Iwona Świątkiewicz

Updated evidence on intracoronary abciximab in ST-elevation myocardial infarction: a systematic review and meta-analysis of randomized clinical trials.

BACKGROUND Intracoronary (IC) abciximab administration remains a promising approach aimed to increase a drug concentration in the target area and possibly improve clinical outcomes in the setting of ST-segment elevation myocardial infarction (STEMI). The goal of this literature review and meta-analysis is to update available knowledge comparing IC and intravenous (IV) abciximab administration in STEMI patients. METHODS A total of 7 randomized clinical trials (RCTs) with a median follow-up of 3 months were included in the meta-analysis (n = 3311). All-cause mortality was selected as the primary end point while recurrent myocardial infarction (re-MI), target vessel revascularization (TVR) and major bleeding complications were the secondary end points. RESULTS IC abciximab did not provide any benefits in terms of all-cause mortality as compared with IV abciximab (odds ratio [OR] 0.67; 95% confidence interval [CI] 0.34-1.34). However, this neutral effect was driven by the AIDA STEMI trial. The IC route was associated with a reduced rate of re-MI when compared with IV administration (OR 0.61; 95% CI 0.40-0.92) but the difference disappeared after one of the RCTs was excluded from the analysis. Both strategies were equal regarding TVR (OR 0.66; 95% CI 0.40-1.09) and major bleeding complications (OR 1.18; 95% CI 0.76-1.83). CONCLUSIONS Our updated meta-analysis shows that the clinical superiority of IC over IV abciximab administration in STEMI patients is no longer clear after the release of the AIDA STEMI trial results. Further research in high-risk STEMI patients is warranted to finally determine clinical advantages of IC vs IV abciximab administration.

Time-related changes in determinants of antiplatelet effect of clopidogrel in patients after myocardial infarction☆

Substantial variability of antiplatelet action is an important limitation of clopidogrel. The aim of this study was to evaluate time-related changes in determinants of clopidogrel responsiveness in patients after myocardial infarction. The study population comprised 191 consecutive patients treated with primary percutaneous coronary intervention for acute myocardial infarction. Follow-up visits were scheduled at 3, 6 and 9 months after discharge. ADP-induced platelet aggregation was tested with Multiplate Analyzer. Patients with ADP-PA>46.8U were defined as clopidogrel non-responders. The prevalence of clopidogrel non-responsiveness was highest during hospitalization and at 9 month follow-up visit, while it was lowest at 3 and 6 months after myocardial infarction (P=0.004). According to multivariate analysis, platelet count, mean platelet volume, concentration of hsCRP and leukocyte count influenced ADP-induced platelet aggregation in multiple assessment points. BMI, concentrations of hemoglobin, glycated hemoglobin, and BNP, hematocrit, adherence to medication, and patient׳s age were found to be independent predictors of high on-treatment ADP-induced platelet aggregation only at a single follow-up visit. Determinants of clopidogrel responsiveness in patients after myocardial infarction change within the long-term therapy. During hospitalization and early after discharge only biological factors affect ADP-induced platelet aggregation, while non-adherence to antiplatelet therapy may be a significant factor in determining clopidogrel non-responsiveness during late follow-up visits.

Discrepancies in Assessment of Adherence to Antiplatelet Treatment after Myocardial Infarction

The poor response to clopidogrel is multifactorial and includes, amongst others, low patient adherence to medication. The aim of this study was to assess the reported patient adherence to treatment with clopidogrel and confront it with adherence assessed by drug availability. We evaluated determinants of adherence and its impact on platelet aggregation and clinical outcome. The study population comprised 184 patients treated with primary percutaneous coronary intervention for acute myocardial infarction. Follow-up visits were scheduled at 3, 6 and 9 months after discharge. Patient adherence to clopidogrel was defined according to self-reported drug intake and verified based on data from the National Health Fund regarding the purchase of prescribed drugs. The patients were judged as adherent when the proportion of drug availability exceeded 80%. According to drug availability, 100 (54.3%) patients were adherent and 84 (45.7%) were nonadherent. The analysis identified the following factors as predictors of low adherence (<80%): adenosine diphosphate-induced platelet aggregation (ADP-PA) during hospitalization ≤45 U, male gender and occurrence of ST-elevation myocardial infarction [(STEMI) vs. non-STEMI (NSTEMI)], while three-vessel disease was predictive of high adherence to medication. Compared with drug availability-based assessment, self-reported drug intake was significantly different: 172 (94.5%) patients reported regular and 10 (5.5%) patients reported irregular intake of clopidogrel. Clinical follow-up suggested that the self-reported nonregular clopidogrel intake may discriminate patients with a high risk of cardiovascular events. We demonstrated a huge discrepancy between the two most widely used methods for the evaluation of adherence to clopidogrel in secondary prevention treatment in patients after STEMI and NSTEMI. ADP-PA during hospitalization ≤45 U, male gender and STEMI (vs. NSTEMI) were independent predictors of nonadherence while three-vessel disease was independently predictive of adherence to treatment with clopidogrel in the investigated population.

Does mobilisation of CD34+ stem cells along with VEGF, angiogenin, IL-6, IL-8, and hsCRP levels allow predicting the direction of left ventricular ejection fraction and wall motion score index changes in patients with myocardial infarction?

BACKGROUND Left ventricular (LV) systolic function is a significant prognostic factor in patients after myocardial infarction (MI). Multiple angiogenic and inflammatory factors are involved in postinfarction LV remodelling process. In addition, CD34+progenitor cells mobilised from bone marrow and tissue niches participate in regeneration of the infarcted myocardium. AIM To examine relationships between LV ejection fraction (LVEF) and wall motion score index (WMSI) and the number of CD34+ cells and plasma levels of vascular endothelial growth factor (VEGF), angiogenin and such inflammatory factors as interleukin 6 (IL-6), interleukin 8 (IL-8), and high-sensitivity C-reactive protein (hsCRP) in patients with ST-elevation MI (STEMI). METHODS The study group included 61 patients with STEMI treated with primary percutaneous coronary intervention (PCI)involving bare metal stent implantation. Plasma levels of the evaluated angiogenic and inflammatory factors were measured by flow cytometry at 4 time points (just before PCI, 24 h later, at hospital discharge, and 30 days after STEMI). LVEF and WMSI were measured by echocardiography at hospital discharge, 1 month later, and 6 months later. We compared angiogenic and inflammatory factor levels in patients with no improvement of the LV systolic function during the follow-up (group 1, n = 22)vs. those with improved LV systolic function (group 2, n = 39). RESULTS No differences in the levels of VEGF, angiogenin, IL-6, IL-8, and hsCRP, and the number of CD34+ cells were observed between the two groups. Despite this, we found significant negative correlations between hsCRP level and LVEF,and positive correlations between hsCRP level and WMSI in both patient groups, but these correlations were much stronger in group 1. We also found a significant negative correlation between WMSI at 6 months and the number of CD34+ cells measured 24 h after PCI. CONCLUSIONS 1. Evaluation of plasma VEGF, angiogenin, IL-6, IL-8, and hsCRP levels and the number of CD34+ cells at different time points in patients with STEMI did not allow predicting the direction of changes in LVEF and WMSI. 2. Observed significant correlations between hsCRP level and LVEF and WMSI may suggest a harmful effect of inflammation on postinfarction myocardial remodelling. 3. A significant negative correlation between the number of CD34+ and WMSI suggests that increased mobilisation of these cells might have a beneficial effect on systolic function after MI.

Prediction of high risk of non-adherence to antiplatelet treatment

BACKGROUND Dual antiplatelet therapy with acetylsalicylic acid (ASA) and clopidogrel is the standard of care for secondary prevention. Premature discontinuation of clopidogrel is associated with an increased risk of myocardial infarction (MI) or death, and greater health care expenditure. AIM To develop an objective method for identification of patients with high risk of non-adherence to clopidogrel after MI. METHODS A total of 189 patients were enrolled into a prospective, observational, single-centre study with a nine-month follow-up. Patients received a 600-mg loading dose and 75-mg maintenance dose of clopidogrel in combination with ASA doses of 300 mg and 75 mg, respectively. Adenosine diposphate-induced platelet aggregation (ADP-PA) was assessed during baseline hospitalisation and at three, six, and nine months after discharge. Adherence to medication with clopidogrel was defined as the proportion of drug availability based on data from the National Health Fund regarding prescribed drug purchases. Adherence was arbitrarily judged adequate when the proportion exceeded 80%. RESULTS According to our hypothesis, ADP-PA in non-adherent patients should be higher at follow-up visits (at least once) as compared with measurement at hospitalisation. Based on the ROC curve analysis, the optimal cut-off point equal to 4 U was defined (p < 0.0001, 95% CI 0.562-0.654; sensitivity: 60.6%, specificity: 57.1%, positive predictive value: 63.3%, negative predictive value: 54.2%). The prevalence of true adherence to medication in groups of high and low probability of adherence defined according to developed criteria amounted 60 (50.8%) and 23 (32.4%) cases, respectively (p = 0.01). CONCLUSIONS The newly developed method of objective identification of patients with high risk of non-adherence to clopidogrel after MI is easily applicable and cheap, and, despite relatively low sensitivity and specificity, it efficiently differentiates patients with regard to clinical end-points during follow-up.

Polish Stress Echocardiography Registry (Pol-STRESS registry) — a multicentre study. Stress echocardiography in Poland: numbers, settings, results, and complications

BACKGROUND Stress echocardiography (SE) is widely used in Europe. No collective data have been available on the use of SE in Poland until now. AIM To evaluate the number of SE investigations performed in Poland, their settings, complications, and results. METHODS In this retrospective survey, referral cardiology centres in Poland were asked to fill in a questionnaire regarding SE examinations performed from May 1, 2014 to May 1, 2015. RESULTS The study included data from 17 university hospitals and large community hospitals, which performed 4611 SE exa-minations, including 4408 tests in patients investigated for coronary artery disease (CAD) and 203 tests to evaluate valvular heart disease (VHD). To evaluate CAD, all centres performed dobutamine SE (100%), 10 centres performed pacing SE (58.8%), while cycle ergometer SE and treadmill SE were performed by six (35.3%) and five (29.4%) centres, respectively. Dipyridamole SE was performed in one centre. All evaluated centres (100%) performed SE to evaluate low-flow/low-gradient aortic stenosis, eight (47%) performed SE to evaluate asymptomatic aortic stenosis, and also eight (47%) performed SE to evaluate mitral regurgitation. The mean number of examinations per year was 271 per centre. Most centres performed more than 100 examinations per year (11 centres, 64.7%). We did not identify any cardiac death during SE examination in any of the centres. Myocardial infarction occurred in three (0.07%) patients. Non-sustained ventricular tachycardia occurred in 52 (1.1%) SE examinations. The rates of minor complications were low. SE to evaluate CAD was more commonly performed in the hospital settings using cycle ergometer (72.6%), treadmill (87.6%), and low-dose dobutamine (68.0%), while a dipyridamole test was more frequently employed in ambulatory patients (77.6%). No significant differences between the rates of examina-tions performed in the ambulatory and hospital settings were found for high-dose dobutamine and pacing SE. Examinations to evaluate VHD were significantly more frequently performed in the hospital settings. SE examinations accounted for more than one third of all stress tests performed in the surveyed centres over the study period. CONCLUSIONS Stress echocardiography is a safe diagnostic method, and major complications are very rare. Despite European recommendations, SE examinations to evaluate CAD are performed less frequently than electrocardiographic exercise tests, although they already comprise a significant proportion of all stress tests. It seems reasonable to promote SE further for the evaluation of both CAD and VHD.

Impact of prior statin therapy on evaluation of the inflammatory process and cortisol concentration in patients with the first ST-segment elevation myocardial infarction undergoing coronary angioplasty with bare metal stent implantation

Introduction. The aim of the current study was to verify the impact of statin therapy on evaluation of the inflammatory process and cortisol concentration in patients with the first episode of ST-segment elevation myocardial infarction undergoing coronary angioplasty with bare metal stent implantation. Material and methods. The study was designed as a prospective, single-center cohort study, with a total number of 200 patients enrolled between 2005 and 2008. Results. Seventeen patients with ongoing statin therapy and 167 patients without those agents underwent pPCI with BMS implantation. The cortisol concentration on admission was significantly lower in statin therapy subgroup — median 14.9 μg/dL (9.5–23.3 IQR) vs. 28,1 μg/dL (17.2–39.9 IQR) for patients without lipid lowering drug, p = 0.01. The level of cortisol after 23h was also significantly lower in statin receiving subgroup: 10.4 μg/dL (8.3–19 IQR) vs. 17.3 μg/dL (10.1–25.9 IQR) adequately, p = 0.021. Those two groups did not differ significantly in relation to CRP, IL-6, IL-10 concentrations and to anti-inflammatory cytokine ratio [IL-6/IL-10] on admission, after 24h and at discharge. Significant differences were observed in the concentrations of cTnI and activities of CK and CK-MB. Conclusions. Ongoing statin therapy before an episode of myocardial infarction has an influence on cortisol concentration and cardiac markers. No significant effect on serum levels of cytokines has been observed.

Treatment of severe mitral regurgitation with MitraClip system — a single-centre study

Introduction. MitraClip (MC) is a catheter-based device to treat mitral regurgitation (MR). This method uses a transseptal approach and is based on the creation of a double orifice mitral valve by suturing of the middle scallops of the mitral valve’s leaflets. Aim. The aim of the study was to assess the effectiveness of MC method in treating patients with severe MR. We analysed MR severity, patient’s clinical condition evaluated by New York Heart Association (NYHA) functional class, and the function of the left ventricle evaluated by Left Ventricle Ejection Fraction (LVEF). Methods. A retrospective single-centre study with patients hospitalised at the Department of Cardiology and Internal Medicine in Bydgoszcz. All diagnosed with severe MR and treated by performing MC procedure in the time period from August 2010 to December 2014. The following data from medical history (NYHA class) and echocardiography examinations (MR severity and LVEF) were analysed in three time points: before, right after the procedure, and after the follow-up period (four weeks since discharge). Results. The studied group consisted of 11 patients — 8 male, 3 female, aged 64.4 ( ± 10.2) years, treated with MC. All of the three analysed parameters improved relevantly as a result of the evaluated procedure. The percentage of patients classified as NYHA class III/IV presents as follows: 90% before the procedure, 55% after MC implantation (ns), and 44% after the follow-up period (p = 0.01). All patients suffered from severe-to-moderate (3+) and severe (4+) MR before the procedure. After implantation only 9% (ns) were still classified with 3+/4+ MR, and after the follow-up this percentage reached 18% (p = 0.0005). We observed relevant changes of LVEF. The average LVEF at baseline was 27.9 ± 2%, which increased to 29.6 ± 2% (ns) after the MC implantation and 34 ± 7% (p = 0.02) after the follow-up. Conclusion. MC therapy is effective in patients with severe symptomatic MR with congestive heart failure and decreased LVEF. It reduces MR severity both acutely and after the follow-up period and improves NYHA class and LVEF.

Device-associated thrombus after percutaneous left atrial appendage closure: a case report and literature review

Introduction. In the setting of atrial fibrillation (AF), left atrial appendage (LAA) closure using the Watchman TM device (WD) was proven to effectively prevent stroke, systemic embolism and cardiovascular death when compared with warfarin therapy. However, this procedure is potentially associated with the risk of complications, including device-attached thrombus formation. Case presentation. We report a case of a 65-year-old woman with permanent non-valvular AF, a history of ischemic stroke on warfarin treatment, hypertension, diabetes mellitus, heart failure with preserved left ventricular ejection fraction, labile values of the international normalized ratio, enlarged left atrium (LA) and spontaneous echo contrast in echocardiography, who was qualified for percutaneous LAA closure using the WD. The pre-procedural patient assessment indicated high thromboembolic (CHA 2 DS 2 -Vasc Score = 5) and bleeding risk (HAS-BLED Score = 4), and optimal morphology of LAA in transesophageal echocardiography (TEE). After a successful procedure using a 30 mm-sized WD, and despite appropriate antiplatelet and anticoagulation therapy, 6-month follow-up TEE revealed a mobile thrombus (2.4 cm × 0.6 cm) at the atrial side of the WD. Therapy with intravenous heparin was started. However, a control TEE examination after one week revealed progression of the thrombus size (4.2 cm × 0.7 cm) and its protrusion across the mitral valve orifice into the left ventricle. Although the patient remained asymptomatic, cardiosurgical excision of the thrombus was performed due to high risk of thrombus embolization. Conclusions. Late device-associated thrombus formation after implantation of the WD remains a rare but severe complication. Formal recommendations regarding prevention and management of device-related thrombosis are still lacking. In this complex clinical setting, we suggest: 1) careful long-term echocardiographic monitoring after percutaneous LAA closure, especially in patients with permanent AF, high thromboembolic risk, large LA and dense spontaneous echo contrast in echocardiography, and 2) an individualized treatment approach.

Percutaneous left atrial appendage closure for thromboembolic prophylaxis in patients with atrial fibrillation. The impact of operator's experience on the procedure course

Background. Left atrial appendage (LAA) closure represents an alternative strategy to oral anticoagulants in thromboembolic prophylaxis in patients with atrial fibrillation (AF). The LAA closure with the WATCHMAN™ device has been proved to be non-inferior to warfarin therapy. Nevertheless, this strategy is associated with numerous periprocedural complications. This study was conducted to determine whether the experience of the operating team affects the duration of the procedure and its complication rate. Methods. This retrospective single-centre study examined LAA percutaneous closure procedures in 43 consecutive AF patients with contraindications to oral anticoagulation (13 female, 30 male; mean age 70.98 ± 10.69 years). All device implantations were performed by two operators using the WATCHMAN™ device and the result was assessed by two echocardiographers. We compared the first 22 (group A) with the subsequent 21 procedures (group B). Results. For group B, a decrease in the overall procedure time (PT) by 28% (from 83.41 min ± 36.49 to 59.76 min ± 21.70; p = 0.006) was found, with a subsequent reduction in fluoroscopy time (FT) by 33% (from 16.59 min ± 7.25 to 11.2 min ± 7.21; p = 0.019) and the volume of contrast medium (CV) by 40% (from 129.14 mL ± 79.81 to 78.05 mL ± 33.82; p = 0.004). The incidence of periprocedural adverse events and complications was 55% (12 patients) in group A and 33% (7 patients) in group B. Conclusions. The increasing operators’ and echocardiographers’ experience in LAA closure is associated with reduction in procedure time, fluoroscopy time and contrast volume.