The impact of stage of chronic kidney disease on the outcomes of diabetics with acute myocardial infarction treated with percutaneous coronary intervention.

BACKGROUND: Patients with diabetes mellitus (DM) or chronic kidney disease (CKD) have a high risk of acute myocardial infarction and recurrent cardiovascular events. According to the previous studies, the combination of the two conditions may have a synergistic impact on prognosis. The aim of this study was to assess the impact of stage of CKD on the outcomes of patients with DM and ST-elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI). METHODS: Study population consisted of 946 consecutive patients with STEMI who underwent PCI from January 2009 to December 2012 and were followed up until the end of 2013. The all-cause mortality during this period was evaluated in relation to DM and severe or moderate reduction in glomerular filtration rate (GFR categories G4-5, or G3; KDIGO classification). Cox regression analysis adjusted for possible confounding factors was used in statistics. RESULTS: Out of the study population (mean age 63 years, 69.6 % males), 217 (22.9 %) patients had DM. Of them, 10.6 % were in GFR category G4-5 and 32.7 % in G3. The in-hospital mortality rates in patients with DM were 34.8 % for G4-5, 18.3 % for G3, and 4.1 % in G1-2 groups. The all-cause mortality at the end of the follow-up period for diabetics within G4-5 was 2.27 -times higher compared to mortality of diabetics in G1-2 (p = 0.047, Cox regression analysis), and there was a trend toward higher mortality for G3 versus G1-2 (HR 1.64, p = 0.12). CONCLUSION: Severe chronic kidney disease (GFR category 4-5) was significantly associated with all-cause mortality of diabetics with STEMI treated with PCI; the association with severe CKD was stronger compared to moderate CKD.

Mortality in patients with TIMI 3 flow after PCI in relation to time delay to reperfusion.

BACKGROUND: Percutaneous coronary intervention (PCI) performed within 12 h from symptom onset enables complete blood flow restoration in infarct-related artery in 90% of patients. Nevertheless, even with complete restoration of epicardial blood flow in culprit vessel (postprocedural Thrombolysis in Myocardial Infarction (TIMI) flow grade 3), myocardial perfusion at tissue level may be insufficient. We hypothesized that the outcome of patients with STEMI/bundle branch block (BBB)-myocardial infarction and post-PCI TIMI 3 flow is related to the time to reperfusion. METHODS: Observational study based on a retrospective analysis of population of 635 consecutive patients with STEMI/BBB-MI and post-PCI TIMI 3 flow from January 2009 to December 2011 (mean age 63 years, 69.6% males). Mortality of patients was evaluated in relation to the time from symptom onset to reperfusion. RESULTS: A total of 83 patients (13.07%) with postprocedural TIMI 3 flow after PCI had died at 1-year follow-up. Median TD in patients who survived was 3.92 h (iqr 5.43), in patients who died 6.0 h (iqr 11.42), P = 0.004. Multiple logistic regression analysis identified time delay ≥ 9 h as significantly related to 1-year mortality of patients with STEMI/BBB-MI and post-PCI TIMI 3 flow (OR 1.958, P = 0.026). Other significant variables associated with mortality in multivariate regression analysis were: left ventricle ejection fraction < 30% (P = 0.006), age > 65 years (P < 0.001), Killip class >2 (P <0.001), female gender (P = 0.019), and creatinine clearance < 30 mL/min (P < 0.001). CONCLUSION: Time delay to reperfusion is significantly related to 1-year mortality of patients with STEMI/BBB-MI and complete restoration of epicardial blood flow in culprit vessel after PCI.

Serum Dickkopf-1 signaling and calcium deposition in aortic valve are significantly related to the presence of concomitant coronary atherosclerosis in patients with symptomatic calcified aortic stenosis.

BACKGROUND: The study aimed to assess serum RANKL:OPG ratio, Dkk-1 and deposition of calcium in aortic valve in relation to the presence of concomitant coronary atherosclerosis in patients with symptomatic calcified aortic stenosis (CAS). METHODS: OPG, soluble RANKL and Dkk-1 were measured in 218 consecutive patients who were undergoing cardiac catheterization because of symptomatic CAS. Values of studied compounds were compared between patients without (Group A) and with (Group B) coronary atherosclerosis. Computed tomography derived Agatston score was assessed by using 256-slice CT. RESULTS: Presence of coronary atherosclerosis was related to significantly (p = 0.007) higher OPG and to significantly (p = 0.004) lower Dkk-1. Coronary atherosclerosis was also associated with a trend towards a decrease of RANKL. RANKL/OPG Ratios (mean (95% C.I.)) were: 20.04 (16.58; 24.23) in Group A and 12.69 (9.96; 16.17) in Group B, resp., p = 0.018). After adjustment, the difference in RANKL:OPG ratios was no longer significant. Multivariable regression underscored the significance of difference in Dkk-1 (pafter adjustement = 0.020). Group A patients had significantly higher Dkk-1, significantly higher deposition of calcium in aortic valve and were symptomatic in significantly younger age (p < 0.001) as compared to group B patients: Agatston score (mean (95% C.I.)) 4069.9 (3211.8; 5134.5) and 2413.5 (1821.3; 3198.1), p = 0.007. CONCLUSIONS: Dkk-1 and deposition of calcium in aortic valve differ significantly in relation to the presence/absence of coronary atherosclerosis in patients with symptomatic CAS. A positive association was found between Dkk-1 and calcium load in aortic valve in patients with symptomatic CAS and angiographically normal coronary arteries.

Oxidative stress: Predictive marker for coronary artery disease.

The role of oxidative stress in cardiovascular disease processes, such as atherogenesis, ischemic-reperfusion injury and cardiac remodelling, has been increasingly recognized in the past few decades. Currently, an increasing number of studies suggest that levels of oxidative stress markers in body fluids correlate with atherosclerotic disease activity. This finding may lead to novel clinical approaches in patients with coronary artery disease. Assessment of oxidative stress markers could modify risk stratification and treatment of patients with suspected coronary artery disease or myocardial infarction.