Heavy weekly alcohol consumption versus binge drinking after an acute coronary syndrome and risk of major adverse cardiovascular events at one year follow up

Background

The association between heavy weekly alcohol consumption or binge drinking and the risk of major adverse cardiovascular events (MACE) after acute coronary syndromes (ACS) is still unclear.

Purpose

To determine the risks of MACE at one year follow up according to baseline alcohol consumption, especially in patients with heavy weekly alcohol consumption or binge drinking.

Methods

We analyzed data of 6053 patients hospitalized in 4 Swiss centres for an ACS and followed over 12 months. Data on alcohol consumption were collected at baseline and at one year follow up after ACS. Binge drinking was defined as the consumption of ≥6 units of alcohol on one occasion, for the 12-months period preceding the one-year follow up. We defined MACE as a composite of cardiac death, myocardial infarction, stroke or clinically indicated target vessel coronary revascularization. We applied Cox regression to assess the risk of MACE associated with heavy alcohol weekly consumption (>14 standard units/week) compared to light consumption (<1 standard unit/week) or abstinence, as well as the risk with binge drinking, compared to no binge drinking, adjusting for baseline differences (age, sex, body-mass index, smoking, diabetes, peripheral artery disease, stroke, hypertension, use of aspirin, anticoagulation, statin, beta-blocker, ACE-inhibitor or ATII receptor blocker).

Results

At baseline, 817 (13.4%) patients reported heavy weekly alcohol consumption and 717 (11.8%) reported to have at least one episode of binge drinking per month. The risk for MACE at one year follow up was not increased in those with heavy weekly consumption compared to light consumption (8.7% vs. 8.5%, HR 0.96, 95% CI 0.69–1.33, P=0.80) or no consumption (8.7% vs. 10.3%, HR 1.26, 95% CI 0.88–1.80, P=0.21). However, the risk of MACE was higher in those reporting binge drinking with less than one episode a month (9.4% vs. 7.7%, HR 1.67, 95% CI 1.32–2.12, P<0.001), as well as in those with at least one episode of binge drinking per month (13.4% vs. 7.7%, HR 2.07, 95% CI 1.62–2.65, P<0.001), when compared to no binge drinking.

Conclusion

In contrast to regular heavy alcohol consumption, binge drinking behavior is associated with significant increased risk of MACE 12 months after ACS.

Funding Acknowledgement

Type of funding sources: None.

Frequency and prognostic impact of periprocedural myocardial infarction determined by various MI definitions in patients with chronic coronary syndromes undergoing percutaneous coronary intervention

Background

Several definitions of peri-procedural myocardial infarction (MI) requiring different biomarker thresholds with or without ancillary criteria for myocardial ischemia are currently recommended without being fully validated in real-world patients with chronic coronary syndrome (CCS) undergoing percutaneous coronary intervention (PCI).

Objectives

We aimed to evaluate the prevalence and prognostic value of high-sensitivity cardiac troponin-based peri-procedural MI according to contemporary MI definitions using a large real-world PCI cohort.

Methods

In CCS patients undergoing elective PCI enrolled to the Bern PCI registry (NCT02241291) between 2010 and 2018, peri-procedural myocardial injury and infarction were assessed according to the 4th and 3rd universal definition of MI (UDMI), academic research consortium (ARC)-2, and Society for Cardiovascular Angiography and Interventions (SCAI) criteria. The primary endpoint was cardiac death at 1 year.

Results

Among 4404 CCS patients, peri-procedural MI defined by the 4th UDMI, 3rd UDMI, ARC-2, and SCAI were observed in 14.9%, 18.0%, 2.0%, and 2.0% of patients, respectively. Cardiac mortality at 1 year in patients with peri-procedural MI defined by 4th UDMI, 3rd UDMI, ARC-2, and SCAI were 3.0%, 2.9%, 5.8%, and 10.0%, respectively. After multivariate adjustments, peri-procedural MI defined by the ARC-2 and SCAI were independently associated with cardiac death at 1 year, while those defined by the 4th and 3rd UDMI were not.

Conclusion

Among CCS patients undergoing PCI, periprocedural MIs defined by theARC-2 and SCAI occurred 7 to 9 times less frequently as compared with the 4th and 3rd UDMI, and were the only definitions significantly associated with cardiac mortality.

Funding Acknowledgement

Type of funding sources: None. Cardiac death at 1 year

Systemic immune-inflammation index predicts major adverse cardiovascular events in patients with ST-elevation myocardial infarction

Background

ST-elevation myocardial infarction (STEMI) represents the life-threatening manifestation of atherosclerosis, a chronic inflammatory disease of arterial wall, and is associated with high rate of morbidity and mortality. Thus, inflammatory biomarkers may be useful in identifying high inflammatory burden patients who may benefit from tailored high-intensity secondary prevention therapy.

Purpose

We therefore assessed the relationship between the systemic immune-inflammation index (SII) and CV outcomesamong 1144 all-comers patients admitted to four Swiss University Hospital for STEMI and enrolled in the prospective multicenter SPUM registry cohort I (NCT 01000701).

Methods

SII was calculated as platelet counts x neutrophil counts / lymphocyte counts. Patients were subdivided into three groups according to SII tertiles. The composite primary endpoint was major adverse cardiac and cerebrovascular events (MACCE: stroke, myocardial infarction, CV death). Adjusted Cox proportional hazards regression models were implemented to determine the risk associated with SII and outcomes.

Results

Out of 1144 STEMI patients, 912 patients (79,7%) had available for SII. Patients within the highest tertile were slightly more frequently male (23.0 vs 22.0%, p=0.05), with higher plasma values of neutrophils (11.4±2.4 vs 6.5±3.7 G/l, p<0.001), platelets (275.3±97.5 vs 202.5±51.6 G/l, p<0.001) and lower levels of lymphocytes (1.0±0.6 vs 2.1±1.1 G/l, p<0.001) and LVEF (46.4±11.5% vs 50.4±10.3%, p<0.001) (Fig. 1A). At 1 year, these patients presented the highest rate of all-cause mortality (7.2% vs 2.6%, p=0.02) and MACCE (8.2% vs 3.3, p=0.03). This enhanced risk persisted for all-cause mortality and MACCE, after adjustment for age, sex, ace-inhibitors and statin therapy (Adj. HR 2.85, 95% CI 1.30–6.70, p=0.03 and Adj. HR 2.63, 95% CI 1.25–5.55, p=0.03, respectively, Fig. 1B).

Conclusions

Among a real-world cohort of STEMI-patients, SII highlights the highest inflammatory risk phenotype, being associated with significant increased rates of MACCE and all-cause of death. These observations might help clinicians to furtherly identify patients who may derive the greatest benefit from tailored more intense secondary prevention therapies including inflammatory modulation.

Funding Acknowledgement

Type of funding sources: None. Figure 1

5-year outcomes in patients with acute coronary syndrome treated with biodegradable polymer sirolimus-eluting stents versus durable polymer everolimus-eluting stents

Background

Newest generation drug-eluting stents (DES) combining ultrathin cobalt chromium platforms with biodegradable polymers may reduce target lesion failure (TLF) as compared to second generation DES among patients with acute coronary syndrome (ACS). While previous studies indicated a potential benefit within the first two years after percutaneous coronary intervention (PCI), it remains uncertain whether the clinical benefit persists after complete degradation of the polymer coating.

Purpose

To compare the long-term effects of ultrathin-strut biodegradable polymer sirolimus-eluting stents (BP-SES) versus thin-strut durable polymer everolimus-eluting stents (DP-EES) for PCI in patients with ACS.

Methods

We performed a subgroup analysis of ACS patients included into the BIOSCIENCE trial (NCT01443104), a randomized trial comparing BP-SES with DP-EES. The primary endpoint of the present post-hoc analysis was TLF, a composite of cardiac death, target vessel myocardial infarction (MI) and clinically indicated target lesion revascularization (TLR), at 5 years.

Results

Among 2,119 patients enrolled between March 2012 and May 2013, 1,131 (53%) presented with ACS (ST-segment elevation myocardial infarction, 36%). Compared to patients with stable CAD, ACS patients were younger, had a lower baseline cardiac risk profile, including a lower prevalence of hypertension, hypercholesterolaemia, diabetes mellitus, and peripheral artery disease, and had a greater incidence of previous revascularization procedures. At 5 years, TLF occurred similarly in 89 patients (cumulative incidence, 16.9%) treated with BP-SES and 85 patients (16.0%) treated with DP-EES (RR 1.04; 95% CI 0.78–1.41; p=0.78) in patients with ACS, and in 109 patients (24.1%) treated with BP-SES and 104 patients (21.8%) treated with DP-EES (RR 1.11; 95% CI 0.85–1.45; p=0.46) in stable CAD patients (p for interaction=0.77) (Figure 1, Panel A). Cumulative incidences of cardiac death (8% vs. 7%; p=0.66), target vessel MI (5.2% vs. 5.8%; p=0.66), clinically indicated TLR (8.9% vs. 8.3%; p=0.63) (Figure 1, Panel B-D), and definite thrombosis (1.4% vs. 1.0%; p=0.57) at 5 years were similar among ACS patients treated with ultrathin-strut BP-SES or thin-strut DP-EES. Overall, there was no interaction between clinical presentation and treatment effect of BP-SES versus DP-EES.

Conclusion

In a subgroup analysis of the BIOSCIENCE trial, we found no difference in long-term clinical outcomes between ACS patients treated with ultrathin-strut BP-SES or thin-strut DP-EES at five years.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Unrestricted research grant to the institution from Biotronik AG, Switzerland

Uncontrolled hypertension and elevated NT-proBNP predict acute kidney injury and cardiac death in all-comer patients 1 year after acute coronary syndromes

Background

Hypertension is a recognized cardiovascular (CV) risk factor and, although many highly effective antihypertensive drugs have been developed, most patients fail to achieve recommended blood pressure target levels. This may increase major adverse CV events after acute coronary syndromes (ACS) such as acute kidney injury (AKI) and cardiac death (CD).

Purpose

We assessed the prognostic value of uncontrolled hypertension (UH) and elevated NT-proBNP among 2,168 all-comer patients admitted to 4 Swiss University Hospitals for acute coronary syndromes (ACS) enrolled in the prospective multicenter SPUM registry.

Methods

Patients with UH defined as a systolic blood pressure≥140 mmHg, and a NT-proBNP>900 ng/l were considered for the analysis. The composite primary endpoint was AKI and CD. Adjusted Cox proportional hazards regression models were implemented to determine risk prediction for UH and elevated NT-proBNP levels.

Results

Out of 2,168 ACS patients, 235 patients (10.8%) showed UH and NT-proBNP>900 ng/l (Fig. 1A). Compared to the general ACS population, those with UH and elevated NT-proBNP were more likely to be older (41.7% vs 20.0%, p<0.001), of female sex (36.2% vs 19.7%, p<0.001) and with a more complex history of CV disease, such as hypertension (77.0% vs 56.2%, p<0.001), diabetes (24.7% vs 17.5%, p=0.006), peripheral artery disease (9.4% vs 5.2%, p=0.011), cerebrovascular disease (6.8% vs 3.4%, p=0.013), chronic heart failure (3.4% vs 1.3%, p=0.025), dialysis (2.1% vs 0.3%, p=0.004) as well as prior CABG (9.4% vs 5.2%, p=0.010) and more often admitted as NSTEMIs (59.6% vs 40.9%, p<0.001). Although these patients were on a more aggressive antihypertensive therapy at admission (all p<0.05 for ACEi, ARB, Beta-blockers, calcium antagonists, nitrates and diuretics), there was a higher rate of death (OR 1.83, 95% CI 1.07–3.14, p=0.027), CD (OR 2.13, 95% CI 1.19–3.81, p=0.009), AKI (OR 2.83, 95% CI 1.41–5.67, p=0.002) and composite endpoint AKI+CD (OR 2.46, 95% CI 1.56–3.90, p<0.001) at one year. This combined risk persisted after adjustment for baseline differences, with a 71% (Adj. HR 1.71, 95% CI 1.44–1.84, p=0.003) increase for the composite endpoint (Fig. 1B).

Conclusions

Among a real-world cohort of ACS patients, coexistence of UH with elevated levels of NT-proBNP confers increased risk for AKI and CD up to one year after ACS. These observations might help clinicians to identify ACS patients at risk using simple clinical parameters and biomarkers and to target them for more intense preventive therapies.

Figure 1. A: GRADE1 = 140–159 mmHg and/or 90–99 mmHg; GRADE2 = 160–179 mmHg and/or 100–109 mmHg; GRADE3 = ≥180 mmHg and/or ≥110 mmHg; ISH (isolate systolic hypertension) = ≥140 mmHg and <90 mmHg; NT-proBNP = N-terminal-pro B-type natriuretic peptide. B: UH = uncontrolled hypertension; AKI = acute kidney injury; CD = cardiac death.

Funding Acknowledgement

Type of funding source: None

Ticagrelor monotherapy beyond 1 month versus standard dual antiplatelet therapy after drug-eluting coronary stenting: a pre-specified per-protocol analysis of the GLOBAL LEADERS trial

Background

In the GLOBAL LEADERS trial, the intention-to-treat (ITT) effect of ticagrelor monotherapy after 1 month of dual antiplatelet therapy (DAPT) was not superior to that of 12-month DAPT followed by aspirin alone in the prevention of 2-year all-cause mortality or new Q-wave myocardial infarction (MI) after coronary stenting. Intention-to-treat analyses can be affected by incomplete protocol adherence. We present a pre-specified per-protocol analysis.

Purpose

To determine whether 1 month of ticagrelor plus aspirin followed by 23 months of ticagrelor monotherapy is superior to 12 months of DAPT followed by aspirin alone in the per-protocol population of the GLOBAL LEADERS (NCT01813435).

Methods

The GLOBAL LEADERS compared two antiplatelet strategies after drug-eluting stenting for stable coronary artery disease or acute coronary syndromes. Per-protocol population consisted of randomized patients fulfilling enrollment criteria and receiving protocol-mandated treatment. Adherence to the allocated antiplatelet therapy was evaluated at discharge, 30 days, and 3, 6, 12, 18, and 24 months, with non-adherence reasons categorized following a hierarchical approach. A protocol-deviation was defined in the case of high perceived bleeding/thrombotic risk, a medical decision without evident clinical reason, patients unwilling to take study drugs, prescription error, logistical issues, unclear reasons. Baseline characteristics, including (but not limited to) age, sex, diabetes, prior PCI, were used to construct time-varying inverse probabilities for not deviation from the protocol to reconstruct a study population with no protocol-deviations. Protocol deviators were artificially censored at the time at which they deviated. The primary endpoint was the composite of 2-year all-cause mortality or non-fatal new Q-wave MI. We used a weighted pooled logistic regression to estimate the per-protocol rate ratio (RR) of experimental vs. control treatment for the primary endpoint.

Results

Of the 15,968 randomized patients, 805 out of 7,980 (10.1%) in experimental group and 537 out of 7,988 (6.7%) in control group were classified as protocol deviators and artificially censored by month 12, not contributing events in the second year. The events for the adherence-adjusted analysis were 279 in experimental group and 325 in control group (25 and 24 less than in ITT analysis, respectively). The estimated adherence-adjusted RR was 0.87 (95% CI: 0.74–1.02; p=0.09), comparable to the ITT RR (0.87; 95% CI: 0.75–1.01; p=0.07).

Conclusion

At per-protocol analysis, ticagrelor monotherapy after 1 month of DAPT was not superior to conventional treatment, in line with the previously reported ITT effect. Similar per-protocol and ITT effects can be accounted for similar per-protocol and ITT populations, as a substantial proportion of patients were non-adherent due to clinically grounded reasons (anticipated in the protocol) and, accordingly, not considered as protocol deviators.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): GLOBAL LEADERS was sponsored by the European Clinical Research Institute, which received funding from Biosensors International, AstraZeneca, and the Medicines Company.

P1222Intensification of lipid lowering therapy before and after publication of the IMPROVE-IT trial: A temporal analysis from the SPUM-ACS cohort

Background

The gradual implementation of evidence-based treatment strategies has improved outcomes in patients with acute coronary syndromes (ACS). The Improved Reduction of Outcomes: Vytorin Efficacy International Trial (IMPROVE-IT) was published on June 3rd, 2015, but its relevance on real life practice has not been explored.

Methods

We analyzed a prospective Swiss cohort of 6266 patients hospitalized for ACS between 2009 and 2017. The primary endpoints were the ezetimibe use overall or in combination with high-intensity statin at discharge and at one year after ACS. Secondary endpoint was LDL-C target achievement at one year in a subsample of 2984 patients. Relative Ratios (RR) were used to assess changes in primary endpoints before and after the publication of IMPROVE-IT, adjusting for age, sex, pre-existing diabetes, history of myocardial infarction, baseline low-density lipoprotein cholesterol (LDL-C) and attendance to cardiac rehabilitation.

Results

The period following the publication of the IMPROVE-IT trial was associated with an overall increase in the use of ezetimibe at discharge (from 1.8% to 3.8%, P<0.001, adjusted RR 2.85, 95% CI 1.90–4.25) and at one year (from 5.0% to 13.8%, P<0.001, adjusted RR 3.00, 95% CI 2.40–3.75). Before IMPROVE-IT trial, ezetimibe use at one year was stable around 5%, then steadily increased after its publication until 20% for patients included in 2017. The combination of high-intensity statin and ezetimibe increased from 0.9% to 2.1% at discharge (P<0.001, adjusted RR 3.35, 95% CI 1.90–5.89) and from 2.1% to 7.8% at one year (P<0.001, adjusted RR 3.98, 95% CI 2.90–5.47). The period following the publication of the IMPROVE-IT trial was associated with an improvement of LDL-C target <1.8 mmol/L (adjusted RR 1.37, 95% CI 1.12–1.68).

Conclusion

After the publication of the IMPROVE-IT trial, the use of ezetimibe was increased by three-fold in a large contemporary cohort of ACS patients, concomitant with an improved LDL-C target achievement.

98Mitral annular calcification, mitral valve diseases and clinical outcomes in patients undergoing transcatheter aortic valve replacement for severe aortic stenosis

Background

Mitral annular calcification (MAC) and mitral valve diseases (MVD) have been identified as strong predictors of mortality in patients undergoing transcatheter aortic valve replacement (TAVR). However, the association between MAC and MVD, and the prognostic implications in these patients remain unclear.

Purpose

This study sought to investigate the association between severity of MAC and the prevalence of MVD as well as to assess the prognostic impact of MAC depending on the presence or absence of MVD in patients undergoing TAVR.

Methods

We identified 967 patients who have comprehensive echocardiographic and computed tomographic assessment of MVD and MAC from our institutional registry that is a part of the Swiss TAVI registry (NCT01368250) between August 2007 and June 2017.

Results

Among these patients, mild or moderate MAC was present in 45.2% and severe MAC was present in 17.8%. The prevalence of MVD was significantly higher in severe MAC patients, while the prevalence in patients with mild and moderate MAC was similar to patients without MAC. Compared to patients without severe MAC and MVD, an increased risk of all-cause death at 1 year was observed in patients with severe MAC and MVD (hazard ratio [HR]: 2.81, 95% confidence interval [CI]: 1.72–4.59, p<0.001) as well as in patients with non-severe MAC and MVD (HR: 2.80, 95% CI: 1.87–4.20, p<0.001) but not in patients with severe MAC and non-MVD (HR: 0.68, 95% CI: 0.27–1.70, p=0.409). In a multivariable analysis, severe MAC concomitant with MVD was found to be an independent predictor of new permanent pacemaker implantation after TAVR (Odds ratio: 2.08, 95% CI: 1.27–3.41, p=0.004).

Conclusions

Severe MAC was associated with higher prevalence of MVD. Severe MAC concomitant with MVD was associated with increased risks of mortality at 1 year and conduction abnormalities after TAVR, whereas severe MAC without MVD was not.

P1968Five-year outcomes in patients with diabetes mellitus treated with biodegradable polymer sirolimus-eluting stents versus durable polymer everolimus-eluting stents

Background

Patients with diabetes mellitus (DM) remain at higher risk for adverse events after percutaneous coronary intervention (PCI) compared with non-diabetic individuals. Among available drug-eluting stents (DES), thin-strut durable polymer everolimus-eluting stents (DP-EES) were shown to provide the best safety and efficacy profile in diabetics. Whether biodegradable polymer DES provide additional long-term clinical benefit compared with DP-EES among diabetic patients remains uncertain.

Purpose

To compare the long-term performance of ultrathin-strut biodegradable polymer sirolimus-eluting stents (BP-SES) versus DP-EES for PCI in patients with insulin-requiring and non-insulin-requiring DM.

Methods

We performed a prespecified subgroup analysis of the randomized, multicenter, non-inferiority BIOSCIENCE trial (NCT01443104). Patients with stable coronary artery disease or acute coronary syndrome were randomly assigned to treatment with ultrathin-strut BP-SES or thin-strut DP-EES. Patients were further divided according to diabetic status. The primary endpoint was target lesion failure (TLF), a composite of cardiac death, target-vessel myocardial infarction (MI) and clinically-indicated target lesion revascularization (TLR), within 12 months.

Results

Among 2'119 patients enrolled between March 2012 and May 2013, 486 (22.9%) presented with DM (insulin-requiring, 33.1%). Compared with non-diabetics, patients with DM were older and had a greater baseline cardiac risk profile, including higher prevalence of hypertension, hypercholesterolaemia, peripheral artery disease, chronic renal failure and prior PCI, coronary artery bypass graft surgery, or stroke. At 5 years, TLF occurred similarly in 74 patients (cumulative incidence, 31.0%) treated with BP-SES and 57 patients (25.8%) treated with DP-EES (RR 1.23; 95% CI 0.87–1.73; p=0.24) in diabetics, and in 124 patients (16.8%) treated with BP-SES and 132 patients (16.8%) treated with DP-EES (RR 0.98; 95% CI 0.77–1.26; p=0.90) in non-diabetics (p for interaction=0.31). Cumulative incidences of cardiac death (14.9% vs. 9.5%; p=0.10), target-vessel MI (11.4% vs. 11.0%; p=0.81), clinically-indicated TLR (16.9% vs. 15.8%; p=0.68), and definite thrombosis (3.0% vs. 2.5%; p=0.63) at 5 years were similar among diabetic patients treated with ultrathin-strut BP-SES or thin-strut DP-EES. Overall, there was no interaction between diabetic status and treatment effect of BP-SES versus DP-EES.

Conclusion

In a prespecified subgroup analysis of the BIOSCIENCE trial, we found no difference in clinical outcomes throughout five years between diabetic patients treated with ultrathin-strut BP-SES or thin-strut DP-EES.

Acknowledgement/Funding

BIOSCIENCE was an investigator-initiated trial supported by a dedicated research grant from Biotronik, Bülach, Switzerland

P6440The perils of polyvascular disease with concomitant type 2 diabetes in a real-world cohort of patients with acute coronary syndrome

Background

Despite substantial improvement in type 2 diabetes (DM2) care, the burden of recurrent cardiovascular (CV) events remains high. Polyvascular disease (PVD), has recently emerged as a potential marker of heightened residual ischemic risk in DM2 patients, that are likely to derive a greater absolute risk reduction from more intense, individualized therapy.

Purpose

We sought to assess the relationship between DM2, PVD and CV outcomes among 2,168 all-comers patients admitted to four Swiss University Hospital for acute coronary syndrome (ACS) and enrolled in the prospective multicenter SPUM registry (NCT 01000701).

Methods

PVD was defined as concomitant peripheral artery disease, stroke or transient ischemic attack, or both. The composite primary endpoint was major adverse cardiac and cerebrovascular events (MACCE: Stroke, myocardial infarction, CV death). Adjusted Cox proportional hazards regression models were implemented to determine the risk associated with PVD disease in DM2 and outcomes, and intention-to-treat analysis was performed.

Results

Out of 2,168 ACS patients, 396 patients (18.3%) had DM2; of these 62 (15%) had PVD. Despite compared with the general ACS population, those with PVD + DM2 were more likely to have a complex history of CV disease, such as previous MI (27.4% vs 14.7%, p=0.021), prior percutaneous (37.1% vs 17%, p<0.001) or surgical (24.2% vs 5.1%, p<0.001) coronary revascularization, one third was not on statin therapy. At 1 year, patients with PVD + DM2 had a higher rate of MACCE compared to those presenting with PVD or DM2 alone. Rates of the single components of the primary endpoint and all-cause of death were all significantly higher in patients with PVD + DM2 vs. PVD or DM2 alone (Fig. 1A, all p<0.001). This enhanced risk persisted after adjustment for significant baseline differences, with a 34% (Adj. HR 1.34, 95% CI 1.15–1.49, p=0.02) increase in MACCE and a 44% increment of all cause of death (Adj. HR 1.44, 95% CI 1.06–1.54, p=0.02, Fig. 1B).

Outcomes by PVD and DM2 status.

Conclusions

Among a real-world cohort of ACS-patients, the coexistence of PVD and DM2 highlights the highest CV risk phenotype, being associated with significant increased rates of MACCE and all-cause of death. These observations might help clinicians to furtherly stratify the very high risk population and to identify patients who may derive the greatest benefit from more intense secondary prevention therapies.

Parental Correlates of Offspring Sex Ratio in Eurasian Oystercatchers

We investigated hatchling and fledgling sex ratios in Eurasian Oystercatchers (Haematopus ostralegus) using random amplified polymorphic DNA markers. The overall hatchling (53% males, n = 374 hatchlings from 177 broods) and fledgling (49% males, n = 51) sex ratio did not differ significantly from unity. Hatchling and fledgling sex ratios were not correlated with laying date, clutch size, brood size, egg-laying sequence, territory quality, male age, or male breeding experience, but hatchling sex ratio was positively correlated with age and breeding experience of females (0.05 < P < 0.075, n = 71). Older females produced more sons irrespective of the position of the offspring in the egg-laying sequence. Fledging mass was not correlated with female age, so the Trivers and Willard (1973) hypothesis is unlikely to explain our results. Sons dispersed less than daughters, so the local resource competition hypothesis of Clark (1978) might apply. The adaptive significance of a male-biased sex ratio in clutches produced by older females is speculative because the costs and benefits of dispersing versus philopatric offspring to parents and offspring are largely unknown.

Genetic analysis of the population structure of socially organized oystercatchers (Haematopus ostralegus) using microsatellites

On the island of Schiermonnikoog (The Netherlands), the breeding population of oystercatchers can be divided into two groups: 'residents' and 'leapfrogs', based on their distinct social characteristics and limited probabilities of status change between breeding seasons. In order to investigate whether this social organization has caused local genetic differentiation, leapfrogs and residents were compared at eight polymorphic microsatellite loci. No significant genetic subdivision between residents and leapfrogs was observed (theta = 0.0000; 95% confidence interval (CI), -0.0027-0.0033), indicating that the oystercatcher population on the island of Schiermonnikoog has to be considered as one panmictic unit. Investigation of three additional locations in the northern part of The Netherlands did not reveal significant genetic population subdivision either (theta = -0.0005; 95% CI, -0.0045-0.0037), despite the fact that adult osytercatchers show extreme fidelity to their breeding localities. These results indicate panmixis and considerable levels of gene flow within the northern part of The Netherlands. Thus, the results from genetical analyses do not seem to be in agreement with observational data on the dispersal behaviour of breeding individuals. It is argued that the lack of population structure, locally on Schiermonnikoog as well as across larger geographical distances, is to be attributed to high levels of gene flow through dispersal of juvenile birds.