Chronic kidney disease (CKD) is associated with high cardiovascular morbidity and mortality. The available data suggest that efforts to reduce mortality in the CKD population should be focused on ...treatment and prevention of, among others, coronary artery disease and congestive heart failure. Accelerated atherosclerosis present in CKD patients also leads to a decline in renal function. Definite data concerning the treatment of heart failure in CKD patients are lacking, because patients with significant renal impairment have mostly been excluded from randomized studies. Nevertheless, it seems that CKD patients should receive similar cardiovascular treatment to that used in patients with normal kidney function, but the doses of drugs ought to be titrated to achieve an optimal effect while avoiding adverse events. Several studies have also shown that despite the high risk, in patients with acute coronary syndrome (ACS), revascularization procedures in patients with CKD appear to be advantageous in the long run and are therefore justified. However, large clinical trials are needed to confirm the benefits and to identify possible disadvantages associated with various methods of treatment.
Impaired glycemic control (GC) is a troubling clinical condition with an unclear prognostic value that is frequent in diabetics, especially in the setting of acute coronary syndrome. Residual ...platelet reactivity can be also affected by GC. We evaluated the relation between response to dual antiplatelet therapy and GC in diabetics with STEMI treated with primary coronary angioplasty (PCI). Sixty diabetic patients were prospectively enrolled in the study. All patients were treated with clopidogrel and aspirin. Platelet reactivity (whole blood aggregation and phosphorylation of vasodilator-stimulated phosphoprotein, VASP) were assessed serially before and 24 hours, 7 days, and 30 days after the PCI. Blood glucose >8.5 mmol/L on admission was an independent predictor of a impaired clopidogrel response measured with platelet reactivity index (PRI) >50% on admission (OR 7.8, 95% CI 1.4-17.7, p<0.02) and 24 hours after PCI (OR 13.1, 95% CI 3.4-28.1, p<0.01). In conclusion, diabetic patients with STEMI and glycemia >8.5 mmol/L on admission is related to a poorer response to clopidogrel. There were no interaction between glycated hemoglobin level or glycemia on admission and platelet reactivity measured with collagen, arachidonic acid or thrombin receptor agonist peptide-induced aggregation. Further clinical studies of the role of GC in the efficacy of antiplatelet agents are warranted.
The distribution of atherosclerotic plaque burden in the human coronary arteries is not uniform. Plaques are located mostly in the left anterior descending artery (LAD), then in the right coronary ...artery (RCA), circumflex branch (LCx) and the left main coronary artery (LM) in a decreasing order of frequency. In the LAD and LCx, plaques tend to cluster within the proximal segment, while in the RCA their distribution is more uniform. Several factors have been involved in this phenomenon, particularly flow patterns in the left and right coronary artery. Nevertheless, it does not explain the difference in lesion frequency between the LAD and the LCx as these are both parts of the left coronary artery. Branching points are considered to be the risk points of atherosclerosis. In the LCx, the number of side branches is lower than in the LAD or RCA and there are no septal perforators with intramuscular courses like in the proximal third of the LAD and the posterior descending artery (PDA). We hypothesized that septal branches generate disturbed flow in the LAD and PDA in a similar fashion to the myocardial bridge (myocardial bridging effect). This coronary architecture determines the non-uniform plaque distribution in coronary arteries and LAD predisposition to plaque formation.
Not All Fat Is Equal Hudzik, Bartosz, MD, PhD; Rozentryt, Piotr, MD, PhD; Lekston, Andrzej, MD, PhD ...
Journal of the American College of Cardiology,
02/2013, Letnik:
61, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Dual-energy X-ray (DXA) absorptiometry is considered by many to be a gold standard for assessing body composition (direct measurement of total body fat and lean soft tissue mass).
The prevalence and impact of total coronary occlusion of an infarct-related artery (IRA) on outcomes in patients with non-ST-elevation myocardial infarction (NSTEMI) remain unclear.
We evaluated the ...clinical significance of total coronary occlusion in NSTEMI patients.
A total of 2767 patients with NSTEMI enrolled in the Polish Registry of Acute Coronary Syndromes, who underwent percutaneous coronary interventions, were analysed. The patients were divided into two groups according to preprocedural culprit vessel thrombolysis in myocardial infarction (TIMI) flows (TIMI flow 0 - total coronary occlusion TO: 728, 26.3% of the patients, and TIMI flow 1-3 - non-total occlusion non-TO: 2039, 73.7% of the patients).
Patients with total occlusion were younger, were more often current smokers, and had lower incidence of hypertension and diabetes mellitus. The left circumflex artery (LCx) was the major IRA in the TO group (48.1%), whereas the left anterior descending artery (LAD) was more commonly the IRA in the non-TO group (38.8%). Multivariate analysis revealed that LCx as the culprit lesion (OR ± 95 CI 1.54 1.26-1.89, p < 0.0001) was an independent predictor of TIMI flow 0 in IRA. In-hospital and one-month mortality occurred more frequently in the TO group (4.0% vs. 1.7%, p = 0.0005 and 5.5% vs. 3.5%, p = 0.0175, respectively), no differences in the 12-, 24-, or 36-month mortalities were observed between these groups.
Only LCx as a culprit lesion was an independent predictor of total occlusion in IRAs. The NSTEMI patients with TO had higher in-hospital and one-month mortalities, but their long-term outcomes were similar to those of non-TO patients.
Background The role of incomplete revascularization (ICR) in patients with acute myocardial infarction (AMI) is controversial. We evaluated the impact of ICR on short- and long-term outcome in ...patients with AMI and multivessel disease (MVD) treated with percutaneous coronary interventions (PCI) during index hospital stay. Methods Single-center observational study covered 798 patients with MVD selected from 1486 consecutive patients with AMI treated with PCI. At discharge, 605 (75.8%) of the patients still had at least 1 diseased artery (ICR group); in 193, complete revascularization (CR) has been achieved (CR group). Any-cause mortality rate and major adverse cardiac events (MACE) during hospitalization, within a follow-up period of 30 days and 29.7 months, were compared between both groups in the whole population and within the high-risk subgroups. Propensity model to predict the probability of CR according to 16 variables was used. Results Mortality and MACE rates were significantly higher in ICR group than among completely revascularized subjects during short- and long-term observation (remote mortality 18.5% vs 7.2%, MACE 53.1% vs 24.3%, both P < .001). Higher mortality rate was also observed within the subgroups with diabetes (25.2% vs 4.8%), renal dysfunction (44.1% vs 13.8%), and lowered ejection fraction (26.5% vs 10.5%, all P < .05). Propensity-adjusted multivariate analysis showed that ICR was a significant and strong predictor of remote death (propensity-adjusted hazard ratio 2.01, 95% CI 1.71-2.31, P = .02) and MACE (hazard ratio 2.08, 95% CI 1.90-2.26, P < .001). Conclusions Incomplete revascularization is a strong and independent risk factor of death and MACE in patients with AMI treated with PCI.
Metformin is one of the antihyperglycaemic drugs, reducing the risk of major cardiovascular events, including fatal ones. Although it is formally contraindicated in moderate and severe functional ...stages of heart failure (HF), it is commonly used in patients with concomitant type 2 diabetes mellitus (T2DM).
We sought to evaluate the effect of metformin and T2DM on total mortality and hospitalisation rates in patients with HF.
This retrospective analysis included 1030 adult patients (> 18 years) with HF from the Polish section of the HF Long-Term Registry (enrolled between 2011 and 2014). Patients with T2DM (n = 350) were identified and divided into two groups: those receiving metformin and those not. Both groups were subjected to one-year follow-up.
Mean patient age was 65.3 ± 13.5 years, with the predominance of male sex (n = 726) and obesity (mean body mass index 30.3 ± 5.5 kg/m2) and mean left ventricular ejection fraction was 34.3% ± 14.1%. Among patients with T2DM (n = 350) only 135 (38.6%) were treated with metformin. During one-year follow-up, 128 patients with HF died, of whom 53 had T2DM (15.1% vs. 10.9%, hazard ratio HR 0.89, 95% confidence interval CI 0.87-0.91, p = 0.045). Metformin was associated with a lower mortality rate compared to other antihyperglycaemic agents (9.6% vs. 18.6%, HR 0.85; 95% CI 0.81-0.89, p = 0.023). There were no significant differences in the hospitalisation rate, including that due to HF decompensation, among patients treated with metformin and the remainder (53.5% vs. 40.0%, respectively HR 0.93, 95% CI 0.82-1.04, p = 0.433).
Metformin treatment in patients with different degrees of HF and T2DM is associated with a reduction in mortality and does not affect the hospitalisation rate.
Abstract Background Mortality of patients with ST-segment elevation myocardial infarction (STEMI) with cardiogenic shock (CS) on admission remains high despite invasive treatment. The aim of this ...analysis was to assess the relationship between the infarct-related artery (IRA) and the early and 12-month outcomes of patients with STEMI and CS treated by percutaneous coronary intervention (PCI). Methods Two thousand ninety patients with STEMI and CS registered in the prospective Polish Registry of Acute Coronary Syndromes from October 2003 to November 2009 were included. Results The in-hospital mortality in the left main (LM), left anterior descending artery (LAD), circumflex artery (Cx), and right coronary artery (RCA) groups was 64.7%, 41.0%, 36.0%, and 30.8%, respectively, with p < 0.0001. The 12-month mortality in the LM, LAD, Cx, and RCA groups was 77.7%, 58.2%, 55.1%, and 45.0%, respectively, with p < 0.0001. After multivariate adjustment, LM as the IRA was significantly associated with higher 12-month mortality (hazard ratio = 1.71, 95% confidence interval = 1.28–2.27, p = 0.0002). Conclusions In-hospital and long-term mortality of patients with STEMI and CS treated by PCI are significantly correlated to the IRA, being highest for LM and lowest for RCA.
Introduction
The aim was to assess the predictive value of estimated glomerular filtration rate (eGFR) using two formulas: modification of diet in renal disease (MDRD) and chronic kidney disease ...epidemiology collaboration (CKD-EPI), in a population with stable coronary artery disease (SCAD) undergoing percutaneous coronary revascularization (PCI).
Methods
The analyzed cohort included 3,141 consecutive patients with SCAD who underwent PCI, between January 2006 and December 2011. Follow-up data were available for 3,123 (99.4 %) patients.
Results
The median follow-up was 1,127 days (interquartile range 566–1,634 days). During the observation period, 330 deaths were reported. In patients with serum creatinine (S-Cr) within normal range, eGFR by CKD-EPI equation predicted long-term outcome more accurately, than eGFR by MDRD formula—continuous Net Reclassification Improvement: 0.296 (95 % CI, 0.08–0.5
p
= 0.03). In patients with elevated S-CR, eGFR calculated by both formulae had similar efficacy in assessing death risk. After adjustment for differences in clinical characteristics, both formulae were associated with mortality, but only in patients with elevated S-Cr: eGFR by MDRD (per 10 ml/min/1.73 m
2
) HR: 0.74 95 % CI, 0.61–0.89,
p
= 0.002, eGFR by CKD-EPI (per 10 ml/min/1.73 m
2
) HR: 0.75 (95 % CI, 0.63–0.89,
p
= 0.001). After adjustment for covariates, eGFR by CKD-EPI equation did not offer more appropriate categorization of individuals with respect to long-term mortality.
Conclusion
Our results indicate that in multivariable analysis eGFR calculated by MDRD and CKD-EPI equations has similar predictive value. In a population of patients with SCAD and S-Cr within normal range, eGFR calculated by CKD-EPI equation outperforms eGFR calculated by MDRD equation in assessing death risk.
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