Prevalence of prediabetes in patients with acute coronary syndrome: impact on in-hospital outcomes.

BACKGROUND: Prediabetes is a serious condition that is associated with an increase in cardiovascular morbidity and mortality. AIMS: We sought to explore the prevalence of prediabetes in patients admitted with acute coronary syndrome (ACS) who were not known to have diabetes and to determine the impact of prediabetes on in-hospital clinical outcomes versus non-diabetic patients. METHODS: Prospectively, we enrolled 200 patients not known to have diabetes or prediabetes, admitted with ACS. Laboratory tests included fasting plasma glucose (FPG), 2-h plasma glucose (2hPG) after 75 g glucose, HbA1c and lipid profile. Electrocardiogram and echocardiography were done. The primary end-point was in-hospital major adverse cardiovascular events (MACE). RESULTS: Mean age was 50.9 ± 6.8 years (70.5% males). The prevalence of patients with diabetes and patients with prediabetes was 24.5% and 20% respectively. Newly discovered diabetic patients were excluded. Compared with patients without diabetes, prediabetic patients had a higher body mass index (BMI) (P = 0.002) and a longer hospital stay (P = 0.09). In-hospital MACE occurred in 10 (25%) patients with prediabetes versus six (5.4%) in patients without diabetes (P = 0.001). In-hospital MACE correlated with prediabetes (r = 0.28, P < 0.001), BMI (r = 0.14, P = 0.093), FPG (r = 0.19, P = 0.014), 2hPG (r = 0.19, P = 0.017) and HbA1c (r = 0.19, P = 0.019). Multivariate regression analysis identified prediabetes as the only independent predictor of in-hospital MACE. CONCLUSIONS: Prediabetes is common in patients presenting with ACS who are not previously known to have diabetes. Prediabetic patients had worse in-hospital clinical outcomes compared with patients without diabetes.

The percent change of strain and strain rate under dobutamine stress echocardiography predicts viability following myocardial infarction.

AIM: The aim of the present study was to explore the accuracy of the dobutamine-induced percent change of myocardial deformation indices to detect viability following myocardial infarction. METHODS: We enrolled 60 consecutive patients presenting for myocardial viability assessment at least 4 weeks following ST-segment-elevation myocardial infarction. Strain (S) and strain rate (SR) were individually measured for all myocardial segments, both at rest and during low-dose dobutamine stress echocardiography. The percent change of S and SR from baseline to dobutamine-induced values (at a dose of 20 µg/kg/min) was calculated individually for each segment. Patients underwent myocardial viability assessment with resting 99mTc-sestamibi scintigraphy. Based on the results of scintigraphy, the percent change of S and SR was compared between viable and non-viable segments. RESULTS: For all segments, the percent change of both S and SR was significantly higher in viable as compared with non-viable segments (P<0.05 for all). Receiver-operating characteristics curve analysis identified the optimal cut-off value for the percent change of both S and SR that best discriminates viable from non-viable segments in the range of 20-25% with a sensitivity range from 95% to 100%, and a specificity range from 85% to 100%. CONCLUSION: In patients undergoing viability assessment following ST segment elevation myocardial infarction, the percent change of both S and SR (from baseline to dobutamine-induced values) was significantly higher in viable versus non-viable segments. A cut-off value of 20-25% of the percent change for both S and SR reliably identified viable from non-viable segments with a high sensitivity and specificity for both.

Outcome of ST-elevation myocardial infarction versus non-ST-elevation acute coronary syndrome treated with titanium-nitride-oxide-coated versus everolimus-eluting stents: insights from the BASE-ACS trial.

AIM: The BASE-ACS trial demonstrated an outcome of titanium-nitride-oxide-coated bioactive stents (BAS) that was statistically non-inferior to that of everolimus-eluting stents (EES) at 12-month follow-up, in patients presenting with acute coronary syndrome (ACS) who underwent early percutaneous coronary intervention (PCI). We explored a post-hoc analysis of the 12-month outcome of the BASE-ACS trial in the subgroup of patients with ST-elevation myocardial infarction (STEMI) versus non-ST-elevation ACS (non-STEACS). METHODS: A total of 827 patients with ACS (321 STEMI) were randomly assigned to receive either BAS or EES. The primary endpoint was a composite of cardiac death, non-fatal myocardial infarction (MI) and ischemia-driven target lesion revascularization (TLR) at 12-month follow-up. RESULTS: The 12-month cumulative incidence of the primary endpoint was similar between the two subgroups (9% versus 9.5%, in STEMI versus non-STEACS patients respectively, P=0.90). The 12-month rate of cardiac death was significantly higher in the STEMI subgroup as compared with the non-STEACS subgroup (2.8 versus 0.6%, respectively, P=0.01). However, the rates of non-fatal MI, ischemia-driven TLR, definite stent thrombosis, and non-cardiac death were all statistically matched between the two subgroups (P>0.05 for all). CONCLUSION: In the current post-hoc analysis of the BASE-ACS trial based on the infarction type, the 12-month outcome of patients who underwent early PCI for ACS was slightly worse in the setting of STEMI as compared with non-STEACS, as reflected by a significantly higher rate of cardiac death.

Atrioventricular plane displacement: does it predict in-hospital outcome after acute myocardial infarction?

BACKGROUND AND OBJECTIVES: Atrioventricular plane displacement is a well-accepted method for assessment of left ventricular systolic function. We explored the ability of atrioventricular plane displacement to predict inhospital outcome in patients with acute ST-elevation myocardial infarction. MATERIALS AND METHODS: Ninety three patients with acute ST-elevation myocardial infarction were prospectively included. Each patient underwent trans-thoracic echocardiography for measurement of the ejection fraction by the Simpson's method. Atrioventricular plane displacement was measured from the apical views, assessed in four different regions, namely, the septal, lateral, anterior and inferior ones, and the mean value was calculated. We used a cutoff value to classify patients into a group with atrioventricular plane displacement <10 mm and another with atrioventricular plane displacement > or=10 mm. Similarly, patients were classified into those with ejection fraction <40% and others with ejection fraction a 40%. All patients were followed-up during their in-hospital stay for the occurrence of major adverse cardiac events, namely, death, heart failure, complex ventricular arrhythmias, post-infarction angina, or mechanical complications. RESULTS: During the follow-up period (3 +/- 1.5 days), major adverse cardiac events occurred in 16 (72.7%) patients with atrioventricular plane displacement <10 mm, and in 6(8.5%) patients with atrioventricular plane displacement > or =10 mm, p < 0.01. An atrioventricular plane displacement below 10 mm was able to predict the occurrence of major events with a sensitivity 72.7%, specificity 91.5%, negative predictive value (NPV) 91.5%, positive predictive value (PVP) 72.7%. Similarly, an ejection fraction below 40% predicted the occurrence of major events with a sensitivity 72.7%, specificity 90.1%, NPV 91.4%, PVP 69.6%. We found a strong correlation between an atrioventricular plane displacement < 10 mm, and an ejection fraction <40%, p < 0.01. CONCLUSION: Left atrioventricular plane displacement below 10 mm, can adequately predict the occurrence of in-hospital major adverse cardiac events after acute ST-elevation myocardial infarction, with a high correlation with ejection fraction below 40%.

Does nickel allergy play a role in the development of in-stent restenosis?

OBJECTIVES: It was suggested that coronary in-stent restenosis might be triggered by allergy to nickel and molybdenum ions released from stainless-steel stents. We sought to explore any possible relationship between nickel allergy and in-stent restenosis. MATERIALS AND METHODS: 50 patients were studied, who underwent elective follow-up coronary angiography for recurrent symptoms after prior coronary stenting, at least 3 months following the index procedure. Consecutively, we enrolled 25 patients with > or = 50% in-stent restenosis (study group), and 25 others with < 50% restenosis (control group), as revealed by coronary angiography. Evaluation for nickel allergy was performed using 5% nickel sulphate solution in petroleum applied as a patch test to the interscapular region by the Finn chamber method. A positive test was defined as an inflammatory response with erythema, edema, papulovesicles, or infiltration after 48 or 72 hours. RESULTS: The mean age of the whole study cohort was 55.9 +/- 13.9 years, 44 (88%) being males. Two patients of the study group (8%) had a history of contact allergy to metals. However, both of them showed a negative patch test result. No patient in the control group had a history of metal allergy (p > 0.05). Only one patient in the study group (4%) had a positive patch test result for nickel contact allergy, whereas all patients in the control group had a negative result (p > 0.05). CONCLUSIONS: Based on the available evidence, a cause-effect relationship between nickel allergy and in-stent restenosis cannot be confirmed.

Titanium-nitride-oxide-coated Titan-2 bioactive coronary stent: a new breakthrough in interventional cardiology.

The introduction of drug-eluting stents (DES) has revolutionized the field of interventional cardiology, since it has reduced the incidence of restenosis by 50% to 70%. However, recent worrisome data from registries and meta-analyses emphasized higher rates of late and very late stent thrombosis associated with DES. The recently introduced titanium-nitride-oxide-coated stent bioactive stent (Titan-2) was manufactured by a proprietary process to coat titanium-nitride-oxide on the surface of the stainless steel stent, based on a plasma technology using the nano-synthesis of gas and metal. This late-breaking stent has demonstrated an excellent biocompatibility, as reflected by lower rates of platelet aggregation and fibrin deposition, and better endothelialization. Preclinical and clinical trials and registries involving real-life unselected populations have shown a low rate of major adverse cardiac events at long-term follow-up. Restenosis rates were comparable with those of DES, with very rare stent thrombosis. Equally favorable results have been obtained in patients at high-risk of in-stent restenosis, such as diabetics and those with small coronary arteries. Results in patients presenting with acute coronary syndrome have been again comparable to those of DES, with tendency to lower rates of myocardial infarction and stent thrombosis. Comparisons with second generation drug-eluting stents have also been promising.

Thyroid hormone patterns in elderly patients undergoing elective coronary procedures.

BACKGROUND AND OBJECTIVES: Thyroid dysfunction is common in the elderly. We sought to explore thyroid hormone patterns in a series of elderly patients undergoing elective coronary procedures and their relation to the extent of coronary artery disease. MATERIALS AND METHODS: We enrolled 81 consecutive elderly patients admitted to undergo elective diagnostic or interventional coronary procedures. Samples were collected for assay of free thyroxin, free tri-iodothyronine, thyroid stimulating hormone, anti-thyroglobulin and anti-thyroid peroxidase antibodies. According to the number of coronary arteries affected by significant stenosis (> or = 70% luminal obstruction), we classified patients into a group with insignificant coronary disease, another with single vessel disease, and a third group with multi-vessel disease. RESULTS: Forty one (50.6%) patients were euthyroid, two patients (2.5%) had subclinical hypothyroidism, and 12 (14.8%) had clinical hypothyroidism. Yet, neither subclinical nor clinical hypothyroidism was statistically different among the 3 groups, (p > 0.05 for both). Additionally, 3 patients (3.7%) had subclinical, and 2 (2.5%) had clinical hyperthyroidism. Finally, 21 patients (25.9%) had sick euthyroid syndrome. Again, all were statistically similar between the study groups, (p > 0.5 for all). Similarly, both anti-thyroglobulin antibodies and anti-thyroid peroxidase antibodies were statistically similar among the 3 groups (p > 0.05 for both). CONCLUSION: Thyroid hormone disturbances are quite frequent in elderly patients undergoing elective coronary procedures, chiefly in the form of a hypothyroid state. These data do not support that thyroid hormone patterns relate to the extent of coronary artery disease in the elderly.