Long term prognostic benefit of complete revascularization in elderly presenting with NSTEMI: real world evidence.

The benefit of complete revascularization in elderly patients with non-ST elevation myocardial infarction (NSTEMI), and multivessel disease remains debated (MVD). The aim of our study was to determine the current long-term prognostic benefit of complete revascularization in this population. A retrospective cohort study of 1722 consecutive elderly NSTEMI patients was performed. Among the study participants 30.4% (n = 524) were completed revascularizated and in 69.6% (n = 1198) culprit vessel only revascularization was performed. A propensity score analysis was performed and we divided the study population into two groups: complete revascularization (n = 500) and culprit vessel only revascularization (n = 500). The median follow-up was 45.7 months, the all cause mortality (44.5% vs 30.5%, p < 0.001) (HR 0.74 (0.57-0.97); p = 0.035) and cardiovascular mortality (32.6% vs 17.4%, p < 0.001) (HR = 0.67 (0.47-0.94); p = 0.021) were significantly lower in patients with complete revascularization. In our study, we observed a long-term benefit of complete revascularization in elderly NSTEMI and MVD patients. Elderly patients should also be managed according to current guidelines to improve their long-term prognosis.

Circulating miR-499a and miR-125b as Potential Predictors of Left Ventricular Ejection Fraction Improvement after Cardiac Resynchronization Therapy.

Cardiac resynchronization therapy represents a therapeutic option for heart failure drug-refractory patients. However, due to the lack of success in 30% of the cases, there is a demand for an in-depth analysis of individual heterogeneity. In this study, we aimed to evaluate the prognostic value of circulating miRNA differences. Responder patients were defined by a composite endpoint of the presence of left ventricular reverse remodelling (a reduction ≥15% in telesystolic volume and an increment ≥10% in left ventricular ejection fraction). Circulating miRNAs signature was analysed at the time of the procedure and at a 6-month follow-up. An expression analysis showed, both at baseline and at follow-up, differences between responders and non-responders. Responders presented lower baseline expressions of miR-499, and at follow-up, downregulation of miR-125b-5p, both associated with a significant improvement in left ventricular ejection fraction. The miRNA profile differences showed a marked sensitivity to distinguish between responders and non-responders. Our data suggest that miRNA differences might contribute to prognostic stratification of patients undergoing cardiac resynchronization therapy and suggest that preimplant cardiac context as well as remodelling response are key to therapeutic success.

Prediction of major adverse cardiac, cerebrovascular events in patients with diabetes after acute coronary syndrome.

BACKGROUND AND OBJECTIVES: The risk of major adverse cardiac and cerebrovascular events following acute coronary syndrome is increased in people with diabetes. Predicting out-of-hospital outcomes upon follow-up remains difficult, and no simple, well-validated tools exist for this population at present. We aim to evaluate several factors in a competing risks model for actionable evaluation of the incidence of major adverse cardiac and cerebrovascular events in diabetic outpatients following acute coronary syndrome. METHODS: Retrospective analysis of consecutive patients admitted for acute coronary syndrome in two centres. A Fine-Gray competing risks model was adjusted to predict major adverse cardiac and cerebrovascular events and all-cause mortality. A point-based score is presented that is based on this model. RESULTS: Out of the 1400 patients, there were 783 (55.9%) with at least one major adverse cardiac and cerebrovascular event (417 deaths). Of them, 143 deaths were due to non-major adverse cardiac and cerebrovascular events. Predictive Fine-Gray models show that the 'PG-HACKER' risk factors (gender, age, peripheral arterial disease, left ventricle function, previous congestive heart failure, Killip class and optimal medical therapy) were associated to major adverse cardiac and cerebrovascular events. CONCLUSION: The PG-HACKER score is a simple and effective tool that is freely available and easily accessible to physicians and patients. The PG-HACKER score can predict major adverse cardiac and cerebrovascular events following acute coronary syndrome in patients with diabetes.

Clinical impact of mineralocorticoid receptor antagonists treatment after acute coronary syndrome in the real world: A propensity score matching analysis.

BACKGROUND: Recent studies suggest that the benefit of mineralocorticoid receptor antagonists in the acute coronary syndrome setting is controversial. The aim of this study was to examine the current long-term prognostic benefit of mineralocorticoid receptor antagonists in patients with acute coronary syndrome. MATERIAL AND METHODS: We conducted a retrospective cohort study of 8318 consecutive acute coronary syndrome patients. Baseline patient characteristics were examined and a follow-up period was established for registry of death, major cardiovascular adverse events and heart failure re-hospitalization. We performed a propensity-matching analysis to draw up two groups of patients paired according to whether or not they had been treated with mineralocorticoid receptor antagonists. The prognostic value of mineralocorticoid receptor antagonists to predict events during follow-up was analysed using Cox regression. RESULTS: Among the study participants, only 524 patients (6.3%) were discharged on mineralocorticoid receptor antagonists. Patients on mineralocorticoid receptor antagonists had a different clinical and pharmacological profile. These differences disappeared after the propensity score analysis. The median follow-up was 40.7 months. After the propensity score analysis, the cardiovascular mortality and heart failure readmission rates were similar between patients who were discharged on mineralocorticoid receptor antagonists and those whose not. The use of mineralocorticoid receptor antagonists was only associated with a reduction in major cardiovascular adverse events (hazard ratio=0.83, 95% confidence interval 0.69-0.97, p=0.001). CONCLUSIONS: Our results do not corroborate the long-term benefit of mineralocorticoid receptor antagonists to improve survival after acute coronary syndrome in a large cohort of patients with heart failure or reduced left ventricular ejection fraction and diabetes. Their prescription was associated with a significantly lower incidence of major cardiovascular adverse events during the long-term follow-up without effect on heart failure development.

Innovative Strategies in Heart Failure: Present and Future.

Heart failure (HF) is a progressively debilitating disease that considerably decreases the life expectancy and quality of life. It has become an important area of focus since it remains one of the most common reasons for admission in patients over the age of 65. Importantly, the incidence of HF has not declined within the past 20 years, but the survival after onset has increased in younger patients and men. This has been in part due to the growing interest in therapies that may decrease morbidity, mortality, along with the substantial health care expenditures associated with the disease. It can be said that over the past 50 years, there have been three distinct eras relating to HF management; a) the non-pharmacologic era, focused its treatments on fluid restriction; b) the pharmacologic era, marked by the increased use of inotropes and diuretics and the discovery of vasodilators, and the posterior discovery of medications relating to neurohormonal pathways; c) the device era, with the discovery, acceptance, and increased use of implantable cardioverter defibrillators, cardiac resynchronization therapy (CRT), and left ventricular assist devices (LVADs) among others. A new forth era could be about to arrive, with the advent of regenerative therapies. In this review article will discuss new therapeutic discoveries as well as provide insight into future therapies.

Determinants and Prognostic Impact of Heart Failure and Left Ventricular Ejection Fraction in Acute Coronary Syndrome Settings.

INTRODUCTION AND OBJECTIVES: Contemporary data on the incidence and prognosis of heart failure (HF) and the influence of left ventricular ejection fraction (LVEF) in the setting of acute coronary syndrome (ACS) are scant. The aim of this study was to examine the relationship between LVEF and HF with long-term prognosis in a cohort of patients with ACS. METHODS: This is a retrospective observational study of 6208 patients consecutively admitted for ACS to 2 different Spanish hospitals. Baseline characteristics were examined and a follow-up period was established for registration of death and HF rehospitalization as the primary endpoint. RESULTS: Among the study participants, 5064 had ACS without HF during hospitalization: 290 (5.8%) had LVEF<40%, 540 (10.6%) LVEF 40% to 49%, and 4234 (83.6%) LVEF ≥ 50%. The remaining 1144 patients developed HF in the acute phase: 395 (34.6%) had LVEF<40%, 251 (21.9%) LVEF 40% to 49%, and 498 (43.5%) LVEF ≥ 50%. Patients with LVEF 40% to 49% had a demographic and clinical profile with intermediate features between the LVEF <40% and LVEF ≥ 50% groups. Kaplan-Meier curves showed that mortality and HF readmissions were statistically different depending on LVEF in the non-HF group but not in the HF group. Left ventricular ejection fraction ≥ 50% was an independent prognostic factor in the non-HF group only. CONCLUSIONS: In ACS, long-term prognosis is considerably worse in patients who develop HF during hospitalization than in patients without HF, irrespective of LVEF. This parameter is a strong prognostic predictor only in patients without HF.

Proposal of a novel clinical score to predict heart failure incidence in long-term survivors of acute coronary syndromes.

INTRODUCTION: HF remains a frequent complication following MI and adversely affects prognosis. The objective of this study was to identify predictors of HF following MI and to design a risk score for its prediction. METHODS: Retrospective study of all consecutive patients admitted for MI. Primary end point was time to incident HF. Patients with previous history of HF were excluded. Death was modelled as competing risk. RESULTS: 5737 patients were included. Mean age was 66.32±12.80. During a median follow-up of 47.0months (23.0-73.0), 686 patients (12%) developed HF. Age, diabetes mellitus, peripheral artery disease, renal insufficiency, chronic obstructive pulmonary disease, persistent atrial fibrillation, haemoglobin, troponin peak, diuretic at admission, ventricular function, and revascularization were independent predictors for HF development. According to this multivariate regression analysis, we developed a novel score that allows for the identification of patients at high (≥16), medium (9-15) and low risk (<9) for HF development, with an AUC of 0.77 (IC 95%, 0.76-0.78; p=0.008). CONCLUSIONS: Clinical comorbidities were determinant for the development of HF following MI. A simple score effectively categorize patients into low, intermediate, and high-risk. This could be important in order to intensify medical treatment or consider additional interventions.