Harm Wienbergen

Comparison of clinical benefits of Clopidogrel therapy in patients with acute coronary syndromes taking Atorvastatin versus other statin therapies

In clinical practice, we found no significant difference between atorvastatin therapy or other statin therapies in the clinical outcomes of patients with acute coronary syndromes receiving clopidogrel therapy. In patients receiving atorvastatin therapy, clopidogrel therapy was associated with a significant decrease in mortality and stroke during univariate analysis and a moderate trend of reduced mortality and stroke without statistical significance in the multivariate analysis.

Impact of the body mass index on occurrence and outcome of acute ST-elevation myocardial infarction

Obesity is a traditional risk factor for the development of cardiovascular disease. However, recent studies have described a better outcome of obese patients in the clinical course of acute coronary syndromes.We investigated the impact of the body mass index (BMI) on occurrence and outcome of acute ST-elevation myocardial infarction (STEMI). Data of 10 534 consecutive patients with STEMI of the German MITRA PLUS registry were analyzed, comparing international classes of the BMI (obesity: BMI ≥ 30 kg/m2, overweight: 25–29.9 kg/m2, normal weight: 18.5–24.9 kg/m2).STEMI occurred at a younger age in obese patients. The obese patients with first STEMI were 3 years younger than the normal weight patients with first STEMI (62.5 vs 65.7 years, p <0.0001).After STEMI has occurred, the obese patients had the lowest hospital (6.0%) and long-term mortality (4.8%) of all compared BMI-groups. In a multivariate analysis, obesity compared to normal weight was associated with a trend of a reduced mortality without significance during the hospital course (OR 0.81, 95% CI 0.60–1.08) and with significance during follow-up (OR 0.56, 95% CI 0.40–0.79).In conclusion, our data show that obesity is a risk factor of a manifestation of STEMI at a younger age compared to normal weight patients. After STEMI has occurred, obesity is associated with a trend of a lower mortality during the following clinical course. Therefore, the focus of prevention should be the reduction of obesity and metabolic syndrome in young people, to avoid the early occurrence of STEMI by primary prevention.

Efficacy and safety of enoxaparin in unselected patients with ST-segment elevation myocardial infarction.

In randomized clinical trials the low-molecular-weight heparin enoxaparin has been shown to reduce ischemic complications in patients with acute ST elevation myocardial infarction (STEMI) treated with fibrinolysis. Little is known about the use and efficacy of enoxaparin in unselected patients with STEMI in clinical practice. In a retrospective analysis of the prospective ACOS registry we compared the outcomes of patients with STEMI treated with enoxaparin or unfractionated heparin. A total of 6,299 patients with STEMI < 12 hours were included in this analysis, 609 (10%) were treated with enoxaparin and 5,690 (90%) with unfractionated heparin. In the multivariable propensity score analysis enoxaparin was associated with a reduction in the combined endpoint of death and non-fatal reinfarction in the entire group (odds ratio 0.59; 95% CI 0.43-0.80) and the subgroups of patients treated without early reperfusion (odds ratio 0.65, 95% CI 0.43-0.97), fibrinolysis (odds ratio 0.64; 95% CI 0.33-1.26) and primary percutaneous coronary intervention (odds ratio 0.33; 95% CI 0.15-0.72). There was no significant increase in severe bleeding complications with enoxaparin (6.5% versus 5.5%, p = 0.4). In clinical practice in unselected patients with STEMI treated with or without early reperfusion therapy early treatment with enoxaparin compared to unfractionated heparin is associated with a significant reduction of the combined endpoint of inhospital death and reinfarction without a significant increase in severe bleeding complications.

Incidence, determinants, and clinical course of reinfarction in-hospital after index acute myocardial infarction (results from the pooled data of the maximal individual therapy in acute myocardial infarction [mitra], and the myocardial infarction registry [MIR])☆

There are few data about the incidence, determinants, and clinical course of in-hospital repeat acute myocardial infarction (RE-AMI) after an index AMI. From June 1994 to June 1998, 22,613 patients with AMI as an index event were registered by the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) and Myocardial Infarction Registries (MIR). Of these, 1,071 (4.7%) had a RE-AMI. For the index event, 9,143 patients (40.5%) were treated with thrombolysis, 1,707 (7.5%) with primary angioplasty, and 443 (2.0%) with a combination of both. Multivariate analysis showed that previous AMI (odds ratio [OR] 1.59; 95% confidence intervals [CI] 1.35 to 1.86), age >70 years (OR 1.57; 95% CI 1.36 to 1.81), diagnostic first electrocardiogram (OR 1.37; 95% CI 1.19 to 1.59), and female gender (OR 1.14; 95% CI 1.05 to 1.32) were independently associated with a higher incidence of RE-AMI. The incidence of RE-AMI was higher when patients received thrombolysis (OR 1.36; 95% CI 1.15 to 1.61), and it was lower when they underwent primary angioplasty (OR 0.74; 95% CI 0.53 to 1.03) or received beta blockers (OR 0.84; 95% CI 0.72 to 0.97). Patients with RE-AMI had higher hospital mortality compared with those without RE-AMI (OR 4.35; 95% CI 3.83 to 4.95). Multivariate logistic regression analysis showed an independent association of RE-AMI with in-hospital death (OR 6.60; 95% CI 5.61 to 7.70), repeat revascularization (OR 2.91; 95% CI 2.42 to 3.50), low workload capacity on the bicycle ergometry test (OR 2.17; 95% CI 1.71 to 2.76), and ejection fraction <40% (OR 1.72; 95% CI 1.38 to 2.14) at discharge. Thus, RE-AMI occurs in 4.7% of patients after an AMI. Previous AMI, age >70 years, diagnostic first electrocardiogram, and female gender are independent determinants for RE-AMI. Thrombolysis is associated with a higher and beta blockers with a lower incidence of RE-AMI. Once a RE-AMI occurs, it is a strong predictor of in-hospital mortality and morbidity.

Influence of presentation at the weekend on treatment and outcome in ST-elevation myocardial infarction in hospitals with catheterization laboratories

BackgroundStudies about the influence of various factors on clinical therapy and course in acute coronary syndromes have shown that the outcome is related to admission time to the hospital, with an impaired prognosis in patients admitted out of regular working hours. However little is known about the impact of admission on weekend in hospitals with catheterisation laboratories.MethodsWe analyzed data of the prospective MITRA-PLUS registry of 11,516 patients with ST-elevation myocardial infarction (STEMI) admitted to hospitals with catheterization facilities for differences of in-hospital mortality between patients admitted during regular working hours, at night and on weekends.ResultsThe prehospital delay and “door-to-balloon”-time were significantly longer on weekends and at nights than at regular working hours (median 196 Vs. 240 Vs. 155 min; P < 0.0001; 60 Vs. 84 min at weekends, resp. 75 min at nights; P < 0.0001). Reperfusion therapy was performed in 72.8% (8,248/11,332) patients, and there were less patients treated on weekend versus “on”-hours (69.7 Vs. 77 %, P < 0.0001). On weekends we found a significant higher in-hospital mortality (11.1 Vs. 9.4%, P = 0.01) and at night there was a trend to higher in-hospital mortality when compared with regular working hours (10.6 Vs. 9.4%, P = 0.07).ConclusionIn patients with STEMI admitted to hospitals with catheterization facilities, admission during the “off”-hours is associated with higher in-hospital mortality. This may be due to lower rates of revascularization therapy and longer prehospital and in-hospital delays as compared to “on”-hours.

Incidence, risk factors, and clinical outcome of stroke after acute myocardial infarction in clinical practice☆

: In this analysis of ischemic and hemorrhagic strokes after acute myocardial infarction (AMI) in 21,330 consecutively included patients with AMI, we found an incidence of stroke after AMI of 1.2% and a very poor prognosis. Previous stroke, atrial fibrillation, and older age were the strongest predictors of stroke after AMI; thrombolysis was a borderline risk factor and early therapy with aspirin was associated with a reduction in stroke after AMI.

Impact of Admission Blood Glucose on Outcomes of Nondiabetic Patients With Acute ST-Elevation Myocardial Infarction (from the German Acute Coronary Syndromes [ACOS] Registry)

High blood glucose in patients with acute coronary syndromes have been associated with adverse short-term outcomes in patients without diabetes. However, the relation of admission glucose to long-term outcomes in these patients was less well established. Accordingly, consecutive patients with ST-elevation myocardial infarction (STEMI) without diabetes enrolled at 155 sites from July 2000 to November 2002 in the ACOS Registry were evaluated. Patients were categorized into tertiles based on admission blood glucose. Clinical end points of interest were 1-year mortality and composite of death, reinfarction, stroke, or rehospitalization (major adverse cardiac clinical events [MACCEs]) in the hospital and after discharge. Of 5,866 patients with STEMI, 36.9% had blood glucose <120 mg/dl; 33.1%, 120 to 150 mg/dl; and 30.0%, >150 mg/dl. Admission blood glucose was significantly related to increased risk of not only in-hospital events (death, glucose >150 vs <120 mg/dl, adjusted odds ratio [OR] 2.86, 95% confidence interval [CI] 2.13 to 3.82, p <0.0001; and MACCE, >150 vs <120 mg/dl, adjusted OR 1.88, 95% CI 1.52 to 2.33; p <0.0001), but this increased risk persisted beyond the acute phase during 1-year follow-up of a mean 380 days (median 387; death, glucose >150 vs <120 mg/dl, adjusted OR 1.46, 95% CI 1.04 to 2.03, p <0.0001; and MACCE, >150 vs <120 mg/dl, adjusted OR 1.31, 95% CI 1.00 to 1.71, p <0.0001). In conclusion, high blood glucose at admission to the hospital independently correlated with short- and midterm mortality in patients with STEMI.

Impact of Ramipril versus other angiotensin-converting enzyme inhibitors on outcome of unselected patients with ST-elevation Acute Myocardial Infarction

We examined the impact of treatment with ramipril versus other angiotensin-converting enzyme (ACE) inhibitors on clinical outcome in unselected patients of the prospective multicenter registry Maximal Individual Therapy of Acute Myocardial Infarction PLUS registry (MITRA PLUS). Of 14,608 consecutive patients with ST-elevation acute myocardial infarction, 4.7% received acute therapy with ramipril, 39.0% received other ACE inhibitor therapy, and 56.3% received no ACE inhibitor therapy. In a multivariate analysis, the treatment with ramipril compared with the treatment without ACE inhibitors was associated with a significantly lower hospital mortality and a lower rate of nonfatal major adverse coronary and cerebrovascular events. Compared with other generic ACE inhibitors, ramipril therapy was independently associated with a significantly lower hospital mortality (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.32 to 0.90) and a lower rate of nonfatal major adverse coronary and cerebrovascular events (OR 0.65, 95% CI 0.46 to 0.93), but not with a lower rate of heart failure at discharge (OR 0.79, 95% CI 0.50 to 1.27).

Beneficial effects of abciximab in patients with primary percutaneous intervention for acute st segment elevation myocardial infarction in clinical practice

Objectives: To assess the safety and effectiveness of abciximab in patients with ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) in clinical practice. Methods: Data were analysed of 2184 consecutive patients treated with primary PCI for acute STEMI and either concomitant abciximab or no glycoprotein IIb/IIIa inhibitor (control group), who were prospectively enrolled in the Acute Coronary Syndromes (ACOS) registry between July 2000 and November 2002. Results: Patients who were treated with abciximab were younger than the control group, and fewer of them had a history of stroke/transient ischaemic attack and systemic hypertension, but more of them had three-vessel coronary artery disease and cardiogenic shock. Cumulated mid-term survival for patients treated with abciximab was significantly higher than in the control group (91% v 79%, log rank p < 0.05, median observational time 375 days, range 12–34 months). The Cox proportional hazards model of mid-term mortality after admission with adjustment for baseline characteristics showed that mortality was significantly lower in the abciximab group than in the control group (hazard ratio 0.68, 95% confidence interval 0.49 to 0.95). Whereas overall there was no difference in bleeding complications, patients older than 75 years had more major bleeding events with abciximab (12.5% v 3.4%, p  =  0.03). Conclusion: In clinical practice adjunctive treatment with abciximab in patients with primary PCI for acute STEMI was associated with a reduction in mid-term mortality. The subgroup of patients older than 75 years who were treated with abciximab had more major bleeding complications.

Smoking ban in public areas is associated with a reduced incidence of hospital admissions due to ST-elevation myocardial infarctions in non-smokers. Results from the BREMEN STEMI REGISTRY:

Introduction Laws banning tobacco smoking from public areas have been passed in several countries, including the region of Bremen, Germany at the end of 2007. The present study analyses the incidence of hospital admissions due to ST-elevation myocardial infarctions (STEMIs) before and after such a smoking ban was implemented, focusing on differences between smokers and non-smokers. In this respect, data of the Bremen STEMI Registry (BSR) give a complete epidemiological overview of a region in northwest Germany with approximately 800,000 inhabitants since all STEMIs are admitted to one central heart centre. Methods and results Between January 2006 and December 2010, data from the BSR was analysed focusing on date of admission, age, gender, and prior nicotine consumption. A total of 3545 patients with STEMI were admitted in the Bremen Heart Centre during this time period. Comparing 2006–2007 vs. 2008–2010, hence before and after the smoking ban, a 16% decrease of the number of STEMIs was observed: from a mean of 65 STEMI/month in 2006–2007 to 55/month in 2008–2010 (p < 0.01). The group of smokers showed a constant number of STEMIs: 25/month in 2006–2007 to 26/month in 2008–2010 (+4%, p = 0.8). However, in non-smokers, a significant reduction of STEMIs over time was found: 39/month in 2006–2007 to 29/month in 2008–2010 (−26%, p < 0.01). The decline of STEMIs in non-smokers was consistently observed in all age groups and both sexes. Adjusting for potentially confounding factors like hypertension, obesity, and diabetes mellitus did not explain the observed decline. Conclusions In the BSR, a significant decline of hospital admissions due to STEMIs in non-smokers was observed after the smoking ban in public areas came into force. No reduction of STEMI-related admissions was found in smokers. These results may be explained by the protection of non-smokers from passive smoking and the absence of such an effect in smokers by the dominant effect of active smoking.