The association between the insertion/deletion polymorphism of the angiotensin-converting enzyme gene and the plasma fibrinogen level in women and men with premature coronary artery atherosclerosis.

INTRODUCTION: The insertion/deletion (I/D) polymorphism of the angiotensin­converting enzyme (ACE) gene is associated with younger age at coronary artery disease (CAD) onset. Some data indicate the relationship between the DD genotype and the fibrinogen level. At the same time, the regulation of the renin-angiotensin system differs in women and men. OBJECTIVES: The objective of the study was to evaluate the sex­dependentassociation of the ACE I/D polymorphism with the plasma fibrinogen level in patients with premature CAD. PATIENTS AND METHODS: The study included 407 participants with premature CAD: 257 women not older than 55 years and 150 men not older than 45 years. Study participants had at least 1 stenosis ≥50% in a major epicardial coronary artery. The ACE I/D polymorphism (rs4343) was genotyped using polymerase chain reaction. Fibrinogen levels were measured with a modified Clauss method. We found a significant interaction indicating that sex modifies the influence of the I/D polymorphism of the ACE gene on fibrinogen levels (P = 0.02). The highest mean fibrinogen level, adjusted for age and smoking status, was observed in women with the DD genotype (575.7 mg/dl) and it was significantly higher than in men with the DD genotype (367.1 mg/dl; P <0.001) or in women with the ID genotype (491.7 mg/dl; P = 0.04). In men, there was no significant difference in mean adjusted fibrinogen levels across genotypes. CONCLUSIONS: The DD genotype of the ACE gene was associated with higher plasma fibrinogen levels in women with premature CAD yet not in men.

Menopause improves the predictive value of common cardiovascular risk scores in women with premature coronary artery disease.

OBJECTIVE: Menopause, particularly its early stage (≤3 years from onset), may be an important risk factor for premature coronary artery disease. The objective of the study was to assess whether the addition of the presence of menopause in women with premature coronary artery disease could improve the predictive value of the Atherosclerotic Cardiovascular Disease risk estimator and the Systematic COronary Risk Evaluation model. METHODS: The case-control study included 307 women with coronary artery disease aged 55 or less, and 347 age-matched controls without coronary artery disease. Diagnostic accuracy parameters were evaluated for traditional risk models versus those enriched with menopausal status. Early and late postmenopausal periods were defined as ≤3 and >3 years from the onset of menopause, respectively. RESULTS: Only the addition of the presence of the early postmenopausal stage to the 10-year Atherosclerotic Cardiovascular Disease risk classes resulted in significantly increased c-statistics from 0.66 (95% confidence interval [CI] 0.62-0.7) to 0.705 (95%CI 0.66-0.75) (P = 0.0003) and an increase of accuracy from 61.3% to 63.8% (P = 0.0025).Adding the presence of early postmenopause to the Systematic COronary Risk Evaluation risk classes also resulted in significantly increased c-statistics from 0.59 (95% CI 0.55-0.63) to 0.641 (95%CI 0.6-0.68) (P = 0.0024) and an increase of accuracy from 64.1% versus 57.5% (P = 0.001). CONCLUSION: Adding the early menopausal period may significantly improve the predictive value of the 10-year Atherosclerotic Cardiovascular Disease risk score and the Systematic COronary Risk Evaluation model in women with premature coronary artery disease.

The impact of early menopause on risk of coronary artery disease (PREmature Coronary Artery Disease In Women--PRECADIW case-control study).

BACKGROUND: Despite improved understanding of atherothrombosis pathophysiology, risk factors associated with premature coronary artery disease (CAD) in women are poorly recognized. DESIGN AND METHODS: A single-centre, case-control study comprised 323 women (less than 55 years) with established CAD, enrolled between April 2005 and January 2008, and 347 age-matched healthy women selected from the Multi-Center All-Polish Health Survey. We aimed to assess the relationship of menopause and premature CAD. RESULTS: In multivariate analysis smoking, parental history of premature CVD, diabetes, menopause and hypertension were the strongest risk markers for premature CAD with ORs (95% CI): 3.83 (2.52-5.82); 3.08 (1.85-5.14); 2.89 (1.59-5.23); 2.82 (1.91-4.19); 2.39 (1.16-3.54). The most significant association was found for early postmenopause in a model including the early and late stage of postmenopause (≤ and >3 years of its onset), with OR 4.55 (95% CI 2.82-7.35), higher than other risk factors. The receiver operating characteristic (ROC) curves area revealed a significant increase from 0.81 in that model that included traditional risk factors and parental premature CVD to 0.85 after addition of the early and late stage of postmenopause. CONCLUSIONS: We have shown that smoking and early postmenopausal stage (≤3 years) are the most important determinants of premature CAD followed by parental CVD, diabetes and hypertension.

Transcatheter aortic valve implantation using transfemoral/transsubclavian or transapical approach: 30-day follow-up of the initial 30 patients.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a new method for the treatment of aortic stenosis (AS). AIM: To evaluate early results of TAVI using transfemoral/transsubclavian approach (TFA/TSA) or transapical approach (TAA) in patients with severe AS and high risk for surgical aortic valve replacement. METHODS: Between January 2009 and May 2010, 30 high-risk patients underwent TAVI. The primary treatment option was TFA, and TAA was used if contraindications to TFA were present; one patient underwent the procedure using TSA. Reasons for selecting TAA were as follows: small diameter (<7 mm) and/or severe calcification of the iliofemoral arteries, peripheral atherosclerosis, "porcelain" aorta and a horizontal course of the ascending aorta. Edwards-Sapien or CoreValve devices were used in all cases, and procedures were performed without the use of cardiopulmonary bypass in a cardiac catheterisation laboratory. RESULTS: Mean patient age was 82.46 ± 5.79 years, mean NYHA class was 3.23 ± 0.41, and predicted mean surgical mortality using logistic Euroscore was 29.18 ± 16.9% (22.72 ± 12.07% in the TFA/TSA group vs 34.6 ± 15.4% in the TAA group; p = 0.031). Eleven patients were treated using TAA. The valve was implanted successfully in 96% of patients. Inhospital mortality was 3.3%. Mean 30-day mortality was 6.6% in the entire cohort, 0% in the TFA/TSA group and 18% in the TAA group. There were no cases of periprocedural myocardial infarction (MI), cardiogenic shock, stroke/transient ischaemic attack, or need for cardiopulmonary resuscitation. One patient died suddenly three weeks after the procedure; except for this case, there were no major adverse cardiovascular events (MACCE: MI, cerebrovascular accident, re-do procedure) at 30-day follow-up. The TAVI was associated with a significant reduction in the mean maximal aortic gradient in both groups (from 99.6 ± 22.07 mm Hg to 21.83 ± 9.38 mm Hg post-procedure and to 23.25 ± 9.22 mm Hg at 30-day follow up), with no cases of severe aortic valve regurgitation. The NYHA class at 30 days improved from 3.23 ± 0.41 to 1.72 ± 0.52 (p = 0.03). CONCLUSIONS: Our results demonstrate lower 30-day complication rate and mortality in the TFA/TSA group. The availability of several techniques of valve implantation in the group of non-surgical patients with severe AS potentially broadens the patient population with indications for this treatment.

Prevalence of classical risk factors in Polish women with premature coronary artery disease.

BACKGROUND: It is generally believed that in 50% of perimenopausal women several factors other than classical risk factors play a significant role in the development of premature coronary artery disease (CAD). AIM: To determine the prevalence of five classical risk factors (cigarette smoking, hypertension, diabetes, hyperlipidaemia and obesity) in women aged〈 55 years with premature CAD. METHODS: We performed a single-centre, case-control study in women〈 55 years with angiographically confirmed CAD or troponin-positive acute coronary syndrome. A total of 330 female patients were enrolled between April 2005 and January 2008. The control group consisted of 347 age-matched healthy women from a similar region selected from the National Health Survey WOBASZ study (Polish Multi-centre Population Health Survey) designed to assess the cardiovascular risk in the Polish adult population. RESULTS: Compared to age-matched healthy controls, women with premature CAD had a very high prevalence of traditional risk factors - hypercholesterolaemia (82% vs 68%), smoking (current and former) (81% vs 48%), and hypertension (68% vs 42%). Women with premature CAD had 4.3 times more often diabetes, 1.68 times smoking and 1.63 times hypertension compared to controls. At least one of five classical risk factors was present in 98.8% of patients, compared to 89% in controls, while 10% of patients vs 1.4% of controls had all five of them. CONCLUSIONS: Classical risk factors are present in the vast majority of females with premature CAD - in 99% of them at least one CAD risk factor is present. Premature CAD is most frequently associated with smoking, hypertension and hyperlipidaemia.

Primary angioplasty in patients > or = 75 years old with ST-elevation myocardial infarction - one-year follow-up results.

BACKGROUND: Efficacy and safety of primary percutaneous coronary angioplasty (PCI) in elderly patients with acute ST-elevation myocardial infarction (STEMI) have not yet been definitely established because these patients were usually excluded from large randomised trials. AIM: To evaluate in-hospital and one-year outcome after primary PCI in elderly patients, and to assess clinical characteristics of this group. METHODS: The study population included 1061 consecutive STEMI patients, mean age 60.6+/-17 years, treated with primary PCI. Clinical characteristics and results of 127 patients aged > or = 75 years were compared to the younger group. RESULTS: Elderly patients were more frequently female (48.4 vs. 23.6%, p <0.005) and diabetics (22.2 vs. 12.1%, p <0.02) and more frequently had renal and/or left ventricular failure (22.3 vs. 9.1%, and 9.1 vs. 4.5%, p <0.005, respectively). In older patients less frequently stents were implanted and TIMI flow 3 was restored (65.1 vs. 78.8%, p <0.05 and 74.6 vs. 84.7%, p <0.03). In-hospital mortality in older versus younger patients was 11.8 vs. 3.0%, p <0.005. The incidence of in-hospital complications (stroke, major bleeding and reinfarction) was similar in both groups. The one-year mortality and MACE rates were higher in older patients (21.3 vs. 6.0% and 24.9 vs. 11.0%, p <0.0005). In multivariate analysis Killip class II-IV (OR 6.73; 95% CI 1.75-25.97, p=0.006) and heart rate (OR 1.04; 95% CI 1.01-1.07, p=0.03) were independent predictors of one-year mortality in patients aged > or = 75 years. CONCLUSIONS: Primary PCI in older STEMI patients is associated with a favourable in-hospital and one-year outcome, although inferior to that seen in younger patients. The in-hospital complication rate is similar in the elderly and in younger patients.

Influenza vaccination in secondary prevention from coronary ischaemic events in coronary artery disease: FLUCAD study.

AIMS: To evaluate the effect of influenza vaccination on the coronary events in patients with confirmed coronary artery disease (CAD). METHODS AND RESULTS: Randomized, double-blind, placebo controlled study. We included 658 optimally treated CAD patients; 477 men, mean age 59.9+/-10.3 years. Three hundred and twenty-five patients received the influenza vaccine, and 333 patients placebo. Median follow-up was 298 (interquartile range 263-317) days. Primary endpoint was the cardiovascular death. Its estimated 12-month cumulative event rate was 0.63% in the vaccine vs. 0.76% in controls (HR 1.06 95% CI: 0.15-7.56, P = 0.95). There were two secondary composite endpoints: (i) the MACE (cardiovascular death, myocardial infarction, coronary revascularization) tended to occur less frequently in the vaccine group vs. placebo with the event rate 3.00 and 5.87%, respectively (HR 0.54;95% CI: 0.24-1.21, P = 0.13). (ii) Coronary ischaemic event (MACE or hospitalization for myocardial ischaemia) estimated 12-month event rate was significantly lower in the vaccine group 6.02 vs. 9.97% in controls (HR 0.54; 95% CI: 0.29-0.99, P = 0.047). CONCLUSION: In optimally treated CAD patients influenza vaccination improves the clinical course of CAD and reduces the frequency of coronary ischaemic events. Large-scale studies are warranted to evaluate the effect of influenza vaccination on cardiovascular mortality. (ClinicalTrials.gov: NCT 00371098).

Long-term results of Fontan procedure in 43 patients.

BACKGROUND: The Fontan operation eliminates the systemic hypoxemia and ventricular volume overload characteristic of prior forms of palliation, however, late outcome of systemic venous and right atrial hypertension were unknown when the procedure was initially proposed. AIM: We assessed the late mortality and the present clinical status atresia and other forms of univentricular heart who had modified Fontan procedure performed between 1981 and 1998, and survived early perioperative period. METHODS: We reviewed the clinical records of 43 early survivors of the modified Fontan procedure. Patients' outcome and late mortality rates were determined and present clinical status was ascertained in all patients. RESULTS: Late overall survival was 76.8%. Reoperation and late complication rates steadily declined according to surgery modification and homografts exclusion. Late mortality was increased only in patients with important atrio-ventricular valve dysfunction and valve replacement. Ninety seven percent of surviving patients are currently in New York Heart Association class I or II. CONCLUSIONS: Our 20-year experience with modified Fontan procedure for tricuspid atresia and various forms of univentricular heart has resulted in improved outcome with most survivors now leading lives of good quality into adulthood.