Doses of renin-angiotensin system inhibitors but not beta-blockers predict outcome after ST-elevation myocardial infarction.

Objectives: In patients with ST-elevation myocardial infarction (STEMI), it is not clear whether low-dose renin-angiotensin system inhibitors and beta-blockers can result in the same benefits achievable with higher target doses. This observational study aims to investigate whether higher doses of angiotensin converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARB) and beta-blockers can improve outcomes in patients with STEMI. Methods: We recorded daily doses of ACEI, ARB, and beta-blockers in 331 patients with STEMI. Echocardiographic studies were performed at baseline and were repeated 6 months later. Clinical events, including all-cause death and heart failure, were followed for 2 years. Results: Patients receiving high-dose ACEI/ARB had less increase in left ventricular end-diastolic volume index (LVEDVI) at 6 months. In multivariable linear regression model, ACEI/ARB dose or beta-blocker dose was not an independent predictor of increase in LVEDVI at 6 months. Kaplan-Meier survival curves showed that doses of ACEI/ARB (p = 0.003) and beta-blockers (p = 0.027) were significant predictors of death and heart failure. In multivariable Cox regression analysis, independent predictors of all-cause death and heart failure were diabetes mellitus (p = 0.001), left ventricular ejection fraction (p = 0.026), and ACEI/ARB dose (p = 0.025). Beta-blockers dose was not a predictor of clinical events in multivariable analysis (p = 0.413). Conclusion: High-dose ACEI/ARB, but not beta-blocker, was associated with lower rate of all-cause death and heart failure in patients with STEMI.

Activin A Predicts Left Ventricular Remodeling and Mortality in Patients with ST-Elevation Myocardial Infarction.

BACKGROUND: Activin A levels increase in a variety of heart diseases including ST-elevation myocardial infarction (STEMI). The aim of this study is to investigate whether the level of activin A can be beneficial in predicting left ventricular remodeling, heart failure, and death in patients with ST-elevation myocardial infarction (STEMI). METHODS: We enrolled 278 patients with STEMI who had their activin A levels measured on day 2 of hospitalization. Echocardiographic studies were performed at baseline and were repeated 6 months later. Thereafter, the clinical events of these patients were followed for a maximum of 3 years, including all-cause death and readmission for heart failure. RESULTS: During hospitalization, higher activin A level was associated with higher triglyceride level, lower left ventricular ejection fraction (LVEF), and lower left ventricular end diastolic ventricular volume index (LVEDVI) in multivariable linear regression model. During follow-up, patients with activin A levels > 129 pg/ml had significantly lower LVEF, and higher LVEDVI at 6 months. Kaplan-Meier survival curves showed that activin A level > 129 pg/ml was a predictor of all-cause death (p = 0.022), but not a predictor of heart failure (p = 0.767). CONCLUSIONS: Activin A level > 129 pg/ml predicts worse left ventricular remodeling and all-cause death in STEMI.

QT interval Independently Predicts Mortality and Heart Failure in Patients with ST-Elevation Myocardial Infarction.

OBJECTIVES: Heart-rate corrected QT (QTc) interval predicts cardiovascular mortality or all-cause mortality in the general population. Little is known about the best cut-off value of QTc interval for predicting clinical events in patients with ST-elevation myocardial infarction (STEMI). METHODS: We enrolled 264 patients with STEMI who received measurement of QTc intervals at ER (QTc-ER), on day 2 (QTc-D2), and on day 3 (QTc-D3) of hospitalization. Clinical events, including all-cause death and readmission for heart failure, were followed for 2 years. RESULTS: Prolonged QTc-ER, but not QTc-D2 or QTc-D3, well predicted clinical events with the best cut-off value of 445 ms. Patient with QTc-ER > 445 ms had lower left ventricular ejection fraction at baseline and at 6 months. Kaplan-Meier survival curves showed that the combination of QTc-ER > 445 ms and N-terminal pro-brain natriuretic peptide (NT-pro BNP) > 936 pg/mL was a strong predictor of clinical events (p<0.001). In multivariable Cox regression analysis, the independent predictors of death and heart failure were QTc-ER (p<0.001), log NT-proBNP (p<0.001), diabetes mellitus (p<0.001), history of stroke (p=0.001), and left ventricular end diastolic volume index (p<0.001). CONCLUSION: QTc-ER > 445 ms independently predicts clinical events in STEMI, providing incremental prognostic value to established clinical predictors and NT-proBNP.

A Novel Technique for Percutaneous Coronary Intervention for Anomalous Right Coronary Artery Arising from the Left Sinus of Valsalva.

BACKGROUND: Percutaneous coronary intervention (PCI) for anomalous right coronary artery (RCA) arising from the left sinus of Valsalva (LSOV) is a technical challenge due to inadequate guiding catheter support to overcome the acute rightward course of the anomalous RCA. In this study we describe a novel technique for PCI for an anomalous RCA arising from the LSOV. METHODS: Six patient cases with anomalous RCA arising from the LSOV who underwent PCI from January 2001 to January 2014. The Judkins left (JL) guiding catheter tip orientation is modified by manually bending at the distal tip 90° vertically to fit the acute rightward course. RESULTS: Of the six patients (mean age: 63 ± 16.7 years), the indication for PCI was acute inferior myocardial infarction (MI) in two, recent inferior MI in two, and angina in two of the cases. Three procedures were performed via a transfemoral approach and the other three via a transradial approach. The median duration of the intervention and total procedure time were 44 and 69.5 minutes, respectively. All patients received successful revascularization without complications. CONCLUSIONS: This novel technique is simple, safe and effective with a 100% procedure success rate for PCI for anomalous RCA arising from the LSOV. KEY WORDS: Anomalous right coronary artery; Left sinus of Valsalva; Percutaneous coronary intervention.

Growth-differentiation factor-15 and major cardiac events.

BACKGROUND: Growth-differentiation factor (GDF)-15 is a strong predictor of cardiovascular events in patients with ST-elevation myocardial infarction (STEMI). However, the effects of GDF-15 on left ventricular (LV) remodeling have not been clearly elucidated. The aim of this study is to investigate whether GDF-15 will be of benefit in predicting LV remodeling, heart failure and death in patients with STEMI. METHODS: The authors enrolled 216 patients with STEMI who received measurement of GDF-15 level on day 2 of hospitalization. Echocardiographic studies were performed at baseline and were repeated 6 months later. Clinical events, including all-cause death and readmission for heart failure, were followed up for a maximum of 3 years. RESULTS: Patients with GDF-15 levels above the median had lower LV ejection fraction at baseline (43.9% versus 48.0%, P = 0.041) and at 6 months (51.5% versus 56.9%, P = 0.025). In univariable regression model, log-transformed GDF-15 level was not a predictor of increase in LV end-diastolic volume index at 6 months (P = 0.767). Kaplan-Meier survival curves showed that the combination of high GDF-15 and high N-terminal pro-B-type natriuretic peptide was a strong predictor of death and heart failure (P < 0.001). In multivariable Cox regression model, the independent predictors of death and heart failure were age, GDF-15 level and diabetes mellitus. CONCLUSIONS: High GDF-15 level is a strong predictor of death and heart failure in patients with STEMI. Although patients with higher GDF-15 levels tend to have lower LV ejection fraction, they have similar degree of the increase in LV end-diastolic volume index at 6 months.

Correlates of impaired global right ventricular function in patients with a reperfused acute myocardial infarction and without right ventricular infarction.

BACKGROUND: The frequency and clinical correlates of global right ventricular (RV) dysfunction in patients treated with primary percutaneous coronary intervention for a first acute ST-elevation myocardial infarction (STEMI) without a coexisting RV infarction is not well known. MATERIALS AND METHODS: One hundred seven consecutive patients underwent conventional echocardiography and pulsed-wave tissue Doppler imaging (TDI) within 72 hours after a successful primary percutaneous coronary intervention to assess their RV function. Global RV function was quantified with the RV myocardial performance index (MPI) by pulsed-wave TDI. An abnormal TDI-derived RV MPI was defined as greater than the upper reference limit of 0.55. RESULTS: Global RV dysfunction was present in 18 (17%) of the 107 patients enrolled. The patients with global RV dysfunction had significantly higher glucose levels on admission (216 ± 102 vs 163 ± 86 mg/dL; P = 0.027), higher peak creatine kinase (4027 ± 2171 vs 2660 ± 1980 IU/L; P = 0.014), and more frequently had anterior infarcts (89% vs 58%; P = 0.016) than those without RV dysfunction. Patients with global RV dysfunction also had a significantly lower left ventricular (LV) ejection fraction (45.1 ± 10.8% vs 51.1 ± 9.7%; P = 0.021), a higher global wall motion score index (1.9 ± 0.3 vs 1.7 ± 0.4; P = 0.007), and greater LV MPI (0.65 ± 0.19 vs 0.47 ± 0.11; P = 0.001) than patients without. With the use of multivariate regression analysis, TDI-derived LV MPI (odds ratio [OR], 3.40; 95% confidence interval [CI], 1.20-9.67; P = 0.022), the ratio of transmitral peak early (E) to late diastolic filling (A) velocities (E/A ratio) (OR, 0.41; 95% CI, 0.18-0.92; P = 0.031), and admission plasma glucose level (OR, 1.01; 95% CI, 1.0-1.02; P = 0.039) were independently associated with the presence of global RV dysfunction. CONCLUSIONS: In patients with a first acute STEMI without an associated RV infarction, depressed global LV function reflected by increased TDI-derived LV MPI, a lower mitral E/A ratio, and a higher glucose level on admission are independent correlates of early global RV dysfunction. Routine assessment of global RV function should be implemented in patients with STEMI with these characteristics.

Right ventricular function in patients with different infarction sites after a first acute myocardial infarction.

INTRODUCTION: To investigate the effect of different infarction sites on right ventricular (RV) functional changes in patients with a first acute ST-elevation myocardial infarction without concomitant RV infarction. METHODS: Sixty consecutive patients underwent conventional echocardiography and pulsed-wave tissue Doppler imaging for RV function evaluation after successful primary percutaneous coronary intervention. They were divided into 2 groups according to infarct location based on the electrocardiographic findings: group I consisted of 35 patients with anterior (including anteroseptal) wall infarction and group II included 25 patients with inferior (including inferoposterior) wall infarction. Ten healthy individuals served as the control group. RESULTS: The tricuspid annular plane systolic excursion was significantly lower in group I compared with that in the controls (20.3 ± 3.8 versus 23.9 ± 2.4 mm, P < 0.05). The ratio of transtricuspid peak early filling velocity to tricuspid annular early diastolic velocity (E/E(m)) was comparable between group I and group II, whereas it was higher in group II than in the controls (6.10 ± 1.37 versus 4.33 ± 1.17, P < 0.05). The RV myocardial performance index determined by tissue Doppler imaging was significantly higher in group I than in group II (0.48 ± 0.25 versus 0.32 ± 0.10, P < 0.05) and the healthy controls (0.48 ± 0.25 versus 0.27 ± 0.08, P < 0.05). CONCLUSIONS: In patients with a first, acute reperfused ST-elevation myocardial infarction without associated RV infarction, RV function may be affected discrepantly depending on the different infarction sites. In patients with inferior infarction without concomitant RV infarction, only regional RV diastolic dysfunction is observed, whereas the alteration of global RV function is more pronounced in patients with anterior wall infarction.

Data feedback reduces door-to-balloon time in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Current guidelines recommend a goal of door-to-balloon (D2B) time < 90 min for patients undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). We aim to prospectively determine the effect of data feedback on D2B time and its seven individual components in primary PCI. From December 7, 2007, to June 2, 2009, 116 consecutive patients with STEMI who received PCI within 12 h of symptom onset were enrolled, including 56 patients before and 60 patients after the implementation of data feedback on July 28, 2008. The proportion of patients treated within 90 min increased from 26.8 to 55.0% (p = 0.002). On multivariable analyses, data feedback (OR 5.3, p = 0.003), known coronary artery disease (OR 5.6, p = 0.043), regular hours presentation (OR 3.3, p = 0.048), and arrival by transfer (OR 14.0, p = 0.003) were independent predictors of a D2B time less than 90 min. Median D2B time decreased from 112 min before data feedback to 87 min after data feedback (p < 0.001). The most significant decrease occurred in median door-to-ECG (11 vs. 3 min, p < 0.001), consult-to-cardiologist (5 vs. 3 min, p < 0.001), and puncture-to-balloon (21 vs. 17 min, p = 0.004) time. Data feedback to the emergency department and catheterization laboratory staff decreases D2B time in primary PCI. This simple approach may be the best first step to decrease D2B time in hospitals that are still striving to achieve the goal of D2B time < 90 min.

C-reactive protein in predicting coronary artery disease in subjects with aortic valve sclerosis before diagnostic coronary angiography.

BACKGROUND: Although previous studies have suggested that aortic valve sclerosis (AVS) shares common histologic features with atherosclerosis and is an indicator of significant coronary artery disease (CAD), many patients with aortic valve disease do not have coexisting coronary atherosclerotic disease and vice versa. It is important to find the subjects with AVS who are most likely to have concomitant CAD and require aggressive evaluation. HYPOTHESIS: We hypothesized that the systemic inflammatory marker, high-sensitive C-reactive protein (hs-CRP), may be associated with AVS, and may be helpful before coronary angiography in identifying the presence of concomitant CAD in patients with AVS. METHODS: This study included 227 patients with suspected CAD undergoing transthoracic echocardiography and coronary angiography. AVS was defined as a focal area of increased echogenicity and thickening of the aortic valve leaflets without restriction in motion. Data of atherosclerotic risk factors including hs-CRP were collected. RESULTS: Technically satisfactory ultrasound recordings were obtained in 217 subjects (96% of enrolled patients). Patients with AVS were older (65+/-10 vs. 60+/-10 years old; P=0.0004), had higher serum creatinine levels (115.2+/-79.7 vs. 88.6 +/-35.4 micromol/L; P=0.04), and had greater prevalence of obstructive CAD (75% vs. 53%; P=0.001) than those with normal aortic valves. CRP levels were not associated with AVS, and failed to predict concomitant CAD in patients with AVS. Additionally, none of the established risk factors were independent predictors of the presence of CAD in AVS patients. CONCLUSION: Hs-CRP levels appear to not be associated with AVS, and are of little value in terms of predicting the presence of concurrent CAD before coronary procedure.