Prediction of Acute Myocardial Injury in Noncardiac Surgery in Patients at Risk for Major Adverse Cardiovascular and Cerebrovascular Events: A Multivariable Risk Model.

BACKGROUND: The best use of perioperative cardiac biomarkers assessment is still under discussion. Massive postoperative troponin surveillance can result in untenably high workloads and costs for health care systems and potentially harmful interventions for patients. In a cohort of patients at risk for major adverse cardiovascular and cerebrovascular events (MACCEs), we aimed to (1) determine whether preoperative biomarkers can identify patients at major risk for acute myocardial injury in noncardiac surgery, (2) develop a risk model for acute myocardial injury prediction, and (3) propose an algorithm to optimize postoperative troponin surveillance. METHODS: Prospective, single-center cohort study enrolling consecutive adult patients (≥45 years) at risk for MACCE scheduled for intermediate-to-high-risk noncardiac surgery. Baseline high-sensitivity troponin T (hsTnT) and N-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP), as well as hsTnT on the first 3 postoperative days were obtained. The main outcome was the occurrence of acute myocardial injury. Candidate predictors of acute myocardial injury were baseline concentrations of hsTnT ≥14 ng/L and NT-proBNP ≥300 pg/mL and preoperative and intraoperative variables. A multivariable risk model and a decision curve were constructed. RESULTS: Of 732 patients, 42.1% had elevated hsTnT and 37.3% had elevated NT-proBNP levels at baseline. Acute myocardial injury occurred in 161 patients (22%). Elevated baseline hsTnT, found in 84% of patients with acute myocardial injury, was strongly associated with this outcome: odds ratio (OR), 12.08 (95% confidence interval [CI], 7.78-19.42). Logistic regression identified 6 other independent predictors for acute myocardial injury: age, sex, estimated glomerular filtration rate (eGFR) <45 mL·min -1 ·1.73 m -2 , functional capacity <4 METs or unknown, NT-proBNP ≥300 pg/mL, and estimated intraoperative blood loss. The c -statistic for the risk model was 77% (95% CI, 0.73-0.81). The net benefit of the model began at a risk threshold of 7%. CONCLUSIONS: Baseline determination of cardiac biomarkers in patients at risk for MACCE shortly before intermediate- or high-risk noncardiac surgery helps identify those with the highest risk for acute myocardial injury. A baseline hsTnT ≥14 ng/L indicates the need for postoperative troponin surveillance. In patients with baseline hsTnT <14 ng/L, our 6-predictor model will identify additional patients at risk for acute myocardial injury who may also benefit from postoperative surveillance.

PCSK9 Inhibitors Have Apolipoprotein C-III-Related Anti-Inflammatory Activity, Assessed by 1H-NMR Glycoprotein Profile in Subjects at High or very High Cardiovascular Risk.

Atherosclerosis is a chronic inflammatory disease caused by the accumulation of cholesterol in the intima. Proprotein convertase subtilisin/kexin type 9 inhibitors (iPCSK9) can reduce low-density lipoprotein (LDL) cholesterol levels by 60%, but there is still no evidence that they can lower markers of systemic inflammation such as high-sensitivity C-reactive protein (hsCRP). Acute-phase serum glycoproteins are upregulated in the liver during systemic inflammation, and their role as inflammatory biomarkers is under clinical evaluation. In this observational study, we evaluate the effects of iPCSK9 on glycoproteins (Glyc) A, B and F. Thirty-nine patients eligible for iPCSK9 therapy were enrolled. One sample before and after one to six months of iPCSK9 therapy with alirocumab was obtained from each patient. Lipids, apolipoproteins, hsCRP and PCSK9 levels were measured by biochemical analyses, and the lipoprotein and glycoprotein profiles were measured by 1H nuclear magnetic resonance (1H-NMR). The PCSK9 inhibitor reduced total (36.27%, p < 0.001), LDL (55.05%, p < 0.001) and non-high-density lipoprotein (HDL) (45.11%, p < 0.001) cholesterol, apolipoprotein (apo) C-III (10%, p < 0.001), triglycerides (9.92%, p < 0.001) and glycoprotein signals GlycA (11.97%, p < 0.001), GlycB (3.83%, p = 0.017) and GlycF (7.26%, p < 0.001). It also increased apoA-I (2.05%, p = 0.043) and HDL cholesterol levels (11.58%, p < 0.001). Circulating PCSK9 levels increased six-fold (626.28%, p < 0.001). The decrease in Glyc signals positively correlated with the decrease in triglycerides and apoC-III. In conclusion, in addition to LDL cholesterol, iPCSK9 therapy also induces a reduction in systemic inflammation measured by 1H-NMR glycoprotein signals, which correlates with a decrease in triglycerides and apoC-III.

Mortality and incidence of cardiovascular events in patients treated with aspirin and statins at one year after myocardial injury in noncardiac surgery: a prospective observational study.

BACKGROUND: Recommendations on the diagnosis and management of myocardial injury in noncardiac surgery (MINS) show remarkable variability. Mortality reports also vary. We aimed to describe mortality and major adverse cardiovascular and cerebrovascular event (MACCE) rates in patients with silent MINS treated with postoperative aspirin-statin therapy and with cardiology follow-up. METHODS: Prospective descriptive cohort study of patients aged 45 years or older scheduled for noncardiac surgery with high risk for cardiovascular complications from May 2017 to April 2019. Aspirin-statin therapy and cardiology follow-up were prescribed for patients with silent (asymptomatic) MINS. The primary outcome was one-year mortality in patients with silent MINS, diagnosed by troponin concentration. Secondary outcomes were mortality in MINS patients with perioperative myocardial infarction (PMI) or chronic myocardial injury (CMI) and MACCE. RESULTS: We identified 766 eligible patients and enrolled 747. MINS occurred in 166 patients (22.2%); 151 (91%) had silent MINS and 15 (9%) had PMI. Thirty-one patients (4.1%) had CMI. One-year mortality was higher in patients with silent MINS (22.5%) than in patients with no MINS (7.8%) (P<0.001). One-year mortality rates in MINS patients with PMI or CMI were 27 and 19%, respectively. MACCE were more frequent in patients with silent MINS at 30 days and one year (18 and 25%) than in patients with no MINS (6 and 12%, respectively). CONCLUSIONS: Rates of mortality and MACCE in patients with silent MINS were high despite aspirin-statin therapy and cardiology follow-up. Further prospective research is needed to assess new postoperative care protocols that might effectively improve outcomes.

An intensive, structured, mobile devices-based healthcare intervention to optimize the lipid-lowering therapy improves lipid control after an acute coronary syndrome.

Aims: Despite the evidence, lipid-lowering treatment (LLT) in secondary prevention remains insufficient, and a low percentage of patients achieve the recommended LDL cholesterol (LDLc) levels by the guidelines. We aimed to evaluate the efficacy of an intensive, mobile devices-based healthcare lipid-lowering intervention after hospital discharge in patients hospitalized for acute coronary syndrome (ACS). Methods and results: Ambiespective register in which a mobile devices-based healthcare intervention including periodic follow-up, serial lipid level controls, and optimization of lipid-lowering therapy, if appropriate, was assessed in terms of serum lipid-level control at 12 weeks after discharge. A total of 497 patients, of which 462 (93%) correctly adhered to the optimization protocol, were included in the analysis. At the end of the optimization period, 327 (70.7%) patients had LDLc levels ≤ 70 mg/dL. 40% of patients in the LDLc ≤ 70 mg/dL group were upgraded to very-high intensity lipid-lowering ability therapy vs. 60.7% in the LDLc > 70 mg/dL group, p < 0.001. Overall, 38.5% of patients had at least a change in their LLT. Side effects were relatively infrequent (10.7%). At 1-year follow-up, LDLc levels were measured by the primary care physician in 342 (68.8%) of the whole cohort of 497 patients. In this group, 71.1% of patients had LDLc levels ≤ 70 mg/dL. Conclusion: An intensive, structured, mobile devices-based healthcare intervention after an ACS is associated with more than 70% of patients reaching the LDLc levels recommended by the clinical guidelines. In patients with LDLc measured at 1-year follow-up, 71.1% had LDLc levels ≤ 70 mg/dL.

Analysis of the prescription process of PCSK9 inhibitors in the cardiology departments of Spanish hospitals and optimization proposal. The IKIGAI study. / Análisis del proceso de prescripción de inhibidores PCSK9 en los servicios de cardiología de los hospitales españoles y propuesta de optimización. Estudio IKIGAI.

AIMS: To ascertain the formalities and procedures required for the prescription of PCSK9 inhibitors in the cardiology departments of Spanish hospitals, making proposals for improvement to optimize the prescription process. METHODS: A first phase of collecting information about the variables and administrative procedures required for the prescription of PCK9 inhibitors and the elaboration of a specific questionnaire and a second phase of collecting data with an online self-administered questionnaire. RESULTS: A total of 88 hospitals participated in the study (mean number of beds 625; mean number of cardiologists 18 ± 10; 78% university hospitals). There was underuse of PCSK9 inhibitors (real prescription of 30 treatments/year; potential prescription of 80), mainly because of not fulfilling the therapeutic positioning report (52%) and application refusal (31%). Beyond the requirements of the therapeutic positioning report, 1.2 ± 0.4 applications are required with 8.5 ± 4.2 variables. Only 21% of hospitals did not require a previous authorization process and in the remaining hospitals, approval from a committee was necessary. The accumulated time of the prescription process was 6 weeks. Discontinuation rates during follow-up were 9% ± 12%. CONCLUSIONS: Treatment with PCSK9 inhibitors is clearly underused in Spain. This is mainly due to both inappropriate identification of patients, and complex administrative procedures that could inhibit/discourage prescription by cardiologists and consequently, limit their use. In addition, there is a substantial delay from drug approval tadministration.

Implementation of clinical practices and pathways optimizing ACS patients lipid management: Focus on eight European initiatives.

Post-acute coronary syndrome (ACS) patients are at very high cardiovascular risk. Despite current guidelines strongly recommend to reduce LDL-C levels and initiation of high-intensity statins as early as possible in patients admitted with an ACS, less than half of ACS patients receive a high intensity statin, and a high percentage of has LDL-C well above the goal despite therapy. There are multiple reasons for that, including physician lack of guideline adherence, patient lack of compliance with treatment, and lack of standardized procedures. Furthermore, although the prevalence of familial hypercholesterolemia is higher among patients with ACS, this condition remains poorly estimated. To fill these gaps, some European countries have launched local initiatives for the in-hospital and post-discharge ACS patient lipid management. It appears that ensuring optimal therapy during hospitalization and dedicated follow-up protocols results in a significant improvement of lipid levels in these very high risk patients, which may translate into a reduced risk of recurrent future events.

A new rational approach to reach LDL-cholesterol concentration objectives after an acute coronary syndrome. / Una nueva estrategia para alcanzar los niveles objetivos de colesterol LDL tras un síndrome coronario agudo.

INTRODUCTION AND OBJECTIVES: Adequate LDL cholesterol (LDLc) control after an acute coronary syndrome (ACS) is a crucial secondary prevention strategy to minimize the incidence of recurrent myocardial infarction and cardiovascular death. There are tables that predict the necessary dosage of lipid-lowering treatment from the initial LDLc but have not been tested in ACS. Variables associated with optimal LDLc after an ACS were analyzed and the therapeutic yield of the use of Masana's recommendations in this setting. METHODS: A total number of 326 ACS-patients were included between January-2015 and May-2016. Baseline LDLc concentration and prescribed hypolipemiant treatment at hospital discharge were registered. We analyzed the variables associated with optimal LDLc levels (<70mg/dL) control during follow-up. RESULTS: Among our patient population (72% male, age 66±13 years), the hypolipemiant treatment at hospital discharge fulfilled the Masana's recommendations in 196 (60%) patients. After a follow-up period of 122 [66-184] days the targeted LDLc levels were achieved in 148 (45%) patients, being this percentage greater among those in whom the Masana's recommendations were fulfilled (109/196, 56%), as compared with the remaining (39/130, 30%; P<.001). The male gender (P<.001), the absence of prior history of dyslipemia (P<.001) and the adherence to Masana's recommendations (P=.007) were independent predictors for the achievement of targeted LDLc levels during follow-up. CONCLUSIONS: In less than half of ACS-patients adequate mid-term LDLc control is obtained. The dosage of the lipid-lowering therapy according to Masana's recommendations helps to achieve this important therapeutic goal.

Secondary prevention strategies after an acute ST-segment elevation myocardial infarction in the AMI code era: beyond myocardial mechanical reperfusion.

BACKGROUND: The AMI code is a regional network enhancing a rapid and widespread access to reperfusion therapy (giving priority to primary angioplasty) in patients with acute ST-segment elevation myocardial infarction (STEMI). We aimed to assess the long-term control of conventional cardiovascular risk factors after a STEMI among patients included in the AMI code registry. DESIGN AND METHODS: Four hundred and fifty-four patients were prospectively included between June-2009 and April-2013. Clinical characteristics were collected at baseline. The long-term control of cardiovascular risk factors and cardiovascular morbidity/mortality was assessed among the 6-months survivors. RESULTS: A total of 423 patients overcame the first 6 months after the STEMI episode, of whom 370 (87%) underwent reperfusion therapy (363, 98% of them, with primary angioplasty). At 1-year follow-up, only 263 (62%) had adequate blood pressure control, 123 (29%) had LDL-cholesterol within targeted levels, 126/210 (60%) smokers had withdrawn from their habit and 40/112 (36%) diabetic patients had adequate glycosylated hemoglobin levels. During a median follow-up of 20 (11-30) months, cumulative mortality of 6 month-survivors was 6.1%, with 9.9% of hospital cardiovascular readmissions. The lack of assessment of LDL and HDL-cholesterol were significantly associated with higher mortality and cardiovascular readmission rates. CONCLUSIONS: Whereas implementation of the AMI code resulted in a widespread access to rapid reperfusion therapy, its long-term therapeutic benefit may be partially counterbalanced by a manifestly suboptimal control of cardiovascular risk factors. Further efforts should be devoted to secondary prevention strategies after STEMI.

Iron Deficiency Is a Determinant of Functional Capacity and Health-related Quality of Life 30 Days After an Acute Coronary Syndrome.

BACKGROUND AND OBJECTIVES: Iron deficiency (ID) is a prevalent condition in patients with ischemic heart disease and heart failure. Little is known about the impact of ID on exercise capacity and quality of life (QoL) in the recovery phase after an acute coronary syndrome (ACS). METHODS: Iron status and its impact on exercise capacity and QoL were prospectively evaluated in 244 patients 30 days after the ACS. QoL was assessed by the standard EuroQoL-5 dimensions, EuroQoL visual analogue scale, and Heart-QoL questionnaires. Exercise capacity was analyzed by treadmill/6-minute walk tests. The effect of ID on cardiovascular mortality and readmission rate was also investigated. RESULTS: A total of 46% of the patients had ID. These patients had lower exercise times (366±162 vs 462±155seconds; P<.001), metabolic consumption rates (7.9±2.9 vs 9.3±2.6 METS; P=.003), and EuroQoL-5 dimensions (0.76±0.25 vs 0.84±0.16), visual analogue scale (66±16 vs 72±17), and Heart-QoL (1.9±0.6 vs 2.2±0.6) scores (P<.05). ID independently predicted lower exercise times (OR, 2.9; 95%CI, 1.1-7.6; P=.023) and worse QoL (OR, 1.9; 95%CI, 1.1-3.3; P<.001) but had no effect on cardiovascular morbidity or mortality. CONCLUSIONS: ID, a prevalent condition in ACS patients, results in a poorer mid-term functional recovery, as measured by exercise capacity and QoL.

In-hospital acquired anemia in acute coronary syndrome. Predictors, in-hospital prognosis and one-year mortality.

INTRODUCTION AND OBJECTIVES: Anemia at hospital admission predicts a poor outcome in patients presenting with acute coronary syndrome. It remains unclear whether in-hospital hemoglobin levels decrease (nosocomial anemia) not related to bleeding also implies a poor prognosis. We aimed to identify predictors of nosocomial anemia and its prognostic significance. METHODS: We prospectively included 221 acute coronary syndrome patients admitted in our institution during the years 2009-2010, with normal hemoglobin levels at admission. Nosocomial anemia was defined as a decrease in hemoglobin levels to <13 g/dL in men and <12 g/dL in women in the absence of apparent bleeding. Clinical variables and hematological inflammatory parameters were assessed in order to identify predictors for the development of nosocomial anemia. We compared the clinical outcome after a 1-year follow-up period of patients without anemia as opposed to those who developed nosocomial anemia. RESULTS: Nosocomial anemia was registered in 25% of study patients. A >3.1 mg/dL value of C-reactive protein was highly predictive of developing nosocomial anemia (odds ratio=5.9; 95% confidence interval, 2.6-13.4; P<.001). The incidence of mortality and cardio-vascular morbidity was higher in the patients who developed nosocomial anemia (34.5% vs 9%; P<.001). Nosocomial anemia was a strong predictor of cardio-vascular morbidity and mortality in the long-term follow-up (hazard ratio=2.47; 95% confidence interval, 1.23-4.96; P=.01). CONCLUSIONS: Nosocomial anemia predicts a poorer outcome in patients with acute coronary syndrome. Increased C-reactive protein levels, indicating inflammatory state, are predictive of developing in-hospital anemia unrelated to apparent bleeding.

QT interval in newborns of different ethnic origin: usefulness of neonatal ECG screening.

The cost-effectiveness of neonatal electrocardiographic (ECG) screening has been questioned. The objective of this study was to establish normal values for the QT interval in newborns of different ethnic origin. Between 2005 and 2006, ECGs were obtained during the first 48 h of life from 1305 at-term newborns at the Hospital del Mar in Barcelona, Spain. The mean corrected QT interval (QTc) was 417.79+/-28.47 ms. A QTc longer than 440 ms was observed in 240 newborns (18.33%). The frequency of a pathologic QTc in Spanish newborns was 17.9%, compared with 27.7% in those of Maghreb or Near Eastern origin (P=.016), and 28.2% in those of Indian or Pakistani origin (P=.033). The QTc may vary for genetic reasons. A routine neonatal ECG is advisable only in ethnic groups in which the QTc is lengthened, to help counter the greater risk of sudden death in these infants.

Reduction in door-to-needle time to meet clinical guideline recommendations. Outcomes after 1 year.

The aim of this study was to reduce the door-to-needle time in patients with ST-elevation acute myocardial infarction by setting up a chest pain service. We compared the door-to-needle time and outcomes at the end of first year of follow-up in patients who received fibrinolysis in the 2 years before implementation of the service (Group 1) and those who received fibrinolysis in the 2 years after its creation (Group 2). In Group 1, the median door-to-needle time was 40 min (P(25-75), 23-52 min); in Group 2, it was 27 min (P(25-75), 15-43 min; P=.003). In addition, the use of reperfusion therapy increased from 55.2% in Group 1 to 64.7% in Group 2 (P< .01). After a follow-up period of 1 year, there was no difference in the rate of revascularization, hospital readmission, reinfarction or cardiovascular mortality.