Alois Suessenbacher

Gender-related outcome following percutaneous coronary intervention for ST-elevation myocardial infarction: data from the Austrian acute PCI registry

AIMS Whether or not primary percutaneous coronary intervention (P-PCI) is equally effective and safe in women and men in a real world setting is still a matter of debate. The aim of this study was to evaluate the effect of gender on in-hospital outcome after P-PCI for ST-elevation myocardial infarction (STEMI) in a prospective national registry. METHODS AND RESULTS This registry includes in-hospital outcome data from 19 PCI-performing hospitals. During 12 months, 1087 patients with STEMI were registered (mean age 62 +/- 13 years; 27% women). Women were older than men (67 +/- 13 vs. 60 +/- 13 years; p < 0.001) and more often had diabetes mellitus (21% vs. 13%; p < 0.001) or cardiogenic shock (15% vs. 9%; p=0.004). PCI was performed in 1004 patients (92.4%) and more frequently in men than in women (93.9 vs. 88.3%, p=0.002), whereas conservative treatment was more often decided in women (9.3% vs 4.3%; p=0.002). No differences were found between women and men in primary success rate (TIMI 2+3 flow, 92.9% vs. 93%; p=0.96). On univariate analysis, in-hospital mortality was higher in women than in men (13.7% vs. 7.2%; p=0.001). On multivariable analysis age, shock, diabetes and TIMI flow before PCI remained associated with mortality. CONCLUSIONS Women have higher in-hospital mortality following PCI for STEMI. On multivariate analysis age, shock, diabetes and TIMI flow, but not gender, were associated with mortality in this national register. Older age and more comorbidity are likely to explain the higher mortality in female patients undergoing P-PCI.

Comparison of peripheral endothelial function in shift versus nonshift workers.

Shift working is related to increased cardiovascular morbidity. Peripheral endothelial dysfunction, an inherent feature of early atherosclerosis, has been suggested as a surrogate marker of cardiovascular risk. Whether shift working is associated with peripheral endothelial dysfunction has not been investigated to date. A total of 48 male shift workers (SWs) and 47 male nonshift workers (NSWs) (mean age 43 ± 5 years) were recruited from a glass manufactory. The SWs and NSWs were matched according to age, body mass index, smoking habits, family history of premature coronary artery disease, prevalence of hypercholesterolemia and hypertension, and work place. Their sport habits were also documented. Peripheral endothelial function was assessed using the EndoPAT technique to determine the peripheral arterial tone (PAT) index. According to the study design, no difference was found in the risk factor profiles between the SWs and NSWs. Despite a greater percentage of regular physical activity among the SWs (16.7 vs 4.3%, p = 0.05), shift working was associated with a reduced PAT index compared to working only on the day shift (PAT index 1.73 ± 0.4 vs 1.94 ± 0.5, p = 0.03). In the NSW group, the participants with regular physical training (n = 16) had a greater PAT index than those without regular physical activity (n = 12; PAT index 2.28 ± 0.45 vs 1.86 ± 0.51, p = 0.03). No such difference was found in the SWs. In conclusion, SWs had a reduced PAT index compared with NSWs, suggesting endothelial dysfunction. Therefore, the known increased cardiovascular risk in those shift working might be related to endothelial dysfunction.

Association of improvement of brachial artery flow-mediated vasodilation with cardiovascular events

The aim of this pilot study was to test the prognostic value of serial measurements of peripheral endothelial function, assessed by brachial artery flow-mediated dilation (FMD), in patients with angiographically proven coronary artery disease. In 68 patients, FMD was measured on the day after coronary angiography and again after a mean of 14 ± 12 months. Patients were divided into two groups: absolute improvement in FMD ≥ 3% (FMD-improver += FMD-i) and <3% (FMD-non-improver = FMD-ni). After a mean follow-up of 44 ± 12 months, cardiovascular events were recorded. Baseline characteristics were similar between groups, except the number of risk factors which was smaller in FMD-i (1.6 ± 0.7 vs 2.1 ± 0.9, p < 0.02). Cardiovascular events were more frequent in FMD-ni (9 vs 1 event; p < 0.05). In Kaplan–Meier analysis, a trend towards a better outcome in patients with improved FMD was found using the log-rank test (p = 0.08). The single baseline FMD showed no relationship with late cardiovascular events. Thus, ‘delta-FMD’ may be more closely related to prognosis than a single FMD measurement.

Neopterin, CD4+CD28− lymphocytes and the extent and severity of coronary artery disease

OBJECTIVES Macrophages and pro-inflammatory CD3+CD4+CD28- T lymphocytes are involved in atherosclerotic plaque destabilization. Whether neopterin, a macrophage-specific activation-marker, and circulating CD3+CD4+CD28- cells are also related to the severity and extent of coronary artery disease (CAD) in stable patients is still unclear. METHODS Coronary angiograms of 30 patients with stable angina pectoris were graded using the Gensini severity and an extent score. Patients were grouped according to the median of each score. Lymphocyte subsets were determined by FACS analysis and neopterin by radioimmunoassay. Peripheral endothelial function of the brachial artery (FMD) shown to correlate with cardiovascular risk factors was evaluated using high-resolution ultrasound. RESULTS More extensive CAD was associated with increased neopterin levels (8.3 +/- 3.3 vs. 5.5 +/- 1.2 nmol/L, p < 0.001) and increased CD3+CD4+CD28- cells (3.1 +/- 1.6 vs. 2.0 +/- 1.2%, p < 0.05). A high Gensini severity score was associated with increased neopterin levels (7.8 +/- 2.7 vs. 6.3 +/- 1.7 nmol/L, p < 0.05), but not with CD3+CD4+CD28- cells. Neopterin correlated with both the extent (r = 0.59, p < 0.001) and the Gensini score (r = 0.57, p < 0.003). FMD was not correlated with both scores. CONCLUSIONS Neopterin and CD3+CD4+CD28- lymphocytes are associated with CAD extent in stable patients, thereby emphasizing the inherent role of inflammation in atherogenesis itself beyond plaque destabilization. Neopterins correlation with CAD severity might be additionally useful in identifying patients eligible for revascularization procedures.

Comparison of Brachial Artery Wall Thickness Versus Endothelial Function to Predict Late Cardiovascular Events in Patients Undergoing Elective Coronary Angiography

An increased brachial artery intima media thickness (BA-IMT) has been shown to be of prognostic value. Conflicting prognostic data have been reported for brachial artery flow-mediated vasodilation (BA-FMD), and the longest evaluated follow-up period to date is 5.5 years. We sought to investigate the very late prognostic value of BA-IMT and BA-FMD in 396 consecutive patients (age 54 ± 9 years) admitted for invasive evaluation of chest pain. BA-IMT and BA-FMD were measured using high-resolution ultrasonography. The patients were divided according to the median BA-IMT (0.37 mm) and median BA-FMD (7.6%). After a mean follow-up of 141 ± 12 months, cardiovascular events were documented. More cardiovascular events were found in patients with an increased BA-IMT (50 vs 78 events, p = 0.003). When the groups were compared according to the median BA-FMD, no differences in the number of events were documented (70 vs 75 events, p = 0.60). On multivariate Cox regression analysis, including age, number of risk factors, BA diameter, presence of coronary artery disease, BA-FMD, and BA-IMT, only the presence of coronary artery disease and BA-IMT remained significantly associated with outcome. In conclusion, BA-IMT, but not BA-FMD, predicted cardiovascular events and cardiovascular death with ≤12 years of follow-up in patients undergoing an invasive evaluation of chest pain. Our results represent, by far, the longest follow-up of BA-IMT and peripheral endothelial function testing compared with previously reported data.

The role of inflammation in the pathophysiology of acute coronary syndromes

SummaryAll stages of atherosclerotic plaques are characterized by an inflammatory component, in which T lymphocytes and macrophages orchestrate lesion progression and destabilization by releasing cytokines (e.g., interferon-γ, tumor necrosis factor-α, tissue factor). At the extreme end of this process plaque rupture occurs, which may manifest clinically as an acute coronary syndrome. Hence, measuring this atherosclerosis-inherent inflammation may help predicting cardiovascular events. Accordingly, different soluble inflammatory markers were studied for their predictive value in acute coronary syndromes. Special attention was paid to high-sensitivity C-reactive protein (hs-CRP) and soluble CD40 ligand (sCD40L). The latter seems not only to be a marker of inflammation and platelet activation, but is suggested to directly destabilize atherosclerotic plaques by stimulating pro-inflammatory T lymphocytes. Therefore, reduction of soluble inflammatory markers is an attractive target for future therapeutic strategies. Statins and glycoprotein IIb/IIIa antagonists, well-established treatments in acute coronary syndromes, were demonstrated to decrease hs-CRP and sCD40L. Whether this reduction translates into a better prognosis has to be investigated in further studies.ZusammenfassungDie Entstehung und Progression atherosklerotischer Plaques geht mit einer Gefäßwand-Inflammation einher. T-Lymphozyten und Makrophagen stellen die zelluläre Grundlage dieser Entzündung dar. Durch Freisetzen verschiedener Zytokine (z.B. Interferon-γ, Tumor-Nekrose-Faktor-α, Tissue Faktor) tragen T-Lymphozyten und Makrophagen zum Plaquewachstum und schlussendlich zur Plaqueruptur bei. Letztere kann sich klinisch als akutes Koronarsyndrom präsentieren. Verschiedene lösliche Entzündungsstoffe (inflammatorische Marker) wurden in Bezug auf ihren prädiktiven Wert bei akuten Koronarsyndromen untersucht. Dem hochsensitiven C-reaktiven Protein (hs-CRP) und dem löslichen CD40 Liganden (sCD40L) wurde dabei besonderes Interesse gezollt. Letzterer scheint dabei nicht nur ein Marker zu sein, sondern auch kausal als vorwiegend von aktivierten Thrombozyten stammendes pro-inflammatorisches, T-Lymphozyten stimulierendes Molekül eine Rolle bei der Destabilisierung atherosklerotischer Läsionen zu spielen. Die medikamentöse Therapie akuter Koronarsyndrome schließt die Behandlung mit Statinen und Glykoprotein IIb/IIIa Antagonisten ein. Von beiden konnte gezeigt werden, dass sie das hs-CRP und den sCD40L im Blut von Patienten reduzieren. Ob das auch mit einer verbesserten Prognose einhergeht, ist noch nicht endgültig geklärt.

Relationship of sonographic wall components of the brachial artery to hypertension and coronary atherosclerosis

The aim of this study was to determine whether sonographically assessed intimal (echodense, ED) or medial (echolucent, EL) thickening of the brachial artery is associated with coronary artery disease (CAD) and/or arterial hypertension (HT). In 201 patients the ED and EL wall components, as well as the total wall thickness of the brachial artery, were measured with high-resolution ultrasound (13 MHz). According to the presence or absence of CAD and HT, the patients were divided into four groups: no HT and no CAD (n = 26, group 1), CAD (≥30% diameter stenosis in ≥1 major branch) only (n = 63, group 2), HT only (n = 34, group 3), and HT and CAD (n = 78, group 4). EL (p < 0.001) and combined wall thickness (p < 0.001), but not the ED wall component, were significantly different between the groups, with the highest values occurring in group 4. On logistic regression analyses adjusting for age, coronary risk factors and body mass index, EL, but not ED, thickness correlated independently with the presence of CAD (p = 0.04) and HT (p < 0.001). High-resolution ultrasound examination of the brachial artery wall structure may contribute to the noninvasive assessment of early atherosclerosis.

[STEMI guidelines 2008--Do they influence today's myocardial infarction treatment strategies in rural areas?].

2008 new guidelines for the management of patients with ST-elevation myocardial infarction were published by the European Society of Cardiology. For daily clinical practice, changes in recommendations concerning the preferred revascularization therapy according to different time delays are of great interest. This review focuses on possible implications of these new guidelines on the choice of reperfusion strategies in rural areas.Summary2008 new guidelines for the management of patients with ST-elevation myocardial infarction were published by the European Society of Cardiology. For daily clinical practice, changes in recommendations concerning the preferred revascularization therapy according to different time delays are of great interest. This review focuses on possible implications of these new guidelines on the choice of reperfusion strategies in rural areas.Zusammenfassung2008 wurden von der Europäischen Kardiologischen Gesellschaft neue Richtlinien zur Versorgung von Patienten mit ST-Hebungs-Myokardinfarkten veröffentlicht. Im klinischen Alltag sind vor allem Änderungen im Hinblick auf die zu bevorzugende Revaskularisations-Strategie in Abhängigkeit von verschiedenen Zeitintervallen von Interesse. Diese Übersichtsarbeit befasst sich mit den möglichen Auswirkungen dieser neuen Richtlinien auf die Wahl der Revaskularisations-Strategie im ländlichen Raum.

STEMI-Guidelines 2008 – Konsequenzen für die heutige Infarktversorgung im ländlichen Raum?

2008 new guidelines for the management of patients with ST-elevation myocardial infarction were published by the European Society of Cardiology. For daily clinical practice, changes in recommendations concerning the preferred revascularization therapy according to different time delays are of great interest. This review focuses on possible implications of these new guidelines on the choice of reperfusion strategies in rural areas.Summary2008 new guidelines for the management of patients with ST-elevation myocardial infarction were published by the European Society of Cardiology. For daily clinical practice, changes in recommendations concerning the preferred revascularization therapy according to different time delays are of great interest. This review focuses on possible implications of these new guidelines on the choice of reperfusion strategies in rural areas.Zusammenfassung2008 wurden von der Europäischen Kardiologischen Gesellschaft neue Richtlinien zur Versorgung von Patienten mit ST-Hebungs-Myokardinfarkten veröffentlicht. Im klinischen Alltag sind vor allem Änderungen im Hinblick auf die zu bevorzugende Revaskularisations-Strategie in Abhängigkeit von verschiedenen Zeitintervallen von Interesse. Diese Übersichtsarbeit befasst sich mit den möglichen Auswirkungen dieser neuen Richtlinien auf die Wahl der Revaskularisations-Strategie im ländlichen Raum.

STEMI-Guidelines 2008 – Konsequenzen für die heutige Infarktversorgung im ländlichen Raum?@@@STEMI guidelines 2008 – Do they influence today's myocardial infarction treatment strategies in rural areas?

2008 new guidelines for the management of patients with ST-elevation myocardial infarction were published by the European Society of Cardiology. For daily clinical practice, changes in recommendations concerning the preferred revascularization therapy according to different time delays are of great interest. This review focuses on possible implications of these new guidelines on the choice of reperfusion strategies in rural areas.Summary2008 new guidelines for the management of patients with ST-elevation myocardial infarction were published by the European Society of Cardiology. For daily clinical practice, changes in recommendations concerning the preferred revascularization therapy according to different time delays are of great interest. This review focuses on possible implications of these new guidelines on the choice of reperfusion strategies in rural areas.Zusammenfassung2008 wurden von der Europäischen Kardiologischen Gesellschaft neue Richtlinien zur Versorgung von Patienten mit ST-Hebungs-Myokardinfarkten veröffentlicht. Im klinischen Alltag sind vor allem Änderungen im Hinblick auf die zu bevorzugende Revaskularisations-Strategie in Abhängigkeit von verschiedenen Zeitintervallen von Interesse. Diese Übersichtsarbeit befasst sich mit den möglichen Auswirkungen dieser neuen Richtlinien auf die Wahl der Revaskularisations-Strategie im ländlichen Raum.