Comparison of modification of diet in renal disease and chronic kidney disease epidemiology collaboration formulas in predicting long-term outcomes in patients undergoing stent implantation due to stable coronary artery disease

Estimated glomerular filtration rate derived from different formulas and prognosis in acute coronary syndrome: Findings from the improving care for cardiovascular disease in China-acute coronary syndrome project

BACKGROUND

The optimal formula for the estimation of glomerular filtration rate (GFR) in patients with acute coronary syndrome (ACS) in terms of predicting in-hospital mortality and adverse events remains unclear.

METHODS

A nationwide registry study, Improving CCC (Care for Cardiovascular Disease in China) ACS project, was launched in 2014 as a collaborative study of the American Heart Association and Chinese Society of Cardiology. The Cockcroft-Gault, modification of diet in renal disease (MDRD) formula for Chinese (C-MDRD), Mayo, and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas were used to calculate estimated GFR in 61,545 ACS patients (38,734 with ST-segment elevation myocardial infarction [STEMI] and 22,811 with non-ST-segment-elevation ACS [NSTE-ACS]).

RESULTS

Prevalence of moderate to severe renal dysfunction was inconsistent among four formulas, ranging from 11.6% to 22.4% in NSTE-ACS and from 8.3% to 16.8% in STEMI, respectively. The in-hospital mortality rate in patients with ACS was inversely associated with estimated GFR. In STEMI, the Mayo-derived eGFR exhibited the highest predictive power for in-hospital death compared with the Cockcroft-Gault-derived eGFR (area under the curve [AUC]: 0.782 vs. 0.768, p=0.004), C-MDRD-derived eGFR (AUC: 0.782 vs. 0.740, p<0.001) and CKD-EPI-derived eGFR (AUC: 0.782 vs. 0.767, p<0.001). In NSTE-ACS, the Mayo-derived eGFR exhibited a similar predictive value with the Cockcroft-Gault (AUC: 0.781 vs. 0.787, p>0.05) and CKD-EPI-derived eGFR (AUC: 0.781 vs. 0.784, p>0.05).

CONCLUSIONS

The Mayo formula was superior to Cockcroft-Gault, C-MDRD, and CKD-EPI formulas for predicting in-hospital mortality in ACS patients, especially for STEMI. The Mayo-derived eGFR may serve as a risk-stratification tool for in-hospital adverse events in ACS patients.

CLINICAL TRIAL REGISTRATION

URL: http://www.

CLINICALTRIALS

gov. Unique identifier: NCT02306616.

Genetic and environmental factors associated with homocysteine concentrations in a population of healthy young adults. Analysis of the MAGNETIC study

BACKGROUND AND AIMS

Elevated homocysteine concentration is associated with a higher risk of cardiovascular disease. The aim of our study was to determine the environmental and genetic factors associated with serum homocysteine concentration in healthy young adults. Moreover, we aimed to determine the cutoff value of homocysteine concentration for predicting unfavorable MTHFR genotype and to investigate whether this association is modified by dietary patterns and serum folate status.

METHODS AND RESULTS

A total of 744 healthy individuals, aged 18-35 years, were included in the study. Diet quality was assessed by establishing diet quality scores and adherence to the pro-Healthy Diet Index (pHDI) and non-Healthy Diet Index (nHDI). Genotyping was performed using the TaqMan method. Multivariate analysis showed that pHDI, creatinine, folate concentrations, and the T/T genotype of the C677T polymorphism in MTHFR, as well as the interaction between the T/T genotype of MTHFR (C677T polymorphism) and folate level, were most strongly related to homocysteine concentrations. The specificity of a homocysteine >13.1 μmol/l in predicting T/T homozygous status was 76% (area under the curve 0.68).

CONCLUSION

Healthy dietary patterns, folate, and creatinine levels, as well as the C677T polymorphism, proved to be the strongest predictors of homocysteine concentrations. T/T genotype of MTHFR modifies the relationship between folate and homocysteine.

Weight loss in heart failure is associated with increased mortality only in non-obese patients without diabetes

BACKGROUND

Weight loss (WL) is an independent predictor of mortality in patients with heart failure (HF). Moderate WL is recommended for overweight or obese patients with type 2 diabetes mellitus (DM). The aim of this study was to assess the prognostic impact of body weight reduction on survival in patients with both HF with reduced ejection fraction (HFrEF) and DM.

METHODS

The study comprised patients with HFrEF at the outpatient clinic. WL was defined as a body weight reduction of at least 7.5% during at least 6 months. Clinical features and 1 year mortality were analysed in WL and DM groups. Multivariate regression model was chosen to assess the predictive role of WL in HF patients with and without DM. The analysis regarding obesity before HF was also performed.

RESULTS

The study comprised 777 patients with HFrEF. Mean age was 53.2 ± 9.2, 12.0% were women, mean EF was 23.7 ± 6.0 %, and New York Heart Association III or IV class, DM, and WL were found in 60.5%, 33.3%, and 47.1% patients, respectively. WL was more prevalent in diabetic patients, comparing with those without DM (53.7% vs. 43.8%, respectively, 0.01), and was associated with higher 1 year mortality only in non-diabetic group (17.6% for WL vs. 8.2% for non-WL, log-rank 0.001). In the multivariate analysis, WL was associated with a higher risk of 1 year mortality in non-diabetic patients: HR 1.76 (1.05-2.95), 0.03 and only in the subgroup without obesity: HR 2.35 (1.28-4.32), 0.006. In non-diabetic patients with obesity and in diabetic patients regardless of weight status, WL was not associated with worse prognosis (thereof, WL was excluded from the multivariate models).

CONCLUSIONS

Overall, WL in HFrEF has emerged as a predictor of unfavourable outcomes only in non-obese patients without DM. More importantly, this study has identified that the presence of DM (irrespective of weight status) or the presence of obesity in non-diabetic patients abolished the unfavourable impact of WL on long-term outcomes.

One-year mortality of patients with ST-Elevation myocardial infarction: Prognostic impact of creatinine-based equations to estimate glomerular filtration rate

BACKGROUND

Renal dysfunction is associated with worse outcomes after primary percutaneous coronary intervention (PCI). However, whether glomerular filtration rate (GFR) estimated with various equations can equally predict outcomes after ST-Elevation Myocardial Infarction (STEMI) is still debated.

METHODS

We compared the clinical impact of 3 different creatinine-based equations (Cockcroft and Gault (CG), CKD-epidemiology (CKD-EPI) and Full Age Spectrum (FAS)) to predict 1-year mortality in STEMI patients.

RESULTS

Among 1755 consecutive STEMI patients who had undergone primary PCI included between 2006 and 2011, median estimated GFR was 79 (61;96) with the CG, 81 (65;95) with CKD-EPI and 75 (60;91) mL/min/1.73 m2 with FAS equation. Reduced GFR values were independently associated with 1-year mortality risk with the 3 equations. Receiver operating curves (ROC) of CG and FAS equations were significantly superior to the CKD-EPI equation, p = 0.03 and p = 0.01, respectively. Better prediction with FAS and CG equations was confirmed by net reclassification index.

CONCLUSIONS

Our results suggest that in STEMI patients who have undergone primary PCI, 1-year mortality is better predicted by CG or FAS equations compared to CKD-EPI.

The Relationship between VEGFA and TGFB1 Polymorphisms and Target Lesion Revascularization after Elective Percutaneous Coronary Intervention

Background and Aim

The specific association between genetic variation and in-stent restenosis is still only partly understood. The aim of this study is to analyze the relationship between functional polymorphisms in the genes encoding vascular endothelial growth factor A (VEGF-A; rs699947) and transforming growth factor beta 1 (TGF-β1; rs1800470) and target lesion revascularization (TLR) risk.

Methods

A total of 676 patients (805 lesions) with stable coronary artery disease (SCAD) who received elective percutaneous coronary intervention (PCI) with at least one bare-metal stent implantation were included. The primary study endpoint was TLR at a 4-year follow-up.

Results

The TLR rate was higher in patients with the VEGFA A/A genotype (15.4%) than in patients with the VEGFA A/C (7.9%) and C/C (8.9%) genotypes (p = 0.009). The VEGFA A/A genotype, after adjustment for clinical and procedural covariates, remained significantly and independently associated with the TLR (hazard ratio—2.09 [95% confidence interval 1.32–3.33, p = 0.0017]). However, we found no association between TLR and the TGFB1 genotype.

Conclusion

The VEGFA A/A genotype is significantly and independently associated with TLR risk in Polish SCAD patients who received elective PCI with bare-metal stent implantation.

Clinical characteristics and treatment of renal artery fibromuscular dysplasia with percutaneous transluminal angioplasty: a long-term follow-up study

BACKGROUND

Renal artery fibromuscular dysplasia (RAFMD) is a non-atherosclerotic cause of renal artery stenosis often affecting the young. Percutaneous transluminal renal angioplasty (PTRA) is the treatment of choice but there are few studies of the outcome of the procedure.

METHODS

This retrospective analysis included 64 patients (56.2 % female; mean age at diagnosis, 28.0 years) with RAFMD who underwent PTRA between November 2003 and August 2015. Technical and clinical success rates and restenosis rates were evaluated.

RESULTS

Seventy-six procedures were performed on 64 RAFMD patients. Technical success was 96.9 %, as defined by <30 % residual stenosis, with stent placement required in 11 patients (17.2 %). In the short term (1 month), the majority (79.7 %) had an immediate clinical benefit, with cure of hypertension in 35.9 %, and improvement in hypertension and a lower requirement for antihypertensive medications in 43.8 %. In the long term (mean, 47.5 months; range, 5-141 months), the survival rate was 96.9 %, freedom from restenosis was 84.4 %, and 76.6 % of patients showed a sustained clinical benefit (cure rate 40.6 %, improvement rate 35.9 %). Eight patients were treated with a second procedure and two had a third procedure, with half of these patients showing an improvement in hypertension.

CONCLUSION

PTRA for symptomatic RAFMD is safe and clinically successful. More than half of patients experience an immediate clinical benefit with sustained long-term effects. For patients with restenosis, there was a good response to a second PTRA.

The Prognostic Role of Red Blood Cell Distribution Width in Coronary Artery Disease: A Review of the Pathophysiology

Red blood cell distribution width (RDW) is a measure of red blood cell volume variations (anisocytosis) and is reported as part of a standard complete blood count. In recent years, numerous studies have noted the importance of RDW as a predictor of poor clinical outcomes in the settings of various diseases, including coronary artery disease (CAD). In this paper, we discuss the prognostic value of RDW in CAD and describe the pathophysiological connection between RDW and acute coronary syndrome. In our opinion, the negative prognostic effects of elevated RDW levels may be attributed to the adverse effects of independent risk factors such as inflammation, oxidative stress, and vitamin D₃ and iron deficiency on bone marrow function (erythropoiesis). Elevated RDW values may reflect the intensity of these phenomena and their unfavorable impacts on bone marrow erythropoiesis. Furthermore, decreased red blood cell deformability among patients with higher RDW values impairs blood flow through the microcirculation, resulting in the diminution of oxygen supply at the tissue level, particularly among patients suffering from myocardial infarction treated with urgent revascularization.

The platelet-to-lymphocyte ratio as a predictor of all-cause mortality in patients with coronary artery disease undergoing elective percutaneous coronary intervention and stent implantation

Background

There is no data regarding the association between the platelet-to-lymphocyte ratio (PLR) and long-term mortality in patients with stable coronary artery disease (SCAD). The aim of this study is to evaluate the utility of the pre-procedural PLR for predicting long-term, all-cause mortality in patients with SCAD undergoing percutaneous coronary intervention (PCI) and stent implantation.

Methods

We analyzed a total of 2959 consecutive patients with SCAD who underwent PCI (balloon angioplasty followed by stent implantation or direct stenting) between July 2006 and December 2011 at our institution. The patients were stratified into tertiles according to their admission PLR. The association between the PLR value and the outcomes was assessed using Cox proportional regression analysis after adjusting for clinical angiographic and laboratory data.

Results

During median follow-up of 1124 days, mortality was highest in patients with PLR within the 3rd tertile as compared to the 2nd and the 1st tertile (11.0% vs 8.7% vs. 9.6%, respectively, p = 0.03). PLR remained associated with mortality in multivariable analysis including clinical variables, ejection fraction and angiographic parameters HR (per 10 units increase) = 1.02 [95%CI,1.01 ÷ 1.04, p = 0.006]. After adjustment for the eGFR and hemoglobin levels, PLR was however no longer significantly associated with mortality.

Conclusion

PLR has potential predictive value in patients with SCAD, which has not been reported previously, but statistical significance disappears after adjusting for estimated glomerular filtration rate (eGFR) and hemoglobin levels as a potential confounding variable.

The obesity paradox in acute coronary syndrome: a meta-analysis

In the general population, the lowest mortality risk is considered to be for the body mass index (BMI) range of 20-24.9 kg/m(2). In chronic diseases (chronic kidney disease, chronic heart failure or chronic obstructive pulmonary disease) the best survival is observed in overweight or obese patients. Recently above-mentioned phenomenon, called obesity paradox, has been described in patients with coronary artery disease. Our aim was to analyze the relationship between BMI and total mortality in patients after acute coronary syndrome (ACS) in the context of obesity paradox. We searched scientific databases for studies describing relation in body mass index with mortality in patients with ACS. The study selection process was performed according to PRISMA statement. Crude mortality rates, odds ratio or risk ratio for all-cause mortality were extracted from articles and included into meta-analysis. 26 studies and 218,532 patients with ACS were included into meta-analysis. The highest risk of mortality was found in Low BMI patients--RR 1.47 (95 % CI 1.24-1.74). Overweight, obese and severely obese patients had lower mortality compared with those with normal BMI-RR 0.70 (95 % CI 0.64-0.76), RR 0.60, (95 % CI 0.53-0.68) and RR 0.70 (95 % CI 0.58-0.86), respectively. The obesity paradox in patients with ACS has been confirmed. Although it seems to be clear and quite obvious, outcomes should be interpreted with caution. It is remarkable that obese patients had more often diabetes mellitus and/or hypertension, but they were younger and had less bleeding complications, which could have influence on their survival.