C-reactive protein and prognosis in women and men with coronary artery disease after percutaneous coronary intervention

BackgroundSex-based differences in the association between C-reactive protein (CRP) and cardiovascular events in patients with coronary artery disease (CAD) are incompletely investigated. We investigated whether there are gender differences in the association between CRP and outcome in patients with CAD after percutaneous coronary intervention (PCI).MethodsThis study included 13,170 consecutive patients with CAD: 10,098 men and 3072 women. CRP was measured on admission in all patients. The primary outcome was 1-year mortality.ResultsCRP level (median [25th–75th percentiles]) was higher in women than in men (3.08 [1.30–8.37] mg/L vs 2.30 [0.92–6.47] mg/L; P < 0.001). CRP was > 3 mg/L in 4250 men (42.1%) and 1554 women (50.6%; P < 0.001). One-year mortality was 4.9% (n = 641 deaths). Deaths occurred in 318 men with CRP > 3 mg/L and 122 men with CRP ≤ 3 mg/L (mortality estimates 7.7% and 2.1%, P < 0.001) and in 154 women with CRP > 3 mg/L and 47 women with CRP ≤ 3 mg/L (mortality estimates 10.1% and 3.2%, P < 0.001). After adjustment in the Cox model, CRP was associated with increased risk of mortality in women (adjusted hazard ratio [HR] = 1.03, 95% confidence interval [CI] 1.01–1.04, P < 0.001 for each 5 mg/L increase) and in men (adjusted HR = 1.02 [1.01–1.03], P < 0.001, for each 5 mg/L increase). CRP predicted mortality with an area under the receiver-operating characteristic curve = 0.721, [0.683–0.760] in women and 0.732, [0.707–0.757] in men (P = 0.659).ConclusionsElevated CRP levels provide similar prognostic information in men and women with CAD after PCI which is independent and supplementary to that provided by conventional cardiovascular risk factors.     

Optimal strategy of coronary revascularization in chronic kidney disease patients: A meta-analysis

BackgroundPatients with chronic kidney disease (CKD) have high risks of coronary artery disease (CAD). Coronary revascularization is beneficial for long-term survival, but the optimal strategy remains still controversial.MethodsWe searched studies that have compared percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) for revascularization of the coronary arteries in CKD patients. Short-term (30 days or in-hospital) mortality, long-term (at least 12 months) all-cause mortality, cardiac mortality and the incidence of late myocardial infarction and recurrence of revascularization were estimated.Results28 studies with 38,740 patients were included. All were retrospective studies from 1977 to 2012. Meta-analysis showed that PCI group had lower short-term mortality (OR 0.55, 95% CI 0.41 to 0.73, P < 0.01), but had higher long-term all-cause mortality (OR 1.29, 95% CI 1.23 to 1.35, P < 0.01). Higher cardiac mortality (OR 1.08, 95% CI 1.01 to 1.15, P < 0.05), higher incidence of late myocardial infarction (OR 1.78, 95% CI 1.65 to 1.91, P < 0.01) and recurring revascularization rate (OR 2.94, 95%CI 2.15 to 4.01, P < 0.01) is found amongst PCI treated patients compared to CABG group.ConclusionsCKD patients with CAD received CABG had higher risk of short-term mortality but lower risks of long-term all-cause mortality, cardiac mortality and late myocardial infarction compared to PCI. This could be due to less probable repeated revascularization.     

Impact of coronary artery calcification on percutaneous coronary intervention and postprocedural complications

BackgroundExcessive coronary calcification can lead to adverse outcomes after percutaneous coronary intervention (PCI). We therefore evaluated the impact of coronary calcium score (CCS) measured by multidetector computed tomography (MDCT) on immediate complications of PCI and rate of restenosis.MethodsWe performed a single-center retrospective analysis of 84 patients with coronary stenosis diagnosed by MDCT who underwent PCI. The Agatston method was used to measure total, target-vessel, and segmental (stent deployment site) CCS.ResultsIn 108 PCI procedures, 32 lesions (29.5%) were American College of Cardiology/American Heart Association type A, 60 (55.5%) were type B, and 16 (15%) were type C. ANOVA showed significantly higher segmental CCS in type C than in type A lesions (29 ± 51 vs. 214 ± 162; p = 0.03). Six patients (7.1%) had periprocedural complications and seven (8.3%) had in-stent restenosis and angina. Mean total, target-vessel, and segmental CCS was significantly higher in complicated than in successful PCI (199 ± 325 vs. 816 ± 624, p = 0.001; 92 ± 207 vs. 337 ± 157, p = 0.001; and 79 ± 158 vs. 256 ± 142, p = 0.003, respectively), but there was no significant difference in CCS between successful PCI and PCI complicated by late restenosis.ConclusionsCCS measured by MDCT has an important role in predicting early, but not late, complications from PCI.     

Circulating irisin levels are lower in patients with either stable coronary artery disease (CAD) or myocardial infarction (MI) versus healthy controls,whereas follistatin and activin A levels are higher and can discriminate MI from CAD with similar to CK-MB accuracy

BackgroundSeveral myokines are produced by cardiac muscle. We investigated changes in myokine levels at the time of acute myocardial infarction (MI) and following reperfusion in relation to controls.MethodsPatients with MI (MI Group, n = 31) treated with percutaneous coronary intervention (PCI) were compared to patients with stable coronary artery disease (CAD) subjected to scheduled PCI (CAD Group, n = 40) and controls with symptoms mimicking CAD without stenosis in angiography (Control Group, n = 43). The number and degree of stenosis were recorded. Irisin, follistatin, follistatin-like 3, activin A and B, ALT, AST, CK and CK-MB were measured at baseline and 6 or 24 h after the intervention.ResultsMI and CAD patients had lower irisin than controls (p < 0.001). MI patients had higher follistatin, activin A, CK, CK-MB and AST than CAD patients and controls (all p ≤ 0.001). None of the myokines changed following reperfusion. Circulating irisin was associated with the degree of stenosis in all patients (p = 0.05). Irisin was not inferior to CK-MB in predicting MI while folistatin and activin A could discriminate MI from CAD patients with similar to CK-MB accuracy. None of these myokines was altered following PCI in contrast to CK-MB.ConclusionsIrisin levels are lower in MI and CAD implying that their production may depend on myocadial blood supply. Follistatin and activin A are higher in MI than in CAD suggesting increased release due to myocardial necrosis. They can predict MI with accuracy similar to CK-MB and their role in the diagnosis of MI remains to be confirmed by prospective large clinical studies.     

Impacto de las diferencias de sexo y los sistemas de red en la mortalidad hospitalaria de pacientes con infarto agudo de miocardio con elevación del segmento ST

Introduction and objectivesNetwork systems have achieved reductions in both time to reperfusion and in-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI). However, the data have not been disaggregated by sex. The aim of this study was to analyze the influence of network systems on sex differences in primary percutaneous coronary intervention (pPCI) and in-hospital mortality from 2005 to 2015.MethodsThe Minimum Data Set of the Spanish National Health System was used to identify patients with STEMI. Logistic multilevel regression models and Poisson regression analysis were used to calculate risk-standardized in-hospital mortality ratios and incidence rate ratios (IRRs).ResultsOf 324 998 STEMI patients, 277 281 were selected after exclusions (29% women). Even when STEMI networks were established, the use of reperfusion therapy (PCI, fibrinolysis, and CABG) was lower in women than in men from 2005 to 2015: 56.6% vs 75.6% in men and 36.4% vs 57.0% in women, respectively (both P < .001). pPCI use increased from 34.9% to 68.1% in men (IRR, 1.07) and from 21.7% to 51.7% in women (IRR, 1.08). The crude in-hospital mortality rate was higher in women (9.3% vs 18.7%; P < .001) but decreased from 2005 to 2015 (IRRs, 0.97 for men and 0.98 for women; both P < .001). Female sex was an independent risk factor for mortality (adjusted OR, 1.23; P < .001). The risk-standardized in-hospital mortality ratio was lower in women when STEMI networks were in place (16.9% vs 19.1%, P < .001). pPCI and the presence of STEMI networks were associated with lower in-hospital mortality in women (adjusted ORs, 0.30 and 0.75, respectively; both P < .001).ConclusionsWomen were less likely to receive pPCI and had higher in-hospital mortality than men throughout the 11-year study period, even with the presence of a network system for STEMI.     

Impact of insulin resistance on 1-year clinical outcomes in non-diabetic patients undergoing percutaneous coronary intervention with drug-eluting stents

BackgroundInsulin resistance (IR) is known to be a risk factor for coronary artery disease (CAD). We aimed to evaluate the impact of IR on 1-year clinical outcomes in non-diabetic CAD patients who underwent percutaneous coronary intervention (PCI) with drug-eluting stents (DESs).Methods and resultsA total of 229 consecutive non-diabetic CAD patients treated with DESs were enrolled. Study population was divided into IR group [homeostasis model assessment (HOMA) index ≥ 2.5, n = 54] and non-IR group (HOMA index < 2.5, n = 175). Baseline clinical and procedural characteristics were similar between the groups except higher incidence of high-sensitivity C-reactive protein and lower incidence of multivessel disease as the target vessel in the non-IR group. There was a trend toward longer restenosis lesion length in the IR group at 6 months angiographic follow up but composite major clinical outcomes up to 1 year were similar between the two groups.ConclusionsDespite worse trend in angiographic outcomes in the IR group (HOMA index ≥ 2.5), it was not translated into worse 1-year major clinical outcomes following PCI with DESs as compared to the non-IR group.     

Evaluation of the impact of chronic kidney disease on the survival of octogenarian patients submitted to percutaneous coronary intervention

ObjectiveTo evaluate the impact of chronic kidney disease on the survival of patients – 80 years of age undergoing percutaneous coronary intervention (PCI) in the long term.Methods273 subjects who underwent PCI between January 2010 and January 2016 were divided into four categories: (1) stable angina (SA) and creatinine clearance – 30 (n = 24); (2) patients with SA and CrCl <30 (n = 70); (3) patients with acute coronary syndrome (ACS) and CrCl – 30 (n = 51); (4) patients with ACS and ICC <30 (n = 128). Mortality curves were evaluated using the Kaplan-Meier method and differences between groups were compared by log-rank statistic. Multivariate analysis was performed using the Cox proportional hazards method. The 4 groups were compared and the survival between the groups was evaluated.ResultsOctogenarian patients with CrCl <30 with SA and ACS have lower long-term survival (p < 0.0001).ConclusionCKD has a worse long-term prognosis for patients undergoing PCI.     

Estimated Glomerular Filtration Rate as a Useful Predictor of Mortality in Patients With Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

BackgroundThis study evaluated the impact of estimated glomerular filtration rate (eGFR) on 30-day and 1-year mortalities in patients with an acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).MethodsBetween January 2002 and November 2009, 1432 consecutive patients who had experienced STEMI with an onset of chest pain < 12 hours of undergoing primary PCI were prospectively enrolled. Patients were categorized into group 1 (eGFR < 30 mL/min/1.73 m²), group 2 (eGFR = 30–60 mL/min/1.73 m²) and group 3 (eGFR > 60 mL/min/1.73 m²).ResultsThe incidence of a high Killip class (defined as class ≥ 3) upon presentation, a requirement for mechanical ventilatory support for respiratory failure and intra-aortic balloon pump support for hemodynamic instability, and duration of hospitalization were substantially higher in group 1 than in groups 2 and 3, and notably higher in group 2 compared with group 3 (all P < 0.001). Conversely, the procedural success of primary PCI was remarkably lower in group 1 compared with groups 2 and 3, and it was also notably lower in group 2 than in group 3 (all P < 0.001). Additionally, both 30-day and 1-year mortalities were markedly increased in group 1 than in groups 2 and 3, and significantly higher in group 2 than in group 3 (all P < 0.001). Multivariate analysis showed that eGFR < 30 mL/min/1.73 m² was a significantly independent predictor of 30-day and 1-year mortalities (all P < 0.001).ConclusionseGFR < 30 mL/min/1.73 m² was strongly and independently predictive of poor short-term and long-term prognostic outcomes in patients with STEMI undergoing primary PCI.     

Identifying a better strategy for ad hoc percutaneous coronary intervention in patients with anticipated unfavorable radial access: the Little Women study

BackgroundTransradial percutaneous coronary intervention (PCI) offers important advantages over transfemoral PCI, including better outcomes. However, when there is indication to ad hoc PCI, a 6 French workflow is a common default strategy, hence potentially influencing vascular access selection in patients with anticipated small size radial artery.MethodsA multidimensional evaluation was performed to compare two ad hoc interventional strategies in women < 160 cm: a full 6 French workflow (namely 6 French introducer sheath, diagnostic catheters and guiding catheter) with a modified workflow consisting in the use of 5 French diagnostic catheters preceded by the placement of a 6 French sheath introducer and followed by a 6 French guiding catheter use for PCI.ResultsOverall 120 women (68 ± 11 years) were enrolled in the study. Coronary angiography has been performed using 5 French or 6 French diagnostic catheters in 57 (47.5%) and 63 (52.5%) cases, respectively. Radial spasm and switch to another access occurred more frequently among women who underwent coronary angiography with 6 French rather than 5 French diagnostic catheters (43% vs. 25%, p = 0.03 and 2% vs. 11%, p = 0.04, respectively). Total time to guidewire lesion crossing was also significantly higher when PCI has been preceded by 6 French rather than 5 French coronary angiography (23 ± 11 min vs 16 ± 7 min, p = 0.013).ConclusionsIn patients with anticipated unfavorable radial access, a workflow consisting in 6 French introducer sheath placement, 5 French coronary angiography, and 6 French coronary intervention is on multiple parameters the most straightforward and effective strategy.     

Safety and feasibility of performing staged non-culprit vessel percutaneous coronary intervention within the index hospitalization in patients with ST-segment elevation myocardial infarction and multivessel disease

ObjectivesTo determine whether staged percutaneous coronary intervention (PCI) within the same hospitalization as primary PCI is safe.BackgroundIn ST-segment elevation myocardial infarction (STEMI) patients with multivessel disease undergoing primary PCI, staged non-culprit vessel PCI at a separate session is recommended.MethodsWe conducted a retrospective analysis of 282 consecutive STEMI patients with multivessel disease who underwent primary PCI followed by staged PCI of the non-culprit vessel. Patients were categorized into staged PCI in the same hospitalization (n = 184) and staged PCI at a separate hospitalization within 8 weeks of primary PCI (n = 98).ResultsBaseline characteristics, presentation of STEMI, and procedural characteristics were similar in both groups. Contrast amount was higher in the separate hospitalization group for both index (175 vs. 153 ml, p = 0.011) and staged (144 vs. 120 ml, p = 0.004) procedures. More staged left main PCI was performed in the separate hospitalization group (3.9 vs. 0.3%, p = 0.008). Angiographic success of staged PCI was similar in both groups, with similar rates of vascular complications and major bleeding. Following staged PCI, in-hospital major adverse cardiac events (3.3 vs. 1.0%, p = 0.43) and mortality (2.7 vs. 0%, p = 0.17) were similar in both groups.ConclusionsOur study supports the safety and feasibility of staged PCI within the same hospitalization as primary PCI, achieving similar procedural success and in-hospital outcomes as staged PCI at a separate hospitalization. Higher contrast amount used during primary PCI and presence of left main lesion in non-culprit vessels may influence the decision to stage the PCI at a separate hospitalization.     

Prognostic impact of concurrence of metabolic syndrome and chronic kidney disease in patients undergoing coronary intervention: Involvement of coronary plaque composition

Background and purposeMetabolic syndrome (MetS) and chronic kidney disease (CKD) have both been reported as risk factors for cardiovascular events. The aim of this study was to assess the synergistic effect of MetS and CKD on atherosclerotic plaque and cardiovascular outcomes.Methods and subjectsA total of 545 consecutive patients who underwent percutaneous coronary intervention (PCI) were divided into 4 groups based on the presence or absence of MetS and CKD. MetS was defined using the criteria of the Adult Treatment Panel III of the US National Cholesterol Education Program. CKD was defined as an estimated glomerular filtration rate of <60 ml/min/1.73 m². We analyzed the incidence of major adverse cardiac events (MACE), including cardiovascular death, nonfatal myocardial infarction, target lesion revascularization, and revascularization for new lesions. We also assessed coronary plaque characteristics of 204 patients using integrated backscatter intravascular ultrasound (IB-IVUS).ResultsMACE occurred more frequently in patients with both MetS and CKD (51.4%) than in the other groups, during the follow-up period (log-rank p < 0.001). In the IB-IVUS analyses, patients with both MetS and CKD exhibited greater plaque burden (p = 0.003) with higher lipid content (p = 0.048) compared to the other groups. In Cox analysis, both MetS and CKD proved to be independent predictors of MACE even after adjustment for confounding factors (p = 0.018).ConclusionsComorbidity of MetS and CKD is an independent predictor of adverse cardiovascular outcomes in patients undergoing coronary intervention, an effect that may be attributed to coronary plaque instability.     

Pre-diabetes and the risk of contrast induced nephropathy in patients undergoing coronary angiography or percutaneous intervention

BackgroundContrast induced nephropathy (CIN) is a complication of coronary angiography/percutaneous intervention (PCI). It is known that diabetes is an independent risk factor for CIN, but we have no data regarding the association between CIN and glycemic levels in patients without diabetes. Aim of our study was to evaluate whether high level of glycated-haemoglobin in patients without diabetes is associated with an increased risk of CIN.MethodsA total of 1324 patients without diabetes, undergoing elective/urgent coronary angiography/angioplasty were divided according to quartiles of baseline glycated-haemoglobin. CIN was defined as an absolute ≥0.5 mg/dL or a relative ≥25% increase in creatinine level at 24–48 h after the procedure.ResultsPatients with elevated glycated-haemoglobin were older, with hypertension, metabolic syndromes, previous history of AMI, PCI and CABG. They had higher gycaemia, fasting-glycaemia and triglycerides but lower HDL-cholesterol. Patients with higher glycated-haemoglobin were more often on therapy with statins, diuretics and calcium-antagonist at admission, had higher basal, 24 and 48 h creatinine, lower creatinine clearance and lower ejection fraction. They had the highest incidence of PCI and contrast volume-eGFR rate. CIN occurred in 10.6% of patients with a linear association with glycated-haemoglobin (p = 0.001). No relationship was found between glycaemia/fasting glycaemia at admission and CIN. The multivariate analysis confirmed the association between elevated glycated haemoglobin (above the median value 5.7%) and the risk of CIN after adjustment for baseline confounding factors (Adjusted OR [95% CI] = 1.69 [1.14–2.51], p = 0.009). In fact, the results were consistent in major high-risk subgroups.ConclusionThis is the first study showing that among patients without diabetes undergoing coronary angiography/PCI elevated glycated-haemoglobin but not glucose levels is independently associated with the risk of CIN.     

Therapeutic effect of urapidil on myocardial perfusion in patients with ST-elevation acute coronary syndrome

ObjectivesTo evaluate the effect of urapidil on myocardial perfusion, and ventricular function in patients with ST-elevation acute coronary syndrome (ACS) treated with primary percutaneous coronary intervention (PCI).MethodsFifty-four patients were randomized into urapidil (12.5 mg, ic, n = 27) or control group. Infarct related artery (IRA) was targeted with PCI following urapidil administration. TIMI blood flow, corrected TIMI frame count (cTFC), myocardial blush grade (MBG), ST resolution (STR) on ECG, creatine kinase MB (CK-MB) and cardiac troponin T (cTnT) were measured before, and after PCI.ResultscTFC (18.38 ± 3.30 vs 21.44 ± 4.26, P = 0.005), in the treatment group was lower than the placebo group, whereas MBG was higher (P = 0.04). More patients in the urapidil group achieved significant STR following PCI (93% vs 70%, P = 0.04). Left ventricular ejection fraction (LVEF), measured with echocardiography, in the urapidil group was higher than the control group 30 days after PCI (0.58 ± 0.06 vs 0.54 ± 0.06, P = 0.04). Peak CK-MB and peak cTnT in the urapidil group was lower than the control group (P < 0.01). Myocardial nitric oxide concentration in the urapidil group was higher than that of the control group (P < 0.01). Following PCI, the endothlin-1 level did not change in the urapidil group (P > 0.05) but it was increased in the control group (P < 0.05).ConclusionsUrapidil treatment improves coronary flow, myocardial perfusion and left ventricular function following PCI in patients with ST-elevation ACS. These beneficial effects are associated with an enhanced biosynthesis of nitric oxide.     

Study of main arteries stiffness in patients with coronary heart disease depending on prevalence of atherosclerosis

ObjectiveTo study the vascular wall stiffness in patients with coronary artery disease based on the prevalence of atherosclerotic lesion.Materials and methodsThe study involved 90 patients diagnosed with unstable angina class II B, the control group consisted of 27 healthy individuals. By using the SphygmoCor (AtCor Medical, Australia) apparatus, stiffness indicators, like pulse wave velocity (PWV) and augmentation index (AIx) were studied by means of the applanation tonometry method. Coronary angiography was performed on the Allura CV-20 (Philips, The Netherlands) unit, the state of the carotid arteries was studied by duplex ultrasonography, involvement of femoral arteries was evaluated based on ankle-brachial index <0.9. In case of doubt, the patients underwent ultrasound duplex scanning. In the main group, patients were divided into 3 subgroups: subgroup A covered patients with isolated coronary lesion; subgroup B covered patients with bifocal atherosclerosis (combined lesion of coronary and carotid arteries or coronary and femoral arteries); subgroup C was represented by multifocal atherosclerosis patients who had atherosclerosis lesion in three vascular basins: carotid, coronary and femoral arteries.ResultsValues of PWV (11.2 ± 1.5 m/s) and AIx (19.8 ± 5.0%) in patients with coronary heart disease were 1.5 (p < 0.001) and 2.4 (p < 0.001) times higher than in those in healthy individuals. During the analysis carried out within the groups, the PWV in all three subgroups was accelerated with maximal values in the subgroup C (13.3 ± 1.5 m/s), which with sufficient level of confidence exceeds the value of this index in the subgroups A (10.1 ± 0.6, p < 0.01) and B (11.0 ± 0.9, p < 0.05). The value of augmentation index AIx was also highest in the subgroup C (26.8 ± 6.4%), relative to the subgroups A (13.7 ± 2.9%, p < 0.001) and B (18.9 ± 4.3%, p < 0.01).ConclusionPatients with coronary heart disease, have demonstrated growing vascular wall stiffness, which is manifested in higher pulse wave velocity (p < 0.001) and augmentation index (p < 0.001) compared with healthy individuals. Whereas in the multifocal atherosclerosis (coronary, carotid and peripheral arteries) were higher AA (p < 0.05), AIx (p < 0.001), PWV (p < 0.01) and the age of patients (p < 0.01). That allows to consider the studied parameters of vascular stiffness as surrogate markers to assess prevalence and progression of atherosclerosis, as well as the effectiveness of pharmacological interventions.     

Fibrinogen-to-albumin ratio is related to the severity of coronary artery disease in chronic kidney disease patients undergoing coronary angiography

ObjectivesThis study was to explore the potential relationship between the fibrinogen-to-albumin ratio (FAR) and the presence and severity of coronary artery disease (CAD) in stage 3–5 predialysis chronic kidney disease (CKD) patients.DesignThis study included 978 patients undergoing coronary angiography (CAG). CAD was defined as the presence of obstructive stenosis > 50% of the lumen diameter in any of the four main coronary arteries. Gensini scores (GSs), left main coronary artery (LMCA) and three-vessel coronary artery disease (TVD) were used to elevate the severity of CAD.ResultsThe adjusted odds ratios of CAD were 3.059 (95% CI: 1.859–5.032) and 2.670 (95% CI: 1.605–4.441) in the third and fourth quartiles of FAR compared with the first quartile, respectively. Among 759 patients diagnosed with CAD, multivariate logistic regression analysis showed that FAR (at the 0.01 level) was significantly positively associated with the presence of LMCA (adjusted OR = 1.177, 95% CI 1.067–1.299, P = 0.001) or TVD (adjusted OR = 1.154, 95% CI 1.076–1.238, P < 0.001), and a higher GS (adjusted OR = 1.152, 95% CI 1.073–1.238, P < 0.001).ConclusionsFAR levels were independently associated with the presence and severity of CAD in stage 3–5 predialysis CKD patients.     

Multicenter HP ACS Registry

BackgroundNo population representative data on characteristics, treatment, and outcome were available in acute coronary syndrome (ACS) patients.MethodsThe clinical characteristics, treatment, and in-hospital outcome of 5180 ACS patients registered in multicenter ACS Registry across 33 hospitals in the state since January 2012 to December 2014 are reported. ACS was diagnosed using standard criteria.Result70.8% were men; mean age was 60.9 ± 12.1. NSTEMI was more frequent than STEMI (54.5% vs. 45.5%). 83.3% of the ACS population were from rural area. Pre-hospital delay was long, with a median of 780 min. 35.6% of STEMI patients received thrombolytic therapy. Evidence-based treatment was prescribed in more than 80% of ACS patients, and the treatment was similar in men and women across all types of health care centers. In-hospital mortality was 7.6%, and was more frequent in STEMI than in NSTEMI (10.8% vs. 5.0%, p < 0.001).InterpretationPre-hospital delay was long, and use of reperfusion therapy was significantly lower. The in-hospital death rates are higher.     

Resultados intrahospitalarios tras tratamiento percutáneo frente a quirúrgico en pacientes con estenosis aórtica y enfermedad arterial coronaria concomitante

Introduction and objectivesConcomitant coronary artery disease (CAD) is prevalent among aortic stenosis patients; however the optimal therapeutic strategy remains debated. We investigated periprocedural outcomes among patients undergoing transcatheter aortic valve implantation with percutaneous coronary intervention (TAVI/PCI) vs surgical aortic valve replacement with coronary artery bypass grafting (SAVR/CABG) for aortic stenosis with CAD.MethodsUsing discharge data from the Spanish National Health System, we identified 6194 patients (5217 SAVR/CABG and 977 TAVI/PCI) between 2016 and 2019. Propensity score matching was adjusted for baseline characteristics. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were in-hospital complications and 30-day cardiovascular readmission.ResultsMatching resulted in 774 pairs. In-hospital all-cause mortality was more common in the SAVR/CABG group (3.4% vs 9.4%, P < .001) as was periprocedural stroke (0.9% vs 2.2%; P = .004), acute kidney injury (4.3% vs 16.0%, P < .001), blood transfusion (9.6% vs 21.1%, P < .001), and hospital-acquired pneumonia (0.1% vs 1.7%, P = .001). Permanent pacemaker implantation was higher for matched TAVI/PCI (12.0% vs 5.7%, P < .001). Lower volume centers (< 130 procedures/y) had higher in-hospital all-cause mortality for both procedures: TAVI/PCI (3.6% vs 2.9%, P < .001) and SAVR/CABG (8.3 vs 6.8%, P < .001). Thirty-day cardiovascular readmission did not differ between groups.ConclusionsIn this large contemporary nationwide study, percutaneous management of aortic stenosis and CAD with TAVI/PCI had lower in-hospital mortality and morbidity than surgical intervention. Higher volume centers had less in-hospital mortality in both groups. Dedicated national high-volume heart centers warrant further investigation.     

Prognostic implications of percutaneous coronary interventions performed according to the appropriate use criteria for coronary revascularization

ObjectivesTo assess the prognostic implication of the ACCF/AHA/SCAI appropriate use criteria (AUC) for coronary revascularization in a cohort of non-acute coronary syndrome patients.BackgroundThe AUC for coronary revascularization were developed in order to deliver high-quality care; however, the prognostic impact of these criteria remains undefined.MethodsConsecutive patients (n = 3817) undergoing elective percutaneous coronary intervention (PCI) at MedStar Washington Hospital Center since the 2009 AUC publication were retrospectively grouped according to AUC as an “Appropriate,” “Inappropriate,” or “Undetermined” indication for PCI. Outcomes to 1 year were compared.ResultsPCI was categorized as “Appropriate” in 47%, “Inappropriate” in 1.8% and as “Uncertain” in 51% of patients. “Appropriate” PCI patients had a higher prevalence of hypertension and diabetes but a lower prevalence of smoking. “Inappropriate” PCI involved the treatment of more complicated lesions, with lower rates of drug-eluting stent utilization. While there were no differences in procedural complications among the 3 groups, in-hospital major complications and outcomes were worse for “Inappropriate” PCI patients. The 30-day (3.2% vs. 7% vs. 4.1%, p = 0.32) and 1-year (13.1% vs. 11.8% vs. 15.3%, p = 0.43) major adverse cardiac event rates of the “Appropriate,” “Inappropriate,” and “Uncertain” PCI patients, respectively, were comparable. In multivariable analysis, the procedural appropriateness was not associated with either in-hospital or 1-year outcome.ConclusionsAt large, physicians practicing in tertiary centers adhere to the AUC when subjecting patients with non-acute coronary syndrome to revascularization. The present analysis did not demonstrate association between long-term outcome and procedure appropriateness according to the AUC.     

Early phosphatemia changes in acute cardiac care patients

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

Comparison of manual compression and vascular hemostasis devices after coronary angiography or percutaneous coronary intervention through femoral artery access: A meta-analysis of randomized controlled trials

ObjectivesTo compare the efficacy and safety of manual compression (MC) with vascular hemostasis devices (VHD) in patients undergoing coronary angiography (CA) or percutaneous coronary intervention (PCI) through femoral artery access.IntroductionThe use of femoral artery access for coronary procedures may result in access-related complications, prolonged immobility and discomfort for the patients. MC results in longer time-to-hemostasis (TTH) and time-to-ambulation (TTA) compared to VHDs but its role in access-related complications remains unclear in patients undergoing coronary procedures.MethodsWe searched MEDLINE, EMBASE, Cochrane CENTRAL and relevant references for English language randomized controlled trials (RCT) from inception through September 30, 2016. We performed the meta-analysis using random effects model. The outcomes were time-to-hemostasis, time-to-ambulation, major bleeding, large hematoma > 5 cm, pseudoaneurysm and other adverse events.ResultsThe electronic database search resulted in a total of 44 RCTs with a total of 18,802 patients for analysis. MC, compared to VHD resulted in longer TTH [mean difference (MD): 11.21 min; 95% confidence interval (CI) 8.13–14.29; P < 0.00001] and TTA [standardized mean difference: 1.2 (0.79–1.62); P < 0.00001] along with excess risk of hematoma > 5 cm formation [risk ratio (RR): 1.38 (1.15–1.67); P = 0.0008]. MC resulted in similar risk of major bleeding [1.01 (0.64–1.60); P = 0.95] pseudoaneurysm [0.99 (0.75–1.29); P = 0.92], infections [0.52 (0.25–1.10); P = 0.09], need of surgery [0.60 (0.29–1.22); P = 0.16), AV fistula [0.93 (0.68–1.27); P = 0.63] and ipsilateral leg ischemia [0.95 (0.57–1.60); P = 0.86] compared to VHD.ConclusionManual compression increase time-to-hemostasis, time-to-ambulation and risk of hematoma formation compared vascular hemostasis devices.