Stroke and death prediction with CHA2DS2-vasc score after myocardial infarction in patients without atrial fibrillation.

AIMS: The CHA2DS2-VASc score is widely used to stratify the risk of stroke in patients with nonvalvular atrial fibrillation. The aim of the study was to assess whether the CHA2DS2-VASc score might be useful to identify patients at a high risk of ischemic stroke and death among individuals after acute myocardial infarction and with no history of atrial fibrillation. METHODS: We analysed consecutive patients with acute myocardial infarction admitted to our centre between 2003 and 2008. On the basis of the CHA2DS2-VASc score, four groups were distinguished: low-risk (1 point), intermediate-risk (2-3 points), high-risk (4-5 points) and very high-risk (>5 points). Data on long-term follow-up were screened to identify patients who experienced stroke or died during remote observation. RESULTS: Out of 2980 registry participants, 333 were excluded because of atrial fibrillation and/or ongoing therapy with oral anticoagulants. Finally, 2647 individuals were included into the analysis. An ischemic stroke occurred in 71 (2.68%) patients, whereas 439 (16.58%) died during a median follow-up of 41.5 months. The risk of stroke and death increased four-fold in the high-risk group compared with the low-risk group (P < 0.001). Every point in the CHA2DS2-VASc score was independently associated with 41% increase in stroke risk and 23% increase in mortality rate (for both P < 0.001). CONCLUSION: The mortality rate and risk of stroke were strongly associated with the CHA2DS2-VASc scores. Hence, this scoring system could be useful to identify high-risk patients with no history of atrial fibrillation, in whom additional preventive measures might be beneficial to improve the outcome.

Efficacy of cardiac resynchronisation therapy in the treatment of end-stage inotrope-dependent heart failure patients.

BACKGROUND AND AIM: Currently, cardiac resynchronisation therapy (CRT) is recommended only for New York Heart Association (NYHA) class IV ambulatory patients. However, some recent reports have suggested that CRT could also be beneficial for end-stage inotrope-dependent heart failure (HF) NYHA class IV patients. In this report, we summarise the results of CRT implantation in a group of 11 HF inotrope-dependent patients who were not candidates for urgent orthotopic heart transplantation (OHT). METHODS AND RESULTS: Between August 2006 and June 2011, 11 end-stage inotrope-dependent HF patients with wide QRS complex, ineligible for urgent OHT, were implanted with CRT in the Silesian Centre for Heart Diseases in Zabrze. Dependence on inotropic therapy was defined as an inability to stop the infusion of the drug without the occurrence of hypotension, oligooranuria and/or hypoxaemia. All patients were successfully implanted with CRT and subsequently weaned from inotropes in a median time of two (1-17) days. Mean QRS duration shortened from 190 ± 34 ms at baseline to 142 ± 25 ms (p < 0.001) after the procedure. Average left ventricular ejection fraction increased from 19 ± 4% to 25 ± 4% (p < 0.001). All patients were discharged from hospital. Median hospital stay after the procedure was ten (5-56) days. During the median follow-upof 1,212 (182-2,048) days, four patients died (one due to arrhythmic storm, three others due to progressive pump failure). During that period, 57 adequate device interventions occurred in three patients, including 52 therapies in one fatal case. CONCLUSIONS: CRT can be an alternative for end-stage inotrope-dependent HF patients with wide QRS who are ineligible for urgent heart transplantation.

The impact of unsuccessful percutaneous coronary intervention on short- and long-term prognosis in STEMI and NSTEMI.

OBJECTIVES: To compare the impact of the efficacy of percutaneous coronary intervention (PCI) on prognosis in ST and non-ST elevation myocardial infarction (STEMI and NSTEMI) patients with respect to infarct-related artery (IRA). BACKGROUND: The significance of the efficacy of PCI in STEMI and NSTEMI depending on the type of IRA has yet to be clarified. METHODS: Study population consisted of 2,179 STEMI and 554 NSTEMI consecutive patients treated with urgent PCI. The efficacy of PCI (TIMI [thrombolysis in myocardial infarction] 3 vs. TIMI < 3) was assessed with regard to the type of IRA (left anterior descending artery, circumflex artery [Cx] or right coronary artery). The mean follow-up was 37.5 months. RESULTS: The rate of unsuccessful PCI was similar in STEMI and NSTEMI irrespectively of IRA (14.1 vs. 17.7%; P = 0.062). In STEMI, unsuccessful PCI was associated with significantly higher early (23.1 vs. 5.6%; P < 0.001) and late (29.9 vs. 12.8%; P < 0.001) mortality regardless of IRA. In NSTEMI, the inefficacious PCI significantly increased early (19.0% vs. 0.9%; P < 0.001) and late (27.3% vs. 6.3%; P < 0.001) mortality only in patients with Cx-related infarction. Unsuccessful PCI of IRA was an independent risk factor for death in STEMI (HR 1.64; P < 0.05), but not in NSTEMI (P = 0.64). Further analysis showed that whilst unsuccessful PCI of any vessel in STEMI is an independent risk factor for death, in NSTEMI this applies to unsuccessful PCI of Cx only. CONCLUSIONS: The significance of unsuccessful PCI of IRA seems to be different in STEMI and NSTEMI. Unsuccessful PCI is an independent risk factor for death in STEMI regardless of IRA and in NSTEMI with the involvement of Cx.

A differential release of matrix metalloproteinases 9 and 2 during coronary artery bypass grafting and off-pump coronary artery bypass surgery.

OBJECTIVES: Extracorporeal circulation is associated with the systemic inflammatory response syndrome. The objective of this study was to measure plasma and myocardial matrix metalloproteinase 2 and 9 levels in patients undergoing off-pump coronary artery bypass and coronary artery bypass grafting. METHODS: Twenty patients subjected to coronary artery bypass grafting and 20 subjected to off-pump coronary artery bypass surgery were included in this study. In both procedures blood was collected in 7 equivalent time points up to 12 hours after grafting. The myocardial biopsy specimens were collected before and after extracorporeal circulation in the coronary artery bypass grafting group and after harvesting and completion of proximal anastomoses in the off-pump coronary artery bypass group. Matrix metalloproteinase levels were measured by means of zymography. Myeloperoxidase and tissue inhibitor of metalloproteinase 1 and 2 levels were measured with an enzyme-linked immunosorbent assay. RESULTS: Coronary artery bypass grafting but not off-pump coronary artery bypass led to a 700- to 900-fold increase of plasma matrix metalloproteinase 9 levels. A small but significant increase in matrix metalloproteinase 2 levels was detected in both procedures. Myocardial matrix metalloproteinase 9 levels significantly increased at the end of coronary artery bypass grafting and off-pump coronary artery bypass. Increased matrix metalloproteinase 9 activity at the end of extracorporeal circulation was accompanied by augmentation of the endogenous matrix metalloproteinase inhibitors tissue inhibitor of metalloproteinase 1 and 2 in plasma, but its magnitude was unable to balance the plasma matrix metalloproteinase 9 increase. The matrix metalloproteinase 9 content in plasma at the end of extracorporeal circulation correlated with the myeloperoxidase plasma concentration (r(2) = 0.8212, P < 0.05). CONCLUSION: We propose that release of matrix metalloproteinase 9 might contribute to the extracorporeal circulation-induced inflammatory reactions.