Kuibao Li

Comparison of glucose-insulin-potassium and insulin-glucose as adjunctive therapy in acute myocardial infarction: a contemporary meta-analysis of randomised controlled trials

Background There is conflicting evidence regarding two different insulin regimens for acute myocardial infarction (AMI), one focusing on delivering insulin (‘insulin focus’, glucose-insulin-potassium (GIK)) and one focusing on tight glycaemic control (‘glycaemia focus’, insulin-glucose). A longstanding controversy has focused on which strategy provides the greatest reduction in mortality. The aim of this study was to perform a meta-analysis of randomised controlled trials (RCTs) comparing GIK or insulin-glucose therapy versus standard therapy for AMI in the reperfusion era. Methods A MEDLINE/EMBASE/CENTRAL search was conducted of RCTs evaluating GIK or insulin-glucose as adjunctive therapy for AMI. The primary endpoint was all-cause mortality. The data were analysed with a random effect model. Results A total of 11 studies (including 23 864 patients) were identified, eight evaluating insulin focus with GIK and three evaluating glycaemia focus with insulin-glucose. Overall, insulin focus with GIK was not associated with a statistically significant effect on mortality (RR 1.07, 95% CI 0.89 to 1.29, p=0.487). Before the use of reperfusion, GIK also had no clear impact on mortality (RR 0.92, 95% CI 0.70 to 1.20, p=0.522). Pooled data from the three studies evaluating glycaemia focus showed that insulin-glucose did not reduce mortality in the absence of glycaemia control in patients with AMI with diabetes (RR 1.07, 95% CI 0.85 to 1.36, p=0.547). Conclusions Current evidence suggests that GIK with insulin does not reduce mortality in patients with AMI. However, studies of glycaemia are inconclusive and it remains possible that glycaemic control is beneficial.

Smoking and Risk of All-cause Deaths in Younger and Older Adults: A Population-based Prospective Cohort Study Among Beijing Adults in China

Abstract Cigarette smoking is the leading preventable cause of death worldwide. Few studies, however, have examined the modified effects of age on the association between smoking and all-cause mortality. In the current study, the authors estimated the association between smoking and age-specific mortality in adults from Beijing, China. This is a large community-based prospective cohort study comprising of 6209 Beijing adults (aged ≥40 years) studied for approximately 8 years (1991–1999). Hazard ratios (HRs) and attributable fractions associated with smoking were estimated by Cox proportional hazard models, adjusting for age, sex, alcohol intake, body mass index, systolic blood pressure, hypertension, and heart rate. The results showed, compared with nonsmokers, the multivariable-adjusted HRs for all-cause mortality were 2.7(95% confidence interval (CI):1.56–4.69) in young adult smokers (40–50 years) and 1.31 (95% CI: 1.13–1.52) in old smokers (>50 years); and the interaction term between smoking and age was significant (P = 0.026). Attributable fractions for all-cause mortality in young and old adults were 63% (95% CI: 41%–85%) and 24% (95% CI: 12%–36%), respectively. The authors estimated multivariate adjusted absolute risk (mortality) by Poisson regression and calculated risk differences and 95% CI by bootstrap estimation. Mortality differences (/10,000 person-years) were 15.99 (95% CI: 15.34–16.64) in the young and 74.61(68.57–80.65) in the old. Compared with current smokers, the HRs of all-cause deaths for former smokers in younger and older adults were 0.57 (95% CI: 0.23–1.42) and 0.96 (95% CI: 0.73–1.26), respectively. The results indicate smoking significantly increases the risks of all-cause mortality in both young and old Beijing adults from the relative and absolute risk perspectives. Smoking cessation could also reduce the excess risk of mortality caused by continuing smoking in younger adults compared with older individuals.

Intensive atorvastatin improves endothelial function and decreases ADP-induced platelet aggregation in patients with STEMI undergoing primary PCI: A single-center randomized controlled trial

BACKGROUND Intensive atorvastatin may be beneficial for patients with ST segment elevated myocardial infarction (STEMI). However, its effects on endothelial and residual platelet function remain uninvestigated in these patients. METHODS This single-center single-blinded prospective randomized controlled trial included STEMI patients undergoing PCI, aiming to investigate the acute effects of intensive atorvastatin (40mg) vs. standard atorvastatin (20mg) on serum endothelin-1 (ET-1) and ADP-induced platelet clot strength (MA-ADP), which were measured before and after 7days of atorvastatin treatment respectively. MA-ADP was measured by thromboelastography. The tolerance and safety of intensive atorvastatin therapy in these patients were also observed. RESULTS A total of 120 patients (60 patients in the intensive group and 60 patients in the standard group) with STEMI, who are undergoing primary PCI, were included into this study (mean age, 63.5years). Patients from these two groups were matched for baseline characteristics. Atorvastatin did not significantly affect the serum level of LDL-C or CRP in either the standard or intensive group. Furthermore, ET-1 did not significantly change following treatment with atorvastatin in the standard group. However, intensive treatment with atorvastatin significantly reduced ET-1 serum level (0.65±0.38pmol/L vs. 0.49±0.21pmol/L, P<0.05) and achieved a greater reduction of MA-ADP (49.2±12.1 vs. 38.4±17.4mm, P<0.05). In addition, although not statistically significant, patients assigned to the intensive group appeared to suffer from less major adverse cardiovascular events. CONCLUSIONS Periprocedural intensive atorvastatin is associated with improved endothelial function and platelet inhibition, and is well-tolerated in STEMI patients undergoing PCI.

Effect of Resting Heart Rate on All-Cause Mortality and Cardiovascular Events According to Age

To examine whether the association between resting heart rate (RHR) and all‐cause mortality and cardiovascular events differs according to age.

Interaction Between Vitamin D and Lipoprotein (a) on the Presence and Extent of Coronary Heart Disease

BACKGROUND Given both lipoprotein (Lp)(a) and vitamin D have been found to be associated with coronary heart disease (CHD) risk and a biochemical link between vitamin D and cholesterol on atherosclerosis has been proposed, we hypothesised there could exist an interaction between Lp(a) and vitamin D on the severity of CHD. METHODS Lp(a) and 25-OH vitamin D were measured in the plasma of 348 consecutive patients (mean age 62.4±10.5 years; 56.3% male) undergoing coronary angiography at our Heart Center. A multivariate logistic regression model was used to estimate the odds ratios (ORs) of CHD. RESULTS Of these patients, CHD was identified in 212 (60.9%). A multivariable logistic regression model showed multivariable-adjusted ORs (95% CI) of CHD for patients with Lp(a)≧30mg/dl and vitamin D <10 ng/ml, Lp(a) <30mg/dl and vitamin D <10 ng/ml, and Lp(a)≧30mg/dl and vitamin D ≧10 ng/ml were 4.62 (2.04-10.46), 1.79 (1.00-3.17), and 1.70 (0.88-3.31), respectively, compared with those with Lp(a) <30mg/dl and vitamin D ≧10 ng/ml; the multivariable-adjusted ORs of a higher Gensini Score for the above three corresponding groups were 3.48 (1.84-6.60), 1.59 (0.96-2.65), and 1.55 (0.86-2.79), respectively. The interaction term between Lp(a) and vitamin D in each of the above two models was significant (p=0.004 and p=0.005, respectively). CONCLUSIONS Among patients undergoing coronary angiography, there existed an interaction between Lp(a) and vitamin D on the severity of CHD. Future cohort studies are warranted to confirm this finding.

Body Mass Index and the Risk of Cardiovascular and All-Cause Mortality Among Patients With Hypertension: A Population-Based Prospective Cohort Study Among Adults in Beijing, China.

Background Studies on the association between body mass index (BMI) and death risk among patients with hypertension are limited, and the results are inconsistent. We investigated the association between BMI and cardiovascular disease (CVD) and all-cause mortality among hypertensive patients in a population of Beijing, China. Methods We conducted a prospective cohort study of 2535 patients with hypertension aged 40 to 91 years from Beijing, China. Participants with a history of CVD at baseline were excluded from analysis. Cox proportional hazards regression models were used to estimate the association of different levels of BMI stratification with CVD and all-cause mortality. Results During a mean follow-up of 8.1 years, 486 deaths were identified, including 233 cases of CVD death. The multivariable-adjusted hazards ratios for all-cause mortality associated with BMI levels (<20, 20–22, 22–24, 24–26 [reference group], 26–28, 28–30, and ≥30 kg/m2) were 2.03 (95% confidence interval [CI], 1.48–2.78), 1.61 (95% CI, 1.18–2.20), 1.30 (95% CI, 0.95–1.78), 1.00 (reference), 1.12 (95% CI, 0.77–1.64), 1.33 (95% CI, 0.90–1.95), and 1.66 (95% CI, 1.10–2.49), respectively. When stratified by age, sex, or smoking status, the U-shaped association was still present in each subgroup (P > 0.05 for all interactions). Regarding the association of BMI with CVD mortality, a U-shaped trend was also observed. Conclusions The present study showed a U-shaped association of BMI with CVD and all-cause mortality among patients with hypertension. A lowest risk of all-cause mortality was found among hypertensive patients with BMI between 24 and 26 kg/m2.

Long-term outcomes following very late stent thrombosis of drug-eluting stent

BACKGROUND Long-term outcomes of very late stent thrombosis (VLST) after implantation of drug-eluting stents (DES) are still unclear. The aim was to evaluate the long-term outcomes after VLST of DES, and to analyze the related factors of long-term outcomes in these patients. METHODS From January 2006 to February 2013, patients with angiographically defined VLST were studied. The clinical characteristics, angiography and interventional data, and anti-platelet therapy protocols were analyzed. The patients were divided into two groups according to the occurrence of major adverse cardiac events (MACE) during follow-up. The clinical and interventional data between the two groups were compared. RESULTS Sixty-two patients were enrolled consisting of 55 males and 7 females with an average age of 58.6±10.2 (41-82) years. The mean time from first implantation of DES to occurrence of VLST was 38.7±18.1 (12.5-84) months. One patient died in hospital. Sixty-one patients survived to discharge, and MACE occurred in 17 patients after a median follow-up of 32.1±19.1 (median: 44, range 5-88) months. The total MACE rate was 29.0% (18/62), and Kaplan-Meier survival analysis showed the estimated MACE-free survival was 45.1%. The rate of implantation of an additional first-generation DES during the first VLST in the group with events was higher (44.4% vs.11.4%, respectively, p=0.007). The percentage of continuous dual antiplatelet therapy (DAPT) at the longest available follow-up was higher in the event-free group (27.8% vs. 75.0%, respectively, p=0.001). Multivariable Cox regression analysis revealed that the only independent predictors for freedom of MACE during long-term follow-up was continuous DAPT at the longest available follow-up [hazard ratio (HR)=0.30, 95% CI: 0.09-0.97, p=0.04]. CONCLUSIONS Long-term outcomes after VLST were unfavorable. Implantation of an additional first-generation DES might be avoided, and DAPT should be continued.

Modification of the association between smoking status and severity of coronary stenosis by vitamin D in patients suspected of coronary heart disease

AbstractGiven both smoking and vitamin D are associated with coronary heart disease (CHD) via inflammation and smoking may interfere with the local antiinflammatory effects of vitamin D. We hypothesized that the relationship between smoking and severity of CHD may be modified by vitamin D.A cross-sectional study was conducted. 25-OH vitamin D values were determined in 348 consecutive patients (mean age 62.4 ± 10.5 years; 56.3% male) undergoing coronary angiography at the Heart Center of Chaoyang Hospital affiliated to Capital Medical University between the period of September 2014 and May 2015. We categorized the patients into 2 groups based on 25-OH vitamin D levels, that is, severe hypovitaminosis D (25-OH vitamin D < 10 ng/mL) and higher vitamin D (25-OH vitamin D > =  10 ng/mL). Multivariable logistic regression models were used to estimate odds ratios (ORs) of severe coronary stenosis or higher Gensini score across three smoking status, that is, never smokers, former smokers, and current smokers in severe hypovitaminosis D and higher vitamin D groups, respectively.Of these patients, we identified 212 (60.9%) cases of severe CHD and 161 (46.3%) cases of severe hypovitaminosis D. Multivariable logistic regression model showed the ORs of severe CHD were 1.94 (95% confidence interval [CI]: 0.47, 7.98) for former smokers and 2.62 (95% CI: 0.83, 8.24) for current smokers, compared with never smokers in group with severe hypovitaminosis D (P-trend = 0.005). In contrast, smoking was not found to be significantly associated with severe CHD in group with higher 25-OH vitamin D (P-trend = 0.115). We found a significant interaction between smoking status and vitamin D on presence of severe CHD (P-interaction = 0.015). In terms of Gensini score as a dependent variable, similar results were identified.Our finding indicated the association between smoking and severity of CHD appeared to be substantially stronger among patients with severe hypovitaminosis D as compared with those with higher vitamin D levels. This suggests vitamin D sufficiency may have a protective effect against the damaging effects of smoking on coronary artery. Future cohort studies are warranted to confirm this finding.

Long-term prognosis of patients with acute myocardial infarction due to unprotected left main coronary artery disease: a single-centre experience over 14 years.

INTRODUCTION Acute myocardial infarction (AMI) due to unprotected left main coronary artery (ULMCA) disease is clinically catastrophic although it has a low incidence. Studies on the long-term prognosis of these patients are rare. METHODS From January 1999 to September 2013, 55 patients whose infarct-related artery was the ULMCA were enrolled. Clinical, angiographic and interventional data was collected. Short-term and long-term clinical follow-up results as well as prognostic determinants during hospitalisation and follow-up were analysed. RESULTS Cardiogenic shock (CS) occurred in 30 (54.5%) patients. During hospitalisation, 22 (40.0%) patients died. Multivariate logistic regression analysis showed that CS (odds ratio [OR] 5.86; p = 0.03), collateral circulation of Grade 2 or 3 (OR 0.14; p = 0.02) and final flow of thrombolysis in myocardial infarction (TIMI) Grade 3 (OR 0.05; p = 0.03) correlated with death during hospitalisation. 33 patients survived to discharge; another seven patients died during the follow-up period of 44.6 ± 31.3 (median 60, range 0.67-117.00) months. The overall mortality rate was 52.7% (n = 29). Kaplan-Meier analysis showed that the total cumulative survival rate was 30.7%. Cox multivariate regression analysis showed that CS during hospitalisation was the only predictor of overall mortality (hazard ratio 4.07, 95% confidence interval 1.40-11.83; p = 0.01). CONCLUSION AMI caused by ULMCA lesions is complicated by high incidence of CS and mortality. CS, poor collateral blood flow and failure to restore final flow of TIMI Grade 3 correlated with death during hospitalisation. CS is the only predictor of long-term overall mortality.

Effect modification of hypertension on the association of vitamin D deficiency with severity of coronary stenosis

Abstract Aims: There may exist an effect modification of hypertension on the relation of vitamin D deficiency with cardiovascular disease. The aim of this study was to investigate this interaction on coronary heart disease. Methods: We investigated 348 consecutive patients (mean age 62.4 ± 10.5 years; 56.3% male) who underwent coronary angiography because of chest discomfort at our heart center. Serum 25-OH vitamin D was also detected by ELISA method in these patients. Multivariable logistic regression models were used to estimate odd ratios (ORs) of CHD across vitamin D levels in hypertensives and normotensives, respectively. Results: We found the multivariable-adjusted ORs of CHD in the bottom(≤8.5 ng/ml) and middle tertiles (8.5–13 ng/ml) of 25-OH vitamin D were 2.86 (95% confidence interval [CI]: 1.38, 5.92) and 1.63 (0.83, 3.20), respectively, compared with those in top tertiles (>13ng/ml) among hypertensives (Ptrend=0.005). In contrast, the corresponding ORs of the above two groups were 0.88 (0.28, 2.74) and 1.23 (0.42, 4.00), respectively, in the normotensives (Ptrend = 0.800; Peffect modification = 0.020). The multivariable-adjusted OR of CHD in patients with severe hypovitaminosis D (<10 ng/ml) versus those with higher vitamin D (≧10 ng/ml) was also greater in hypertensives (2.76; 95% CI: 1.51, 5.04) than that in normotensives (0.92; 95% CI: 0.37, 2.33; Peffect modification=0.013). Similar results were observed when Gensini Score was treated as a dependent variable. Conclusion: Our finding suggests the presence of hypertension may modify the association of vitamin D deficiency with severity of coronary stenosis.