Joanna Oettinger

Changes in management of elderly patients with myocardial infarction

AIMS Despite being at higher risk for mortality, elderly patients (>/=75 years) admitted for acute myocardial infarction (MI) often receive fewer effective therapies, because of contraindications or higher risk of drug-induced adverse events. The aim of this study was to assess the changes in the use of effective treatments between 2001 and 2006 in elderly patients, and the relation with 1-month mortality. METHODS AND RESULTS Prospective, multicentre registry, considering two periods: 6 months between October 2000 and March 2001 (cohort 1) and 12 months between October 2005 and October 2006 (cohort 2). Demographic and clinical characteristics at admission, in-hospital treatment (reperfusion or early invasive therapy, oral antiplatelets, anticoagulants, angiotensin-converting enzyme (ACE)-inhibitors, beta-blockers, and statins), and 1-month survival were compared between the two cohorts, after adjustment on a propensity score (for being admitted in 2001). Eight hundred and sixty-eight elderly patients were included, 280 in cohort 1 and 588 in cohort 2. When compared with cohort 1, patients from cohort 2 presented with comparable characteristics, except for the Global Registry of Acute Coronary Events risk score and we observed a significant increase in the use of aspirin, clopidogrel, reperfusion therapy, ACE-inhibitors, and statins in cohort 2. One-month mortality was significantly lower in cohort 2 (13.6% in cohort 1 vs. 7.1% in cohort 2, P = 0.001), mainly driven by a decrease in the mortality among patients with ST-segment elevation MI (23.3% in cohort 1 vs. 9.2% in cohort 2, P < 0.001). Adjustment on the propensity score did not alter these results. By multivariable analysis, the three-fold higher mortality in patients from cohort 1 was offset when the rate of use of treatments was considered in the model, suggesting that the treatment intensity was related to lower mortality. CONCLUSION Between 2001 and 2006, a significant increase in the use of guidelines-recommended treatments (GRTs) was observed, associated with lower 30-day mortality, in elderly patients. These data confirm that high-risk patients, such as the elderly, benefit from an increase in the use of GRTs.

Anemia for Risk Assessment of Patients With Acute Coronary Syndromes

In patients admitted with acute coronary syndromes, those with anemia are at higher risk. However, current risk score systems do not take into account the presence of anemia. The impact of anemia on mortality was studied, and its incremental predictive value was evaluated. Demographic, clinical, and biologic characteristics at admission, as well as treatments and mortality, were recorded for 1,410 consecutive patients with acute coronary syndromes. The incremental value of adding anemia information to risk score evaluation was determined using changes in the appropriateness of Cox models when anemia was added. Anemia was detected in 381 patients (27%). They were older, had more co-morbidities, had higher Global Registry of Acute Coronary Events (GRACE) risk scores, received fewer guideline-recommended treatments, and, as a result, had 4-fold higher mortality. When included in a prediction model based on the GRACE risk score, anemia remained an independent predictor of mortality. The addition of anemia improved both the discriminatory capacity and calibration of the models. According to the GRACE risk score, the population was divided into 4 groups of different risk levels of <1%, 1% to <5%, 5% to <10%, and > or =10%. The addition of anemia to the model made it possible to reclassify 9%, 43%, 47%, and 23% of patients into the different risk categories, respectively. In conclusion, our data confirmed that anemia was an independent predictive factor of mortality and had incremental predictive value to the GRACE score system for early clinical outcomes.

Prognostic value of albuminuria on 1-month mortality in acute myocardial infarction.

RATIONALE An increase in albuminuria occurs in the early days after acute myocardial infarction. The aim of this study was to assess the relation between albuminuria and 30-day mortality, as well as its incremental predictive value, on top of established prognostic parameters. METHODS AND RESULTS Demographic, clinical, and biological characteristics at admission, as well as in-hospital treatments and 1-month survival, were recorded in 1,211 consecutive patients admitted for acute myocardial infarction. Albuminuria was assessed from an 8-hour overnight urine collection within the first 2 days using immunonephelemetry. The population was categorized into 3 groups according to albuminuria levels (<20, 20-200, and >200 microg/min). Among survivors on day 2, 52% (625/1,211) of patients had an albuminuria level <20 microg/min, 39% (477) between 20 and 200 microg/min, and 9% (109) >200 microg/min. High levels of albuminuria were associated with older age, peripheral vessel disease, systolic blood pressure, glucose, creatinine, troponin, B-type natriuretic peptide, and high-sensitivity C reactive protein levels, as well as use of angiography, angiotensin-converting enzyme inhibitors, and beta blockers. At 1 month, there was a significantly higher mortality rate in groups with higher albuminuria. After adjustment for baseline characteristics, patients with albuminuria level of >20 microg/min had a 2.7-fold higher 30-day mortality, and those with >200 microg/min had an almost 4-fold higher 30-day mortality compared to those with albuminuria level of <20 microg/min. The addition of albuminuria information improved the discrimination capacity of the model and the global risk prediction. CONCLUSIONS Albuminuria level, taken as a quantitative or categorical variable, is an independent and powerful predictor of mortality after acute myocardial infarction.

Changes in Unstable Coronary Atherosclerotic Plaque Composition After Balloon Angioplasty as Determined by Analysis of Intravascular Ultrasound Radiofrequency

The effects of balloon angioplasty (BA) on plaque distribution remain incompletely documented. In 20 patients with unstable angina pectoris, intravascular ultrasound gray scale and radiofrequency analyses were performed before and after BA. Composition of the plaque was 61% fibrotic tissue, 15% fibrofatty tissue, 15% necrotic tissue, and 7% dense calcium tissue. After BA, 35% of lumen enlargement was due to an increase in total vessel area and 65% to a significant decrease in plaque area. This resulted from a longitudinal redistribution of the tissue toward the reference segments. Radiofrequency analysis showed that the fibrous and fibrofatty tissues were able to redistribute longitudinally, whereas calcium remained at the same level. A third of necrotic tissue was lost after BA. In conclusion, in unstable plaques, BA resulted in a longitudinal redistribution of fibrotic and fibrofatty tissues and disappearance of 1/3 of necrotic tissue.

046 C-Reactive Protein Improves Risk Prediction in Patients with Acute Coronary Syndromes

Rationale and aim Elevated C-reactive protein level is a risk marker in patients with acute coronary syndromes (ACS), but current risk score systems do not consider this factor. We studied the incremental predictive value of adding CRP to the GRACE risk score. Methods and results Characteristics, treatments and 30-day mortality were recorded for 1408/1901 consecutive ACS patients. Changes in global model fit, discrimination, calibration and reclassification were evaluated upon addition of CRP to the GRACE risk score. High-CRP patients (CRP >22 mg/L, 4 th quartile of CRP) were older, had more comorbidities and worse hemodynamic conditions, received less recommended treatment and had a four-fold higher 30 day mortality. Multivariable analysis demonstrated high-CRP as an important and independent predictor of mortality. Addition of high-CRP in the GRACE model improved global fit, discriminatory capacity and calibration. Patients were divided into 4 groups according to GRACE risk score prediction: =10%. The model with high-CRP allowed adequate reclassification in 12.2%. Conclusions Elevated CRP level is an independent and important predictive factor of 30-day mortality in ACS patients, even after adjustment for co-morbidities, hemodynamic conditions and treatment. Combined with the GRACE risk score, CRP information improves risk classification.

025 Benefit of Drug Eluting Stents over Bare Metal Stents after Rotational Atherectomy. A propensity score adjusted comparison in revascularization, mortality and MACE

Rationale Rotational atherectomy makes possible to attempt small and calcified arteries while Drug Eluting Stents (DES) properties may reduce the restenosis process, rendering this combination attractive in selected cases. We compared 1year clinical outcome after rotational atherectomy following by either DES or Bare Metal Stents (BMS) implantation. Methods Single centre registry including all consecutive cases of rotational atherectomy use. Clinical follow-up was obtained in all patients. Propensity score for being treated with a DES was calculated using 18 clinical, angiographic and procedural variables. Comparison was adjusted on 4 strata of the propensity score. Results Between 2002 and 2008, 223 patients were treated: 114 with BMS and 110 with DES. Most of the patients with BMS between 2002 and 2004 and later with DES. No significant difference was observed in clinical characteristics between groups: age 70 years, reference diameter 2.40±0.60mm, lesion length 10±9mm. Two cases of coronary perforation occurred, 7 lesion failure, and 12 transcient no-reflow. The use of GP2b3a inhibitors was similar in both groups, but, compared with BMS, patients in the DES group had longer duration of combination of aspirin and Clopidogrel. At one year, significantly lower rates of vessel revascularisation (2% vs 12%, p=0.005), of all cause mortality (5% vs 14%, p=0.05) and of MACE (10% vs 22%, p=0.02) were observed in the DES than in the BMS group. Adjustment on the strata of the propensity score did not change significantly these results (figure). Conclusions Despite propensity score adjusted, this comparison has limitations. After rotational atherectomy we observed clear benefit for DES implantation over BMS on vessel revascularisation, mortality and MACE rates. Download : Download full-size image

011 Insights from endogenous thrombin generation in patients undergoing percutaneous coronary intervention. A cohort study

Background Determination of appropriate dosing of antithrombotic drugs is difficult, and clinical studies to define appropriate monitoring techniques are needed. Objective We compared the endogenous thrombin potential (ETP) in patients planning to undergo percutaneous coronary intervention (PCI) being pre-treated with a combination of two or three antiplatelet agents and with fondaparinux or unfractionated heparin (UFH). Pre-treatment was dependent upon clinical presentation. Calibrated Automated Thrombography was performed in voluntary blood donors and in patients submitted to PCI. Thrombin generation was studied in platelet poor plasma by a fluorimetric technique. Patients/Methods A total of 152 patients were included. Group 1 patients were pre-treated with aspirin alone, group 2 were pre-treated with aspirin and clopidogrel, group 3 were treated with a combination of aspirin, clopidogrel, and 2.5 mg fondaparinux, group 4 were treated with aspirin, clopidogrel, 2.5 mg fondaparinux, and tirofiban, and group 5 received a bolus of 50 IU/kg UFH plus antiplatelet agents. Results Compared with voluntary blood donors, there was a significant decrease in ETP in group 2. The addition of fondaparinux (group 3) induced Download : Download full-size image a 24% decrease in ETP; a further 25% decrease in ETP was observed between groups 3 and 4. No thrombin generation was observed after UFH treatment. Conclusion Assessment of thrombin generation is potentially very useful in the setting of PCI, where a combination of antiplatelet agents and an anticoagulant is mandatory.