Search

Background The efficacy and safety of pharmacoinvasive strategy following fibrinolysis for ST-elevation myocardial infarction (STEMI) in relation to renal function have not been established. Methods Using patient-level data from 4 randomized controlled trials, we examined the efficacy and safety of pharmacoinvasive versus standard treatment after fibrinolysis for STEMI. Patients were stratified based on the estimated glomerular filtration rate (eGFR) on presentation ( 2 vs ≥60 mL/min/1.73 m 2 ). The primary outcome was the composite of death or reinfarction at 30 days. Results Of 2,029 patients, 457 (23%) had an eGFR 2 . Patients with eGFR 2 were older and had higher Thrombolysis in Myocardial Infarction risk scores. Compared with patients with eGFR ≥ 60 mL/min/1.73 m 2 , patients with renal dysfunction had higher rates of the primary outcome (5.3% vs 11.8%, respectively; P P heterogeneity = .73) or the rate of death or reinfarction at 1 year ( P heterogeneity = .64) in relation to eGFR. Patients with renal dysfunction had higher rates of in-hospital major bleeding compared with patients with eGFR ≥60 mL/min/1.73 m 2 (7.7% vs 4.3%, respectively; P = .004); however, there was no difference in bleeding events between treatment arms in the overall cohort or in relation to eGFR ( P heterogeneity = .67). Conclusions Renal impairment is associated with increased rates of adverse events in STEMI patients treated with fibrinolysis. However, the safety and efficacy of pharmacoinvasive strategy are preserved in patients with renal impairment on presentation.

Background Elderly patients have high ischemic and bleeding rates after acute coronary syndrome; however, the occurrence of these complications over time has never been studied. This study sought to characterize average daily ischemic rates (ADIRs) and average daily bleeding rates (ADBRs) over 1 year in patients aged >74 years with acute coronary syndrome undergoing percutaneous coronary intervention who were randomized in the Elderly ACS 2 trial, comparing low‐dose prasugrel (5 mg daily) with clopidogrel (75 mg daily). Methods and Results ADIRs and ADBRs were calculated as the total number of events, including recurrent events, divided by the number of patient‐days of follow‐up and assessed within different clinical phases: acute (0–3 days), subacute (4–30 days), and late (31–365 days). Generalized estimating equations were used to test the least squares mean differences for the pairwise comparisons of ADIRs and ADBRs and the pairwise comparison of clopidogrel versus prasugrel effects. Globally, ADIRs were 2.6 times (95% CI, 2.4–2.9) higher than ADBRs. ADIRs were significantly higher in the clopidogrel arm than in the low‐dose prasugrel arm in the subacute phase (P adj, See Editorial by Kinnaird

Aim: To evaluate the long-term outcome of patients with Takotsubo syndrome (TTS) and severely reduced left ventricular ejection fraction (LVEF ≤ 35%) at presentation. Methods and results: The study population included 326 patients (mean age 69.5 ± 10.7 years, 28 male) with TTS enrolled in the Takotsubo Italian Network, divided into two groups according to LVEF (≤ 35%, n = 131; > 35%, n = 195), as assessed by transthoracic echocardiography at hospital admission. In-hospital events were recorded in both groups. At long-term follow-up (median 26.5 months, interquartile range 18–33), composite major adverse cardiac events (MACE: cardiac death, acute myocardial infarction, heart failure, and TTS recurrence) and rehospitalization were investigated. Compared to patients with LVEF > 35%, patients with LVEF ≤ 35% were older (71.2 ± 10.8 vs. 68.4 ± 10.6 years; P = 0.026) and experienced more frequently cardiogenic shock (16% vs. 4.6%; P < 0.001), acute heart failure (28.2% vs. 12.8%; P = 0.001), and intra-aortic balloon pump support (11.5% vs. 2.6%; P = 0.001) in the acute phase. At long-term follow-up, higher rates of composite MACE (25.2% vs. 10.8%; P = 0.001) and rehospitalization for cardiac causes (26% vs. 13.3%; P = 0.004) were observed in these patients. LVEF ≤ 35% at admission [hazard ratio (HR) 2.184, 95% confidence interval (CI) 1.231–3.872; P = 0.008] and age (HR 1.041, 95% CI 1.011–1.073; P = 0.006) were independent predictors of MACE. Patients with LVEF ≤ 35% also had a significant lower freedom from composite MACE during long-term follow-up (χ2 = 11.551, P = 0.001). Conclusion: Left ventricular ejection fraction ≤ 35% at presentation is a key parameter to identify TTS patients at higher risk not only in the acute phase but also at long-term follow-up.

Background: Elderly treated with dual antiplatelet therapy after percutaneous coronary intervention (PCI) represent a challenging population because of increased risk of both ischemic and bleeding events. We aimed to investigate the association between high on-treatment platelet reactivity (HPR) and long-term outcome in elderly with non-ST-elevated acute coronary syndromes (NSTE-ACS) undergoing PCI.Methods: Platelet reactivity was measured by vasodilator-stimulated phosphoprotein (VASP) assay at three time points (baseline, discharge, 1 month after PCI) in 1053 NSTE-ACS patients (311 elderly) treated with clopidogrel. Major adverse cardiac events (MACE) were assessed up to 1 year-follow-up.Results: Elderly with HPR at discharge showed a significantly higher incidence of overall MACE (13 vs 4%, p=.006), cardiac death (6 vs 0.7%, p=.020), myocardial infarction (MI, 12 vs 4%, p=.031) and a trend for higher stent-thrombosis (5 vs 0.7%, p=.068). Similarly, elderly with 1-month-HPR showed between 1 month and 1 year significantly higher incidence of MACE (10 vs 4%, p=.012), cardiac death (6 vs 0.7%, p=.019) and composite cardiac death/MI (11 vs 4%, p=.014). Up to 1 year, elderly with HPR showed a 4-fold increased risk of MACE compared to both elderly without HPR (for discharge-HPR: p =. 005; for 1-month-HPR: p =. 01) and non-elderly with HPR (for discharge-HPR: p

AIMS: To describe the contemporary management by cardiologists of patients after an episode of myocardial infarction (MI). METHODS: The EYESHOT Post-MI was a prospective, observational, nationwide study aimed to evaluate the management of patients referring to cardiologists 1 to 3 years from the last MI event. RESULTS: Over a 3-month period, 1633 consecutive patients [median 22 (IQR 15-28) months from MI] were enrolled: 1028 (63.0%) at the second and 605 (37.0%) at the third year from MI. During the 12 months prior to enrolment, the majority of patients received a transthoracic echocardiogram (60% and 54%), followed by coronary angiography (24% and 16%, in the second and third year from MI groups, respectively). At the time of enrolment, the majority of patients were prescribed on statins (93%) and beta-blockers (82%), without significant differences between the 2 groups. A dual antiplatelet therapy (DAPT) was used more frequently among patients presenting during the second compared to the third year from MI (40% vs 24%; p

Dual antiplatelet therapy (DAPT) is a cornerstone of treatment for patients with acute coronary syndromes (ACS). Mounting evidences have opened the debate about the optimal DAPT duration. Considering the ACS-pathophysiology, the most recent guidelines recommend DAPT in all ACS patients for at least 12 months unless there are contraindications such as excessive risk of bleeding. Thus, it can be considered acceptable earlier discontinuation if the risk of morbidity from bleeding outweighs the anticipated benefit. On the other hand, several studies have clearly indicated that a significant burden of platelet related-events, such as stroke and new ACS might occur after this period, suggesting that potential benefits might derive by prolonging DAPT beyond 12 months (Long DAPT). Indeed, although current guidelines give some indications about patients eligible for Long DAPT, they do not embrace several real-life clinical scenarios. Thus, in such scenarios, how to decide whether a patient is eligible for Long DAPT or not might be still challenging for clinicians. This position paper presents and discusses various “real-life” clinical scenarios in ACS patients, in order to propose several possible recommendations to overcome guidelines potential limitations.

Background: Although intracoronary abciximab failed to improve prognosis compared with intravenous route in unselected ST-segment elevation myocardial infarction (STEMI) patients, little is known about the role of intracoronary abciximab in diabetic patients.Objectives: To evaluate the efficacy of intracoronary abciximab administration in diabetic patients with STEMI undergoing primary percutaneous coronary intervention (PCI).Methods: Reperfusional and clinical outcomes of intracoronary abciximab compared with intravenous bolus abciximab according to diabetic status were evaluated in a pooled analysis of five randomized trials including 3158 STEMI patients. The primary clinical endpoint of the study was the composite of death or reinfarction at 30-day follow-up.Results: Among 584 diabetic patients (18.5%), the composite of death or reinfarction was significantly reduced with intracoronary abciximab compared to intravenous abciximab (4.7% vs. 8.8%; rate ratio [RR], 0.50; 95% confidence intervals [CI], 0.26-0.99; p = 0.04), driven by numerically lower deaths (3.7% vs. 6.4%; RR, 0.56; 95% CI, 0.26-1.20; p = 0.13). Moreover, a significant reduction in definite or probable stent thrombosis was observed in patients receiving intracoronary abciximab (1% vs. 3.5%; RR, 0.27; 95% CI, 0.07-0.99; p = 0.04). Although formal tests for interaction were not significant, no clinical benefit was apparent in the cohort of STEMI patients without diabetes (n = 2574).Conclusions: In diabetic patients with STEMI undergoing primary PCI, intracoronary abciximab may improve clinical outcomes as compared with standard intravenous use. These findings require confirmation in a dedicated randomized trial. (C) 2015 Elsevier Inc. All rights reserved.

Statin use is associated with enhanced pharmacodynamic response to clopidogrel in patients with stable coronary artery disease undergoing percutaneous coronary intervention (PCI). However, the impact of statin therapy on clopidogrel response profiles in patients with acute coronary syndrome (ACS) undergoing PCI has not been established and represents the objective of this investigation. On-treatment -P2Y(12) platelet reactivity was measured using the vasodilator stimulated phosphoprotein (VASP) phosphorylation assay before PCI, at hospital discharge, and at 1 month after PCI in ACS patients enrolled in the multicenter, prospective GEne polymorphisms, Platelet Reactivity, and Syntax Score (GEPRESS) study (n = 962). High platelet reactivity (HPR) was defined as platelet reactivity index >= 50%. Statins were prescribed at hospital discharge in 87% (n = 835) of patients. All patients were followed for 1 year. The 1-month HPR rate was lower in statin than in non-statin treated patients (39.6 vs 52%, respectively, p=0.009). This finding was confirmed also among statin-treated patients with high Syntax score (>= 15). After adjustment for differences in baseline characteristics, statin use at discharge was independently associated with 1-month HPR rate (odds ratio, 0.58, 95% confidence interval, 0.38-0.89; p=0.015). In ACS patients undergoing PCI treated with clopidogrel the use of statins at discharge was associated with significantly lower 1-month HPR rates compared with patients not treated with statins.

Several studies have highlighted the prognostic role of preprocedural Thrombolysis In Myocardial Infarction (TIMI) flow in the infarct-related artery (IRA) in patients with ST-segment elevation myocardial infarction (STEMI). However, the impact of preprocedural IRA occlusion in patients with diabetes with STEMI has been insufficiently studied. The aim of this study was to evaluate the effects of baseline IRA occlusion and diabetic status in patients with STEMI who underwent primary percutaneous coronary intervention by using data from a pooled analysis of randomized trials comparing intracoronary with intravenous abciximab bolus administration. A total of 3,046 patients with STEMI who underwent primary percutaneous coronary intervention were included. Diabetes was present in 578 patients (19%). The primary outcome was mortality after a median follow-up period of 375 days. Secondary end points were reinfarction and stent thrombosis. In patients without diabetes, IRA occlusion versus no occlusion was not associated with increased rates of mortality (4.3% vs 2.7%, p = 0.051) and reinfarction (3.3% vs 2.5%, p = 0.33). Patients with diabetes with IRA occlusion compared with those without occlusion showed higher rates of mortality (10.6% vs 4.6%, p = 0.01) and reinfarction (5.6% vs 2.1%, p = 0.03). Baseline IRA occlusion increased the rate of stent thrombosis in the nondiabetic (2.1% vs 1.0%, p = 0.04) and diabetic (3.2% vs 0.8%, p = 0.05) cohorts. Interaction analysis demonstrated that the risk for death and reinfarction was significantly increased when diabetes and IRA occlusion occurred concomitantly. In conclusion, patients with STEMI with diabetes and baseline IRA occlusion had disproportionately higher rates of death and reinfarction. Preprocedural IRA occlusion increased the risk for stent thrombosis, irrespective of diabetic status. (C) 2014 Elsevier Inc. All rights reserved.

BACKGROUND: Diabetic patients are at increased risk for future cardiovascular events after ST-segment elevation myocardial infarction (STEMI). Administration of an intracoronary abciximab bolus during primary percutaneous coronary intervention (PCI) may be beneficial in this high-risk subgroup. OBJECTIVES: This study sought to report the 1-year clinical outcomes and cardiac magnetic resonance (CMR) findings in STEMI patients with and without diabetes randomized to intracoronary or intravenous abciximab bolus at the time of primary PCI. METHODS: Patient-level data from 3 randomized trials were pooled. The primary endpoint was the composite of death or reinfarction. Comprehensive CMR imaging was performed in 1 study. RESULTS: Of 2,470 patients, 473 (19%) had diabetes and 1,997 (81%) did not. At 1 year, the primary endpoint was significantly reduced in diabetic patients randomized to intracoronary abciximab compared with those randomized to intravenous bolus (9.2% vs. 17.6%; hazard ratio [HR]: 0.49; 95% confidence interval [CI]: 0.28 to 0.83; p = 0.009). The intracoronary abciximab bolus did not reduce the primary endpoint in patients without diabetes (7.4% vs. 7.5%; HR: 0.95; 95% CI: 0.68 to 1.33; p = 0.77), resulting in a significant interaction (p = 0.034). Among diabetic patients, intracoronary versus intravenous abciximab bolus was associated with a significantly reduced risk of death (5.8% vs. 11.2%; HR: 0.51; 95% CI: 0.26 to 0.98; p = 0.043) and definite/probable stent thrombosis (1.3% vs. 4.8%; HR: 0.27; 95% CI: 0.08 to 0.98; p = 0.046). At CMR (n = 792), the myocardial salvage index was significantly increased only in diabetic patients randomized to intracoronary compared with intravenous abciximab (54.4; interquartile range: 35.1 to 78.2 vs. 39.0, interquartile range: 24.7 to 61.7; p = 0.011; p for interaction vs. no diabetes = 0.016). CONCLUSIONS: In diabetic patients with STEMI, the administration of intracoronary abciximab improved the effectiveness of primary PCI compared with the intravenous bolus. Sin financiación 19.896 JCR (2016) Q1, 2/126 Cardiac & Cardiovascular Systems UEC

Cigarette smokers with ST-segment elevation myocardial infarction (STEMI) may present different response to potent antithrombotic therapy compared to nonsmokers. We assessed the impact of smoking status and intracoronary abciximab in patients with STEMI undergoing primary percutaneous coronary intervention (PCI). We pooled data from 5 randomized trials comparing intracoronary versus intravenous abciximab bolus in patients undergoing primary PCI. The primary end point was the composite of death or reinfarction at a mean follow-up of 292 ± 138 days. Of 3,158 participants, 1,369 (43.3%) were smokers, and they had a lower risk of the primary end point in crude, but not in adjusted analyses (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.63 to 1.21, p = 0.405). Intracoronary versus intravenous abciximab was associated with a significant reduction in the risk of primary end point among smokers (3.6% vs 8.0%; HR 0.43, 95% CI 0.26 to 0.72, p = 0.001), but not in nonsmokers (10.2% vs 9.9%; HR 0.99, 95% CI 0.72 to 1.36, p = 0.96), with a significant interaction (p = 0.009). Furthermore, intracoronary abciximab decreased the risk of reinfarction in smokers (HR 0.30, 95% CI 0.15 to 0.62, p = 0.001), with no difference in nonsmokers (HR 1.20, 95% CI 0.71 to 2.01, p = 0.50). Stent thrombosis was lowered by intracoronary abciximab in smokers (HR 0.28, 95% CI 0.06 to 0.66, p = 0.009), but was ineffective in nonsmokers (HR 1.04, 95% CI 0.54 to 2.00, p = 0.903). Interaction testing showed heterogeneity in treatment effect for reinfarction (p = 0.002) and stent thrombosis (p = 0.018) according to smoking status. In conclusion, among patients with STEMI undergoing primary PCI, smoking status did not affect the adjusted risk of clinical events. Intracoronary abciximab bolus improved clinical outcomes by reducing the risk of death or reinfarction. Sin financiación 3.398 JCR (2016) Q2, 47/126 Cardiac & Cardiovascular Systems UEC

Aims: In patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) treated with PCI, high (H) platelet reactivity (PR) significantly affects one-year outcome. The aim of this report was to analyse the relationships between HPR, the SYNTAX score (SS) and one-year major adverse cardiac events (MACE: cardiac death, myocardial infarction, stent thrombosis) according to diabetes mellitus (DM) status in patients included in the GEne Polymorphism, Platelet REactivity, and the Syntax Score (GEPRESS) study.Methods and results: PR was measured using the vasodilator-stimulated phosphoprotein (VASP) assay at three time points (before PCI, at hospital discharge and at one month after PCI), with HPR defined as >50% PR index in 1,042 patients treated with aspirin and clopidogrel for one year after PCI. Patients with DM and an SS >= 15 had the highest MACE rate between one month and one year, further increased by the presence of HPR (16.4%). On the other hand, among all patients with an SS = 15 and HPR characterised a cohort with the highest MACE rate from one month to one year. In such high-risk patients, careful clinical monitoring and implementation of secondary prevention measures, including the use of potent P2Y(12) inhibitors, are strongly advised.

Purpose To test the accuracy of different mitral annular sites of the E / e ′ ratio in predicting invasive left ventricular filling pressure (LVFP) in patients hospitalized for coronary artery disease (CAD). Methods Forty-one patients with suspected or ascertained chronic CAD underwent non-invasive estimation of LVFP the same day as coronary angiography combined with right catheterization for pulmonary capillary wedge pressure (PCWP) assessment. The ratio between E velocity and early diastolic velocity of the mitral annulus (e′) was calculated as a surrogate of PWCP by (i) averaging septal and lateral e′ ( E / e ′A2); (ii) averaging septal, lateral, inferior, anterior ( E / e ′A4); (iii) using the sole septal ( E / e ′S); or (iv) lateral annulus ( E / e ′L). Patients were divided in two groups according to the PCWP: 25 with the PCWP

Background To investigate the relationship between arterial access site choice (radial versus femoral) and clinical outcomes among STEMI patients undergoing routine PCI after fibrinolysis. Methods Patient-level data from trials of STEMI patients evaluating routine PCI after fibrinolysis were included. The primary endpoint was 30-day major bleeding; secondary endpoints included 30-day death and re-infarction. Results 1891 patients underwent PCI (trans-radial n = 338, trans-femoral n = 1553). Trans-radial PCI patients were less likely to be > 75 years (2% vs. 8%, p = 0.0001), heavier (median weight 82 [72–90] vs. 80 [70–90] kg, p = 0.0013) and more likely in Killip class I at presentation (87% vs. 82%, p = 0.03). At 30 days, trans-radial PCI was associated with a similar unadjusted risk for major bleeding (3.7% vs. 1.2%, Odds Ratio [OR] 0.43 [95% CI 0.13–1.48], p = 0.18), mortality (3.4% vs. 1.2%, OR 0.34 [0.09–1.28], p = 0.11) and re-infarction (3.9% vs. 4.7%, OR 1.25 [0.60–2.58], p = 0.56). In multivariable analysis, radial access was associated with similar estimates for bleeding and death/reinfarction risk. Conclusions In STEMI patients treated with fibrinolysis and undergoing an early routine invasive strategy, radial compared to femoral PCI is chosen in younger, less ill patients and is independently associated with similar risk of bleeding, re-infarction, and mortality. Summary This study evaluated the relationship between arterial access choice (radial versus femoral) and in-hospital and 30-day outcomes in patients undergoing routine PCI after fibrinolysis for STEMI. We included patient-level data from trials evaluating a strategy of routine PCI after fibrinolysis for STEMI. Of 1891 patients undergoing PCI, trans-radial access (n = 338) was chosen in younger, lower risk patients. At 30 days, trans-radial access was associated with a similar unadjusted and adjusted risk of major bleeding, re-infarction and mortality.

BACKGROUND: Despite short-term outcomes of patients with ST-segment elevation myocardial infarction (STEMI) indicate a benefit of DES in terms of reintervention, limited information is available on the long-term safety and efficacy of DES in these patients. Our aim was to perform a meta-analysis of randomized trials evaluating the long-term outcomes of drug-eluting stents (DES) versus bare-metal stents (BMS) in patients with STEMI. METHODS AND RESULTS: A systematic literature search of MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, scientific session abstracts and relevant websites, through September 2010, was performed using specific search terms. Included trials were randomized studies comparing DES to BMS in patients presenting with STEMI, with a follow-up ≥ 3 years. Ten of the 1496 studies initially identified met inclusion criteria, with a total of 6774 patients enrolled. At a mean follow-up of 3.6 years, DES significantly reduced target-vessel revascularization compared with BMS (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.43-0.59; p

BACKGROUND: Optimal strategy for patients who need coronary revascularization before undeferrable non-cardiac surgery is still unknown. We performed a pilot study of dual antiplatelet therapy discontinuation followed by major non-cardiac surgery and endovascular aortic repair early after successful endothelial-progenitor cell-capture coronary stent deployment. METHODS AND RESULTS: Thirty consecutive patients underwent coronary angioplasty plus stenting, before upcoming endovascular or surgical procedures requiring early interruption of antiplatelet therapy. An optimal acute procedural result was observed in all patients. Antiplatelet therapy was stopped before surgery in all patients, achieving an average antiplatelet therapy time of 12.2 ± 3.9 days. Surgery was performed after antiplatelet therapy interruption at an average time interval from revascularization of 17.2 ± 3.9 days. No patient suffered cardiac events during the perioperative period. At thirty day follow-up after surgery there were no cardiac events in all patients. CONCLUSIONS: Our preliminary data might suggest a role for EPC-capture stent in patients requiring surgical procedures early after coronary stent placement. Further studies on larger population are needed to confirm the clinical impact of our findings.

Adaptive immune responses are involved in all stages of atherosclerotic plaque development, including plaque complication (i.e., rupture, ulceration, etc), which may lead to the clinical occurrence of Acute Coronary Syndromes (ACS) [1]. Unstable coronary plaques, in addition to macrophages, contain a 10-fold increase in T-lymphocytes, as compared to stable plaques [2]. T-cells produce and release cytokines, and, in turn, regulate macrophage activity [3]; thus, T-cell activation, through cytokine production, might play a pivotal role in the pathophysiology of plaque complication [4]. Several studies have focused on cytokine plasma levels in patients with ACS, demonstrating that many of these substances are elevated in the systemic blood of patients with ACS (for a review, see Ref. [5]), some of which may even correlate with an adverse prognosis [6]. However, most of these studies have measured cytokine levels in the peripheral blood, raising the issue that the local cytokine milieu is still largely unexplored. This is not a trivial issue, since the assessment of the local inflammatory milieu could contribute to a better understanding of different inflammatory and immune-mediated pathways determining different outcomes in patients affected by ACS [7]. Twenty-eight patients with a clinical diagnosis of ACS and 16 patients with Stable Angina (SA) undergoing coronary angiography were studied. After coronary angiography, a 6 F multipurpose catheter was positioned into the Coronary Sinus (CS); thereafter, blood samples (4.5 mL) were simultaneously obtained from the CS and the ascending aorta (Ao) and placed in pre-chilled Vacutainer tubes containing sodium citrate. Transcoronary cytokine levels (expressed as a Δ% of CS–Ao levels) were measured by LuminexTM technology [8]. We found that transcoronary serum levels of IL-1β, IL-2, IL-6, IL12p40/70, IL-15, and IFN-γ – all of which can be ascribed to a Th1related response – were all significantly increased with the exception of IL-2. (Fig. 1, panel A). On the contrary, transcoronary serum levels of IL-4, IL-5, IL-10, IL-13, (Th2-related response) did not change significantly in patients with ACS as compared to SA patients, with the exception of IL-10 transcoronary levels, which were significantly lower in the ACS group (Fig. 1, panel B). Finally, we have found a significant increase in the transcoronary blood levels of EGF, eotaxin, MCP-1, IP-10, RANTES, and TNF-α in the ACS patients, as compared to their SA counterparts (Fig. 2). Systemic inflammation has been associatedwith an altered pattern of cytokine profile in patients with ACS [5]. However, many large studies attempting to link specific cytokine/chemokine levels to ACS have been inconclusive [9], probably because the inflammatory responses accounting for the outcome of the lesion occur predominantly at the level of the complicated plaque, which may not be paralleled by similar changes in the peripheral blood. Therefore, consistent with this hypothesis, we have focused our attention on the local, i.e., intracoronary cytokine production profile in patients with ACS and compared it to patients with SA. In particular, we have observed that local cytokine release was characterized by an increase in the transcardiac levels of those substances which characterize a Th1-like type of immune response. In contrast, the local production of those cytokines which represent the “fingerprint” of the Th2-like response, did not change significantlywhen compared to that found in patients with SA. Interestingly, the transcoronary levels of IL-10, a cytokine able to down-regulate the inflammatory responses via multiple mechanisms, were even lower in ACS patients, as compared to those obtained in patients with SA. The observed increase in IP-10 and MCP-1 transcoronary blood levels also suggests that the recruitment of inflammatory cells is taking place locally, i.e., at the International Journal of Cardiology 176 (2014) 227–299

The present clinical case shows that assessment of longitudinal strain in the coronary care unit using speckle tracking echocardiography can help to quantify myocardial damage in the context of acute coronary syndromes and detect changes otherwise not visible with semi-quantitative evaluation of wall motion.

For a long time, open surgical repair has been considered the preferred management option for the exclusion of isolated iliac artery aneurysms.The development of transluminally placed endovascular stent grafts, which have been studied extensively for aneurysm exclusion in the abdominal and thoracic aorta, provided a less invasive approach for exclusion of iliac artery aneurysms as compared with surgical reconstruction or open surgical graft placement.Here we report a case of concomitant bilateral common and internal iliac artery aneurysms excluded successfully with multiple stent-grafting deployment with extension to the external iliac arteries and without coil embolization requirements.

ObjectivesThis study investigated the relationship between beta2-adrenergic receptor (B2AR) Ile164 polymorphism and coronary artery disease (CAD).BackgroundB2ARs are crucial to the regulation of vascular tone, and neoangiogenesis is impaired in the presence of isoleucine at position 164 (Ile164) B2AR gene polymorphism. No data deal with the role of the variants at position 164 of the B2AR gene in the setting of CAD.MethodsThe study population consisted of 330 patients undergoing percutaneous coronary intervention (PCI).ResultsThe Ile164 polymorphism frequency was higher in CAD (12.1% vs. 3%, p = 0.008) with respect to the control population. We divided our population into 2 groups: group 1 (290 patients, threonine/threonine genotype at position 164 [164Thr/Thr]) and group 2 (40 patients, threonine/isoleucine genotype at position 164 [164Thr/Ile]). Patients of group 2 presented an earlier onset of CAD (56.7 ± 7.8 vs. 59.5 ± 10, p = 0.04) and a higher incidence of multivessel disease (25.4% vs. 41%, p = 0.044). At follow-up, group 2 showed a higher incidence of new acute myocardial infarction (17.5% vs. 4.5%, p = 0.001), new PCI (37.5% vs. 13.1%, p < 0.0001), and cardiac death (10% vs. 3.1%, p = 0.036). Cox regression analysis identified Ile164 as an independent predictor of cardiac death (odds ratio [OR]: 3.731, 95% confidence interval [CI]: 1.004 to 13.867, p = 0.049) and an overall major adverse cardiac event (OR: 4.100, 95% CI: 1.945 to 8.640, p = 0.0001). A replication study was done on a population of 150 patients with peripheral artery disease. The presence of the Ile164 allele was associated with a higher incidence of acute myocardial infarction (54.5% vs. 25.2%, p = 0.035) or combined events (acute myocardial infarction, PCI, or coronary artery bypass graft) (63.6% vs. 30.9%, p = 0.027).ConclusionsOur study suggests that the B2AR Ile164 mutant is associated with a more aggressive CAD and adversely affects prognosis in patients undergoing PCI.

Incidence of chronic heart failure (HF) is rapidly increasing, approaching a 10 per 1000 rate after 65 years of age. In the last decades, despite pharmacological, interventional and supportive innovations, HF prognosis remained poor, with about 30% of death within one year from the diagnosis. Current guidelines recommend for these patients management programs providing follow-up through dedicated outpatient clinic. Limits of these programs are represented by great difficulties in getting patients adherence, being still too elevated the rate of abandonments. In this paper, we analyzed the impact of 58 months of activity in our dedicated to heart failure outpatient clinic on mortality, hospitalization and abandonment rate. 477 HF patients (346 M, 72.5%, mean age 69.6 years) were enrolled. Mean follow-up and visit were 18.2 and 2.6 months respectively. Total mortality rate was 11.5%, 4% of patients per year. Total hospitalizations for acute HF were 212 and, among all patients left in follow-up, the number of hospitalizations for acute de-compensation significantly decreased from 0.49/patient/year before enrollment to 0.29/patient/year during follow-up (p=0.015). Patients who abandoned outpatient clinic were 94 (19%, 1 abandonment every 23 days), mostly observed over the first months of activity. In conclusion, our patients experienced a major decrease in rates of acute de-compensation and need of inhospital admissions.

Management of PCI patients undergoing early surgery is still a matter of debate. Noteworthy, PCI patients require a dual antiplatelet therapy (DAPT), with aspirine and a thienopiridine (clopidogrel, prasugrel, ticagrelor), because of the high risk of stent thrombosis (ST), myocardial infarction (MI) and death, especially within the first month. Indeed, the number of surgical interventions after PCI is actually increasing, and physicians are looking for the best antiplatelet therapy management, in order to reduce both, bleeding and thrombosis risk. In this paper, current guidelines therapy management and new optional strategies to reduce the cardiovascular risk, related to early surgery, are discussed.

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.

SummaryAlthough bivalirudin has been shown to reduce bleeding events in patients undergoing percutaneous coronary intervention, residual concerns remain about a possible higher risk of early (within 30 days) stent thrombosis (ST). Therefore, we performed a meta-analysis of randomised trials reporting ST events with bivalirudin compared to other antithrombotic therapies (heparins ± glycoprotein IIb/IIIa inhibitors). A systematic literature search of electronic resources was performed through May, 2014. The primary endpoint was definite early ST, according to Academic Research Consortium criteria. Secondary endpoints included: all-cause death, myocardial infarction and major bleeding. A total of 11 trials, including 16,415 patients, were accrued. Compared to other regimens, bivalirudin significantly increased the risk of early ST (odds ratio [OR]=1.80; 95 % confidence interval [CI], 1.28 2.52; p=0.0007) and reduced the risk of major bleeding (OR [95 %CI]=0.64 [0.51 0.82], p=0.0003), with a comparable risk of mortality or myocardial infarction. The higher risk of early ST was mainly attributable to acute (OR [95 % CI] =4.33 [2.33 8.05], p < 0.001) than subacute (OR [95 % CI] =0.89 [0.53 1.50], p =0.67) ST events (p for interaction < 0.001). Non-fatal myocardial infarction was the most common presentation (83 %) of early ST events, while death occurred infrequently (about 5 %). In conclusion, in patients undergoing PCI, bivalirudin compared to heparins is associated with a higher risk of early ST, which is mainly related to more frequent acute events. Further studies are required to evaluate alternative strategies to mitigate this risk, without hampering the benefits derived from the reduction in bleeding events with bivalirudin.

The efficacy of a routine invasive strategy early after fibrinolysis in relation to baseline risk status is unclear. We sought to characterize the interaction between patient risk and treatment with routine invasive strategy early after fibrinolysis for ST-segment elevation myocardial infarction.We pooled 2,974 patients from 7 randomized trials of fibrinolysis-treated patients with ST-segment elevation myocardial infarction comparing a routine early invasive strategy with a standard approach of percutaneous coronary intervention (PCI) guided by recurrent ischemia or need for rescue. Cox proportional hazards regression was used to examine the interaction between baseline patient risk classified by Thrombolysis in Myocardial Infarction risk score (low/intermediate: ≤ 5 [n = 2,697] vs high:5 [n = 277]) and treatment with routine early invasive strategy.Time to PCI after fibrinolysis was longer among patients randomized to standard treatment compared with routine early invasive strategy in the low/intermediate-risk strata (median 11.4 vs 3.5 hours), but was only marginally different between the 2 groups in the high-risk strata (median 4.1 vs 3.5 hours). There was a significant interaction between treatment assignment and risk status for the composite of 30-day death or reinfarction (P = .01). Compared with standard treatment, routine early invasive strategy was associated with lower 30-day death/reinfarction in the low/intermediate-risk stratum (7.5% vs 4.0%, P.001), but not in the high-risk stratum (14.9% vs 19.6%, P = .45).Although clearly beneficial among the larger subgroup of patients at low/intermediate risk, the benefit of a routine early invasive strategy was not evident in the smaller subgroup of higher-risk patients in the context of an increased requirement for urgent PCI in the comparative standard treatment arm.

The investigators performed a network meta-analysis of randomized trials comparing the effectiveness of currently available strategies for the treatment of drug-eluting stent (DES) restenosis. Despite the widespread use of DES in patients who undergo percutaneous coronary intervention, the optimal treatment for DES restenosis remains poorly defined. A systematic search of electronic resources was performed. The primary end point was diameter stenosis at follow-up angiography. Seven trials were included, enrolling a total of 1,586 patients with 1,728 restenotic lesions. The following treatment options were found: balloon angioplasty (BA) in 343 patients (19.3%), iopromide-based paclitaxel-eluting balloons (PEB) in 343 (21.6%), sirolimus-eluting stents in 441 (27.8%), paclitaxel-eluting stents in 462 (29.1%), and everolimus-eluting stents in 34 (2.2%). Compared with BA, PEB (-17.74%, 95% credible interval [CI] -25.17% to -11.31%), everolimus-eluting stents (-14.93%, 95% CI -33.47% to 1.16%), paclitaxel-eluting stents (-15.3%, 95% CI -22.96% to -8.35%), and sirolimus-eluting stents (-11.08%, 95% CI -17.89% to -3.4%) had similar reductions in diameter stenosis at follow-up angiography. PEB (85%) and everolimus-eluting stents (68%) had the greatest probabilities for being the best treatment option. Furthermore, PEB were the best treatment in terms of late luminal loss (85%) and binary restenosis (85%). BA had the lowest efficacy with respect to all study end points. In conclusion, in patients with DES restenosis, repeat DES implantation and iopromide-based PEB are valid alternatives. However, PEB had greater angiographic efficacy and therefore should be considered the new benchmark comparator in the treatment of DES restenosis. The use of BA should be discouraged in patients with DES restenosis.

OBJECTIVE—To evaluate the effects of chronic coronary occlusion on the accuracy of low dose dobutamine echocardiography in predicting recovery of dysfunctional myocardium after revascularisation. DESIGN—Retrospective study. SETTING—Tertiary referral centre. PATIENTS—53 consecutive patients with ⩾ 70% stenosis of the left anterior descending coronary artery (LAD) and regional ventricular dysfunction (group 1, non-occluded LAD; group 2, occluded LAD) who underwent dobutamine echocardiography. INTERVENTIONS—26 patients underwent coronary artery bypass grafting and 27 had percutaneous transluminal coronary angioplasty. MAIN OUTCOME MEASURES—Baseline studies before revascularisation included cross sectional echocardiography at rest and during dobutamine infusion (5-10 µg/kg/min), and coronary angiography. The dobutamine study was performed mean (SD) 35 (28) days before revascularisation. Echocardiography at rest was repeated 90 (48) days after revascularisation. RESULTS—Of 296 dysfunctional segments, 63 in group 1 (43%; 63/146) and 69 in group 2 (46%; 69/150) (NS) improved at follow up. Mean (SD) regional wall motion score index decreased from 1.97 (0.48) (95% confidence interval (CI) 1.01 to 2.93) before revascularisation to 1.74 (0.52) (95% CI 0.70 to 2.78) at follow up in group 1 (p = 0.001), and from 2.12 (0.41) (95% CI 1.30 to 2.98) to 1.88 (0.36) (95% CI 1.16 to 2.60) in group 2 (p = 0.0006). In group 1, sensitivity (87% v 52%; p

Direct stenting (DS) was attempted in 99 coronary lesions in 94 patients while standard stenting (SS) was attempted in 113 lesions in 103 patients matched for clinical characteristics, stenosis type, and location and stent type. The angiographic result was also evaluated according to TIMI frame count method (TFC) before and after procedure. A clinical follow-up was performed 1 year after the procedure. Before the procedure, TIMI grade 3 flow was detected in 42 cases (42.4%), grade 2 in 40 cases (40.4%), grade 1 in 5 cases (5.1%), and grade 0 in 12 cases (12.1%) in the DS group; these data were similar in SS group. After the procedure, TIMI grade flow was 3 in 90 cases (92.8%) in DS group and in 87 (77.0%) in SS group (P < 0.005); grade 2 was observed in 7 case (7.2%) in DS group and in 25 (22.1%) in SS group (P < 0.005). Major adverse cardiac events during hospitalization and at follow-up were similar in two groups. Radiation exposure time and procedure costs per lesion were significantly reduced in DS group compared to SS group (10.1 ± 8 min vs. 13.9 ± 4.7 min, P < 0.001; and 1901 ± 687 Euro vs. 2352 ± 743 Euro, P < 0.001, respectively). This study confirms that, in selected patients, direct stenting is a safe and successful procedure, allowing a significant reduction in radiation exposure time and procedural costs compared to standard stenting technique. The angiographic success is confirmed by the improvement in TFC in all cases. Cathet Cardiovasc Intervent 2001;53:464–473. © 2001 Wiley-Liss, Inc.

Background In patients with coronary artery disease, dysfunctional hypoperfused myocardium at rest may represent either necrotic or viable hibernating myocardium. The accuracy of inotropic stimulation in identifying hypoperfused, reversibly dysfunctional myocardium has not been extensively investigated. Methods and Results Eighteen patients with stable chronic coronary artery disease underwent, while off drugs, quantitative 201 Tl single-photon emission computed tomography after rest injection (2 to 3 mCi), two-dimensional echocardiography at rest and during dobutamine (5 to 10 μg/kg per minute IV), and radionuclide angiography. Single-photon emission computed tomography and echocardiography at rest were repeated 34±10 days after coronary revascularization, and radionuclide angiography was repeated 45±13 days after revascularization. Resting hypoperfusion was defined as 201 Tl uptake 1 grade. Of 79 dysfunctional hypoperfused segments, 48 (61%) improved function after revascularization. In 42 (88%) of these latter segments, function had improved during dobutamine. Conversely, systolic function after revascularization did not improve in 31 segments, and in 27 (87%), it had not improved during dobutamine. Functional improvement after revascularization was observed in 42 (91%) of 46 segments manifesting an improvement during dobutamine as opposed to 6 (18%) of 33 segments that did not improve during dobutamine. Resting 201 Tl uptake (% of maximal activity) before revascularization (65±9%) significantly increased at follow-up in segments where function improved (70±12%, P P =NS). In 10 patients with prerevascularization ejection fraction P Conclusions Inotropic stimulation using dobutamine echocardiography identifies hypoperfused reversibly dysfunctional myocardium. Functional improvement during dobutamine is highly predictive of improvement after revascularization.

We examined the effects of peri-procedural intensive glycemic control (IGC) during early percutaneous coronary intervention (PCI) on restenosis rate in hyperglycemic patients with ST-segment elevation myocardial infarction (STEMI).A total of 165 hyperglycemic patients (glucose ≥ 140 mg/dl) with first STEMI undergoing PCI were studied. Patients were randomized to IGC for almost 24 h after PCI (n = 82; glucose, 80-140 mg/dl) followed by multidose sc insulin during the hospital stay or conventional glycemic control (CGC; n = 83; glucose, 180-200 mg/dl) followed by conventional therapy. Coronary angiography was performed at study entry and at 6-month follow-up. Blood samples for glycemia, hemoglobin A1c, inflammatory markers (C-reactive protein and TNF-α), monocyte chemoattractant-protein-1, and oxidative stress (nitrotyrosine) were collected immediately before and 24 h, 30 and 180 d after PCI.After insulin infusion, mean plasma glucose during the peri-procedural period was greater in the CGC group than in the IGC group (CGC, 191 ± 15 mg/dl; IGC, 145 ± 35 mg/dl; P0.001). After the insulin infusion period, the levels of markers of oxidative stress (nitrotyrosine), inflammation (C-reactive protein, TNF-α), and monocyte chemoattractant-protein-1 were significantly higher in CGC patients compared with IGC patients. Moreover, ICG during PCI reduces restenosis by half (48 and 24%) at 6 months. During follow-up, there was no difference in mortality rates, glucose, inflammatory and oxidative stress markers among the groups. In-stent restenosis was positively associated with mean plasma glucose levels as well as oxidative stress and inflammatory markers during the insulin infusion period.In hyperglycemic patients with STEMI, optimal peri-procedural glycemic control by reducing oxidative stress and inflammation may improve the outcome after PCI.

Hematological disorders are considered risk factors for acute and late complications in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). In particular, thrombocytopenia (TP) is associated with a higher risk for bleeding in patients with ACS treated with antithrombotic therapies1 and has been shown to be a predictor of in-hospital mortality in patients undergoing PCI. In acute myeloid leukemia (AML), replacement of normal bone marrow with leukemic cells causes anemia, TP, and abnormal white blood cells count.

Objectives: Early angioplasty after thrombolysis is now recommended for ST-elevation myocardial infarction, but the current guidelines propose a wide time-window ranging between 3 and 24 h after lytic administration. To identify the optimal timing for PCI after thrombolysis, we analyzed frequency and time course of the adverse events in patients randomized in the multicenter CARESS-in-AMI trial. Methods: 598 high-risk patients with STEMI recruited in the CARESS-in-AMI study, were divided into the Immediate PCI group (IMM, n=298), Rescue PCI group (RES, n=107) and Standard Treatment Arm without rescue PCI (STA, n=193). Results: RES patients had worse pre-procedural TIMI flow and post-procedural blush grade. At 30 days, there were 23 deaths: 11 (10.3%) in RES, 9 (3%) in IMM and 3 (1.6%) in STA (pb0.001). There were 22 episodes of refractory ischemia or re-infarction: 17 (8.8%) in the STA group, 4 (1.6%) in IMM and 1 (0.9%) in RES (pb0.001). In the RES group 10/11 (90.9%) deaths occurred before day 5. In the STA group, all deaths and the majority of ischemic events occurred after day 3. A reduction of risk of de Conclusions: The mortality benefit of immediate referral to PCI after pharmacological treatment for STEMI derives from a reduction in the time to reperfusion of patients with failed thrombolysis in need of rescue PCI. In patients with evidence of successful reperfusion, "elective" PCI within 3 days may be sufficient to reduce the recurrent ischemic events. (C) 2010 Elsevier Ireland Ltd. All rights reserved.

Here we report a case of a 79-year-old woman with inferior myocardial infarction, transferred to our cath lab to perform a primary percutaneous coronary intervention (PPCI). During the procedure, a massive dissection complicated the thrombotic lesion of the right coronary artery (RCA). In this case, we decided to use the MGuard stent to treat both the large dissection and the thrombotic lesion. MGuard stent is a combination of a coronary stent merged with an embolic protection device. After multiple MGuard stent implantation we obtained a complete resolution of the coronary dissection obtaining a patent RCA with normal antegrade flow.

During the last two decades, a new perspective on atherosclerosis has prevailed based on accumulating evidence on the role of inflammatory and immune-competent cells, such as monocytes and T-lymphocytes, in contributing to the development of this disease. It is now generally accepted that a specific T-cell response is crucial in determining not only the development and growth of the atherosclerotic lesion, but also its fate toward a stable or an unstable pattern of evolution (i.e., rupture or ulceration), eventually leading to the clinical occurrence of acute coronary syndromes (ACS). We found that transcoronary IL-17 levels tended to be higher in ACS patients as compared to patients with Stable Angina. We observed a bimodal distribution of IL-17 transcoronary gradients, with 10 out of 23 patients showing elevated IL-17 transcoronary gradients. The ACS patients with elevated transcoronary IL-17 levels, showed also a significant increase in the percentage of Th-17 lymphocytes when samples from the coronary sinus were compared to the ones obtained from the Aorta Finally, patients with a Δ% transcoronary IL-17 gradient > 10 showed troponin I (Tn I) levels at admission significantly higher as compared to the levels measured in the patient population with a Δ% transcoronary IL-17 gradient < 10. Intriguingly, a significant correlation between ∆% transcoronary IL-17 levels and Tn I levels at admission was found only in patients with ∆% transcoronary IL-17 levels > 10 while no correlation was found in the other ACS patients. Our findings highlight that expansion of Th-17 lymphocytes, with the consequent increase in transcoronary IL-17 gradient, might have an important pathophysiological role in a subset of patients with ACS. In addition, data about relationship existing between IL-17 and troponin levels, indicate that this subset of patients presents with a more severe disease and suggest that they may possibly have a poorer prognosis.

Purpose: To evaluate the usefulness of a new transfemoral device to avoid major complications related to residual type A aortic dissection following ascending aortic replacement. Case Reports: Three men (aged 60, 61, and 72 years, respectively) with a residual type A aortic dissection following replacement of the ascending aorta 1, 4, and 5 years prior, respectively, were treated with the Djumbodis Dissection System. The residual dissection developed at the distal anastomosis of the aortic graft and involved all the aortic arch. The Djumbodis Dissection System is an uncovered steel stent, available in 3 lengths (40, 90, 140 mm), pre-mounted on a low pressure (0.3 bars) balloon catheter. The mesh of the device is sufficiently large to bring together the dissected layers without occluding main vital branches. The device was implanted through the femoral artery over a stiff guidewire to exclude the residual false lumen. Satisfactory aortic remodeling was documented in all cases at 1 year. Conclusion: The Djumbodis Dissection System might be a purely endovascular treatment to replace open surgery for residual type A aortic dissection. More cases and longer follow-up are required.

A persistent distal false lumen perfusion--residual type A aortic dissection--is found in 50% to 100% of patients following ascending aorta replacement. Complications of persistent or newly developed dissection of the distal aorta are often fatal and require reoperation, leading to a higher morbidity and mortality rate for these patients than with primary surgery. Thus, many efforts have been done to treat this aortic disease by an endovascular approach. Unfortunately, patency of the supra-aortic vessel still remains an unresolved issue. The present report describes the case of a patient with a residual type A aortic dissection persisting after ascending aorta replacement, successfully treated by implantation of a new endovascular device, the Djumbodis® Dissection System, a bare stent with sufficiently large mesh to join the dissected layers without occluding main vital branches such as supra-aortic arteries.

Coronary artery fistula (CAF) is a congenital condition characterized by a pathological communication between a coronary artery and a systemic vein or one of the cardiac chambers. Iatrogenic CAFs were reported to develop secondary to the rupture of coronary aneurysm. Instances of acquired CAF draining into the cardiac chambers have been described after acute myocardial infarction. Angiography is the gold standard in diagnosing CAF. We describe the case of a patient who developed a fistula draining into the middle cardiac vein on the posterior interventricular sulcus, after acute myocardial infarction, revealed by CT scan.

Aims Several studies have shown that muscle mass loss is an important pathogenic issue in heart failure (HF). Atrogin-1 is a F-box protein selectively expressed in cardiac and skeletal muscle tissue, which plays a pivotal role in muscle wasting regulation. The aim of this study was to investigate the expression of Atrogin-1 and the molecular pathway involved in Atrogin-1 regulation in human HF. Methods and results Cardiac tissue from patients with HF (HF group: n = 10) or with normal left ventricular function (control group: n = 9) was studied by western blot and real time-PCR analysis. Linear regression analysis between patients left ventricular ejection fraction (LVEF) and Atrogin1 or its regulator Forkhead box O 3a (Foxo3a) myocardial expression was performed to test correlations between protein expression and LVEF. Western blot analysis revealed that the myocardial expression of Atrogin-1 in the HF group was 2.5-fold increased compared with controls (P = 0.007). Accordingly, Atrogin-1 mRNA was 1.5 higher than in controls (P = 0.003). The expression of Foxo3a and its up-stream regulator AKT were also measured. Western blot analysis demonstrated in the HF group a 2.56-fold reduction of AKT phosphorylation and a 3.32-fold increase of Foxo3a as compared with controls (P = 0.002 and P = 0.001, respectively). Finally, linear regression showed a significant relationship between Foxo3a or Atrogin-1 expression and LVEF (R = 0.976, P < 0.0001 and R = 0.895, P = 0.003, respectively). Conclusion Our results suggest that in human HF, the activity of AKT decreases, with activation of Foxo3a and induction of Atrogin-1, thereby leading to a molecular state that favours heart muscle loss and left ventricular dysfunction.