Mariusz Gąsior

Prospective, multicenter validation of a clinical risk score for left atrial arrhythmogenic substrate based on voltage analysis: DR-FLASH score

BACKGROUND Left atrial (LA) low-voltage areas (LVAs) are frequently observed in patients with atrial fibrillation (AF) and may predict AF recurrence after catheter ablation. OBJECTIVE The aim of this study was to develop and validate a clinical tool to identify LVAs that are associated with AF recurrence after pulmonary vein isolation (PVI). METHODS In a cohort of 238 patients, voltage maps were created during LA procedures. LVAs were defined as areas with electrogram amplitudes <0.5 mV. On the basis of regression analysis, predictors of LA substrate were identified. These parameters were used to establish a dedicated risk score (DR-FLASH score, based on diabetes mellitus, renal dysfunction, persistent form of AF, LA diameter >45 mm, age >65 years, female sex, and hypertension). This risk score was then prospectively validated in a multicenter cohort of 180 patients. The association of the score with long-term recurrence of atrial arrhythmias after circumferential PVI was tested in a retrospective cohort of 484 patients. RESULTS The DR-FLASH score effectively identified LVA substrate (C statistic = 0.801, P < .001). In the prospective multicenter validation cohort, the predictive value of the DR-FLASH score was confirmed (C statistic = 0.767, P < .001). The probability for the presence of LA substrate increased by a factor of 2.2 (95% confidence interval [CI] 1.6-2.9, P < .001) with each point scored. Furthermore, the risk of AF recurrence after PVI increased by a factor of 1.3 (95% CI 1.1-1.5, P < .001) with every additional point and was almost 2 times higher in patients with a DR-FLASH score >3 (odds ratio 1.7, 95% CI 1.1-2.8, P = .026). CONCLUSION The DR-FLASH score may be useful to identify patients who may require extensive substrate modification instead of PVI alone.

Mean platelet volume-to-lymphocyte ratio: a novel marker of poor short- and long-term prognosis in patients with diabetes mellitus and acute myocardial infarction

INTRODUCTION Platelet activation and hyperreactivity plays a pivotal role in developing intravascular thrombus in ST elevation myocardial infarction (STEMI). Mean platelet volume (MPV), which is readily available in clinical settings, has been linked to poor prognosis following STEMI. Recently, platelet-to-lymphocyte ratio (PLR) has emerged as a new marker of worse outcomes linking inflammation and thrombosis. We investigated the prognostic significance of the new marker, MPVLR, in diabetic patients with STEMI undergoing percutaneous coronary intervention (PCI). METHODS A total of 623 patients with diabetes mellitus and STEMI undergoing primary PCI were enrolled and divided based on the median MPVLR on admission into two groups: group 1 (N=266) with an MPVLR ≤4.46 and group 2 (N=257) with an MPVLR >4,46. RESULTS Despite similar clinical features patients with elevated MPVLR (group 2) had worse angiographic characteristic suggestive of a higher thrombus burden. In-hospital and one-year mortality was higher in group 2. ROC analysis revealed moderate diagnostic value in predicting in-hospital mortality (adjusted HR 1.13; 95% CI 1.04-1.23; P=0.003; MPVLR cut-off >6.13) similar to that of PLR a good diagnostic value in predicting long-term mortality (adjusted HR 1.52; 95% CI 1.42-1.63; P<0.0001; MPVLR cut-off >5.88) better than that of PLR. MPVLR remained an independent risk factor of early and late mortality. CONCLUSIONS To the best of our knowledge, this is the first ever study that has investigated MPVLR. Despite similar clinical characteristics, patients with elevated MPVLR had worse angiographic features which may indicate a greater thrombus burden. Elevated MPVLR is an independent risk factor of early and late mortality following STEMI. In addition, it has similar value to PLR in predicting in-hospital mortality, and a better value than PLR in predicting long-term mortality.

The Prognostic Role of Red Blood Cell Distribution Width in Coronary Artery Disease: A Review of the Pathophysiology.

Red blood cell distribution width (RDW) is a measure of red blood cell volume variations (anisocytosis) and is reported as part of a standard complete blood count. In recent years, numerous studies have noted the importance of RDW as a predictor of poor clinical outcomes in the settings of various diseases, including coronary artery disease (CAD). In this paper, we discuss the prognostic value of RDW in CAD and describe the pathophysiological connection between RDW and acute coronary syndrome. In our opinion, the negative prognostic effects of elevated RDW levels may be attributed to the adverse effects of independent risk factors such as inflammation, oxidative stress, and vitamin D3 and iron deficiency on bone marrow function (erythropoiesis). Elevated RDW values may reflect the intensity of these phenomena and their unfavorable impacts on bone marrow erythropoiesis. Furthermore, decreased red blood cell deformability among patients with higher RDW values impairs blood flow through the microcirculation, resulting in the diminution of oxygen supply at the tissue level, particularly among patients suffering from myocardial infarction treated with urgent revascularization.

Higher mortality in women after ST-segment elevation myocardial infarction in very young patients

Introduction Data on mortality in young patients with ST-segment elevation myocardial infarction (STEMI) when compared to older people or regarding therapeutic strategies are contradictory. We investigate the prognosis of women under 40 after STEMI in a prospective nationwide acute coronary syndrome registry. Material and methods We analyzed all 527 consecutive men and women (12.3% females) aged from 20 to 40 years (mean 35.7 ±4.5) presenting with STEMI, of all 26035 STEMI patients enrolled. Results Differences between genders in the major cardiovascular risk factors, clinical presentation, extent of the disease and time to reperfusion were insignificant. The majority of patients (67%) underwent coronary angiography followed by primary percutaneous coronary intervention (PCI) in 79.9% of them. A 92% reperfusion success rate measured by post-procedural TIMI 3 flow was achieved. There were no significant differences between genders in the administration of modern pharmacotherapy both on admission and after discharge from hospital. In-hospital mortality was very low in both genders, but 12-month mortality was significantly higher in women (10.8% vs. 3.0%; p = 0.003). Killip class 3 or 4 on admission (95% CI 19.6-288.4), age per 5-year increase (95% CI 1.01-3.73) and primary PCI (95% CI 0.1-0.93) affected mortality. In patients who underwent reperfusion there was moderately higher mortality in women than in men (7.1% vs. 1.9%; p = 0.046). Conclusions Despite little difference in the basic clinical characteristics and the management including a wide use of primary PCI, long-term mortality in women under forty after STEMI is significantly higher than in men.

Mortality of patients with ST-segment elevation myocardial infarction and cardiogenic shock treated by PCI is correlated to the infarct-related artery – Results from the PL-ACS Registry

BACKGROUND Mortality of patients with ST-segment elevation myocardial infarction (STEMI) with cardiogenic shock (CS) on admission remains high despite invasive treatment. The aim of this analysis was to assess the relationship between the infarct-related artery (IRA) and the early and 12-month outcomes of patients with STEMI and CS treated by percutaneous coronary intervention (PCI). METHODS Two thousand ninety patients with STEMI and CS registered in the prospective Polish Registry of Acute Coronary Syndromes from October 2003 to November 2009 were included. RESULTS The in-hospital mortality in the left main (LM), left anterior descending artery (LAD), circumflex artery (Cx), and right coronary artery (RCA) groups was 64.7%, 41.0%, 36.0%, and 30.8%, respectively, with p<0.0001. The 12-month mortality in the LM, LAD, Cx, and RCA groups was 77.7%, 58.2%, 55.1%, and 45.0%, respectively, with p<0.0001. After multivariate adjustment, LM as the IRA was significantly associated with higher 12-month mortality (hazard ratio=1.71, 95% confidence interval=1.28-2.27, p=0.0002). CONCLUSIONS In-hospital and long-term mortality of patients with STEMI and CS treated by PCI are significantly correlated to the IRA, being highest for LM and lowest for RCA.

Acute myocardial infarction due to left main coronary artery disease: A large multicenter national registry

BACKGROUND Optimal management of patients with acute myocardial infarction (MI) due to critical stenosis of an unprotected left main coronary artery (ULMCA) is not established. However, data from observational studies and registries encourage to perform percutaneous coronary intervention (PCI) in high risk patients. We investigated gender-related discrepancies, clinical course and prognosis in patients with acute MI and ULMCA as an infarct-related artery. METHODS A total of 643 consecutive patients (184 [28.6%] females and 459 [71.4%] males) with acute MI due to critical ULMCA stenosis were selected from the population of 121,526 patients hospitalized due to acute coronary syndromes between 2003 and 2006. The primary endpoints were in-hospital, 30-day, 6-month and 12-month mortality. RESULTS Women were older than men with significantly higher proportion of women older than 65 and with unfavorable risk profile. The management in men and women was similar. There was no significant gender-related differences in mortality in all follow-up periods. In multivariate analysis cardiogenic shock, pulmonary edema, ST elevation myocardial infarction (STEMI) and advanced age significantly increased mortality, whereas successful PCI decreased mortality. CONCLUSIONS No significant differences in clinical course, treatment and prognosis between men and women were noted. Mortality remained very high in both genders. The most unfavorable prognostic factors were cardiogenic shock, pulmonary edema, STEMI and advanced age. Percutaneous coronary angioplasty is feasible and offers high success rate in this subset of patients.

Effect of Glycemic Control on Response to Antiplatelet Therapy in Patients With Diabetes Mellitus and ST-Segment Elevation Myocardial Infarction

Impaired glycemic control (GC) is a troubling clinical condition with an unclear prognostic value that is frequent in diabetics, especially in the setting of acute coronary syndrome. Residual platelet reactivity can be also affected by GC. We evaluated the relation between response to dual antiplatelet therapy and GC in diabetics with STEMI treated with primary coronary angioplasty (PCI). Sixty diabetic patients were prospectively enrolled in the study. All patients were treated with clopidogrel and aspirin. Platelet reactivity (whole blood aggregation and phosphorylation of vasodilator-stimulated phosphoprotein, VASP) were assessed serially before and 24 hours, 7 days, and 30 days after the PCI. Blood glucose >8.5 mmol/L on admission was an independent predictor of a impaired clopidogrel response measured with platelet reactivity index (PRI) >50% on admission (OR 7.8, 95% CI 1.4-17.7, p<0.02) and 24 hours after PCI (OR 13.1, 95% CI 3.4-28.1, p<0.01). In conclusion, diabetic patients with STEMI and glycemia >8.5 mmol/L on admission is related to a poorer response to clopidogrel. There were no interaction between glycated hemoglobin level or glycemia on admission and platelet reactivity measured with collagen, arachidonic acid or thrombin receptor agonist peptide-induced aggregation. Further clinical studies of the role of GC in the efficacy of antiplatelet agents are warranted.

Outcomes of invasive treatment in very elderly Polish patients with non-ST-segment-elevation myocardial infarction from 2003–2009 (from the PL-ACS registry)

BACKGROUND Elderly patients with non-ST-segment elevation myocardial infarction (NSTEMI) are rarely included in randomized trials due to concomitant diseases. As a result, invasive treatment and aggressive pharmacotherapy are used less frequently in this group. The aim of the study was to analyze the impact of invasive treatment used for elderly patients (≥ 80 years) with NSTEMI from 2003-2009 and its impact on 24-month outcomes. METHODS We performed analysis of 13,707 elderly patients, out of 78,422 total NSTEMI patients, enrolled in the prospective, nationwide, Polish Registry of Acute Coronary Syndromes (PL-ACS) from 2003 to 2009. RESULTS The percentage of elderly NSTEMI population was 17.5%. Invasive treatment received 24% of them. In-hospital complications (stroke, reinfarction and death) were significantly less frequent in the invasive group, with the exception of major bleeding, which occurred almost three times more frequently (2.9% vs. 1.1%, p < 0.0001) in the invasive group. The 24-month mortality was lower (29.4% vs. 50.4%, p < 0.0001) in the invasive group and remained so after matching patients by the propensity score method (31.1% vs. 40.9%, p < 0.0001). From 2003 to 2009 the use of thienopyridines, beta-blockers and statins rose significantly. The frequency of invasive strategy increased significantly, from 10% in to over 50% in 2009. The frequency of major bleeding increased twofold, however a significant reduction in the 24-month mortality was observed over the years. CONCLUSIONS Elderly patients with NSTEMI benefit significantly from invasive strategies and modern pharmacotherapy recommended by treatment guidelines. Nevertheless, this approach is associated with an increased incidence of major bleeding.

Staged hybrid ablation for persistent and longstanding persistent atrial fibrillation effectively restores sinus rhythm in long-term observation

Introduction Hybrid ablation (HABL) of atrial fibrillation combining endoscopic, minimally invasive, closed chest epicardial ablation with endocardial CARTO-guided accuracy was introduced to overcome the limitations of current therapeutic options for patients with persistent (PSAF) and longstanding persistent atrial fibrillation (LSPAF). The purpose of this study was to evaluate the procedural safety and feasibility as well as effectiveness of HABL in patients with PSAF and LSPAF 1 year after the procedure. Material and methods The study is a single-center, prospective clinical registry. From 07/2009 to 12.2014, 90 patients with PSAF (n = 39) and LSPAF (n = 51), at the mean age of 54.8 ±9.8, in mean EHRA class 2.6, underwent HABL. 64.4% of patients had a history of prior cardioversion or catheter ablation. Thirteen patients had LVEF less than 35%. Mean AF duration was 4.5 ±3.7 years. Patients were scheduled for 3-, 6- and 12-month follow-up with 7-day Holter monitoring. Results At 6 months after the procedure 78% (54/69) of patients were in SR. At 12 months after the procedure 86% (59/69) were in SR and 62.3% (43/69) in SR and off class I/III antiarrhythmic drugs (AADs). Only 1% (1/69) of patients required a repeat ablation for atrial flutter. A significant decrease in LA dimension and an increase in LVEF were noted. Conclusions A combination of epicardial and endocardial RF ablation should be considered as a treatment option for patients with persistent and long-standing persistent atrial fibrillation as it is safe and effective in restoring sinus rhythm.

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.