Prasugrel compared to ticagrelor in primary PCI

Background

Prasugrel and ticagrelor have similar recommendations in the setting of primary PCI by current guidelines. Data comparing both in daily clinical practice of primary PCI for ST-elevation myocardial infarction is limited.

Purpose

To compare the effect of prasugrel and ticagrelor on in-hospital outcomes after primary PCI.

Methods and results

We prospectively enrolled 5365 patients treated with prasugrel (n=2785, 51.9%) or ticagrelor (n=2580; 48.1%) in the setting of primary PCI from January 2011 to December 2018 in a nationwide registry. In-hospital outcomes were compared and multiple logistic regression analysis was performed. Prasugrel treated patients were younger, less often in cardiogenic shock, with lower rates of previous stroke and had shorter ischemic time. Both groups showed similar rates of previous MI, diabetes and current resuscitation. In the univariate analysis mortality was lower in patients with prasugrel (2.5% vs. 4.4% p<0.01). Similarly, MACE (3.3% vs. 5.3%, p<0.01) and NACE (4.0% vs. 5.7% p<0.01) were lower in prasugrel treated patients, whereas major bleeding events did not differ (0.4% vs. 0.6% p=0.24).

After adjustment in multivariable analysis mortality (0.99 95% CI 0.57 to 1.72), MACE (OR 0.99 95% CI 0.65 to 1.52) as well as NACE (0.86 95% CI 0.61 to 1.22) did not differ in patients treated with prasugrel compared to ticagrelor.

Conclusion

Patients treated with prasugrel showed improved outcomes compared to ticagrelor in a large cohort of primary PCI. However, after adjustment for confounders the Advantage of prasugrel in primary PCI did not persist.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Austrian Society of Cardiology

Obesity, body fat and coronary atherosclerosis

BACKGROUND

Recent prospective studies have provided compelling evidence that obesity is a risk factor for the occurrence of clinical coronary events. However, the link between angiographically determined coronary atherosclerosis and obesity still remains controversial. We conducted this cross-sectional study in a clinical setting to investigate the relation of the obesity and body fat (BF) with angiographically defined coronary atherosclerosis.

PATIENTS AND METHODS

Six hundred and seventy-three men (median age 64 years) and four hundred and twenty-eight women (median age 69 years) who underwent coronary angiography for suspected or known coronary heart disease were analyzed. The body mass index (BMI) and the BF were used as main exposure variables, and either the presence of significant (> or =50%) coronary diameter stenosis or a coronary artery disease severity score were defined as outcome variables, in a sex-specific logistic regression analysis.

RESULTS

Among male patients, BF was slightly higher with increasing number of vessels involved (adjusted P for trend <0.05). In contrast, BMI showed no association with presence and severity of coronary artery disease (CAD). The odds ratios (ORs) for the presence of significant stenosis across quartiles of BMI were 1.0 (reference), 0.9, 1.1 and 0.7 (adjusted P for trend 0.61). This result did not differ between younger and older men. Among females, however, both BF and BMI were not significantly associated with an increasing number of vessels involved.

CONCLUSION

These results suggested that BF may be predictive of an increasing number of coronary vessels involved among male patients, but not among female patients. This study failed to detect a positive association of presence and severity of CAD with BMI.

Increased serum concentrations of soluble CD95/Fas and caspase 1/ICE in patients with acute angina

OBJECTIVES

To investigate the expression of death inducing receptors in the sera of patients with stable and unstable angina.

DESIGN

80 consecutive patients with stable (n = 40) or unstable (n = 40) angina pectoris were studied. Serum concentrations of soluble CD95 (sCD95), soluble CD95 ligand (sCD95L; CD178), tumour necrosis factor (TNF) alpha, soluble TNFalpha receptor type 1 (sTNFR1), and interleukin 1beta converting enzyme (ICE; caspase 1) were measured by enzyme linked immunosorbent assay (ELISA).

RESULTS

Significant increases in the concentrations of sCD95 and ICE (p < 0.001 and p < 0.023, respectively) were found in the serum from patients with unstable angina relative to those with stable angina. There were no significant differences in the concentrations of sCD95L, TNF alpha, and sTNFR1 between the groups.

CONCLUSIONS

These data provide the first evidence that sCD95 and ICE are important serological markers that may help to discriminate between stable and unstable angina. This observation may warrant further clinical study to elucidate the clinical impact of sCD95 and ICE in acute coronary syndromes.

Antiarrhythmic Therapy on Prevention of Postoperative Atrial Fibrillation in Patients After Heart Surgery

The incidence of supraventricular arrhythmias is high following open-heart surgery, occurring in 25% to about 50% of patients. The most common of these arrhythmias is atrial fibrillation (AF). Postoperative AF has been associated with increased incidence of other complications and increased hospital length of stay. Atrial arrhythmias are most frequent in the first two to three days after cardiothoracic surgery, but they can occur at any point in the recovery period. Age and concomitant valular heart disease are consistently the independent factors most strongly associated with postoperative atrial fibrillation. Prevention of AF seems to be a reasonable clinical goal, and, consequently, many randomized trials have evaluated the effectiveness of pharmacological and nonpharmacological interventions for prevention of AF. The main indication for AF prophylaxis remains the shorteningof length of hospital stay and possibly reduction in stroke. The optimal treatment strategies for reducing postoperative AF are not well established. Commonly used therapeutic approaches include the use of rate-controlling drugs such as beta-blockers, calcium antagonists, and digoxin. Some pharmacological strategies including beta-blockers, sotalol, and amiodarone have shown to reduce risk of postoperative AF and may reduce length of hospital stay. There is no convincing evidence that reducing postoperative AF reduces stroke. This review summarizes current evidence from randomized controlled trials to estimate the effect of pharmacological and non pharmacologic interventions on the occurrence of AF after open-heart surgery and its effects on postoperative outcome.

Thyroid function is associated with presence and severity of coronary atherosclerosis

BACKGROUND

Overt hypothyroidism has been found to be associated with cardiovascular disease. Moreover, subclinical hypothyroidism is a strong indicator of risk for aortic atherosclerosis and myocardial infarction.

HYPOTHESIS

We hypothesized that variation of thyroid function within the normal range may influence the presence and severity of coronary atherosclerosis.

METHODS

We studied a total of 100 consecutive men and women (59 men, 41 women, age 63.7 +/- 11.0 years) who underwent coronary angiography. Blood was tested for serum thyrotropin concentrations and for free tri-iodothyronine and free thyroxine concentrations. In addition to the assessment of thyroid function, conventional risk factors for coronary artery disease (CAD), clinical characteristics, serum lipid levels, fasting total homocysteine, and angiographic results of coronary artery assessment were obtained. Two experienced cardiologists blinded to clinical and laboratory data reviewed the cinefilms. The severity of CAD was scored as 0 for those with smooth normal epicardial coronary arteries, 0.5 for plaquing (< 50% diameter stenosis), and 1, 2, or 3 for those with single-, double-, or triple-vessel epicardial coronary artery stenosis of > 50%, respectively.

RESULTS

The severity of CAD was scored as 0, 0.5, 1, 2, and 3 in 14, 26, 25, 22, and 13 patients, respectively. Higher levels of serum-free thyroid hormone concentrations were associated with decreased severity of coronary atherosclerosis. Serum-free tri-iodothyronine was 2.99 +/- 0.33 pg/ml in patients with a CAD severity score of 0 to 1 and 2.74 +/- 0.49 pg/ml in patients with CAD severity scores of 2 and 3 (p < 0.01). Moreover, serum-free thyroxine concentrations showed a trend toward higher levels in patients with CAD severity score 0 to 1 compared with patients with CAD severity scores 2 and 3 (11.65 +/- 1.87 pg/ml vs. 10.9 +/- 2.3 pg/ml; p = 0.09). Higher levels of serum thyrotropin concentrations were associated with increased severity of coronary atherosclerosis (1.37 +/- 1.02 mU/l vs. 1.98 +/- 2.13 mU/l in patients with CAD severity score 0 to 1 versus CAD severity scores 2 and 3; p = 0.049). When grouped into three subsets according to their serum free tri-iodothyronine levels (< 2.79, 2.8 to 3.09, and +/- 3.1 pg/ml), the prevalence of CAD scores 2 and 3 was significantly higher in the subset of patients with low serum free tri-iodothyronine levels (48.5%) than in the subsets of patients with medium or high tri-iodothyronine concentrations (32.25 and 25%, respectively, p for trend < 0.05).

CONCLUSION

These data in patients referred for coronary angiography suggest that variation of thyroid function within the statistical normal range may influence the presence and severity of coronary atherosclerosis.

Hepatitis A IgG seropositivity and coronary atherosclerosis assessed by angiography

BACKGROUND

Infectious agents, in particular intracellular pathogens that can establish long-term, persistent infection, may play an important role in atherogenesis. We tested the hypothesis that hepatitis A virus (HAV) could be associated with significant coronary artery disease.

METHODS

The possible association between HAV infection and angiographically proven coronary artery disease (CAD) was studied. Blood from 218 patients undergoing coronary angiography was tested for serum IgG antibodies to HAV.

RESULTS

Of the 218 patients, 178 (81.7%) had anti-HAV IgG antibodies. CAD prevalence was 66.3% in HAV seropositive and 57.5% in HAV seronegative patients (P=0.385). In contrast, the number of infectious pathogens to which an individual has been exposed correlates with CAD. Four or more of the six seromarkers tested for particular infections (HAV, Chlamydia pneumoniae, Helicobacter pylori, cytomegalovirus, influenza type A and type B) were positive in 48.8% of patients with CAD and in 31.2% of patients in patients without CAD (P=0.02).

CONCLUSIONS

This analysis demonstrated that HAV seropositivity is not a predictor of risk for CAD. HAV infection, therefore, seems not to be associated with CAD. The number of infectious agents to which an individual has been exposed ('infectious burden') correlates with CAD.

Subarachnoid haemorrhage with "Ecstasy" abuse in a young adult

Abuse of the drugs like amphetamine, cocaine and "Ecstasy" may be complicated by intracerebral, subdural or subarachnoid haemorrhage. Contrary to historical opinion, drug-related intracranial haemorrhage (ICH) is frequently related to an underlying vascular malformation. We report the case of an 18-year-old man with a history of Ecstasy abuse preceding the onset of severe occipital headache. Cerebral computed tomography revealed right-sided subarachnoid haemorrhage and cerebral angiography showed right-sided middle cerebral artery aneurysm of 1 cm diameter. The patient was treated surgically with aneurysm clipping. Three weeks after onset of intracranial haemorrhage, neurological examination demonstrated normal findings. A history of severe headache immediately after using amphetamine, Ecstasy, or cocaine should alert doctors to the possibility of intracerebral haemorrhage. Arteriography should be part of the evaluation of most young patients with stroke or non-traumatic ICH.

Body iron stores and coronary atherosclerosis assessed by coronary angiography

BACKGROUND AND AIM

Epidemiological studies have suggested an association between higher body iron stores and coronary artery disease (CAD), but recent trials have reported conflicting data on the role of ferritin in CAD. To assess these findings, we examined the association between serum ferritin and the angiographic extent of coronary atherosclerosis in consecutive patients referred for coronary angiography.

METHODS AND RESULTS

We studied 100 consecutive white subjects (41 women and 59 men; mean age 63.7 +/- 11.0 years) who underwent coronary angiography. The data collected at baseline included conventional risk factors for coronary artery disease (CAD), lipid and fasting total homocysteine levels, serum ferritin levels and transferrin saturation, and clinical characteristics. Serum ferritin levels and transferrin saturation (serum iron concentration divided by total iron-binding capacity) were used as measures of the amount of circulating iron available to tissues. Two experienced cardiologists blinded to the clinical and laboratory data reviewed the angiographic cinefilms, and defined the angiographic severity of CAD on the basis of the sum of three vessel scorring systems. The risk of CAD assessed by coronary angiography was not related to ferritin concentrations or transferrin saturation levels. The estimated relative risk of CAD for the fifth vs the first quintile of serum ferritin was 0.83 (95% CI: 0.63-1.24). Forty of the 100 patients had no or minimal CAD (group A; score 0-3), 33 moderate CAD (group B; score 4-8) and 27 severe CAD (group C; score > 8): the serum ferritin levels in the three groups were respectively 165 +/- 126, 167 +/- 121 and 164 +/- 110 ng/ml, and did not represent an independent risk factor for CAD (p = 0.98). Transferrin saturation in the three groups was 22.9 +/- 10%, 21 +/- 9% and 19.9 +/- 10%, with no significant relationship to the severity of CAD (p = 0.23). The presence of angiographic CAD was associated with patient age (p = 0.048), male gender (p < 0.01), high lowdensity lipoprotein cholesterol levels (p = 0.02), low high-density lipoprotein cholesterol levels (p = 0.02), high plasma fibrinogen levels (p < 0.01) and high fasting total homocysteine levels (p = 0.04).

CONCLUSION

In patients referred for coronary angiography, higher ferritin concentrations and transferrin saturation levels were not associated with an increased extent of coronary atherosclerosis.

[Intracoronary brachytherapy--an update]

Restenosis following angioplasty represents a major clinical problem in the field of percutaneous coronary interventions. Intravascular brachytherapy reduces risk of restenosis following percutaneous interventions of native lesions and in-stent restenosis up to 50%-60%. This effect can be shown for at least one to two years. This novel therapeutic strategy is limited by a higher rate of target vessel reinterventions, and late coronary thrombosis, when platelet inhibiting drugs has been withdrawn or after implantation of multiple stents. Currently, intracoronary brachytherapy is mainly considered for treatment of in-stent-restenosis.

Relation of C-reactive protein levels to presence, extent, and severity of angiographic coronary artery disease

BACKGROUND

C-reactive protein is a valid marker of cardiovascular risk. It is not known whether C-reactive protein is a marker of atherosclerotic burden or whether it reflects a process (e.g. inflammatory fibrous cap degradation) leading to acute coronary events. This study was performed to determine whetherthe concentration of C-reactive protein is associated with coronary atherosclerosis assessed by coronary angiography.

METHODS AND RESULTS

We studied a total of 100 men and women (41 women, 59 men, mean age 63.7 +/- 11.0 years) who were referred for coronary angiography. Baseline data collection comprised clinical characteristics and conventional risk factors for coronary artery disease, levels of serum lipids and fasting total homocysteine levels. The relation between serum C-reactive protein levels and the severity and extension of coronary lesions was studied. The coronary angiograms were evaluated in a blinded manner according to three scores: vessel score (0-3 points for 0-3 vessels with coronary artery disease), stenosis score (0-3 points: number and severity of coronary stenoses or lesions; 0 for no, 1 for coronary lesion with diameter stenosis less than 50%, 2 for 50%-75%, and 3 for more than 75% diameter stenosis), and extent score (0-3 points; segment-extension of all coronary lesions within the total coronary vessel length). According to the total score values obtained, groups for coronary artery disease risk were defined and analyzed forcorrelations with age and levels of total cholesterol. high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, fasting total homocysteine. and C-reactive protein in serum. From the 100 patients, 40 were found to have no or minimal coronary artery disease (group A; score 0-3), 33 had moderate (group B; score 4-8) and 27 had severe (group C: score more than 8) coronary artery disease assessed by coronary angiography. Estimates of the relative risk of coronary heart disease for the third quintile of serum C-reactive protein as compared with the first quintile were 1.79 (95 percent confidence interval 1.23-2.39). Serum C-reactive protein levels were 3.54 (+/- 7.07) mg/L, 11.41 (+/- 13.5) mg/L and 5.66 (+/- 8.32) mg/L in groups A, B and C and represented an independent risk factor for the presence of coronary artery disease assessed by coronary angiography (p<0.01). With step-wise logistic regression analyses, use of C-reactive protein values maintained the ability to predict the probability of coronary artery disease. Moreover, the presence of angiographic coronary artery disease was associated with patient age (p=0.048), male sex (p<0.01), high LDL-cholesterol levels (p=0.02), low HDL-cholesterol levels (p=0.02), high plasma fibrinogen levels (p<0.01) and high fasting total homocysteine levels (p=0.04).

CONCLUSIONS

These results suggest that the serum concentration of C-reactive protein is associated with presence, but not severity, of coronary artery disease in patients referred for coronary angiography.

Early investigation of silver-coated Silzone heart valves prosthesis in 126 patients

BACKGROUND AND AIM OF THE STUDY

Permanent silver (Silzone) coating of the sewing cuff of St. Jude Medical prosthetic heart valves may reduce the rate of prosthetic valve endocarditis (PVE). However, the incidence of paravalvular leaks and stroke in patients after implantation of Silzone-coated heart valve prostheses is largely unknown.

METHODS

Complications were analyzed among 126 consecutive patients (78 males, 48 females; mean age 64.7 years; range: 40-80 years) who received Silzone-coated prostheses at our institution between February 1998 and December 1999. Among patients, 94 had aortic valve replacement, 29 mitral valve replacement, and three had aortic and mitral valve replacement. Concomitant cardiac procedures (mainly coronary bypass) were performed in 47 patients (37.3%).

RESULTS

Hospital mortality was 1.6% (2/126) and freedom from valve-related mortality 99.2+/-0.9%. Total follow up was 137.4 patient-years, and 98.4% complete. Strokes or transitory ischemic attacks (TIAs) occurred in four cases (two strokes, two TIAs; stroke rate 1.5%/year; 95% CI 0.4-2.6%/year; stroke+TIA rate 3%/year; 95% CI 0.4-5.25%/year). There was no case of prosthetic valve dysfunction or PVE. Freedom from reoperation due to procedure-associated complications was 97.6% (one aortic dissection, two major bleeds). Paravalvular leak was detected in 19 cases, and graded trivial or mild in 17 cases (11 grade 0-I, six grade I), and moderate in two cases (grade I-II in one, grade II in one). No patient needed reoperation due to paravalvular leak. Left ventricular (LV) function was normal in 80 cases, but was impaired mildly in 20 cases, moderately in 16, and severely in eight. Bicycle exercise testing in 92 patients (73%) showed median exercise performance (81.4+/-23.9% of normal) after correction for age and weight. Cerebral magnetic resonance imaging was performed in 64 patients (50.8%); median MRI score was 2.0+/-1.8 according to a 12-scaled score system.

CONCLUSION

The overall incidence of echocardiographic paravalvular leak graded more than trivial or mild was low (1.6%) in patients followed for a mean of 1.1+/-0.5 years (range: 1-27 months) after valve replacement with Silzone-coated heart valve prostheses. No patient required reoperation due to paravalvular leak; moreover, the stroke rate (1.5%/year) was low in these patients. The present data indicated no significant disadvantages or higher rate of complications related to silver coating compared with other, non-silver-coated prostheses. Future investigation is needed to determine long-term outcome.

Headache as a manifestation of fatal myocardial infarction

Cardiac ischemia typically causes chest pain, variously radiating elsewhere. Convergence of cardiac nerve fibers on central pathways receiving somatic afferents from the head is likely to be responsible for the perception of cardiac ischemic pain as headache. A 47-year-old man was admitted to the emergency room of our hospital with a 2-hour history of occipital headache. Routine electrocardiography revealed monophasic ST-segment elevation in leads I and aVL and ST-segment depression in leads II, III, and aVF. During recording of lead VI, ventricular fibrillation occurred. Advanced life support was started immediately but failed to restore rhythm and cardiac function. Autopsy showed two-vessel disease with a ruptured plaque and total thrombotic occlusion of the proximal left anterior descending artery and 80% stenosis of the right coronary artery. In this patient, headache was the only symptom of myocardial ischemia. Anatomic convergence of cardiac nerve fibers on central pathways receiving somatic afferents from the head is likely to be responsible for the perception of cardiac ischemic pain as headache. Owing to the very rare occurrence of headache as a symptom of myocardial ischemia, diagnosis is difficult and requires a high degree of suspicion.

[Homocysteine and cardiovascular risk]

Homocysteine is an amino acid that plays a key role in methionine- and homocysteine metabolism. Homocystinuria has been described about four decades ago to be an inherited (autosomal recessive) disorder with rapid progressive atherosclerosis. Thus, homocysteine has been investigated intensively with respect to vascular wall injury and atherogenesis. Folic acid and vitamin B12 are cofactors of methioninsynthase, a key enzyme in homocysteine metabolism. Plasma levels of homocysteine are higher in patients with coronary artery disease documented by coronary angiography than in individuals with normal coronary arteries. Supplementation of folic acid is the treatment of choice to lower plasma homocysteine concentrations. Improvement in endothelial function could be documented in patients with folic acid supplementation. Large scaled clinical trials investigating folic acid supplementation in secondary prevention are now in progress. Today, homocysteine and its association with atherosclerosis raise a lot of questions to be answered. A distinct pathophysiological model linking hyperhomocysteinaemia and atherosclerosis is still not available. The presence of hyperhomocysteinemia in atherosclerotic vascular disease as a surrogate with no pathophysiological relevance itself cannot be ruled out. Routine testing of homocysteine levels is not yet recommended. Treatment of patients with folic acid or vitamin B for primary and secondary prevention of atherosclerotic vascular disease cannot be recommended today, because large scaled intervention trials on homocysteine lowering by vitamin B or folic acid are not available yet. Possible effects of these interventions on acute vascular events are not known.

Distribution of GABAA receptor alpha 1 subunit-like immunoreactivity in comparison with that of enkephalin and substance P in the rat forebrain

The gamma-aminobutyric acid-A receptor consists of several subunits. In this immunohistochemical study we investigated the regional distribution of the alpha 1 subunit with an antibody directed against a specific amino acid sequence (1-9) of the (1-9) of the alpha 1 subunit. We compared the distribution pattern of the alpha 1 subunit-like immunoreactivity with that of substance P- and enkephalin-like immunoreactivities in adjacent sections of the rat forebrain. alpha 1 subunit-like immunoreactivity appeared in the form of varicosities and fibers. A band-like terminal staining pattern (woolly fibers) that has been shown by others for substance P- and enkephalin-like immunoreactivity is also observed for alpha 1 subunit-like immunoreactivity. In contrast to substance P and enkephalin, numerous alpha 1 subunit-like immunoreactive perikarya were found. The highest density of alpha 1 subunit-like immunoreactive fibers and perikarya was found in the pallidal areas and the substantia nigra pars reticulata whereas the nucleus accumbens and the caudate putamen displayed a low density. alpha 1 subunit-like immunoreactive neurons resembled typical pallidal neurons. Some of these neurons were pericellularly stained with enkephalin-like immunoreactive varicosities in the dorsal pallidum. The distribution pattern of alpha 1 subunit-like immunoreactivity reflects a partial overlap with the substance P and enkephalin system although a differential distribution to each of these peptides was observed for cell bodies, fibers, and axon terminals.

Evidence for a high density of secretoneurin-like immunoreactivity in the extended amygdala of the rat

Secretoneurin is a novel 33-amino-acid neuropeptide produced by endoproteolytic processing from secretogranin II, which is a member of the chromogranin/secretogranin family. In this immunocytochemical study, we compared the distribution pattern of secretoneurin immunoreactivity with that of tyrosine hydroxylase, calbindin, substance P, and Leu-enkephalin in adjacent sections of rat forebrain. Secretoneurin appeared mainly in varicosities and fibers. Only a few cell bodies were stained. In the nucleus accumbens, a partial overlap of secretoneurin-immunoreactive patches with enkephalin-immunopositive areas was found. Secretoneurin displayed low to moderate levels of immunoreaction in calbindin-rich as well as in calbindin-immunonegative areas of the caudate-putamen. In the globus pallidus, entopeduncular nucleus, and substantia nigra, secretoneurin immunoreactivity was oriented ventromedially preferentially in woolly fibers. The dense immunostaining in the medial nucleus accumbens was directly continuous with dense secretoneurin immunoreactivity in the bed nucleus of the stria terminalis. Two strongly secretoneurin-immunopositive bands, one in the sublenticular portion and a smaller one along the posterior limb of the anterior commissure, interconnected the highly secretoneurin-immunopositive centromedial amygdala with the bed nucleus of the stria terminalis. Thus, the distribution pattern of secretoneurin immunoreactivity provides a marker of the extended amygdala that forms a continuum between the centromedial amygdala and the bed nucleus of the stria terminalis.