Miklos Rohla

Predictors of response to renal denervation for resistant arterial hypertension: a single center experience.

Background: Renal denervation (RDN) has been shown to reduce blood pressure in patients with resistant arterial hypertension (RAH). We aimed to investigate predictors for response to RDN. Methods: Patients suffering from RAH underwent RDN after exclusion of secondary causes of hypertension. Ambulatory blood pressure measurement (ABPM) for 24 h was performed at baseline, 6 and 12 months after RDN. Response was defined as a at least 5 mmHg 24 h SBP drop at 6 months. A linear regression model was used to analyze an association between baseline variables and response to RDN. Results: In total, 45.6% of patients were responders to RDN. In those, there was a significant reduction in ABPM values at 6 and 12 months (12 months: 24 h SBP: −17.2 ± 9.0 mmHg, P < 0.01; 24 h DBP: −9.0 ± 11.6 mmHg, P < 0.01). Per 10 mmHg increase in baseline 24 h SBP, there was a 5.5 mmHg 24 h SBP reduction at 6 months. Per kg/m2 increase in BMI, 24 h SBP increased by 0.7 mmHg at 6 months. Per increment in antihypertensive drugs used at baseline, there was a 2.7 mmHg 24 h SBP reduction at 6 months. Conclusion: Out of a wide range of baseline variables, elevated systolic ABPM values, BMI and the number of antihypertensive drugs used were associated with response. One has to consider the Hawthorne effect, the regression to the mean phenomenon, the actual effect of sympathetic denervation and the interaction of therapy modification when interpreting data from RDN registries without a control arm.

Double or triple antithrombotic combination therapy in patients who need anticoagulation and antiplatelet therapy in parallel

The optimal strategy to balance bleeding and ischaemic events in patients with atrial fibrillation, requiring antiplatelet therapy on top of anticoagulation, is subject to debate, since specifically designed and powered randomized trials are not available yet. The review aims to highlight the current developments in the light of the 2014 joint consensus document of the European Society of Cardiology (ESC) Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS) and of the 2014 ESC myocardial revascularization guidelines, both published recently.

A study of modulated ventricular parasystole by programmed stimulation

To analyze the phase-dependent sensitivity of the parasystolic pacemaker to nonparasystolic beats, 11 patients with modulated ventricular parasystole were studied using the ventricular extrastimulus method. The intrinsic parasystolic cycle lengths ranged from 1,100 to 1,800 ms. Premature stimuli altered the duration of the parasystolic cycle lengths by amounts that depended on timing of the test impulses within the parasystolic cycles. Premature impulses delivered during the first part of the parasystolic cycles prolonged the parasystolic cycle lengths to 107 to 151% of the intrinsic parasystolic cycle lengths and impulses applied during the second part abbreviated them to 70 to 81% of the intrinsic parasystolic cycle lengths. In 10 patients the accelerating effects were of greater magnitude than the decelerating effects. Transition from the accelerating to slowing phases was progressive or unstable in 9 patients and abrupt in 2. Changes induced by individual stimuli were short-lived and the parasystolic pacemakers returned immediately to their original rates. In 1 patient the biphasic sensitivity of parasystole to premature stimuli was shown to sustain for 21 days.

High-degree atrioventricular block in patients with preexisting bundle branch block or bundle branch block occurring during transcatheter aortic valve implantation

BACKGROUND Transcatheter aortic valve implantation (TAVI) has become the standard therapy for high-risk and non-operable patients with severe aortic stenosis. However, the procedure involves several adverse effects, such as rhythm and conduction disturbances. Patients with postprocedural left bundle branch block may have an increased mortality risk, whereas patients with preprocedural right bundle branch block display a higher rate of postinterventional bradyarrhythmias. OBJECTIVE The purpose of this study was to investigate the occurrence of high-degree atrioventricular block (AVB) in patients with preexisting bundle branch block (BBB) or BBB occurring during TAVI. METHODS In this prospective single-center study, 50 consecutive patients undergoing TAVI with the Medtronic CoreValve Revalving System were included. Of these patients, 17 with preexisting BBB or BBB occurring during TAVI received a primary prophylactic permanent DDD pacemaker, programmed to the SafeR-mode and featuring dual-channel event counters as well as stored intracardiac electrograms. Pacemaker readouts and intracardiac electrograms were analyzed for the occurrence of high-degree AVB. RESULTS Ten of 17 patients (58.8%) with preexisting BBB or BBB occurring during TAVI developed episodes of high-degree AVB that were immediately terminated due to switch into DDD backup pacing. In 5 of the cases (29.4%), the first documented episode of high-degree AVB occurred after hospital discharge. Mean follow-up period was 578.1 ± 294.9 days. CONCLUSION Development of high-degree AVB is a common complication in patients with preexisting BBB or BBB occurring during TAVI. Accordingly, intensified monitoring might be reasonable, especially in patients treated with the self-expandable Medtronic CoreValve Revalving System.

Clinical predictors of patient related delay in the VIENNA ST-elevation myocardial infarction network and impact on long-term mortality

Background: While contributors to system delay in ST-elevation myocardial infarction (STEMI) are well described, predictors of patient-related delays are less clear. The aim of this study was to identify predictors that cause delayed diagnosis of STEMI in a metropolitan system of care (VIENNA STEMI network) and to investigate a possible association with long-term mortality. Methods: The study population investigated consisted of 2366 patients treated for acute STEMI in the Vienna STEMI registry from 2003–2009. Multivariable regression modelling was performed for (a) onset of pain to first medical contact (FMC) as a categorical variable (pain-to-FMC⩽60 min versus >60 min: ‘early presenters’ versus ‘late presenters’); and for (b) onset of pain-to-FMC (min) as a continuous variable. Results: After multivariable adjustment, female sex (odds ratio (OR) 1.348; 95% confidence interval (CI) 1.013–1.792; p=0.04) and diabetes mellitus (OR 1.355; 95% CI 1.001–1.835; p=0.05) were independently associated with late presentation in STEMI patients, whereas cardiogenic shock (OR 0.582; 95% CI 0.368–0.921; p=0.021) was a predictor of early diagnosis. When onset of pain-to-FMC was treated as a continuous variable, female sex (p=0.003), anterior infarction (p=0.004) and diabetes mellitus (p=0.035) were independently associated with longer delay, while hyperlipidaemia (p=0.002) and cardiogenic shock (p=0.017) were strong predictors of short pain-to-FMC times. Three-year-all cause mortality was 9.6% and 11.3% (p=0.289) for early and late presenters, respectively. After adjustment for clinical factors (sex, age, diabetes, current smoking, hypertension, hyperlipidaemia, cardiogenic shock and location of myocardial infarction) only a trend for increased risk of all-cause death was observed for longer pain-to-FMC times in a cox regression model (hazard ratio (HR) 1.012; 95% CI 0.999–1.025 for every 10 min of delay; p=0.061). Interestingly, early presentation within one hour of symptom onset was not associated with three-year mortality survival (HR 1.031; 95% CI 0.676–1.573; p=0.886). Conclusion: In this all-comers study of STEMI patients in the VIENNA STEMI network, cardiogenic shock was the strongest predictor of short patient-related delays, whereas a history of diabetes and female sex were independent associated with late diagnosis in STEMI. After adjustment for clinical confounders, patient related delay did not significantly impact on long-term all-cause mortality.

Platelet turnover predicts outcome after coronary intervention

Summary Elevated platelet turnover contributes to high platelet reactivity. High platelet reactivity after percutaneous coronary intervention (PCI) is associated with major adverse cardiovascular events (MACE). The purpose of this study was to determine the prognostic value of platelet turnover and function with regard to MACE after PCI with stent implantation. In this prospective observational study, 486 consecutive patients after PCI on aspirin and clopidogrel were included to determine platelet turnover (mean platelet volume (MPV), reticulated platelet fraction (RPF)) and platelet function (multiple electrode aggregometry (MEA), vasodilator-stimulated phosphoprotein-phosphorylation (VASP-P) assay). At six-months follow-up, MACE occurred in 10.7 % of patients. RPF (odds ratio [OR]=1.173 (95% confidence interval [CI 95 %] 1.040–1.324), p=0.009) and MPV (OR=1.459 (CI 95 % 1.059–2.008), p=0.021) were univariable predictors of MACE, whereas VASP-P (OR=1.016 (CI 95 % 1.000–1.032), p=0.052) and MEA (OR=0.999 (CI 95 % 0.980–1.017), p=0.895) failed to predict MACE. RPF remained the only platelet variable independently associated with MACE. The best model to predict MACE included: troponin I (OR=1.007 (CI 95 % 1.002–1.012), p=0.009), RPF (OR=1.136 (CI 95 % 1.001–1.288), p=0.048), CRP (OR=1.008 (CI 95 % 1.001–1.014), p=0.023) and history of myocardial infarction (OR=2.039 (CI 95 % 1.093–3.806), p=0.025). RPF (OR=1.211 (CI 95 % 1.042–1.406), p=0.012) was also independently associated with in-hospital bleedings. In conclusion, RPF as index of platelet turnover is an independent predictor of MACE and bleeding events in PCI patients on dual antiplatelet therapy. Since RPF can reliably be quantified along with routine haemograms, RPF might easily be applied in the setting of cardiovascular risk prediction.

Awareness, treatment, and control of hypertension in Austria: a multicentre cross-sectional study.

Background: Hypertension (HTN) control is achieved in 30–50% of all diagnosed and treated patients in Europe today. There is no large, recent, and properly conducted Austrian study available, with the last representative data being obtained in the 1990s. We sought to close this gap of evidence in Europe by providing information on HTN control in predominantly adherent patients. Methods and results: In October 2015, we enrolled 4303 patients with HTN who approached one of 158 participating pharmacies with a prescription filled for antihypertensive medication. The recruitment was completed within 10 days. Patients mean age was 68 ± 12 years, 53% were women. The mean SBP/DBP was 144 ± 20/84 ± 12 mmHg. On average, patients received 2.2 ± 1.1 different antihypertensive substances, 45% received a fixed-dose combination drug. A total of 93% were aware of their disease, 90% claimed to have taken their medication prior to the survey, and 41% had their blood pressure (BP) controlled at a threshold of 140/90 mmHg. Predictors of HTN control were lower age [per decade increase, odds ratio (OR) 0.90, 95% confidence interval (CI) 0.85; 0.96, P < 0.01], female sex (OR 1.23, 95% CI 1.07;1.41), the intake of medication on the day of the conduct of the survey (OR 2.15, 95% CI 1.67;2.76), a university degree (OR 1.58, 95% CI 1.19; 2.08), and the consultation of a specialist for internal medicine/cardiology vs. a general practitioner (OR 1.20, 95% CI 1.04; 1.39). Conclusion: Despite a high degree of awareness and frequent use of fixed-dose combination drugs, only 41% of diagnosed, treated, and adherent HTN patients had their BP controlled. Immediate action is required to improve BP control in Austria. Video abstract: http://links.lww.com/HJH/A624.

Plasma osmolality predicts clinical outcome in patients with acute coronary syndrome undergoing percutaneous coronary intervention

Aims: The impact of plasma osmolality on clinical outcome in acute coronary syndrome (ACS) patients has not been investigated so far. Methods: In a retrospective analysis, we included 985 patients with ACS undergoing percutaneous coronary intervention (PCI). Plasma osmolality was calculated using concentrations of sodium, plasma glucose, and blood urea nitrogen at admission. Patients were stratified by quartiles (Q) of admission osmolality, clinical outcome was compared between those groups. The primary endpoints were in-hospital, 30-day, and 1-year mortality. Results: Univariate analysis in the Cox proportional-hazards model revealed significantly higher rates of in-hospital death for patients with osmolality in Q4, as compared to patients with osmolality in Q1–3 (HR 5.4, 95% CI 3.3–9.0, p<0.01). After adjustment for confounding baseline variables, osmolality in Q4 was associated with 2.8-fold hazard of in-hospital death (HR 2.75, 95% CI 1.35–5.61, p=0.005). Upon multivariate analysis, admission osmolality in Q4 vs. Q1–3 was associated with higher mortality rates after 30 days (HR 2.53, 95% CI 1.23–5.21, p=0.012) and 1 year (HR 1.73, 95% CI 1.02–2.91, p=0.04). Moreover, we performed landmark analysis in order to exclude critically ill patients, which revealed similar adjusted rates of death beyond 30 days to 1 year (HR 1.21, 95% CI 0.55–2.66, p=0.642). Conclusions: Using the 4th quartile of plasma osmolality at admission as a natural cut-off point, osmolality in Q4, as compared to Q1–3, was significantly predictive of short term but not long-term outcome in ACS patients undergoing coronary stenting. Our data suggest osmolality to be an independent, feasible, and cost-effective tool for rapid risk stratification in ACS patients.

Contemporary use of P2Y12-inhibitors in patients with acute coronary syndrome undergoing percutaneous coronary intervention in Austria: A prospective, multi-centre registry.

Background To this day, there is no data concerning guideline adherence on P2Y12-inhibitors in Austria. Prasugrel and ticagrelor have been shown to be superior to clopidogrel in the treatment of acute coronary syndromes (ACS). However, recent data from European registries showed a reluctant prescription policy with rates of clopidogrel at discharge ranging from 35 to 55%. Methods In this prospective, multi-centre registry we assessed prescription rates of P2Y12-inhibitors in patients with ACS in four Austrian PCI centres. Parameters associated with the use of clopidogrel have been evaluated in multivariate logistic regression. Results Between January and June 2015, 808 patients with ACS undergoing PCI were considered for further analysis. 416 (51.5%) presented with STEMI and 392 (48.5%) with NSTE-ACS. Mean age was 65.7 ± 12.4 and 240 (30.9%) were female. Twenty-eight (3.5%) died during the hospital stay. At discharge, 212 (27.2% of all patients) received clopidogrel, 260 (32.2%) prasugrel and 297 (36.8%) ticagrelor, while 11 (1.4%) did not receive any P2Y12-inhibitor. Of those patients, who were discharged with clopidogrel, 117 (55.2%) had no absolute contraindication against a more potent P2Y12-inhibitor. Diagnosis of NSTE-ACS (p<0.001), COPD (p = 0.049), and age (p<0.001) next to factors contributing to absolute contraindication were positively associated with the use of clopidogrel. Conclusions Despite a high level of care, a considerable number of patients were not treated with the more potent P2Y12-inhibitors. Parameters associated with a presumably higher risk of bleeding and side-effects against the more effective P2Y12 inhibitors were the most prominent factors for the prescription of clopidogrel.

Activated protein C levels and outcome in patients with cardiogenic shock complicating acute myocardial infarction.

Introduction: In patients with severe sepsis, low levels of activated protein C are associated with high morbidity and mortality. In an observational study we investigated whether patients with cardiogenic shock have decreased circulatory levels of activated protein C, and if these are associated with increased mortality. Methods: We measured serum activated protein C and interleukin-6 levels in 43 patients with cardiogenic shock following acute myocardial infarction and in 15 control patients with uncomplicated myocardial infarction at days 0–5 and 7 after the onset of shock/myocardial infarction. Results: Activated protein C levels were significantly lower in patients with cardiogenic shock compared to controls. In cardiogenic shock patients, there was no difference in activated protein C levels at baseline, whereas activated protein C levels significantly declined in 28-day non-survivors at day 2, compared with 28-day survivors. Lower levels of activated protein C were associated with a higher degree of vasopressor need, whereas there was no significant association with multiple organ failure in the first days. Regarding the inflammatory response, a strong inverse correlation was observed between interleukin-6 and activated protein C levels. Conclusion: Patients with cardiogenic shock who did not survive up to 28 days showed a decline in activated protein C levels during the course of the disease, which was inversely correlated with interleukin-6. This study underlines sustained inflammatory mechanisms in the development and persistence of cardiogenic shock, highlighting a potential effect of anti-inflammatory interventions early during cardiogenic shock.