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Cardiac catheterization laboratory (CCL) morbidity and mortality conferences (MMCs) are a critical component of CCL quality improvement programs and are important for the education of cardiology trainees and the lifelong learning of CCL physicians and team members. Despite their fundamental role in the functioning of the CCL, no consensus exists on how CCL MMCs should identify and select cases for review, how they should be conducted, and how results should be used to improve CCL quality. In addition, medicolegal ramifications of CCL MMCs are not well understood. This document from the American College of Cardiology's Interventional Section attempts to clarify current issues and options in the conduct of CCL MMCs and to recommend best practices for their conduct. [Display omitted] • Most cardiac cath labs hold MMCs, but standards for their conduct have not been established. • This paper suggests best practices for MMCs to meet the needs of different types of cath labs. • Cath lab directors should review their morbidity and mortality processes to ensure protection from legal discovery. [ABSTRACT FROM AUTHOR]

In less than 1 percent of the population, the left main coronary artery is absent. Although this anomaly is rare, it should be recognized, because it affects clinical management of heart disease in these patients. The congenital development of the condition and techniques for recognizing it during angiography (radiographic imaging of the heart and blood vessels) are discussed. Fifty-three men and 30 women (0.04 percent) out of 20,332 patients who underwent cardiac catheterization had no left main coronary artery. After catheterization, 25 of these patients underwent coronary artery bypass surgery, and four had heart valve replacements. Failure to identify the absence of a left main coronary artery during angiography may confuse interpretation, and falsely suggest that an artery is completely occluded when it is not. During cardiac bypass surgery or valve replacement, this condition could lead to failure to perfuse the vessel, causing serious complications. The absence of the left main coronary artery does not impair circulation. (Consumer Summary produced by Reliance Medical Information, Inc.)

Myocardial ischemia is a reduction in cardiac blood flow that can result in pain, permanent damage to the heart muscle, and in severe cases, death. Acute myocardial infarction (AMI; heart attack) and unstable angina are both a consequence of myocardial ischemia, and it is believed that the underlying mechanism involves alterations in the fatty, cholesterol-rich plaque lining diseased arteries which leads to thrombus (clot) formation. Thrombolytic (clot-dissolving) drugs are commonly used in the treatment of AMI; dissolution of the thrombus and subsequent restoration of blood flow prevent further damage from AMI. Several studies have reported that thrombolytic therapy has beneficial long-term effects on patients suffering from unstable angina, but the immediate effects of this treatment have not been reported. To further investigate the effects of thrombolytic drugs on reversal of unstable angina, a study was carried out with four men and three women suffering from this condition. All patients were being treated with heparin (an anticoagulant medication) and aspirin. Thrombolytic therapy took the form of infusion of recombinant tissue-type plasminogen activator (rt-PA) directly into the coronary arteries. Two of the patients showed immediate improvement, two showed no change, and three had immediate worsening of the condition (which had to be repaired by emergency balloon dilation of the afflicted artery). These variable results suggest that thrombolysis alone may not be a suitable treatment for all patients with unstable angina. (Consumer Summary produced by Reliance Medical Information, Inc.)

Aneurysms (localized dilation of a blood vessel due to weakness of the wall) and pseudoaneurysms (similar, but histologically distinct occurrences) of the ascending aorta (the major artery supplying the upper half of the body) are rare following heart operations, but can be extremely serious. It is estimated that between 3 and 5 percent of all in-hospital and late mortality seen after cardiac surgery results from aneurysms and pseudoaneurysms of the aorta. Calcium deposits and fatty degeneration of the arteries, as well as high blood pressure of long duration, are predisposing factors. Frequently, aneurysms and pseudoaneurysms result from physical defects in the implantation of coronary artery bypass grafts (CABG). An illustrative case history of a 50-year-old patient who developed pseudoaneurysm 10 years after CABG is reported. Infections may also contribute to the development of this condition. In many cases, small aneurysms and pseudoaneurysms are asymptomatic, and are detected only upon routine chest X-ray or angiographic examination; computerized tomography (CAT scan), magnetic resonance imaging (MRI), and ultrasound (echocardiography) offer ready confirmation of this diagnosis. Contrast aortography (injection of radiopaque material into the aorta to visualize its shape) is the definitive diagnostic tool for this condition. For small, asymptomatic aneurysms, repeat testing 6 to 12 months after diagnosis is warranted to exclude progressive enlargement of the defect; larger aneurysms, or those undergoing size changes should be surgically repaired, even though surgical mortality for this procedure is relatively high. (Consumer Summary produced by Reliance Medical Information, Inc.)

Coronary artery disease (CAD) is a condition in which the arteries supplying the heart with blood become narrowed (stenotic), depriving the heart muscle of blood. When untreated, CAD can lead to death. One successful treatment for this condition is percutaneous transluminal coronary angioplasty (PTCA), in which a balloon-tipped catheter is inserted into the occluded artery and inflated, widening the stenotic region and reestablishing blood flow. The technique is highly effective in patients in whom the stenosis is discretely localized; however, its use is controversial when the stenotic region extends diffusely throughout much or all of the affected artery. To evaluate the risks and benefits of PTCA in patients with diffuse CAD, 98 patients (65 men and 33 women) undergoing angioplasty of at least one diffusely diseased coronary artery were studied. Of 396 stenotic arterial segments (approximately two per patient), successful reversal of the stenosis was accomplished in 382. Clinical success (reversal of the symptoms) was accomplished in 91 of the 98 patients. The complication rate was low: six patients had perioperative heart attacks, one required emergency bypass surgery, and two patients died. Almost all of the complications occurred in patients who had diffuse involvement of an entire coronary artery (as opposed to individual or multiple smaller sites of stenosis). During follow-up examinations, restenosis was noted in about 30 percent of the patients, mostly in the treated artery. Three years after surgery, the survival rate was 93 percent; 82 percent of the patients remained symptom-free during that period. Hence, PTCA is safe and effective when performed on selected patients with diffuse CAD. (Consumer Summary produced by Reliance Medical Information, Inc.)

Pseudoaneurysms are widened or twisted areas in a blood vessel resembling an aneurysm, a ballooning out of a vessel wall. Pseudoaneurysms are rare and may be fatal, and can occur after surgery on blood vessels. Occurrences of pseudoaneurysms have been reported following liver, pancreas, and kidney transplants, but not heart transplants. Two cases are described involving pseudoaneurysms in the aortas of patients who received heart transplants. The first patient, a 45-year-old man, had pneumonia and rejection episodes in the months following surgery. A routine X-ray suggested an abnormality of the aorta, which was then further viewed with a computed tomographic (CT) scan and a magnetic resonance imaging (MRI) study. The MRI images showed a hemispherical structure containing flowing blood, and this was confirmed by imaging with contrast media. The second patient, a 60-year-old man, developed an infection of the surgical wound, and an MRI study was done to determine the extent of the infection. The MRI images revealed a pseudoaneurysm that contained flowing blood and was surrounded by clot. These findings were confirmed by other imaging results and during surgery. As in these two cases, pseudoaneurysms often follow infections (case two) and may occur at sites involved in grafting procedures (case one). MRI imaging is better than CT scans because it can provide optimum images of the pseudoaneurysm, as well as not needing contrast media nor using ionizing radiation. (Consumer Summary produced by Reliance Medical Information, Inc.)

Percutaneous transluminal coronary angioplasty (PTCA) is a procedure used to improve the blood flow through an occluded or blocked coronary artery, the major blood vessel supplying the heart. In PTCA, a catheter with a small deflated balloon attached is inserted into the occluded portion of a coronary artery, and the balloon is briefly inflated, resulting in the dilatation of the blood vessel and improved blood flow. The effectiveness of longer periods of inflation in reducing restenosis (recurrence of narrowing) of the coronary artery was assessed in 49 patients with occluded coronary arteries. Twenty-one patients underwent inflations of less than one minute, whereas 28 patients underwent at least one inflation of five minutes duration. The age, proportion of males, and frequency of PTCA performed on the left anterior descending (LAD) coronary artery were similar for both groups. Restenosis after PTCA was 29 percent for patients who underwent one minute of inflation and 33 percent for patients who underwent five minutes of inflation. The average period of follow-up after PTCA was eight months. Symptoms recurred in 8 of 21 patients who had inflations of less than one minute and in 12 of 28 patients with inflations of five minutes duration. X-ray of the blood vessel confirmed restenosis in 7 of 21 patients with one-minute inflations and 11 of 28 patients with five-minute inflations. These findings indicate that recurrence of stenosis is not reduced by increasing the duration of PTCA balloon inflation from one to five minutes. (Consumer Summary produced by Reliance Medical Information, Inc.)

Management of patients requiring temporary, mechanical hemodynamic support during high- risk percutaneous coronary intervention (PCI) or in cardiogenic shock is rapidly evolving. With the availability of the Impella 2.5, CP, 5.0, LD, and RP percutaneous mechanical circulatory support devices, there is a need for continued surveillance of outcomes. Three factors underline the importance of a registry for these populations. First, large randomized trials of hemodynamic support, involving cardiogenic shock, are challenging to conduct. Second, there is increasing interest in the use of registries to provide "real-world" experience and to allow the flexibility to evaluate individual patient uses and outcomes. Third, current, large databases have not captured the specific impact of mechanical support treatment of cardiogenic shock. The predecessor to the catheter-based ventricular assist devices registry, known as USpella, began in 2009 with paper data acquisition but beginning in 2011 transferred to electronic data capture, enrolling 3,339 patients through 2016. Throughout, registry data have been used to assess the outcomes of Impella therapy, leading to 8 publications and 4 Food and Drug Administration premarket approvals covering multiple indications and Impella devices. Going forward, the registry will continue to assess not only in-hospital outcomes but long-term follow-up to 1 year. In addition, data management will be enhanced to assess quality and clinical experiences. The registry will also provide a mechanism for postmarketing surveillance. This manuscript reviews the ongoing catheter-based ventricular assist devices registry design, management, and contributions of the registry data. The upgraded registry will provide a more robust opportunity to assess acute and late outcomes of current and future device use worldwide.Condensed Abstract: The current catheter-based ventricular assist devices registry is an international database documenting outcomes with temporary Impella hemodynamic support. The registry has supported 8 publications and 4 Food and Drug Administration premarket approvals since its inception in 2009. The current registry is more robust containing outcomes up to 1 year postprocedure. [ABSTRACT FROM AUTHOR]

Objectives The aim of this study was to compare bivalirudin with heparin as anticoagulant agents in patients with ST-segment elevation myocardial infarction treated with radial primary percutaneous coronary intervention (PCI). Background Recent studies in which PCI was performed predominantly via radial access did not show bivalirudin to be superior to heparin. Methods Outcomes were compared in patients with STEMI included in the National Cardiovascular Data Registry CathPCI database from 2009 to 2015 who underwent primary PCI via radial access and who were anticoagulated with bivalirudin or heparin. Results The sample included 67,368 patients, of whom 29,660 received bivalirudin and 37,708 received heparin. The 2 groups of patients did not differ significantly in their mean age or percentage of men. The unadjusted comparison showed no significant difference in the rate of the composite endpoint of death, myocardial infarction, or stroke (4.6% vs. 4.7%; p = 0.47) and a significantly higher rate of acute stent thrombosis (1.00% vs. 0.60%; p < 0.001) with bivalirudin compared with heparin. After adjusting for multiple variables, including a propensity score reflecting the probability of receiving bivalirudin, the odds ratio of the composite endpoint of death, myocardial infarction, or stroke for bivalirudin versus heparin was 0.95 (95% confidence interval: 0.87 to 1.05; p = 0.152), and the odds ratio for acute stent thrombosis was 2.11 (95% confidence interval: 1.73 to 2.57) for bivalirudin versus heparin. Major bleeding rates were not significantly different. Conclusions In patients undergoing primary PCI via transradial access anticoagulated with bivalirudin or heparin, there was no difference in the composite endpoint of death, myocardial infarction, or stroke. [ABSTRACT FROM AUTHOR]

Background: High-risk percutaneous coronary intervention (PCI) supported by percutaneous left ventricular assist devices offers a treatment option for patients with severe symptoms, complex and extensive coronary artery disease, and multiple comorbidities. The extrapolation from clinical trial to real-world practice has inherent uncertainties. We compared the characteristics, procedures, and outcomes of high-risk PCI supported by a microaxial pump (Impella 2.5) in a multicenter registry versus the randomized PROTECT II trial (NCT00562016).Methods: The USpella registry is an observational multicenter voluntary registry of Impella technology. A total of 637 patients treated between June 2007 and September 2013 were included. Of them, 339 patients would have met enrollment criteria for the PROTECT II trial. These were compared with 216 patients treated in the Impella arm of PROTECT II.Results: Compared to the clinical trial, registry patients were older (70 ± 11.5 vs 67.5 ± 11.0 years); more likely to have chronic kidney disease (30% vs 22.7%), prior myocardial infarction (69.3% vs 56.5%), or prior bypass surgery (39.4% vs. 30.2%); and had similar prevalence of diabetes, peripheral vascular disease, and prior stroke. Registry patients had more extensive coronary artery disease (2.2 vs 1.8 diseased vessels) and had a similar Society of Thoracic Surgeons predicted risk of mortality. At hospital discharge, registry patients experienced a similar reduction in New York Heart Association class III to IV symptoms compared to trial patients. Registry patients had a trend toward lower in-hospital mortality (2.7% vs 4.6, P = .27).Conclusions: USpella provides a real-world and contemporary estimation of the type of procedures and outcomes of high-risk patients undergoing PCI supported by Impella 2.5. Despite the higher risk of registry patients, clinical outcomes appeared to be favorable and consistent compared with the randomized trial. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: We evaluated the impact of emergency physician (EP)–initiated primary percutaneous coronary intervention (PCI) via a single-group page on door to balloon (D2B) interval times in patients with ST-segment elevation myocardial infarction. Methods: Consecutive ST-segment elevation myocardial infarction patients presenting to the emergency department between February 2004 and September 2008 were divided into 4 groups: group 1, PCI performed on an ad hoc basis after cardiology consultation; group 2, primary PCI activated via a single-group page only on-call cardiology consultation; group 3, primary PCI with EP cardiac catheterization laboratory (CCL) activation via the same page strategy; group 4, prehospital CCL activation based on prehospital diagnostic electrocardiogram. Composite D2B and relevant time intervals were measured for each time group. Results: A total of 295 consecutive patients undergoing emergent angiography were included. Times decreased for most time intervals from groups 1 to 4. Although there was no significant change in composite D2B or any measured interval time with the introduction of PCI after emergent cardiology consultation, each decreased significantly after implementing an EP-initiated PCI strategy except CCL2B (D2B 95 to 77 minutes, D2E 14 to 10 minutes, D2CCL 71 to 50 minutes). Further significant reductions in D2B time were achieved among all patients after the institution of emergency medicine services activation of the CCL (D2B 77 to 64 minutes, D2CCL 50 to 38 minutes, CCL2B 28 to 22 minutes). Conclusions: A systematic process of initiating D2B recommendations, including EP-initiated CCL activation via a single-group page, significantly reduces D2CCL and D2B times. [ABSTRACT FROM AUTHOR]

Introduction: Guidelines derived from patients in clinical trials indicate that emergency department patients with likely myocardial infarction (MI) who have new left bundle-branch block (LBBB) should undergo rapid reperfusion therapy. Whether this pertains to lower risk emergency department patients with LBBB is unclear. Methods: A total of 401 consecutive patients with LBBB undergoing an MI rule-out protocol were included. Left bundle-branch blocks were classified as chronic; new; or, if no prior electrocardiogram (ECG) was available, as presumably new. Left bundle-branch blocks were considered concordant if there was ≥1 mm concordant ST elevation or depression. Rates of MI, peak MB values in MI patients, and 30-day mortality were compared across groups. Results: A majority of patients (64%) had new (37%) or presumably new LBBB (27%). A total of 116 patients (29%) had MI, with no significant difference in prevalence or size of MI among the 3 ECG groups. Myocardial infarction was diagnosed in 86% of patients with concordant ECG changes versus 27% of patients without concordant ECG changes (P < .01). Peak MB was >5× normal in 50% who had concordant ST changes compared to none of those who did not. Concordant ST changes were the most important predictor of MI (odds ratio 17, 95% CI 3.4-81, P < .001) and an independent predictor of mortality (odds ratio 4.3, 95% CI 1.3-15, P < .001); new or presumably new LBBB was neither. Conclusions: Most patients with possible MI with new or presumably new LBBB do not have MI. Concordant ECG changes were an important predictor of MI and death. Current guidelines regarding early reperfusion therapy for patients with LBBB should be reconsidered. [ABSTRACT FROM AUTHOR]

Study objective: Current recommendations indicate that emergency physicians should activate cardiac catheterization laboratory personnel by a single page for ST-segment elevation myocardial infarction (STEMI) patients. We assessed the accuracy of emergency physician cardiac catheterization laboratory activations, angiographic findings, outcomes, and treatment times among patients with and without STEMI. Methods: We classified the appropriateness and outcomes of consecutive emergency physician STEMI pages between June 2006 and September 2008. Emergency physician activations of the cardiac catheterization laboratory were classified according to the findings of the initial ECG compared with cardiology interpretation for the presence of STEMI and presence of coronary disease. Results: During a 27-month period, emergency physician activation of the cardiac catheterization laboratory occurred 249 times. There were 188 (76%) patients with a true STEMI, of whom 13 did not receive emergency angiography. Of the 37 (15%) patients who had ECG findings meeting STEMI criteria and who ultimately did not have myocardial necrosis and underwent emergency angiography, 12 had significant disease and 5 had revascularization performed. Eleven patients had ECGs concerning for but not meeting STEMI criteria; all had emergency angiography (n=11) or received a diagnosis of non-STEMI (n=6). Only 13 patients were considered as having received unnecessary cardiac catheterization laboratory activations (5.2%) in which emergency angiography was not performed and myocardial infarction was excluded. Conclusion: A significant number of emergency physician STEMI cardiac catheterization laboratory activations are for patients who did not meet standard STEMI criteria. However, most had ECG findings and symptoms that lead to emergency angiography, had significant disease, or were diagnosed with non-STEMI. Only a small percentage of patients received unnecessary cardiac catheterization laboratory activations. Our findings support current recommendations for emergency physician cardiac catheterization laboratory activation for potential STEMI patients. [Copyright &y& Elsevier]

Objectives: We sought to determine whether gadolinium (Gd)-containing lipid-based nanoparticles (NPs) targeting the macrophage scavenger receptor-B (CD36) improve cardiac magnetic resonance (CMR) detection and characterization of human atherosclerosis. Background: Gd-containing lipid-based NPs targeting macrophages have improved MR detection of murine atherosclerosis. Methods: Gadolinium-containing untargeted NPs, anti-CD36 NPs, and nonspecific Fc-NPs were created. Macrophages were incubated with fluorescent targeted and nontargeted NPs to determine uptake via confocal microscopy and inductively coupled plasma mass spectroscopy (ICP-MS) quantified Gd uptake. Human aortic specimens were harvested at autopsy. With a 1.5-T scanner, T1, T2, and PDW 3-dimensional scans were performed along with post-contrast scans after 24 h incubation. The T1 and cluster analyses were performed and compared with immunohistopathology. Results: The NPs had a mean diameter of 125 nm and 14,900 Gd-ions, and relaxivity was 37 mmol/l−1s−1 at 1.5-T and 37°C. Confocal microscopy and ICP-MS demonstrated significant in vitro macrophage uptake of targeted NPs, whereas non-targeted NPs had minimal uptake. On T1 imaging, targeted NPs increased contrast-to-noise ratio (CNR) by 52.5%, which was significantly greater than Fc-NPs (CNR increased 17.2%) and nontargeted NPs (CNR increased 18.7%) (p = 0.001). Confocal fluorescent microscopy showed that NPs target resident macrophages, whereas the untargeted NPs and Fc-NPs are found diffusely throughout the plaque. Targeted NPs had a greater signal intensity increase in the fibrous cap compared with non-targeted NPs. Conclusions: Macrophage-specific (CD36) NPs bind human macrophages and improve CMR detection and characterization of human aortic atherosclerosis. Thus, macrophage-specific NPs could help identify high-risk human plaque before the development of an atherothrombotic event. [Copyright &y& Elsevier]

Abstract: Background: The ability to better predict outcome with exercise testing in patients with heart failure (HF) and left ventricular systolic dysfunction (LVSD) may prove extremely valuable in determining which patients are at increased risk. This study evaluated the ability of heart rate recovery (HRR) to predict outcome in patients with HF and validate previous findings in LVSD. Methods and Results: HRR was measured at 1-, 2-, 3-, and 5-minute time points after treadmill testing in 2,193 males being evaluated for chest pain at the Palo Alto and Long Beach VA Hospitals. Left ventricular ejection fraction (LVEF) was calculated using biplane ventriculography and patients were considered to have LVSD if they had an LVEF <50%. Angiographic and clinical data was available for all patients. Of the 2,193 patients, 314 patients had LVSD and 109 had a history of HF. Both HF patients and patients with LVSD with a normal HRR at 2 minutes had improved survival compared with patients that had an abnormal HRR at 2 minutes when adjusted for age and β-blocker use (HF adjusted odds ratio 0.25, 95% CI 0.10–0.66, P < .006; LVSD alone adjusted odds ratio 0.25, 95% CI 0.13–0.47, P < .0001). Stepwise proportional hazard regression analysis revealed that only 2-minute HRR, age, LVEF, and chronic obstructive pulmonary disorder were significant predictors of mortality in patients with LVSD and only HRR at 2 minutes and LV hypertrophy were significant predictors of mortality in patients with HF. Conclusion: HRR is a significant predictor of mortality in patients with HF and patients with LVSD and may be useful in better determining prognosis. [Copyright &y& Elsevier]

We retrospectively analyzed exercise treadmill and coronary angiographic data of 2,193 men to compare heart rate (HR) recovery with angiographic and mortality data during a follow-up study of 7 ± 2.7 years. Only the first 2 minutes of HR recovery predicted mortality (p <0.001), and the HR decrease during the second minute of recovery predicted the presence of coronary artery disease (p <0.05). [Copyright &y& Elsevier]

Analyzes the occurrence of cardiovascular events and death in the Pfizer Inc. hypertension trial databases for amlopidine and nifedipine in the gastrointestinal therapeutic system formulation Procardia XL. Safety of calcium channel blockers; Angina; Myocardial infarction; Arrhythmia; Stroke; Congestive heart failure; Bleeding.

More women than men with myocardial infarction have previous stable angina pectoris. Women also have an increased incidence of angina after percutaneous coronary intervention and coronary artery bypass grafting. Data from 1,737 patients with stable angina pectoris in 4 international trials (Monotherapy Assessment of Ranolazine In Stable Angina [MARISA], Combination Assessment of Ranolazine In Stable Angina [CARISA], Ranolazine Versus Atenolol Comparison in Chronic Angina [RAN080], and Efficacy of Ranolazine in Chronic Angina [ERICA]) were used to compare efficacy and safety of ranolazine therapy for angina in women and men. MARISA, CARISA, and RAN080 included exercise testing; CARISA, RAN080, and ERICA assessed angina frequency and nitroglycerin consumption; and ERICA included quality-of-life assessment using the Seattle Angina Questionnaire. MARISA, CARISA, and ERICA used the extended-release formulation of ranolazine; RAN080 used ranolazine immediate release. All 4 studies showed overall efficacy and safety of ranolazine. In subgroup analyses, women showed less improvement than men in exercise testing. However, similar improvements for women and men were noted in angina frequency and nitroglycerin consumption, and in ERICA, in the angina frequency dimension of the Seattle Angina Questionnaire. In conclusion, explanations for the gender treatment differences for exercise parameters but comparable effects on decrease in angina frequency and nitroglycerin use are uncertain, but may include differences in patient demographics, reasons for stopping exercise, and type of exercise protocol used. [Copyright &y& Elsevier]

Two pilot studies of interleukin-1 (IL-1) blockade in ST-segment elevation myocardial infarction (STEMI) showed blunted acute inflammatory response and overall favorable outcomes at 3 months follow-up. We hereby present a patient-level pooled analysis with extended follow-up of 40 patients with clinically stable STEMI randomized to anakinra, a recombinant IL-1 receptor antagonist, 100 mg/day for 14 days or placebo in a doubleblinded fashion. End points included death, cardiac death, recurrent acute myocardial infarction (AMI), stroke, unstable angina, and symptomatic heart failure. Median follow-up was 28 (interquartile range 3 to 38) months. Sixteen patients (40%) had a total of 22 adverse cardiovascular events: 1 cardiac death, 4 recurrent AMI, 5 episodes of unstable angina pectoris requiring hospitalization and/or urgent revascularization, and 11 new diagnoses of heart failure. Treatment with anakinra was associated with a hazard ratio of 1.08 (95% confidence interval 0.31 to 3.74, p [ 0.90) for the combined end point of death, recurrent AMI, unstable angina pectoris, or stroke and a hazard ratio of 0.16 (95% confidence interval 0.03 to 0.76, p [ 0.008) for death or heart failure. In conclusion, IL-1 blockade with anakinra for 2 weeks appears, therefore, to have a neutral effect on recurrent ischemic events, whereas it may prevent new-onset heart failure long term after STEMI. [ABSTRACT FROM AUTHOR]

Aims Limited data are available on prognostic indicators for HIV patients presenting with ACS. Methods and results Data on consecutive patients with HIV infection receiving standard highly active antiretroviral therapy (HAART) presenting with ACS between January 2001 and September 2012 were collected. Cardiac death and myocardial infarction (MI) were the primary end-points. 10,050 patients with ACS were screened, and among them a total of 201 patients (179 [89%] males and a median age of 53 [47-62] years) were included, 48% of them admitted for ST-elevation myocardial infarction and 14% having left ventricular systolic dysfunction (LVSD) at discharge. CD4 + counts less than 200 cells/mm3 were reported in 18 patients (9%), and 136 patients (67%) were treated with nucleoside-reverse transcriptase inhibitors (NRTI). After a median of 24 months (10-41), 30 patients (15%) died, 12 (6%) for cardiac reasons, 20 (10%) suffered a MI, 29 (15%) a subsequent revascularization, and 7 (3%) a stent thrombosis. Other than LVSD (hazard ratio = 6.4 [95% confidence interval [CI]: 1.6-26: p = 0.009]), the only other independent predictor of cardiac death was not being treated with NRTI (hazard ratio = 9.9 [95% CI: 2.1-46: p = 0.03); a CD4 cell count < 200 cells/mm3 was the only predictor of MI (hazard ratio = 5.9 [95% CI: 1.4-25: p = 0.016]). Conclusions HIV patients presenting with ACS are at significantly increased risk for cardiac death if not treated with NRTI, and at significantly increased risk of MI if their CD4 cell count is < 200 cells/mm3, suggesting that the stage of HIV disease (and lack of NRTI treatment) may contribute to cardiovascular instability. Abbreviations ACS, Acute coronary syndromes; CABG, Coronary artery bypass grafting; CV, Cardiovascular; HAART, Highly active antiretroviral therapy; HIV, Human immunodeficiency virus; LVSD, Left ventricular systolic dysfunction; MI, Myocardial infarction; NRTI, Nucleoside-reverse transcriptase inhibitors; NSTEMI, Non-ST-elevation myocardial infarction; PCI, Percutaneous coronary intervention; PHD, Percutaneous coronary intervention and surgical revascularization in HIV Database; STEMI, ST-elevation myocardial infarction; TLR, Target lesion revascularization; TVR, Target vessel revascularization; UA, Unstable angina [ABSTRACT FROM AUTHOR]

A first pilot study of interleukin-1 blockade in ST-segment elevation acute myocardial infarction showed improved remodeling. In the present second pilot study, we enrolled 30 patients with clinically stable ST-segment elevation acute myocardial infarction randomized to anakinra, recombinant interleukin-1 receptor antagonist, 100 mg/day for 14 days or placebo in a double-blind fashion. The primary end point was the difference in the interval change in left ventricular (LV) end-systolic volume index between the 2 groups within 10 to 14 weeks. The secondary end points included changes in the LV end-diastolic volume index, LV ejection fraction, and C-reactive protein levels. No significant changes in endsystolic volume index, LV end-diastolic volume index, or LV ejection fraction were seen in the placebo group. Compared to placebo, treatment with anakinra led to no measurable differences in these parameters. Anakinra significantly blunted the increase in C-reactive protein between admission and 72 hours (D0.8 mg/dl, interquartile range L6.4 to D4.2, vs D21.1 mg/dl, interquartile range D8.7 to D36.6, p [ 0.002), which correlated with the changes in LV end-diastolic volume index and LV end-systolic volume index at 10 to 14 weeks (R [ D0.83, p [ 0.002, and R [ D0.55, p [ 0.077, respectively). One patient in the placebo group (7%) died. One patient (7%) in the anakinra group developed recurrent acute myocardial infarction. More patients were diagnosed with new-onset heart failure in the placebo group (4, 27%) than in the anakinra group (1, 7%; p [ 0.13). When the data were pooled with those from the first Virginia Commonwealth University- Anakinra Remodeling Trial (n [ 40), this difference reached statistical significance (30% vs 5%, p [ 0.035). In conclusion, interleukin-1 blockade with anakinra blunted the acute inflammatory response associated with ST-segment elevation acute myocardial infarction. Although it failed to show a statistically significant effect on LV end-systolic volume index, LV end-diastolic volume index, or LV ejection fraction in this cohort of clinically stable patients with near-normal LV dimensions and function, anakinra led to a numerically lower incidence of heart failure. [ABSTRACT FROM AUTHOR]