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An increasing proportion of women believe that smoking few cigarettes daily substantially reduces their risk of developing cardiovascular (CV) related disorders. The effect of low intensity smoking is still largely understudied. We investigated the relation among sex, age, cigarette smoking and ST segment elevation myocardial infarction (STEMI) as initial manifestation of CV disease. We analyzed data of 50,713 acute coronary syndrome patients with no prior manifestation of CV disease from the ISACS-Archives (NCT04008173) registry. We compared the rates of STEMI in current smokers (n = 11,530) versus nonsmokers (n = 39,183). In the young middle age group (<60 years), there was evidence of a more harmful effect in women compared with men (RR ratios: 1.90; 95% CI: 1.69–2.14 versus 1.68; 95% CI: 1.56–1.80). This association persisted even in women who smoked 1 to 10 packs per year (RR ratios: 2.02; 95% CI: 1.65 to 2.48 versus 1.38; 95% CI: 1.22 to 1.57). In the older group, rates of STEMI were similar for women and men (RR ratios: 1.36; 95% CI: 1.22–1.53 versus 1.39; 95% CI: 1.28–1.50). STEMI was associated with a twofold higher 30-day mortality rate in young middle age women compared with men of the same age (odds ratios, 5.54; 95% CI, 3.83–8.03 vs. 2.93; 95% CI, 2.33–3.69). Low intensity smoking provides inadequate protection in young - middle age women as they still have a substantially higher rate of STEMI and related mortality compared with men even smoking less than 10 packs per year. This finding is worrying as more young - middle age women are smoking, and rates of smoking among young-middle age men continue to fall. [Display omitted] • Many female light smokers consider smoking as not harmful; while they understood smoking to be risky, they did not consider the risk as high as non-smokers. • Young – middle aged women who smoke have a 22% higher risk of STEMI as initial clinical manifestation of CVD than young-middle age men compared with nonsmokers. • STEMI was associated with a twofold higher 30-day mortality rate in young-middle age women compared with men of the same age. • Low intensity smoking provides inadequate protection in young-middle age women as they still have a substantial high rate of STEMI and related mortality even smoking less than 10 packs per year. • Patients' age and sex must be considered in assessments of health promotion initiatives for quitting smoking and preventing CVD. [ABSTRACT FROM AUTHOR]

Aim: The duration of new-onset atrial fibrillation (AF) following the acute myocardial infarction (AMI) was evaluated as well as its relation to in-hospital and 7-year mortality. Methods and Results: A total of 320 consecutive patients with AF following AMI were examined and patients with AF <7 h (n = 141) were compared to those with AF ≥7 h in duration (n = 179). Receiver Operating Characteristic analysis was performed to identify the most useful AF duration cut-off level for the prediction of poor outcome. Patients with longer AF duration were older and had more advanced heart failure than patients with short arrhythmia duration. Patients with longer AF duration had worse outcome, including higher in-hospital (22.3 vs. 12.8%) and 7-year (67.4 vs. 34.4%) mortality. After multivariate adjustment, longer AF duration remained an independent predictor of long-term mortality (relative risk = 2.04, 95% confidence interval = 1.39–2.99, p = 0.0002). Conclusion: New-onset AF ≥7 h in duration following the AMI independently predicts long-term mortality. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Abstract: Higher levels of natriuretic peptides were identified in outpatients after myocardial infarction (MI) compared to the healthy population, even in the absence of heart failure (HF). Therefore, we assessed the optimal cut-off value of B-type natriuretic peptide (BNP) in relation to new-onset HF prediction in 79 post-MI patients with preserved left ventricular systolic function (ejection fraction >40%). Plasma BNP was measured by enzyme immunoassay, 6 months after MI and patients were followed-up for the next one year. Cox proportional regression model analysis revealed the independent prognostic value of BNP for HF prediction (p =0.005). As assessed by ROC analysis the optimal cut-off value of BNP was 175pg/mL (sensitivity 82%; specificity 77%, AUC 0.77), associated with significantly different rates of incident HF by Kaplan–Meier analysis (p =0.001). In this population of outpatients with preserved left ventricular systolic function after MI, BNP strongly correlated with new-onset HF development at the optimal cut-off value of 175pg/mL. [Copyright &y& Elsevier]

Background: Since serial analyses of NT-proBNP in patients with acute coronary syndromes have shown that levels measured during a chronic, later phase are a better predictor of prognosis and indicator of left ventricular function than the levels measured during an acute phase, we sought to assess the association of NT-proBNP, measured 6 months after acute myocardial infarction (AMI), with traditional risk factors, characteristics of in-hospital and early postinfarction course, as well as its prognostic value and optimal cut-points in the ensuing 1-year follow-up. Methods: Fasting venous blood samples were drawn from 100 ambulatory patients and NT-proBNP concentrations in lithium-heparin plasma were determined using a one-step enzyme immunoassay based on the »sandwich« principle on a Dimension RxL clinical chemistry system (DADE Behring-Siemens). Patients were followed-up for the next 1 year, for the occurrence of new cardiac events. Results: Median (IQR) level of NT-proBNP was 521 (335-1095) pg/mL. Highest values were mostly associated with cardiac events during the first 6 months after AMI. Negative association with reperfusion therapy for index infarction confirmed its long-term beneficial effect. In the next one-year follow-up of stable patients, multivariate Cox regression analysis revealed the independent prognostic value of NT-proBNP for new-onset heart failure prediction (p=0.014), as well as for new coronary events prediction (p=0.035). Calculation of the AUCs revealed the optimal NT-proBNP cut-points of 800 pg/mL and 516 pg/mL, respectively. Conclusions: NT-proBNP values 6 months after AMI are mainly associated with the characteristics of early infarction and postinfarction course and can predict new cardiac events in the next one-year follow-up. [ABSTRACT FROM AUTHOR]

Background: There is uncertainty regarding the impact of statins on the risk of atherosclerotic cardiovascular disease (ASCVD) and its major complication, acute heart failure (AHF).Objectives: The aim of this study was to investigate whether previous statin therapy translates into lower AHF events and improved survival from AHF among patients presenting with an acute coronary syndrome (ACS) as a first manifestation of ASCVD.Methods: Data were drawn from the International Survey of Acute Coronary Syndromes Archives. The study participants consisted of 14,542 Caucasian patients presenting with ACS without previous ASCVD events. Statin users before the index event were compared with nonusers by using inverse probability weighting models. Estimates were compared by test of interaction on the log scale. Main outcome measures were the incidence of AHF according to Killip class and the rate of 30-day all-cause mortality in patients presenting with AHF.Results: Previous statin therapy was associated with a significantly decreased rate of AHF on admission (4.3% absolute risk reduction; risk ratio [RR]: 0.72; 95% CI: 0.62-0.83) regardless of younger (40-75 years) or older age (interaction P = 0.27) and sex (interaction P = 0.22). Moreover, previous statin therapy predicted a lower risk of 30-day mortality in the subset of patients presenting with AHF on admission (5.2 % absolute risk reduction; RR: 0.71; 95% CI: 0.50-0.99).Conclusions: Among adults presenting with ACS as a first manifestation of ASCVD, previous statin therapy is associated with a reduced risk of AHF and improved survival from AHF. (International Survey of Acute Coronary Syndromes [ISACS] Archives; NCT04008173). [ABSTRACT FROM AUTHOR]

Objective We sought explore the relative benefits of unfractionated heparin (UFH) compared with enoxaparin, alone or in combination with clopidogrel, in ST-segment elevation myocardial infarction (STEMI) patients not undergoing reperfusion therapy. Methods This is a propensity score study from The International Survey on Acute Coronary Syndromes in Transition Countries (ISACS-TC/NCT01218776) on patients admitted between October 2010–June 2013. There were a total of 1175 STEMI patients who did not receive mechanical or pharmacological reperfusion. Of these, 1063 were eligible for the aim of the study, being treated with UFH (522/1175; 44.4%) or enoxaparin (541/1175; 46%). Clopidogrel in combination with UFH or enoxaparin was given to 751 (63.9%) patients. The primary endpoint was in-hospital mortality. Secondary endpoints were intracranial hemorrhages, and clinically relevant bleedings. Results After adjustment for any confounders, UFH was associated with a lower risk of in-hospital mortality in clopidogrel users (multivariate adjusted regression analysis: odds ratio [OR]: 0.62, 95% Confidence Interval [CI] 0.41–0.94) as compared with clopidogrel non-users (OR: 0.94, 95% CI 0.55–1.60). The observed effect was not associated with combined enoxaparin and clopidogrel therapy. Major bleeding events were comparable in the enoxaparin group and UFH group (0.4% and 1.5% respectively, p = 0.06). The risk of major hemorrhage was nearly similar with combined UFH-clopidogrel therapy (1.4%) as compared with UFH alone (1.9%), p = 0.67. Conclusion UFH – Clopidogrel combination was associated with a large mortality reduction in STEMI patients not undergoing reperfusion therapy and did not significantly increase the risk of major bleeding. [ABSTRACT FROM AUTHOR]

Background: ST-segment elevation myocardial infarction (STEMI) complicated by symptoms of acute de novo heart failure is associated with excess mortality. Whether development of heart failure and its outcomes differ by sex is unknown.Objectives: This study sought to examine the relationships among sex, acute heart failure, and related outcomes after STEMI in patients with no prior history of heart failure recorded at baseline.Methods: Patients were recruited from a network of hospitals in the ISACS-TC (International Survey of Acute Coronary Syndromes in Transitional Countries) registry (NCT01218776). Main outcome measures were incidence of Killip class ≥II at hospital presentation and risk-adjusted 30-day mortality rates were estimated using inverse probability of weighting and logistic regression models.Results: This study included 10,443 patients (3,112 women). After covariate adjustment and matching for age, cardiovascular risk factors, comorbidities, disease severity, and delay to hospital presentation, the incidence of de novo heart failure at hospital presentation was significantly higher for women than for men (25.1% vs. 20.0%, odds ratio [OR]: 1.34; 95% confidence interval [CI]: 1.21 to 1.48). Women with de novo heart failure had higher 30-day mortality than did their male counterparts (25.1% vs. 20.6%; OR: 1.29; 95% CI: 1.05 to 1.58). The sex-related difference in mortality rates was still apparent in patients with de novo heart failure undergoing reperfusion therapy after hospital presentation (21.3% vs. 15.7%; OR: 1.45; 95% CI: 1.07 to 1.96).Conclusions: Women are at higher risk to develop de novo heart failure after STEMI and women with de novo heart failure have worse survival than do their male counterparts. Therefore, de novo heart failure is a key feature to explain mortality gap after STEMI among women and men. [ABSTRACT FROM AUTHOR]

Introduction: The USPSTF has recommended the use of preventive aspirin in all subjects aged 55-79 years without known heart disease when the potential benefit of a reduction in myocardial infarction outweighs the potential harm of bleeding. However, some studies have suggested that for women, the risks of aspirin may outweigh the benefit. Hypothesis: To investigate whether the risk of initial presentation of coronary heart disease with STEMI is lower in aspirin users and, if so, to assess the role of age and concomitant medications and procedures in the reduction of risk. Methods: We analyzed clinical characteristics and outcomes of patients without preexisting CVD that were enrolled in 41 hospitals referring data to the ISACS-TC registry (NCT01218776) from January 2010 to January 2018. Primary end points included rates of STEMI at clinical presentation and adjusted 30-day mortality. For the safety analysis, hemorrhagic events, consisting of gastrointestinal bleeding, hemorrhagic stroke, and bleeding from any other sites, were also analyzed. Estimates were obtained using logistic regression models. Results: There were 1098 subjects with a mean (SD) age of 66 (11.3) years in the aspirin group and 8978 subjects with a mean (SD) age of 60.3 (12.0) years in the no-aspirin group included in the study. After multivariable adjustment for age, sex, kidney function and risk factors, aspirin therapy reduced clinical presentation with STEMI in the protocol cohort (OR, 0.52; 95% CI, 0.46-0.60) with no heterogeneity of efficacy in subgroup analyses stratified by each of these factors (all interaction P>0.05). Similar treatment effects with aspirin therapy were found when concomitant medications were included as dummy variables in sequential logistic analyses (OR, 0.62 for statins, 0.59 for ACE inhibitors and 0.61 for beta-blockers) (Figure 1.). Bleeding events occurred in 8 patients (1.4%) in the aspirin group and 88 (2.4%) in the no-aspirin group (P=0.12), and the incidence of hemorrhagic stroke was not different between groups (P=0.28). Conclusions: Aspirin reduces the risk for STEMI without increasing risk for gastrointestinal bleeding in women and men in a primary prevention setting. These data support the routine use of aspirin as recommended by the USPSTF. [ABSTRACT FROM AUTHOR]

Introduction: Information on sex differences in clinical presentation and outcomes of STEMI with nonobstructive CAD is poor as prior studies have pooled together all patients with MI. STEMI and NSTEMI are clinical entities that differ considerably in the pathophysiology and management options Hypothesis: The current study aimed to determine the clinical characteristics, outcomes and predictors of STEMI by sex and CAD status Methods: We identified 5858 patients who underwent coronary angiography for STEMI in the ISACS-TC registry from 2010-2016. Patients with prior revascularization (n=797) and cardiomyopathies/myocarditis (n=12) were excluded, giving a final study population of 5049 STEMI patients. The primary outcome measure was all cause 30 day death. Secondary outcome was the incidence of severe left ventricular dysfunction at discharge (EF<30%). Risk factors, clinical history, presentation, and hospital treatments within 24 hours from admission were compared by sex and CAD status (obstructive vs nonobstructive) by multivariable logistic methods Results: Of the 5049 STEMI patients, 94.2% had significant CAD and 5.8% had nonobstructive CAD. Younger age (OR 1.19 CI 1.05- 1.35), prior MI (OR 1.66 CI 1.01-2.76) and prior heart failure (OR 2.09 CI 1.11-3.92) were independent determinants for clinical presentation with STEMI and nonobstructive CAD. There were no differences between men and women in rates of nonobstructive CAD (5.7% vs 5.9% P=0.77). The primary and secondary outcomes did not differ among men and women with nonobstructive CAD (OR 1.79 P=0.46 and OR 3.27 P=0.26 respectively). Sex specific regression models of obstructive versus nonobstructive CAD showed that older age (OR 1.20 CI 1.04-1.39) only predicts significant CAD in men whereas current smoking (OR 2.19 CI 1.15-4.17) and diabetes (OR 3.57 CI 1.49-8.53) were only significant predictors in women. The relative risk of hypercholesterolemia was similar in men (OR 2.01 CI 1.38-2.92) and women (OR 1.92 CI 1.05-3.51). The risk of death among women with obstructive CAD was most pronounced than their male counterpart (OR 1.45 CI 1.03-2.06) Conclusions: Women have a higher risk of death after STEMI in comparison with men only in patients with obstructive CAD. Development of obstructive CAD is, therefore, the most serious and life-threatening event in women. Diabetes and current smoking were found to have a greater impact on development of obstructive CAD in women compared with men. Prevention of traditional risk factors is a major need for improving cardiovascular health among women. [ABSTRACT FROM AUTHOR]

Background We explored benefits and risks of an early invasive compared with a conservative strategy in women versus men after non-ST elevation acute coronary syndromes (NSTE-ACS) using the ISACS-TC database. Methods From October 2010 to May 2014, 4145 patients were diagnosed as having a NSTE-ACS. We excluded 258 patients managed with coronary bypass surgery. Of the remaining 3887 patients, 1737 underwent PCI (26% women). The primary endpoint was the composite of 30-day mortality and severe left ventricular dysfunction defined as an ejection fraction < 40% at discharge. Results Women were older and more likely to exhibit more risk factors and Killip Class ≥ 2 at admission as compared with men. In patients who underwent PCI, peri-procedural myocardial injury was not different among sexes (3.1% vs. 3.2%). Women undergoing PCI experienced higher rates of the composite endpoint (8.9% vs. 4.9%, p = 0.002) and 30-day mortality (4.4% vs. 2.0%, p = 0.008) compared with men, whereas those who managed with only routine medical therapy (RMT) did not show any sex difference in outcomes. In multivariable analysis, female sex was associated with favorable outcomes (adjusted HR for the composite endpoint: 0.72, 95% CI: 0.58–0.91) in patients managed with RMT, but not in those undergoing PCI (adjusted HR: 0.96, 95% CI: 0.61–1.52). Conclusions We observed a more favorable outcome in women than men when patients were managed with RMT. Women and men undergoing PCI have similar outcomes. These data suggest caution in extrapolating the results from men to women in an overall population of patients in the context of different therapeutic strategies. [ABSTRACT FROM AUTHOR]

Background Limited data are available on the outcome of primary percutaneous coronary intervention (PCI) in octogenarian patients, as the elderly are under-represented in randomized trials. This study aims to provide insights on clinical characteristics, management and outcome of the elderly and very elderly presenting with STEMI. Methods 2225 STEMI patients ≥ 70 years old (mean age 76.8 ± 5.1 years and 53.8% men) were admitted into the network of the ISACS-TC registry. Of these patients, 72.8% were ≥ 70 to 79 years old (elderly) and 27.2% were ≥ 80 years old (very-elderly). The primary end-point was 30-day mortality. Results Thirty-day mortality rates were 13.4% in the elderly and 23.9% in the very-elderly. Primary PCI decreased the unadjusted risk of death both in the elderly (OR: 0.32, 95% CI: 0.24–0.43) and very-elderly patients (OR: 0.45, 95% CI 0.30–0.68), without significant difference between groups. In the very-elderly hypertension and Killip class ≥ 2 were the only independent factors associated with mortality; whereas in the elderly female gender, prior stroke, chronic kidney disease and Killip class ≥ 2 were all factors independently associated with mortality. Factors associated with the lack of use of reperfusion were female gender and atypical chest pain in the very-elderly and in the elderly; in the elderly, however, there were some more factors, namely: history of diabetes, current smoking, prior stroke, Killip class ≥ 2 and history chronic kidney disease. Conclusions Age is relevant in the prognosis of STEMI, but its importance should not be considered secondary to other major clinical factors. Primary PCI appears to have beneficial effects in the octogenarian STEMI patients. [ABSTRACT FROM AUTHOR]

Background The objectives of this study were to evaluate the incidence of no-reflow as independent predictor of adverse events and to assess whether baseline pre-procedural treatment options may affect clinical outcomes. Methods Data were derived from the ISACS-TC registry ( NCT01218776 ) from October 2010 to January 2015. No-reflow was defined as post-PCI TIMI flow grades 0–1, in the absence of post-procedural significant (≥ 25%) residual stenosis, abrupt vessel closure, dissection, perforation, thrombus of the original target lesion, or epicardial spasm. The outcome measure was in-hospital mortality. Results No-reflow was identified in 128 of 5997 patients who have undergone PCI (2.1%). On multivariate analysis, patients with no-reflow were more likely to be older (OR: 1.20, 95% CI: 1.01–1.44), to have a history of hypercholesterolemia (OR: 1.95, 95% CI: 1.31–2.91) and to be admitted with a diagnosis of STEMI (OR: 2.96, 95% CI: 1.85–4.72). Angiographic characteristics associated with no-reflow phenomenon were: stenosis ≥ 50% of the right coronary artery, presence of multivessel disease and pre-procedural TIMI blood flow grades 0–1. No-reflow was highly predictive of in-hospital mortality (17.2% vs. 4.2%; adjusted OR: 4.60, 95% CI: 2.61–8.09). Administration of pre-procedural unfractioned heparin or 600 mg clopidogrel loading dose was associated with less incidence of no-reflow (OR: 0.65, 95% CI: 0.43–0.99 and 0.61, 95% CI: 0.37–1.00, respectively). Aspirin, enoxaparin, and 300 mg clopidogrel loading dose, did not significantly impact the occurrence of the no-reflow. Conclusions We found that pre-procedural administration of 600 mg loading dose of clopidogrel and/or unfractioned heparin is associated with reduced incidence of no-reflow. [ABSTRACT FROM AUTHOR]

The aim of this study was to determine if earlier administration of oral β ​blocker therapy in patients with acute coronary syndromes (ACSs) is associated with an increased short-term survival rate and improved left ventricular (LV) function. We studied 11,581 patients enrolled in the International Survey of Acute Coronary Syndromes in Transitional Countries registry from January 2010 to June 2014. Of these patients, 6,117 were excluded as they received intravenous β blockers or remained free of any β ​blocker treatment during hospital stay, 23 as timing of oral β ​blocker administration was unknown, and 182 patients because they died before oral β blockers could be given. The final study population comprised 5,259 patients. The primary outcome was the incidence of in-hospital mortality. The secondary outcome was the incidence of severe LV dysfunction defined as an ejection fraction <40% at hospital discharge. Oral β blockers were administered soon (≤24 hours) after hospital admission in 1,377 patients and later (>24 hours) during hospital stay in the remaining 3,882 patients. Early β ​blocker therapy was significantly associated with reduced in-hospital mortality (odds ratio 0.41, 95% CI 0.21 to 0.80) and reduced incidence of severe LV dysfunction (odds ratio 0.57, 95% CI 0.42 to 0.78). Significant mortality benefits with early β ​blocker therapy disappeared when patients with Killip class III/IV were included as dummy variables. The results were confirmed by propensity score-matched analyses. In conclusion, in patients with ACSs, earlier administration of oral β ​blocker therapy should be a priority with a greater probability of improving LV function and in-hospital survival rate. Patients presenting with acute pulmonary edema or cardiogenic shock should be excluded from this early treatment regimen. [ABSTRACT FROM AUTHOR]

Abstract: Background: Patients with high post-loading platelet aggregation (PPA) are at increased risk of stent thrombosis and death after primary percutaneous coronary intervention (pPCI). The objective of the present trial was to examine whether high PPA is associated with adverse clinical outcomes in pPCI patients whose therapy was modified in accordance with PPA. Methods: We analyzed 961 consecutive pPCI patients who underwent pPCI between February 2008 and June 2011. High PPA was defined as PPA >50%, 24h after the loading dose. Patients with high PPA were treated with aspirin 300mg, clopidogrel 150mg or ticlopidine 500mg for 30days. The co-primary efficacy and safety end points at 30days were major adverse cardiovascular events (MACE) and major bleeding. Results: We detected high PPA to clopidogrel and aspirin in 44.4% and 16.5% of patients, respectively. The rates of 30-day MACE (adjusted OR 1.76, 95% CI 1.05–2.97), definite subacute stent thrombosis (DSST, adjusted OR 2.15, 95% CI 1.09–4.22) and nonfatal infarction (adjusted OR 3.99, 95% CI 1.57–10.13) were higher in patients with high PPA to clopidogrel compared with responders. High PPA to aspirin was not associated with an adverse 30-day clinical outcome. Compared with high PPA patients who were not tailored, a significantly better outcome with respect to the primary end point was observed in the tailored group (OR 0.42, 95% CI 0.19–0.93). Conclusion: High PPA to clopidogrel was an independent predictor of 30-day adverse events after pPCI. Among high PPA patients, tailoring was associated with an improved primary outcome. [Copyright &y& Elsevier]

Abstract: Background: Identification of patients at risk for major adverse cardiovascular events (MACE) might help selecting candidates for aggressive treatment or early discharge after primary percutaneous coronary intervention (pPCI). Methods: The RISK-PCI is an observational trial of 2096 consecutive patients who underwent pPCI between 2006 and 2009, randomly allocated to derivation and validation sets with a set ratio of 80% to 20%. Thirty-day MACE comprising death, nonfatal reinfarction and stroke was the primary end point. Multivariable logistic regression was used to determine the independent predictors of outcome. A sum of weighted points for specific predictors was calculated to define the final score. Results: The RISK-PCI score comprised 12 independent predictors of 30-day MACE, with a graded 125-fold increase in the primary end point with increasing risk score from ≤1 to ≥15. The model showed good discrimination and calibration for the prediction of 30-day MACE (c-statistic 0.83, goodness-of-fit p=0.72) and 30-day death (c-statistic 0.87, goodness-of-fit p=0.56). Bootstrapping with 1000 resample confirmed the stability of the model''s performance. Patients were classified into risk classes, with the observed incidence of 30-day MACE of 1.9, 5.9, 13.3 and 39.4% in the low, intermediate, high and very high-risk classes, respectively. An 18-fold graded increase in the primary end point was observed between patients in a low risk class and those in a very high risk class. Conclusion: We derived a novel risk model to predict 30-day MACE after pPCI, which might help clinician decide the most appropriate treatment in accordance with the patient''s risk profile. [Copyright &y& Elsevier]

Abstract: The predictive value of B-type natriuretic peptide (BNP) with respect to the occurrence of new-onset atrial fibrillation (AF) in patients with ST-segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PCI) is unknown. The aim of this study was to evaluate whether BNP has a predictive value for the occurrence of new-onset AF in patients with STEMI treated by primary PCI. In 180 patients with STEMI treated by primary PCI, BNP concentrations were measured 24h after chest pain onset. The Receiver Operating Characteristic analysis was performed to identify the most useful BNP cut-off level for the prediction of AF. The patients were divided into the two groups according to calculated cut-off level: high BNP group (BNP≥720pg/mL, n =33) and low BNP group (BNP<720pg/mL, n =147). The incidence of AF was 5.0%, and occurred more frequently in high BNP group (7/33, 21.2%) than in low BNP group (2/147, 1.4%), (p <0.001). Patients with high BNP were older (p =0.017), had more often anterior wall infarction (p =0.015), higher Killip class on admission (p =0.038), higher peak troponin I (p =0.002), lower left ventricular ejection fraction (p =0.029) than patients with low BNP. After multivariate adjustment, BNP was an independent predictor of AF (OR 3.70, 95% CI 1.40–9.77, p =0.008). BNP independently predicts the occurrence of new-onset AF in STEMI patients treated by primary PCI. [Copyright &y& Elsevier]

Abstract: Objectives: To analyze the prognostic value of myeloperoxidase (MPO) in relation to in-hospital mortality and to identify the optimum time point for sampling in patients with the first anterior ST-segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (pPCI). Design and methods: A total of 100 consecutive patients with the first anterior STEMI undergoing pPCI were included. Blood samples were collected at baseline, 4, 8, 12, 18, 24, 48 and 168 hours (h) after pPCI. Results: MPO concentrations have showed a biphasic pattern over time; the highest MPO levels were at4h and 24h after pPCI. In-hospital mortality was 6%. MPO at 24h significantly correlated with troponin I as well as heart failure. After multivariate adjustment, MPO at 24h was an independent predictor of the in-hospital mortality (OR 3.34, 95% CI 1.13–9.86, P=0.029). Conclusions: In patients with the first anterior STEMI treated by pPCI, MPO at 24h after procedure was an independent predictor of the in-hospital mortality. [Copyright &y& Elsevier]

Background: The aim of this study was to assess the impact of combined left ventricular systolic dysfunction (LVSD) and renal dysfunction (RD) on 1-year overall mortality and major adverse cardiovascular events (MACEs) (comprising cardiovascular death, nonfatal renfarction, target vessel revascularization, and nonfatal stroke) in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention (pPCI). Methods: One thousand three hundred ninety eight patients with first myocardial infarction, undergoing pPCI were divided into four groups according to the presence of LVSD (ejection fraction [EF] <40%) and/or baseline RD (estimated glomerular filtration rate <60 mL/min per m2): Group I (no LVSD and no RD); Group II (LVSD, no RD); Group III (RD, no LVSD); Group IV (LVSD + RD). Results: One-year mortality rates in Groups I, II, III, and IV were 2.6%, 15.2%, 10.6%, and 34.2% and 1-year MACE rates were 5.7%, 19.5%, 17.1% and 35.7%, respectively. Patients in Groups II, III, and IV had an increased probability of 1-year overall mortality and MACE as compared to Group I. Overall mortality: Group II HR 2.1 (95% CI 1.1-4.2); Group III HR 2.1 (95% CI 1.1-4.1); Group IV HR 4.8 (95% CI 2.4-9.4); MACE: Group II HR 2.2 (95% CI 1.1-4.2); Group III HR 2.2 (95% CI 1.1-4.3); Group IV HR 5.1 (95% CI 2.6-10.1). The LVSD-RD combination was the strongest independent predictor for 1-year outcomes. Conclusions: The LVSD-RD combination is associated with an approximately five-fold increase in 1-year overall mortality and MACE after pPCI. The evaluation of the renal function in patients with LVSD represents a simple method which enables a more precise stratification of the risks related to the occurrence of adverse events in long-term patient follow-up. (J Interven Cardiol 2012;25:132-139) [ABSTRACT FROM AUTHOR]

Background: Mitral annular calcification (MAC) has been suggested as a reliable, time-averaged marker of atherosclerosis and is associated with coronary artery disease, heart failure, ischemic stroke, and increased mortality. Data on the relationship between MAC and cardiovascular morbidity and mortality in atrial fibrillation (AF) are sparse, with the exception of the relationship between MAC and stroke. We investigated the association of MAC with cardiovascular morbidity, stroke, cardiovascular mortality, and all-cause death in a cohort of middle-aged patients with AF with a mean 10-year follow-up.Methods: This was an observational study of patients with nonvalvular AF between 1992 and 2007.Results: Of 1,056 patients, 33 (3.1%) had MAC; they were more likely to be older and female and to have a dilated left atrium, reduced left ventricular ejection fraction, permanent AF, hypertension, and/or diabetes mellitus (all P < .05). Total follow-up was 10,418.5 years (mean, 9.9 ± 5.9 years), and the mean age was 52.7 ± 12.2 years. In univariate analysis, MAC was associated with all-cause death, cardiovascular death, stroke, new cardiac morbidity (all P < .05), and the composite end point of ischemic stroke, myocardial infarction (MI), and all-cause death (P < .001). In multivariate analyses, MAC was related to all-cause death (hazard ratio [HR], 4.3; 95% CI, 1.8-10.0; P < .001), cardiovascular death (HR, 3.5; 95% CI, 1.2-10.4; P = .025), the composite end point (HR, 2.1; 95% CI, 1.0-4.3; P = .048), and new cardiac morbidity (HR, 2.4; 95% CI, 1.3-4.5; P = .005). There was no significant relationship between MAC and stroke or MI in the multivariate analyses.Conclusions: MAC is associated with increased cardiovascular morbidity, cardiovascular mortality, and all-cause mortality of patients with AF. MAC should be acknowledged as a marker of increased cardiovascular risk in middle-aged patients with AF. [ABSTRACT FROM AUTHOR]

Background: No comprehensive primary PCI (pPCI) risk model to predict net adverse cardiovascular events (NACE) has been reported with the use of clopidogrel 600 mg, which is now considered the standard loading dose. The primary hypothesis of the RISK-PCI trial is that an accurate risk prediction may be achieved by using clinical, angiographic, and procedural variables available at the time of intervention. Methods: The present single-center, longitudinal, cohort study will include 1,750 consecutive patients with ST-elevation myocardial infarction (STEMI), undergoing pPCI after pretreatment with 300 mg aspirin and 600 mg clopidogrel. The primary end-points of the trial (NACE) include major adverse cardiovascular events (MACE) and major bleeding. A logistic regression model will be developed to predict 30-day and 1-year NACE after pPCI. A risk score derived from study set data will be validated using validation set data. Results: Until June 1, 2008, 1,166 patients have been enrolled. Thirty-day follow-up is available in 1,007 patients. Conclusions: The RISK-PCI study is designed to develop an accurate risk scoring system, using variables available at the time of intervention, to predict long-term adverse outcomes after pPCI. Trial Registration: Current Controlled Trials Register—ISRCTN83474650— . [ABSTRACT FROM AUTHOR]

Abstract: Background: Although new-onset atrial fibrillation (AF) frequently recurs following the acute myocardial infarction, the significance of AF recurrences is unknown. Objective: The objective of the present study was to evaluate the incidence, clinical predictors and prognostic significance of AF recurrences following the acute myocardial infarction. Methods and results: A total of 320 consecutive patients with AF following the acute myocardial infarction were evaluated and the patients with AF recurrences were compared to those with single episodes of AF in whom AF did not recur after restoration of sinus rhythm. The incidence of AF recurrences was 22.5%. AF recurrences were highly associated with congestive heart failure and worse Killip class was identified as the most important predictor of AF recurrences. Patients with AF recurrences had poorer outcome, including higher in-hospital (36.1% versus 12.9%) and 7-year (68.2% versus 48.6%) mortality. After multivariate adjustment, AF recurrence remained an independent predictor of in-hospital [odds ratio (OR)=3.08, 95% confidence interval (CI), 1.45–6.53, p =0.001], and 7-year [relative risk (RR)=1.52, 95% CI, 1.00–2.31, p =0.026] mortality. Conclusion: New-onset AF frequently recurs following the acute myocardial infarction and our analysis demonstrated that recurrences of AF independently predicted in-hospital and long-term mortality. [Copyright &y& Elsevier]

Abstract: Background: New-onset atrial fibrillation (AF) after acute myocardial infarction (AMI) frequently occurs in association with postinfarction complications, particularly with heart failure (HF). Aims: To evaluate whether postinfarction HF is associated with the subsequent development of AF and whether AF independently predicts poorer prognosis. Methods and results: We examined 650 patients with AMI and compared patients with AF (n=320) to those without (n=330). AF patients were classified as either early AF (n=208)—patients who developed AF within 24 h of symptom onset or late AF (n=112)—patients who had AF thereafter. We compared outcomes between these groups, adjusting for differences in baseline characteristics and postinfarction HF. Heart failure was the most important predictor of AF. In most patients, AF occurred secondary to HF. AF patients had poorer outcomes, including higher in-hospital and 7-year mortality. After multivariate adjustment, overall, AF was not an independent predictor of in-hospital [odds ratio (OR)=0.70) and 7-year [relative risk (RR)=1.14] mortality, but late AF remained an independent predictor of 7-year (RR=2.48, 95% confidence interval, 1.26–4.87) mortality. Conclusions: Heart failure mostly preceded the occurrence of new-onset atrial fibrillation after acute myocardial infarction, but only late atrial fibrillation was independently related to long-term mortality. [Copyright &y& Elsevier]

Background: Due to an ageing population in Europe, there will be more and more elderly patients presenting with non-ST-elevation acute coronary syndromes (NSTE-ACS). Despite these findings there is limited data available on outcomes of elderly patients (>75 years) either in observational studies or randomized controlled trials.1 Objective: To explore whether early percutaneous coronary intervention (PCI) within 24 hours of admission may improve outcomes in elderly patients (>75 years). Patients and Methods: We analyzed elderly patients enrolled in 41 hospitals referring data to the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC) registry (NCT01218776) from January 2010 to January 2018. The primary end-point was composed of 30-day mortality and severe LVSD, defined as ejection fraction <30% as measured by echocardiography on discharge. The components of primary end-point were analyzed as secondary end points. For the safety analysis Thrombolysis in Myocardial Infarction (TIMI) major and minor bleeding events were analyzed. A landmark analysis was performed with a cut-off point of 24h excluding all patients that died within this time. We also excluded all patients who received PCI after 24h or who had a coronary artery bypass surgery. As an added analysis we also performed an inverse probability of treatment weighting (IPTW) analysis to balance clinical covariates. Results: There were 957 subjects with a mean age of 80±4 years in the medical therapy group and 298 subjects with a mean age of 79±4 years in the PCI group. After multivariate adjustment for age, sex, renal function, risk factors, clinical presentation, prior cardiovascular disease and in hospital medical therapy (within 24h), early PCI reduced the occurrence of the primary end-point in the cohort (OR, 0,38; 95% CI 0.22–0.68). The secondary endpoints of severe LVSD and 30-day mortality were reduced in the PCI cohort as well (OR 0,45; 95% CI 0,23-0,88) and (OR 0,33; 95% CI 0,13- 0,84) respectively. The effect on the primary end-point persisted after IPTW, even though the effect was less pronounced in comparison with the unweighted model (OR 0,89; 95% CI 0,85–0,92); Figure 1). Bleeding events oc curred in 4 patients (2.4%) in the PCI group and 0 in the medical therapy group (P=0.671). Conclusion: Elderly patients treated with early PCI showed reduced rates of primary and secondary end-points compared to those treated with medical therapy. There was no significant difference in the number of bleeding rates between the groups. [ABSTRACT FROM AUTHOR]

Introduction: Trans-radial access (TRA) for PCI has been consistently shown to reduce mortality and bleeding complications compared with trans-femoral access (TFA) in pts with STEMI. On the contrary the efficacy and the safety of TRA in NSTE-ACS is still matter of debate Hypothesis: The purpose of this study was to determine the potential clinical benefits of TRA in the NSTE-ACS patient population Methods: We compared outcomes of TRA versus TFA in a real world population of patients with NSTE-ACS drawn from the ISACS-TC registry (NCT01218776) The primary outcome was the incidence of all cause death and stroke at 30 days. The secondary outcome was the combined endpoint of periprocedural major complications (MI type 4, abrupt closure, loss of side branches, distal embolization and postPCI TIMI flow≤2). The incidence of nonCABG related major bleeding (TIMI definition) was also noted Results: Of 3127 NSTE ACS patients undergoing PCI 2047 (65.5%) underwent TRA, which was more likely to be employed among male sex and patients with lower-risk characteristics: patients were younger with a lower burden of risk factors. Patients undergoing TRA had significantly more periprocedural complications than those who received TFA (24.4% vs 8.6% p<0.001). The combined endpoint was driven mainly by the rate of noreflow phenomenon (24.4% vs 9.7%). After adjustment for baseline variables, the risk of periprocedural complications was attenuated but still remained significant between the radial and femoral groups (OR 3.63 CI: 2.52-5.22). There were significant differences in center experience: 1651 of the 2047 TRA procedures were performed by centers with high volume characteristics. There was heterogeneity in treatment effect in patients receiving TRA in centers with high versus medium/low volume characteristics. The risk of periprocedural complications was no longer significant after adjustment for center characteristics (OR 0.94 CI 0.52-1.68). The rate of the primary outcome was 1.6% in the TRA group compared with 2.2% in the TFA (adjusted OR 0.65 CI 0.33-1.29). The rate of nonCABG-related major bleeding at 30 days was 1.5% in the TRA group compared with 0.5% in the TFA group. Yet this rate was substantially lower in centers with high volume characteristics. (Adjusted for age and sex OR 0.25 CI 0.03-2.06). Conclusions: No significant differences in the combined outcome of 30 day mortality and ischemic stroke were seen between TRA and TFA approach in patients with NSTE-ACS undergoing PCI. TRA may be preferred in these patients only in centers with considerable experience. [ABSTRACT FROM AUTHOR]

Background To evaluate the impact of comorbidities on the management and outcomes of acute coronary syndrome (ACS) patients without chest pain/discomfort (i.e. ACS without typical presentation). Methods Of the 11,458 ACS patients, enrolled by the International Survey of Acute Coronary Syndrome in Transitional Countries (ISACS-TC; ClinicalTrials.gov : NCT01218776 ), 8.7% did not have typical presentation at the initial evaluation, and 40.2% had comorbidities. The odds of atypical presentation increased proportionally with the number of comorbidities (odds ratio [OR]: 1, no-comorbid; OR: 1.64, 1 comorbidity; OR: 2.52, 2 comorbidities; OR: 4.57, ≥ 3 comorbidities). Results Stratifying the study population by the presence/absence of comorbidities and typical presentation, we found a decreasing trend for use of medications and percutaneous intervention (OR: 1, typical presentation and no-comorbidities; OR: 0.70, typical presentation and comorbidities; OR: 0.23, atypical presentation and no-comorbidities; OR: 0.18, atypical presentation and comorbidities). On the opposite, compared with patients with typical presentation and no-comorbidities (OR: 1, referent), there was an increasing trend (p < 0.001) in the risk of death (OR: 2.00, OR: 2.52 and OR: 4.83) in the above subgroups. However, after adjusting for comorbidities, medications and invasive procedures, atypical presentation was not a predictor of in-hospital death. Independent predictors of poor outcome were history of stroke (OR: 2.04), chronic kidney disease (OR: 1.57), diabetes mellitus (OR: 1.49) and underuse of invasive procedures. Conclusions In the ISACS-TC, atypical ACS presentation was often associated with comorbidities. Atypical presentation and comorbidities influenced underuse of in-hospital treatments. The latter and comorbidities are related with poor in-hospital outcome, but not atypical presentation, per se. [ABSTRACT FROM AUTHOR]

Background A substantial proportion of elderly with ST segment elevation myocardial infarction (STEMI) do not undergo percutaneous coronary intervention (PCI). We sought to investigate factors associated with the decision not to perform coronary angiography at admission in these patients. Methods We evaluated 1315 STEMI patients aged ≥ 75 years old enrolled in the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS TC) registry between October 2010 and February 2015. They were compared with 6667 patients aged < 75 years old enrolled in the registry in the same time frame. Results Elderly patients were less likely to undertake invasive coronary evaluation compared with younger patients (62.1% vs. 78.9; p < 0.001%). In the older group there were a lower proportion of patients presenting < 12 h after symptom onset (66.5% vs.76.9%, p < 0.001), and a higher prevalence of comorbidities. Few elderly were treated with current recommended evidence based treatments (aspirin, clopidogrel, heparins, beta-blocker, statins, and ACE-inhibitors). Logistic analysis adjusted for age and sex showed that older age was associated with underuse of coronary angiography (OR 0.46, 95% CI: 0.41–0.53, p < 0.001). Clinical factors that were associated with underuse of angiography in patients over 75 were: female sex (OR: 0.77), presence of comorbidities (OR: 0.91), anemia (OR: 0.44) and late hospital admission (OR: 0.89). Conclusions In the ISACS-TC, more than one third of the elderly with STEMI did not undergo coronary angiography at admission. Sex, comorbidities, and late hospital admission were independent factors associated with the underuse of PCI in these patients. [ABSTRACT FROM AUTHOR]