Chronic Kidney Disease, But Not Diabetes, Can Predict 30-Day Outcomes in Patients with ST-Elevation Myocardial Infarction after Primary Percutaneous Coronary Intervention: A Single-Center Experience.

BACKGROUND: Patients with acute coronary syndrome and impaired renal function have been shown to have high mortality. However, there is scarce literature to date addressing the impact of diabetes mellitus (DM) and renal function on clinical outcomes of ST elevation myocardial infarction (STEMI) in Taiwan. METHOD: This study enrolled 512 STEMI patients who received primary percutaneous coronary intervention. Patients were divided into 4 groups including group 1: patients without DM or CKD (nDM-nCKD); group 2: patients with DM but without CKD (DM-nCKD); group 3: patients with CKD but without DM (nDM-CKD); group 4: patients with DM and CKD (DM-CKD). Patients were also classified into four groups based on their estimated glomerular filtration rates (eGFR): stage 1 (eGFR ≥ 90 ml/min/1.73 m(2), n = 163), stage 2 (eGFR = 89-60 ml/min/1.73 m(2), n = 171), stage 3 (eGFR = 59-30 ml/min/1.73 m(2), n = 136), and stage 4 (eGFR < 30 ml/min/1.73 m(2), n = 42). The complication rates, length of hospital stay, and 30-day outcomes were analyzed. RESULTS: The patients in both the nDM-CKD group and DM-CKD group had higher incidences of hypotension, intra-aortic balloon counterpulsation use, and respiratory failure (p < 0.005). They had significantly longer hospital stay and 30-day mortality rates (p < 0.001). The patients with CKD stage 3 and 4 had longer hospital stay and higher 30-day mortality rates (p < 0.001). However, DM was not an independent factor on the length of hospital stay and 30-day mortality rates. CONCLUSIONS: STEMI patients with impaired renal function, but not DM, had significantly longer hospital stay and higher 30-day mortality rates. KEY WORDS: Chronic kidney disease; Diabetes mellitus; Mortality; Primary percutaneous coronary intervention; ST-segment elevation myocardial infarction.

The Effect of Intensified Low Density Lipoprotein Cholesterol Reduction on Recurrent Myocardial Infarction and Cardiovascular Mortality.

BACKGROUND: Lipid-lowering therapy plays an important role in preventing the recurrence of cardiovascular events in patients after acute myocardial infarction (AMI). This study aimed to assess the effect of intensified low density lipoprotein cholesterol (LDL-C) reduction on recurrent myocardial infarction and cardiovascular mortality in patients after AMI. METHOD: The 562 enrolled AMI patients (84.2% male) were divided into two groups according to 3-month LDL-C decrease percentage equal to or more than 40% (n = 165) and less than 40% (n = 397). To evaluate the long-term efficacy of LDL-C reduction, the 5-year outcomes were collected, including time to the first occurrence of myocardial infarction and time to cardiovascular death. RESULTS: The baseline characteristics and complication rates were not different between the two study groups. The patients with 3-month LDL-C decrease ≥ 40% had higher baseline LDL-C and lower 3-month, 1-year, 2-year, 3-year, 4-year and 5-year LDL-C than the patients with 3-month LDL-C decrease < 40%. In Kaplan-Meier analyses, those patients with 3-month LDL-C decrease ≥ 40% had a higher rate of freedom from myocardial infarction (p = 0.006) and survival rate (p = 0.02) at 5-year follow-up. The 3-month LDL-C < 40% parameter was significantly related to cardiovascular death (HR: 9.62, 95% CI 1.18-78.62, p < 0.04). CONCLUSIONS: After acute myocardial infarction, 3-month LDL-C decrease < 40% was identified to be a significant risk factor for predicting 5-year cardiovascular death. The patients with 3-month LDL-C decrease ≥ 40% had a higher rate of freedom from myocardial infarction and lower cardiovascular mortality, even though these patients had higher baseline LDL-C value. KEY WORDS: Acute myocardial infarction; Cardiovascular death; Low-density lipoprotein cholesterol; Mortality; Statin.

Body Mass Index and Outcome of Acute Myocardial Infarction - Is There an Obesity Paradox?

BACKGROUND: Although there have been some studies focusing on the relationship between body mass index (BMI), coronary artery disease (CAD) and acute coronary syndrome, the clinical effects of BMI on outcomes after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI) are not well known in a Taiwanese population. METHODS: From January 2005 to December 2011, 1298 AMI patients who received PCI were enrolled from a single center in Taiwan. The patients were divided into 4 groups according to their BMI: underweight (BMI < 18.5 kg/m(2)); normal weight (18.5 ≤ BMI < 24 kg/m(2)); overweight (24 ≤ BMI < 27 kg/m(2)) and obese (BMI ≥ 27). All patients had been followed up for at least 12 months, and 30-day and 5-year all-cause and cardiovascular-cause mortality were compared among the study groups. RESULTS: The patients in the underweight group had a lower 30-day survival rate than the other 3 groups, and the underweight and normal weight patients had a lower 5-year survival rate than the overweight and obese patients. The multivariate regression analysis showed that Killip class ≥ 2, non-use of statin, older age, hemoglobin < 12 g/dl and chronic kidney disease, but not BMI, are independent predictors of all-cause mortality. CONCLUSIONS: In this present study, the major factors affecting long-term survival are lack of using statin and older age, but not obese paradox. KEY WORDS: Acute myocardial infarction; Mortality; Obesity; Percutaneous coronary intervention; Survival.

Upper gastrointestinal lesions in patients receiving clopidogrel anti-platelet therapy.

BACKGROUND/PURPOSE: Clopidogrel is associated with a high incidence of upper gastrointestinal bleeding in high-risk patients. However, the characteristic upper gastrointestinal lesions in symptomatic clopidogrel users remain unclear. The aims of this study were to investigate the characteristics of endoscopic findings in clopidogrel users undergoing endoscopy for upper gastrointestinal symptoms and to compare the clinical characteristics and upper gastrointestinal lesions between symptomatic clopidogrel and aspirin users. METHODS: This observational study included 215 consecutive patients receiving clopidogrel (n=106) or low-dose aspirin (n=109) therapy who underwent endoscopy for dyspeptic symptoms. The upper gastrointestinal lesions were carefully assessed, and a complete medical history was obtained by a standard questionnaire. RESULTS: The frequencies of hemorrhagic spots, erosions and peptic ulcers in the symptomatic clopidogrel users were 25%, 39% and 39%, respectively. Among the peptic ulcer patients on clopidogrel therapy, the distributions of ulcers were 78%, 5% and 17% in the stomach, duodenum and both, respectively. Compared with the aspirin group, the clopidogrel group was older and had higher frequencies of past ulcer history and past gastrointestinal bleeding history in their clinical characteristics. By contrast, the clopidogrel users had a lower prevalence of active Helicobacter pylori infection than aspirin users (17% vs. 35%, respectively, p=0.007). Regarding to the endoscopic findings, the clopidogrel users had higher frequencies of hemorrhagic spots (25% vs. 10%) and peptic ulcer (39% vs. 24%) than aspirin users (p=0.004 and 0.027, respectively). CONCLUSION: Most peptic ulcers in clopidogrel users are located in the stomach. The frequencies of hemorrhagic spots and peptic ulcers in symptomatic clopidogrel users are higher than those in symptomatic aspirin users.

Role of shortened QTc dispersion in in-hospital cardiac events in patients undergoing percutaneous coronary intervention for acute coronary syndrome.

BACKGROUND: QT dispersion (QTD) refers to the difference between maximal and minimal QT values on the electrocardiogram (ECG). QTD values are calculated and corrected with Bazett's formula (corrected QTD = QTcD = QTD/square root of RR). QTcD increases in patients with acute coronary syndrome (ACS). Recovery of increased QTcD (shortened QTcD) develops after successful revascularization, but prolonged QTcD occurs in certain patients. The aim of this study is to ascertain the clinical significance between shortened and prolonged QTcD groups after percutaneous coronary intervention (PCI). METHODS: We retrospectively enrolled 128 patients with ACS who had received PCI. The values of QTcD were measured manually on 12-lead standard ECGs obtained within 3 days before and after PCI (pre-PCI QTcD and post-PCI QTcD). All the patients were divided into 2 groups. The shortened QTcD group was defined as those patients with a decrease in QTcD after PCI and the prolonged QTcD group as those with an increase in QTcD after PCI. The underlying diseases, various clinical classifications and some prognostic factors were taken into comparison and statistical analysis between these 2 groups. RESULTS: The shortened QTcD group showed a significantly higher rate of in-hospital cardiac death (13% vs. 0%, p = 0.006) and a greater pre-PCI QTcD (100.8 +/- 39.5 vs. 61.3 +/- 24.1 ms, p < 0.001) than the prolonged QTcD group. There was a significantly greater pre-PCI QTcD in patients with cardiac death than those without cardiac death (111.6 +/- 38.3 vs. 83.3 +/- 38.3ms, p = 0.027). Furthermore, the patients with in-hospital cardiac death presented with a significantly more frequent occurrence of in-hospital ventricular arrhythmia, compared with those without cardiac death (30.0% vs. 4.0%, p = 0.014). CONCLUSION: Among the patients with ACS undergoing PCI, directly divided into shortened and prolonged QTcD groups regardless of initial pre-PCI QTcD, the shortened QTcD group showed a higher occurrence of in-hospital cardiac death and a greater pre-PCI QTcD. Shortened QTcD might be 1 risk factor for in-hospital cardiac death.