Effects of Smoking on Very-Long Term Mortality after First ST Elevation Myocardial Infarction. / Efeitos do Ato de Fumar na Mortalidade de Longo Prazo após Infarto do Miocárdio por Elevação de ST.

BACKGROUND: The smoking paradox has been a matter of debate for acute myocardial infarction patients for more than two decades. Although there is huge evidence claiming that is no real paradox, publications supporting better outcomes in post-MI smokers are still being released. OBJECTIVE: To explore the effect of smoking on very long-term mortality after ST Elevation myocardial infarction (STEMI). METHODS: This study included STEMI patients who were diagnosed between the years of 2004-2006 at three tertiary centers. Patients were categorized according to tobacco exposure (Group 1: non-smokers; Group 2: <20 package*years users, Group 3: 20-40 package*years users, Group 4: >40 package*years users). A Cox regression model was used to estimate the relative risks for very long-term mortality. P value <0.05 was considered as statistically significant. RESULTS: There were 313 patients (201 smokers, 112 non-smokers) who were followed-up for a median period of 174 months. Smokers were younger (54±9 vs. 62±11, p: <0.001), and the presence of cardiometabolic risk factors were more prevalent in non-smokers. A univariate analysis of the impact of the smoking habit on mortality revealed a better survival curve in Group 2 than in Group 1. However, after adjustment for confounders, it was observed that smokers had a significantly increased risk of death. The relative risk became higher with increased exposure (Group 2 vs. Group 1; HR: 1.141; 95% CI: 0.599 to 2.171, Group 3 vs Group 1; HR: 2.130; 95% CI: 1.236 to 3.670, Group 4 vs Group 1; HR: 2.602; 95% CI: 1.461 to 4.634). CONCLUSION: Smoking gradually increases the risk of all-cause mortality after STEMI.

FUNDAMENTO: O paradoxo do fumante tem sido motivo de debate para pacientes com infarto agudo do miocárdio (IM) há mais de duas décadas. Embora haja muitas evidências demonstrando que não existe tal paradoxo, publicações defendendo desfechos melhores em fumantes pós-IM ainda são lançadas. OBJETIVO: Explorar o efeito do fumo na mortalidade de longo prazo após infarto do miocárdio por elevação de ST (STEMI). MÉTODOS: Este estudo incluiu pacientes com STEMI que foram diagnosticados entre 2004 e 2006 em três centros terciários. Os pacientes foram categorizados de acordo com a exposição ao tabaco (Grupo 1: não-fumantes; Grupo 2: <20 pacotes*anos; Grupo 3: 2-040 pacotes*anos; Grupo 4: >40 pacotes*anos). Um modelo de regressão de Cox foi utilizado para estimar os riscos relativos para mortalidade de longo prazo. O valor de p <0,05 foi considerado como estatisticamente significativo. RESULTADOS: Trezentos e treze pacientes (201 fumantes e 112 não-fumantes) foram acompanhados por um período médio de 174 meses. Os fumantes eram mais novos (54±9 vs. 62±11, p: <0,001), e a presença de fatores de risco cardiometabólicos foi mais prevalente entre os não-fumantes. Uma análise univariada do impacto do hábito de fumar na mortalidade revelou uma curva de sobrevivência melhor no Grupo 2 do que no Grupo 1. Porém, após ajustes para fatores de confusão, observou-se que os fumantes tinham um risco de morte significativamente maior. O risco relativo tornou-se maior de acordo com a maior exposição (Grupo 2 vs. Grupo 1: RR: 1,141; IC95%: 0,599 a 2.171; Grupo 3 vs. Grupo 1: RR: 2,130; IC95%: 1,236 a 3,670; Grupo 4 vs. Grupo 1: RR: 2,602; IC95%: 1,461 a 4,634). CONCLUSÃO: O hábito de fumar gradualmente aumenta o risco de mortalidade por todas as causas após STEMI.

Efeitos do Ato de Fumar na Mortalidade de Longo Prazo após Infarto do Miocárdio por Elevação de ST / Effects of Smoking on Very-Long Term Mortality after First ST Elevation Myocardial Infarction

Resumo Fundamento O paradoxo do fumante tem sido motivo de debate para pacientes com infarto agudo do miocárdio (IM) há mais de duas décadas. Embora haja muitas evidências demonstrando que não existe tal paradoxo, publicações defendendo desfechos melhores em fumantes pós-IM ainda são lançadas. Objetivo Explorar o efeito do fumo na mortalidade de longo prazo após infarto do miocárdio por elevação de ST (STEMI). Métodos Este estudo incluiu pacientes com STEMI que foram diagnosticados entre 2004 e 2006 em três centros terciários. Os pacientes foram categorizados de acordo com a exposição ao tabaco (Grupo 1: não-fumantes; Grupo 2: <20 pacotes*anos; Grupo 3: 2-040 pacotes*anos; Grupo 4: >40 pacotes*anos). Um modelo de regressão de Cox foi utilizado para estimar os riscos relativos para mortalidade de longo prazo. O valor de p <0,05 foi considerado como estatisticamente significativo. Resultados Trezentos e treze pacientes (201 fumantes e 112 não-fumantes) foram acompanhados por um período médio de 174 meses. Os fumantes eram mais novos (54±9 vs. 62±11, p: <0,001), e a presença de fatores de risco cardiometabólicos foi mais prevalente entre os não-fumantes. Uma análise univariada do impacto do hábito de fumar na mortalidade revelou uma curva de sobrevivência melhor no Grupo 2 do que no Grupo 1. Porém, após ajustes para fatores de confusão, observou-se que os fumantes tinham um risco de morte significativamente maior. O risco relativo tornou-se maior de acordo com a maior exposição (Grupo 2 vs. Grupo 1: RR: 1,141; IC95%: 0,599 a 2.171; Grupo 3 vs. Grupo 1: RR: 2,130; IC95%: 1,236 a 3,670; Grupo 4 vs. Grupo 1: RR: 2,602; IC95%: 1,461 a 4,634). Conclusão O hábito de fumar gradualmente aumenta o risco de mortalidade por todas as causas após STEMI.

Abstract Background The smoking paradox has been a matter of debate for acute myocardial infarction patients for more than two decades. Although there is huge evidence claiming that is no real paradox, publications supporting better outcomes in post-MI smokers are still being released. Objective To explore the effect of smoking on very long-term mortality after ST Elevation myocardial infarction (STEMI). Methods This study included STEMI patients who were diagnosed between the years of 2004-2006 at three tertiary centers. Patients were categorized according to tobacco exposure (Group 1: non-smokers; Group 2: <20 package*years users, Group 3: 20-40 package*years users, Group 4: >40 package*years users). A Cox regression model was used to estimate the relative risks for very long-term mortality. P value <0.05 was considered as statistically significant. Results There were 313 patients (201 smokers, 112 non-smokers) who were followed-up for a median period of 174 months. Smokers were younger (54±9 vs. 62±11, p: <0.001), and the presence of cardiometabolic risk factors were more prevalent in non-smokers. A univariate analysis of the impact of the smoking habit on mortality revealed a better survival curve in Group 2 than in Group 1. However, after adjustment for confounders, it was observed that smokers had a significantly increased risk of death. The relative risk became higher with increased exposure (Group 2 vs. Group 1; HR: 1.141; 95% CI: 0.599 to 2.171, Group 3 vs Group 1; HR: 2.130; 95% CI: 1.236 to 3.670, Group 4 vs Group 1; HR: 2.602; 95% CI: 1.461 to 4.634). Conclusion Smoking gradually increases the risk of all-cause mortality after STEMI.

Data on smoking in Turkey: Systematic review, meta-analysis and meta-regression of epidemiological studies on cardiovascular risk factors.

OBJECTIVE: Smoking is one of the most important public health problems and preventable causes of mortality in Turkey. Major healthcare policies have been implemented to combat this problem over the past 10 years. The aim of this study was to conduct a systematic review and meta-analysis of epidemiological studies performed in the country in the last 15 years to determine the prevalence of smoking in Turkey. METHODS: Ovid Medline, the Web of Science Core Collection, and the Turkish Academic Network and Information Center (ULAKBIM), as well as the websites of the Ministry of Health and the Turkish Statistical Institute were searched for the appropriate epidemiological studies. Studies included in the analysis were evaluated by a selfdeveloped bias score regarding their potential to represent Turkey and standardization of measurements. The meta-analysis and metaregression analysis were performed using a random effects model. RESULTS: Ten epidemiological studies (n=122383) that included data about smoking were found. Eight of them (all with low bias score) included separate data about the smoking habit of women (n=49524) and men (n=37684). The smoking prevalence was determined to be 30.5% for the whole group, 15.7% for women, and 46.1% for men, when occasional smokers were included. Although the change observed in crude prevalence values over time was not statistically significant, when the data of the 3 studies that gave prevalence values according to age categories were standardized according to age, the incidence of smoking between 2003 and 2012 decreased 6.8% (20.2%) when occasional smokers were included and 8.4% (26.3%) when they are excluded. CONCLUSION: Despite implementation of major healthcare policies and some success in decreasing rate of smoking, one-third of the Turkish population aged over 15 years and nearly half of the men are smokers. It is essential to continue and to strengthen measures to combat smoking.

Diffuse alveolar hemorrhage associated with low molecular weight heparin and dual anti-platelet therapy after percutaneous coronary intervention.

A 54-year-old man underwent percutaneous coronary intervention (PCI) and two stents were placed on left anterior coronary artery and circumflex artery. Low molecular weight heparin (LMWH) together with ticagrelor 90 mg twice a day and acetylsalicylic acid (Aspirin) were started after PCI due to high risk of stent thrombosis. On the fourth day of patient's follow-up in the intensive care unit (ICU), bloody secretion was started from endotracheal tube. Hemoglobin dropping, bilateral infiltration on the chest X-ray and bleeding from lung were diagnosed as diffuse alveolar hemorrhage (DAH). Apart from LMWH and antiplatelet therapies with aspirin and ticagrelor, there were no other identified risk factors for DAH. As far as we know, our report is the first case of DAH caused by LMWH and dual anti-platelet therapy including ticagrelor.

The relationship of plasma neuropeptide Y levels with coronary collateral development.

OBJECTIVE: Neuropeptide Y (NPY), a sympathetic cotransmitter, has been shown to promote angiogenesis in in-vitro models. The aim of this study was to evaluate the relationship of plasma NPY levels with coronary collateral vessel development in patients with coronary artery disease. METHODS: The study included 81 patients with at least one coronary stenosis with at least 80% narrowing in coronary angiography. Collateral vessels were graded according to the Rentrop classification. The study patients were divided into two groups, namely patients with well-developed collaterals and patients with poorly developed collaterals. Well-developed collaterals were defined as Rentrop collateral score of at least 2. Plasma levels of NPY, vascular endothelial growth factor, fibroblast growth factor, and noradrenaline were measured using an enzyme-linked immunosorbent assay. RESULTS: Plasma NPY was significantly higher in patients with well-developed collaterals as compared with patients with poorly developed collaterals (P=0.026). In contrast, plasma noradrenaline was significantly lower in patients with well-developed collaterals (P=0.022). There was no statistically significant difference in vascular endothelial growth factor and fibroblast growth factor levels between groups. The NPY level was positively correlated with the presence of diabetes (r=0.528, P<0.001). The extent of coronary artery disease (Gensini score) was significantly higher in patients with well-developed collaterals (P<0.001). After confounding variables were controlled for, the NPY level in patients with well-developed collaterals was significantly higher than those patients with poorly developed collaterals. CONCLUSION: In this study, NPY levels were found to be significantly higher in patients with well-developed coronary collaterals compared with patients with poorly developed collaterals. New studies are needed to show whether this relationship is causal.

Short and long term complications of device closure of atrial septal defect and patent foramen ovale: meta-analysis of 28,142 patients from 203 studies.

BACKGROUND: Device closure of atrial septal defect (ASD) and patent foramen ovale (PFO) are both associated with short- and long-term complications. Our knowledge of the complication rates of ASD and PFO closure is limited. Our objective was to review the peri-procedural and long-term complications of ASD and PFO closure. METHODS: Medline, EMBASE, and Scopus databases were searched between 1973 and 2012. A total of 28,142 patients from 203 case series were included. Of these 203 articles, 111 were reporting ASD closure, 61 were reporting PFO closure, and 31 were reporting both. Pooled incidence rates of cardiac complications were calculated separately for peri-procedural and at follow-up. RESULTS: Peri-procedural major complications were reported from 0% to 9.4%, with a pooled estimate rate of 1.4% (95% CI: 1.3-1.6%). It was 1.6% (95% CI: 1.4-1.8%) in ASD group, 1.1% (95% CI: 0.9-1.3%) in PFO group, and 1.3% (95% CI: 0.9-1.9%) in ASD/PFO group. The most common major complication was the device embolization requiring surgery. Peri-procedural minor complications were reported with a pooled estimate rate of 1.4% (95% CI: 1.2-1.7%). It was 1.6% (95% CI: 1.2-2.1%) in ASD group, 1.3% (95% CI: 1.0-1.7%) in PFO group, and 1.5% (95% CI: 1.1-1.2.1%) in ASD/PFO group. The most frequent major complications at follow-up were cerebrovascular events [1.3% (95% CI: 1.1-1.6%)] and device thrombosis [1.2% (95% CI: 1.0-1.4%)]. Both were more frequent in PFO group. CONCLUSION: Device closure of ASD and PFO are associated with non-negligible serious complications, both in early and long-term.

Management of cardiovascular risk factors for primary prevention: evaluation of Turkey results of the EURIKA study.

OBJECTIVES: The EURIKA study (The European Study on Cardiovascular Risk Prevention and Management in Daily Practice), which covers 12 European countries including our country, aimed to describe the management of cardiovascular risk factors in the daily practice and to detect areas of improvement. We evaluated our country-based data on the methods used by physicians to manage cardiovascular risk factors and the results of patients who participated in this study. STUDY DESIGN: The EURIKA study recruited 663 patients (mean age 59.4±7.6 years; 47.2% males) and 67 physicians (55 men, 12 women; mean age 40.7±8.6 years) from Turkey. Risk factor definition and treatment goals were based on the 2007 European guidelines on cardiovascular disease prevention. Blood samples were analyzed in a central laboratory. The 10-year risk for fatal cardiovascular disease was estimated based on the SCORE system. RESULTS: About one-third (34.8%) of the doctors did not use any cardiovascular disease guidelines. Only 48.5% used cardiovascular risk calculation. The most common (74%) reason for not using risk calculation was stated as having limited time. The rates of reaching target total/LDL cholesterol, blood pressure, and HbA1c levels were 30.4%, 32.1%, and 26% in treated dyslipidemics, hypertensives, and diabetics, respectively. Hypertension, diabetes, dyslipidemia, and smoking accounted for 59.4% of attributable cardiovascular risk. Lack of control of these risk factors accounted for 31.8% of cardiovascular risk. CONCLUSION: Only half of our doctors use cardiovascular risk calculation, and therapeutic guidelines are not adequately used. Moreover, the control rates of risk factors in primary prevention are low.

Comparison of traditional risk factors, angiographic findings, and in-hospital mortality between smoking and nonsmoking Turkish men and women with acute myocardial infarction.

BACKGROUND: The prevalence of smoking is high in Turkey. However, there are no data available evaluating the differences between smokers and nonsmokers according to their sex in patients with acute myocardial infarction (AMI) in Turkey. HYPOTHESIS: The aim of the study was to determine the prevalence of smoking and its relationship to age, localization, and extension of coronary heart disease (CHD), and other risk factors in Turkish men and women with first AMI. METHODS: This study included, 1502 patients with first AMI from 3 different cities in Turkey. The baseline characteristics and traditional risk factors for CHD, Coronary angiographic results, and in-hospital outcome were recorded. RESULTS: The proportion of male smokers was significantly higher than that of women (68% vs 18%, P < 0.001). Smokers were younger by almost a decade than nonsmokers (P < 0.001). Male nonsmokers were younger than females; however, the mean age of first AMI was similar in male and female smokers. In both genders, prevalence of hypertension and diabetes mellitus was significantly lower in smokers than in nonsmokers (P < 0.001). Smokers had less multivessel disease and less comorbidity as compared to nonsmokers. Although the in-hospital mortality rate was lower in smokers, smoking status was not an independent predictor of mortality. CONCLUSIONS: Smoking, by decreasing the age of first AMI in women, offsets the age difference in first AMI between men and women. The mean age of first AMI is lower in Turkey than most European countries due to a high percentage of smoking.

Prevalence of risk factors of ST segment elevation myocardial infarction in Turkish patients living in Central Anatolia.

OBJECTIVE: There is not enough available data in our country about the prevalence of risk factors for ST-elevation myocardial infarction (STEMI), which has the highest in-hospital mortality rate within subtypes of acute coronary syndromes. Therefore, in this study, we aimed to evaluate the prevalence of risk factors for STEMI in Central Anatolia, one of the regions with high risk for coronary heart disease (CHD). METHODS: This cross-sectional observational study included 1210 patients (962 men, 248 women) with the diagnosis of STEMI in 3 tertiary-medical centers in 3 cities in Central-Anatolia (Ankara, Konya, and Kayseri). Demographic characteristics (age, gender) and risk factors known to be traditional risk factors for CHD (history of hypertension (HT), diabetes mellitus (DM), smoking, and family history) were inquired and fasting blood samples within 24 hours from onset of STEMI were taken to analyze lipid levels. Patients were divided into 3 groups based on their ages: Group A--age = or <44 years; Group B--age 45-64 years; and Group C--age = or >65 years. Prevalence of risk factors and differences within age-groups and genders were evaluated. RESULTS: The mean age was 58+/- 11 years (range 24-96 years). Although the percentage of female patients increased in relation to increasing age, 80% of the total patients were male. While prevalence of smoking and family history was observed to decrease with aging, there was a statistically significant increase in prevalence of HT and DM (p<0.001). Prevalence of smoking was the highest in young patients and males (p<0.001). Prevalence of HT and DM, on the other hand, was significantly higher in women than in men (p<0.001). Although the number of modifiable risk factors was found to be significantly smaller in men, male patients with STEMI were 8 years younger than females on average. CONCLUSIONS: The results of our study, in which modifiable risk factors and especially smoking were found to have a high prevalence in patients with STEMI living in Central Anatolia, suggested that most STEMI cases especially at younger ages might be prevented by the modification of these risk factors.

A new definition of aspirin non-responsiveness by platelet function analyzer-100 and its predictors.

BACKGROUND: Aspirin non-responsiveness has been described as having a normal closure time (CT) by platelet function analyzer (PFA)-100 assay despite confirmed treatment with aspirin. There is no standard definition of aspirin non-responsiveness by PFA-100, with a variety of cut-off values having been used. We proposed an alternative definition of aspirin non-responsiveness by PFA-100 assay. METHODS: One hundred eighty-four patients with diagnosis of stable coronary artery disease or diabetes mellitus were included in the study. Blood samples were drawn before and after the 7 days of aspirin therapy. An individual was labelled as aspirin non-responder if his/her post-aspirin CT was not 2SD above his/her baseline CT, where SD was calculated from the baseline CTs of the study population. Aspirin non-responsiveness was also defined as having a normal post-aspirin CT (< or =193 s) regardless of pre-aspirin CT. RESULTS: The baseline CT ranged 82-187 s (mean 129.1 +/- 27.5, median 128 s) in the study population. At the end of 1 week of aspirin administration, CT increased to a mean of 260.7 +/- 63.6 s (range 102-301). According to our definition, 28 (15.2%) of 184 patients were aspirin non-responders. Univariate analysis indicated that aspirin non-responsiveness was closely associated with gender (P = 0.012) diabetes (P = 0.006), smoking (P = 0.0496) and hypertension (P = 0.021). Multivariate analysis identified diabetes (P = 0.016) as the only significant independent predictor for the presence of aspirin non-responsiveness. Thirty-four of 184 patients (18.5%) classified as aspirin non-responders according to the second criteria. Seven patients with prolongation of post-aspirin CT more than 2SD were classified as aspirin non-responders by the second criteria. Only 1 patient without prolongation of CT more than 2SD was classified as aspirin responsive by the second criteria. CONCLUSION: Definition of aspirin non-responsiveness as post-aspirin CTs < or =193 s might overestimate the prevalence of aspirin non-responsiveness. Nevertheless, definition of aspirin non-responsiveness by PFA-100 must be standardized and its utility as a predictor of cardiovascular events needs to be further investigated.

Possible anaphylactic reaction to taxus stent: a case report.

We report a patient who experienced an anaphylactic reaction during coronary artery stenting. Immediately after a polymer-based paclitaxel-eluting stent (Taxus, Boston-Scientific) is deployed, the patient developed profound hypotension and an erythematous rash. The case complicated with coronary spasm and a new thrombus formation making a second stent implantation necessary. The reaction was successfully reversed with epinephrine, steroid, antihistaminic, a 9-hr infusion of dopamine, and intraaortic balloon counterpulsation.