Tadeusz Osadnik

A comparison of ST elevation versus non-ST elevation myocardial infarction outcomes in a large registry database: are non-ST myocardial infarctions associated with worse long-term prognoses?

BACKGROUND Prognoses in STEMI and NSTEMI beyond one year from onset remain unclear. We aimed to compare the treatments and the two-year outcomes in patients with myocardial infarction (MI) enrolled at the Polish Registry of Acute Coronary Syndromes (PL-ACS). METHODS A total of 13,441 patients with MI (8250 with STEMI, and 5191 with NSTEMI) underwent medical care between October 2003 and June 2005 in the Silesia region (4.8 million inhabitants). The events analyzed were death, MI, stroke and percutaneous (PCI) or surgical (CABG) revascularization. RESULTS After two years, NSTEMI was associated with a higher incidence of death (hazard ratio (HR) of 1.09 (95% confidence interval (CI) 1.02-1.17, p<0.0001)); a higher incidence of reinfarction, stroke, CABG and a lower rate of PCI. Adjustments for baseline characteristics and treatment strategy (invasive vs. non-invasive) reversed the HR for mortality and eliminated the difference in MI and stroke. The adjusted HR for mortality was 0.76 (95% CI, 0.71-0.83, p<0.0001). STEMI and NSTEMI patients treated non-invasively were older and showed higher incidences of diabetes, obesity, pulmonary edema and cardiogenic shock than their invasively treated counterparts. Invasively treated patients received aspirin, beta-blockers, ACE inhibitors and statins more often during hospitalization and at discharge. CONCLUSIONS The unadjusted long-term prognosis was worse in NSTEMI. After adjustment for the baseline characteristics and treatment strategy, the long-term prognosis was worse in STEMI. Patients with MI treated invasively showed more favorable clinical characteristics and received guideline-recommended therapy more often than patients who did not undergo invasive treatment.

Impact of chronic total occlusion artery on 12-month mortality in patients with non-ST-segment elevation myocardial infarction treated by percutaneous coronary intervention (From the PL-ACS Registry)

BACKGROUND Three-vessel coronary artery disease is associated with high mortality in patients with non-ST-segment elevation myocardial infarction (NSTEMI). The purpose of this study was to assess the impact on 12-month mortality of chronic total occlusion (CTO) in the non-infarct-related artery (non-IRA), as assessed by coronary angiography during percutaneous coronary intervention (PCI) for NSTEMI, of patients with 3-vessel disease. METHODS The study included all of the NSTEMI patients with 3-vessel disease by coronary angiogram who were treated by PCI and who were registered in the prospective Polish Registry of Acute Coronary Syndromes (PL-ACS) from July 2007 to November 2009. The patients with prior coronary artery bypass grafting and those with significant stenosis of the left main coronary artery were excluded. The 12-month mortality was obtained from a government database. RESULTS Of the 925 patients fulfilling the inclusion and exclusion criteria, 438 (47.4%) patients had 1 or more CTO of a major non-IRA coronary artery (+CTO), and 487 (52.6%) patients had 3-vessel disease without CTO (-CTO). The in-hospital mortality for the +CTO and -CTO patients was 5.3% and 2.1%, respectively (p=0.009), whilst the 12-month mortality was 21.1% and 11.9%, respectively (p=0.0001). After multivariate adjustment for differences in the baseline characteristics, the presence of CTO remained significantly associated with higher 12-month mortality (relative risk=1.42, 95%CI=1.01-2.00, p=0.047). CONCLUSIONS The presence of CTO in non-IRA in patients with NSTEMI and 3-vessel coronary disease predicts higher 12-month mortality.

Temporal Trends in the Treatment and Outcomes of Patients With Non-ST-Segment Elevation Myocardial Infarction in Poland from 2004–2010 (from the Polish Registry of Acute Coronary Syndromes)

The aim of this work was to analyze temporal trends in clinical presentation, treatment methods, and outcomes of patients in Poland with non-ST-segment elevation myocardial infarction (NSTEMI) from 2004 to 2010. A total of 90,153 patients with NSTEMI enrolled in the Polish Registry of Acute Coronary Syndromes (PL-ACS) from 2004 to 2010 were analyzed. The main outcome measure was all-cause mortality after 12 months, identified from official mortality records. The percentage of admissions for NSTEMI among all acute coronary syndromes increased from 24% in 2004 to 38% in 2010 (p < 0.0001). From 2004 to 2010, the percentage of invasive treatment for NSTEMI increased significantly, almost threefold, to 83% (p < 0.0001). The frequency of recurrent myocardial infarction and stroke during hospitalization decreased significantly over the years, while the frequency of major bleeding increased. Twelve-month mortality decreased significantly throughout the time period, from 19.1% to 14.5%, but was stable in patients treated invasively and slightly higher in the last years in patients treated noninvasively. The invasive treatment of NSTEMI (relative risk 0.62, 95% confidence interval 0.57 to 0.67, p < 0.0001), together with the pharmacotherapy recommended by the guidelines, had a significant impact on reducing 12-month mortality in a multifactor analysis. In conclusion, the distinct improvement in the short- and long-term prognoses of patients with NSTEMI may be in part the result of the popularization of invasive treatment and the optimization of pharmacotherapy.

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.

The platelet-to-lymphocyte ratio as a predictor of all-cause mortality in patients with coronary artery disease undergoing elective percutaneous coronary intervention and stent implantation

Background There is no data regarding the association between the platelet-to-lymphocyte ratio (PLR) and long-term mortality in patients with stable coronary artery disease (SCAD). The aim of this study is to evaluate the utility of the pre-procedural PLR for predicting long-term, all-cause mortality in patients with SCAD undergoing percutaneous coronary intervention (PCI) and stent implantation. Methods We analyzed a total of 2959 consecutive patients with SCAD who underwent PCI (balloon angioplasty followed by stent implantation or direct stenting) between July 2006 and December 2011 at our institution. The patients were stratified into tertiles according to their admission PLR. The association between the PLR value and the outcomes was assessed using Cox proportional regression analysis after adjusting for clinical angiographic and laboratory data. Results During median follow-up of 1124 days, mortality was highest in patients with PLR within the 3rd tertile as compared to the 2nd and the 1st tertile (11.0% vs 8.7% vs. 9.6%, respectively, p = 0.03). PLR remained associated with mortality in multivariable analysis including clinical variables, ejection fraction and angiographic parameters HR (per 10 units increase) = 1.02 [95%CI,1.01 ÷ 1.04, p = 0.006]. After adjustment for the eGFR and hemoglobin levels, PLR was however no longer significantly associated with mortality. Conclusion PLR has potential predictive value in patients with SCAD, which has not been reported previously, but statistical significance disappears after adjusting for estimated glomerular filtration rate (eGFR) and hemoglobin levels as a potential confounding variable.

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.

Prognostic implications of mean platelet volume on short- and long-term outcomes among patients with non-ST-segment elevation myocardial infarction treated with percutaneous coronary intervention: A single-center large observational study

Abstract Background: Mean platelet volume (MPV) is a simple and reliable indicator of platelet size that correlates with platelet activation and their ability to aggregate. We studied the predictive value of MPV in patients with non-ST-segment elevation myocardial infarction (NSTEMI) treated with percutaneous coronary intervention (PCI). Methods: We analyzed the consecutive records of 1001 patients who were hospitalized due to NSTEMI at our center. The primary end point was a composite end point that included the rates of all-cause death, non-fatal myocardial infarction, and acute coronary syndrome (ACS) driven revascularization at 12 months. The enrolled patients were stratified according to the quartile of the MPV level at admission. Results: Along with the increasing quartile of MPV, the 12-month composite end point increased significantly (p = 0.010), and this association remained significant after the risk-adjusted analyses (per 1 fL higher MPV; adjusted hazard ratio [HR] 1.13; 95% confidence interval [CI] 1.02–1.27; p = 0.026). In the multivariate analysis, the MPV was also an independent factor of all-cause mortality (per 1 fL increase; adjusted HR 1.34; 95% CI 1.12–1.61; p = 0.0014) and death or non-fatal myocardial infarction (per 1 fL increase; adjusted HR 1.16; 95% CI 1.03–1.31; p = 0.017). Conclusion: In patients with NSTEMI treated with PCI, a high MPV value was associated with a significantly increased incidence of long-term adverse events, particularly for all-cause mortality.

Functional polymorphism rs710218 in the gene coding GLUT1 protein is associated with in-stent restenosis

AIM To analyze the association between in-stent restenosis (ISR) and polymorphisms in genes coding IGF-1, IGFBP3, ITGB3 and GLUT1, which play an important role in the smooth muscle cell proliferation and extracellular matrix synthesis - the main components of neointima. MATERIALS & METHODS We analyzed 265 patients who underwent bare metal stent implantation. RESULTS The differences in the occurrence of ISR between genotypes of the analyzed polymorphisms in the IGF-1, IGFBP3 and ITGB3 were not statistically significant. The T/T genotype of the rs710218 polymorphism in the GLUT1 (SLC2A1) gene was more common in the ISR group compared with non-ISR patients (81.1 vs 64.8%; p = 0.02). In a multivariable model the A/A and A/T genotype remained correlated with lower occurrence of ISR (odds ratio: 0.45; 95% CI: 0.21-0.97; p = 0.03). CONCLUSION The rs710218 polymorphism in the gene coding GLUT1 protein is a novel risk factor for ISR.

The Relationships between Polymorphisms in Genes Encoding the Growth Factors TGF-β1, PDGFB, EGF, bFGF and VEGF-A and the Restenosis Process in Patients with Stable Coronary Artery Disease Treated with Bare Metal Stent.

Background Neointima forming after stent implantation consists of vascular smooth muscle cells (VSMCs) in 90%. Growth factors TGF-β1, PDGFB, EGF, bFGF and VEGF-A play an important role in VSMC proliferation and migration to the tunica intima after arterial wall injury. The aim of this paper was an analysis of functional polymorphisms in genes encoding TGF-β1, PDGFB, EGF, bFGF and VEGF-A in relation to in-stent restenosis (ISR). Materials and Methods 265 patients with a stable coronary artery disease (SCAD) hospitalized in our center in the years 2007–2011 were included in the study. All patients underwent stent implantation at admission to the hospital and had another coronary angiography performed due to recurrence of the ailments or a positive result of the test assessing the coronary flow reserve. Angiographically significant ISR was defined as stenosis >50% in the stented coronary artery segment. The patients were divided into two groups–with angiographically significant ISR (n = 53) and without significant ISR (n = 212). Additionally, the assessment of late lumen loss (LLL) in vessel was performed. EGF rs4444903 polymorphism was genotyped using the PCR-RFLP method whilst rs1800470 (TGFB1), rs2285094 (PDGFB) rs308395 (bFGF) and rs699947 (VEGF-A) were determined using the TaqMan method. Results Angiographically significant ISR was significantly less frequently observed in the group of patients with the A/A genotype of rs1800470 polymorphism (TGFB1) versus patients with A/G and G/G genotypes. In the multivariable analysis, LLL was significantly lower in patients with the A/A genotype of rs1800470 (TGFB1) versus those with the A/G and G/G genotypes and higher in patients with the A/A genotype of the VEGF-A polymorphism versus the A/C and C/C genotypes. The C/C genotype of rs2285094 (PDGFB) was associated with greater LLL compared to C/T heterozygotes and T/T homozygotes. Conclusions The polymorphisms rs1800470, rs2285094 and rs6999447 of the TGFB1, PDGFB and VEGF-A genes, respectively, are associated with LLL in patients with SCAD treated by PCI with a metal stent implantation.

Who is eligible for randomized trials? A comparison between the exclusion criteria defined by the ISCHEMIA trial and 3102 real-world patients with stable coronary artery disease undergoing stent implantation in a single cardiology center

BackgroundRandomized controlled trials are the gold standard for evaluating therapy; however, controversy exists regarding the applicability of such results to daily practice, as patients are often pre-selected and may not reflect real-world clinical settings. We studied the eligibility criteria for 3102 “real-life” patients with stable coronary artery disease (SCAD) according to the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial exclusion criteria. The aim of our analysis was to estimate the percentage of real-life patients who would have met the exclusion criteria for the ISCHEMIA trial.MethodsWe analyzed 3102 patients with SCAD referred to the Silesian Center for Heart Disease who underwent both coronary angiography and stent implantation between January 2006 and December 2011. The patients were divided into two groups. Group A was composed of patients with SCAD who would have been excluded from the ongoing ISCHEMIA trial, whereas group B represented the remaining patients.ResultsA total of 1900 (61.3 %) patients met at least one of the exclusion criteria. The most frequent exclusion criterion noted was revascularization within the previous 12 months (938 patients; 49.4 %), followed by unacceptable level of angina symptoms (532 patients; 28 %), low ejection fraction (467 patients; 24.6 %), and acute coronary syndrome within the previous 2 months (456 patients; 24 %). Patients from our cohort who would have been excluded from the ISCHEMIA trial were older, had more comorbidities, and experienced worse long-term outcomes.ConclusionsThe ISCHEMIA trial exclusion criteria ruled out the majority of the patients with SCAD undergoing percutaneous coronary intervention in “real life”. Our cohort of patients who would have been excluded from the ISCHEMIA trial had more comorbidities and experienced significantly worse long-term outcomes than patients who did not meet the ISCHEMIA trial exclusion criteria.Trial registrationClinicalTrials.gov NCT01471522.