Cardiac events after using clarithromycin for anti-Helicobacter pylori therapy in patients with coronary artery disease.

Clarithromycin is an antibiotic commonly used to treat Helicobacter pylori infections. The US Food and Drug Administration (FDA) advises caution before prescribing clarithromycin to patients with cardiac diseases. This study aimed to evaluate cardiac events after anti-H pylori treatment in patients with coronary artery disease. A retrospective 5-year study was conducted on outpatients who received anti-H pylori therapy. Among the 7855 patients receiving therapy, 228 patients (2.9%) underwent angiography with coronary artery disease before therapy, and 193 patients received clarithromycin. Clarithromycin users seemed not to be at risk for cardiac events as compared with non-clarithromycin users at 3 months (4.7% vs 2.9%, P = .63) and 1 year (10.9% vs 5.7%, P = .35). Neither life-threatening dysrhythmia nor cardiac death was noted. The risk factors for cardiac events within 3 months after therapy were smoker (OR:5.38, 95% CI:1.39-20.78), and events within 1 year were smoker (OR:3.8, 95% CI:1.41-10.22), and diabetes mellitus (OR:5.68, 95% CI:1.9-16.98). Among patients with coronary artery disease who received anti-H pylori therapy, short-term cardiac events did not increase in clarithromycin users but should be considered in diabetic and smoking patients.

Integrating Health Data-Driven Machine Learning Algorithms to Evaluate Risk Factors of Early Stage Hypertension at Different Levels of HDL and LDL Cholesterol.

PURPOSE: Cardiovascular disease (CVD) is a major worldwide health burden. As the risk factors of CVD, hypertension, and hyperlipidemia are most mentioned. Early stage hypertension in the population with dyslipidemia is an important public health hazard. This study was the application of data-driven machine learning (ML), demonstrating complex relationships between risk factors and outcomes and promising predictive performance with vast amounts of medical data, aimed to investigate the association between dyslipidemia and the incidence of early stage hypertension in a large cohort with normal blood pressure at baseline. METHODS: This study analyzed annual health screening data for 71,108 people from 2005 to 2017, including data for 27 risk-related indicators, sourced from the MJ Group, a major health screening center in Taiwan. We used five machine learning (ML) methods-stochastic gradient boosting (SGB), multivariate adaptive regression splines (MARS), least absolute shrinkage and selection operator regression (Lasso), ridge regression (Ridge), and gradient boosting with categorical features support (CatBoost)-to develop a multi-stage ML algorithm-based prediction scheme and then evaluate important risk factors at the early stage of hypertension, especially for groups with high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) levels within or out of the reference range. RESULTS: Age, body mass index, waist circumference, waist-to-hip ratio, fasting plasma glucose, and C-reactive protein (CRP) were associated with hypertension. The hemoglobin level was also a positive contributor to blood pressure elevation and it appeared among the top three important risk factors in all LDL-C/HDL-C groups; therefore, these variables may be important in affecting blood pressure in the early stage of hypertension. A residual contribution to blood pressure elevation was found in groups with increased LDL-C. This suggests that LDL-C levels are associated with CPR levels, and that the LDL-C level may be an important factor for predicting the development of hypertension. CONCLUSION: The five prediction models provided similar classifications of risk factors. The results of this study show that an increase in LDL-C is more important than the start of a drop in HDL-C in health screening of sub-healthy adults. The findings of this study should be of value to health awareness raising about hypertension and further discussion and follow-up research.

Modulators of Mortality Benefit From Peri-Angioplasty Adjunctive Tirofiban in Patients With ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention.

BACKGROUND: Studies investigating the modulators of mortality benefit conferred by peri-angioplasty glycoprotein IIb/IIIa inhibitors in ST-elevation myocardial infarction (STEMI) are still lacking.Methods and Results:A prospective database (n=1,025) of consecutive cases undergoing primary percutaneous coronary intervention for STEMI was retrospectively analyzed. For patients in Killip class I, II or III, IV, the multivariate-adjusted hazard ratios of 30-day all-cause mortality associated with adjunctive tirofiban were 3.873 (95% CI 0.504-29.745; P=0.193), 0.550 (95% CI 0.188-1.609; P=0.275), and 0.264 (95% CI 0.099-0.704; P=0.008), respectively. The P value for a linear trend was 0.032. Patients who had a body mass index (BMI) within 22.9-25.0 kg/m2had a significant benefit from tirofiban (adjusted HR 0.344; 95% CI 0.145-0.814; P=0.015) compared to other BMI groups. The P value for a quadratic trend was 0.012. A novel Killip-BMI score (KBS = 2.5 × Killip category - | BMI - 24 |) was calculated to select the beneficial population. A KBS ≥2 was associated with significant mortality benefit, whereas a KBS <0 predicted increased 30-day mortality with tirofiban use. CONCLUSIONS: Survival benefit from peri-angioplasty tirofiban therapy for STEMI was positively correlated with the Killip class. Tirofiban should be used cautiously in either underweight or overweight patients. The novel KBS used in this study can guide peri-angioplasty use of adjunctive tirofiban in patients with STEMI undergoing primary angioplasty.

Clinical, Demographic, and Biochemical Characteristics of Patients with Acute ST-Segment Elevation Myocardial Infarction: An Analysis of Acute Coronary Syndrome Registry Data of a Single Medical Center from 2005 to 2016.

BACKGROUND: ST-segment elevation myocardial infarction (STEMI) is one of the leading causes of morbidity and mortality in developed countries. Therefore, understanding the prevalence and trends of major risk factors may facilitate primary and secondary prevention of STEMI. METHODS: In the present study, 2446 consecutive patients with STEMI admitted to Far Eastern Memorial Hospital from 2005 to 2016 were enrolled. A comprehensive analysis of the prevalence, distribution, and trends over time of major risk factors as well as Framingham risk scores of all patients was performed. RESULTS: The most prevalent risk factors were male sex, hypertension (HTN), smoking, age, dyslipidemia, and diabetes mellitus. Furthermore, 95%-97% of the patients had at least one modifiable risk factor, and < 1% of the patients did not have any identifiable risk factors. The prevalence trends of smoking, HTN, dyslipidemia, and metabolic syndrome increased significantly from 2005 to 2016. Seasonal variation analysis revealed a 15% increase in STEMI cases between January and March compared with those between April and December. Isolated low high- density lipoprotein-cholesterol syndrome was the second most common type of dyslipidemia, with a prevalence rate of 16.6%. Moreover, only 56.8% of the male and 32% of the female patients were in the Framingham high-risk group. CONCLUSIONS: A high prevalence rate and an increasing trend of modifiable risk factors resulted in a high number of STEMI cases at our hospital. Controlling modifiable risk factors and improving nontraditional risk factor detection could facilitate primary and secondary preventions for STEMI.

Implementation of extracorporeal membrane oxygenation before primary percutaneous coronary intervention may improve the survival of patients with ST-segment elevation myocardial infarction and refractory cardiogenic shock.

BACKGROUND: The mortality of patients with ST-segment elevation myocardial infarction (STEMI) and refractory cardiogenic shock (RCS) is high. Extracorporeal membrane oxygenation (ECMO) before percutaneous coronary intervention (PCI) has shown some favorable results, but this may delay door-to-balloon (D2B) time. Whether the benefit surpasses the risk of longer D2B time remains controversial. METHODS: From January 2005 to December 2014, there were 46 patients with STEMI RCS who received ECMO and PCI. Comparison was made between patients whose ECMO were setup before (n = 12) and after (n = 34) the coronary angiography. RESULTS: There were no significant differences on the baseline characteristics. The ECMO before PCI group had significantly better six-month survival (58.3% vs. 14.7%, p = 0.006), and the benefit persisted to the end of two-year follow-up (41.7% vs. 11.8%, p = 0.045). The rates of neurological, vascular, or bleeding complications were not different between the groups. ECMO before PCI was associated with a nonsignificant increase of median D2B time (30 min) and decrease of patients achieving D2B time < 90 min (9.1% vs. 32.0%). After adjusting for GRACE score, gender, D2B time, complete revascularization, ECMO before PCI and shock index < 0.8 before PCI were significantly associated with six-month survival. CONCLUSIONS: In STEMI RCS patients, ECMO before PCI improves both short- and long-term outcomes, even if it nonsignificantly increases the D2B time. Our data suggests that ECMO before PCI is a reasonable and safe strategy in this particularly-ill population.

Real-World Experience with Idarucizumab to Reverse Anticoagulant Effect in Dabigatran-Treated Patients: Report of 11 Cases from Taiwan.

BACKGROUND: This study aims to observe the effectiveness and safety of idarucizumab in dabigatran-treated patients with severe bleeding or requiring surgery in Taiwan. METHODS AND RESULTS: In Taiwan, 11 dabigatran-treated patients developed severe bleeding, fracture that needed surgery, and acute ischemic stroke requiring thrombolysis. These patients were treated with idarucizumab and obtained adequate hemostasis. Our experiences reconfirmed the efficacy and safety of idarucizumab in Asian patients. CONCLUSIONS: Idarucizumab improves safety in dabigatran-treated patients. Continued education about the availability and appropriate use of idarucizumab is necessary in Asia.

SYNTAX Score of Infarct-Related Artery Other Than the Number of Coronary Balloon Inflations and Deflations as an Independent Predictor of Contrast-Induced Acute Kidney Injury in Patients with ST-Segment Elevation Myocardial Infarction.

BACKGROUND: Although remote ischemic post-conditioning (RIPC) has been shown to prevent contrast-induced acute kidney injury (CIAKI) in patients with acute coronary syndrome, its efficacy in patients with ST-segment elevation myocardial infarction (STEMI) remains unclear. We examined the relationship among balloon inflations and deflations (BID) times, SYNTAX score of infarction-related artery (SI), periprocedural complications, and CIAKI in STEMI patients undergoing primary percutaneous coronary intervention (pPCI). METHODS: Patients with STEMI undergoing pPCI with Mehran risk score (MRS) ≥ 5 were enrolled between February 2007 and September 2012. The study end point was the development of CIAKI. RESULTS: Of 206 patients, the median age was 65 years [interquartile range (IQR): 55-77] with 72.8% male and Mehran risk score (MRS) 8 (IQR: 6-12). Receiver operating characteristic curve showed that BID times > 9 times or SI > 10 was the best cut-off associated with CIAKI. In univariate analysis, significant association with CIAKI existed in BID > 9 times [odds ratio (OR): 3.106, 95% confidence interval (CI): 1.284-7.513, p = 0.012] and SI > 10 (OR: 3.909, 95% CI: 1.570-9.735, p = 0.003). Other variables associated with CIAKI included creatinine, hemoglobin, angiotensin converting enzyme inhibitor or angiotensin receptor blocker use at discharge. In multivariate analysis, SI > 10 remained an independent predictor of CIAKI in different adjustment model, even on top of MRS (adjusted OR: 3.498, 95% CI: 1.086-11.268, p = 0.036). CONCLUSIONS: Vascular complexity of infarct-related artery rather than higher BID times (> 9) was the major determinant of the development of CIAKI after pPCI in STEMI patients.

Relationship of serum uric acid and Killip class on mortality after acute ST-segment elevation myocardial infarction and primary percutaneous coronary intervention.

BACKGROUND: There is conflicting information regarding the association between hyperuricemia and survival in STEMI patients. Our study examined the interaction between hyperuricemia and Killip class on mortality of STEMI patients. METHODS: We analyzed 951 consecutive STEMI patients between February 2006 and September 2012. Hyperuricemia was defined as SUA of at least 7mg/dL in males and 6mg/dL in females. Killip class I patients were divided into hyperuricemia and normouricemia groups. RESULTS: The Killip class I hyperuricemia and normouricemia groups had similar baseline and procedural characteristics, but the hyperuricemia group had significantly greater BMI, serum creatinine, and SUA, and a lower TIMI risk score (2, IQR: 1-4 vs. 3, IQR: 2-4, p=0.019). The hyperuricemia group also had greater 30-day and 1-year mortality rates (2.9% vs. 0.3%, p=0.022; 6.5% vs. 1.1%, p=0.002, respectively). However, hyperuricemia was not associated with mortality of patients in Killip classes II-IV or in the overall study population. Hyperuricemia was associated with increased mortality in subgroups of patients who were at least 65years-old, male, had BMI of 25kg/m2 or less, were in Killip class I, without diabetes, and who did not receive intra-aortic balloon pump support. Hyperuricemia interacted with Killip class I in increasing the risk for 1-year mortality (p for interaction=0.038). CONCLUSIONS: Hyperuricemia increased the 1-year mortality of STEMI patients in Killip class I, but not of patients in Killip classes II-IV. An interaction of hyperuricemia and Killip class significantly affects the mortality of STEMI patients.

Baseline Hemoglobin Levels Associated with One-Year Mortality in ST-Segment Elevation Myocardial Infarction Patients.

BACKGROUND: The association between hemoglobin (Hb) levels and mortality in patients with ST-segment elevation myocardial infarction (STEMI) remains controversial. The purpose of this study was to examine the mortality among STEMI patients with anemia or erythrocytosis, and further establish the relationship between mortality and the increment of Hb level. METHODS: Between 2006 and 2012, 951 consecutive patients with STEMI undergoing primary percutaneous coronary intervention in a medical center in Northern Taiwan were enrolled in our study, including 535 patients with normal Hb level, 148 with anemia (male Hb ≤ 13 g/dl, female ≤ 12) and 268 with erythrocytosis (male Hb ≥ 16, female ≥ 15). RESULTS: Patients in the anemia group were the oldest, and had higher morbidity than the normal Hb group, followed by the erythrocytosis group. In regression analyses, neither anemia nor erythrocytosis was associated with 30-day and 1-year mortality. Each 1-g/dl increment of Hb level was not associated with 30-day mortality both in patients with anemia or erythrocytosis. However, it was associated with a decreased risk of 1-year mortality in anemic patients [hazard ratio (HR): 0.756, 95% confidence interval (CI): 0.608-0.938, p = 0.011] and an increased risk of 1-year mortality in those with erythrocytosis (HR: 2.086, 95%CI: 1.106-3.937, p = 0.023). In multivariate analysis, each 1-g/dl increment of Hb level was associated with 1-year mortality both in anemic patients and those with erythrocytosis (HR: 0.788, 95%CI: 0.621-0.999, p = 0.049; HR: 2.302, 95%CI: 1.051-5.04, p = 0.037). CONCLUSIONS: Higher hemoglobin levels in STEMI patients with anemia were associated with decreased risks of 1-year mortality, whereas higher hemoglobin levels in those with erythrocytosis were associated with increased risks of one-year mortality.

Heart Attack Causes Head-Ache - Cardiac Cephalalgia.

UNLABELLED: Chest pain is the typical symptom of myocardial infarction (MI), and there are many atypical manifestations such as stomachache or dyspnea. Headache is a rare presentation of MI, which has specifically been termed "cardiac cephalalgia" or "cardiac cephalgia". In this article, we have reported a case of sudden onset headache and neck pain, of whom MI was confirmed by electrocardiography, cardiac markers, and coronary angiogram. The patient's headache subsided dramatically after coronary angioplasty, and it had not recurred in the following one year. Additionally, diagnostic clues and possible mechanisms of cardiac cephalalgia are discussed as well. KEY WORDS: Headache • Cardiac cephalgia • Cardiac cephalalgia • Myocardial infarction.

Rapid Early Triage by Leukocytosis and the Thrombolysis in Myocardial Infarction (TIMI) Risk Score for ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention: An Observational Study.

The clinical utility of leukocytosis in risk assessment for ST-elevation myocardial infarction (STEMI) is still unclear. We aim to demonstrate the prognostic value of leukocyte counts independent from traditional risk factors and the TIMI risk score (TRS) for STEMI and to propose a practical model comprising leukocyte count for early triage in STEMI undergoing primary angioplasty. A prospective database (n = 796) of consecutive STEMI cases receiving primary angioplasty at a tertiary medical center was retrospectively analyzed in the period from February 1, 2007 through December 31, 2012. Primary endpoints were 30-day and 1-year mortality. Propensity score-adjusted Cox regression models and subdivision analysis were performed. Leukocytosis group (n = 306) had higher 30-day mortality (5.9% vs 3.1%, P = 0.048) and 1-year mortality (9.2% vs 5.1%, P = 0.022). After adjustment by propensity score and TRS, leukocyte count (per 10/µL) was an independent predictor of 1-year mortality (HR: 1.086, 95% CI: 1.034-1.140, P = 0.001). Subdivision analysis demonstrated the correlation between leukocytosis and higher 1-year mortality within both high and low TRS strata (divided by 4, the median of TRS). Additionally, 24% (191 out of 796) of patients were characterized by nonleukocytosis and TRS < 4, having 0% of mortality rate at 1-year follow-up. In conclusion, leukocyte count is an independent prognostic factor adding incremental value to TRS for STEMI. Nonleukocytosis in conjunction with TRS < 4 identifies a large patient group at extremely low risk and thus provides rapid early triage for STEMI patients undergoing primary PCI. This finding is worth validation in the future.

Effects of Door-to-Balloon Times on Outcomes in Taiwanese Patients Receiving Primary Percutaneous Coronary Intervention: A Report of Taiwan Acute Coronary Syndrome Full Spectrum Registry.

PURPOSE: The impact of door-to-balloon (DTB) time on patient outcomes is unclear in a Taiwanese population receiving primary percutaneous coronary intervention (PCI). The study aimed to investigate the relationship between stratified DTB times and outcomes through analysis of the database from the Taiwan acute coronary syndrome full spectrum registry. METHODS: Relevant data were collected from case report forms of patients receiving primary PCI who were categorized as group 1, 2, 3, and 4 according to the DTB time < 45, 45-90, 91-135, and > 135 minutes, respectively. The differences were analyzed by using ANOVA and Kaplan-Meier analyses. RESULTS: There were significant variations in DTB times at baseline, which included patients salvaged at centers, patients with prior cardiovascular disease, and those patients with different coronary artery flows (p < 0.01) separated into 4 groups (n = 189, 443, 299, and 401, respectively). The in-hospital adverse event rates were identical among the 4 groups except for a higher rate of acute renal failure and a longer hospital stay observed in group 4 (p < 0.01). The results showed no decrease in the incidences of repeated revascularization, major adverse cardiac event, or cardiovascular composite at 1 year in group 1. CONCLUSIONS: This study suggested that the DTB time is not a good determinant for outcomes in Taiwanese patients receiving primary PCI. KEY WORDS: Acute myocardial infarction; Cardiovascular outcome; Door-to-balloon time; Myocardial ischemia; Percutaneous coronary intervention.

Impact of an audit program and other factors on door-to-balloon times in acute ST-elevation myocardial infarction patients destined for primary coronary intervention.

OBJECTIVES: This before-after study investigated the association between an audit program and door-to-balloon times in patients with acute ST-elevation myocardial infarction (STEMI) and explored other factors associated with the door-to-balloon time. METHODS: An audit program that collected time data for essential time intervals in acute STEMI was developed with data feedback to both the Department of Emergency Medicine and the Department of Cardiology. The door-to-balloon times for 76 consecutive acute STEMI patients were collected from February 16, 2007, through October 31, 2007, after the implementation of the audit program, as the intervention group. The control group was defined by 104 consecutive acute STEMI patients presenting from April 1, 2006, through February 15, 2007, before the audit was applied. A multivariate linear regression model was used for analysis of factors associated with the door-to-balloon time. RESULTS: The geometric mean 95% CI of the door-to-balloon time decreased from 164.9 (150.3, 180.9) minutes to 141.9 (127.4, 158.2) minutes (p = 0.039) in the intervention phase. The median door-to-balloon time was 147.5 minutes in the control group and 136.0 minutes in the intervention group (p = 0.09). In the multivariate regression model, the audit program was associated with a shortening of the door-to-balloon time by 35.5 minutes (160.4 minutes vs. 195.9 minutes, p = 0.004); female gender was associated with a mean delay of 58.4 minutes (208.9 minutes vs. 150.5 minutes; p = 0.001); posterolateral wall infarction was associated with a mean delay of 70.5 minutes compared to anterior wall infarction (215.4 minutes vs. 144.9 minutes; p = 0.037) and a mean delay of 69.5 minutes compared to inferior wall infarction (215.4 minutes vs. 145.9 minutes; p = 0.044). The use of a glycoprotein IIb/IIIa inhibitor was associated with a 46.1 minutes mean shortening of door-to-balloon time (155.7 minutes vs. 201.8 minutes; p < 0.001). CONCLUSIONS: The implementation of an audit program was associated with a significant reduction in door-to-balloon times among patients with acute STEMI. In addition, female patients, posterolateral wall infarction territory, and nonuse of glycoprotein IIb/IIIa inhibitor were associated with longer door-to-balloon times.