Tarunjit Singh

ST-elevation myocardial infarction in the elderly — Temporal Trends in incidence, utilization of percutaneous coronary intervention and outcomes in the United States

BACKGROUND Elderly patients with ST-elevation myocardial infarction (STEMI) are often underrepresented in major percutaneous coronary intervention (PCI) trials. Use of PCI for STEMI, and associated outcomes in patients aged ≥65 years with STEMI needed further investigation. METHODS We used the 2001-2010 United States Nationwide Inpatient Sample (NIS) database to examine the temporal trends in STEMI, use of PCI for STEMI, and outcomes among patients aged 65-79 and ≥80 years. RESULTS During 2001-2010, of 4,017,367 patients aged ≥65 years with acute myocardial infarction (AMI), 1,434,579 (35.7%) had STEMI. Over this period, among patients aged 65-79 and ≥80 years, STEMI decreased by 16.4% and 19%, whereas the use of PCI for STEMI increased by 33.5% and 22%, respectively (Ptrend<0.001). There was a significant decrease in age-adjusted in-hospital mortality (per 1000) in patients aged ≥80 years (150 versus 116, Ptrend=0.02) but not in patients aged 65-79 years (63 versus 59, Ptrend=0.886). Stepwise logistic regression identified intra-aortic balloon pump use, acute renal failure, acute cerebrovascular disease, age ≥80 years, peripheral vascular disease, gastrointestinal bleeding, female gender, congestive heart failure, chronic lung disease, weekend admission and multivessel PCI as independent predictors of in-hospital mortality among all patients ≥65 years of age who underwent PCI for STEMI. CONCLUSIONS In this large, multi-institutional cohort of elderly patients, a decreasing trend in STEMI, an increasing trend in PCI utilization for STEMI, and reduction in in-hospital mortality were observed from 2001 to 2010.

Warfarin use and the risk of valvular calcification.

Summary.  Background: Warfarin affects the synthesis and function of the matrix Gla‐protein, a vitamin K‐dependent protein, which is a potent inhibitor of tissue calcification. Objectives: To investigate the incidence of mitral valve calcium (MVC), mitral annular calcium (MAC) and aortic valve calcium (AVC) in patients with non‐valvular atrial fibrillation (AF) treated with warfarin vs. no warfarin. Patients and methods: Of 1155 patients, mean age 74 years, with AF, 725 (63%) were treated with warfarin and 430 (37%) without warfarin. The incidence of MVC, MAC and AVC was investigated in these 1155 patients with two‐dimensional echocardiograms. Unadjusted logistic regression analysis was conducted to examine the association between the use of warfarin and the incidence of MVC, MAC or AVC. Logistic regression analyses were also conducted to investigate whether the relationship stands after adjustment for confounding risk factors such as age, sex, race, ejection fraction, smoking, hypertension, diabetes, dyslipidemia, coronary artery disease (CAD), glomerular filtration rate, calcium, phosphorus, calcium‐phosphorus product, alkaline phosphatase, use of aspirin, beta blockers, angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers, and statins. Results: There was a significant association between the use of warfarin and the risk of calcification [unadjusted odds ratio = 1.71, 95% CI = (1.34–2.18)]. The association still stands after adjustment for confounding risk factors. MVC, MAC or AVC was present in 473 of 725 patients (65%) on warfarin vs. 225 of 430 patients (52%) not on warfarin (P < 0.0001). Whether this is a causal relationship remains unknown. Conclusions: Use of warfarin in patients with AF is associated with an increased prevalence of MVC, MAC or AVC.

Psoriasis induced by losartan therapy: a case report and review of the literature.

Psoriasis is a papulosquamous disease of multifactorial etiology. A combination of genetic and environmental agents is implicated in its pathogenesis. A variety of triggers, including infection, stress, and medications, have been recognized as precipitants of this disease. Nonsteroidal anti-inflammatory drugs, beta-blockers, lithium, synthetic antimalarials, and gold are the most common drugs implicated in precipitating psoriasis. We report a patient with psoriasis induced by initiation of losartan therapy, which resolved with discontinuation of the drug. The Naranjo adverse drug reaction probability scale score indicated that the association between losartan use and psoriasis was probable.

Brugada electrocardiographic pattern induced by amitriptyline overdose.

Tricyclic antidepressants (TCAs) remain a common cause of fatal drug poisoning as a result of their cardiovascular toxicity manifested by electrocardiographic abnormalities, arrhythmias, and hypotension. The principal mechanism of toxicity is cardiac sodium channel blockade. Brugada electrocardiographic pattern (BEP) has also been described in TCA overdose. Currently, very little is known about the relationship between the Brugada syndrome and TCAs. We report the case of a patient who presented with BEP after intake of a high dose of amitriptyline. The patient was treated with continuous sodium bicarbonate infusion leading to resolution of BEP.

Warfarin use and prevalence of coronary artery calcification assessed by multislice computed tomography.

Warfarin inhibits the synthesis and function of matrix Gla protein, a vitamin K–dependent protein, which is a potent inhibitor of tissue calcification. We had earlier reported the association of warfarin use with valvular calcification in patients with nonvalvular atrial fibrillation. The aim of our present study was to investigate the association of warfarin use with the presence and severity of coronary artery calcification. A total of 233 patients underwent computed tomography scan (CT) at our institution for the assessment of coronary artery calcium score (CACS). Of 233 patients, the mean age was 63 years, 28 patients (12%) were treated with warfarin, and 205 patients (88%) were not on warfarin. Based on their total CACS, the patients were subsequently stratified into 59 with no coronary calcium (CACS = 0), 63 with low CACS (1–100), 49 with moderate CACS (101–400), 33 with severe CACS (410–1000), and 29 with very severe CACS (>1000). The &khgr;2 test and Student t-test were used for the comparison of categorical and continuous variables, respectively, between warfarin users and nonusers. Using the variables age, gender, race, smoking, hypertension, diabetes, dyslipidemia, glomerular filtration rate, calcium–phosphorus product, alkaline phosphatase, use of aspirin, beta blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins, stepwise logistic regression analysis did not show any association of coronary calcification with use of warfarin. In our study, warfarin use was not associated with a higher prevalence or severity of CACS assessed by coronary computed tomography.

Major adverse cardiac events in patients with moderate to severe renal insufficiency treated with first-generation drug-eluting stents.

No data are available comparing the long-term outcome of sirolimus-eluting stents (SESs) versus paclitaxel-eluting stents (PESs) in patients with moderate to severe renal insufficiency. The incidence of major adverse cardiac events (MACE), including death, myocardial infarction, and target vessel revascularization, during long-term follow-up were studied in patients with a glomerular filtration rate of <60 ml/min/1.73 m(2), as measured by the Modification of Diet in Renal Disease (MDRD) study equation, who also underwent percutaneous coronary intervention with drug-eluting stents. Of 428 patients studied, PESs were placed in 287 patients and SESs in 141 patients. Stepwise Cox regression analyses were performed to identify significant independent risk factors for MACE. At 47 + or - 19 months of follow-up, MACE had occurred in 49 (17%) of 287 patients in the PES group (mean age 71 + or - 11 years, 55% men) and in 31 (22%) of 141 patients in the SES group (mean age 71 + or - 12 years, 53% men). No significant difference was found in the MACE rate between the PES and SES groups. This persisted even after controlling for stent length, lesion complexity, and other co-morbidities. Also, all-cause mortality was not significantly different between the PES and SES groups (7.1% vs 8.5%, respectively). In conclusion, during long-term follow-up of patients with moderate to severe renal insufficiency, the rates of MACE and all-cause mortality were similar in the PES and SES groups.

Comparison of prevalence of >70% diameter narrowing of one or more major coronary arteries in patients with versus without mitral annular calcium and clinically suspected coronary artery disease.

The prevalence of >70% narrowing of 1, 2, or 3 major coronary arteries and of 3 major coronary arteries was investigated in 2,465 patients (1,437 men, 1,028 women; mean age 69 +/- 13 years) with severe, moderate, mild, or no mitral annular calcium (MAC) diagnosed by 2-dimensional echocardiography who underwent coronary angiography for suspected coronary artery disease. Greater than 70% narrowing of 1, 2, or 3 major coronary arteries was present in 259 of 315 patients (82%) with severe MAC (group 1), in 835 of 1,052 patients (79%) with moderate or mild MAC (group 2), and in 756 of 1,098 patients (69%) with no MAC (group 3) (p <0.001 comparing group 1 with group 3 and group 2 with group 3). Greater than 70% narrowing of 3 major coronary arteries was present in 149 of 315 patients (47%) in group 1, in 366 of 1,052 patients (35%) in group 2, and in 325 of 1,098 patients (30%) in group 3 (p <0.001 comparing group 1 with group 3 and group 1 with group 2; p <0.01 comparing group 2 with group 3). In conclusion, MAC is associated with obstructive >or=1-vessel coronary artery disease and with obstructive 3-vessel coronary artery disease.

Major Adverse Cardiac Events at Follow-Up After Bare-Metal Stenting Versus Drug-Eluting Stenting in ST-Elevated Myocardial Infarction

After thrombolytic therapy with tenecteplase for ST-segment elevation acute myocardial infarction, 376 patients were transferred from their hospital to Westchester Medical Center for percutaneous coronary intervention with stenting. Of 376 patients, 102 (27%) received bare-metal stents and 274 (73%) received drug-eluting stents with sirolimus-eluting or paclitaxel-eluting stents. At 43 months of follow-up, major adverse cardiac events occurred in 25 (25%) of 102 patients treated with bare-metal stents versus 40 (15%) of 274 patients treated with drug-eluting stents (p = 0.024). Cox regression analysis showed that significant independent prognostic factors for major adverse cardiac events were previous coronary artery bypass surgery (hazard ratio 2.2, p = 0.019), width of stent (hazard ratio 0.44, p = 0.006), and bare-metal stent (hazard ratio 1.8, p = 0.019). In conclusion, patients with bare-metal stents had a 1.8 times greater risk of developing major adverse cardiac events than did those using drug-eluting stents after controlling the confounding effects of previous coronary artery bypass surgery and stent width.

Obstructive coronary artery disease in high-risk diabetic patients with and without atrial fibrillation.

ObjectiveTo investigate the severity of coronary artery disease by coronary angiography in age-matched and sex-matched patients with diabetes mellitus with atrial fibrillation versus sinus rhythm. MethodsThe patients included 245 men and women, mean age of 70 years, with diabetes and atrial fibrillation and 245 age-matched and sex-matched patients with diabetes and sinus rhythm who underwent coronary angiography. Baseline characteristics and indications for coronary angiography were similar in both groups. ResultsGreater than 50% narrowing of one, two, or three major coronary arteries were present in 229 of 245 patients (94%) with diabetes and atrial fibrillation and in 211 of 245 patients (86%) with diabetes and with sinus rhythm (P<0.01). Greater than 50% narrowing of three major coronary arteries were present in 150 of 245 patients (61%) with diabetes and atrial fibrillation and in 75 of 245 patients (31%) with diabetes and sinus rhythm (P<0.001). ConclusionPatients with diabetes and atrial fibrillation have a significantly higher prevalence of greater than 50% narrowing of one or more major coronary arteries and of three major coronary arteries than patients with diabetes and sinus rhythm.

Use of antiplatelet therapy after percutaneous coronary intervention with bare-metal stents and different types of drug-eluting stents.

Dual antiplatelet therapy (DAPT) with a thienopyridine and aspirin has been the standard of care post coronary stent implantation. DAPT has been shown to reduce the risk of stent thrombosis (ST) and complications of myocardial infarction and death after placement of a drug-eluting stent (DES) and bare-metal stent (BMS). This article reviews the available clinical efficacy and safety data of antiplatelet therapies. The aim of this review is to highlight not only the importance of antiplatelets in the prevention of early and late thrombosis but also emphasize the importance of newer more potent antiplatelet agents and their role in the setting of clopidogrel resistance. MEDLINE, and EMBASE were searched for studies related to the clinical efficacy and safety of antiplatelet therapy after DES and BMS placement using the terms dual antiplatelet therapy, thienopyridine, aspirin, clopidogrel, prasugrel, ticagrelor,elinogrel, bare-metal stents, drug-eluting stent, stent thrombosis and myocardial infarction.