Patients with Acute Coronary Syndrome are at High Risk Prior to the Event and Lipid Management is Underachieved Pre- and Post- Hospitalization.

BACKGROUND: Current European Guidelines suggest the use of cardiovascular risk categories and also recommend using high-intensity statins for patients with acute coronary syndromes (ACS). OBJECTIVE: We examined the risk of ACS patients prior to the event, as well as the overall use and intensity of statins. METHODS: We enrolled 687 ACS patients (mean age 63 years, 78% males). Low-density lipoprotein cholesterol (LDL-C) levels upon admission were used to assess attainment of LDL-C targets. Patients were categorized as very high, high, moderate and low risk based on their prior to admission cardiovascular (CV) risk. We examined statin use and dosage intensity among patients discharged from the hospital. Patients were followed for a median period of 189 days. RESULTS: The majority of the patients (n=371, 54%) were at very high CV risk prior to admission, while 101 patients were at high risk (15%), 147 (21%) moderate risk and 68 (10%) low risk. Interestingly, LDL-C target attainment decreased as the risk increased (p<0.001). The majority (96%) of patients received statins at discharge; however, most of them (60.4%) received low/moderate intensity statins and just 35.9% received the suggested by the Guidelines high-intensity dose of statins. At follow-up, the rate of patients at high-intensity dose of statins remained similar (34.8%); 6% received no statins at all at follow-up. CONCLUSION: According to our study, the majority of ACS patients are already at high risk prior to their admission. Further, LDL-C targets are underachieved prior to the event and high-intensity statins are underutilized in ACS patients at, and post-discharge.

Epidemiological characteristics, management and early outcomes of acute coronary syndromes in Greece: The PHAETHON study.

INTRODUCTION: In view of recent therapeutic breakthroughs in acute coronary syndromes (ACS) and essential demographic and socioeconomic changes in Greece, we conducted the prospective, multi-center, nationwide PHAETHON study (An Epidemiological Cohort Study of Acute Coronary Syndromes in the Greek Population) that aimed to recruit a representative cohort of ACS patients and examine current management practices and patient prognosis. METHODS: The PHAETHON study was conducted from May 2012 to February 2014. We enrolled 800 consecutive ACS patients from 37 hospitals with a proportional representation of all types of hospitals and geographical areas. Patients were followed for a median period of 189 days. Outcome was assessed with a composite endpoint of death, myocardial infarction, stroke, urgent revascularization and urgent hospitalization for cardiovascular causes. RESULTS: The mean age of patients was 62.7 years (78% males). The majority of patients (n=411, 51%) presented with ST-elevation myocardial infarction (STEMI), whereas 389 patients presented with NSTEMI (n=303, 38%) or UA (n=86, 11%). Overall, 58.8% of the patients had hypertension, 26.5% were diabetic, 52.5% had dyslipidemia, 71.1% had a smoking history (current or past), 25.8% had a family history of coronary artery disease (CAD) and 24.1% had a prior history of CAD. In STEMI patients, 44.5% of patients were treated with thrombolysis, 38.9% underwent a coronary angiogram (34.1% were treated with primary percutaneous coronary intervention) and 16.5% did not receive urgent treatment. The pain-to-door time was 169 minutes. During hospitalization, 301 (38%) patients presented one or more complications, and 13 died (1.6%). During follow-up, 99 (12.6%) patients experienced the composite endpoint, and 21 died (2.7%). CONCLUSIONS: The PHAETHON study provided valuable insights into the epidemiology, management and outcome of ACS patients in Greece. Management of ACS resembles the management observed in other European countries. However, several issues still to be addressed by public authorities for the timely and proper management of ACS.

Cardiovascular involvement in patients with beta-thalassemia major without cardiac iron overload.

BACKGROUND: Cardiovascular complications are common in beta-thalassemia major (beta-TM), mainly attributed to increased cardiac iron depositions. Early cardiovascular involvement in patients without cardiac symptoms and without cardiac iron overload has not been adequately investigated. METHODS: Twenty six patients (11 males) with beta-TM, on chelation therapy, age 23+/-4 years without cardiac iron overload (measured by magnetic resonance imaging), and 30 age and gender matched healthy controls were included in the study. Carotid-femoral and carotid-radial pulse wave velocity (PWVc-f and PWVc-r) and augmentation index (AI) were measured by SphygmoCor device; carotid intima-media thickness; left ventricular (LV) dimensions and function; left atrial (LA) volume and function were assessed by echocardiography. RESULTS: Patients with beta-TM had higher PWVc-f (8.4+/-1.4 vs 7.2+/-1.1 m/s, p=0.002) and augmentation index (21.7+/-10.9 vs 14.7+/-9.7%, p=0.04) indicating decreased aortic elastic properties; greater LV mass index (72.0+/-13.3 vs 63.8+/-11.5 g/m(2), p=0.04) and greater LA volumes. Multivariate logistic regression analysis revealed that higher PWVc-f was independently associated with higher LV mass [OR 1.74 95%CI (1.09-2.88), p=0.026]; and greater LA dimensions [OR 1.68 95%CI (1.04-2.72), p=0.035]. CONCLUSIONS: In the absence of cardiac iron overload, asymptomatic patients with beta-TM demonstrated aortic stiffening associated with increased LV mass and LA enlargement. These alterations may represent signs of early cardiovascular involvement.

Aortic arch calcification predicts the extent of coronary atherosclerosis in patients with or without type 2 diabetes: short communication.

AIM OF THE STUDY: The aim of this study was to evaluate the sensitivity and specificity of aortic arch calcification for detection of severe coronary atherosclerosis in patients suffering from coronary artery disease (CAD), with or without type 2 diabetes. PATIENTS AND METHODS: This study included 107 type 2 diabetic patients (68 men) with a mean age of 62.4 +/- 10.7 years and a mean diabetes duration of 14.2 +/- 5.9 years and 104 patients (63 men) with a mean age of 64.5 +/- 9.3 years who did not have diabetes. All patients had CAD, documented by coronary arteriography. Severe CAD was defined as atherosclerosis of the left main branch or atherosclerosis of three coronary arteries or atherosclerosis of the proximal part of the left anterior descending artery. Aortic arch calcification was assessed by means of posteroanterior chest X-rays, studied by a radiologist kept blind to the result of coronary arteriography. RESULTS: In type 2 diabetic patients, diagnosis of aortic arch calcification had 65.6% sensitivity and 86.9% specificity for detection of severe CAD. In patients without diabetes, diagnosis of aortic arch calcification had 47.7% sensitivity and 96.7% specificity for detection of severe CAD. CONCLUSIONS: Aortic arch calcification has a high specificity for detection of severe coronary atherosclerosis in patients with CAD. Sensitivity is higher in patients with type 2 diabetes, while specificity is slightly higher in non-diabetic patients.

Could sustained monomorphic ventricular tachycardia in the early phase of a prime acute myocardial infarction affect patient outcome?

OBJECTIVES: Sustained monomorphic ventricular tachycardia (SMVT) in the course of a prime acute myocardial infarction is not a common arrhythmia and its prognostic significance has not been specifically elucidated. The aim of the study was to estimate the prognostic implications of the occurrence of sustained monomorphic ventricular tachycardia in the early phase (<72 h) of a prime acute myocardial infarction. METHODS: We studied 690 consecutive patients admitted to the coronary care unit with a diagnosis of a prime myocardial infarction. SMVT was observed in 18 (2.6%) patients and we followed these patients for establishing the prognostic value of the arrhythmia according to the clinical characteristics. RESULTS: Patients with SMVT had a more extensive myocardial infarction based on the peak of the CK-MB isoenzyme activity (480+/-290 IU/L, vs 270+/-190 IU/L, P < .01), and higher mortality rate (40% vs 9%, P < .001). The independent predictors of SMVT were CK-MB (odds ratio [OR] 12.4), presence of complex ventricular arrhythmias (OR = 5.7), a wide QRS complex > or =130 milliseconds (OR = 4.8) and Killip class (OR = 4.8). The SMVT was itself an independent predictor of mortality (OR = 5.0). Compared with patients with ventricular fibrillation or polymorphic ventricular tachycardia, those with SMVT had a higher CK-MB activity, higher rate of wide QRS > or =130 milliseconds (33% vs 8%, P < .002), had a worse hemodynamic condition (Killip class >I:58% vs 23%, P < .04) and higher recurrence rate of ischemic events (68% vs 16%, P < .05). During the one year follow-up period, 4 patients (36.3%) of the 11 survivors from those with SMVT died of cardiac related causes. CONCLUSIONS: SMVT during the first 72 h of a prime myocardial infarction is an index of a larger healing myocardium with acute very complexed electrophysiological changes and it is an independent predictor of in-hospital mortality and a prognostic factor of a poor one year outcome.

Risk factors for concomitant peripheral arterial occlusive disease in patients with coronary artery disease: is there a difference between diabetic and non-diabetic patients?

AIM OF THE STUDY: The aim of the present study was investigation of cardiovascular risk factors for concomitant Peripheral Arterial Occlusive Disease (PAOD) in diabetic vs. non-diabetic patients with coronary artery disease (CAD). PATIENTS AND METHODS: This study included 302 patients (229 men) with a mean age of 62.2 +/- 11.5 years and angiographically documented CAD. These were divided into Group A comprising 116 diabetic patients (79 men) and Group B comprising 186 non-diabetic patients (150 men). Peripheral Arterial Occlusive Disease (PAOD) was diagnosed using a Doppler apparatus. Cardiovascular risk factors that were investigated included age, history of myocardial infarction, smoking, Body-Mass Index, Waist-Hip-Ratio, hypertension and serum lipids. RESULTS: PAOD was diagnosed in 49 patients of Group A (42.4%) and 20 patients of Group B (10.8%). In Group A concomitant PAOD was associated with significantly (p = 0.0001) longer diabetes duration and significantly (p = 0.0001) higher frequency of insulin treatment, as well as significantly (p = 0.02) higher triglycerides and significantly (p = 0.039) lower HDL-Cholesterol. In Group B patients with PAOD had significantly (p = 0.0001) higher age and significantly higher (p = 0.041) LDL-Cholesterol levels than those without PAOD. No association was found between PAOD and presence of remaining risk factors in either group. In multiple regression analysis, concomitant PAOD was associated with diabetes duration (p = 0.0026) and insulin treatment (p = 0.0004) in Group A, while it was associated with age (p = 0.01) in Group B. The associations with serum lipids were no longer significant. CONCLUSIONS: Among non-diabetic patients with CAD, those who have concomitant PAOD are significantly older. Among diabetic patients with CAD, those who have concomitant PAOD show significantly longer diabetes duration and significantly higher frequency of insulin treatment.

Long term cardiovascular effects of oral antidiabetic agents in non-diabetic patients with insulin resistance: double blind, prospective, randomised study.

OBJECTIVE: To study the long term cardiovascular effects of oral antidiabetic agents in non-diabetic patients with insulin resistance. PATIENTS: 181 African American subjects with insulin resistance and normal glucose tolerance test were randomised to receive glipizide 5 mg/day (n = 25), metformin 500 mg/day (n = 59), or placebo (n = 97) for 24 months. Insulin sensitivity, glucose tolerance, lipid profile, left ventricular mass (echocardiography), aortic distensibility (echocardiography, blood pressure), aortic pulse wave velocity (PWV, carotid to femoral artery, Doppler) were measured at baseline and at 12 and 24 months after randomisation. RESULTS: A significant increase in PWV was observed in both glipizide (mean (SEM) change at 24 months 2.8 (2.7) m/s, p = 0.012) and metformin (2.2 (0.7) m/s, p = 0.01) groups during the follow up period. In contrast, PWV remained unchanged in the placebo group. The increase in PWV in the treatment groups was significant compared with placebo (analysis of variance p < 0.05). Other cardiovascular or metabolic variables did not change significantly compared with placebo during follow up. CONCLUSIONS: The observed increase in PWV is consistent with a decrease in the elastic properties of the aorta. The use of oral antidiabetic agents for the prevention of cardiovascular complications in non-diabetic African Americans with insulin resistance needs to be critically evaluated.

Detection of Mycobacterium tuberculosis complex DNA in pericardial fluid, bone marrow and peripheral blood in a patient with pericardial tuberculosis. A case report.

Definitive diagnosis of tuberculous pericarditis requires identification of bacilli in pericardial fluid or tissue. Conventional diagnostic methods are time-consuming and have a low sensitivity making bacteriological confirmation of the disease very difficult. Hereby, we report the case of molecular detection of Mycobacterium tuberculosis in pericardial fluid, bone marrow and peripheral blood from a 63-year-old woman with pericardial tuberculosis, using a nested PCR assay specific for IS6110 insertion element of M. tuberculosis complex. The patient had an excellent response to a three-drug combination anti-tuberculous regimen and 1 year later was asymptomatic, without evidence of constrictive pericarditis.