Vojko Kanic

A prospective study about impact of renal dysfunction and morbidity and mortality on cardiovascular events after ischemic stroke

BACKGROUND The aim of our prospective study was to define the impact of renal dysfunction on future cardiovascular events and total mortality in 390 patients suffering from ischemic stroke. METHODS A quantitative measurement of neurologic deficit according to National Institutes of Health Stroke Scale (NIHSS) score was performed. Blood parameters were measured. Diabetes, hypertension and smoking habits were defined. Estimated glomerular filtration rate was calculated. RESULTS 153 (39.2%) patients had renal dysfunction. In the follow-up period in 36 (9.2%) patients acute coronary syndrome, in 102 (26.2%) recurrent ischemic stroke and in 44 (11.3%) peripheral arterial disease were documented. 191 (49%) patient died, 118 (30.3%) of whom died of cardiovascular events. Patients who died were older, had higher prevalence of renal dysfunction and NIHSS score. The Kaplan-Meier survival analysis showed that total mortality (p < 0.003) and cardiovascular mortality (p < 0.01) were higher in patients with renal dysfunction. According to Coxs regression analysis, renal dysfunction was the predictor of cardiovascular events, cardiovascular and total mortality. CONCLUSIONS Patients with ischemic stroke and renal dysfunction are at higher risk for long term cardiovascular and total mortality. The patients with ischemic stroke and renal dysfunction are also at higher risk of new cardiovascular morbidity. Renal dysfunction should be added to the other known prognostic factors in patients with ischemic stroke. Our results also emphasize the importance of identification and management of renal dysfunction in stroke patients.

Influence of minor deterioration of renal function after PCI on outcome in patients with ST‐elevation myocardial infarction

OBJECTIVES Our aim was to assess the possible impact of a deterioration of renal function (DRF) not fulfilling the criteria for acute kidney injury after percutaneous coronary intervention (PCI) on outcome in patients with ST-elevation myocardial infarction (STEMI) on 30-day and long-term outcomes. BACKGROUND Data is lacking on the influence of DRF after PCI on outcome in patients with STEMI. METHODS The present study is an analysis of 2572 STEMI patients who underwent PCI. The group with DRF (1022 patients) and the group without DRF (1550 patients) were compared. Thirty-day and long-term all-cause mortality were observed. Data was analyzed using descriptive statistics. RESULTS Similar mortality was observed in both groups at day 30 (4.2% patients with DRF died vs 3.2% without DRF; ns) but more patients had died in the DRF group (18.9% patients with DRF vs 14.0% without DRF; P = 0.001) by the end of the observation period. After adjustments, DRF did not independently predict long-term mortality. Age more than 70 years, bleeding, hyperlipidemia, renal dysfunction on admission, anemia on admission, diabetes, PCI of LAD, the use of more than 200 mL contrast, but not DRF after PCI, were identified as independent prognostic factors for increased long-term mortality. Renal dysfunction, bleeding, contrast >200 mL, hyperlipidemia, age >70 years, anemia, and PCI LAD predicted DRF. CONCLUSION DRF identified patients at increased risk of higher long-term mortality but was not independently associated with mortality.

Gender Related Survival Differences in ST-Elevation Myocardial Infarction Patients Treated with Primary PCI.

Background: Data about gender as an independent risk factor for death in ST-elevation myocardial infarction (STEMI) patients is still contrasting. Aim was to assess how gender influences in-hospital and long-term all-cause mortality in STEMI patients with primary percutaneous coronary intervention (PCI) in our region. Methods: We analysed data from 2069 STEMI patients undergoing primary PCI in our institution from January 2009-December 2014, of whom 28.9% were women. In-hospital and long-term mortality were observed in women and men. The effect of gender on in-hospital mortality was assessed by binary logistic regression modelling and by Cox regression analysis for long-term mortality. Results: Women were older (68.3±61.8 vs 61.8±12.0 years; p<0.0001), with a higher prevalence of diabetes (13.7% vs 9.9%; p=0.013) and tend to be more frequently admitted in cardiogenic shock (8.4% vs 6.3%; p =0.085). They were less frequently treated with bivalirudin (15.9% vs 20.3%; p=0.022). In-hospital mortality was higher among women (14.2% vs 7.8%; p<0.0001). After adjustment, age (adjusted OR: 1.05; 95% CI: 1.03 to 1.08; p < 0.001) and cardiogenic shock at admission (adjusted OR: 24.56; 95% CI: 11.98 to 50.35; p < 0.001), but not sex (adjusted OR: 1.47; 95% CI: 0.80 to 2.71) were identified as prognostic factors of in-hospital mortality. During the median follow-up of 27 months (25th, 75th percentile: 9, 48) the mortality rate (23.6% vs 15.1%; p<0.0001) was significantly higher in women. The multivariate adjusted Cox regression model identified age (HR 1.05; 95% CI 1.04-1.07; p<0.0001), cardiogenic shock at admission (HR 6.09; 95% CI 3.78-9.81; p<0.0001), hypertension (HR 1.49; 95% CI 1.02-2.18; p<0.046), but not sex (HR 1.04; 95% CI 0.74-1.47) as independent prognostic factors of follow-up mortality. Conclusion: Older age and worse clinical presentation rather than gender may explain the higher mortality rate in women with STEMI undergoing primary PCI.

Deterioration of renal function at stent implantation can predict long-term outcome after stent thrombosis

SummaryObjectivesThe aim of the study was to examine the possible influence of minor deterioration of the renal function after stent implantation not fulfilling the criteria for acute kidney injury on long-term outcomes after stent thrombosis (ST).BackgroundDecreased renal function (DRF) is associated with an increased risk for worse outcome after percutaneous coronary intervention. There is no data if the deterioration of renal function after stent implantation influences the prognosis after ST. If so patients with a higher risk for worse outcome after ST could be identified already at the time of stent implantation.MethodsData from 4824 consecutive patients treated with percutaneous coronary intervention in our center was recorded from March 2004 to April 2010. We excluded patients with acute kidney injury at stent implantation and 86 of them with ST without acute kidney injury at stent implantation were involved in the study. They were prospectively followed until December 2012 for 50.2 ± 28.1 months. Only patients with definite ST were included in the study. The Academic Research Consortium definition of ST was used. Data on death, myocardial infarction, and repeated percutaneous or operative revascularization after ST were ascertained from the hospital database, by phone or with clinical examinations. The outcomes after definite ST were compared in patients with and without deterioration of renal function after stent implantation (DRFafterSI).ResultsDuring the observational period patients with DRFafterSI had a higher mortality rate after ST than patients without DRFafterSI (35.1 vs. 10.3 %; p <0.019). The incidence of major adverse cardiac events (major adverse coronary event (MACE)—death, myocardial infarction, repeated revascularization) rate after ST was similar in both groups (66.1 % with DRFafterSI vs. 55.2 % without DRFafterSI). The prevalence of myocardial infarction was also similar in both groups (31.6 vs. 34.5 %) as was the revascularizations rate (43.9 vs. 48.3 %). Death was predicted by DRFafterSI (adjusted hazard ratio (HR) 3.96; 95 % confidence interval (CI) 1.11 to 14.10; p <0.034) and age > 75 years (adjusted HR 2.85: 95 % CI 1.12–7.30; p = 0.029). We could not find any predictor for MACE.ConclusionsEven more subtle DRFafterSI (not fulfilling the criteria for acute kidney injury) at stent implantation were associated with higher long-term mortality after ST. Especially at risk were patients older than 75 years at stent implantation. DRFafterSI and age more than 75 years pointed out the group of patients with a high risk for death after ST already at the time of stent implantation. The best treatment option for preventing ST in these patients is still to be determined. Until then, we must pay a special attention to proper patients’ preparation and hydration to avoid DRFafterSI.

Impact of the New P2Y12 Receptor Inhibitors on Mortality in STElevationMyocardial Infarction Patients with Cardiogenic Shock and / orAfter Cardiopulmonary Resuscitation Undergoing Percutaneous CoronaryIntervention

Background: Little is known about clinical efficacy of newer P2Y12 receptor inhibitors in ST-elevation myocardial infarction patients presenting with cardiogenic shock or after cardiopulmonary resuscitation. The aim of our study was to establish the possible role of newer P2Y12 receptor inhibitors prasugrel and ticagrelor on survival in comparison to clopidogrel administration in ST-elevation myocardial infarction patients presenting with cardiogenic shock and / or after cardiopulmonary resuscitation. Method: The present study was an analysis of 187 patients with ST-elevation myocardial infarction presenting with cardiogenic shock and / or after cardiopulmonary resuscitation. Groups with newer P2Y12 receptor inhibitors (107 patients) and with clopidogrel (80 patients) were compared and followed for median 160 days (25th, 75th percentile: 6,841). Mortality at 14 days, 30 days and one year were compared between the groups. Results: Mortality at 14 days was similar in both groups. A strong trend towards a lower mortality at 30 days was noticed in the newer P2Y12 receptor inhibitors group [39 (48.8%) patients in clopidogrel group died versus 38 (35.5%) in the newer P2Y12 group receptor inhibitors; p = 0.07]. All-cause mortality at one year was significantly higher in the group with clopidogrel administration [47 (58.8%) patients in clopidogrel group died versus 46 (43.0%) in the newer P2Y12 receptor inhibitors group; p = 0.039]. Conclusion: In ST-elevation myocardial infarction patients presenting with cardiogenic shock and/or after cardiopulmonary resuscitation, the administration of newer P2Y12 receptor inhibitors reduced the one-year mortality in comparison to clopidogrel. The use of newer P2Y12 receptor inhibitors may be advocated in this very high risk group of patients.

Catheter Aspiration in ST-Elevation Myocardial Infarction and Different Extent of Coronary Thrombus

Manual catheter aspiration appears to be a useful adjunct to primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction. We investigated effects of catheter aspiration during primary PCI in patients with different extents of coronary thrombus. The study included 46 patients with no or possible thrombus (thrombus scale [TS] grades 0 to 1) and 135 patients with angiographic evidence of obvious thrombus (TS grades 2 to 5). Reference vessel diameter, which was significantly larger in the group with TS grades 2 to 5 (3.4 vs 3.2 mm, p = 0.004), was the only independent predictor of angiographically visible thrombus (odds ratio 3.3, 95% confidence interval 1.3 to 8.7, p = 0.015, per millimeter increase). Aspiration catheter was successfully advanced across the lesion in 89% of patients with TS grades 0 to 1 and 96% of those with TS grades 2 to 5 (p = 0.115). Number of aspirations varied from 1 to 5 and was significantly larger in patients with TS grades 2 to 5. Visually observable aspirate was obtained in 90% of patients with TS grades 2 to 5 and in 67% of patients with TS grades 0 to 1 (p <0.001) with more patients with TS grades 2 to 5 having aspirate >5 mm in length (49% vs 11%, p <0.001). Final Thrombolysis In Myocardial Infarction grade 3 flow (89% vs 92%), residual TS (0.2 vs 0.1), frequency of distal embolization (2% vs 6%), and early complete ST resolution (65% vs 70%) were comparable between groups with TS grades 0 to 1 and 2 to 5. In conclusion, although the amount of aspirate is larger in patients with angiographically obvious thrombus, visually observable aspirate can be obtained in most patients without definite signs of thrombus. Extent of coronary thrombus does not influence primary PCI result if manual aspiration is used.

Women and acute kidney injury in myocardial infarction

BackgroundData on the relationship between gender and acute kidney injury (AKI) in patients with myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI) are conflicting and inconclusive. The contrast volume-to-estimated glomerular filtration rate ratio (CV/GFR) was shown to predict AKI in patients with MI undergoing PCI. We assessed gender-based differences in AKI and evaluated the association between the CV/GFR and AKI in MI patients undergoing PCI.MethodsWe retrospectively studied 4675 consecutive patients with MI who underwent PCI between January 2007 and December 2015. The incidence of AKI and CV/GFR in men and women were compared. Data were analyzed using descriptive statistics.ResultsWomen suffered more AKI than men [152 (10.5%) women suffered AKI compared to 252 (7.8%) men; p = 0.003]. After adjustment for potential confounders, female gender was identified as an independent predictive factor for AKI. CV/GFR was higher in women (2.57 ± 1.95 in women vs. 2.25 ± 1.60 in men; p < 0.0001) and predicted AKI.ConclusionAKI occurs more often in women than men with MI undergoing PCI. Female gender independently predicted AKI in our analysis. A high CV/GFR denotes a group of patients who are at higher risk of AKI after PCI. CV/GFR was significantly higher in women, which may help to explain their worse outcome as regards AKI.

GPIIb-IIIa Receptor Inhibitors in Acute Coronary Syndrome Patients Presenting With Cardiogenic Shock and/or After Cardiopulmonary Resuscitation

BACKGROUND Data on the use of GPIIb-IIIa receptor inhibitors (GPI) in acute coronary syndrome (ACS) patients presenting with cardiogenic shock and/or after cardiopulmonary resuscitation is sparse. The aim of the study was to establish the possible influence of the adjunctive use of GPI on 30-day and 1-year mortality in these high-risk patients. METHODS Acute coronary syndrome patients (261), who presented with cardiogenic shock and/or were cardiopulmonary resuscitated on admission, were analysed. Groups receiving (170 patients) and not receiving (91 patients) GPI were compared regarding 30-day and 1-year mortality. RESULTS The unadjusted all-cause 30-day and 1-year mortality were similar in patients receiving GPI and those not receiving GPI [79 patients (46.5%) vs 50 patients (54.9%) at 30 days; ns, 91 patients (53.5%) vs. 55 (61.1%) at 1 year; ns]. After the adjustment for baseline and clinical characteristics, the adjunctive usage of GPI was identified as an independent prognostic factor in lower 30-day mortality (adjusted OR: 0.41; 95%CI: 0.20 to 0.84; p=0.015) and 1-year mortality (HR 0.62; 95%CI 0.39-0.97; p=0.037). Age, left main PCI and major bleeding, were also identified as independent prognostic factors in worse 30-day and 1-year mortality. In addition, Thrombolysis in Myocardial Infarction (TIMI) flow 0/1 pre-percutaneous coronary intervention (PCI) predicted a worse 1-year outcome. Novel oral P2Y12 receptor antagonists predicted better 30-day and 1-year survival. CONCLUSION Our study suggests that the adjunctive usage of GPI may be beneficial in this high-risk group of patients in whom a delayed onset of action of oral antiplatelet therapy would be expected.

Impact of KDIGO-Defined Acute Kidney Injury on Mortality after Percutaneous Coronary Intervention for Acute Myocardial Infarction

Background: There are limited data regarding the incidence and long-term impact of acute kidney injury (AKI) according to the KDIGO guidelines on the outcome in patients with myocardial infarction (MI) treated with percutaneous coronary intervention (PCI). The aim of the study was to evaluate the prevalence of AKI, as classified by the KDIGO criteria, and its association with long-term mortality. Methods: Data from 5,859 MI patients undergoing PCI at our institution were analyzed. We compared the group without and with AKI according to the KDIGO criteria in relation to long-term mortality. Results: AKI was documented in 499 (8.5%) patients. AKI stage 1 occurred in 6.2% of patients, AKI stage 2 in 0.9% of patients, and AKI stage 3 in 1.5% of patients. Patients with AKI had a higher long-term mortality (57.3 vs. 20.6%; p < 0.0001). The mortality was 50.3% in AKI stage 1, 56.9% in AKI stage 2, and 87.2% in AKI stage 3. The hazard ratios for all-cause mortality for AKI stages 1–3 were 1.77, 1.85, and 6.30 compared to patients with no AKI. Cardiogenic shock, bleeding, heart failure, age, renal dysfunction, diabetes, hyperlipidemia, ST-elevation MI, contrast volume/glomerular filtration ratio, P2Y12 receptor antagonists, and radial access were associated with the development of AKI. Conclusion: A slight increase in serum creatinine was associated with a progressive increase in long-term mortality in patients with AKI according to the KDIGO definition.

Acute total occlusion of the left main coronary artery treated with percutaneous intervention and simultaneous implantation of intra-aortic balloon pump

Electrocardiographic findings at first medical contact and direct transfer to the catheterization laboratory are important in acute total occlusion of the left main coronary artery. Simultaneous emergency angioplasty and intra‐aortic balloon pump implantation might be beneficial in overcoming the patients most critical hemodynamic instability.