Pretreatment with prasugrel in non-ST-segment elevation acute coronary syndromes.

BACKGROUND: Although P2Y12 antagonists are effective in patients with non-ST-segment elevation (NSTE) acute coronary syndromes, the effect of the timing of administration--before or after coronary angiography--is not known. We evaluated the effect of administering the P2Y12 antagonist prasugrel at the time of diagnosis versus administering it after the coronary angiography if percutaneous coronary intervention (PCI) was indicated. METHODS: We enrolled 4033 patients with NSTE acute coronary syndromes and a positive troponin level who were scheduled to undergo coronary angiography within 2 to 48 hours after randomization. Patients were randomly assigned to receive prasugrel (a 30-mg loading dose) before the angiography (pretreatment group) or placebo (control group). When PCI was indicated, an additional 30 mg of prasugrel was given in the pretreatment group at the time of PCI and 60 mg of prasugrel was given in the control group. RESULTS: The rate of the primary efficacy end point, a composite of death from cardiovascular causes, myocardial infarction, stroke, urgent revascularization, or glycoprotein IIb/IIIa inhibitor rescue therapy (glycoprotein IIb/IIIa bailout) through day 7, did not differ significantly between the two groups (hazard ratio with pretreatment, 1.02; 95% confidence interval [CI], 0.84 to 1.25; P=0.81). The rate of the key safety end point of all Thrombolysis in Myocardial Infarction (TIMI) major bleeding episodes, whether related or not related to coronary-artery bypass grafting (CABG), through day 7 was increased with pretreatment (hazard ratio, 1.90; 95% CI, 1.19 to 3.02; P=0.006). The rates of TIMI major bleeding and life-threatening bleeding not related to CABG were increased by a factor of 3 and 6, respectively. Pretreatment did not reduce the rate of the primary outcome among patients undergoing PCI (69% of the patients) but increased the rate of TIMI major bleeding at 7 days. All the results were confirmed at 30 days and in prespecified subgroups. CONCLUSIONS: Among patients with NSTE acute coronary syndromes who were scheduled to undergo catheterization, pretreatment with prasugrel did not reduce the rate of major ischemic events up to 30 days but increased the rate of major bleeding complications. (Funded by Daiichi Sankyo and Eli Lilly; ACCOAST ClinicalTrials.gov number, NCT01015287.).

Development of In-Hospital Outcomes in Patients undergoing Transcatheter Aortic Valve Implantation (TAVI) at an Interdisciplinary Heart Center: A Single-Center Experience of 489 Consecutive Cases.

Background: Transcatheter Aortic Valve Implantation (TAVI) has emerged over time, reflected in appropriate adjustments in the European Society of Cardiology (ESC) guidelines in 2007, 2012 and 2017. Objective: The aim of this study was to analyze in-hospital outcomes after TAVI in the development within a single heart center over a period of 10 years depending on adjustments in the guidelines, infrastructural and procedural determinants. Methods: 489 consecutive patients who underwent TAVI from 2010 and 2019 at our center were analyzed retrospectively. Patients were divided into 3 groups of different treatment circumstances depending on guidelines adjustments and local infrastructural progress (group 1: 2010-2015 (n = 132), group 2: 2016-2017 (n = 155), group 3: 2018-2019 (n = 202). The primary endpoint was defined as all-cause in-hospital mortality. Secondary endpoints were selected according to the Valve Academic Research Consortium (VARC)-2 definitions. Multivariate logistic regression analysis was performed to determine predictors of in-hospital mortality. Statistical significance was assumed for p < 0.05. Results: 489 patients (346 (70.8 %) transfemoral and 143 (29.2 %) transapical) underwent TAVI. Comparing periods (group 1 vs. 2 vs. 3) age (82.1 ± 6.2 vs. 82.5 ± 4.8 vs. 81.1 ± 5.1 years, p = 0.012) and EuroSCORE II (8.4 ± 6.0 vs. 5.8 ± 4.9 vs. 5.5 ± 5.0 %, p < 0.001) declined over time. Rates of in-hospital mortality decreased significantly (9.1 % vs. 5.8 % vs. 2.5 %, p = 0.029), especially with observed-to-expected mortality ratios indicating a disproportionate decline of in-hospital mortality (1.08 vs. 1.00 vs. 0.45). Furthermore, post-procedural complications, such as acute kidney injury stage 3 (10.6 % vs. 3.2 % vs. 4.5 %, p = 0.016) and bleeding complications (14.4 % vs. 11.6 % vs 7.9 %, p = 0.165) decreased from group 1 to 3. However, rates of permanent pacemaker implantations (7.6 % vs. 11.0 % vs. 22.8 %, p < 0.001) increased, associated with a switch towards self-expanding valves (0.0 % vs. 61.3 % vs. 76.7 %, p < 0.001). Length of hospitalization as well as stay at intensive care and intermediate care unit could be reduced significantly during the observation period. In multivariate analysis age (OR: 1.103; 95 % CI: 1.013 - 1.202; p = 0.025), creatinine level before TAVI (OR: 1.497; 95 % CI: 1.013 - 2.212; p = 0.043), atrial fibrillation (OR: 2.956; 95 % CI: 1.127 - 7.749; p = 0.028) and procedure duration (OR: 1.017; 95 % CI: 1.009 - 1.025; p < 0.001) could be identified as independent predictors of in-hospital mortality. Conclusion: This study identified age, creatinine level before TAVI, the presence of atrial fibrillation and procedure duration as independent predictors for in-hospital mortality. Although these predictors decreased during the observation period, the decline in hospital-mortality was disproportionate, which was indicated by an observed-to-expected mortality ratio of 0.45 for the last observation period. However, it can be assumed that apart from patient-related factors, there were further institutional, technical and procedural developments, which ran in parallel and affected in-hospital mortality rates after TAVI.

Comparative Methodological Assessment of the Randomized GLOBAL LEADERS Trial Using Total Ischemic and Bleeding Events.

BACKGROUND: Time-to-first-event analysis considers only the first event irrespective of its severity. There are several methods to assess trial outcomes beyond time-to-first-event analysis, such as analyzing total events and ranking outcomes. In the GLOBAL LEADERS study, time-to-first-event analysis did not show superiority of ticagrelor monotherapy following one-month dual antiplatelet therapy (DAPT) after percutaneous coronary intervention to conventional 12-month DAPT followed by aspirin monotherapy in the reduction of the primary composite end point of all-cause mortality or new Q-wave myocardial infarction. This study sought to explore various analytical approaches in assessing total ischemic and bleeding events after percutaneous coronary intervention in the GLOBAL LEADERS study. METHODS AND RESULTS: Total ischemic and bleeding events were defined as all-cause mortality, any stroke, any myocardial infarction, any revascularization, or Bleeding Academic Research Consortium grade 2 or 3 bleeding. We used various analytical approaches to analyze the benefit of ticagrelor monotherapy over conventional DAPT. For ischemic and bleeding events at 2 years after percutaneous coronary intervention, ticagrelor monotherapy demonstrated a 6% risk reduction, compared with conventional 12-month DAPT in time-to-first-event analysis (hazard ratio, 0.94 [95% CI, 0.88-1.01]; log-rank P=0.10). In win ratio analysis, win ratio was 1.05 (95% CI, 0.97-1.13; P=0.20). Negative binomial regression and Andersen-Gill analyses which include repeated events showed statistically significant advantage for ticagrelor monotherapy (rate ratio, 0.92 [95% CI, 0.85-0.99; P=0.020] and hazard ratio, 0.92 [95% CI, 0.85-0.99; P=0.028], respectively), although in weighted composite end point analysis, the hazard ratio was 0.93 (95% CI, 0.84-1.04; log-rank P=0.22). CONCLUSIONS: Statistical analyses considering repeated events or event severity showed that ticagrelor monotherapy consistently reduced ischemic and bleeding events by 5% to 8%, compared with conventional 1-year DAPT. Applying multiple statistical methods could emphasize the multiple facets of a trial and result in accurate and more appropriate analyses. Considering the recurrence of ischemic and bleeding events, ticagrelor monotherapy appeared to be beneficial after percutaneous coronary intervention. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01813435.

Elevated TNFalpha production in whole blood in patients with severe COPD: the potential link to disease severity.

OBJECTIVE: The relationship between tumour necrosis factor-alpha (TNFalpha), severity of pulmonary disease and nutritional depletion in chronic obstructive pulmonary disease (COPD) remains unclear. We aimed to clarify the role of lipopolysaccharide (LPS) as a potential stimulus of cytokine production and the role of these cytokines in the alteration of body composition in patients with different degrees of COPD. PATIENTS AND METHODS: We studied 29 weight-stable out-patients with different severites of COPD who had no evidence of recent infection or significant co-morbidity. Baseline serum TNFalpha levels and TNFalpha response to LPS in whole blood were measured in patients and 20 aged matched controls. RESULTS: Serum TNFalpha was significantly elevated in patients versus controls (2.1 +/- 0.3 vs. 1.1 +/- 0.1 pg/ml, mean +/- SEM, P = 0.007). In patients with COPD, we found a significant correlation between serum TNFalpha levels and disease severity, assessed as FEV(1) %predicted (r = 0.49, P = 0.02). Response to lipopolysaccharide did not differ significantly between patients and controls. However, within the patient group those with more severe disease (FEV(1) < or = 30% predicted, n = 12) had an enhanced response compared to patients with mild-to-moderate disease (all P < 0.05 for LPS > 1 ng/ml). Spontaneous TNFalpha production was 5.0 times higher in patients with severe COPD compared to mild-to-moderate COPD (P = 0.02). There was no relation between body composition and serum TNFalpha or TNFalpha response to LPS. CONCLUSION: Increasing airflow obstruction and hypercapnia are associated with an enhanced TNFalpha response in COPD.

Anticoagulation with argatroban for elective percutaneous coronary intervention: population pharmacokinetics and pharmacokinetic-pharmacodynamic relationship of coagulation parameters.

The synthetic direct thrombin inhibitor argatroban has a rapid onset and offset of anticoagulation. However, there are no data about the pharmacokinetic-pharmacodynamic (PK-PD) relationship of argatroban in patients undergoing contemporary percutaneous coronary intervention (PCI) and no data about other coagulation parameters than activated clotting time (ACT) in this setting. In the ARG-E04-trial, 140 patients were randomly assigned to argatroban (250, 300, or 350 µg/kg as bolus before PCI, followed by 15, 20, or 25 µg/kg/min infusion) or unfractionated heparin (70-100 IU/kg bolus). A 2-compartment model with first-order elimination adequately described the pharmacokinetic profile of argatroban over all 3 dosing groups. Clearance (CL) and distribution volumes (V1 and V2) were 21 L/h, 9.2 L, and 6.6 L, respectively. A significant sigmoidal E(max) relationship was established between the argatroban plasma concentration and the response in ACT and the endogenous thrombin potential (ETP), whereas the response in activated partial thromoplastin time (aPTT), ecarin time (ECA-T), and prothrombinase-induced clotting time (PiCT) could be described by a nonsigmoidal E(max) model. This study proves a relatively small interindividual variability of both PK and PK-PD properties of argatroban even at high doses and supports the profile of argatroban as a drug with a predictive dose-effect relationship and therefore good controllability.

Inflammation in right ventricular dysfunction due to thromboembolic pulmonary hypertension.

OBJECTIVES AND BACKGROUND: Activation of the immune system is well established in patients with chronic heart failure (CHF) and impaired left ventricular function. High levels of pro-inflammatory cytokines are associated with a poor prognosis. Chronic thromboembolic pulmonary hypertension (CTEPH) frequently leads to impaired right ventricular function. It is not known whether such patients display chronic immune activation as well. METHODS AND RESULTS: We studied 49 patients with CTEPH (50±2 years, right ventricular ejection fraction [RVEF] 29±2%, left ventricular ejection fraction [LVEF] 51±3%, mean±SEM) and compared their results with 17 patients with CHF (71±2 years, LVEF 23±1%) and 34 age-matched control subjects (age 57±2 years). We studied serum levels of tumor necrosis factor-α (TNFα), its soluble receptors 1 and 2 (sTNFR1 and 2), interleukin-10 (IL-10) and plasma N-terminal-pro-B-type natriuretic peptide (NT-proBNP). Serum TNFα was not different in CTEPH compared with CHF patients (p=0.67) but both their levels were significantly higher than in controls (both p<0.001). Similar results were obtained for sTNFR1, sTNFR2, and IL-10. Levels of NT-proBNP were not different in patients with CTEPH or CHF (p=0.54), but significantly higher than in control subjects (both p<0.001). There were significant correlations between RVEF as assessed by magnetic resonance imaging and sTNFR1, sTNFR2, IL-6, high sensitivity C-reactive protein, and NT-proBNP (all p<0.05) in patients with CTEPH. CONCLUSION: Similar levels of immune activation as reflected by high levels of pro-inflammatory cytokines are present in patients with isolated right ventricular dysfunction due to CTEPH and patients with CHF and left ventricular dysfunction.

Inflammatory pathways in patients with heart failure and preserved ejection fraction.

UNLABELLED: Immune activation is well established in patients with chronic heart failure and reduced ejection fraction (HF and reduced EF) and is associated with an impaired prognosis. Patients with heart failure and preserved ejection fraction (HF and preserved EF) have an impaired prognosis as well. It is not known whether they have signs of immune activation. METHODS: We studied patients with HF and preserved EF (n=17, NYHA II [n=7]/III [n=10]) and patients with HF and reduced EF (n=17 NYHA II [n=1]/III [n=16]) and 20 controls. Echocardiography demonstrated preserved ejection fraction (LVEF 59+/-9%), but LV hypertrophy in patients with preserved EF as compared with patients with reduced EF (LVEF 23+/-5%). We evaluated levels of TNFalpha, its receptors (sTNFR-1 and 2), IL-6, IL-10 and NT-proBNP. RESULTS: TNFalpha, was highest in HF with reduced EF (2.87+/-0.65 vs 1.67+/-0.58 pg/mL, p<0.001) compared to preserved EF and similar between HF with preserved EF and controls. However, sTNFR1 (1618+/-384 vs 1017+/-302 pg/mL, p<0.001) and sTNFR2 levels (3554+/-916 vs 2041+/-586 pg/mL, p<0.001) in HF with preserved EF were significantly higher compared with controls. The same was true for IL-6, IL-10 and NT-proBNP. The highest cytokine and NT-proBNP levels were present in HF with reduced EF. There was a negative correlation between TNFalpha, and LVEF (r=- 0.700; p<0.0001) and positive correlations between sTNFR1 and 2 with NT-proBNP. CONCLUSION: Patients with HF and preserved EF already show signs of systemic-immune activation which may contribute to the impaired prognosis and the progression to HF with reduced EF.