Athanasios Pipilis

Outcome of patients with acute myocardial infarction admitted in hospitals with or without catheterization laboratory: results from the HELIOS registry.

Aims To compare the treatment and outcomes of myocardial infarction patients in hospitals with and without catheterization laboratory. Methods and results The Hellenic Infarction Observation Study was a countrywide registry of acute myocardial infarction, conducted during 2005-2006. The registry enrolled 1840 patients with myocardial infarction from 31 hospitals with a proportional representation of all types of hospitals and of all geographical areas. Out of these patients, 645 (35%) were admitted in 11 hospitals with and 1195 (65%) in 20 hospitals without catheterization laboratory. Patients admitted in hospitals with catheterization laboratory in comparison with patients admitted in hospitals without were younger (66 ± 14 vs. 68 ±13, P < 0.004) with less diabetes (27 vs. 33%, P < 0.001), but without other baseline differences (female 27 vs. 25%, prior myocardial infarction 20 vs. 17%, Killip class >1 22 vs. 23%). Reperfusion rates for ST-segment elevation myocardial infarction were 67% (43% lytic, 24% primary percutaneous coronary interventions) versus 56% (55% lytic, 1% percutaneous coronary interventions; P < 0.01). In-hospital outcomes in hospitals with versus in hospitals without laboratory were: mortality 6.5 versus 8.3% (NS), stroke 2.2 versus 1.1% (NS), major bleeding 1.1 versus 0.6% (NS), and heart failure 11 versus 16% (P < 0.01). In multivariate regression analysis, being admitted in a hospital without catheterization laboratory was not an independent predictor of increased in-hospital mortality (odds ratio = 1.18, 95% confidence interval: 0.72-1.93, P = 0.505). Conclusion Although the majority of acute myocardial infarction patients was admitted in hospitals without catheterization laboratory, these patients do not have a survival disadvantage, provided they are treated with lytic therapy, medical secondary prevention drugs, and eventual revascularization according to current guidelines. Eur J Cardiovasc Prev Rehabil 16:85-90

Use of ticagrelor in patients with ST-elevation myocardial infarction undergoing thrombolysis.

To the Editor, At present, immediate fibrinolysis remains a valuable treatment option for many patients who presented with STelevation myocardial infarction (STEMI) in developed countries. The beneficial effects of co-administration of aspirin and clopidogrel with fibrinolytic therapy in STEMI patients are well established and guidelines recommendations are class I, level of evidence A [1]. Ticagrelor is an oral, reversible, direct-acting inhibitor of the adenosine diphosphate receptor P2Y12 that has a faster onset of action and achieves more pronounced platelet inhibition than clopidogrel. It has been shown that platelet reactivity, as assessed by post-treatment P2Y12 mediated reactivity, is heightened after thrombolytic therapy during STEMI management [2]. Of note, a delay in the onset of ticagrelor’s antiplatelet action has been recently described in STEMI patients undergoing primary PCI [3, 4]. Although these apply to patients who received thrombolysis, they need to be studied. In the PLATelet inhibition and patient outcomes (PLATO) trial, the administration of ticagrelor in STEMI patients prevented more ischemic events than clopidogrel, with no excess in overall major bleeding [5]. In PLATO trial, thrombolysis was an exclusion criterion and the current guidelines for STEMI do not recommend ticagrelor for patients with STEMI undergoing thrombolysis [1]. To the best of our knowledge, administration of ticagrelor instead of clopidogrel after thrombolysis in STEMI patients has not been previously described. During the last year we identified 44 patients with STEMI (age 59 ± 20 years, six female, three patients [75 years old) who had received full dose of fibrinolytic agent (alteplase or reteplase or tenekteplase) within 6 h after the onset of chest pain, aspirin and ticagrelor (180 mg loading dose and 90 mg twice daily). Patients were then transferred to tertiary care hospitals for coronary angiography (at a median time from the onset of pain 61 h). Most cases (n = 28) were identified in the context of the GReek AntiPlatelet rEgistry (GRAPE), an ongoing prospective, observational, multicenter cohort study focusing on contemporary antiplatelet use in eight tertiary Greek hospitals with percutaneous coronary intervention (PCI) facilities, selected on the basis of geographic coverage of a large part of the country. The remaining 16 patients were not enrolled in the GRAPE registry, but were identified by clinical records of tertiary care hospitals. All patients had a 30 day follow-up. We could not be certain about the reasons why in the primary care hospital ticagrelor was used off-label with fibrinolysis. In some cases the initial intention was to proceed with primary PCI but then immediate transfer could not be arranged. Thirty-nine patients underwent PCI (six rescue), two patients underwent coronary artery bypass grafting (CABG) and the other three were managed medically. At coronary angiography the TIMI grade flow was 3, 2, 1 and 0 in 22 (50 %), 13 (29.54 %), 6 (13.63 %) and 3 (6.81 %) patients respectively. In a case of a patient who was already on ticagrelor, primary PCI of a totally occluded LAD was J. Goudevenos (&) I. Ntalas K. Kalantzi Division of Cardiology, Cardiology Department, Medical School, University Hospital of Ioannina, 45110 Ioannina, Greece e-mail: igoudev@cc.uoi.gr

Anticoagulation therapy in elderly patients with atrial fibrillation: results from the Registry of Atrial Fibrillation To Investigate the Implementation of New Guidelines (rafting)

Background Patients with atrial fibrillation aged 75 years or older have a CHA2DS2VASc score that dictates oral anticoagulants. We recorded physicians’ anticoagulation attitudes in elderly patients with atrial fibrillation and assessed the impact of stroke and bleeding risk. Methods Atrial Fibrillation To Investigate the Implementation of New Guidelines , a countrywide prospective registry performed in Greece during 2010, a period when only vitamin-K antagonists (VKA) were available, enrolled 1127 patients with atrial fibrillation diagnosis during Emergency Departments visit in 31 representative hospitals; 807 patients had known atrial fibrillation and of those, 342 aged 75 years or older. We recorded preadmission anticoagulation treatment and associated it with clinical characteristics and stroke/bleeding risk. Results Patients on VKA (n = 207; 61%) were younger (81 ± 4 vs. 83 ± 5; P < 0.001) but no other significant differences were noticed, including mean CHA2DS2VASc (high: 2–4, very high: >4) or modified HASBLED (low: 0–2, high: >2) scores. VKA were prescribed in 65% of patients with very high CHA2DS2VASc score as compared with 55% of those with high score (P = 0.065). VKA were used equally in low or high-modified HASBLED score (61% vs. 59%; P = 0.78). The interaction between CHA2DS2VASc and HASBLED was significant (P < 0.001) in patients on VKA; in patients with low HASBLED, VKA use was similar in high versus very high CHA2DS2VASc score (58 vs. 64%), whereas in patients with high HASBLED, VKA use tended to be higher in very high versus high CHA2DS2VASc score (66 vs. 43%). Conclusion In this countrywide atrial fibrillation registry, 61% of elderly patients received VKA, a decision driven mainly by stroke risk. VKA use was not higher in patients with low bleeding risk.

New-onset atrial fibrillation and clinical outcome in non-cardiac intensive care unit patients

BACKGROUND Data regarding new onset atrial fibrillation (nAF) in general, non-cardiac, intensive care unit (ICU) patients are limited. However, it has been suggested that nAF is associated with worse clinical outcome in these patients. OBJECTIVE The purpose of the present work was to study the prognostic impact of nAF, in this setting. METHODS We prospectively studied all patients admitted to a single ICU for a period of 12 months. Patients admitted for brief post-operative monitoring, patients with chronic, intermittent atrial fibrillation and atrial fibrillation present upon admission, were excluded. Death during ICU stay (ICUD) was the pre-specified study end-point. Length of stay (LOS) for survivors was also reported. A number of factors related to the occurrence of nAF and the present disease were recorded for each patient. RESULTS The study population was comprised of 133 patients. Twenty (15%) of them manifested nAF. The end-point of ICUD was observed in 27.1% of the patients. The median LOS reported was 8 days. Patients with nAF seemed to have significantly worse prognosis, compared to those who did not manifest nAF (OR=3.35, 95%CI:1.26-8.92; P=0.016). Additionally, nAF patients appear to require significantly extended LOS (P=0.01). Nevertheless, when the effect of nAF on ICUD was adjusted for sepsis, there was no statistically significant difference between those that manifested nAF and the rest of the patients. CONCLUSION Patients suffering nAF seem to have worse prognosis during ICU stay. However, a direct impact of nAF on mortality was not documented.

Direct Oral Anticoagulants in Nonvalvular Atrial Fibrillation: Practical Considerations on the Choice of Agent and Dosing

Direct or new oral anticoagulants (NOACs), including the direct thrombin inhibitor dabigatran and the direct factor Xa inhibitors rivaroxaban, apixaban, and edoxaban, have recently revolutionized the field of antithrombotic therapy for stroke and systemic embolism prevention in nonvalvular atrial fibrillation (NVAF). Randomized controlled trials have shown that these agents have at least comparable efficacy with vitamin K antagonists along with superior safety, at least in what concerns intracranial hemorrhage. As a result, NOACs are indicated as first-line anticoagulation therapy for NVAF patients with at least one risk factor for stroke or systemic embolism. The rapid introduction, however, of NOACs in a field dominated for decades by vitamin antagonists and the variety of agents and dosing schemes may create difficulties in decision making. In the present article, we attempt to determine a practical approach to the choice of agent and dose in different clinical scenarios by considering not only the results of seminal randomized trials and post hoc analyses but also data from real-world patient populations as well as the recently available possibility of rapid NOAC reversal.

MOST PATIENTS WITH ACUTE CORONARY SYNDROMES ARE ALREADY AT HIGH RISK PRIOR TO THE EVENT AND LIPID MANAGEMENT IS UNDERACHIEVED BOTH BEFORE AND AFTER HOSPITALIZATION: THE PHAETHON STUDY

Background: Guidelines suggest use of cardiovascular risk categories and high intensity statins for patients with acute coronary syndromes (ACS). We examined the risk of ACS patients prior to the event, as well as the overall use and intensity of statins. Methods: We enrolled 687 ACS patients (mean