Post-procedure anticoagulation in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

Background

Post-procedural anticoagulation (PPAC) after primary percutaneous coronary intervention (pPCI) in patient with ST-segment elevation myocardial infarction (STEMI) may prevent recurrent ischemic events but may increase the risk of bleeding. No consensus has been reached on PPAC use.

Methods

Using data from the CCC-ACS registry, conducted between 2014 and 2019, we stratified all STEMI patients who underwent pPCI according to the use of PPAC or not. Inverse probability of treatment weighting (IPTW) and Cox proportional hazards model with hospital as random effect were used to analyze differences in in-hospital clinical outcomes: the primary efficacy endpoint was mortality, and the primary safety endpoint was major bleeding.

Results

Of 34,826 evaluable patients 26,272 (75.4%) were treated with PPAC, and were on average younger, more stable at admission with lower bleeding risk score, more likely to have comorbidities and multivessel disease, and more often treated within 12 hours of symptom onset than those without PPAC. After IPTW adjustment for baseline differences, PPAC was associated with significantly reduced risk of in-hospital mortality (0.9% vs. 1.8%; hazard ratio (HR): 0.62 [95% confidence interval 0.43, 0.89]; p<0.001) and a nonsignificant difference in risk of in-hospital major bleeding (2.5% vs. 2.2%; HR: 1.05 [0.83, 1.32]; p=0.14).

Conclusions

PPAC in STEMI patients after pPCI was associated with reduced mortality without increasing major bleeding complications. Dedicated randomized trials with contemporary STEMI management are needed to confirm these findings.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Improving Care for Cardiovascular Disease in China – Acute Coronary Syndrome (CCC-ACS) project is a collaborative study of the American Heart Association (AHA) and the Chinese Society of Cardiology (CSC). The AHA has been funded by Pfizer and AstraZeneca for quality improvement initiatives through an independent grant. In-hospital clinical outcomes

P3797Increased risk of cardiovascular events and stroke among patients with atrial fibrillation and obstructive sleep apnea

Background

Obstructive sleep apnea (OSA) is common in patients with atrial fibrillation (AF). It is not well understood if OSA impacts cardiovascular outcomes in patients with AF.

Purpose

To investigate patient characteristics and major adverse cardiovascular and neurological events (MACNE) in patients with AF and OSA.

Methods

Using the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF I) and ORBIT-AF II we compared the adjusted risk of the composite of cardiovascular death, myocardial infarction, stroke/transient ischemic attack/non-CNS embolism (stroke/SE), and new-onset heart failure (MACNE) according to the presence or absence of OSA, using multivariable adjusted Cox proportional hazard models. Secondary outcomes were the individual components of MACNE.

Results

Among 22,760 patients with AF, there were 4,045 (17.8%) with OSA at baseline. Median follow-up time was 1.5 (IQR: 1–2.2) years. OSA patients were younger (median [IQR] 68 [61–75] years vs. 74 [66–81] years, were more likely to be male (70.7% vs. 55.3%), and had markedly increased body mass index (BMI) (median 34.6 kg/m2 [29.8–40.2] vs. 28.7 kg/m2 [25.2–33.0]). Those with OSA had a higher prevalence of diabetes (39.2% vs. 25.2%), chronic obstructive pulmonary disease (COPD) (20% vs. 12%), heart failure (32.2% vs. 25.1%), and hyperlipidemia (73.2% vs. 66.7%). After adjustment, the presence of OSA was significantly associated with MACNE (HR: 1.16 [95% CI: 1.03–1.31], p=0.011) [Figure]. Stroke/SE was higher in patients with OSA (HR: 1.38 [95% CI 1.12–1.70], p=0.003). Addition of OSA to a model containing the CHA2DS2-VASc risk factors slightly improved discrimination for stroke/SE: CHA2DS2-VASc risk factors alone C-index (Standard Error) was 0.6867 (0.0125) vs. CHA2DS2-VASc risk factors plus OSA 0.6876 (0.0124), p=0.022.

Figure 1. Hazard ratios with 95% confidence intervals and event rates for the association between obstructive sleep apnea and major adverse cardiovascular and neurological events combined and separately. Abbreviations: OSA; obstructive sleep apnea MACNE; major adverse cardiovascular and neurological events, CV; cardiovascular, TIA; transient ischemic attack.

Conclusion

One in five patients with AF in community practice had OSA. The presence of OSA was associated with higher risk of MACNE and stroke/SE. Addition of OSA to CHA2DS2-VASc risk factors only slightly improved discrimination for the occurrence of stroke.

Acknowledgement/Funding

The Danish Heart Foundation, T32 NIH Grant HL079896. The ORBIT-AF registry is sponsored by Janssen.

Sexuality of patients with advanced heart failure and their spouses or partners

BACKGROUND

Sexuality is an important aspect of quality of life for patients with advanced heart failure and their spouses or partners. Therefore, we conducted a study to determine the types of sexual problems and concerns of patients and their spouses/partners, their level of interest in receiving information on this topic, and the relationship between their need for information and the degree of sexual problems.

METHODS

Sixty-three couples were recruited from a university-affiliated, outpatient, heart failure program during their initial visit.

RESULTS

The most important sexual relationship issue of both patients and spouses/partners was related to decreased frequency in sexual relations. They reported the need to receive specific information about sexual activity as moderate to very high, but it was unrelated to the level of need for education and counseling.

CONCLUSIONS

Nurses and physicians need to assume interest and provide instruction related to the sexual activity needs of patients and their spouses/partners.

Relationship between right and left-sided filling pressures in 1000 patients with advanced heart failure

BACKGROUND

Elevated left ventricular filling pressures present a major target of therapy for symptomatic heart failure but are difficult to assess directly. Because the relationship of left- and right-sided pressures remains ill defined in chronic heart failure, this study compared 3 right-sided measurements (right atrial [RA] pressure, pulmonary artery systolic [PAS] pressure, and severity of tricuspid regurgitation [TR]) to the pulmonary capillary wedge (PCW) pressure.

METHODS

Hemodynamic measurements and echocardiography were available from 1000 patients undergoing transplant evaluation. Right atrial and PAS pressure, and TR severity were compared to PCW pressure. For 754 patients undergoing repeat measurements, changes in RA and PAS pressures were compared to PCW changes.

RESULTS

Right atrial pressure correlated with PCW pressure (r = 0.64), regardless of etiology or TR severity. Right atrial pressure changes correlated with PCW changes (r = 0.62). Discordance was defined as either RA > or = 10 mm Hg despite PCW < 22 mm Hg (6%) or RA < 10 mm Hg despite PCW > or = 22 mm Hg (15%). For detection of PCW > or = 22 mm Hg, positive predictive values were 88% for RA > or = 10 mm Hg, 95% for PAS > or = 60 mm Hg, and 79% for > or = moderate TR. Pulmonary artery systolic pressure correlated very closely with PCW (r = 0.79), and could be estimated as 2 x PCW. Reduction in PAS pressure during therapy was strongly determined by PCW pressure reduction (r = 0.67).

CONCLUSIONS

Accurate estimation of RA pressure can potentially guide therapy of left ventricular filling pressures in approximately 80% of chronic heart failure patients without obvious non-cardiac disease. In this population, elevated PAS pressures are largely determined by elevated left-sided filling pressures.

The University of California at Los Angeles experience in heart transplantation

In the last decade, the number of patients undergoing heart transplant has steadily increased as a result of expanding indications for this procedure. The limitation on the number of transplants performed has been the number of donor organs available. At UCLA, 900 heart transplant procedures have been performed from 1984-1998. Since 1991, the percent of patients free from rejection and infection in the first year after transplant was 70% and 73%, respectively. Actuarial one-, 3-, and 5-year survival rates are 84%, 76%, and 72%, respectively. Survival of patients aged 60 years and over (n = 105) was comparable to that of patients under age 60. We have been pursuing corticosteroid-free immunosuppression, which has led to a decrease in infection complications. Our work with pravastatin early after transplantation has led to a decrease in clinically severe rejection episodes, which has translated into improved survival. Pravastatin also appears to decrease the development of transplant coronary artery disease and appears to have an adjunct immunosuppressive effect in our heart transplant patients on CsA-based immunosuppression. We have also demonstrated benefit of cardiac rehabilitation early after transplant which should therefore be considered as standard postoperative care. Finally, we have participated and led the multicenter mycophenolate study in demonstrating this drug's effectiveness in improved outcomes in primary heart transplant recipients. Future studies include the use of Rapamycin and interleukin-2 receptor blockers which have been demonstrated in kidney transplantation to significantly reduce rejection. Our program is committed to seek better ways to improve outcome and the quality of life of our heart transplant patients.

The alternate recipient list for heart transplantation: does it work?

BACKGROUND

One quarter of patients awaiting heart transplantation die while on the waiting list. This is largely due to the shortage of donor organs. The alternate recipient list was created to establish a means by which patients who would otherwise be turned down for heart transplantation solely because of age over 65 or a need for a third heart transplantation can receive organs considered marginal that may otherwise be wasted. The hope is that these patients may achieve improved survival with these substandard hearts than they would achieve with medical therapy alone.

METHODS

Twenty-two patients ages 47 to 71 years (mean 66.7 years) were listed on the alternate recipient list at the University of California at Los Angeles Medical Center from 1991 to 1996. Seventeen patients underwent heart transplantation from the alternate waiting list. The outcome of this group was compared with the outcome of a contemporaneous group of 266 patients ages 18 to 66 years (mean age 52.1 years) from the standard heart transplantation waiting list.

RESULTS

The early mortality rate for the patients in the alternate group was 11.8% (2/ 17). Actuarial survival from time of orthotopic heart transplantation at 6 months and 1 year was the same 74.5% at a mean follow-up was 13.4 months. In comparison, the early mortality rate for the patients on the standard list was 5.6% (15/266), and actuarial survival at 6 months and 1 year was 86.8% and 83.1%, respectively (mean follow-up was 30 months). There was no significant difference in early mortality rate or actuarial survival between the two groups.

CONCLUSION

The alternate recipient list for heart transplantation is a valid and ethical option for patients who would otherwise be denied heart transplantation. It provides these patients with similar early and medium-term outcomes in comparison to patients on the standard list, and organs that may otherwise be wasted are used.

Estimation of the left ventricular ejection fraction using a novel multiphase, dark-blood, breath-hold MR imaging technique

OBJECTIVE

In this paper, we evaluate a recently proposed dual-phase dark-blood MR sequence for estimating the left ventricular ejection fraction, compare Simpson's method of estimation of ejection fraction with a model based on the biplane method, assess the reproducibility of both methods, and finally, test a semiautomated method for contouring the endocardial border.

SUBJECTS AND METHODS

An MR pulse sequence was implemented to acquire cardiac images in both diastolic and systolic phases within a single breath-hold. A special magnetization preparation scheme rendered blood dark while a segmented acquisition allowed breath-hold scan times. Five healthy volunteers and five patients with cardiac disease were imaged. Ejection fractions were estimated using (1) long-axis and four-chamber biplane views with an ellipsoid model and (2) a series of short-axis views in combination with Simpson's model. These values of ejection fractions were then compared with values obtained from echocardiography.

RESULTS

Estimates of ejection fractions obtained using biplane ellipsoid volume and Simpson's rule methods varied by 14% in healthy volunteers. However, for patients with severe cardiomyopathy, differences between the values of ejection fraction obtained with the two methods varied by as much as 150%. Ejection fraction estimates obtained from MR images with the biplane ellipsoid method and from echocardiography varied by approximately 14% for all subjects. Ejection fraction estimates obtained with the semiautomated algorithm agreed well with estimates obtained with manual contours made by experienced radiologists. Intraobserver variability was low for both the short-axis (3%) and biplane (4%) methods. However, interobserver variability of the biplane method (12%) exceeded that of the short-axis method (4%). Interexamination variability (9%) was the largest factor in determining the reproducibility of the ejection fraction estimates.

CONCLUSION

Breath-hold dark-blood MR imaging technique with simultaneous acquisition of a series of short-axis views during systolic and diastolic phases permits rapid and accurate estimates of ejection fractions in healthy subjects and in patients. Model based biplane MR imaging methods are less reliable in patients with global cardiomyopathy. The estimation of ejection fractions can be automated using the proposed contouring algorithm and the dark-blood short-axis views.

Target heart failure populations for newer therapies

BACKGROUND

The scarcity of donor hearts has created a large population of heart failure patients who are unlikely to undergo transplantation. Newer surgical therapies that might sustain such patients at home previously have been applied in critical situations in which early outcome is jeopardized by multiorgan failure. The optimal population for studies of extended support would be ambulatory patients with low operative risk but high risk of later unfavorable outcome.

METHODS AND RESULTS

Baseline clinical, echocardiographic, and hemodynamic data were collected prospectively between 1988 and 1993 in 500 patients who were discharged on tailored medical therapy after evaluation for transplantation. Specific criteria were examined to identify high risk of death or need for urgent transplantation during the next 2 years. In 265 patients with ejection fraction < or = 25% and initial New York Heart Association class IV symptoms, survival at 2 years was 55% (without urgent transplantation, 45%). Lower cardiac index or higher filling pressures at the time of referral did not confer higher risk, which was predicted by persistence of higher pressures after therapy. Serum sodium below 133 was associated with 34% 2-year survival without urgent transplantation, and ventricular dimension > 80 mm with a rate of 25%. Patients with initial peak oxygen consumption > 10 mL/kg per minute had a 2-year event-free rate of 72% compared with 48% for those with < 10 mL/kg per minute and 32% for those unable to exercise at referral. Demonstration of a 30% decrease in mortality with a controlled trial of new therapy in patients with ejection fraction < or = 25% would require 600 patients with class III symptoms or almost 300 patients with class IV symptoms unless another criterion were added.

CONCLUSIONS

Ambulatory populations with high predicted event rates can be identified at initial evaluation, when hemodynamic criteria may be less useful than ventricular dimension, serum sodium, and ability to exercise. The use of outcome data from previous eras may lead to overestimation of benefits from newer therapies and underestimation of the sample size required in a prospective trials.

The University of California at Los Angeles experience in heart transplantation

In the last decade, the number of patients undergoing heart transplantation has steadily increased as a result of expanding indications for cardiac transplantation. The limitation on the number of transplants performed has been the number of donor organs available. At UCLA, 511 heart transplant procedures were performed from 1984-1994. The mean number of rejection episodes and infections per patient in the first year after transplant was 1.1+/-1.3 and 1.0+/-1.2, respectively. Actuarial one-, 3-, and 5-year survival rates were 84%, 77% and 73%, respectively. Survival of patients age 60 years and over (n=105) was comparable to that of patients under age 60. Despite transplanting more critically ill patients (Status 1) and having longer cold ischemic times, outcomes have been improving. We have been pursuing corticosteroid-free immunosuppression, which no doubt has led to the decrease in infection complications. Furthermore, our work with pravastatin early after transplantation has led to a decrease in clinically severe rejection episodes which has translated into improved survival. Pravastatin also appeared to decrease the development of transplant coronary artery disease and appeared to have an adjunct immunosuppressive effect in our heart transplant patients on CsA-based immunosuppression. Future studies will include the use of mycophenolate mofetil which has properties against B-lymphocytes in addition to T-lymphocytes to block both humoral and cellular rejection. Our program continues to seek better ways to improve survival and the quality of life of our patient population.

Improvement in exercise capacity of candidates awaiting heart transplantation

OBJECTIVES

This study determined the frequency of improvement in peak oxygen uptake and its role in reevaluation of candidates awaiting heart transplantation.

BACKGROUND

Ambulatory candidates for transplantation usually wait > 6 months to undergo the procedure, and during this period symptoms may lessen, and peak oxygen uptake may improve. Whereas initial transplant candidacy is based increasingly on objective criteria, there are no established guidelines for reevaluation to determine who can leave the active waiting list.

METHODS

All ambulatory transplant candidates with initial peak oxygen uptake < 14 ml/kg per min were identified. Of 107 such patients listed, 68 survived without early deterioration or transplantation to undergo repeat exercise. A strategy of reevaluation using specific clinical criteria and exercise performance was tested to determine whether patients with improved oxygen uptake could safely be followed without transplantation.

RESULTS

In 38 of the 68 patients, peak oxygen uptake increased by > or = 2 ml/kg per min to a level > or = 12 ml/kg per min after 6 +/- 5 months, together with an increase in anaerobic threshold, peak oxygen pulse and exercise heart rate reserve and a decrease in heart rate at rest. Increased peak oxygen uptake was accompanied by stable clinical status without congestion in 31 of 38 patients, and these 31 were taken off the active waiting list. At 2 years, their actuarial survival rate was 100%, and the survival rate without relisting for transplantation was 85%.

CONCLUSION

Reevaluation of exercise capacity and clinical status allowed removal of 31 (29%) of 107 ambulatory transplant candidates from the waiting list with excellent early survival despite low peak oxygen uptake on initial testing. The ability to increase peak oxygen uptake, particularly with increased peak oxygen pulse, may indicate improved prognosis as well as functional capacity and, in combination with stable clinical status, may be an indication to defer transplantation in favor of more compromised candidates.

Predicting death from progressive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy

Data were retrospectively reviewed on 528 consecutive patients hospitalized for treatment of advanced heart failure (left ventricular ejection fraction 0.2 +/- 0.07) and cardiac transplant evaluation, who were stabilized with medical therapy and discharged home. Predictors of heart failure death or rehospitalization for urgent transplantation were identified using the Cox proportional-hazards model. Within 1 year, 59 patients (11%) died suddenly and 70 (13%) died of heart failure or required urgent transplantation. A serum sodium < or = 134 mEq/liter, pulmonary arterial diastolic pressure > 19 mm Hg, left ventricular diastolic dimension index > 44 mm/m2, peak oxygen consumption during exercise testing < 11 ml/kg/min and the presence of a permanent pacemaker were independent predictors of hemodynamic deterioration. In the absence of these risk factors the risk of hemodynamic deterioration within 1 year from this study was only 2%. This risk increased to > 50% in the presence of hyponatremia and any 2 additional risk factors. Thus, patients with advanced heart failure at highest risk for progressive hemodynamic deterioration can be identified from clinical variables that could aid in triaging such patients to earlier cardiac transplantation.

Vasodilators. A re-evaluation of their role in heart failure

Over the past 25 years, the concept of circulation in heart failure has evolved from that of a simple circuit with a weak pump and high pressures to a complex integrated system of cellular modification, cardiac compensation and systemic neurohumoral responses. The original model of cardiac afterload as the systemic vascular resistance has been refined to reflect the interdependence of preload and afterload and the central role of atrioventricular valve regurgitation. It is becoming increasingly apparent that the impact of vasodilator therapy far exceeds the direct haemodynamic effects on preload and afterload, and depends on the mechanism by which vasodilation is achieved, with increasing emphasis on those agents which oppose neurohumoral activation. The potential goals of therapy have broadened to include not only haemodynamic stabilisation through tailored therapy for patients referred with advanced heart failure, but also the prevention of disease progression for patients with asymptomatic ventricular dilation. As the different profiles of heart failure have come to be recognised, the purpose and design of vasodilator treatment must now be considered individually for each patient.