Michal Mazurek

Prognostic Significance of Hyperuricemia in Patients with Different Types of Renal Dysfunction and Acute Myocardial Infarction Treated with Percutaneous Coronary Intervention

Aim: This study evaluated the impact of hyperuricemia (HUR) on outcome in patients with different types of impaired renal function (IRF) and acute myocardial infarction (AMI) treated invasively. Methods: Out of 3,593 consecutive AMI patients treated invasively, 1,015 IRF patients were selected. The IRF group consisted of patients with baseline kidney dysfunction (BKD group) and/or patients with contrast-induced nephropathy (CIN group). HUR was defined as a serum uric acid concentration (SUAC) >420 µmol/l (>7 mg/dl). Independent predictors of death and major adverse cardiovascular events (MACE) were selected by the multivariate Cox-regression model. Results: Remote mortality rates were higher in HUR patients: IRF (32.7 vs. 18.6%), BKD (41.3 vs. 25.9%), CIN (35.4 vs. 16.7%); all p < 0.001. HUR was an independent predictor of death in BKD (hazard ratio (HR) 1.38, p < 0.05). Each 100-µmol/l increase in SUAC was associated with a significant increase of HR for mortality: 1.087 in IRF patients, 1.108 in BKD patients, 1.128 in CIN patients; all p < 0.05. Remote major adverse cardiovascular event rates were higher in HUR patients: IRF (55.4 vs. 48.9%), CIN (56.8 vs. 48%); both p < 0.05. Conclusions: In AMI patients treated invasively, an increase in SUAC is an independent predictor of death within all types of renal dysfunction; HUR defined as SUAC >420 µmol/l (>7 mg/dl) is a predictor only in BKD patients.

The prognostic value of different glucose abnormalities in patients with acute myocardial infarction treated invasively

BackgroundDiabetes (DM) deteriorates the prognosis in patients with coronary heart disease. However, the prognostic value of different glucose abnormalities (GA) other than DM in subjects with acute myocardial infarction (AMI) treated invasively remains unclear.AimsTo assess the incidence and impact of GA on clinical outcomes in AMI patients treated with percutaneous coronary intervention (PCI).MethodsA single-center, prospective registry encompassed 2733 consecutive AMI subjects treated with PCI. In all in-hospital survivors (n = 2527, 92.5%) without the history of DM diagnosed before or during index hospitalization standard oral glucose tolerance test (OGTT) was performed during stable condition before hospital discharge and interpreted according to WHO criteria. The mean follow-up period was 37.5 months.ResultsThe incidence of GA was as follows: impaired fasting glycaemia - IFG (n = 376, 15%); impaired glucose tolerance - IGT (n = 560, 22%); DM (n = 425, 17%); new onset DM (n = 384, 15%); and normal glucose tolerance – NGT (n = 782, 31%). During the long-term follow-up, death rate events for previously known DM, new onset DM and IGT were significantly more frequent than those for IFG and NGT (12.3; 9.6 and 9.4 vs. 5.6 and 6.4%, respectively, P < 0.05). The strongest and common independent predictors of death in GA patients were glomerular filtration rate < 60 ml/min/1,73 m^2 (HR 2.0 and 2.8) and left ventricle ejection fraction < 35% (HR 2.5 and 1.8, all P < 0.05) respectively.ConclusionsGlucose abnormalities are very common in AMI patients. DM, new onset DM and IGT increase remote mortality. Impaired glucose tolerance bears similar long-term prognosis as diabetes.

Prognostic significance of HbA1c in patients with AMI treated invasively and newly detected glucose abnormalities

Background Glucose abnormalities are frequent comorbidities influencing prognosis in patients with cardiovascular diseases. The objective of this study was to evaluate prognostic role of HbA1c in patients with acute myocardial infarction (AMI) treated invasively, who had newly detected glucose abnormalities. Design Single-centre registry encompassed 2146 survivors of AMI. In all patients without diabetes mellitus (DM), oral glucose tolerance test was performed before hospital discharge and interpreted according to the guidelines. Methods From the study population, two major groups with defined new glucose abnormalities and estimated HbA1c were selected: 457 patients with impaired glucose tolerance (IGT) and 306 patients with newly detected DM (newDM). In each of these groups, the median value of HbA1c was calculated and established as the cut-off point for further analysis. The median HbA1c for IGT group was 5.9% and for newDM was 7.0%. Results Patients with IGT and HbA1c ≤ 5.9% had significantly lower posthospital mortality (4.5%) than those with HbA1c >5.9% (25.0%; p<0.001). Similarly, patients with newDM and HbA1c ≤7.0% had lower mortality (6.4%) than those with HbA1c >7.0% (14.3%; p<0.05). Multivariate regression analysis revealed that increase of HbA1c was one of the strongest independent risk factors of death among IGT patients (HR 2.9, 95% CI 2.7–3.1; p < 0.001) and newDM (HR 1.53, 95% CI 1.39–1.66; p<0.05). Conclusions Increase of HbA1c in patients with newly detected glucose abnormalities was associated with significantly reduced survival after AMI treated invasively. Moreover, increase of HbA1c in patients with IGT and newDM was one of the strongest independent risk factors of death in these populations.

Long-term outcomes of cardiac resynchronization therapy are worse in patients who require atrioventricular junction ablation for atrial fibrillation than in those with sinus rhythm

BACKGROUND The aim of the study was to assess the impact of atrial fibrillation (AF) with and without the need for atrioventricular junction (AVJ) ablation on outcomes in patients undergoing cardiac resynchronization therapy (CRT). METHODS A single center cohort of 200 consecutive CRT patients was divided into three groups: 1) AF with CRT pacing < 95% in which AVJ ablation was performed (AF-ABL, n = 40; 20%), 2) AF without the need for AVJ ablation (AF-non ABL, n = 40; 20%), 3) sinus rhythm (SR, n = 120; 60%). All patients were assessed before CRT implantation and at 6-month follow-up. Positive clinical response to CRT was considered alive status without the need for heart transplantation and improvement ≥ 1 NYHA after 6 months. The comparative analysis among all study groups with respect to response-rate and long-term survival was performed. RESULTS The 6-month response-rate in both AF-ABL and AF-nonABL was significantly lower than in SR (52.5 and 50 vs.77.5%, respectively; both p < 0.017), though there were no differences in baseline characteristics among study groups apart from higher baseline NT-proBNP levels in AF-ABL. However, after adjustment for this confounder, and despite optimal CRT pacing burden in study groups, the remote all-cause mortality during median follow-up of 36.1 months was significantly higher in AF-ABL than in SR (adjusted HR = 2.57, 95% CI 1.09-6.02, p = 0.03). What is more, no difference in long-term survival between SR and AF-nonABL was observed. CONCLUSIONS Despite the improvement of CRT pacing burden and thus response-rate up to the level of AF subjects without the need for ablation, the long-term survival of AF patients requiring AVJ ablation remains still worse than in SR.

The impact of unsuccessful percutaneous coronary intervention on short- and long-term prognosis in STEMI and NSTEMI.

Objectives: To compare the impact of the efficacy of percutaneous coronary intervention (PCI) on prognosis in ST and non‐ST elevation myocardial infarction (STEMI and NSTEMI) patients with respect to infarct‐related artery (IRA). Background: The significance of the efficacy of PCI in STEMI and NSTEMI depending on the type of IRA has yet to be clarified. Methods: Study population consisted of 2,179 STEMI and 554 NSTEMI consecutive patients treated with urgent PCI. The efficacy of PCI (TIMI [thrombolysis in myocardial infarction] 3 vs. TIMI < 3) was assessed with regard to the type of IRA (left anterior descending artery, circumflex artery [Cx] or right coronary artery). The mean follow‐up was 37.5 months. Results: The rate of unsuccessful PCI was similar in STEMI and NSTEMI irrespectively of IRA (14.1 vs. 17.7%; P = 0.062). In STEMI, unsuccessful PCI was associated with significantly higher early (23.1 vs. 5.6%; P < 0.001) and late (29.9 vs. 12.8%; P < 0.001) mortality regardless of IRA. In NSTEMI, the inefficacious PCI significantly increased early (19.0% vs. 0.9%; P < 0.001) and late (27.3% vs. 6.3%; P < 0.001) mortality only in patients with Cx‐related infarction. Unsuccessful PCI of IRA was an independent risk factor for death in STEMI (HR 1.64; P < 0.05), but not in NSTEMI (P = 0.64). Further analysis showed that whilst unsuccessful PCI of any vessel in STEMI is an independent risk factor for death, in NSTEMI this applies to unsuccessful PCI of Cx only. Conclusions: The significance of unsuccessful PCI of IRA seems to be different in STEMI and NSTEMI. Unsuccessful PCI is an independent risk factor for death in STEMI regardless of IRA and in NSTEMI with the involvement of Cx.

The risk of stroke in patients with acute myocardial infarction treated invasively.

BackgroundTo assess the incidence, clinical significance, and independent risk factors of stroke in patients with acute myocardial infarction (AMI) treated invasively. Materials and methodsWe analyzed 2520 consecutive patients with AMI admitted between 2003 and 2007. Data on long-term follow-up were screened to identify patients who had stroke. ResultsDuring a median of 25.5 months, 52 patients (2.07%) had stroke. The cumulative risk of stroke was the highest during the first year (1.23%) and particularly within the first month after AMI (0.28%). Patients with stroke were at a significantly higher risk of developing major adverse cardiovascular events, including repeated AMI (26.9 vs. 14.6%, P<0.05) and death (40.4 vs. 13.6%, P<0.001). Previous stroke [hazard ratio (HR) 5.89], female sex (HR 2.60), glomerular filtration rate <60 ml/min/1.73 m2 (HR 1.92), and contrast nephropathy (HR 1.87, all P<0.05) were independent predictors of stroke. The receiver-operating curve calculated for the Contrast nephropathy, renal Insufficiency, Female, prior Stroke (CIFS) risk scale demonstrated a significant predictive value of this scale (area under curve 0.73, P<0.001). Patients with the lowest, median, and highest risk scores (<4, 4–5, ≥6 points, respectively) differed significantly with regard to stroke incidence (2.1 vs. 7.9 vs. 14.0%, respectively, P<0.05). ConclusionThe risk of stroke is the highest within the first month after AMI. Stroke is a marker of unfavorable outcome in this population. Independent risk factors for stroke after invasive treatment of AMI are different from those commonly perceived as stroke predictors. A risk scale based on sex, stroke history, and renal impairment is useful in risk stratification.

Early therapy following myocardial infarction: arguments for and against implantable cardioverter-defibrillators

The implantable cardioverter-defibrillator (ICD), when implanted in the late phase of myocardial infarction (MI) in the primary prevention of sudden cardiac death, reduces total mortality by 23-31%. Current guidelines recommend ICD implantation at least 40 days after MI. Despite optimal MI therapy, the risk of sudden cardiac death or cardiac arrest remains highest within the first 30 days after index infarction. Two randomized trials with ICD implantation early after MI failed to show the reduction of total mortality in a long-term follow-up study. The decrease of sudden cardiac death incidence was counterbalanced by an increase of nonsudden deaths, which may have been caused by the augmentation of heart failure deaths in ICD groups, presumably due to ICD interventions. Therefore, optimizing ICD appears to be the most important issue influencing the long-term outcome.