Janusz Szkodzinski

Reperfusion by primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction within 12 to 24 hours of the onset of symptoms (from a prospective national observational study [PL-ACS]).

The aim of the present study was to investigate whether reperfusion by primary percutaneous coronary intervention (PCI) improves 12-month survival in late presenters with ST-segment elevation myocardial infarction (STEMI). We analyzed 2,036 patients with STEMI presenting 12 to 24 hours from onset of symptoms, without cardiogenic shock or pulmonary edema and not reperfused by thrombolysis, of 23,517 patients with STEMI enrolled in the Polish Registry of Acute Coronary Syndromes from June 2005 to August 2006. An invasive approach was chosen in 910 (44.7%) of late presenters and 92% of them underwent reperfusion by PCI. Patients with an invasive approach had lower mortality after 12 months than patients with a conservative approach (9.3% vs 17.9%, p <0.0001). The benefit of an invasive approach was also observed after multivariate adjustment with a relative risk 0.73 for 12-month mortality (95% confidence interval 0.56 to 0.96) and in a subpopulation of patients selected by a propensity-score matching procedure with an adjusted relative risk 0.73 for 12-month mortality (0.58 to 0.99). In conclusion, almost 1/2 of late presenters with STEMI were considered eligible for reperfusion by primary PCI. These patients had a lower 12-month mortality rate than they would have had if they had been treated conservatively, which supports the idea of late reperfusion in STEMI. However, whether all late presenters with STEMI should be treated invasively remains unanswered. Nevertheless, until a randomized trial is undertaken, late presenters with STEMI could be considered for reperfusion by primary PCI.

Platelet-to-lymphocyte ratio is a marker of poor prognosis in patients with diabetes mellitus and ST-elevation myocardial infarction

AIM Platelet-to-lymphocyte ratio (PLR) has emerged as a strong marker of worse outcomes. We determined the association between PLR and clinical outcomes in patients with diabetes mellitus and ST-elevation myocardial infarction. METHODS Five hundred and twenty three patients were enrolled. Low PLR (group 1, n = 349) was defined as ≤ 124 and high PLR (group 2, n = 174) as >124. RESULTS In-hospital and 1-year mortality was higher in group 2. Receiver operating characteristic analysis revealed moderate diagnostic value in predicting in-hospital (PLR cut-off >155) and long-term (PLR cut-off >146) death. PLR remained an independent risk factor of early and late mortality. CONCLUSION PLR proved to have good prognostic value for in-hospital and late mortality. PLR cut-off value for predicting in-hospital mortality was higher to that predicting late mortality. PLR remained an independent risk factor early and late mortality.

Outcomes of primary coronary angioplasty and angioplasty after initial thrombolysis in the treatment of 374 consecutive patients with acute myocardial infarction

BACKGROUND In patients with acute myocardial infarction (MI), the efficacy of thrombolysis is low. Angioplasty after failed thrombolysis (rescue percutaneous coronary angioplasty [PTCA]) has been associated with an increase in the incidence of inhospital complications. It has been proposed that these complications result from the procedure itself. Thus, the aim of this study was to compare the efficacy, inhospital complications, and mortality rate of patients with MI who are treated with primary PTCA and PTCA after initial thrombolysis (rescue or immediate rescue) in an experienced clinical center specializing in percutaneous coronary interventions. METHODS AND RESULTS The study group consisted of consecutive patients with MI treated with primary PTCA (n = 195) or PTCA after initial thrombolysis (n = 179). The study was performed in a referral center with a 24-hour catheter-laboratory service. The success rate of the procedure was 90.5% and 88.2% in the PTCA after initial thrombolysis group and primary PTCA group, respectively. The groups did not differ in the frequency of reocclusion, emergency surgical revascularization (coronary artery bypass grafting), or stroke. In patients without cardiogenic shock, the inhospital mortality rates were 3.2% and 0.6% in the rescue and immediate rescue group and primary PTCA group, respectively (not significant). In a subgroup of patients with cardiogenic shock, the mortality rate was 36.0% in the initial thrombolysis PTCA group and 30.8% in the primary PTCA group. However, after successful PTCA in this subgroup, the mortality rate dropped to 18% and 10%, respectively. CONCLUSIONS After initial thrombolysis, PTCA is safe, effective, and likely to restore grade 3 Thrombolysis In Myocardial Infarction flow in about 90% of patients. When available, immediate rescue PTCA should be performed in all patients, including patients with cardiogenic shock.

Serum interleukin-6 concentration reflects the extent of asymptomatic left ventricular dysfunction and predicts progression to heart failure in patients with stable coronary artery disease

BACKGROUND Left ventricular ejection fraction (LVEF) remains one of the strongest predictors of long-term prognosis in patients with stable coronary artery disease (CAD). Asymptomatic left ventricular systolic dysfunction (LVSD) often precedes clinically overt heart failure (HF) and is an area of extensive research nowadays. We studied the association between serum IL-6 concentrations and the extent of LV dysfunction in patients with asymptomatic LVSD. We aimed to investigate the diagnostic value of serum IL-6 concentrations in predicting the risk of progression to HF. Seventy-one patients entered the study and were divided into three groups based on LVEF: group 1 - patients with LVEF <30% (N=7), group 2 - patients with LVEF 30-50% (N=37) and group 3 - patients with LVEF >50% (N=27). RESULTS Demographics were similar in all three groups. IL-6 concentration was the highest in group 1 (median 8.6 pg/mL) and the lowest in group 3 (median 2.6 pg/mL), whereas IL-6 concentration in group 2 was intermediate (median 3.7 pg/mL) (P=0.002). We found a significant, inverse correlation between IL-6 concentration and ejection fraction. During 18-month follow-up clinically overt HF developed in 71.4% of patients in group 1 and in 37.5% of patients in group 2. None of the patients in group 3 manifested HF symptoms (P<0.001). ROC analysis revealed high diagnostic value of serum IL-6 and LVEF in predicting progression to HF. We also found a strong, inverse correlation between IL-6 and the time of progression to HF. CONCLUSIONS There is a strong correlation between IL-6 and the extent of asymptomatic LVSD in patients with documented CAD. Elevated IL-6 concentrations preceded progression to clinically overt HF. Moreover, the higher the IL-6 concentration the earlier the manifestation of HF symptoms.

Prognostic significance of mean platelet volume in diabetic patients with ST-elevation myocardial infarction

PURPOSE Mean platelet volume (MPV) is a universally available parameter with routine blood counts. It has been linked to many cardiovascular risk factors. MPV is a marker of platelet size and activity and has been linked to poor prognosis following STEMI. There has been an increasing number of reports linking diabetes mellitus (DM) to platelet dysfunction. The aim of the study was to examine the association between admission MPV and clinical outcomes in patients with DM and STEMI undergoing primary percutaneous coronary intervention (PCI). The secondary objective of the study was to evaluate whether this index can be used to determine the long-term prognosis. METHODS A total of 1,557 patients with STEMI undergoing primary PCI were enrolled and divided into two groups depending on their diabetes mellitus status: Group 1 - patients with diabetes mellitus (N=539) and Group 2 - patients without diabetes mellitus (N=1018). RESULTS MPV and peak CK-MB concentration were higher in diabetic patients as compared to non-diabetic patients. In diabetic patients, MPV was positively correlated with admission Killip class and negatively correlated with time to death during follow-up, initial TIMI flow, final TIMI flow, and erythrocyte count. In non-diabetic patients, MPV was positively correlated with the number of diseased coronary arteries, admission Killip class, and negatively correlated with time to death during follow-up and initial TIMI flow. ROC analysis revealed high diagnostic value of MPV in predicting in-hospital and one-year mortality. MPV cut-off level was lower for diabetic patients compared to non-diabetic patients. CONCLUSIONS Diabetic patients had higher MPV than non-diabetic patients. Both in diabetic and non-diabetic patients MPV proved to have good prognostic value for in-hospital and late mortality. MPV cut-off value for predicting mortality was lower in diabetic patients. Mortality rate was the highest in the fourth quartiles of MPV in both study groups.

Serum interleukin-6 concentration predicts contrast-induced nephropathy in patients undergoing percutaneous coronary intervention

BACKGROUND Contrast media are being widely applied for both diagnostic and therapeutic purposes. This has resulted in increasing incidence of contrast-induced nephropathy (CIN). METHODS We aimed to investigate the value of baseline serum IL-6 concentrations in predicting CIN before the rise of serum creatinine (SCr) in patients undergoing percutaneous coronary intervention. Seventy four Caucasian patients were enrolled. CIN was defined as an increase in SCr concentration of more than 44 micromol/L, or a 25% increase above baseline within 48 hours after contrast administration. RESULTS CIN developed in 16 out of 74 patients (21.6%). The median concentration of IL-6 was 3.2 pg/mL. The median IL-6 concentration on admission was lower in patients who subsequently did not develop CIN (2.7 pg/mL versus 8.3 pg/mL, p < 0.0001). Receiver operating characteristics analysis showed a high diagnostic value of baseline SCr and IL-6. The cut-off value to predict CIN for IL-6 was over 4.0 pg/mL (sensitivity 88%, specificity 76%, PPV 50%, NPV 96%). Multivariate logistic regression analysis revealed three independent predictors of CIN: IL-6 (OR 1.43; 95%CI: 1.17-1.76), serum creatinine (OR 1.79; 95%CI: 1.1-3.39), and ejection fraction (OR 0.86; 95%CI: 0.50-0.95). CONCLUSIONS Increased concentrations of IL-6 on admission are associated with subsequent CIN. Our study proposes that IL-6 be added to the list of potential markers that could be used, along with renal function parameters, in clinical practice.

Comparison between five-year mortality of patients with and without red blood cell transfusion after percutaneous coronary intervention for ST-elevation acute myocardial infarction

BACKGROUND Red blood cell (RBC) transfusion can be lifesaving. However, in many clinical cases, including acute coronary syndromes, percutaneous coronary interventions (PCI), cardiac surgery, and acute critical care, detrimental effects (excess death and myocardial infarction [MI], and also lung infections) have been observed in patients after a RBC transfusion. AIM To evaluate the long-term impact on the prognosis of patients who received a RBC transfusion after PCI for the treatment of ST-segment elevation MI (STEMI). METHODS Between 1999 and 2004, 2,415 consecutive patients, with an STEMI treated with PCI, were included in the analysis. The patients were divided into two groups: 82 patients with a RBC transfusion (3.5%) and 2,333 without a RBC transfusion (96.5%). RESULTS The in-hospital mortality rate was 15.8% and 4.2% (p < 0.0001) and the five-year mortality rate was 42.7% and 19% (p < 0.0001) for patients who received and who did not receive a RBC transfusion, respectively. Moreover, multivariate analysis revealed that, after correction for baseline differences, RBC transfusion was an independent predictor of five-year mortality in patients treated with PCI (HR 1.45; 95% CI 1.0-2.1; p = 0.04). CONCLUSIONS Red blood cell transfusion is associated with higher five-year mortality in STEMI patients treated with PCI.

Effect of omeprazole on the concentration of interleukin-6 and transforming growth factor-β1 in patients receiving dual antiplatelet therapy after percutaneous coronary intervention

BACKGROUND Dual antiplatelet therapy (aspirin plus clopidogrel) is recommended in patients undergoing percutaneous coronary intervention (PCI). Treatment with proton pump inhibitors (PPIs) decreases bleeding rate. Alarming reports have been made that PPIs may decrease the antiplatelet activity of clopidogrel. We sought to determine whether levels of interleukin-6 (IL-6) and transforming growth factor-β1 (TGF-β1) might help distinguish individuals at risk for adverse events. METHODS Thirty-eight patients on aspirin and clopidogrel were enrolled and divided into two groups: group 1 [patients receiving omeprazole (n = 18)] and group 2 [patients not receiving omeprazole (n = 20)]. Patients underwent PCI and were scheduled for twelve-month clinical follow-up. The major, adverse cardiac and cerebrovascular events (MACCE) include death, re-hospitalization for acute coronary syndromes, and stroke. RESULTS Median concentrations of IL-6 were higher in group 1 at 4.7 pg/mL, in comparison with group 2, 1.65 pg/mL (p = 0.003). Median concentrations of TGF-β1 were similar in both groups (p = 0.5). Patients in group 1 had a significantly higher leukocyte count [103/mm3] (median 7.5 vs 6.5; p = 0.04). There were no deaths during follow-up. The incidence of myocardial infarction was higher in group 1 (33.4% vs 5.0%; p = 0.03). MACCE at twelve months were more frequent in group 1 (55.6% vs 20.0%; p = 0.02). The cut-off value to predict MACCEs for IL-6 was > 3.6 pg/mL (sensitivity 64%, specificity 88%, positive predictive value 75%, negative predictive value 81%). INTERPRETATION We show here that concomitant omeprazole use is associated with an increased inflammatory reaction. Drug interactions may reduce the anti-inflammatory effect of clopidogrel. This mechanism maybe responsible for an increased risk of non-fatal, cardiovascular events, following stent placement.

Plasma Pentraxin 3 May Be a More Sensitive Marker of Inflammatory Response Than High-Sensitivity C-Reactive Protein After Bare-Metal Stent Compared to Drug-Eluting Stent Implantation

C-reactive protein (CRP) and pentraxin 3 (PTX3) are members of a highly conserved pentraxin superfamily. CRP is synthesized in the liver and may represent a systemic response to local inflammation. PTX3 is synthesized locally at the inflammatory sites and may represent a marker for local inflammation at sites of vessel injury. We compared plasma high-sensitivity CRP (hsCRP) and PTX3 concentrations after bare-metal stent (BMS) and drug-eluting stent (DES) implantation. Fifty-three patients with stable coronary artery disease who underwent percutaneous coronary intervention were divided into 2 groups: 1-24 patients (BMS group) and 2-29 patients (DES group). Patients were scheduled for an elective, 6-month clinical follow-up. Major adverse cardiovascular events (MACEs) (death, myocardial infarction, target vessel revascularization) were assessed. Baseline clinical characteristics were similar in both groups. Patients after BMS implantation had a higher median PTX3 concentration 1.02 ng/mL compared to patients after DES implantation 0.80 ng/mL, P=0.045. Median hsCRP concentrations were similar in both groups: 0.9 mg/L versus 0.89 mg/L, respectively. Six-month follow-up was available in 33 patients. Four out of 33 patients had MACEs during follow-up. The cut-off value to predict MACEs for PTX3 was >1.16 ng/mL (P=0.004) and for hsCRP was >0.95 mg/L (P<0.001). Patients after DES implantation showed significantly lower plasma PTX3 levels compared with patients after BMS implantation. hsCRP showed no difference between the study groups. PTX3 may be a more sensitive marker of local inflammatory response due to vessel injury by BMS than hsCRP. DES implantation may attenuate the early inflammatory response. Lower PTX3 levels may reflect potent anti-inflammatory properties of DES.

Effect of HMG-CoA (3-hydroxy-3-methyl-glutaryl-CoA) reductase inhibitors on the concentration of insulin-like growth factor-1 (IGF-1) in hypercholesterolemic patients

UNLABELLED Studies have shown that HMG-CoA reductase inhibitors (statins) play an important role in the prevention and treatment of atherosclerosis and hyperlipidemia. The aim of this study was to investigate the effect of 3-month treatment with simvastatin on serum levels of Insulin-Like Growth Factor-1 (IGF-1) in patients with diagnosed hypercholesterolemia. In total, 156 patients with hypercholesterolemia were recruited for the study. The inclusion criteria for this study were designed to allow the enrollment of a representative group of patients for cytokine studies. The patients were divided into two groups: (1) patients with a mild-to-moderate risk of heart disease, who had total cholesterol (TC) < 300 mg/dl (7.8 mmol/l), LDL-cholesterol < 210 mg/dl (5.4 mmol/l), and who lacked risk factors for coronary artery disease (CAD) after treatment with a diet for 3 months; (2) patients with a high-to-very high risk of CAD, who had TC > 300 mg/dl (7.8 mmol/l), LDL-cholesterol > 210 mg/dl (5.4 mmol/l), and at least two risk factors for CAD after treatment with a diet and administration of simvastatin (20 mg/day) for a three month period. The control group consisted of ten healthy volunteers who each had a normal lipid profile. Total cholesterol, LDL-cholesterol and IGF-1 concentrations were measured at baseline and either after six months of dietary supplementation (first group) or after three months of dietary supplementation and three months of simvastatin treatment (second group). CONCLUSIONS In patients with mild-to-moderate risk of CAD, a decreased serum concentration of IGF-1 was observed three months after beginning a low-fat diet. However, no changes in the serum concentration of IGF-1 were noted in patients with high-to-very high risk of CAD. Additional three-month treatment with simvastatin decreased the serum concentration of IGF-1.