Effects of different strategies on high thrombus burden in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary catheterization Objective This study aimed at evaluating efficacy and safety of thrombus aspiration and intracoronary-targeted thrombolysis on coronary thrombus burden in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous catheterization, comparing their effects on myocardial perfusion through index of microcirculatory resistance (IMR) and single-photon emission computed tomography (SPECT). Participants and methods From January 2017 to January 2018, STEMI patients with high thrombus burden undergoing primary catheterization were enrolled and randomly assigned to receiving thrombus aspiration (TA group) or intracoronary thrombolysis (IT group). IMR, SPECT, and other conventional measurements were adopted to assess myocardial perfusion. Major adverse cardiovascular events (MACEs) and complications were recorded over a 90-day follow-up and a 12-month follow-up after the procedure. Results The study consisted of 38 patients in the IT group and 33 in the TA group. After recanalization, thrombus burden score, corrected thrombolysis in myocardial infarction (TIMI) frame count, the proportion of TIMI myocardial perfusion 3 grade, and IMR in the IT group were significantly better than those of the TA group (P<0.05). During the 90-day follow-up, no difference was observed in cardiac function and MACEs. During the 12-month follow-up, there were significant differences in infarct size of SPECT (18.56±8.56 vs. 22.67±7.66, P=0.046), left ventricular ejection fraction of echocardiography (58.13±5.92 vs. 55.17±5.68, P=0.043), and the composite MACEs between the two groups (P=0.034). Conclusion Thrombus aspiration and intracoronary-targeted thrombolysis are effective and safe strategies in managing high coronary thrombus burden in STEMI patients. Compared with aspiration, intracoronary-targeted thrombolysis is more beneficial in improving myocardial microcirculation perfusion.

Acute renal impairment in older adults treated with percutaneous coronary intervention for ST-segment elevation myocardial infarction Background Elderly individuals ( ≥ 75 years) constitute an increasing proportion of patients presenting with myocardial infarction treated with primary percutaneous coronary intervention (PCI), but only limited data are available regarding the incidence and prognostic implications of acute kidney injury (AKI) in this group of patients. Objective To evaluate the incidence and prognostic implications of AKI in older adults ( ≥ 75 years) with ST-segment elevation myocardial infarction (STEMI) treated with primary PCI. Patients and methods A retrospective cohort, observational, single-center study of consecutive 416 older patients with STEMI (≥ 75 years) treated with primary PCI between January 2008 and August 2017 was conducted. AKI was defined as an increase of at least 0.3 mg/dl in serum creatinine within 48 h following admission. Results A total of 96/416 (23%) patients developed AKI. The occurrence of AKI was associated with adverse in-hospital outcomes, higher 30 days (25 vs. 6%; P < 0.001), and long-term mortality (46 vs. 17%; hazard ratio: 3.2; 95% confidence interval: 2.1–4.7; P < 0.001). Among patients with AKI, 46/96 (48%) demonstrated recovery of renal function at hospital discharge. Lack of renal function recovery at discharge (50/96 patients; 52%) was associated with the occurrence of new or progression of baseline chronic kidney disease. Conclusion Among older patients with STEMI undergoing primary PCI, AKI is a frequent complication associated with adverse renal short-term and long-term outcomes.

The predictive value of age, creatinine, ejection fraction score for in-hospital mortality in patients with cardiogenic shock Introduction: The aim of the present study was to assess the predictive value of the age, creatinine, ejection fraction score for in-hospital mortality in patients with cardiogenic shock secondary to ST-elevation myocardial infarction. Material and methods: This single-center, retrospective study was based on a comprehensive analysis of the hospital records of 318 consecutive cardiogenic shock patients. The age, creatinine, ejection fraction score was calculated for each patient using the equation of age/ejection fraction +1 if creatinine level is >2 mg/dl. The study population was stratified into tertiles: T1, T2, and T3, based on the age, creatinine, ejection fraction score. The primary endpoint of the study was the incidence of in-hospital mortality. Results: The incidence of in-hospital mortality was significantly greater in patients with a high age, creatinine, ejection fraction score (T3 group) compared with the intermediate (T2 group) or the low score group (T1 group) [86.8% (n = 92 patients) vs. 57.5% (n = 61 patients) vs. 34.9% (n = 37 patients), respectively; P < 0.05 for each]. In multivariable models, after adjusting for all covariables, the risk of in-hospital mortality was 3.21 (95% confidence interval: 2.29–4.58) for patients allocated to the T3 group. The optimal cutoff for the age, creatinine, ejection fraction score for in-hospital mortality was 2.24, with a sensitivity of 74% and a specificity of 77%. Conclusion: To the best of our knowledge, this is the first study that has demonstrated a prognostic value of the age, creatinine, ejection fraction score in patients with ST-elevation myocardial infarction-related cardiogenic shock.

Association of shock index with short-term and long-term prognosis after ST-segment elevation myocardial infarction Background The association of shock index with long-term mortality after ST-segment elevation myocardial infarction (STEMI) remains poorly investigated. We aimed to assess the association between shock index and eight-year mortality after STEMI. Methods The study included 1369 patients with STEMI undergoing primary percutaneous coronary intervention (PPCI). Patients were categorized into three groups: a group with shock index in the first tertile (shock index, 0.21 to 0.52; n = 458), a group with shock index in the second tertile (shock index > 0.52 to 0.67; n = 457) and a group with shock index in the third tertile (shock index > 0.67 to 2.80; n = 454). The primary outcome was eight-year mortality. Results In patients with shock index in the first to third tertiles, inhospital cardiogenic shock (n = 153) occurred in 3.5, 3.9 and 26.2% of patients, respectively [adjusted odds ratio = 1.54, 95% confidence interval (CI) 1.40 to 1.69, P < 0.001]; 30-day deaths (n = 122) occurred in 2.8, 5.5 and 18.5% of patients, respectively [adjusted hazard ratio = 1.06 (1.01–1.12); P = 0.024]; eight-year deaths (n = 300) occurred in 22.9, 21.6 and 36.1% of patients, respectively [adjusted hazard ratio = 1.06 (1.02–1.11); P = 0.007] with all risk estimates calculated per 0.1 unit increment in shock index values. From 30 days to 8 years, deaths (n = 178) occurred in 20.7, 17.0 and 21.5% of patients in the first to third shock index tertiles, respectively (the difference was nonsignificant for all intertertile comparisons). Conclusions In patients with STEMI, elevated shock index is associated with the risk of inhospital cardiogenic shock and mortality up to 8 years after PPCI. The long-term adverse prognosis was almost entirely driven by events within the first 30 days.

Clinical features and outcomes of revascularization in very old patients with left main coronary artery disease Background Coronary artery disease (CAD) is often more extensive in older adults and may involve multivessel and left main coronary artery (LMCA) disease. Elderly patients are commonly excluded from clinical trials, and limited real-world data exist on the management of LMCA disease in the very old. We aimed to investigate clinical features and outcomes of very old patients undergoing revascularization due to LMCA disease. Patients and methods A retrospective single-center analysis of patients at least 80 years (n = 139) who underwent revascularization owing to CAD involving unprotected LMCA stenosis more than 50% was conducted. Subsequent major adverse cardiovascular events (MACE: myocardial infarction, stroke, and all-cause death) and repeat revascularizations were recorded, and their relation to revascularization procedure was studied. Results Percutaneous coronary intervention (PCI) was performed in 74 patients and coronary artery bypass surgery (CABG) in 65. Most patients (80%) had multivessel disease involving at least 2 additional coronary arteries. PCI was associated with older age, higher rates of baseline disability, previous revascularization, reduced ventricular function, significant aortic stenosis, and presentation with acute coronary syndrome, compared with CABG. Cumulative 3-year MACE rates were higher in patients undergoing PCI versus CABG (P = 0.009). After multivariable adjustment, predictors of MACE included presentation with ST-segment elevation myocardial infarction (STEMI) [hazard ratio (HR) = 2.39; 95% confidence interval: 1.24–4.63; P = 0.010], revascularization by PCI compared with CABG [HR = 2.21 (1.18–4.15); P = 0.013], baseline disability [HR = 2.17 (1.20–3.91); P = 0.010], and distal LMCA disease [HR = 1.87 (1.04–3.38); P = 0.038]. The difference in 3-year MACE between PCI and CABG was not observed in a propensity-score analysis of 90 patients matched 1: 1 for baseline disability, STEMI, and aortic stenosis (P = 0.797). Conclusion In very old patients undergoing coronary revascularization owing to LMCA disease, PCI was associated with worse cardiovascular outcomes compared with CABG, influenced by a more severe and comorbid population selected for PCI. Baseline disability, presentation with STEMI, and distal LMCA bifurcation disease were additional independent outcome predictors.

Comparison of efficacy and safety between ultrathin bioresorbable polymer sirolimus-eluting stents and thin durable polymer drug-eluting stents: a systematic review and meta-analysis of the literature Objective Ultrathin bioresorbable polymer sirolimus-eluting stents (BP SES) have been proposed as an alternative to thin durable polymer drug-eluting stents (DP DES). Although BP SES show a significant decrease in target lesion failure rates, clear superiority with respect to efficacy and safety of BP SES in comparison to DP EES has not been consistently proven. Methods and Results A comprehensive search of several electronic databases identified studies that assessed efficacy and safety of BP SES, compared with DP EES. Relative risks (RRs) were pooled across studies using a fixed-effects model and a random-effect model, respectively, calculating pooled RRs and associated 95% confidence intervals (CIs). The I2 statistic was used to assess heterogeneity. We retrieved six studies enrolling >7000 patients. BP SES significantly reduced the risk of target vessel myocardial infarction (RR, 0.79; 95% CI, 0.64–0.97; I2 = 0%; Test for overall effect: z = 2.24, P = 0.03) in comparison with DP EES using a random-effects model. Use of BP SES was associated with a significant reduction in any myocardial infarction (RR, 0.83; 95% CI, 0.70–0.98; I2 = 12%; Test for overall effect: z = 2.19, P = 0.03), using a fixed-effects model. The subgroup analyses demonstrated, following-up ≥2 years, a statistically significant 27% RR increase in the risk of all-case death for patients randomized to BP SES (RR, 1.27; 95% CI, 1.01–1.60; I2 = 0%; Test for overall effect: z = 2.08, P = 0.04). No differences in cardiac death, stent thrombosis events (STE), target lesion revascularization (TLR) and target vessel revascularization (TVR) between BP SES and DP EES were observed. Conclusion BP SES significantly reduced the risk of any myocardial infarction and target vessel myocardial infarction in comparison with DP EES. There were no differences in cardiac death, STE, TLR, TVR and all-cause death with its follow-up time <2 year between BP SES and DP EES. Following-up ≥2 years, a statistically significant 27% RR increase in the risk of all-case death for patients randomized to BP SES was observed.

Prognostic impact of lipoprotein(a) levels during lipid management with statins after ST-elevation acute myocardial infarction The causal relationship of lipoprotein(a) with cardiovascular disease has been established. However, clinical impacts of lipoprotein(a) levels on adverse vascular events in patients with established coronary artery disease who are undergoing statin treatment have not been fully elucidated. We measured lipoprotein(a) levels of 668 consecutive patients with ST-elevated myocardial infarction upon admission and reevaluated lipoprotein(a) of 189 of these patients during statin treatment at least 6 months later than the date of index ST-elevated myocardial infarction. Changes in lipoprotein(a) and associations between lipoprotein(a) levels and the incidence of major adverse cardiac and cerebrovascular event for 3 years were examined. Lipoprotein(a) at baseline was an independent predictor of 3-year major adverse cardiac and cerebrovascular event after ST-elevated myocardial infarction. Levels of lipoprotein(a) at follow-up were slightly but significantly elevated despite improvements in other lipid parameters due to statin treatment. Furthermore, higher levels of lipoprotein(a) achieved with statin treatment were also associated with the subsequent incidence of major adverse cardiac and cerebrovascular event over 3 years, regardless of whether or not the LDL-cholesterol levels were below 100 mg/dl. In conclusion, lipoprotein(a) levels during lipid management by statin are also predictive of adverse vascular events in Japanese patients with ST-elevated myocardial infarction.

Coronary artery calcium as a predictor of coronary heart disease, cardiovascular disease, and all-cause mortality in Asian-Americans: The Coronary Artery Calcium Consortium Background Coronary artery calcium (CAC) has been shown in multiple populations to predict atherosclerotic cardiovascular disease. However, its predictive value in Asian-Americans is poorly described. Patients and methods We studied 1621 asymptomatic Asian-Americans in the CAC Consortium, a large multicenter retrospective cohort. CAC was modeled in categorical (CAC = 0; CAC = 1–99; CAC = 100–399; CAC ≥ 400) and continuous [ln (CAC + 1)] forms. Participants were followed over a mean follow-up of 12 ± 4 years for coronary heart disease (CHD) death, cardiovascular disease (CVD) death, and all-cause mortality. The predictive value of CAC for individual outcomes was assessed using multivariable-adjusted Cox regression models adjusted for traditional cardiovascular risk factors and reported as hazard ratios (95% confidence interval). Results The mean (SD) age of the population was 54 (11.2) years and 64% were men. The mean 10-year atherosclerotic cardiovascular disease risk score was 8%. Approximately half had a CAC score of 0, whereas 22.5% had a CAC score of greater than 100. A total of 56 deaths (16 CVD and 8 CHD) were recorded, with no CVD or CHD deaths in the CAC = 0 group. We noted a significantly increased risk of CHD [hazard ratio (HR): 2.6 (1.5–4.3)] and CVD [HR: 2.3 (1.8–2.9)] mortality per unit increase in In (CAC + 1). Compared to those with CAC scores of 0, individuals with CAC scores of at least 400 had over a three-fold increased risk of all-cause mortality [HR: 3.3 (1.3–8.6)]. Conclusion Although Asian-Americans are a relatively low-risk group, CAC strongly predicts CHD, CVD, and all-cause mortality beyond traditional risk factors. These findings may help address existing knowledge gaps in CVD risk prediction in Asian-Americans.

Utility of mean platelet volume to predict the prevalence of coronary artery disease on coronary angiography in patients with stable angina Background Approximately 50% of patients with stable angina have coronary artery disease (CAD) on coronary angiography. The mean platelet volume (MPV) has been proposed as a marker that reflects platelet size and reactivity. This study investigated the predictive value of high MPV in patients with stable angina for diagnosing stable CAD. Patients and methods A total of 491 patients with chest pain who underwent selective coronary angiography for suspected CAD were enrolled. The patients were divided into the CAD group and non-CAD group according to angiography. All demographic, laboratory, and angiographic data were collected. Results Patients with MPV in the highest tertile were more likely to have CAD (66.9 vs. 51.0 vs. 35.7% for the highest, middle, and lowest tertiles; P = 0.001), had lower platelet counts (186 ± 48 vs. 199 ± 52 vs. 223 ± 63; P < 0.001), and had higher hemoglobin A1c levels (6.8 ± 1.5 vs. 6.5 ± 1.5 vs. 6.2 ± 1.1; P < 0.001). MPV had a positive correlation with hemoglobin A1c (r = 0.16; P < 0.001). Patients with CAD (n = 248) had higher MPV than those without CAD (n = 243) (11.0 ± 1.0 vs. 10.5 ± 0.9; P < 0.001). MPV was an independent predictor of CAD in patients with stable angina, with an adjusted odds ratio of 1.820 (95% confidence interval: 1.453–2.279; P < 0.001). Conclusion The presence of high MPV predicts the prevalence of CAD on coronary angiography in patients with stable angina, and this result may ultimately reduce unnecessary invasive coronary angiography.

Low serum level of sirtuin 1 predicts coronary atherosclerosis plaques during computed tomography angiography among an asymptomatic cohort Objectives: Whether in asymptomatic populations levels of serum sirtuin 1 (Sirt1) are associated with coronary atherosclerosis plaque characteristics remains unclear. This article aims to evaluate the possibility of Sirt1 serum levels predicting high-risk coronary plaques revealed through computed tomography angiography (CTA). Methods: The current cross-sectional investigation was performed on patients from non high-risk plaque (HRP) group (control group) as well as HRP group. CTA was conducted and the Framingham Risk Score (FRS) was generated each patient. Serum Sirt1 level was determined through ELISA. Univariate analysis and receiver-operating characteristic curve were used to examine the role of Sirt1 to predict HRP. Results: Lower Sirt1 serum levels were observed in patients in the HRP group in comparison with those in the control group. Gender, hyperlipidemia, age, the total cholesterol to high-density lipoproteincholesterol (HDL-C) ratio, HDL-C, apolipoprotein B and Sirt1 displayed independent association with HRP as revealed by the univariate analysis. Area under curve of the univariate model for HRP was 0.848 (95% confidence interval: 0.798–0.899); 75.4% specificity, 75.2% sensitivity, the negative predictive value was 83.0%, and the positive predictive value was 66.2%. Conclusion: Low serum level of Sirt1 predicted HRP in individuals with low–intermediate FRS, implying that Sirt1 may play a predictive role in the plaque screening before coronary CTA.