Current lipid-lowering approach and LDL target achievement in very high-risk patients: in-hospital results of a high-volume primary percutaneous coronary intervention tertiary center

Funding Acknowledgements

Type of funding sources: None.

Background

Low-density lipoprotein-cholesterol (LDL-C) is a well-accepted causal risk factor for atherothrombotic cardiovascular disease. Several randomized controlled trials and meta-analyses have shown that lipid-lowering therapies reduce cardiovascular events and have a positive effect in reducing vulnerable plaques. In particular, the recommended target for LDL-C has become more and more stringent, moving to 1.4 mmol/l (55 mg/dl) for very high-risk patients. According to the 2019 ESC/EAS Guidelines, the current paradigm for lipid management favors a stepwise approach consisting of early initiation of high-intensity statin, followed by subsequent addition of ezetimibe, and ultimately a consideration of PCSK9 inhibitor treatment if LDL-C levels remain elevated.

Methods

We recruited 307 patients admitted for acute coronary syndrome (ACS) during the COVID-19 pandemic from March 2020 to December 2020. Baseline LDL-C concentration and prescribed hypolipemiant treatment at hospital admission and discharge were registered. Therefore, we included all consecutive patients identified as very-high cardiovascular risk, according to 2019 ESC guidelines. We stratified our population through variables independently associated with non-attainment of LDL-cholesterol such as hypertension, diabetes, peripheral arterial disease, clinical manifestations of ACS, number of main vessels treated, and complexity of the atherosclerotic disease.

Results

274 patients were included. Mean age was 69,9 years (SD 11,4), 20,8 % were women, 23,7 % had diabetes, 16,4 % had PAD and 32,1 % suffered from valvular disease, mainly with mitral regurgitation or aortic stenosis no more than mild or moderate. Of 25.1% with a previous history of acute myocardial infarction, the 33,3% of whom didn’t have statin therapy pre-ACS index (p =0,001). At admission, medium cholesterol levels of patients that underwent previous coronary revascularization (25,5% of the total population) were 84,21 ± 31,2 mg/dL, not in range according to both 2016 and 2019 ESC guidelines. At discharge, 77,37 % of all the patients included received only statin therapy VS 22,63% with statin plus ezetimibe. In the subpopulation of patients with recurring ACS events with LDL pre-admission > 100 mg/dL,despite high dose statin, only 25% of this population were discharged adding ezetimibe (VS 75% who kept on the treatment of high dose statin without up-titration).

Conclusions

Management of dyslipidemia is frequently suboptimal and the gap between guidelines and clinical practice for lipid management across Europe has been exacerbated by the 2019 guidelines. A greater utilization of non-statin lipid-lowering therapies is likely needed to reach the LDL-C optimal target. A correct stratification of the risk class would help to identify, in a personalized perspective of treatment, patients at very high risk that would take advantage of more aggressive therapy to reach the lowest target of LDL-C ("the lower is better").

Predictive factors of Permanent Pacemaker Implantation following Transcatheter Aortic Valve Replacement: membranous septum length and implantation depth evaluated with preoperative computed tomography

Background/Introduction

In the last decades, transcatheter aortic valve replacement (TAVR) revolutionized the treatment of symptomatic severe aortic stenosis. Cardiac conduction disturbances (CD) and the need for permanent pacemaker implantation (PPMI) remain the most frequent drawback of TAVR.The efficacy and safety of TAVR is proven not only in inoperable and high-risk patients, but TAVR use is increasing rapidly among intermediate- and low-risk populations, including progressively younger patients. In these prospective the risk of new-onset CD becomes increasingly important in clinical management. Several pre-procedural nonmodifiable factors (e.g., right bundle branch block [RBBB]) and modifiable factors (such as valve type and implantation depth) have been associated with conduction disturbances post-TAVR.

Purpose

The His bundle passes through the membranous septum (MS) and it is therefore not surprising that deeper valve implantation increases the likelihood of mechanical damage of the His bundle, leading to a transient or persistent CD. To date, it remains uncertain whether the association between valve type and CD relates primarily to a valve class effect or it is mainly secondary to differences in valve positioning accuracy and implantation depth between valve types. The aim of this study is to evaluate the length of the membranous septum (MS) and the implant depth (ID) in relation to the risk of permanent pacemaker (PPM) with both balloon-expandable (BE) and self-expanding (SE) transcatheter heart valves.

Methods

Of the 104 patients in the study, 79 patients underwent TAVIs with BE (44) and SE valves (35). Using preoperative computed tomography (CT) and angiography, MS length and implantation depth (ID) were retrospectively assessed. 14 patients were excluded for the presence of pre-TAVI PPM, 3 for the presence of congenital bicuspid aortic valve, 8 due to the presence of non-evaluable CT angiography.

Results

In the study population, out of the total of 79 patients, PPMs were implanted in 8 patients (10.12%), of which 7 in 35 (20%) patients undergoing TAVI with SE and 1 in 44 (2.27%) with BE valves. The measurements of MS was 4±2.1 mm for BE vs 3.3±2 mm for SE valves (p=0.141) and ID was 4.9±1.7 mm for BE vs 5.9±3.2 mm for SE valves (p=0.046). At multivariate logistic regression, two significant variables related to the post-TAVI PPMI were identified: MS (p=0.029) and ID (p=0.009), moreover the MS / ID ratio represents an additional predictor for PPMI regardless of the type of valve used (p=0.002).

Conclusion(s)

The study confirms the importance of the pre-TAVI MS length measurement for both types of valves. The only modifiable factor is the implantation technique which, knowing the PPMI's preoperative risk must be modified according to the patient's septum. Therefore it will be possible to modify the valve ID according to the patient's septum, looking for higher implants in higher-risk cases, particularly with self-expanding valves.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): No fundings

Determinants of homocysteine levels in colorectal and breast cancer patients

BACKGROUND

Homocysteinemia has been associated with oncogenic risk. This study was designed to investigate the homocysteine (Hcy) genotype/phenotype interactions together with the inflammatory and nutritional status of cancer patients.

PATIENTS AND METHODS

The Hcy levels were analyzed in 47 cancer patients in association with methylenetetrahydrofolate reductase (MTHFR) polymorphisms, folate and inflammatory markers.

RESULTS

The MTHFR C677T and A1298C genotype distributions did not differ from those predicted by the Hardy-Weinberg distribution. Conversely, the Hcy levels were higher in the cancer patients (p=0.04), who were also characterized by low-grade inflammation. The Hcy levels correlated with the interleukin-6 (IL-6) (p=0.001), tumor necrosis factor-alpha (TNF-alpha) (p=0.042) and folate (p<0.0001) levels of the patients. Multivariate analysis showed that TNF-alpha (p=0.014) and folate (p=0.019) were independent predictors of elevated Hcy levels in the cancer patients.

CONCLUSION

The MTHFR polymorphisms do not significantly contribute to tHcy (total Hcy) levels in cancer patients, and cancer-related inflammation may be associated with elevated tHcy levels, possibly involving a TNF-alpha mediated pathway.

Ganglioside content of human platelets--differences in resting and activated platelets

Gangliosides may play functional roles in platelet physiology, therefore this study has been designed to evaluate whether changes in ganglioside composition may occur as a consequence of platelet activation. The results obtained indicate that lactosylceramide and GM3 are the major glycosphingolipids of human platelets. The lipid-bound sialic acid (LBSA) content was 1.27 +/- 0.04 micrograms/mg of protein. Resting platelets did not express GD3; GD3 was synthesized upon platelet activation (24 +/- 8 ng/mg of protein). The stimulation of platelets with adenosine diphosphate showed the appearance of GD3 even in the absence of degranulation. Finally, incorporation of pyrene-labeled GM3 into platelet membranes, followed by stimulation with adenosine diphosphate, resulted in the appearance of a fluorescent band comigrating with GD3. The present studies indicate that sialytransferase activation may occur as an early event following platelet stimulation, leading to GD3 synthesis mainly from the GM3 pool.

Effects of storage on in vitro platelet responses: comparison of ACD and Na citrate anticoagulated samples

The present study was designed to evaluate whether the use of acid citrate dextrose (ACD) Formula A may enhance the survival of platelets during storage, thus allowing the continuance of platelet studies over the period of 2-3 hours usually recommended. For this purpose the effects of time on in vitro platelet response to several agonists have been investigated in platelet-rich plasma (PRP) obtained from blood samples anticoagulated with either Na citrate or ACD Formula A. The analysis of the data obtained in in vitro platelet aggregation studies using various parameters and at different time points demonstrated that storage of PRP obtained from citrated samples caused a marked reduction of platelet responses. This reduction was already evident after 6 hours, and a strong decrease was observed after 8 hours with all the agonists used. On the other hand, storage of ACD anticoagulated blood did not cause any significant decrease of platelet responsiveness up to 6 hours. A reduction of platelet aggregation became evident only after 8 hours, but not to the same extent as the one observed in citrated samples. Therefore, it may be concluded that the use of ACD Formula A as anticoagulant is capable of maintaining a normal platelet responsiveness up to 6-8 hours, thus permitting the investigation of platelet function for periods of time over those commonly recommended.

Acid citrate dextrose (ACD) formula A as a new anticoagulant in the measurement of in vitro platelet aggregation

To evaluate whether the use of ACD Formula A may affect in vitro platelet function, blood samples were obtained from 21 healthy blood donors and anticoagulated in ACD (acid-citrate dextrose, NIH Formula A), Na citrate 3.8%, and K3EDTA. Platelet count, mean platelet volume, and in vitro platelet aggregation were evaluated on each sample. No significant difference was observed in platelet count and mean platelet volume among the different samples. Conversely, the ACD treated platelets showed a higher reactivity to the agonists as demonstrated by a significant increase of the maximum percentages of aggregation induced by ADP, epinephrine, and collagen, as well as a significant decrease of secondary aggregation thresholds to ADP and epinephrine. In conclusion, it may be speculated that ACD Formula A is capable of better maintaining the intraplatelet signal transduction mechanisms during PRP preparation, thus improving the overall responsiveness of platelets.