The relationship between protein convertase subtilisin kexin type-9 levels and extent of coronary artery disease in patients with non-ST-elevation myocardial infarction.

BACKGROUND: Cardiovascular disease is one of the leading causes of death worldwide. According to the results of various studies, protein convertase subtilisin kexin type-9 (PCSK9) was determined as a novel risk factor for stable coronary artery disease. Few studies have investigated the relationship between PCSK9 levels and the severity of coronary artery disease in patients with acute coronary syndrome; thus, we herein aimed to investigate this relationship in patients with non-ST-elevation myocardial infarction (NSTEMI) who underwent coronary angiography. PATIENTS AND METHODS: Herein, 168 patients with NSTEMI were prospectively enrolled, and severity of atherosclerotic lesions was determined using SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX), Gensini and Jeopardy scores. Plasma PCSK9 levels, lipid parameters and C-reactive protein levels were measured after a 12-h fasting period. The relationship of PCSK9 levels and clinical and laboratory parameters of patients with their SYNTAX, Gensini and Jeopardy scores was investigated. RESULTS: Pearson correlation analysis showed a strong positive correlation between PCSK9 and the three scores (P < 0.001, r > 0.5 for all). In ROC analysis, a mid-high SYNTAX score of at least 25 was predicted with a sensitivity of 81% and a specificity of 63% when the PCSK9 level was higher than 52.8 ng/ml (area under a curve 0.76, P < 0.001). Multivariate linear regression analysis revealed that PCSK9, low-density lipoprotein cholesterol and creatinine levels were independent predictors of a high SYNTAX score. CONCLUSION: Taken together, high PCSK9 levels may be a risk factor for adverse events in patients with NSTEMI. Aggressive lipid-lowering therapies may benefit this group of patients.

Comparison of Long-Term Outcomes in Real-World Patients Between Resolute Zotarilumus-Eluting and Paclitaxel-Eluting Stents in Small Vessel.

OBJECTIVE: To compare the long-term clinical outcomes between Resolute zotarolimus-eluting stent (R-ZES) and paclitaxel-eluting stent (PES) in patients with small coronary artery disease. BACKGROUND: Patients with a small vessel diameter are independently associated with increased risk of adverse cardiac events after drug-eluting stent implantation. METHODS: A cohort of 265 patients treated with R-ZES (185 patients with 211 lesions) or PES (80 patients with 100 lesions) in small vessel (≤2.5 mm) lesions were retrospectively analyzed. The primary end point of the study was the composite of major adverse cardiac events. The secondary end points included target lesion revascularization (TLR), target vessel revascularization (TVR), and stent thrombosis at 3 years. RESULTS: The baseline characteristics were similar between the 2 groups. In the R-ZES group, the mean stent diameter was smaller and the total stent length per lesion was longer. Major adverse cardiac events occurred in 8 (10%) patients who had received PES and in 7 (3.8%) patients who had received R-ZES (P = .07). The rates of 3-year TLR (2.2% vs 2.5%; P = 1.00) and TVR (5.4% vs 10.0%; P = .17) showed no statistically significant difference between the R-ZES and PES groups. The rate of stent thrombosis was 0.5% in the R-ZES group and 2.5% in the PES group (P = .21). CONCLUSION: The rates of major adverse cardiac events and cardiac death were similar in the R-ZES-treated group compared with the PES-treated group.

Laboratory signs of aspirin response in haemodialysis patients.

INTRODUCTION: Aspirin is effective in the secondary prevention and high-risk primary prevention of cardiovascular events. However, clinical and laboratory evidence demonstrates diminished or no response to aspirin in some patients. This study was designed to assess aspirin response in haemodialysis patients. METHODS: We prospectively enrolled 78 haemodialysis patients (28 female; 58.4 ± 12.6 years old) and 79 patients (29 female; 58.4 ± 10.6 years old) with normal renal function (glomerular filtration rate (GFR) >60 mL/min/1.73 m(2)). All subjects in both the haemodialysis patient group and the control group were taking aspirin (80-300 mg) for at least 30 days and were not taking other antiplatelet agents. Platelet function was assessed by arachidonic acid-induced aggregometry with a Multiplate analyser (Dynabyte Medical, Munich, Germany). Multiplate electrode aggregometry values below 300 AU were applied as a cut-off for response to aspirin. RESULTS: Aspirin non-response was two-fold more prevalent in haemodialysis patients (42.3%) than in patients with normal renal function (21.5%), and this difference was statistically significant (p = 0.005). The two groups were similar in terms of sex, age, tobacco use, the presence of diabetes mellitus, and platelet count. CONCLUSIONS: The frequency of aspirin non-response as defined in this study was higher in haemodialysis patients than in patients with normal renal function. However, larger subsets of patients are needed to confirm the present study.

The relationship between chronic kidney disease and SYNTAX score.

Chronic kidney disease (CKD) is associated with increased risk of cardiovascular disease and death. We evaluated the association between CKD and severity of coronary artery stenosis by calculating SYNTAX Score in patients with left main coronary artery and/or 3-vessel coronary artery disease. Coronary angiograms of 217 patients were assessed. Chronic kidney disease was staged using the estimated glomerular filtration rate (eGFR, mL/min per 1.73 m(2)) prior to coronary angiography. Patients were divided into 5 groups according to the National Kidney Foundation Kidney Disease Outcome Quality Initiative (NKF KDOQI) Clinical Practice Guidelines (14). Patients with eGFR >90 mL/min per 1.73 m(2) (group 1), patients with eGFR 60 to 89 mL/min per 1.73 m(2) (group 2), patients with eGFR 30 to 59 mL/min per 1.73 m(2) (group 3), patients with eGFR >15 to < 30 per 1.73 m(2) and dialysis patients with eGFR < 15 per 1.73 m(2) were combined as group 4. The risk of significant lesion complexity increased progressively with decreasing kidney function (P = .001). Estimated glomerular filtration rate was a strong predictor of higher SYNTAX Score.

Chronic kidney disease as a predictor of coronary lesion morphology.

Coronary artery disease (CAD) is the main cause of death in patients with chronic kidney disease (CKD). We investigated whether CKD stage affected coronary lesion morphology in patients with established CAD. Coronary angiograms of 264 patients were evaluated. Chronic kidney disease was staged using the estimated glomerular filtration rate (eGFR) from the serum creatinine prior to coronary angiography. Patients were divided into 3 groups: dialysis or severe decrease in GFR <30 mL/min per 1.73 m(2) (group 1; n = 60), patients with moderate kidney failure (group 2; n = 116), and patients with normal renal function or mild decrease in GFR (group 3; n = 88). The likelihood of CAD and lesion complexity increased with decreasing eGFR (P = .001). Patients with CKD also had more significant CAD. The risk of significant coronary obstruction and lesion complexity increased progressively with decreasing eGFR. The eGFR may predict lesion complexity among patients with CKD undergoing coronary angiography.

Postinfarction ventricular septal rupture: surgical intervention and risk factors influencing hospital mortality.

Postinfarction rupture of the interventricular septum is usually fatal without surgical intervention and requires urgent closure. Between 1989 and 2003 twenty consecutive patients (15 male, 5 female), underwent postinfarction ventricular septal rupture (VSR) repair. Mean age of the patients was 62.05 +/- 7.51 years. Fifteen patients were operated within 48 hours after myocardial infarction. Patch reconstruction was performed in all patients. Infarct locations were anterior in 65%, posterior in 35%. Coronary artery surgery was performed in 14 patients (70%). Hospital mortality was 30% (6 patients). Four patients were presented for surgical therapy with frank cardiogenic shock or low cardiac output syndrome. A residual shunt was detected in 4 patients and three of these patients were reoperated. One of them, who has been reoperated on the first day of the postoperative period, did not survive. The statistical analysis of the patients' records demonstrated that time period between MI and surgery, applied additional CABG procedure, the sex of the patients and the site of the rupture are significant factors influencing in-hospital mortality. Preoperative condition, age of the patients and the number of the affected coronary vessels do not have an important effect on the mortality. Postinfarction ventricular septal rupture is a fatal complication of the myocardial infarction and must be treated surgically. The time interval between septal rupture independent from the preoperative haemodynamic condition, the location of the defect and additional myocardial revascularization procedure are the factors influencing the early outcome.

Stunning of the left atrium after conversion of atrial fibrillation: predictor for maintenance of sinus rhythm?

Recurrence of atrial fibrillation (AF) after cardioversion (CV) to sinus rhythm (SR) is determined by various clinical and echocardiographic parameters. The aim of this study was to determine the value of mitral inflow A-wave velocity, performed at 24 hours after CV in estimation of AF recurrence. The study group consisted of 187 consecutive patients with nonvalvular atrial fibrillation, who had been cardioverted to SR from 1998 to 2000. Transthoracic echocardiography was performed in all cases recruited for the study 24 hours after CV. Left atrial (LA) diameter, left ventricular ejection fraction, and mitral inflow A-wave velocity were measured. The patients were evaluated in five groups according to their recurrence time (<30 days, 31-90 days, 91-180 days, 181-365 days, and >365 days). Maintenance of SR was determined to have a negative linear correlation with age (r =-0.97, P = 0.006), LA diameter (r =-0.93, P = 0.02), and AF duration (r =-0.93, P = 0.02), while having a positive linear correlation with mitral inflow A-wave velocity (r = 0.96, P = 0.008). In the maintenance of sinus rhythm, age, LA diameter, and AF duration were not affected from the method of CV, while mitral inflow A-wave velocity was found to be affected with the method of CV. No relationship was determined between mitral inflow A-wave velocity and the maintenance of sinus rhythm in those performed electrical cardioversion, while frequency of recurrence was found to be higher in those with slow mitral inflow A-wave velocity who were performed pharmacological cardioversion (r = 0.89, P = 0.004). In conclusion, age, duration of AF, LA diameter, and the mitral inflow A-wave velocity can be used to predict the maintenance of SR after CV.

Comparison of rate and rhythm control in patients with atrial fibrillation and nonischemic heart failure.

Atrial fibrillation (AF) is a very common cardiac arrhythmia with an increased mortality in patients with heart failure. Whether the best therapeutic approach to these patients is to restore sinus rhythm or to adequately control the ventricular rate is still controversial. The aim of this study was to compare both strategies in patients with AF and nonischemic heart failure. One hundred and fifty-four patients with AF duration greater than 48 hours and nonischemic left ventricular dysfunction were randomized either to a rhythm (n = 84) or rate (n = 74) control group. The composite end points of the study were embolism, death, and exercise capacity. The average age of the patients was 61 +/- 10 years in the rhythm control group and 58 +/- 12 years in the rate control group (P = NS). The average follow-up period was 35 +/- 21 months in the rhythm control group and 37 +/- 19 months in the rate control group (P = NS). In the first year of the study, exercise capacity and left ventricular ejection fraction (LVEF) were improved in the rhythm control group compared to the exercise capacity and LVEF of the rate control group (P < 0.0001 and P = 0.0005, respectively). There were no statistically significant differences in the embolic event rate between the two groups (P = NS). The mortality rate, especially for death due to pump failure, was significantly higher in the rate control group at the end of the study (P < 0.0001). Restoring and maintaining sinus rhythm had a beneficial effect on mortality and exercise capacity in patients with nonischemic heart failure and AF.

The Relation Between Early Ventricular Tachycardia and QT Dispersion in Patients with Acute Myocardial Infarction Treated with Thrombolytic Therapy.

In this study, we investigated the influence of increased QT dispersion (defined as maximal QT interval minus minimal QT interval) on the occurrence of early nonsustained ventricular tachycardia (NSVT) in patients with acute myocardial infarction (AMI) who received thrombolytic therapy. In the retrospective analysis of 96 patients with clinical reperfusion criteria, 36 had NSVT within the first 12 hours after the onset of thrombolytic therapy (group A), and 60 patients did not have NSVT during the same period (group B). On admission ECG, QT and QT(c) dispersion and the amount of jeopardized myocardial area (Aldrich score) were calculated. In group A, Aldrich score was significantly higher (21.4 +/- 7.2% vs 14.2 +/- 4.9%; p < 0.005). There were significantly higher QT dispersion values on admission (83.3 +/- 23.4 vs 67.5 +/- 23.7 msec; p < 0.005), at 24th hour (87.1 +/- 12.6 vs 72.1 +/- 27.4 msec; p < 0.005) and on the 10th day (63.5 +/- 31.2 vs 49.5 +/- 14.3 msec; p < 0.005) in group A. In subgroup analysis of group A, patients with NSVT between 6-12 hours (group A2) had significantly higher Aldrich score and QT dispersion values at all above time points compared to patients with NSVT between 0-6 hours (group A1) after AMI. In conclusion, in this study we found a strong relation between the occurrence of NSVT within 12 hours and increased QT dispersion on admission ECG in patients with AMI who received thrombolytic therapy. This relation was even stronger for the subgroup of patients with NSVT within 6-12 hours. Thus, these results may indicate that NSVT is related to increased QT dispersion which is secondary to larger jeopardized myocardial area in patients with AMI.