Outcomes of Patients with Normal LDL-Cholesterol at Admission for Acute Coronary Syndromes: Lower Is Not Always Better.

BACKGROUND AND AIM: There are few prospective data on the prognostic value of normal admission low-density lipoprotein cholesterol (LDL-C) in statin-naïve patients with acute coronary syndromes (ACS) who are treated with a preemptive invasive strategy. We aimed to analyze the proportion of patients with normal LDL-C at admission for ACS in our practice, and their characteristics and clinical outcomes in comparison to patients with high admission LDL-C. PATIENTS AND METHODS: Two institutions' prospective registries of patients with confirmed ACS from Jan 2017 to Jan 2023 were used to identify 1579 statin-naïve patients with no history of prior coronary artery disease (CAD), and with available LDL-C admission results, relevant clinical and procedural data, and short- and long-term follow-up data. Normal LDL-C at admission was defined as lower than 2.6 mmol/L. All demographic, clinical, procedural, and follow-up data were compared between patients with normal LDL-C and patients with a high LDL-C level (≥2.6 mmol/L) at admission. RESULTS: There were 242 (15%) patients with normal LDL-C at admission. In comparison to patients with high LDL-cholesterol at admission, they were significantly older (median 67 vs. 62 years) with worse renal function, had significantly more cases of diabetes mellitus (DM) (26% vs. 17%), peripheral artery disease (PAD) (14% vs. 9%), chronic obstructive pulmonary disease (COPD) (8% vs. 2%), and psychological disorders requiring medical attention (19% vs. 10%). There were no significant differences in clinical type of ACS. Complexity of CAD estimated by coronary angiography was similar between the two groups (median Syntax score 12 for both groups). There were no significant differences in rates of complete revascularization (67% vs. 72%). Patients with normal LDL-C had significantly lower left ventricular ejection fraction (LVEF) at discharge (median LVEF 52% vs. 55%). Patients with normal LDL-C at admission had both significantly higher in-hospital mortality (5% vs. 2%, RR 2.07, 95% CI 1.08-3.96) and overall mortality during a median follow-up of 43 months (27% vs. 14%, RR 1.86, 95% CI 1.45-2.37). After adjusting for age, renal function, presence of diabetes mellitus, PAD, COPD, psychological disorders, BMI, and LVEF at discharge in a multivariate Cox regression analysis, normal LDL-C at admission remained significantly and independently associated with higher long-term mortality during follow-up (RR 1.48, 95% CI 1.05-2.09). CONCLUSIONS: A spontaneously normal LDL-C level at admission for ACS in statin-naïve patients was not rare and it was an independent risk factor for both substantially higher in-hospital mortality and mortality during long-term follow-up. Patients with normal LDL-C and otherwise high total cardiovascular risk scores should be detected early and treated with optimal medical therapy. However, additional research is needed to reveal all the missing pieces in their survival puzzle after ACS-beyond coronary anatomy, PCI optimization, numerical LDL-C levels, and statin therapy.

Echocardiographic assessment of revascularization completeness impact on diastolic dysfunction in ischemic heart disease.

Diastolic dysfunction indicates a functional abnormality of diastolic relaxation, filling, or distensibility of the left ventricle (LV), regardless of whether the LVEF is normal or abnormal. Diastolic dysfunction is practically always progressive and connected with higher morbidity and mortality rates, and, if not treated may lead to a diastolic heart failure. The golden standard for evaluation of diastolic function is echocardiography. One of the most important causes of diastolic dysfunction is ischemic heart disease. The revascularization of chronic myocardial ischemia can be partial (incomplete) or complete. Previous data have shown that the completeness of revascularization could have influence on clinical outcomes. The aim of this study was to asses, by means of echocardiography, the impact of completeness of revascularization on diastolic dysfunction in ischemic heart disease. This study included 65 consecutive patients with previously recognized diastolic dysfunction that met criteria for PCI revascularization. Two groups of patients were identified; one with complete revascularization achieved and another one with incomplete one. There were no statistical differences between two groups considering gender age, arterial hypertension, hyperlipoproteinaemia, previous CABG and left ventricle systolic function. In the incomplete revascularization group, the proportion of patients that had diabetes mellitus, previous myocardial infarction and previous PCI procedure were statistically higher (p < 0.05). The diastolic function recovery was statistically significant in both groups (p < 0.001), and there was no statistically significant difference in recovery between the two groups. Lack of recovery was registered in 18.2% patients with incomplete revascularization achieved, and 15.6% in the complete group, which was not significant, but shows a trend. The causes of somewhat worse recovery in the incomplete revascularization group could be attributed to the higher proportion of diabetics, to the somewhat older population and ultimately to the incomplete revascularization. The E/A ratio on diastolic transmitral flow as well as the E/E lat ratio on tissue doppler were found as the best echocardiographic parameters in diastolic function evaluation. In follow up recovery after complete or incomplete revascularization the tissue doppler (E/E lat) was recognized as the best parameter. In conclusion, we found that echocardiographic assessment of diastolic function recovery was a safe method, and our results showed that even in incomplete revascularization group of patients the recovery of diastolic function could be as good as in the complete one, if the indication for revascularization was correct.

Relationship of genetic markers for atherosclerosis and long-term outcome after percutaneous coronary intervention with stenting.

The aim of the study was to describe the relationship of clinical outcome after percutaneous coronary intervention (PCI) with stenting and genetic polymorphisms (GP) which are known to relate to the incidence of in-stent restenosis and late thrombotic complications. The study included 190 patients with standardized clinical follow-up over 5 years, which were initially treated with PCI. We investigated clinical data, angiographic characteristics, 10 polymorphisms involved in neointimal hyperplasia and late thrombosis at 6 different levels and their relationship with the major adverse cardiac events (MACE). The long-term clinical outcome was defined by MACE: death, target vessel revascularization (PCI or coronary bypass grafting, CABG) and myocardial infarction. Angiotensin receptor type I (AGTR A1166C) and angiotensinogen (AGT MET235THR) GPs correlated with repeat revascularization and total MACE. Carriers of G allele for NOS3 A922G GP were shown to have a significantly lower repeat revascularization rate in comparison with the AA genotype, as did the T allele carriers in the NOS3 C690T GP analysis when compared to the CC genotype. The Asp genome carriers with the NOS3 GLU298ASP GP were also shown to have significantly less re-PCI in contrast to the Glu/Glu genotype. The study could document the protective influence of the 4G/5G GP for plasminogen inhibitor activator-1, which carried the lowest rate of re-PCI and total MACE during the follow-up. GPs for beta-1 G-protein subunit GNB3 C825T, fibrinogen FGB G455A and E-selectins Ser128Arg and Leu554Phe did not show statistical correlation with the clinical outcome. The results illustrate the potential use of genetic markers in defining patients with possibly worse clinical outcome after PCI, who may profit from more aggressive prevention of restenosis and late thrombotic complications.

Angiographic control and percutaneous treatment of myocardial ischemia immediately after CABG.

Perioperative myocardial ischemia is rare but serious complication of CABG. Graft dysfunction, coronary artery thrombosis and incomplete revascularization are main causes. Pharmacological treatment, intra aortic counter pulsation and immediate additional grafting have limited results. Treatment strategy based on coronary angiography findings could lessen the burden of high mortality rate in these patients. The purpose of this study was to analyze the causes of perioperative ischemia and angiography based treatment strategy including percutaneous intervention. We enrolled all 55 consecutive patients that went early coronary angiography for perioperative myocardial ischemia in a prospective longitudinal study. Incorrect graft anastomosis, graft spasm, displacement and dissection were found in 49%, 7%, 5% and 4% of patients, respectively. Acute coronary artery thrombotic occlusion was found in 5% of patients and ischemia due to incomplete revascularization in 6% of patients. In 22% of patients no cause of myocardial ischemia could be detected. There were no complications of coronary angiography. Based on coronary angiography findings percutaneous intervention was performed in 30 patients, additional grafting in 8 patients and no action was taken in 17 patients. Percutaneous intervention with stenting was performed on coronary arteries (78%) and graft anastomosis (22%) with primary success 97%. One anastomosis rupture with treatable tamponade and one lethal stent thrombosis were complications of percutaneous treatment. Overall in hospital mortality was 30%. We concluded that graft dysfunction is usual cause of myocardial ischemia due to incorrect anastomosis and that percutaneous intervention on bypass graft or coronary artery can lessen high mortality rate in these patients.

Is the extent of left atrial fibrosis associated with body mass index in patients undergoing pulmonary vein isolation for atrial fibrillation?

BACKGROUND: Left atrial (LA) fibrosis is associated with a higher rate of recurrence of atrial fibrillation (AF) after pulmonary vein isolation (PVI). Body mass index (BMI) is strongly associated with the prevalence of AF, but there is insufficient data about the association between BMI and LA fibrosis. AIMS: The aim of the study was to examine the association between LA fibrosis and BMI in patients with AF undergoing PVI. METHODS: In 114 patients an electro-anatomical voltage map was created using the CARTO 3 three-dimensional system before PVI. The total fibrosis area (voltage criteria ≤0.5 mV), percentage, and the number of fibrotic areas were calculated. A general linear model was used to determine the differences in BMI with confounders between groups of patients with differing extents of fibrosis and numbers of focuses. RESULTS: Advanced fibrosis was found in 53 (47%) patients, in up to 9 areas with a median of 2 and an interquartile range (IQR) of 0-3. The median total fibrotic area was 27.3 cm2 with an IQR of 0.1-30.3 cm2. Patients were stratified by percentage of fibrotic area: <5%, 5%-20%, 20%-35%, and above 35%; no significant difference in mean BMI was found between the groups (P = 0.57). When stratified by the number of fibrotic areas (0, 1, 2, and ≥3 fibrotic areas), no difference in BMI was noted between the groups (P = 0.67). CONCLUSIONS: Fibrosis of the LA, as the strongest predictor of AF recurrence after PVI, does not correlate with BMI in patients with AF where PVI is indicated.

Management of perioperative myocardial ischaemia after isolated coronary artery bypass graft surgery.

Objectives: Updated knowledge about perioperative myocardial ischaemia (MI) after coronary artery bypass grafting (CABG) and treatment of acute graft failure is needed. We analysed main factors associated with perioperative MI and effects of immediate coronary angiography-based treatment strategy on patient outcome. Methods: Among 1119 consecutive patients with coronary artery disease who underwent isolated CABG between January 2011 and December 2015, 43 (3.8%) patients underwent urgent coronary angiography due to suspected perioperative MI. All the data were prospectively collected and retrospectively analysed. The primary endpoint was 30-day mortality; postoperative left ventricular ejection fraction) and major adverse cardiac events were secondary endpoints.ResultsOverall, 30-day mortality in patients with CABG was 1.4% while in patients who developed perioperative MI was 9% (4 patients). Angiographic findings included incorrect graft anastomosis, graft spasm, dissection, acute coronary artery thrombotic occlusion and ischaemia due to incomplete revascularisation. Emergency reoperation (Redo) was performed in 14 (32%), acute percutaneous coronary intervention (PCI) in 15 (36%) and conservative treatment (Non-op) in 14 patients. Demographic and preoperative clinical characteristics between the groups were comparable. Postoperative LVEF was significantly reduced in the Redo group (45% post-op vs 53% pre-op) and did not change in groups PCI (56% post-op vs 57% pre-op) and Non-op (58% post-op vs 57% pre-op). Conclusions: Urgent angiography allows identification of the various underlying causes of perioperative MI and urgent treatment when this is needed. Urgent PCI may be associated with improved clinical outcome in patients with early graft failure.

Acute ischemic stroke mimicking subarachnoid hemorrhage after coronary angioplasty.

Use of non-ionic contrast media (CM) in coronary arteriography has been reported to cause transient cortical blindness, confusion, amnesia and very rare focal deficits. We report a 69-year old patient with stable angina pectoris who underwent coronary angioplasty with stent placement due to in-stent thrombosis of the right coronary artery and developed stroke symptoms with radiological suspicion of subarachnoid hemorrhage. No vascular malformations were detected on CT cerebral angiography. Dual antiplatelet treatment was continued. Complete neurological recovery was observed within 48 hours post angiography. As observed with repeated CT scans, sulcal hyperdensities mostly faded after 24 hours and totally disappeared within 7 days when she was discharged home. Our case shows transient neurological symptoms and rapid disappearing of sulcal hyperdensities, suggesting temporary blood brain barrier disruption, consequential cerebral infarction and contrast media extravasation as the main mechanisms which allowed us to treat the patient with dual antiplatelet treatment.

Connections between nutritional status and proton pump inhibitor therapy in patients scheduled for cardiovascular rehabilitation after treatment for ischaemic and valvular heart disease.

BACKGROUND: Multiple and yet uncertain connections exist between cardiovascular diseases and the nutritional status of patients, particularly in relation to cardiovascular treatments. Proton pump inhibitors (PPI) are among the most commonly used group of drugs. AIM: To analyse utilisation of PPI in association with nutritional risk of patients scheduled for rehabilitation after treatment for ischaemic and valvular heart disease. METHODS: Retrospective analyses on a consecutive sample of patients, which included drug utilisation of PPI and nutritional risk screening, using a standardised NRS-2002 tool. The patients (n = 536) were divided into groups based on previous cardiovascular treatments and use of PPI. RESULTS: Nearly half of the patients (244, 46.1%) had PPI in their chronic therapy despite the clinically negligible prevalence of conditions that are their fundamental indications. The odds for using PPI in patients with increased nutritional risk, estimated by logistic regression, were 3.34 (95% confidence intervals [CI] 2.26-4.94), p < 0.001. Receiver operating curve analyses also revealed significant differences of PPI utilisation in connection with NRS-2002 > 3: positive likelihood-ratio (LR) 2.35 (95% CI 2.10-2.60); negative LR 0.46 (95% CI 0.4-0.6); area under the curve (AUC) 0.720; p < 0.001; as well as the percentage weigh loss history > 6.36% (positive LR 2.22 [95% CI 2.00-2.50]; negative LR 0.41 [95% CI 0.30-0.50]; AUC 0.707; p < 0.001). CONCLUSIONS: Utilisation of PPI was found to be of relatively high prevalence and significantly associated with parameters of nutritional risk screening. Furthermore, it was in correlation with the age of patients and the existence of chronic kidney disease, which are well-established predispositions for poor nutritional status. Nutritional risk seems to be additionally negatively challenged by utilisation of PPI due to gastric malabsorption and anaemia.