 for 1 grade increment) and 21.7% (115 deaths) and 13.7% (75 deaths) according to infarct size >10% (median value) and infarct size ≤10% of the left ventricle (adjusted HR 1.08 [1.03 to 1.13], p = 0.001, for 5% of left ventricle increment in infarct size). The C statistic of the model for all-cause mortality was 0.810 (0.781 to 0.839) with baseline variables, 0.812 (0.783 to 0.841) after incorporation of TIMI flow (P for significance compared to the model with baseline variables = 0.140), 0.813 (0.784 to 0.841) after incorporation of MPG (p = 0.345) and 0.815 (0.786 to 0.842) after incorporation of infarct size (p = 0.08). In conclusion, markers of reperfusion independently predict long-term mortality after primary percutaneous coronary intervention but offer limited incremental prognostic value to that provided by evaluation of baseline cardiovascular risk factors and clinical data., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The association of postprocedural high-sensitivity troponin T (hs-TnT) with prognosis of non-ST-segment elevation myocardial infarction (NSTEMI) patients is incompletely investigated., Aim: To assess the prognostic value of hs-TnT in NSTEMI patients undergoing early percutaneous coronary intervention (PCI)., Methods: This study included 3783 patients with NSTEMI undergoing early PCI. Preprocedural and peak postprocedural hs-TnT was measured. Patients were divided into 3 groups: a group with postprocedural hs-TnT in the 1st tertile (hs-TnT <105ng/L; n=1264), a group with postprocedural hs-TnT in the 2nd tertile (hs-TnT ≥105ng/L to 470ng/L; n=1258) and a group with postprocedural hs-TnT in the 3rd tertile (hs-TnT >470ng/L; n=1261). The primary outcome was 1-year all-cause mortality., Results: Overall, there were 299 deaths: 59 (5.5%), 98 (8.2%) and 142 deaths (12.6%) among patients of the 1st, 2nd and 3rd postprocedural hs-TnT tertiles (unadjusted hazard ratio [HR]=1.65, 95% confidence interval [CI] 1.20 to 2.67; P=0.002 for tertile 2 vs tertile 1 and unadjusted HR=2.41 [1.79-3.25]; P<0.001 for tertile 3 vs tertile 1). After adjustment postprocedural hs-TnT was independently associated with the risk of all-cause mortality (adjusted [HR]=1.22 [1.13-1.33], P<0.001 for 1 unit higher log hs-TnT). Postprocedural hs-TnT improved the risk prediction of the model of all-cause mortality (the C statistic of the model without [with baseline variables only] and with incorporation of postprocedural hs-TnT was 0.759 [0.732-0.782] and 0.772 [0.746-0.794], respectively; P<0.001)., Conclusions: In patients with NSTEMI undergoing early PCI, postprocedural hs-TnT is independently associated with increased risk of mortality up to 1year after PCI., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The relation between body mass index (BMI) and bleeding after percutaneous coronary intervention (PCI) remains incompletely understood. This study aimed to assess the association between BMI and bleeding and mortality after PCI. The study included 14,178 patients with coronary artery disease treated by PCI. Bleeding within 30 days of PCI was defined using the Bleeding Academic Research Consortium criteria. The primary outcome was 1-year all-cause mortality. BMI quartiles were 14.1 to 24.8 kg/m(2) (first quartile [Q1]), >24.8 to 27.1 kg/m(2) (second quartile [Q2]), >27.1 to 29.8 kg/m(2) (third quartile [Q3]), and >29.8 to 56.3 kg/m(2) (fourth quartile [Q4]). In BMI Q1, Q2, Q3, and Q4, the frequency of bleeding was 13.8%, 10.1%, 10.8%, and 7.7%, respectively (odds ratio [OR] 1.90, 95% confidence interval [CI] 1.63 to 2.23, p <0.001, for Q1 vs Q4). Multiple logistic regression showed that BMI was independently associated with bleeding (adjusted OR 1.05, 95% CI 1.04 to 1.07, p <0.001, for any bleeding; adjusted OR 1.07, 95% CI 1.04 to 1.09, p <0.001, for access site bleeding; and adjusted OR 1.03, 95% CI 1.01 to 1.05, p = 0.039, for non-access site bleeding with all 3 risk estimates calculated per 1 kg/m(2) decrease in BMI). Analysis by sex showed an increase in the frequency of bleeding with the decrease in BMI for women and men (p for trend <0.001 for women and men) with no sex-by-BMI interaction (p = 0.90). The Cox proportional hazards model showed that bleeding (adjusted hazard ratio [HR] 2.17, 95% CI 1.67 to 2.82, p <0.001) and BMI (HR 1.03, 95% CI 1.01 to 1.06, p = 0.048, per 1 kg/m(2) decrease in the BMI) were independently associated with increased risk of 1-year mortality with no bleeding-by-BMI interaction (p = 0.81). In conclusion, BMI is inversely associated with the increased risk of bleeding and mortality after PCI., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Inhospital stent thrombosis (ST) and cerebrovascular accidents (CVA) are rare but serious adverse events after percutaneous coronary intervention (PCI). The association of ST or CVA with long-term outcome after PCI remains poorly investigated., Methods: The study included 18,334 consecutive patients who underwent PCI. Patients were divided into 3 groups: the group with ST, the group with CVA, and the group without these events. The primary outcome was all-cause mortality at 3-year follow-up., Results: Inhospital ST or CVA occurred in 59 patients (0.32%) and in 90 patients (0. 49%), respectively. There were 2,149 deaths (11.7%) during the follow-up: 26 deaths among patients with ST, 32 deaths among patients with CVA, and 2,091 deaths among patients without ST or CVA (Kaplan-Meier estimates of 3-year mortality 45.3%, 38.0%, and 12.9%, odds ratio 6.1, 95% CI 3.6-10.2, P < .001 for ST group vs the group without ST or CVA and odds ratio 4.2 [2.7-6.6], P < .001 for CVA group vs the group without ST or CVA). There was no significant difference in the 3-year mortality between CVA and ST groups (P = .29). The Cox proportional hazards model showed that ST (adjusted hazard ratio 4.97, 95% CI 2.58-9.56, P < .001) and CVA (adjusted hazard ratio 2.25 [1.25-4.04], P = .006) were independently associated with the increased risk of 3-year mortality., Conclusion: Inhospital ST and CVA after PCI are associated with the increased risk of 3-year mortality. Both events seem to have a similar impact on long-term survival., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Limited information exists on the prognostic impact of bleeding after percutaneous coronary intervention (PCI) in patients with chronic kidney disease (CKD). We investigated the impact of bleeding after PCI on the outcome of these patients., Methods: The study included 2,934 patients with estimated creatinine clearance <60 ml/min. Bleeding events within 30 days after PCI were assessed using the Bleeding Academic Research Consortium (BARC) criteria. The primary outcome was 1-year mortality., Results: Bleeding events occurred in 485 patients (16.5 %). BARC classes were: class 1 (n = 155), class 2 (n = 73), class 3a (n = 182), class 3b (n = 68), class 3c (n = 6) and class 4 (n = 1). There were 212 deaths over the first year after PCI: 60 deaths in patients who bled and 152 deaths in patients who did not bleed (Kaplan-Meier [KM] estimates, 12.5 and 6.3 %; odds ratio [OR] = 2.11, 95 % confidence interval [CI] 1.57-2.83, P < 0.001). Nonfatal myocardial infarction occurred in 71 patients who bled and in 141 patients who did not bleed (KM estimates, 14.8 and 5.8 %; OR = 2.70 [2.05-3.55], P < 0.001). After adjustment, bleeding was independently associated with increased risk of 1-year mortality (adjusted hazard ratio [HR] = 1.90 [1.33-2.72], P < 0.001) and myocardial infarction (adjusted HR = 2.74 [1.99-3.78], P < 0.001). Bleeding improved the discriminatory power of the multivariable model for prediction of mortality (absolute and relative integrated discrimination improvement [IDI], 0.011 and 15.4 %; P = 0.004) or myocardial infarction (absolute and relative IDI, 0.017 and 70.8 %; P < 0.001)., Conclusions: Peri-PCI bleeding in patients with CKD is independently associated with the increased risk of 1-year mortality and nonfatal myocardial infarction.

Background: Statins have multiple effects in patients with coronary artery disease. No studies have investigated whether chronic statin pretreatment before percutaneous coronary intervention (PCI) has an impact on long-term mortality in patients with stable angina., Methods: The study included 8041 patients with stable angina. At the time of PCI, 5939 patients (73.8%) were receiving statins for ≥ 1 month before procedure and 2102 patients (26.2%) were not receiving statins. The primary outcome analysis was 1-year mortality., Results: There were 192 deaths during the follow-up: 119 deaths among patients receiving statins and 73 deaths among patients not receiving statins (Kaplan-Meier estimates of 1-year mortality 2.06% and 3.59%; unadjusted hazards ratio [HR]=0.56, 95% confidence interval [CI] 0.42-0.75; P<0.001). Landmark analysis showed that almost all mortality benefit occurred in the first 30-days after PCI: 10 deaths among patients receiving statins and 22 deaths among patients not receiving statins (Kaplan-Meier estimates of 30-day death, 0.17% and 1.06%, respectively; HR=0.16, 95% CI 0.08-0.34, P<0.001). No significant difference in mortality according to statin pretreatment between 30 days and 1 year was observed (109 deaths among patients receiving statins vs 51 deaths among patients not receiving statins; Kaplan-Meier estimates 1.89% and 2.53%; HR=0.75, 95% CI 0.53-1.05, P=0.095). After adjustment in the Cox proportional hazards model, statin pretreatment was associated with a 35% reduction in the adjusted risk for 1-year mortality (adjusted HR=0.65, 95% CI 0.44-0.98, P=0.039)., Conclusions: Pretreatment with statins before PCI was associated with a significant reduction of 1-year mortality in patients with stable angina., (Copyright © 2012 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

The association between uric acid and cardiovascular disease is incompletely understood. In particular, the prognostic value of uric acid in patients with acute coronary syndromes who undergo percutaneous coronary intervention has not been studied. This study included 5,124 patients with acute coronary syndromes who underwent percutaneous coronary intervention: 1,629 with acute ST-segment elevation myocardial infarction, 1,332 with acute non-ST-segment elevation myocardial infarction, and 2,163 with unstable angina. The primary end point was 1-year mortality. Patients were divided into quartiles according to uric acid level as follows: quartile 1, 1.3 to <5.3 mg/dl; quartile 2, 5.3 to <6.3 mg/dl; quartile 3, 6.3 to <7.5 mg/dl; and quartile 4, 7.5 to 18.4 mg/dl. There were 450 deaths during follow-up: 80 deaths in quartile 1, 77deaths in quartile 2, 72 deaths in quartile 3, and 221 deaths in quartile 4 of uric acid (Kaplan-Meier estimates of 1-year mortality 6.4%, 6.2%, 5.6%, and 17.4%, respectively; unadjusted hazard ratio 3.05, 95% confidence interval 2.54 to 3.67, p <0.001 for fourth vs first quartile of uric acid). After adjustment for traditional cardiovascular risk factors, renal function, and inflammatory status, the association between uric acid and mortality remained significant, with a 12% increase in the adjusted risk for 1-year mortality for every 1 mg/dl increase in the uric acid level. Uric acid improved the discriminatory power of the predictive model regarding 1-year mortality (absolute integrated discrimination improvement 0.008, p = 0.005). In conclusion, elevated levels of uric acid are an independent predictor of 1-year mortality across the whole spectrum of patients with acute coronary syndromes treated with percutaneous coronary intervention., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: The association between ST-segment resolution and clinical outcome in patients with acute ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PPCI) remains unclear. Recent studies on the association between ST-segment resolution and mortality have given conflicting results. We undertook this study to assess whether ST-segment resolution in electrocardiograms recorded 90-120 min after initiation of PPCI predicts long-term mortality in patients with STEMI., Methods: The study included 900 patients with STEMI presenting within the first 24 h after symptom onset who were treated with PPCI. The ST-segment resolution was assessed in electrocardiograms recorded 90-120 min after the first balloon inflation. The ST-segment resolution was dichotomized as follows: < 30% (no resolution), 30% to ≤ 70% (partial resolution) and > 70% (complete resolution). The primary endpoint was five-year mortality., Results: ST-segment resolution was < 30% in 263 (29.0%) patients, between 30% and ≤ 70% in 356 (40.0%) patients and > 70% in 281 (31.0%) patients. There were 62 deaths during the follow-up. In patients with ST-segment resolution < 30%, 30 to ≤ 70% and > 70%, the Kaplan-Meier estimates of mortality were 8.3% (n = 17 deaths), 11.5% (n = 29 deaths) and 6.8% (n = 16 deaths), respectively; unadjusted hazard ratio (HR) = 0.88, 95% confidence interval (CI) 0.46-1.67, p = 0.695 for ST-segment resolution > 70% vs < 30%; adjusted HR = 0.91, 95% CI 0.61-1.33; p = 0.607, for ST-segment resolution > 70% vs ST-segment resolution < 30%., Conclusions: In patients with STEMI undergoing PPCI, ST-segment resolution in electrocardiograms recorded 90-120 min after initiation of PPCI did not predict long-term mortality.

Background: high-sensitivity cardiac troponin assays enable the measurement of cardiac troponin concentrations in the majority of patients with coronary artery disease. The objective of this study was to investigate the prognostic value of sensitive cardiac troponin in patients with stable and unstable angina presenting with undetectable levels of conventional troponin., Methods: this study included 1,057 patients with stable (808 patients) or unstable (249 patients) angina who presented with undetectable conventional cardiac troponin T and underwent coronary artery revascularization. The cardiac troponin T was measured with conventional and high-sensitivity assays, in parallel, using the same plasma sample. The primary end point was 4-year mortality., Results: the total sensitive troponin T level (median [interquartile range]) was 0.008 (0.005-0.014) microg/L. Variables independently associated with an elevated level of sensitive troponin T were elderly age, male sex, higher body mass index, presence of diabetes, unstable angina, increased New York Heart Association class, reduced left ventricular ejection fraction, elevated level of N-terminal pro-brain natriuretic peptide, reduced glomerular filtration rate, and elevated level of C-reactive protein. During the follow-up period, there were 83 deaths. The sensitive troponin T level was an independent predictor of 4-year mortality (adjusted hazard ratio = 1.47 with 95% CI 1.17-1.84, P < .001 for each unit increase in the natural logarithm of the sensitive troponin T)., Conclusions: the elevated levels of sensitive cardiac troponin T in patients with stable or unstable angina presenting with undetectable conventional cardiac troponin T are significantly associated with reduced survival.

Bleeding complications in patients undergoing percutaneous coronary interventions (PCIs) are associated with increased risk of subsequent mortality. We undertook this study to characterize the subset of patients with bleeding complications who are at an increased risk of death within the first year after a PCI procedure. The study included 331 patients with bleeding complications among 9 954 patients who underwent PCI. The primary outcome analysis was 1-year mortality. Within the first year following PCI there were 39 deaths among 331 patients (11.8%), with bleeding complications and 240 deaths among 9 623 patients without bleeding complications (Kaplan-Meier estimates of 1-year mortality; 11.8% vs 2.5%, odds ratio 5.09, 95% confidence interval 3.76-6.90, P < 0.001). Time to death (median [25th-75th percentiles]) was 38.5 [7.2-125.9] days in patients with bleeding complications vs 137.1 [68.3-234.0] days in patients without bleeding complications (P < 0.001). Compared with survivors (n = 292), nonsurvivors (n = 39) had a significantly more adverse risk profile. The Cox proportional hazards model identified the elevated troponin level as the only independent correlate of 1-year mortality (hazard ratio = 2.35, 95% confidence interval 1.04-5.31, P = 0.039). In conclusion, patients with peri-PCI bleeding complications who die have a more adverse cardiovascular risk profile than patients with bleeding complications who survive the first year after PCI. Patients with bleeding complications and an elevated troponin level are at high risk of death within the first year following PCI. The majority of deaths in patients with peri-PCI bleeding occur within the first 3 months after PCI procedure.

The ability of N-terminal pro-brain natriuretic peptide (NT-pro-BNP) to predict mortality in various subsets of patients with coronary artery disease (CAD) is not known. The aim of present study was to investigate the ability of NT-pro-BNP to predict mortality in various subsets of patients with CAD. The study included 1,552 consecutive patients with angiographically proven CAD. Based on receiver-operating characteristic curve analysis, the best NT-pro-BNP level for mortality prediction was 721 ng/L (sensitivity 71.3%, specificity 71.3%). Patients were divided into 2 groups: the group with NT-pro-BNP level < or =721 ng/L (1,034 patients) and the group with NT-pro-BNP level >721 ng/L (518 patients). The primary end point of the study was mortality. The median follow-up was 3.6 years (interquartile range 3.3 to 4.6). In total there were 171 deaths: 49 deaths in the group with NT-pro-BNP < or =721 ng/L and 122 deaths in the group with NT-pro-BNP >721 ng/L (mortality estimates 6.6% vs 29.5%, odds ratio 5.2; 95% confidence intervals 3.9 to 7.0, p <0.001). In 28 subsets of patients, NT-pro-BNP level predicted mortality with odds ratio varying from 2.8 to 7.5. In conclusion, NT-pro-BNP is a reliable predictive marker of mortality in all subsets of patients with CAD.

Background: Despite a large amount of data assessing outcomes of out-of-hospital cardiac arrests (OHCAs), little information is available about physician-staffed emergency medical service (EMS) systems. The aim of our study was to investigate the impact of a physician on the outcome of patients after OHCA., Methods: This is a prospective, observational study that included 539 consecutive patients (63.9 +/- 19.1 years old; 349 males) with OHCA in the community of Dachau (135,000 inhabitants) in whom resuscitation was attempted between January 2000 and January 2006 according to Utstein style. Patients were followed up to hospital discharge. The primary end point of the study was that the patients was discharged alive from hospital., Results: Of 412 patients with an OHCA, 180 (43.7%) were admitted to hospital, and 47 (11.4%) were discharged alive. Resuscitation was started by a physician in 117 (28.4%) patients, by a layperson in 118 (28.6%), or by an EMS personnel in 177 (43.0%). A total of 18 patients (18.6%) treated by physicians, 13 patients (8.0%) treated by EMS personnel (P = .02 vs treatment by physician), and 16 patients (16.5%) resuscitated by laypersons were discharged from hospital (P = .8 vs treatment by physician). In 105 patients with bystander-witnessed OHCA of cardiac origin with shockable rhythm, the discharge rate was 32.4% (n = 34). Multivariate analysis identified ventricular fibrillation on first electrocardiogram, observed OHCA, short response time intervals but not the unit that performed the first resuscitation attempt as independent predictors of survival., Conclusions: A physician on board of the advanced life support unit was not identified as an independent factor of improved survival.

Background: Braintype natriuretic peptide (BNP) or N-terminal segment of the prohormone (NT-proBNP) measured within the first few days after symptom onset offer prognostic information in patients with non- ST elevation acute coronary syndromes (ACS)., Methods and Results: This prospective cohort study included 493 patients with non-ST segment elevation ACS who underwent percutaneous coronary intervention in the Deutsches Herzzentrum and Klinikum rechts der Isar in Munich, Germany. NT-proBNP was measured on admission. Patients were divided into four groups according to quartiles of NT-proBNP. The primary end point of the study was mortality. Patients were followed for a median of 4.0 years [interquartile range 3.6 to 4.9 years]. During this time period, there were 65 deaths: 4 deaths in the 1st quartile, 9 deaths in the 2nd quartile, 16 deaths in the 3rd quartile and 36 deaths in the 4th quartile (Kaplan-Meier estimates of mortality: 3.4, 7.8, 16.0 and 33.9%; odds ratio [OR] 10.2, 95% confidence interval [CI] 4.5 to 23.5; P< 0.001 for 4th vs 1st quartile). Patients in the upper quartile of NT-proBNP had a more adverse cardiovascular risk profile than patients in lower quartiles of NT-proBNP. After adjustment in the Cox proportional hazards model, the NT-proBNP remained an independent correlate of mortality (adjusted hazard ratio [HR] 1.23, 95% confidence interval [CI] 1.04 to 1.45, P = 0.014 for 4th vs 1st quartiles) but weaker than age (adjusted HR 2.11, 95% CI 1.53 to 2.90; P < 0.001 for a 10-year increase in age) or left ventricular ejection fraction (adjusted HR 1.35, 95% CI 1.09 to 1.68; P = 0.007 for a 10% decrease)., Conclusion: N-terminal probrain natriuretic peptide is a marker of weak-to-moderate strength in predicting the long-term prognosis in patients with non-ST segment elevation acute coronary syndromes after percutaneous coronary intervention.

Background: Little evidence exists on the role of homocysteine as a predictor of mortality in patients with type 2 diabetes. The aim of this study was to investigate whether elevated plasma homocysteine levels are independently associated with all-cause or cardiovascular mortality in patients with type 2 diabetes and coronary artery disease., Methods: This is a prospective cohort study that included 507 patients with type 2 diabetes and angiographically proven coronary artery disease. Patients were divided into 2 groups according to homocysteine level above or below median value (12.4 micromol/L): the high homocysteine group (255 patients) and the low homocysteine group (252 patients). The primary end-point of the study was all-cause mortality., Results: There were 103 deaths during a 4-year follow-up: 62 deaths in the high homocysteine group and 41 deaths in the low homocysteine group (Kaplan-Meier estimates of mortality 25.6% and 17.4%, respectively (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.03-2.27, P=0.031). Sixty-two of 103 deaths (60.2%) were of cardiovascular origin: 37 deaths (14.5%) occurred in the high homocysteine group and 25 deaths (9.9%) occurred in the low homocysteine group (P=0.115). Cox proportional hazards model showed that plasma homocysteine was not an independent correlate of all-cause (adjusted hazard ratio [HR] 1.10, 95% CI 0.89-1.33; P=0.397 for 5 micromol/L increase in concentration) or cardiovascular (adjusted HR 1.04, 95% CI 0.80-1.36, P=0.753, for 5 micromol/L increase in concentration) mortality., Conclusion: In patients with type 2 diabetes and coronary artery disease, elevated level of homocysteine is an associate of increased cardiovascular risk but not an independent predictor of cardiovascular mortality.

Aim: To assess the prevalence of diastolic dysfunction of the left ventricle in patients with non-insulin-dependent diabetes mellitus (NIDDM) and its relation to patients' age and duration of diabetes., Methods: This case-control study included 228 subjects. The group of cases consisted of 114 patients with NIDDM. The group of controls included 114 subjects without diabetes, enrolled in the study at the same time as the group of cases. Diastolic function of the left ventricle was assessed by pulsed Doppler echocardiography. The ratio between the maximal early filling velocity (E wave) and the maximal late (atrial) filling velocity (A wave) less than 1 (E/A ratio<1) was considered as a criterion for left ventricle diastolic dysfunction., Results: The E/A ratio<1 was found in 75 patients (65.8%) in the group with diabetes, and in 38 subjects (33.3%) in the control group (P=0.001). Multiple logistic regression model showed that diabetes was the strongest independent correlate of left ventricle diastolic dysfunction (odds ratio 8.92, 95% confidence interval [CI] 4.20 to 18.52, P<0.001). In the group with diabetes, the multivariate analysis showed that age (P=0.001), level of triglycerides (P=0.006), history of smoking (P=0.011), and the duration of diabetes (P=0.019) were independently associated with left ventricle diastolic dysfunction., Conclusions: Non-insulin dependent diabetes is an independent predictor of left ventricular diastolic dysfunction in patients without clinical evidence of structural heart disease. In patients with NIDDM, the age, history of smoking, plasma level of triglycerides, and the duration of diabetes were independently associated with the diastolic dysfunction of the left ventricle.

The aim of this study was to investigate the differences between sustained and non-sustained forms of human atrial fibrillation (AF) using multielectrode endocardial recordings. Methods. Sixty-four pole basket catheters were deployed in the right atrium (RA) of 3 groups of patients: 1) patients with persistent AF (> 48 hours); 2) induced sustained AF (> 15 minutes); and 3) induced non-sustained AF (< 15 minutes). Beat to beat AF intervals (FF) were evaluated for each bipole. On the basis of signal characteristics and direction of wavefront propagation, the degree of spatial and temporal organization of AF was assessed. Results. Persistent AF showed the shortest FF intervals (161 ms) and lowest overall degree of AF organization, induced non-sustained AF the longest FF intervals (192 ms) and highest degree of organization. FF intervals of induced sustained AF were only slightly longer (169 ms) compared to persistent AF. Within each AF group, the lateral wall showed the highest degree of organization, the septal region the lowest. Conclusion. In humans, FF interval and overall degree of AF organization were found to increase significantly from sustained to non-sustained AF. Persistent and induced sustained AF, however, only slightly differed in these parameters.