Carlos Labata

Results of Primary Percutaneous Coronary Intervention in Patients ≥75 Years Treated by the Transradial Approach

Previous trials in elderly patients with ST-elevation myocardial infarction (STEMI) have not shown a definitive benefit of primary percutaneous coronary intervention (PPCI) by transfemoral approach over thrombolysis. The transradial approach (TRA) is associated with a significant decrease in mortality, MACE (Major Adverse Cardiac Event), and serious access site complications compared with the transfemoral approach. We have evaluated clinical outcomes in a cohort of real-life unselected ≥75-year-old patients with STEMI treated by TRA-PPCI. This is a single-center prospective, observational registry of consecutive patients with STEMI who underwent PPCI between February 2007 and February 2013. MACE was defined as death, reinfarction, or stroke. A total of 307 patients were treated by PPCI, 293 (95.1%) with TRA-PPCI (mean age 80 ± 2 years, 42% women). Patients had high co-morbidity levels (cardiogenic shock on admission 8.5%, previous myocardial infarction 11.6%, diabetes 30.4%, previous renal failure 25.6%, previous PCI 9.6%, and peripheral arterial disease 14.3%); IIbIIIa inhibitors were used in 45.1% of patients. Severe bleeding and need for transfusion were recorded for 6.5% and 9.9% of patients, respectively. In-hospital mortality, 1-year mortality, and 1-year MACE were 11.9%, 17.4%, and 22.2%, respectively. Excluding 25 patients with cardiogenic shock on admission, the in-hospital mortality, 1-year mortality, and 1-year MACE were 7.8%, 13.1%, and 17.9%, respectively. In conclusion, TRA-PPCI was feasible in the vast majority of elderly patients with STEMI. In-hospital mortality, 1-year mortality, and 1-year MACE were lower than reported for transfemoral access, suggesting a benefit of the TRA in these patients.

Prognostic Value of New‐Generation Troponins in ST‐Segment–Elevation Myocardial Infarction in the Modern Era: The RUTI‐STEMI Study

Background In ST‐segment–elevation myocardial infarction (STEMI), troponins are not needed for diagnosis: symptoms and ECG data are sufficient to activate percutaneous coronary intervention. This study explored the prognostic value of new‐generation troponins in a real‐life cohort contemporarily treated for STEMI. Methods and Results We studied 1260 consecutive patients with primary STEMI treated with percutaneous coronary intervention between February 22, 2011, and August 31, 2015. We collected data on clinical characteristics and major adverse cardiovascular and cerebrovascular events (MACCEs) at 30 days and 1 year. Peak high‐sensitivity troponin T and sensitive‐contemporary troponin I levels were recorded. MACCEs occurred in 75 patients (6.1%) by day 30 and in 124 patients (10.8%) between day 31 and 1 year. A short‐term (0–30 days) multivariable Cox regression analysis revealed that age, Killip‐Kimball class, and left ventricular ejection fraction were independent predictors of MACCEs. In adjusted analysis, peak high‐sensitivity troponin T and sensitive‐contemporary troponin I were not significant (hazard ratio, 1.23 [95% confidence interval, 0.98–1.54] [P=0.071]; and hazard ratio, 1.15 [95% confidence interval, 0.93–1.43] [P=0.200], respectively). A long‐term (31 days–1 year) multivariable Cox regression analysis revealed that age, female sex, diabetes mellitus, prior coronary artery disease, Killip‐Kimball class, and left ventricular ejection fraction were statistically significantly associated with MACCEs. However, peak high‐sensitivity troponin T and peak sensitive‐contemporary troponin I were not significantly associated with MACCEs (hazard ratio, 1.03 [95% confidence interval, 0.88–1.20] [P=0.715]; and hazard ratio, 0.99 [95% confidence interval, 0.85–1.15] [P=0.856], respectively). Conclusions In the modern era, new‐generation troponins do not provide significant prognostic information for predicting clinical events in STEMI. We should reconsider the value of serial troponin measurements for risk stratification in STEMI.

β-Blocker treatment and prognosis in acute coronary syndrome associated with cocaine consumption: The RUTI-Cocaine Study

BACKGROUND The use of β-blocker therapy in the setting of acute coronary syndrome (ACS) associated with cocaine consumption (ACS-ACC) is discouraged due to the risk of coronary vasoconstriction. We examined the prognostic value of β-blocker therapy in a contemporary ACS cohort. METHODS AND RESULTS Prospective, single-center study conducted between January 2001 and December 2014 that examined cocaine use among young (≤50-year-old) consecutive patients admitted with an ACS. During the study period, 1002 patients were admitted; of these, 57 (5.7%) had a positive cocaine urine test We collected data on clinical characteristics and major adverse cardiovascular events (MACE) during follow-up. Among ACS-ACC patients, 33 (57.9%) received β-blocker therapy during hospital admission and after discharge. During a median follow-up of 4.0 (IQR: 2.4-6.5) years after the index event, 2 (6.1%) patients treated with β-blocker therapy died and 6 (18.2%) experienced hospital re-admission for myocardial infarction (MI); in contrast, there were 5 (20.8%) deaths and 5 (20.8%) readmissions due to MI in patients without β-blocker therapy. Lower rates of MACE were observed in patients treated with β-blocker therapy (30.3%) than those without β-blocker therapy (41.7%). The 90-day survival was higher in patients treated with β-blocker therapy (87.5% vs. 100%; Log rank test p = 0.035). CONCLUSIONS In patients with ACS-ACC, β-blocker treatment was associated with a significantly better clinical outcome, with lower rates of death and MI. Our findings support the evidence for long-term β-blocker administration in high-risk patients and highlight the need for large prospective multicenter studies of β-blocker treatment in ACS-ACC.

Primary Ventricular Fibrillation in the Primary Percutaneous Coronary Intervention ST-Segment Elevation Myocardial Infarction Era (from the “Codi IAM” Multicenter Registry)

Primary ventricular fibrillation (PVF) is a dreadful complication of ST segment elevation myocardial infarction (STEMI). Scarce data are available regarding PVF prognosis since primary percutaneous coronary intervention (PPCI) became routine practice in STEMI. Our aim was to compare 30-day and 1-year mortality for patients with and without PVF (including out-of-hospital and in-hospital PVF) within a regional registry of PPCI-treated STEMI patients. This prospective multicenter registry included all consecutive STEMI patients treated with PPCI from January 2010 to December 2014. Patients were classified as non-PVF or PVF, with further subdivision into out-of-hospital and in-hospital PVF. We analyzed 30-day and 1-year all-cause mortality in groups. The registry included 10,965 patients. PVF occurred in 949 patients (8.65%), including 74.2% out-of-hospital and 25.8% in-hospital PVF. Compared with the non-PVF group, PVF patients were younger; less commonly diabetic; more frequently had anterior wall STEMI, higher Killip-Kimball class, and left main disease; and showed significantly higher 24-hour (5.1% vs 1.1%), 30-day (18.5% vs 4.7%), and 1-year mortality (23.2% vs 7.9%) (all p <0.001). Mortality did not differ in out-of-hospital versus in-hospital PVF. After multivariable adjustment, PVF remained associated with all-cause 30-day (2.32, 95% CI: 1.91 to 2.82, p <0.001) and 1-year (HR: 1.59, 95% CI: 1.13 to 2.24, p = 0.008) mortality. In conclusion, we present the largest registry of PVF patients in the era of routine PPCI in STEMI. Although overall STEMI mortality has declined, PVF emerged as a predictor of both 30-day and 1-year mortality. These data warrant prospective validation and proper identification and protection of high-risk patients.

Growth differentiation factor-15 is a predictive biomarker in primary ventricular fibrillation: The RUTI-STEMI-PVF study

Background: Primary ventricular fibrillation is an ominous complication of ST-segment elevation myocardial infarction, and proper biomarkers for risk prediction are lacking. Growth differentiation factor-15 is a marker of inflammation, oxidative stress and hypoxia with well-established prognostic value in ST-segment elevation myocardial infarction patients. We explored the predictive value of growth differentiation factor-15 in a subgroup of ST-segment elevation myocardial infarction patients with primary ventricular fibrillation. Methods: Prospective registry of ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention from February 2011–August 2015. Growth differentiation factor-15 concentrations were measured on admission. Logistic regression and Cox proportional regression analyses were used. Results: A total of 1165 ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention (men 78.5%, age 62.3±13.1 years) and 72 patients with primary ventricular fibrillation (6.2%) were included. Compared to patients without primary ventricular fibrillation, median growth differentiation factor-15 concentration was two-fold higher in ST-segment elevation myocardial infarction patients with primary ventricular fibrillation (2655 vs 1367 pg/ml, p<0.001). At 30 days, mortality was 13.9% and 3.6% in patients with and without primary ventricular fibrillation, respectively (p<0.001), and median growth differentiation factor-15 concentration in patients with primary ventricular fibrillation was five-fold higher among those who died vs survivors (13,098 vs 2415 pg/ml, p<0.001). In a comprehensive multivariable analysis including age, sex, clinical variables, reperfusion time, left ventricular ejection fraction, N-terminal pro-B-type natriuretic peptide and high-sensitivity troponin T, growth differentiation factor-15 remained an independent predictor of 30-day mortality, with odds ratios of 3.92 (95% confidence interval 1.35–11.39) in patients with primary ventricular fibrillation (p=0.012) and 1.72 (95% confidence interval 1.23–2.40) in patients without primary ventricular fibrillation (p=0.001). Conclusions: Growth differentiation factor-15 is a robust independent predictor of 30-day mortality in ST-segment elevation myocardial infarction patients with primary ventricular fibrillation.

Intermediate Care Unit After Cardiac Surgery: Impact on Length of Stay and Outcomes

INTRODUCTION AND OBJECTIVES Current postoperative management of adult cardiac surgery often comprises transfer from the intensive care unit (ICU) to a conventional ward. Intermediate care units (IMCU) permit hospital resource optimization. We analyzed the impact of an IMCU on length of stay (both ICU and in-hospital) and outcomes (in-hospital mortality and 30-day readmissions) after adult cardiac surgery (IMCU-CS). METHODS From November 2012 to April 2015, 1324 consecutive patients were admitted to a university hospital for cardiac surgery. In May 2014, an IMCU-CS was established for postoperative care. For the purposes of this study, patients were classified into 2 groups, depending on the admission period: pre-IMCU-CS (November 2012-April 2014, n=674) and post-IMCU-CS (May 2014-April 2015, n=650). RESULTS There were no statistically significant differences in age, sex, risk factors, comorbidities, EuroSCORE 2, left ventricular ejection fraction, or the types of surgery (valvular in 53%, coronary in 26%, valvular plus coronary in 11.5%, and aorta in 1.8%). The ICU length of stay decreased from 4.9±11 to 2.9±6 days (mean±standard deviation; P<.001); 2 [1-4] to 1 [0-3] (median [Q1-Q3]); in-hospital length of stay decreased from 13.5±15 to 12.7±11 days (mean±standard deviation; P=.01); 9 [7-13] to 9 [7-11] (median [Q1-Q3]), in pre-IMCU-CS to post-IMCU-CS, respectively. There were no statistically significant differences in in-hospital mortality (4.9% vs 3.5%; P=.28) or 30-day readmission rate (4.3% vs 4.2%; P=.89). CONCLUSIONS After the establishment of an IMCU-CS for postoperative cardiac surgery, there was a reduction in ICU and in-hospital mean lengths of stay with no increase in in-hospital mortality or 30-day readmissions.