Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Correlation between coronary artery disease and coronary microvascular dysfunction symptoms and cardiac SPECT results in Latvian women patients

Introduction

The clinical evaluation of symptomatic women is challenging due to their varying clinical presentation. Women patients with intermediate or high pre-test probability for coronary artery disease – even asymptomatic or with non-informative exercise test should be referred for further focused diagnostics. Myocardial perfusion imaging with single photon emission computed tomography (SPECT) is one of the most performed non-invasive cardiac imaging tests to diagnose CAD or coronary microvascular dysfunction (CMVD).

Purpose

To evaluate the correlation between various CAD symptoms and cardiac SPECT results in women patients undergoing examination due to diagnosis of CAD or CMVD.

Methods

During the period from 2018 till 2021 we performed cardiac SPECT for women patients with intermediate or high pre-test probability or non-informative exercise test. Patients were divided into 2 groups: normal myocardial perfusion or true myocardial perfusion defect, defined as area of ischemia ≥10% of the left ventricle myocardium mass. According to the clinical symptoms patients were categorized in “asymptomatic”, “atypical symptom” and “patients with chest pain” group. The presence of CMVD and CAD in each group was determined by invasive coronary angiography or computed tomography angiography.

Results

In 4 years, SPECT was performed in 726 women patients. The most common presented symptoms were: chest pain (n=487, 67.1%), dyspnea (n=323, 44.5%), tachycardia and palpitations (n=117, 16.1%), fatigue (n=129, 17.8%), headache (n=28, 3.86%) and excessive sweating (n=15, 2.1%). 104 (14.3%) patients were asymptomatic, 487 (67.1%) with chest pain and 135 (18.6%) with atypical symptoms. True myocardial perfusion defect was detected in 125 patients (17.2%). The obstructive CAD was found in 32 cases (25.6%; 4.4% of all SPECTs). The CMVD was diagnosed in 68 women (54.4%; 9.4% of all SPECTs). In asymptomatic patient group obstructive CAD was diagnosed in 5 (4.8%) cases, in chest pain group – 11 (2.3%) cases and in atypical symptom group – 16 (11.9%) patients (p<0.001). None of asymptomatic women had CMVD. The CMVD was detected in 53 (42.4%; 7.3% of all) cases in chest pain group and in 14 (11.3%; 1.9% of all) patients in atypical symptom group (p=0.006).

Conclusion

Women patients with typical chest pain were more likely to have CMVD, but with atypical symptoms – CAD. Since women are in a very high cardiovascular risk group in Latvia, the cardiac SPECT is highly recommended for detection of CAD and CMVD, especially in patients with atypical symptoms.

Funding Acknowledgement

Type of funding sources: None.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

The role of cardiac nuclear imaging of women with suspected coronary artery disease: data from Latvian cardiac SPECT registry

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardiac imaging is a leading method in the diagnosis and treatment of ischemic heart disease. As the prognostic value of exercise stress tests for women is relatively low, ESC Guidelines suggest more accurate imaging method. Myocardial perfusion imaging with SPECT is one of the most commonly performed non-invasive cardiac imaging tests evaluating myocardial viability, assessing prognosis and estimating the efficacy of therapy.

Purpose

To determine the role for cardiac nuclear imaging for women with suspected coronary artery disease (CAD) in Latvia and to analyze prescribed further diagnostic approaches to establish the diagnosis and appropriate treatment.

Methods

For women included in Latvian cardiac SPECT registry the cardiac SPECT was performed in single University Hospital from 2018 till 2021. The patients were divided into 2 groups: normal myocardial perfusion and true myocardial perfusion defect, defined as area of ischemia ≥ 10% of the left ventricle myocardium. Patients with perfusion defect were analyzed according to prescribed further diagnostic test or treatment option.

Results

700 women with suspected CAD were analyzed. True myocardial perfusion defect was detected in 120 patients (17.1%). As further diagnostic approach in 29 (24.2%) cases cardiac computed tomography angiography (CTA) was performed; the invasive coronary angiography (ICA) - in 76 (63.3%) cases and percutaneous coronary intervention (PCI) in 15 (12.5%) cases was suggested.

Analyzing results of all performed CTAs’, stenosis in main coronary arteries were not found (100%) and CAD was excluded. Of all performed ICA, in 41 (53.9%) women atherosclerosis in main coronary arteries was not observed and microvascular angina as a primary diagnosis was assessed. In 17 (22.3%) patients the significant stenosis in main coronary arteries was present and PCI was performed, of whom 10 (58.5%) women were primarily diagnosed. 1 patient (1.3%) underwent coronary artery bypass surgery (CBP). In 9 (11.8%) patients significant stenosis was not detected and they were discharged on optimal medical treatment (OMT). In all these 9 patients the CAD was already known before the SPECT. From all suggested PCIs’: 8 women underwent PCI (53.3 %), 1 – CBP (6.6%) and 6 (40%) patients continued OMT.

Conclusion

Based on Latvian cardiac SPECT registry data, myocardial perfusion imaging with cardiac SPECT is valuable and is highly recommended for the diagnostics of women with known or suspected CAD. Despite the low availability of cardiac SPECT in Latvia, the registry shows the importance of nuclear diagnostics for such a difficult to diagnose group as women.

A nationwide cross-sectional epidemiological study of cardiovascular risk factors as a tool for management of primary and secondary prevention in Latvia

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): EUROPEAN SOCIAL FUND MINISTRY OF HEALTH, LATVIA

Background.

An increasing prevalence (PREV.) of noncomunicable diseases is a major public health concern  in Latvia. Regular nationwide epidemiological studies present an opportunity to estimate the dinamics of PREV of health risk factors (RF) and thus assist in planning resources and improving prevention strategies at national level.

Objective.  The aim  was to analyze the PREV of cardiovascular  RF identified in a  epidemiological study in 2019-2020. To assess changes in RF prevalence, the results were compared to data from a similar study in 2009-2010.

Methods. 4070 inhabitants (age 25-74) of Latvia  enrolled. The statistical sample (6000 pers.) was random selected from the Housing Register, Central Statistical Bureau (1’209’756 INDV). The survey included an interview, physical examination (body mass index (BMI), arterial pressure etc.) and venous blood sample collection for fasting glucose (Glu), total cholesterol (TC), high and low-density lipoprotein cholesterol (LDL-C), triglycerides (Tg) measurement.  The data were processed using Microsoft Excel and SPSS.

Results. The mean number of  RF ((AH, TC, LDL-C, Tg, BMI, smoking, arterial hypertension) was 2,93 ±0.1 (mean ± SE) per person for the overall study population. The men group had a significantly greater  number of RF than  the female group  (3.15 ± 0.15 vs.2.55 ± 0.12). A positive correlation between age and the number of RF was found. In the age group 65 and more, the mean number of RF decreased in men and stabilized in women. Although the mean number of RFs has decreased statistically insignificantly over 10 years, changes in the PREV of individual RFs are significant  (see table).  Decrease of PREV of elevated TC, LDL-C, Glu ≥3.0 mmol/L, as well as a decrease in the PREV of young smokers, men, should be noted.

Conclusion. The nationwide data can be used as the baseline characteristics against which other measurements can be compared down the road including of health prevention activities

Prevalence of most important RF (%) 2019-2020 2009-2010 RF All Men Women All Men Women TC≥5.0 mmol/L 63.2× 60.7× 65.4× 75,2 72.0 78.0 LDL-C≥3.0 mmol/L 62.0× 63.1× 61.1× 73.7 73.1 73.9 Glucose 5.6-6.99 mmol/L 22.1× 27.1× 17.8× 28.7 35.3 24.9 Arterial Hypertension 38.0× 41.1× 35.3× 44.8 52.9 40.2 BMI≥30.0 kg/m² 29.1 28.1 29.8 30.7 25.6 32.6 Daily smokers 25-34 y 30.3× 21.8 46.3 22.3 (x) p below 0.05 comparing years 2019-20 and 2009-10

Blood transfusion and ischaemic outcomes according to anemia and bleeding in patients with non-ST-segment elevation acute coronary syndromes: Insights from the TAO randomized clinical trial

BACKGROUND

The benefits and risks of blood transfusion in patients with acute myocardial infarction who are anemic or who experience bleeding are debated. We sought to study the association between blood transfusion and ischemic outcomes according to haemoglobin nadir and bleeding status in patients with NST-elevation myocardial infarction (NSTEMI).

METHODS

The TAO trial randomized patients with NSTEMI and coronary angiogram scheduled within 72h to heparin plus eptifibatide versus otamixaban. After exclusion of patients who underwent coronary artery bypass surgery, patients were categorized according to transfusion status considering transfusion as a time-varying covariate. The primary ischemic outcome was the composite of all-cause death or MI within 180 days of randomization. Subgroup analyses were performed according to pre-transfusion hemoglobin nadir and bleeding status.

RESULTS

12,547 patients were enrolled. Among these, blood transfusion was used in 489 (3.9%) patients. Patients who received transfusion had a higher rate of death or MI (29.9% vs. 8.1%, p<0.01). This excess risk persisted after adjustment on GRACE score and nadir of hemoglobin (HR 3.36 95%CI 2.63-4.29 p<0.01). Subgroup analyses showed that blood transfusion was associated with a higher risk in patients without overt bleeding (adjusted HR 6.25 vs. 2.85; p-interaction 0.001) as well as in those with hemoglobin nadir > 9.0 g/dl (HR 4.01; p-interaction<0.0001).

CONCLUSION

In patients with NSTEMI, blood transfusion was associated with an overall increased risk of ischaemic events. However, this was mainly driven by patients without overt bleeding and those hemoglobin nadir > 9.0g/dl. This suggests possible harm of transfusion in those groups.

P2238Prognostic value and incremental benefit of ischaemic myocardial burden subtended by non-invasive CT-derived fractional flow reserve (FFRCT) significant stenoses

Background

Fractional flow reserve derived from CT-coronary angiography (FFRCT) accurately identifies ischaemic vessels which may be associated with clinical outcomes. Its predictive value in grey zone FFRCT values between 0.7–0.8 is not defined. The technique permits estimation of burden of ischaemic myocardium subtended by FFRCT significant vessels.

Purpose

To evaluate the prognostic value and incremental benefit of FFRCT defined ischaemic myocardial burden when compared to FFRCT alone.

Methods

This is a subanalysis of NXT (Analysis of Coronary Blood-Flow Using CTA:Next-Steps), a prospective study of stable coronary artery disease (CAD) patients referred for invasive angiography (ICA) undergoing invasive FFR, CTA and FFRCT in whom treating physicians had been blinded to FFRCT results. Primary endpoint, defined as a composite of non-fatal myocardial infarction and any revascularisation, was determined in 206 patients (age 64±9.5 years, 64% male) and 618 vessels. Burden of ischaemic myocardium was defined as percentage of myocardium subtended beyond the point at which a vessel's FFRCT becomes ≤0.8 as estimated by APPROACH score (FFRCT-APPROACH). In significant FFRCT vessels, the predictive value and incremental benefit of FFRCT-APPROACH was compared with significant FFRCT (≤0.8) for primary endpoint as measured by area under the receiver operator characteristic curve (AUC). Significant ischaemic myocardial burden was defined as >10%. The incidence and relationship between the primary endpoint with each 10% increase in FFRCT-APPROACH and 0.05-unit decrease in FFRCT values ≤0.8 was determined.

Results

Significant FFRCT was identified in 52.9% of patients (109/206) and 29.3% of vessels (181/618). At 4.7 years median follow-up the incidence of the primary endpoint in vessels with significant FFRCT-APPROACH was 58.9% (96/163) which was comparable with vessels with significant FFRCT (55.2%,100/181; P=0.50). The predictive value of FFRCT-APPROACH for the primary endpoint was comparable with FFRCT (AUC 0.72 [95% CI 0.65–0.79] vs 0.71 [0.63–0.78], P=0.79). When combined, there was significant predictive improvement compared with FFRCT alone (AUC 0.77 [0.70–0.84]; P=0.01). The largest incremental benefit upon FFRCT was observed in vessels with FFRCT values in the grey zone between 0.70–0.80 (AUC 0.76 [0.65–0.86] vs 0.62 [0.48–0.74]; P<0.01). Each 10% increase in FFRCT-APPROACH (Adjusted-HR 1.36; 95% CI 1.16–1.60; P<0.001) and each 0.05-unit FFRCT decrease (Adjusted-HR 1.42; 1.19–1.70; P<0.001) were independently associated with significant increase in the incidence of the primary-endpoint.

Conclusion

In patients with stable CAD referred for ICA, the burden of ischaemic myocardium subtended by FFRCT significant vessels predicted non-fatal myocardial infarction and future revascularisation. This provided significant incremental benefit when used in combination with FFRCT particularly at FFRCT values in the grey zone between 0.7 to 0.8.

P6172Management of silent myocardial ischemia in patients with peripheral arterial disease needing surgery

Background

Patients with peripheral arterial disease (PAD) needing surgery have increased risk for post-operative myocardial infarction (MI)/death due to coexisting coronary artery disease (CAD). Coronary CT angiography (CTA)-derived fractional flow reserve (FFRCT) can reliably identify ischemia-producing coronary stenosis in patients with suspected CAD but its value in PAD patients is unknown.

Purpose

To determine the prevalence of silent coronary ischemia in PAD patients undergoing surgery and to assess the value of FFRCT in guiding management of patients with multisite arterial ischemia.

Methods

Patients admitted for elective carotid, aortic or peripheral vascular surgery with no cardiac history or CAD symptoms were enrolled in a prospective, open-label, ethics committee-approved study and underwent pre-op CTA and FFRCT evaluation with results available to treating physicians. Ischemia-producing coronary stenosis was defined as FFRCT≤0.80 distal to stenosis in >2mm diameter vessels. Patient management was guided by a multidisciplinary team of cardiologists, cardiovascular surgeons and anaesthesiologists. Primary endpoint was major adverse cardiac events (MACE= cardiac death, MI, urgent revasc) at 30 days with follow up at 3,6,12 months.

Results

Coronary CTA and FFRCT analysis was performed in 179 consecutive patients (age 66±8 years, male 78%, hypertension 79%, diabetes 10%, dyslipidemia 31%, smoking 37%). CTA revealed extensive coronary calcification (Agatston score 995±1004, range 0–4810) and ≥50% stenosis in 64% of patients. Ischemic coronary stenosis (FFRCT≤0.80) was present in 114 patients (64%) with FFRCT ≤0.75 in 97 (54%) and multivessel ischemia in 63 (35%). Clinically indicated vascular surgery was performed as planned in 170/179 patients (95%) with cardiac anaesthesia and close monitoring and postponed in 9 patients for coronary revascularization (3) or medical/other therapy (6). There were no post-op cardiac complications. Elective coronary angiography, performed 1–3 months post surgery in 86 patients with left main, severe or multivessel ischemia, confirmed significant stenosis in each patient with revascularization in 58 patients (53 PCI and 5 CABG) including 8 for LM disease. There have been no cardiovascular deaths; 3 patients have died of lung cancer which was first discovered on CTA. One patient had peri-procedural MI at time of PCI and one had MI and urgent PCI at 6 months. MACE at 30 days=0/179, 3 months = 1/154, 6 months=2/123, 12 months=0/65.

Conclusions

Patients undergoing elective PAD surgery have a high prevalence (64%) of unsuspected ischemia-producing coronary stenosis. Pre-op diagnosis with CTA- FFRCT can help guide a multidisciplinary team approach with optimum medical management and staged peripheral and coronary revascularization. Favourable early results are promising and suggest the need for prospective controlled studies to define the role of coronary revascularization in PAD patients.

Acknowledgement/Funding

Heartflow, Inc.; Mikrotikls Ltd

Loop diuretics decrease the renal elimination rate and increase the plasma levels of trimethylamine-N-oxide

AIMS

Trimethylamine-N-oxide (TMAO) is a novel cardiovascular risk marker. We explored the association of commonly used cardiovascular medications with TMAO levels in patients and validated the identified associations in mice.

METHODS

Detailed history of drug treatment was recorded in 300 patients with cardiovascular disease without diabetes in an observational, cross-sectional study. Animal study was performed in CD1 mice.

RESULTS

Median plasma TMAO (interquartile range) level was 2.144 (1.570-3.104) μmol l^-1 . Among nine cardiovascular drug groups, the use of loop diuretics (0.510 ± 0.296 in users vs. 0.336 ± 0.272 in nonusers, P = 0.008) and mineralocorticoid receptor antagonists (0.482 ± 0.293 in users vs. 0.334 ± 0.272 in nonusers, P = 0.007) was associated with increased log-TMAO. Acute concomitant administration of furosemide or torasemide with TMAO in mice significantly influenced TMAO pharmacokinetic profile and almost doubled the plasma TMAO area under the curve. Furosemide decreased the TMAO excretion rate by 1.9-fold during the first 30 min after administration and increased TMAO concentrations in kidney, heart and liver, suggesting the interaction of furosemide and TMAO with efflux transporters. The concentrations of TMAO in blood plasma after the administration of the organic anion transporter inhibitor probenecid were not different from those of the control group, suggesting an effect not mediated by organic anion transporters.

CONCLUSIONS

Loop diuretics increased plasma TMAO concentration by decreasing its urinary excretion rate. Loop diuretic use should be considered a potential confounder in TMAO studies.

Diabetes is Associated with Higher Trimethylamine N-oxide Plasma Levels

Recent studies have revealed strong associations between systemic trimethylamine N-oxide (TMAO) levels, atherosclerosis and cardiovascular risk. In addition, plasma L-carnitine levels in patients with high TMAO concentrations predicted an increased risk for cardiovascular disease and incident major adverse cardiac events. The aim of the present study was to investigate the relation between TMAO and L-carnitine plasma levels and diabetes. Blood plasma samples were collected from 12 and 20 weeks old db/db mice and patients undergoing percutaneous coronary intervention. Diabetic compared to non-diabetic db/L mice presented 10-fold higher TMAO, but lower L-carnitine plasma concentrations at 12 weeks of age. After 8 weeks of observation, diabetic db/db mice had significantly increased body weight, insulin resistance and TMAO concentration in comparison to non-diabetic control. In 191 patients undergoing percutaneous coronary intervention the median (interquartile range) plasma concentration of TMAO was 1.8 (1.2-2.6) µmol/L. Analysis of the samples showed a bivariate association of TMAO level with age, total cholesterol and L-carnitine. The multivariate linear regression analysis revealed that, in addition to L-carnitine as the strongest predictor of log transformed TMAO (p<0.001), the parameters of age, diabetes status and body mass index (BMI) were independently associated with increased log transformed TMAO levels (p<0.01).Our data provide evidence that age, diabetes and BMI are associated with higher TMAO levels independently of L-carnitine. These data support the hypothesis of TMAO as a cardiovascular risk marker and warrant further investigation of TMAO for diabetes research applications.

Common haplotype of interleukin-6 gene is associated with chronic total occlusions of coronary arteries

AIM

Genetic polymorphisms in genes coding for cytokines may predispose patients to coronary artery disease and chronic total occlusion (CTO) of coronary arteries. The aim of the study was to evaluate association of common genetic variations of interleukins (IL) with CTOs.

METHODS

We reviewed coronary angiograms and evaluated presence of CTOs in 684 consecutive patients with no history of revascularization. The following genetic variations were analyzed: IL-1B +3954 C>T, IL-1B -511 C>T, IL-1RN VNTR and haplotypes of IL-6 encompassing IL-6 -596 G>A, IL-6 -572 G>C, IL-6 -373 AnTn and IL-6 -174 G>C polymorphisms.

RESULTS

In 254 patients (37.1%) CTO of at least one artery was found. We observed nine IL-6 haplotypes, of which five were common (>1%) and one (GG9/12G, n=8) was not previously reported in literature. The most prevalent IL-6 haplotype (AG8/12C or Hap*1, 49.5%) correlated with CTOs, that were present in 31.5%, 36.5% and 44.5% of patients with none, one and two Hap*1, respectively (OR [95%CI] 1.252 [0.844-1.856] and 1.746 [1.104-2.762] for heterozygots and homozygots, respectively). In multivariate analysis this association became non-significant (OR [95%CI] 1.202 [0.805-1.796] and 1.529 [0.955-2.450]). In subgroup analysis Hap*1 was, however, associated with CTOs in the left anterior descending artery (p for trend 0.032) and the left circumflex artery (P=0.047), but not in the right coronary artery (p=0.799). In multivariate analysis CTOs of the left coronary arteries were associated only with total cholesterol (OR [95%CI] 1.170 [1.020-1.341]) and Hap*1 (OR [95%CI] 1.469 [0.914-2.361] and 1.970 [1.151-3.372] for heterozyogots and homozygots, respectively).

CONCLUSION

Our study suggests that common IL-6 haplotype (AG8/12C or Hap*1) is associated with development of CTOs in left coronary arteries.

Left main coronary artery disease in 2011: CABG or PCI?

Left main coronary artery disease, present in 5-9% of patients with angina pectoris, is associated with high mortality risk when treated medically. For several decades coronary artery bypass grafting (CABG) has been regarded as the treatment choice for unprotected left main coronary artery (ULMCA) disease patients. However, proximal location and large caliber of the left main has set challenge for interventional cardiologists. Recent clinical guidelines have stated that elective percutaneous coronary intervention (PCI) can be considered for patients with ULMCA disease, although suggesting that the aggregated evidence favors CABG. A number of registry reports, as well as a substudy from a large, randomized trial, have indicated that PCI may be an acceptable alternative to CABG in some patients with ULMCA stenosis. PCI already offers tangible short-term advantages over CABG as it is less invasive, reduces hospitalization duration, avoids the disability of surgical recovery, and allows patients to subsequently have CABG if necessary.

[Interventional cardiology in Latvia from 1993 to 2003]

A nationale programme for combatting cardiovascular diseases is being implemented in Letvia. A milestone was reached in 1993 with the establishment of a Letvian Centre for Cardiology. Within 10 years the only cardiac catheterization unit in the country has developed into a centre of excellence. But to meet the cardiological needs for all of Letvia requires at least three additional units for left heart catheterization and one for paediatric a cardiac catheterization.

Immune activation and degradation of tryptophan in coronary heart disease

BACKGROUND

Inflammation and immune activation appear to be important in the pathogenesis of coronary heart disease (CHD). Cytokine interferon-gamma, which is released during cell-mediated immune responses, induces indoleamine (2,3)-dioxygenase (IDO), an enzyme degrading tryptophan to kynurenine. Therefore, immune stimulation is commonly associated with an increased kynurenine to tryptophan ratio (kyn trp-1) indicative for activated indoleamine (2,3)-dioxygenase and a measurable decline of tryptophan.

METHODS

Blood concentrations of kynurenine and free tryptophan and the kynurenine to tryptophan ratio were examined in 35 patients with coronary heart disease verified by coronary angiography and compared with healthy controls. Patients were observed before percutaneous transluminal coronary angioplasty (21 patients: one with artery disease, nine with 2- or 3-artery disease, and five with restenosis).

RESULTS AND CONCLUSIONS

Decreased tryptophan concentrations were found in a significant proportion of coronary heart disease patients and coincided with increased kyn trp-1 and also with increased neopterin concentrations, indicating an activated cellular immune response. We conclude that in coronary heart disease immune activation is associated with an increased rate of tryptophan degradation and thereby lowered tryptophan levels. Results may provide a basis for a better understanding of the pathogenesis of mood disturbances and depression in coronary heart disease patients.

Plasma HDL-cholesterol has an effect on nitric oxide production and arachidonic acid metabolism in the platelet membranes of coronary heart disease patients without LDL-hypercholesterolemia

AIM

To evaluate nitric oxide (NO) production and [3H]arachidonic acid (AA) incorporation into platelet membranes of coronary artery disease (CAD) patients with/without HDL-hypocholesterolemia.

MATERIAL

16 healthy controls (C), 14 CAD patients with plasma HDL-hypocholesterolemia (nCAD) and 14--without HDL-hypocholesterolemia (nCAD). All subjects were without peripheral vascular disease and hypertension. The groups were matched for age, sex, BMI. The diagnosis of CAD was substantiated by coronary angiography.

METHODS

Nitric oxide end products xNO (NO2- plus NO3-) levels in the platelet membranes were measured using anion-exchange chromatography. [3H]AA release from labelled platelets was studied by the method of Neufeld and Majerus; radioactivity was measured by liquid scintillation counting. Levels of plasma HDL-cholesterol (HDL-Ch) and triglycerides were enzymatically determined.

RESULTS

Significant increase (mean +/- SD; Mann-Whitney U test) of [3H]AA incorporation into platelet membrane phospholipids was noted in CAD patients in comparison with healthy subjects (p < 0.001). A correlation (multiple regression analysis) was established between HDL-C level and [3H]AA (r = -0.58, p < 0.05, n = 28); and between HDL-Ch and NOx levels (r = 0.76, p < 0.05, n = 28) in CAD patients. CAD patients had lower NOx than healthy subjects (p < 0.0001), NOx was lower in the group with decreased HDL-Ch concentration (wCAD 36 +/- 5 vs. nCAD 42.3 +/- 6 mumol/mg, p < 0.002).

CONCLUSIONS

CAD patients show decreased ability to produce platelet-derived NO that leads to higher platelet sensitivity to aggregating stimuli. Decreased plasma HDL-Ch may affect AA metabolism and NO production in the platelet membranes of CAD patients without LDL-hypercholesterolemia.