Complex high-risk indicated percutaneous coronary interventions (CHIP-PCI) in elderly patients

Introduction

Complex high-risk indicated percutaneous coronary intervention (CHIP-PCI) is a poorly defined concept. A recent large-scale study identified various patient- and procedure-related factors that were associated with in-hospital major adverse cardiac or cerebrovascular events (MACCE), which were used to construct a CHIP-score [1].

Purpose

To investigate the predictive value of patient- and procedure related risk factors, based on the CHIP-score, in a large cohort of elderly patients.

Methods

This is a retrospective multicenter study of 20 centers, including patients of ≥75 years of age, that underwent PCI in the period of 2012–2019. The primary endpoint of MACCE was defined as cardiovascular death, myocardial infarction, revascularization or stroke. The follow-up time was 1 year. We created univariate and multivariate Cox regression models in order to investigate the predictive value of the CHIP-score variables (other than age, Table 2).

Results

A total of 2724 patients with a mean age of 81 (± 4.3) years were included in the study. Baseline characteristics are depicted in Table 1. The mean CHIP score was 1.74 (± 1.2) and 2262 (83%) had at least one CHIP criteria. At 1-year follow-up, 267 (9.8%) met the primary endpoint. Out of 11 investigated CHIP-score variables, only 5 were independent predictors of 1-year MACCE in adjusted regression models: Prior myocardial infarction (HR 1.56 (95% CI: 1.10–1.90), p=0.009), left ventricular ejection fraction <30% (HR: 2.02 (95% CI: 1.34–3.0, p<0.001), chronic kidney disease (HR 1.55 (95% CI: 1.21–2.02, p<0.001), left main coronary PCI (HR: 2.35 (95% CI: 1.29–4.89, p<0.001) and non-radial access (HR: 1.57 (95% CI: 1.19–1.85, p=0.002). See Table 2 for details. Overall MACCE was 4.5% when CHIP was 0, as compared to 10.7% with any CHIP factor present (p<0.001) (Figure 1). A CHIP of 4+ or higher was present in 246 (9%) patients and was associated with a three-fold increase in 1-year MACCE (HR: 2.9 (95% CI: 2.1–3.9), p<0.001).

Conclusions

The CHIP-score retains significant prognostic value in the elderly population. The implication of a CHIP-score might be a future tool for risk stratification in clinical practice, not only for in-hospital MACCE but also on long-term follow-up. In the special population of elderly patients, 3 patient related and 2 procedure related factors showed to be especially helpful for risk assessment.

Funding Acknowledgement

Type of funding sources: None.

Antithrombotic strategies in elderly patients with atrial fibrillation revascularized with drug-eluting stents: PACO-PCI (EPIC-15) registry

Background

The strategy of antithrombotic therapy in patients with atrial fibrillation (AF) after revascularization with drug-eluting stents continues to be debated. The evidence in elderly population in this scenario is particularly scarce.

Purpose

We sought to investigate the antithrombotic regimens applied and their prognostic effects in patients over 75 years old with AF after revascularization with drug-eluting stents.

Methods

Retrospective registry in 20 centers including consecutive patients over 75 years with AF treated with drug-eluting stents. A primary endpoint of MACCE and a co-primary endpoint of major bleeding by ISTH criteria were considered at 12 months.

Results

Out of 41,000 patients undergoing PCI 1,249 patients (81.1±4.2 years, 33.1% women, 66.6% ACS, 30.6% complex PCI) were included. Triple antithrombotic therapy (TAT) was prescribed in 81.7% and dual antithrombotic therapy (DAT) in 18.3%. TAT was based on direct oral anticoagulants (DOAC) in 48.4% and maintained for only 1 month in 52.2%, and DAT included DOAC in 70.6%. Primary endpoint of MACCE was met in 9.6% and primary endpoint of major bleeding in 9.4%. TAT was significantly associated with more bleeding (10.2% vs. 6.1%, p=0.04) but less MACCE (8.7% vs. 13.6%, p=0.02) than DAT and the use of DOAC was significantly associated to less bleeding (8% vs. 11.1%, p=0.03) and similar MACCE (9.8% vs. 9.4%, p=0.8). TAT over 1 month or with VKA was associated with more major bleeding but comparable MACCE rates.

Conclusions

Despite advanced age TAT prevails, but prolonged durations or use of VKA are associated with increased bleeding without additional MACCE prevention. DAT reduces bleeding but with a trade-off in terms of ischemic events. DOAC use was significantly associated to less bleeding and similar MACCE rates.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Bristol-Myers-Squibb/Pfizer

Impact of COVID-19 disease on platelet reactivity and association with inflammatory parameters

Background

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the pathogen responsible for the coronavirus disease 2019 (COVID-19) pandemic. Aside from the pulmonary manifestations, COVID-19 is associated with increased risk of venous and arterial thrombotic complications. The actual impact of SARS-CoV-2 infection on platelet reactivity and whether this is mediated by a hyperinflammatory status has not been fully elucidated to date.

Objective

To evaluate platelet reactivity in COVID-19 patients compared to healthy subjects and to assess the association between platelet reactivity and levels of inflammatory biomarkers among COVID-19 patients.

Methods

This prospective observational investigation included COVID-19 patients admitted into a tertiary care hospital and adult healthy volunteers, all of them not receiving any antiplatelet therapy. Subjects were classified in three groups: 1) Healthy subjects (HS group); 2) COVID-19 patients in a pulmonary phase (viral pneumonia and bilateral infiltrates) but without meeting criteria for systemic hyperinflammation (C19-Pulm group); and 3) COVID-19 patients in a hyperinflammation phase (C19-Infl group) meeting at least 2 of the following criteria: CRP>100mg/l, D-dimer >1000mcg/l, LDH>400U/l, ferritin>1000ng/ml, IL-6>70ng/l. Blood samples for platelet function testing and quantification of inflammatory parkers were collected at a single visit. Platelet function was measured with multiple electrode aggregometry using ADP (MEA-ADP, primary endpoint), arachidonic acid (AA) and thrombin receptor activating peptide (TRAP) as stimuli. Unadjusted analyses are presented.

Results

A total of 60 patients were included in the present investigation (20 in each group). A significantly greater platelet reactivity, measured with MEA-ADP, was observed in both groups of COVID-patients compared to healthy subjects (HS: 634,9±53,5, C19-Pulm: 919,9±53,5 and C19-Infl: 931,6±53,5 AU*min; p for C19-Pulm vs. HS <0,001, p for C19-Infl vs. HS <0,001, p for C19-Pulm vs. C19-Infl 0,878; Figure 1). Parallel findings were found when using AA as stimulus for platelet aggregation showing greater platelet aggregation in COVID-19 patients compared to healthy subjects, but numerical differences were not statistically significant when using TRAP. Among COVID-19 patients, when stratified by IL-6 levels splitted into tertiles, greater platelet reactivity was observed in patients with higher IL-6 concentrations (mid and upper tertile together) compared to those with values in the lower tertile, as assessed with MEA-ADP (lower tertile: 829,0±75,8, mid and upper tertile: 1028,7±56,2; p=0,043); a similar trend was observed with AA and TRAP as stimuli.

Conclusion

Patients with severe COVID-19 disease have greater platelet reactivity than healthy subjects. Increased IL-6 levels might be associated with the observed heightened platelet reactivity among COVID-19 patients.

Funding Acknowledgement

Type of funding sources: None.

Neurohormonal activation induces intracellular iron deficiency and mitochondrial dysfunction in cardiac cells

Background

Iron deficiency (ID) is common in patients with heart failure (HF) and is associated with poor outcomes, yet its role in the pathophysiology of HF is not well-defined. We sought to determine the consequences of HF neurohormonal activation in iron homeostasis and mitochondrial function in cardiac cells.

Methods

HF was induced in C57BL/6 mice by using isoproterenol osmotic pumps and embryonic rat heart-derived H9c2 cells were subsequently challenged with Angiotensin II and/or Norepinephrine. The expression of several genes and proteins related to intracellular iron metabolism were assessed by Real time-PCR and immunoblotting, respectively. The intracellular iron levels were also determined. Mitochondrial function was analyzed by studying the mitochondrial membrane potential, the accumulation of radical oxygen species (ROS) and the adenosine triphosphate (ATP) production.

Results

Hearts from isoproterenol-stimulated mice showed a decreased in both mRNA and protein levels of iron regulatory proteins, transferrin receptor 1, ferroportin 1 and hepcidin compared to control mice. Furthermore, mitoferrin 2 and mitochondrial ferritin were also downregulated in the hearts from HF mice. Similar data regarding these key iron regulatory molecules were found in the H9c2 cells challenged with neurohormonal stimuli. Accordingly, a depletion of intracellular iron levels was found in the stimulated cells compared to non-stimulated cells, as well as in the hearts from the isoproterenol-induced HF mice. Finally, neurohormonal activation impaired mitochondrial function as indicated by the accumulation of ROS, the impaired mitochondrial membrane potential and the decrease in the ATP levels in the cardiac cells.

Conclusions

HF characteristic neurohormonal activation induced changes in the regulation of key molecules involved in iron homeostasis, reduced intracellular iron levels and impaired mitochondrial function. The current results suggest that iron could be involved in the pathophysiology of HF.

P1515Female sex is an independent predictor of mortality in patients with STEMI in Spain: a study in 325,017 episodes over 11 years (2005–2015)

Background

Recent studies reported a decrease in the mortality of ST-elevation myocardial infarction (STEMI) patients. This favorable evolution could not extend to women. The interaction between gender and mortality in STEMI remains controversial.

Purpose

To assess the impact of female sex on mortality of patients with STEMI through of period of 11 years.

Methods

We conducted a retrospective longitudinal study using information provided by the minimal database system of the Spanish National Health System to identify all hospitalizations in patients aged 35–94 years with the principal diagnosis of STEMI from 2005–2015.

Results

A total of 325,017 STEMI were identified. Of them, 273,182 were included, and 106,277 (38.8%) were women. Women were older than men and had more comorbidities. Through the study period 53% men vs 37.2% underwent PTCA; women presented more frequently heart failure, shock and stroke than men (p<0.001, respectively). The mean crude in-hospital mortality rate for the whole study period was higher in women (OR: 2.18; 95% CI: 2.12.-2.23, p<0.0001). Female sex was independently associated with higher in-hospital mortality (adjusted OR: 1.18; 95% CI: 1.14–1.22, p<0.001) (Table 1). The risk was maintained through the whole study period (lower OR: 1.14 in 2014; higher OR: 1.28 in 2006).

Table 1. Variables independently associated with in-hospital mortality adjusted by risk in a multilevel logistic regression model, 2005–2015 STEMI In-hospital mortality Odds Ratio P 95% CI Woman 1.18 <0.001 1.14 1.22 Age 1.06 <0.001 1.06 1.06 History of PTCA 1.58 <0.001 1.40 1.77 Congestive heart failure 1.26 <0.001 1.22 1.30 Acute Myocardial Infarction 1.84 <0.001 1.54 2.20 Anterior myocardial infarction 1.47 <0.001 1.23 1.76 Cardio-respiratory failure or shock 15.25 <0.001 14.78 15.75 Hypertension 0.81 <0.001 0.79 0.84 Stroke 5.76 <0.001 5.18 6.42 Cerebrovascular disease 0.86 <0.001 0.79 0.93 Renal failure 1.95 <0.001 1.88 2.02 Vascular disease and complications 7.03 <0.001 5.72 8.63 CI, Confidence Interval.

Conclusions

Female sex is an independent predictor of mortality in patients with STEMI in Spain, maintaining through a period of the 11 years.

255Impact of the type of acute coronary syndrome on the pharmocodynamic response to P2Y12 inhibitors in the acute and maintenance phase of therapy

Background

The presence of an acute coronary syndrome (ACS) is per se a predictor of reduced responsiveness to clopidogrel; in particular, patients with ST-elevation myocardial infarction (STEMI) have impaired clopidogrel-induced platelet inhibition than those with other forms of ACS. However, the impact of the type of ACS on the pharmocodynamic efficacy of more potent P2Y12 antagonists such as prasugrel or ticagrelor has not been fully elucidated to date.

Purpose

To assess the impact of the type of ACS on platelet inhibition mediated by P2Y12 receptor antagonists in the acute and the maintenance phase of therapy in a contemporary cohort of ACS patients undergoing percutaneous coronary intervention (PCI).

Methods

Substudy of a prospective, national, multicentre, pharmacodynamic registry conducted in a population of ACS patients undergoing PCI and treated with dual antiplatelet therapy including aspirin and a P2Y12 inhibitor as per clinical indication. Patients were classified according to the ACS diagnosis into groups: a) STEMI, b) non-ST-elevation ACS (NSTEACS), c) unstable angina (UA), and d) other (excluded from the present analysis). Platelet function tests (PFT) were performed at day 1 and day 30 (±5) after PCI and included: 1) VerifyNow P2Y12 assay, expressed as P2Y12 reaction units (PRUs); 2) Vasodilator-stimulated phosphoprotein (VASP) assay; and 3) Multiple electrode aggregometry (MEA).

Results

A total of 965 patients (372 with STEMI, 395 with NSTEACS and 198 with UA) were included in the present substudy. At day 1, the proportions of patients with each type of ACS according to the P2Y12 inhibitor received were: 1) clopidogrel (n=317): STEMI 35.0%, NSTEACS 34.4% and UA 30.6%; 2) prasugrel (n=192): STEMI 70.3%, NSTEACS 17.7% and UA 12.0%; 3) ticagrelor (n=456): STEMI 27.6%, NSTEACS 55.3% and UA 17.1%. A statistically significant reduced platelet inhibition, measured with the VerifyNow system, was observed in STEMI patients compared with the other forms of ACS in patients receiving clopidogrel (STEMI: 217.3±8.1, NSTEACS: 157.1±7.9 and UA: 164.9±8.6 PRUs; p for STEMI vs. NSTEACS <0.001 and p for STEMI vs. UA <0.001) and ticagrelor (STEMI: 57.7±3.8, NSTEACS: 45.2.1±2.6 and UA: 40.6±4.9 PRUs; p for STEMI vs. NSTEACS 0.008 and p for STEMI vs. UA 0.007), while a numerical trend towards greater platelet reactivity in STEMI compared to UA was observed in subjects receiving prasugrel (Figure). Remarkably, at day 30, no significant differences on platelet inhibition were observed according to the ACS type with any of the P2Y12 inhibitors. Similar results were observed with MEA and VASP assays.

PD response according to the ACS type

Conclusions

Patients presenting with STEMI have impaired platelet inhibition mediated by P2Y12 antagonists compared to other types of ACS during the acute phase of therapy, whereas no difference is observed during the maintenance phase of treatment.

Acknowledgement/Funding

Funded by Instituto de Salud Carlos III through the project PI13/01012 (co-funded by European Regional Development Fund. ERDF, a way to build Europe)

P3605Lower benefit of women than men with ST-elevation myocardial infarction networks system in Spain: a study of 325,017 episodes over 10 years (2005–2015)

Background

Sex differences are known to exist in the management of women presenting with ST elevation myocardial infarction (STEMI).Few studies have examined whether the clinical management and prognosis differs by sex when the STEMI network system is applied.

Purpose

To assess whether the STEMI network system improves management and prognosis both in men and women in Spain and to analyze possible differences according to sex.

Methods

We conducted a retrospective longitudinal study using information provided by the minimal database system (MDBS) of the Spanish National Health System (SNHS) to identify all hospitalizations in patients aged 35–94 years with the principal diagnosis of STEMI from 2005–2015. The risk-standardized in-hospital mortality ratio (RSMR) was defined as the ratio between predicted mortality and expected mortality, multiplied by the crude rate of mortality. The RSMR was calculated using multilevel risk adjustment models developed by the Medicare and Medicaid Services. The year of the development of organized systems of care for STEMI patients in the different Autonomous Communities was double-checked using data from the National Cardiac Catheterization and Interventional Cardiology Annual Registry. RSMR was used to compare outcomes related with gender and with the presence of regional AMI networks and the performance of PCI. Temporal trends for in-hospital mortality during the observed period were modeled using Poisson regression analysis with year as the only independent variable. In all models, incidence rate ratios (IRR) and their 95% confidence intervals (95% CI) were calculated.

Results

A total of 325,017 STEMI were identified among patients aged 35–94 years old. Of them 273,182 were selected after exclusions, and 106,277 (38.8%) were women. Women were on average 10 years older than men and had more comorbidities burden. The overall proportion of STEMI patients underwent to PCI increased, when a regional STEMI network was present from 2005–2015: (63.7% vs 48.2% in men; and 47.4% vs 32.9% in women; p<0.001). Differences in crude mortality between sexes was 15%, maintaining through 10 years, despite a higher increased of PCI (figure 1).However, women were less likely to be treated with PCI even though when STEMI network was stablished (63.7% vs 48.2% in men, 47.4% vs 32.9% in women, p<0.001) (figure 1).The mean crude in-hospital mortality rate for the whole study period was higher in women (9.3% vs 18.3%; unadjusted OR: 2.18, 95% CI: 2.12.-2.23, p<0.0001). RSMR was lower for women when STEMI network were working (17.7% vs. 19.7%; p<0.001).PCI and the presence of STEMI network were associated with a lower in-hospital mortality in STEMI women (adjusted OR, 0.48; 95% CI 0.41–0.52 and OR, 0.84; 95% CI 0.79–0.89, p<0.001, respectively).

Conclusions

Women were less likely to be treated with PCI and had higher in-hospital risk-adjusted mortality than men, despite the existence of STEMI network system.

Antiplatelet therapy: new pharmacological agents and changing paradigms

Recurrent atherothrombotic events in patients with acute coronary syndromes (ACS) and/or those undergoing percutaneous coronary intervention (PCI) are essentially platelet-driven processes, underscoring the need for effective pharmacological platelet inhibition. Dual antiplatelet therapy with aspirin and clopidogrel has been, for over a decade, the mainstay of antiplatelet management in ACS/PCI. However, atherothrombotic events continue to occur in a relevant proportion of subjects despite the benefit of this combination, which has led to the clinical development of newer and more potent antiplatelet drugs. Two of these, prasugrel and ticagrelor, have been recently approved for clinical use. The scope of this manuscript is to provide an up-to-date overview on new antiplatelet drugs in the setting of ACS and PCI, including the most recent advances on newly approved agents as well as on emerging compounds in clinical development.

[Osteoarticular infections caused by Streptococcus agalactiae. Report of 4 cases]

BACKGROUND

Streptococcus agalactiae (group B streptococcus) is a rare etiology of osteoarticular infection in adults. In a literature review (Medline-Embase plus) up until may 1994, we have found only 51 cases. In most patients, diabetes mellitus, liver disease or long-term steroid therapy were documented.

METHODS

Four adult patients with osteoarticular infection due to S. agalactiae from two Galician hospitals were studied from January 1988 to October 1994: prepatellar bursitis (one case), septic monoarthritis (2 cases) and psoas abscess associated to cervical spondylodiscitis and oligoarthritis (left sternoclavicular and left hip joints).

RESULTS

In the first patient, a young woman with prepatellar bursitis, a previous local trauma was recorded. The second case, a man with septic arthritis of right knee, had degenerative disease of the knees and a prostatic adenocarcinoma. In the third patient, a diabetic woman with septic arthritis of the left shoulder, vulvovaginitis due to Candida albicans was found. The last patient suffered vertebral osteomyelitis of the cervical spine (C3-C4), arthritis of the left sternoclavicular and hip joints and abscess of the ipsilateral psoas. The evolution was favourable in the four cases.

CONCLUSIONS

Although uncommon, osteomyelitis and arthritis caused by group B streptococcus should be considered as opportunistic pathogen in adults with debilitating conditions. Early recognition and prompt institution of adequate therapy can help avoid joint destruction and severe complications.

Case report 866. Pseudotumor of the muscle associated with necrotizing vasculitis of medium- and small-sized arteries and chronic myositis

A case of polymyositis and localized vasculitis presenting as a muscular pseudotumor of a lower extremity and periostitis several years after the onset of symptoms was reported and the MRI characteristics were described. This imaging modality demonstrated muscle signal abnormalities in several muscle groups and was useful in ruling out the presence of a mass and fatty degeneration of the muscle. The ability of the STIR sequence (Fig. 3D) to show muscle abnormalities and to allow fatty infiltration or degeneration to be ruled out has not been reported before in patients with vasculitic muscle involvement.

Clinical and pathologic studies of twenty-six patients with penetrating foreign body injury to the joints, bursae, and tendon sheaths

Foreign body synovitis has been neglected in the rheumatology literature. We describe 26 patients in whom arthritis, bursitis, or tenosynovitis appeared within 1 day to 7 years after an initial injury by a penetrating foreign body. Twenty-two patients presented with acute synovitis, which was followed by chronic or recurrent inflammation mimicking septic arthritis, osteomyelitis, monarticular juvenile rheumatoid arthritis, bone tumor, or apatite deposition disease. Foreign bodies were not seen in 5 inflammatory synovial fluids studied, but were seen in the synovium or periarticular tissues of 17 patients. Excisional biopsy was required in most patients for precise diagnosis and treatment.

[Chronic toluene poisoning]

The long-term inhalation of compounds in which toluene is the main ingredient leads to the damage of both central and peripheral nervous system. We present the case of a 24 year-old man who, sniffing these compounds since he was 17, slowly develops a variegated syndrome including psychiatric impairment, signs of bilateral pyramidalism, cerebellar and sensitive alterations, and peripheral neuropathy. CT scan, electrophysiological and laboratory modifications are reported. A comparative study with other reports is made, reviewing the associated pathology to this form of chronic intoxication, caused by the noxious action of each one of these substances or by their interaction. Liposolubility is established as the main pathogenic factor of this intoxication.

[Optic neuropathy caused by amiodarone]

Amiodarone has been used for the last 20 years, initially as antianginal and then as antiarrhythmic agent. To the collateral effects described, the optic neuropathy must be added as a complication, not so frequent, caused apparently by the prolonged ingestion of it. Two patients treated with MDD of 250 mg of amiodarone, for a mean of 17 months, are reported. They presented a decrease of the visual acuity. After proposing the possible differential diagnosis, the relation between the use of amiodarone and the optic alteration observed is briefly exposed, relating it with the demyelination neuropathy induced by this drug. This presumption is corroborated by the ultrastructural alterations registered in the optic nerve of animals in which amiodarone was used, similar to those of the peripheral nerves, as an expression of a disorder of the lipidic metabolism, which allow it to be integrated to the so called iatrogenic lipidoses.

Tuberculous arthritis of peripheral joints in patients with previous inflammatory rheumatic disease

Four patients with a previous inflammatory rheumatic disease developed a peripheral tuberculous (TB) arthritis in a joint apparently affected by a rheumatic disease. The single most important factor in the diagnosis of TB was the presence of past or present pulmonary TB or a family history on a background of steroid use. Clinical presentation, disease evolution, and routine laboratory tests were unhelpful. The most effective method of diagnosis was synovial biopsy.