Acute myocardial infarction (AMI) patients are at increased risk of death and recurrent ischemic events. We aimed to elaborate a risk score, based on the PEGASUS-TIMI 54 criteria, to predict ...mortality and non-fatal AMI in AMI patients.
We retrospectively analyzed two prospectively collected AMI cohorts. We calculated a cut-off for the developed score and investigated its 1-year prognostic power in the derivation cohort (n = 1257). We externally validated our score in 913 AMI patients with a longer follow-up.
In the derivation cohort, the area under the curve of the score for the primary endpoint (1-year death and non-fatal AMI) was 0.70 (95% CI 0.65–0.76; P < 0.0001) and a cut-off of 6 was identified. The primary endpoint incidence in patients with a score above and below the cut-off was 12% and 3% (P < 0.001) in the derivation cohort and 16% and 6% in the validation cohort (P < 0.001). At multivariate analysis, the HR for the primary endpoint associated with a score ≥ 6 was 4.45 (P < 0.0001) in the derivation cohort and 2.86 (P < 0.0001) in the validation cohort. One-year major bleeding rate was low (<0.2% overall) and similar between risk groups. The prognostic performance of the score cut-off persisted beyond the first year after AMI in the validation cohort, maintaining a similar risk for death and non-fatal AMI (HR 3) at every following year.
Our score, based on the PEGASUS-TIMI 54 criteria, may identify AMI patients at high risk of recurrent ischemic events, who might benefit from thorough preventive strategies.
•Patients with AMI are at risk of death and recurrent ischemic events after discharge, particularly in the first year.•The risk of death and recurrent AMI after AMI can be predicted early by a score based on the PEGASUS-TIMI 54 criteria.•Our score is a simple bedside risk assessment tool easily employable in daily clinical practice.•The evaluation of our score may also support clinical decision-making with respect to a closer clinical follow-up.•Our score identifies AMI patients at high ischemic risk who may derive the greatest benefit from a more intensive therapy.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Women have a worse prognosis after ST-segment elevation myocardial infarction (STEMI) than men. The prognostic role of thrombus burden (TB) in influencing the sex-related differences in clinical ...outcomes after STEMI has not been clearly investigated.
The aim of this study was to assess the sex-related differences in TB and its clinical implications in patients with STEMI.
Individual patient data from the 3 major randomized clinical trials of manual thrombus aspiration were analyzed, encompassing a total of 19,047 patients with STEMI, of whom 13,885 (76.1%) were men and 4,371 (23.9%) were women. The primary outcome of interest was 1-year cardiovascular (CV) death. The secondary outcomes of interest were recurrent myocardial infarction, heart failure, all-cause mortality, stroke, stent thrombosis (ST), and target vessel revascularization at 1 year.
Patients with high TB (HTB) had worse 1-year outcomes compared with those presenting with low TB (adjusted HR for CV death: 1.52; 95% CI: 1.10-2.12; P = 0.01). In unadjusted analyses, female sex was associated with an increased risk for 1-year CV death regardless of TB. After adjustment, the risk for 1-year CV death was higher only in women with HTB (HR: 1.23; 95% CI: 1.18-1.28; P < 0.001), who also had an increased risk for all-cause death and ST than men.
In patients with STEMI, angiographic evidence of HTB negatively affected prognosis. Among patients with HTB, women had an excess risk for ST, CV, and all-cause mortality than men. Further investigations are warranted to better understand the pathophysiological mechanisms leading to excess mortality in women with STEMI and HTB.
Display omitted
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract
Aims
In ST-segment-elevation myocardial infarction (STEMI), cardiovascular magnetic resonance (CMR) holds the potentiality to improve risk stratification in addition to Thrombolysis in ...Myocardial Infarction (TIMI) risk score. Nevertheless, the optimal timing for CMR after STEMI remains poorly defined. We aim at comparing the prognostic performance of three stratification strategies according to the timing of CMR after STEMI.
Methods and results
The population of this prospective registry-based study included 492 reperfused STEMI patients. All patients underwent post-reperfusion (median: 4 days post-STEMI) and follow-up (median: 4.8 months post-STEMI) CMR. Left ventricular (LV) volumes, function, infarct size, and microvascular obstruction extent were quantified. Primary endpoint was a composite of all-death and heart failure (HF) hospitalization. Baseline-to-follow-up percentage increase of LV end-diastolic (EDV; ΔLV-EDV) ≥20% or end-systolic volumes (ESV; ΔLV-ESV) ≥15% were tested against outcome. Three multivariate models were developed including TIMI risk score plus early post-STEMI (early-CMR) or follow-up CMR (deferred-CMR) or both CMRs parameters along with adverse LV remodelling (paired-CMRs). During a median follow-up of 8.3 years, the primary endpoint occurred in 84 patients (47 deaths; 37 HF hospitalizations). Early-CMR, deferred-CMR, and paired-CMR demonstrated similar predictive value for the primary endpoint (C-statistic: 0.726, 0.728, and 0.738, respectively; P = 0.663). ΔLV-EDV ≥20% or ΔLV-ESV ≥15% were unadjusted outcome predictors (hazard ratio: 2.020 and 2.032, respectively; P = 0.002 for both) but lost their predictive value when corrected for other covariates in paired-CMR model.
Conclusion
In STEMI patients, early-, deferred-, or paired-CMR were equivalent stratification strategies for outcome prediction. Adverse LV remodelling parameters were not independent prognosticators.
Objectives The aim of this study was to evaluate the relative frequency of access and nonaccess site bleeding, the association of these events with 1-year mortality, and the impact of randomized ...antithrombotic therapy. Background Post-percutaneous coronary intervention (PCI) bleeding has been strongly associated with subsequent mortality. The extent to which access versus nonaccess site bleeding contributes to this poor prognosis and the role of antithrombotic therapies remains poorly understood. Methods The incidence and impact of Thrombolysis In Myocardial Infarction (TIMI) major/minor 30-day bleeding and randomized antithrombotic therapy were examined in a combined dataset from the REPLACE-2 (Randomized Evaluation in PCI Linking Angiomax to Reduced Clinical Events), Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY), and HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trials in 17,393 PCI patients. Results The TIMI major/minor bleeding occurred in 5.3% of patients, 61.4% of which (3.3%) were nonaccess site bleeds. After multivariable adjustment, TIMI bleeding was associated with an increased risk of 1-year mortality (hazard ratio HR: 3.17, 95% confidence interval CI: 2.51 to 4.00, p < 0.0001). The HR of a nonaccess site bleed was approximately 2-fold that of an access site bleed: HR: 3.94, 95% CI: 3.07 to 5.15, p < 0.0001 versus HR: 1.82, 95% CI: 1.17 to 2.83, p = 0.008, respectively. Randomization to bivalirudin versus heparin + a glycoprotein IIb/IIIa inhibitor resulted in 38% and 43% relative reductions in TIMI major/minor and TIMI major bleeding, respectively (p < 0.0001 for both), with significant reductions in both access and nonaccess site bleeding. Conclusions Nonaccess site bleeding after PCI is common, representing approximately two-thirds of all TIMI bleeding events, and is associated with a 4-fold increase in 1-year mortality. Use of bivalirudin rather than heparin + a glycoprotein IIb/IIIa inhibitor significantly decreases both nonaccess site as well as access site bleeding events by approximately 40%.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Introduction The efficacy of coronary artery bypass graft (CABG) surgery for patients with ischemic heart disease is dependent on the patency of the selected conduit. The left internal thoracic ...artery is considered to be the best conduit for CABG. However, the preferred conduit between the radial artery (RA) and saphenous vein (SV) remains controversial. The present meta-analysis aims to establish the current level IA evidence on patency outcomes comparing the RA and SV. Methods Electronic searches were performed using 6 databases from their inception to March 2012. Two reviewers independently identified all relevant randomized controlled trials (RCTs) comparing patency outcomes of RA and SV grafts after CABG. Data were extracted and meta-analyzed according to angiographic end points at specified follow-up intervals. Results Five relevant RCTs were identified for inclusion in the present meta-analysis. Angiographic results indicated that the RA was significantly more likely to be completely patent and less likely to be associated with graft failure or complete occlusion at 4 years' follow-up and beyond. However, the RA was significantly more likely to be associated with string sign at 1 year of follow-up. Conclusions While acknowledging the limitations of heterogeneous surgical techniques, results from the present meta-analysis suggest potential superiority of the RA compared with the SV at midterm angiographic follow-up. However, the increased incidence of string sign associated with the RA is of potential clinical concern. Further research should be directed at correlating angiographic findings of string sign and graft failure to clinical symptoms and major adverse cardiac and cerebrovascular events at long-term follow-up.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality across the world, warranting continuous research in this field. The elucidation of the atherogenesis ...mechanism is considered one of the most relevant scientific accomplishments of the last century. This has led to the clinical development of various novel therapeutic interventions for patients with or at risk of ASCVD, in which randomized clinical trials played a crucial role.The Thrombolysis in Myocardial Infarction (TIMI) Study Group was initially established to conduct a clinical trial studying thrombolysis for treatment of myocardial infarction. However, over the years, the TIMI Study Group has expanded their research interests to include antithrombotic therapy, lipid lowering, anti-diabetes, anti-obesity, and even heart failure. By leading large-scale, international, randomized, controlled trials of novel therapeutics, the TIMI Study Group has helped shape the very practice of cardiovascular medicine for over a quarter of a century, and decades of research continue to provide future promise for further advancement. Through a mutual goal to improve the care of ASCVD patients, the Japanese scientific community has become one of the important contributors to the TIMI Study Group’s clinical research.In this review article, the authors aim to summarize major research lead by the TIMI Study Group in the ASCVD field.
The relationships between drug exposure and the composite risk of cardiovascular (CV) death, myocardial infarction (MI), and stroke as well as the risk of TIMI major bleeding were estimated following ...long‐term treatment with ticagrelor 60 or 90 mg twice daily in 20,942 patients with prior MI. These analyses support the primary reported efficacy and safety evaluations by showing that there were clear separations from placebo early in treatment with both doses, regardless of ticagrelor exposure, for both endpoints. In addition, the exposure‐response analyses provided new insight into the contribution of individual exposure levels, rather than dose, as a predictor of events and accounted for differences in the baseline risk between patients. The predicted risks of CV death/MI/stroke were similar despite an increase in the median predicted ticagrelor average steady‐state concentration from 606 nmol/L with ticagrelor 60 mg to 998 nmol/L with ticagrelor 90 mg (hazard ratios vs placebo of 0.83 and 0.81, respectively). The corresponding predicted risk of TIMI major bleeding slightly increased (hazard ratios vs placebo of 2.4 and 2.6, respectively). Apart from Japanese patients, showing a lower risk of CV death/MI/stroke, the response to ticagrelor was consistent across the study population, as supported by the combination of relatively flat exposure‐response relationships in the studied exposure range, similar sensitivity to ticagrelor exposure, and small exposure differences. Consequently, the present analyses support the selection of the 60‐mg dose for all demographic subgroups of patients studied.
Full text
Available for:
FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
We assessed the prognostic value of serum levels of endocan in patients with the acute coronary syndrome (ACS) through its correlation with the Thrombolysis in Myocardial Infarction (TIMI) risk score ...and compared the possible association with clinical outcomes. In this prospective cross-sectional study, we enrolled 320 patients with documented ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), or unstable angina (UA) who underwent diagnostic coronary angiography. Endocan was measured soon after admission in the emergency department. In-hospital death, heart failure, and recurrent infarction were considered major adverse cardiac events (MACEs). There was a significant positive correlation between endocan level and TIMI risk score and MACE. The optimal cutoff values of endocan to predict clinical end points were 3.45 ng/mL in patients with STEMI and 2.85 ng/mL in patients with UA/NSTEMI. Multivariate logistic regression analysis indicated that endocan independently correlated with MACE. Moreover, cardiac troponin I, creatine kinase-MB, and circulating endocan were found to be independently associated with MACE in patients with ACS. In conclusion, a high endocan level on hospital admission is an independent predictor of worse cardiovascular outcomes and higher TIMI risk score in patients with ACS.
Full text
Available for:
NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
We recently described the CHA2DS2-VASc-HS score as a novel predictor of coronary artery disease (CAD) severity in stable CAD patients. We aimed to assess the accuracy of the CHA2DS2-VASc-HS score in ...the determination of CAD severity and complexity and its availability in the risk stratification of in-hospital major adverse cardiovascular events (MACE) in non-ST elevation acute coronary syndrome (NSTE-ACS) patients.
We prospectively analyzed the clinical and angiographic data of consecutive NSTE-ACS patients in our clinic. Patients were classified into three tertiles according to their SYNTAX score (SS): tertile 1 had an SS of 0-22; tertile 2 had an SS of 23-32; and tertile 3 had an SS of >32. There were no specific exclusion criteria except for previous coronary artery bypass grafting (CABG) because SS was validated for only native coronary arteries for this study. We used the following analyses: χ2 or Fisher's exact tests, one-way analysis of variance or Kruskal-Wallis tests, Pearson's or Spearman's tests, the receiver operating characteristics (ROC) curve analysis, the area under the curve (AUC) or C-statistic, and pairwise comparisons of the ROC curves.
A total of 252 patients were enrolled. There were 131 patients in tertile 1, 79 in tertile 2, and 42 in tertile 3. The number of diseased vessels was correlated with the Global Registry for Acute Coronary Events (GRACE) (p<0.001), Thrombolysis in Myocardial Infarction (TIMI) (p<0.001), and CHA2DS2-VASc-HS (p<0.001) scores. In the ROC curve analyses, the cut-off value of the CHA2DS2-VASc-HS score in the prediction of in-hospital MACE was >5 with a sensitivity of 69.6% and specificity of 90.3% (AUC: 0.804, 95%: CI 0.750-0.851, p<0.001). We also compared the diagnostic accuracy of the CHA2DS2-VASc-HS score with the TIMI and GRACE risk scores in the determination of the in-hospital MACE and found no differences.
The CHA2DS2-VASc-HS score was positively correlated with the severity and complexity of CAD. We also found that CHA2DS2-VASc-HS was comparable with other risk scores for the risk stratification of the in-hospital MACE of NSTE-ACS patients. Therefore, it may play an important role as a predictive model of NSTE-ACS patients in clinical practice.
Full text
Available for:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objectives: To study the impact of injection of verapamil and adenosine in the coronary arteries on TIMI (Thrombolysis in Myocardial Infarction) frame count (TFC) after percutaneous coronary ...intervention (PCI) in patients with an acute coronary syndrome (ACS). Methods: Prospective, randomised, controlled study of the intracoronary administration of normal saline versus verapamil versus adenosine in patients undergoing PCI in the setting of an ACS, even when flow is visually established to be normal or near normal. Patients were randomised to receive verapamil (n = 49), adenosine (n = 51) or normal saline (n = 50) after PCI. Quantitative angiography, TIMI flow grade (TFG), TFC and myocardial blush grade were assessed before PCI, after PCI and after drugs were given. Wall motion index (WMI) was measured at days 1 and 30. Results: 9 patients in the verapamil group developed transient heart block, not seen with adenosine (p ⩽ 0.001). Compared with saline, coronary flow measured by TFC improved significantly and WMI improved slightly but insignificantly in both the verapamil (TFC: p = 0.02; mean difference in improvement in WMI: 0.09, 95% confidence interval (CI) 0.015 to 0.17, p = 0.02) and the adenosine groups (TFC: p = 0.002; mean difference in improvement in WMI: 0.08, 95% CI 0.004 to 0.16, p = 0.04). The improvements in TFC and WMI did not differ significantly between the verapamil and the adenosine groups (TFC: p = 0.2; mean difference in improvement in WMI: 0.01, 95% CI −0.055 to 0.08, p = 0.7, respectively). Conclusion: Administration of verapamil or adenosine significantly improves coronary flow and WMI after PCI in the setting of an ACS. Flow and WMI did not differ significantly between verapamil and adenosine but verapamil was associated with the development of transient heart block.
PDF
