In patients with carotid disease, the purpose of carotid artery revascularization is stroke prevention. For >50 years, carotid endarterectomy has been considered the standard treatment for severe ...asymptomatic and symptomatic carotid stenoses. Carotid artery stenting (CAS) has emerged in the last 15 years as minimally invasive alternative to surgery. However, the value of the endovascular approach in the management of carotid disease patients remains highly controversial. The aims of this review are to elucidate the current role of CAS, to describe the major technology advancements in the field, and to speculate about the future of this therapy.
Aims Restenosis after percutaneous coronary angioplasty remains an important limitation of this procedure. This study evaluates whether elevated total plasma homocysteine levels contribute to the ...development of restenosis after coronary angioplasty. Methods and Results Two hundred and five patients were recruited after successful angioplasty of at least one coronary stenosis (≥50%). End-points were restenosis (≥50%) and a composite of major adverse cardiac events. Of the 205 patients, 183 (89·3%) underwent 6 months angiographic follow-up. Patients with restenosis had significantly higher homocysteine levels than those without (10·9± 3·9μmol.l−1 vs 9·3±3·8μmol.l−1, P<0·01). Homocysteine levels were significantly correlated to follow-up diameter stenosis (r=0·24, P=0·0001), especially in small vessels (<3mm) treated with balloon angioplasty only (r=0·40,P <0·0005). Late lumen loss at follow-up was significantly smaller with homocysteine levels below 9μmol.l−1 (0·62±0·82mm vs 0·90±0·77mm, P<0·01). Restenosis rate (25·3% vs 50·0%,P <0·001) and major adverse cardiac events (15·7% vs 28·4%,P <0·05) were also significantly lower in patients with homocysteine levels below 9μmol.l−1. Multivariate analysis did not weaken these findings. Conclusion Total plasma homocysteine is a strong predictor of restenosis and major adverse cardiac events after coronary angioplasty. Thus, plasma homocysteine appears to be an important cardiovascular risk factor influencing outcome after successful coronary angioplasty.
Early exercise after coronary stenting is safe Roffi, Marco; Wenaweser, Peter; Windecker, Stephan ...
Journal of the American College of Cardiology,
11/2003, Letnik:
42, Številka:
9
Journal Article
Recenzirano
Odprti dostop
In this study, we sought to assess safety of symptom-limited exercise stress tests the day after coronary stenting.
Isolated cases of coronary stent thrombosis have been linked to early exercise ...stress testing, thereby questioning the safety of unrestricted physical activity after the coronary procedure.
At a single center, 1,000 patients were randomized to a symptom-limited stress test the day after coronary stenting or no stress test. The antiplatelet regimen consisted of acetylsalicylic acid and postprocedural ticlopidine or clopidogrel. The primary end point of the study was the incidence of clinical stent thrombosis at 14 days. The secondary end point was the occurrence of access site complications.
Clinical stent thrombosis occurred in five patients (1%) undergoing stress test and in five patients (1%) randomized to no stress test (p = 1.0). Access site complications were detected in 4% and 5.2% of cases, respectively (p = 0.37).
Symptom-limited exercise stress testing the day after coronary stenting does not increase the risk of clinical stent thrombosis or access site complications. Further investigations on safety of early vigorous exercise after coronary stenting in a non-supervised setting are warranted.
Abstract
Background
Evaluation of bleeding risk is critical to the management of patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). The CRUSADE score is the most established ...tool to estimate major bleeding events following the index NSTE-ACS.
Purpose
We aimed to assess the performance of the CRUSADE score and the predictive utility of the individual score variables in contemporary European populations.
Methods
The CRUSADE score was studied in prospectively recruited Swiss patients with NSTE-ACS included in the multicentre SPUM-ACS study (n=4'787) and main findings were validated in the nation-wide AMIS Plus registry (n=46'939). Major bleeding during hospitalization was defined as Bleeding Academic Research Consortium (BARC) class IIIB, IIIC, IV, or V. Discrimination was evaluated by the area under the receiver operating characteristic curve (AUC). Multivariable-adjusted risk ratios (adj RR) were estimated for each of the 8 score variables. Hematocrit estimates were based on hemoglobin concentrations in AMIS Plus. Analyses were performed on complete and imputed data (multiple imputation using chained equations).
Results
CRUSADE showed poor discriminatory performance (SPUM-ACS: AUC, 0.65; 95% CI 0.57 to 0.72) and low balanced accuracy (SPUM-ACS: 0.50). Risk predicted by CRUSADE exceeded the observed risk across all predefined risk categories (very low, low, moderate, high, and very high). Decision curve analyses suggested little to no net benefit from using the score. Adjusting for other score variables, signs of heart failure (adj RR, 3.83; 95% CI, 1.93 to 7.37), low hematocrit (adj RR, 2.16; 95% CI, 0.55 to 7.70; <31% vs. >40%), and low systolic blood pressure (adj RR, 2.70; 95% CI, 1.14 to 6.16; <100 mmHg vs. >121 mmHg) were the strongest predictors of major in-hospital bleeds in SPUM-ACS. These findings were similarly observed in AMIS Plus.
Conclusion
The CRUSADE score overestimates bleeding risk in NSTE-ACS. Among all 8 score variables, signs of heart failure, low hematocrit, and low systolic blood pressure are the strongest predictors of major in-hospital bleeds in contemporary patients with NSTE-ACS.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): Swiss National Science FoundationSwiss Heart Foundation
Abstract
Introduction
Risk prediction scores adopted in acute coronary syndromes use incremental models to estimate mortality for heart rate (HR) above 60 bpm. Nonetheless, a non-linear, bimodal ...relationship, with higher event rates at low or high HR, has been described, potentially hampering risk prediction accuracy.
Purpose
Our aim was to assess the prognostic impact of bradycardia, defined as admission HR <50 bpm, in myocardial infarction (MI) among patients enrolled in a large nationwide registry.
Methods
Data of patients enrolled between 1999 and 2021 stratified by admission HR were retrospectively analysed. The primary endpoint was in-hospital mortality. The secondary endpoint was a composite of death, cerebrovascular event, and reinfarction. Associations between HR and outcomes were assessed at univariate and multivariable logistic regression analyses, then verified after sequential propensity-score matchings among HR groups.
Results
51001 patients (median age 66 years, IQR 56–76) were included. Crude estimates showed a bimodal distribution of primary and secondary endpoints with peaks at low and high HR. Association of HR <50 bpm with mortality was recognised only at primary multivariable logistic regression analysis (OR 1.49; 95% CI 1.01–2.13 p=0.038) but not at multiple sensitivity analyses after exclusion of patients on negative chronotropic therapy. Three sequential propensity-score matching were performed among patients with HR <50 bpm at admission and those with HR 50–75 bpm, HR 76–100 bpm and HR >100 bpm at admission, identifying 1159, 1159 and 1158 matched pairs, respectively. After propensity-score matching, rates of primary and secondary endpoints equalled among groups with HR <100 bpm.
Conclusions
Bradycardia (HR <50 bpm) at admission in patients with MI identified a group with higher crude rate of adverse events. Nonetheless, the signal supporting an independent association between bradycardia at admission and short-term mortality is weak and was not confirmed after correction for relevant baseline differences by propensity score matching. These findings support the hypothesis that lower HR might not be causative for the worse outcomes, but rather serves as a marker of underlying morbidity.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): The AMIS Plus registry is funded by unrestricted grants from the Swiss Heart Foundation and from Abbot AG, Amgen AG, AstraZeneca AG, Bayer (Schweiz) AG, Biotronik AG, Boston Scientific AG, B. Braun Medical AG, Daiichi-Sankyo/Lilly AG, Cordis Cardinal Health GmbH, Medtronic AG, Novartis Pharma Schweiz AG, Sanofi-Aventis (Schweiz) AG, SIS Medical AG, Terumo AG, Vascular Medical GmbH, all in Switzerland, and the Swiss Working Group for Interventional Cardiology. The sponsors did not play any role in the design, data collection, analysis, or interpretation of data.
Abstract
Introduction
The impact of collateral circulation in the presence of severe coronary artery disease such as chronic total occlusion (CTO) has been extensively studied, with results despite ...few discrepancies, supporting an overall benefit on preservation of myocardial tissue and left ventricular ejection fraction (LVEF). However, less is known about the protective effects of collaterals in the context of acute coronary syndromes (ACS). In the current study we sought to analyze the incidence, grade and impact of collateral circulation in a large prospectively recruited cohort of patients presenting with ACS with independent events adjudication.
Methods and results
4'546 ACS patients presenting with ACS, enrolled in the prospective Special Program University Medicine ACS (SPUM-ACS) cohort were included. The current analysis showed the presence of a collateralized culprit lesion in 12.9% (n=586) of patients, 84% (n=492) originating from the contralateral side and 16% (n=94) from the ipsilateral side. Of those 64.6% (n=378) were being graded as Rentrop 2 or more. There were no differences in baseline characteristics between the two groups including incidence of diabetes, coronary artery disease, age and gender. However, despite the presence of collaterals graded Rentrop 2 or more, those patients had a significantly lower LVEF mean 48,44% vs 51.6%, p=0.025 and higher creatinine Kinase levels, mean (CK) 981 U/I vs 957 UI, p<0.001 as compared to patients with absent collateral-circulation on admission. Interestingly a sub analysis of the STEMI population showed no significant differences in both LVEF and CK at presentation, while troponin (TNT) plasma levels were significantly lower in patients with collaterals (mean TNT 0.0031 ug/l vs 0.035 ug/l p=0.001). Additionally no differences in cardiovascular mortality, stent thrombosis or MI was seen at one year follow-up.
Conclusion
The current analysis highlights a possible protective impact of a pre-existing collateral circulation against myocardial injury in the setting of ACS and ST elevation myocardial infarction. However this was not translated into improvement in hard outcomes acutely and up to one year of follow up, but may be important in the long run.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): Swiss National Research Foundation - ZurichHeart House
Abstract
Background
Clinical use of the GRACE scoring system is recommended across international guidelines to guide early treatment stratification in patients with non-ST-segment elevation acute ...coronary syndromes (NSTE-ACS). Recently, the machine learning-based GRACE 3.0 score was derived from patients with NSTE-ACS undergoing contemporary treatment approaches. External validation studies and the reassessment of clinical risk categories are lacking.
Purpose
We aimed to evaluate the predictive performance of the GRACE 3.0 score and to explore clinically meaningful risk groups in contemporary patients with NSTE-ACS.
Methods
We studied the GRACE 3.0 score in 8070 patients with NSTE-ACS in contemporary ACS cohorts from Denmark (VERDICT, n=2147), Germany (Heidelberg-ACS, n=2034), Italy and Spain (CORALYS, n=1650), and Switzerland (SPUM-ACS, n=2239). Heterogeneity in the treatment effect of very early invasive management (within 12 hours) or standard invasive management (within 48 to 72 hours) on the primary composite outcome of all-cause death, nonfatal recurrent myocardial infarction, hospital admission for refractory myocardial ischemia, or hospital admission for heart failure in relation to baseline mortality risk was assessed in 2147 patients enrolled in the VERDICT trial who were randomized to different timing of invasive treatment.
Results
The GRACE 3.0 score showed excellent discriminatory properties with an area under the receiver operating characteristic curve (AUC) for in-hospital death of 0.89 (95% CI, 0.85–0.93) in the total study cohort. Similar results were observed in Denmark (AUC 0.93, 95% CI, 0.88–0.98), Germany (AUC 0.90, 95% CI, 0.85–0.94), and Italy and Spain (AUC 0.85, 95% CI, 0.77–0.94), and Switzerland (AUC 0.93, 95% CI, 0.86–1.00). Early invasive treatment reduced the composite endpoint (absolute risk reduction: 0.12, 95% CI, 0.03–0.21, P=0.011) in patients at high risk (≥1.7%), but not in those with lower risk profiles (P interaction=0.033). Based on this new high-risk threshold, GRACE 3.0 stratified 475 (42.2%) more patients into the high-risk group, as compared to traditional GRACE risk categories (P<0.001).
Conclusion
GRACE 3.0 shows unprecedented predictive performance in patients with NSTE-ACS. In the context of a comprehensive clinical evaluation, GRACE 3.0 can support clinical decision making for the timing of invasive treatment. The high-risk group of patients with NSTE-ACS who benefit from early invasive treatment is substantially larger than previously described.ROC curve and risk groupsRestratfication towards high risk group
Abstract
Background
Dipeptidyl peptidase 3 (DPP3) is mechanistically involved in the degradation of angiotensin II and in the depression of systolic left ventricular function thereby disturbing ...peripheral blood pressure regulation. Small pilot studies suggested that circulating DPP3 (cDPP3) portends poor outcomes in acute heart failure and may refine risk assessment in patients with acute coronary syndromes (ACS).
Purpose
We aimed to assess the predictive value of cDPP3 in contemporary patients with ACS.
Methods
Circulating DPP3 was studied in 4311 patients with ACS in the prospective multicentre SPUM-ACS study. DPP3 levels were centrally measured in EDTA plasma by blinded study personnel using an established sandwich-type luminometric immunoassay. Kaplan-Meier survival curves and multivariable-adjusted regression models adjusted for sex, age, heart rate, systolic blood pressure, history of diabetes, levels of creatinine, centrally measured high-sensitivity troponin T, N-terminal pro-B-type natriuretic peptide, and high-sensitivity C-reactive protein, and the Global Registry of Acute Coronary Events (GRACE) risk score.
Results
At baseline, median cDPP3 levels were 19.0 ng/ml (interquartile range IQR 15.0-26.0) with higher levels observed in patients with ST-segment elevation myocardial infarction than in those with non-ST-segment elevation ACS (20.1 15.9-28.2 vs. 18.0 14.1-23.9, respectively, P<0.001). High cDPP3 was linked to longer hospitalization and higher risk to require vasopressor use or mechanical circulatory support (per log2 increase: odds ratio OR 1.91, 95% confidence interval CI 1.62-2.24, P<0.001; adjusted OR 1.35 95% CI 1.08-1.69, P=0.008). In line, high cDPP was strongly associated with increased mortality at 30 days (per log2 increase: hazard ratio HR 1.96, 95% CI 1.48-2.59, P<0.001) and at 1 year (HR 1.51, 95% CI 1.24-1.83, P<0.001). When accounting for established risk factors, cDPP3 remained an independent predictor of premature death with doubling in cDPP3 levels translating into an 58% and 40% increase in 30-day and 1-year mortality risk, respectively (adjusted HR 1.58, 95% CI 1.06-2.34, P<0.023, adjusted HR 1.40, 95% CI 1.10-1.77, P=0.006, respectively).
Conclusion
We identified cDPP3 as a novel marker of cardiogenic shock and increased mortality in patients with ACS. Circulating DPP3 provides prognostic information beyond established risk factors and improves early risk assessment.DPP3 is linked to hemodynamic impairmentDPP3 independently predicts mortality
Abstract
Introduction
The aim of this study was to analyse whether prehospital delay in ST-elevation myocardial infarction (STEMI) has changed in men and women since 2002.
Methods
We used data from ...the AMIS Plus registry of patients who were admitted for STEMI between 2002 and 2019. Patients who were transferred from another hospital or were resuscitated before admission were excluded. Patient delay was defined as the difference between symptom onset and hospital admission time. Trends in delay according to gender were depicted by medians per year with a 95% confidence interval. Differences between men and women were tested using the Mann-Whitney test. To analyse the adjusted effect of gender on delay, multivariable quantile regression was applied including the interaction between gender and admission year as well as the covariates age, diabetes, pain at presentation and myocardial infarction (MI) history.
Results
Among the 15,154 patients included (74.5% men), the overall median (IQR) delay between 2002 and 2019 was 150 (84; 345) minutes for men and 180 (100; 415) for women. Women were older (71.3y vs. 62.8y, p<0.001), had more often diabetes (20.0% vs. 16.9%, p<0.001), but less often MI history (11.2% vs. 14.9%, p<0.001) and less often pain at presentation (92.0% vs. 94.8%, p<0.001).
The unadjusted median delay decreased over the admission years. The decreasing trend was stronger in women than men: the unadjusted difference in delay between men and women decreased from 60 min in 2002 (p=0.003) to 15 min in 2019 (p=0.155) (Fig 1). The multivariable model confirmed a significant interaction between gender and admission year (p=0.042) indicating that the decrease in delay was stronger for women (−3.1 min per year) than for men (−1.4 min per year) even after adjustment. The adjusted difference between men and women decreased from 27.4 min in 2002 to −1.6 min for women in 2019. Additional independent predictors of longer delay were the covariates age (+1.6 min per additional year, p<0.001) and diabetes (+27.1 min, p<0.001). Conversely, pain at admission (−46.3 min, p<0.001) and MI history (−32.9 min, p<0.001) predicted a shorter delay.
Conclusions
The difference in delay between symptom onset and hospital admission in STEMI patients between men and women steadily diminished from 2002 to 2019. This might indicate that the public and health professionals' awareness of STEMI in women has ameliorated over time.
Unadjusted delay according to gender
Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): AMIS Plus Foundation
PDF
