Coronary lesion complexity in patients with heterozygous familial hypercholesterolemia hospitalized for acute myocardial infarction: data from the RICO survey.

BACKGROUND: Although patients with familial heterozygous hypercholesterolemia (FH) have a high risk of early myocardial infarction (MI), the coronary artery disease (CAD) burden in FH patients with acute MI remains to be investigated. METHODS: The data for all consecutive patients hospitalized in 2012-2019 for an acute MI and who underwent coronary angiography were collected from a multicenter database (RICO database). FH (n = 120) was diagnosed using Dutch Lipid Clinic Network criteria (score ≥ 6). We compared the angiographic features of MI patients with and without FH (score 0-2) (n = 234) after matching for age, sex, and diabetes (1:2). RESULTS: Although LDL-cholesterol was high (208 [174-239] mg/dl), less than half of FH patients had chronic statin treatment. When compared with non-FH patients, FH increased the extent of CAD (as assessed by SYNTAX score; P = 0.005), and was associated with more frequent multivessel disease (P = 0.004), multiple complex lesions (P = 0.022) and significant stenosis location on left circumflex and right coronary arteries. Moreover, FH patients had more multiple lesions, with an increased rate of bifurcation lesions or calcifications (P = 0.021 and P = 0.036, respectively). In multivariate analysis, LDL-cholesterol levels (OR 1.948; 95% CI 1.090-3.480, P = 0.024) remained an independent estimator of anatomical complexity of coronary lesions, in addition to age (OR 1.035; 95% CI 1.014-1.057, P = 0.001). CONCLUSIONS: FH patients with acute MI had more severe CAD, characterized by complex anatomical features that are mainly dependent on the LDL-cholesterol burden. Our findings reinforce the need for more aggressive preventive strategies in these high-risk patients, and for intensive lipid-lowering therapy as secondary prevention.

Prevalence, risk factor burden, and severity of coronary artery disease in patients with heterozygous familial hypercholesterolemia hospitalized for an acute myocardial infarction: Data from the French RICO survey.

BACKGROUND: Individuals with heterozygous familial hypercholesterolemia (FH) are at high risk of early myocardial infarction (MI). However, coronary artery disease (CAD) burden of FH remains not well described, especially for French patients. OBJECTIVE: The objective of this study was to assess the prevalence of FH and severity of CAD from a large database of a French regional registry of acute MI. METHODS: All consecutive patients hospitalized for an acute MI in a multicenter database from 2001 to 2017 were considered. FH was diagnosed using an algorithm adapted from the Dutch Lipid Clinic Network criteria. The prevalence and clinical features of FH and the severity of CAD were assessed. RESULTS: Among the 11,624 patients included in the study, the proportion of "probable/definite", "possible", and "unlikely" FH in patients with MI was 2.1% (n = 249), 20.7% (n = 2405), and 77.2% (n = 8970), respectively. When compared with patients with "unlikely" FH, patients with "probable/definite" FH were 20 years younger (51 vs 71, P < .001), with a lower rate of diabetes (17% vs 25%, P = .007) and a higher prevalence of personal and familial history of CAD. Chronic statin treatment was only used in 48% of FH patients and ezetimibe in 8%. After adjustment for age, sex, and diabetes, patients with FH were characterized by increased extent of CAD (SYNTAX score 11 vs 7, P < .001) and multivessel disease (55% vs 40%, P < .001). CONCLUSIONS: In this large cohort of French individuals, FH was common in patients with MI, associated with markedly early age of MI and severity of CAD burden and limited use of preventive lipid-lowering therapy.

Predicting the development of in-hospital cardiogenic shock in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention: the ORBI risk score.

Aims: To derive and validate a readily useable risk score to identify patients at high-risk of in-hospital ST-segment elevation myocardial infarction (STEMI)-related cardiogenic shock (CS). Methods and results: In all, 6838 patients without CS on admission and treated by primary percutaneous coronary intervention (pPCI), included in the Observatoire Régional Breton sur l'Infarctus (ORBI), served as a derivation cohort, and 2208 patients included in the obseRvatoire des Infarctus de Côte-d'Or (RICO) constituted the external validation cohort. Stepwise multivariable logistic regression was used to build the score. Eleven variables were independently associated with the development of in-hospital CS: age >70 years, prior stroke/transient ischaemic attack, cardiac arrest upon admission, anterior STEMI, first medical contact-to-pPCI delay >90 min, Killip class, heart rate >90/min, a combination of systolic blood pressure <125 mmHg and pulse pressure <45 mmHg, glycaemia >10 mmol/L, culprit lesion of the left main coronary artery, and post-pPCI thrombolysis in myocardial infarction flow grade <3. The score derived from these variables allowed the classification of patients into four risk categories: low (0-7), low-to-intermediate (8-10), intermediate-to-high (11-12), and high (≥13). Observed in-hospital CS rates were 1.3%, 6.6%, 11.7%, and 31.8%, across the four risk categories, respectively. Validation in the RICO cohort demonstrated in-hospital CS rates of 3.1% (score 0-7), 10.6% (score 8-10), 18.1% (score 11-12), and 34.1% (score ≥13). The score demonstrated high discrimination (c-statistic of 0.84 in the derivation cohort, 0.80 in the validation cohort) and adequate calibration in both cohorts. Conclusion: The ORBI risk score provides a readily useable and efficient tool to identify patients at high-risk of developing CS during hospitalization following STEMI, which may aid in further risk-stratification and thus potentially facilitate pre-emptive clinical decision making.

N-Terminal Fragment of Pro B-type Natriuretic Peptide as a Marker of Contrast-Induced Nephropathy After Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction.

Contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) is frequent and associated with long-term renal impairment and mortality. Early markers of CIN are needed to improve risk stratification. We aimed to assess whether N-terminal fragment of pro B-type natriuretic peptide (Nt-proBNP) could be associated with CIN. From the French regional RICO survey, all the consecutive patients who underwent primary PCI for STEMI, from January 1, 2001, to December 3, 2013, were included. Nt-proBNP circulating levels were assessed on admission. CIN was defined as an increase in serum creatinine >26.5 µmol/L or >50% within 48 to 72 hours after PCI (KDIGO criteria). Of the 1,243 patients included, CIN occurred in 130 patients (10.4%). Nt-proBNP levels were 5 times greater in patients who developed CIN than without CIN (1,275 [435 to 4,022] vs 247 [79 to 986] pg/mL, p <0.001). Hospital mortality rate was markedly higher in patients with CIN (6.9% vs 1.1%, p <0.001). Nt-proBNP levels were univariate predictors for CIN as were age, hypertension, diabetes, smoking, previous stroke, heart rate, impaired left ventricular ejection fraction C-reactive protein, history of renal failure, anemia, and estimated glomerular filtration rate <30 ml/min/1.73 m(2) at baseline. Nt-proBNP levels remained strongly associated with the occurrence of CIN even after adjustment for risk factors, treatments, clinical and biological variables (odds ratio 1.99, 95% confidence interval 1.49 to 2.66). Net reclassification improvement was achieved by the addition of Nt-proBNP to the risk model (p = 0.003). In conclusion, from this large contemporary prospective study in nonselected population, our work suggests that Nt-proBNP levels at admission could help to identify patients at risk of CIN beyond traditional risk factors.

Pre-infarction angina and outcomes in non-ST-segment elevation myocardial infarction: data from the RICO survey.

BACKGROUND: The presence of pre-infarction angina (PIA) has been shown to confer cardioprotection after ST-segment elevation myocardial infarction (STEMI). However, the clinical impact of PIA in non-ST-segment elevation myocardial infarction (NSTEMI) remains to be determined. METHODS AND RESULTS: From the obseRvatoire des Infarctus de Côte d'Or (RICO) survey, 1541 consecutive patients admitted in intensive care unit with a first NSTEMI were included. Patients who experienced chest pain <7 days before the episode leading to admission were defined as having PIA and were compared with patients without PIA. Incidence of in-hospital ventricular arrhythmias (VAs), heart failure and 30-day mortality were collected. Among the 1541 patients included in the study, 693 (45%) patients presented PIA. PIA was associated with a lower creatine kinase peak, as a reflection of infarct size (231(109-520) vs. 322(148-844) IU/L, p<0.001) when compared with the group without PIA. Patients with PIA developed fewer VAs, by 3 fold (1.6% vs. 4.0%, p = 0.008) and heart failure (18.0% vs. 22.4%, p = 0.040) during the hospital stay. Overall, there was a decrease in early CV events by 26% in patients with PIA (19.2% vs. 25.9%, p = 0.002). By multivariate analysis, PIA remained independently associated with less VAs. CONCLUSION: From this large contemporary prospective study, our work showed that PIA is very frequent in patients admitted for a first NSTEMI, and is associated with a better prognosis, including reduced infarct size and in hospital VAs. Accordingly, protecting the myocardium by ischemic or pharmacological conditioning not only in STEMI, but in all type of MI merits further attention.

Early improvement of left ventricular function after implantation of a transcutaneous aortic valve: a tissue Doppler ultrasound study.

INTRODUCTION: The long-term effects of surgical treatment for aortic narrowing in left ventricular (LV) remodelling have been well described. The immediate benefit after release of obstruction is unknown. METHOD AND RESULTS: Nineteen patients with significant and symptomatic aortic stenosis underwent transcutaneous implantation of an aortic valve. A conventional and tissue Doppler echocardiography was performed 48 hours before and 24 hours after the procedure. Apart from the dimensions, LV function and aortic haemodynamics, we measured systolic and diastolic myocardial velocities and systolic strain. The procedure resulted in a decrease to the mean transaortic gradient (from 43+/-13 to 10+/- 3 mmHg, p=0.001), an increase of the aortic surface area (from 0.6+/-0.1 to 1.7+/-0.1cm(2), p=0.001) and a reduction in the systolic LV volume (62+/-27 to 48+/-22, p=0.04). We observed an improvement in the systolic radial and longitudinal strain of the posterior wall (p<0.05), septal wall (p<0.05) and lateral wall (p<0.05). Improvement in systolic velocities on these walls and the inferior wall (p<0.01) was also recorded. The regional diastolic velocity was significantly better on the posterior (p<0.05) and septal (p<0.05) walls. CONCLUSION: The immediate drop in the transaortic gradient resulted in an improvement in myocardial velocities and strain, a sign of improvement in the regional systolic and diastolic regional function.