Comparison of ticagrelor and clopidogrel in anemic patients with acute coronary syndrome: efficacy and safety outcomes over one year.

OBJECTIVE: This retrospective study aimed to investigate the potential impact of ticagrelor and clopidogrel treatment on cardiovascular outcomes in patients with anemia and acute coronary syndrome (ACS) and to provide insights into the optimal therapeutic approach for this vulnerable patient population. METHODS: A retrospective research design was employed, involving patients diagnosed with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI) between 2014 and 2021. Inclusion criteria required a hemoglobin level below 12 mg/dL and a minimum 12-month P2Y12 inhibitor treatment. Comprehensive clinical, biochemical, and echocardiographic data were collected from the hospital's electronic repository. The primary efficacy endpoint was major adverse cardiovascular events (MACE), encompassing total mortality, cardiovascular mortality, reinfarction, ischemic stroke, and hemorrhagic stroke. Major hemorrhage was the primary safety endpoint. Secondary outcomes included total mortality, cardiovascular mortality, reinfarction, ischemic stroke, and hemorrhagic stroke, individually. RESULTS: Patients treated with ticagrelor (n = 118) and clopidogrel (n = 538) were compared. No significant difference was observed in major adverse cardiovascular events (MACE) and major bleeding between ticagrelor and clopidogrel treatment groups (MACE: clopidogrel 10.0% vs. ticagrelor 11.0%, p = 0.75; major bleeding: clopidogrel 2.8%, ticagrelor 2.5%, p = 0.88). Patients with hemoglobin levels ≤ 8 mg/dL demonstrated significantly higher MACE and major bleeding rates in the ticagrelor group (p = 0.008 and p = 0.002, respectively). Among patients aged ≥ 75 years, ticagrelor treatment was associated with a higher risk of major bleeding (p = 0.04). CONCLUSIONS: Ticagrelor and clopidogrel exhibited comparable efficacy and safety outcomes in anemic ACS patients over a one-year period. Although ticagrelor demonstrated superiority in reducing ischemic events, it is crucial to recognize the limitations of retrospective studies in informing clinical practice. This study offers valuable insights into tailoring antiplatelet therapy for anemic ACS patients and provides guidance for personalized treatment strategies, acknowledging the hypothesis-generating nature of retrospective analyses.

Comparison of echocardiographic and clinical characteristics in embolic stroke and migraine patients with patent foramen ovale.

BACKGROUND: This single-center observational study aimed to compare the echocardiographic and clinical features in patients diagnosed with migraine and embolic stroke of undetermined source (ESUS) who presented with a known patent foramen ovale (PFO). METHODS: Two-dimensional and color Doppler images were obtained using various transthoracic echocardiography views for both migraine and ESUS patients. Suspected PFO cases underwent further assessment through contrast echocardiography and transesophageal echocardiography (TEE). High-risk PFO characteristics were evaluated using TEE, and the Risk of Paradoxical Embolism (RoPe) score was calculated. RESULTS: The study included 310 participants (age range: 18-60, 73.2% female), with 43.5% diagnosed with migraine and 56.5% with ESUS. Common comorbidities included diabetes (26.1%). High-velocity shunting through the interatrial septum was observed in 35.5% of patients. ESUS patients were older, with higher rates of diabetes and hypertension, while active smoking was more prevalent among migraine patients. Basic echocardiographic parameters were mostly similar, except for elevated pulmonary artery systolic pressure in ESUS. ESUS patients exhibited a greater occurrence of large microbubble passage through the interatrial septum and longer PFO lengths compared to migraine patients. However, the RoPe and High-risk PFO scores were similar between the groups. CONCLUSIONS: ESUS patients, characterized by older age and higher rates of diabetes and hypertension, demonstrated increased pulmonary artery pressure, more significant microbubble crossings, and longer PFO lengths. Conversely, migraine patients had a higher prevalence of active smoking. Despite differing clinical profiles, the risk scores for PFO-related embolic events were comparable between the groups. These findings underscore potential distinctions between ESUS and migraine patients with PFO and their implications for management strategies.

The predictive value of PRECISE-DAPT score for long-term mortality in patients with acute coronary syndrome complicated by cardiogenic shock.

BACKGROUND: Besides its primary clinical utility in predicting bleeding risk in patients with acute coronary syndrome (ACS), the PRECISE-DAPT (Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Anti-Platelet Therapy) score may also be useful for predicting long-term mortality in ACS patients presenting with cardiogenic shock (CS) since several studies have reported an association between the score and certain cardiovascular conditions or events. The aim of the present study was to evaluate the utility of the PRECISE-DAPT score for predicting the long-term all-cause mortality in patients (n = 293) with ACS presenting with CS. METHODS: The PRECISE-DAPT score was calculated for each patient who survived in hospital, and the association with long-term mortality was studied. Median follow-up time was 2.7 years. The performance of the final model was determined with measurements of its discriminative power (Harrell's and Uno's C indices and time-dependent area under the receiver operating characteristic curve [AUC]) and predictive accuracy (coefficient of determination [R2] and likelihood ratio χ2). Hazard ratios (HRs) were used to assess the relationship between the variables of the model and long-term all-cause death. RESULTS: All-cause death occurred in 197 patients (67%). There was a positive association between the PRECISE-DAPT score (change from 17 to 38 was associated with an HR of 2.42 [95% CI: 1.59-3.68], R2 = 0.209, time-dependent AUC = 0.69) and the risk of death such that in the adjusted survival curve, the risk of mortality increased as the PRECISE-DAPT score increased. CONCLUSION: The PRECISE-DAPT score may be a useful easy-to-use tool for predicting long-term mortality in patients with ACS complicated by CS.

Comparison of Ticagrelor and Clopidogrel in Patients With Acute Coronary Syndrome at High Bleeding or Ischemic Risk.

Current guidelines recommend individualizing the choice and duration of P2Y12 inhibitor therapy based on the trade-off between bleeding and ischemic risk. However, whether a potent P2Y12 inhibitor (ticagrelor) or a less potent one (clopidogrel) is more appropriate in patients with acute coronary syndrome (ACS) in the setting of high bleeding or ischemic risk is not clear. The study aimed to compare the clinical outcomes of clopidogrel and ticagrelor in patients with ACS at high bleeding or ischemic risk. A total of 5,713 patients with ACS were included in this retrospective study. The Cox proportional hazard regression model was adjusted by applying the inverse probability weighted approach to reduce treatment selection bias. The primary clinical outcome was all-cause death. Secondary outcomes included in-hospital death, ACS, target vessel revascularization, stent thrombosis, stroke, or clinically significant or major bleeding. The median follow-up duration was 53.6 months. After multivariable Cox model using an inverse probability weighted approach, all-cause death in the overall population and subgroups of patients at high bleeding risk, and/or at high ischemic risk were not significantly different between clopidogrel and ticagrelor. Rates for secondary outcomes were also similar between the groups. In conclusion, ticagrelor and clopidogrel are associated with comparable clinical outcomes in patients with ACS irrespective of bleeding and ischemic risk.

Predictive value of PRECISE-DAPT score for long-term all-cause mortality in atrial fibrillation patients with non-ST-elevation myocardial infarction.

Introduction: Atrial fibrillation (AF) may co-exist in patients with non-ST-elevation myocardial infarction (NSTEMI). In patients with NSTEMI, AF should therefore be regarded as an important risk factor irrespective of its presentation. To predict outcomes in AF patients presenting with NSTEMI, early risk stratification can help to identify the patients with a possible poor long-term prognosis. The development of the PRECISE-DAPT score aimed to predict the risk of bleeding in patients who underwent stent implantation and received dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI), providing a valuable tool for assessing bleeding risk in this specific patient population. Aim: To assess the performance of the PRECISE-DAPT score in predicting long-term prognosis in AF patients with NSTEMI. Material and methods: Five hundred and twenty-six consecutive AF patients presenting with NSTEMI were included in the present study. The PRECISE-DAPT score was calculated in each case and evaluated for the association of increased mortality in the study population, who survived in-hospital but died in the long term. Results: All-cause mortality deaths occurred in 278 (52.6%) patients. Higher PRECISE-DAPT score, shorter duration of P2Y12 inhibitor therapy, decreased left ventricular ejection fraction (LVEF), and a history of diabetes mellitus (DM) were all associated with an increased risk of all-cause mortality in the multivariable logistic regression model. Conclusions: High PRECISE-DAPT score was associated with higher long-term all-cause mortality in AF patients presenting with NSTEMI.

The relation of polymer structure of stent used in patients with acute coronary syndrome revascularized by stent implantation with long-term cardiovascular events.

INTRODUCTION: Drug-eluting stents (DES) have revolutionized percutaneous coronary intervention (PCI) by improving event-free survival compared to older stent designs. However, early-generation DES with polymer matrixes have raised concerns regarding late stent thrombosis due to delayed vascular healing. To address these issues, biologically bioabsorbable polymer drug-eluting stents (BP-DES) and polymer-free drug-eluting stents (PF-DES) have been developed. AIM: The aim of the present study is to evaluate and compare the long-term effects of different stent platforms in patients with acute coronary syndrome (ACS) undergoing PCI. MATERIAL AND METHODS: We conducted a retrospective, observational study involving 1192 ACS patients who underwent urgent PCI. Patients were treated with thin- strut DP-DES, ultra-thin strut BP-DES, or thin-strut PF-DES. The primary endpoint was a composite of cardiac death, target vessel myocardial infarction (TVMI), and clinically driven target lesion revascularization (CITLR) at 12 months and 4 years. RESULTS: The baseline demographics and clinical characteristics of patients in the three stent subgroups were similar. No significant differences were observed in target lesion failure (TLF), cardiac mortality, TVMI, and stent thrombosis (ST) rates among the three subgroups at both 12 months and 4 years. However, beyond the first year, the rate of CITLR was significantly lower in the ultra-thin strut BP-DES subgroup compared to thin-strut DP-DES, suggesting potential long-term advantages of ultra-thin strut BP-DES. Additionally, both ultra-thin strut BP-DES and thin-strut PF-DES demonstrated lower ST rates after the first year compared to thin-strut DP-DES. CONCLUSION: Our study highlights the potential advantages of ultra-thin strut BP-DES in reducing CITLR rates in the long term, and both ultra-thin strut BP-DES and thin-strut PF-DES demonstrate lower rates of ST beyond the first year compared to thin-strut DP-DES. However, no significant differences were observed in overall TLF, cardiac mortality and TVMI rates among the three stent subgroups at both 12 months and 4 years.

The effect of ticagrelor based dual antiplatelet therapy on development of late left ventricular thrombus after acute anterior ST elevation myocardial infarction.

AIM: The aim of this study is to investigate the impact of ticagrelor as compared to clopidogrel based dual antiplatelet therapy (DAPT) during post-discharge management on the incidence of left ventricular (LV) thrombus in patients with first acute anterior ST elevation myocardial infarction (STEMI). METHOD: 641 patients who met the inclusion criteria were divided into two groups based on the receipt of either ticagrelor or clopidogrel based DAPT. RESULT: Left ventricular thrombus was detected in 73 (11.4%) patients at the first month echocardiographic examination. Ticagrelor based DAPT was associated with significantly less incidence of LV thrombus when compared to clopidogrel [20 (7.4%) vs 53 (14.0%) OR: 0.50 (0.29-0.86)]. Penalized maximum likelihood estimation (PMLE) logistic regression analyses were performed to fourteen candidate variables for identifying the independent predictors of LV thrombus, ticagrelor (compared with clopidogrel) [OR: 0.53 (0.28-0.96), p = 0.039], body mass index (BMI) [OR: 0.58 (0.44-0.77), p < 0.001], KILLIP class (I vs II-IV) [OR: 0.35 (0.14-0.83), p = 0.017], age [OR: 1.22 (1.08-1.40), p < 0.001], poor postprocedural myocardial blush grade (MBG) [OR: 3.35 (1.32-8.15), p = 0.012] and LVEF predischarge [OR: 0.79 (0.72-0.86), p < 0.001] were found to be associated with LV thrombus. CONCLUSION: Our study demonstrated that the incidence of LV trombus was significantly lower with ticagrelor than clopidogrel-based DAPT during postdischarge treatment for anterior STEMI patients.

Inadvertent Left Ventricle Endocardial or Uncomplicated Right Ventricular Pacing: How to Differentiate in the Emergency Department.

BACKGROUND: Temporary transvenous pacemaker implantation is an important and critical procedure for emergency physicians. Traditionally, temporary pacemakers are inserted by electrocardiography (ECG) guidance in the emergency department because fluoroscopy at the bedside in an unstable patient can be limited by time and equipment availability. However, in the presence of atrial septal defect, ventricular septal defect, and patent foramen ovale, the pacemaker lead can be implanted inadvertently into the left ventricle or directly into the coronary sinus instead of right ventricle. Regular pacemaker rhythm can be achieved despite inadvertent implantation of the pacemaker lead into the left ventricle, leading to ignorance of the possibility of lead malposition. CASE REPORT: A 65-year-old female patient with hemodynamic instability and complete atrioventricular block underwent temporary pacemaker implantation via right jugular vein with ECG guidance at the emergency department. Approximately 12 h after implantation, it was noticed that the ECG revealed right bundle branch block (RBBB)-type paced QRS complexes. Diagnostic workup revealed that the lead was inadvertently located in the left ventricular apex. This case illustrates the importance of careful scrutiny of the 12-lead ECG and imaging clues in identifying lead malposition in the emergency department. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Because inadvertent left ventricle endocardial pacing carries a high risk for systemic embolization, it is important to determine whether an RBBB pattern induced by ventricular pacing is the result of a malpositioned lead or uncomplicated transvenous right ventricular pacing.

Relation of hemoglobin level to no-reflow in patients with ST-segment elevation myocardial infarction undergoing primary coronary intervention.

INTRODUCTION: The primary goal in the management of acute ST segment elevation myocardial infarction (STEMI) is to open the occluded artery at an early stage. The development of no-reflow is multifactorial, and the etiology is not fully understood. There is accumulating evidence that anemia is related to a series of severe complications in cardiovascular disease (CVD) such as thromboembolic events, bleeding complications, uncontrolled hypertension, and inflammation characterized by elevated levels of inflammatory cytokines. AIM: We investigated the relationship between hemoglobin level and the no-reflow of infarct-related artery (IRA) in patients with STEMI undergoing primary percutaneous coronary intervention (PPCI). MATERIAL AND METHODS: A total of 3804 patients with acute STEMI who underwent PPCI were enrolled. The patients were divided into two groups according to thrombolysis in myocardial infarction (TIMI) flow grades after PPCI. Hematological parameters were measured on admission. Univariate and multivariate logistic regression analyses were conducted to assess the association between hemoglobin level and no-reflow. RESULTS: In the current study, 471 (12.4%) patients presented with no-reflow after PPCI. The patients in the no-reflow group had a significantly lower hemoglobin level (12.1 ±1.9 g/dl vs. 13.8 ±1.8 g/dl, p < 0.001). The multivariate logistic regression models revealed that hemoglobin level (OR = 0.564, 95% CI: 0.526-0.605; p < 0.001) was an independent predictor of development of no-reflow. The cutoff value for hemoglobin level was 11.5 g/dl with sensitivity of 83.0% and specificity of 80.0% (AUC = 0.844, 95% CI: 0.821-0.867; p < 0.001). CONCLUSIONS: Our results suggest that hemoglobin level showed a moderate diagnostic performance regarding the prediction of no-reflow in patients with STEMI undergoing PPCI.

Relationship between fragmented QRS complexes in leads V4-V6 and left ventricular apical thrombus formation in patients presenting with first acute anterior myocardial infarction.

OBJECTIVE: The present study was an investigation of the relationship between fragmented QRS (fQRS) and left ventricular apical thrombus (LVAT) in patients presenting with first acute anterior myocardial infarction (MI). METHODS: Consecutive 148 patients (mean age: 60.1±10.1 years; male: 75.6%) with first acute anterior MI who underwent primary percutaneous coronary intervention (PCI) were included. Study population was divided into 2 groups based on presence of LVAT. fQRS was defined as presence of various RSR' patterns, which included additional R wave or notching of R wave or S wave, and presence of more than 1 R in 2 contiguous leads corresponding to major coronary artery territory on 12-lead electrocardiogram. Patients with bundle branch block were excluded from the study. RESULTS: Of these, 32 (21.6%) had LVAT. Patients with LVAT had higher prevalence of fQRS (53.1% vs. 22.4%; p<0.001) and lower rate of successful PCI (75% vs. 94%; p=0.002) compared with patients without LVAT. More patients in LVAT group had left ventricular ejection fraction of <30% (87.5% vs 65.5%; p=0.010). Groups were similar with respect to other baseline characteristics (p>0.05 for all). Presence of fQRS was independent predictor of LVAT (odds ratio [OR], 2.795; 95% confidence interval [CI], 1.058-7.396) in multivariable logistic regression analysis. CONCLUSION: Presence of fQRS in leads V4-V6 is independently associated with LVAT in patients presenting with first acute anterior MI.

[Can ischemia-modified albumin help in differentiating myocardial perfusion scintigraphy results?]. / Iskemi modifiye albümin miyokart perfüzyon sintigrafisi sonuçlarinin ayirici tanisinda faydali olabilir mi?

OBJECTIVE: Myocardial perfusion scintigraphy (MPS) is a diagnostic tool commonly used to detect significant coronary lesion. However equivocal, false negative or positive results can be yielded. Controversial findings regarding the role of ischemia-modified albumin (IMA) in MPS evaluation persist. The aim of the present study was to examine the role of serum IMA in the assessment of MPS results. METHODS: MPS using technetium (99mTc) sestamibi and transthoracic echocardiography was performed on 62 consecutive subjects prospectively enrolled. Exercise treadmill test (ETT) with modified Bruce protocol was used to induce coronary ischemia. During MPS performance, blood samples for serum IMA were obtained at 3 times: at pre-exercise, at the peak of ETT, and 6 hours after ETT. Patients were classified into 3 groups according to MPS results (normal, equivocal, and ischemia). RESULTS: Sixty-two patients (23 normal, 20 equivocal, 19 with ischemia) were included. Pre- and peak-exercise IMA values were similar among the groups (p=0.706 and 0.904). Post-exercise IMA values of the normal and equivocal groups were similar (p=0.733), while that of the ischemia group was significantly higher than the values of either the normal (p<0.001) or equivocal groups (p<0.001). ΔIMA (the difference between post-exercise and peak-exercise IMA) of the ischemia group was significantly higher than that of either the normal (p<0.001) or equivocal groups (p<0.001). CONCLUSION: Serum IMA was found to be significantly increased in cases of ischemia on MPS. Subjects with normal and equivocal MPS had a similar pattern during the test. IMA may be used in differentiation of equivocal results from false positive results.

The effect of serum potassium level on in-hospital and long-term mortality in ST elevation myocardial infarction.

Current studies evaluating the effect of serum potassium levels on mortality in patients with ST elevation myocardial infarction (STEMI) are lacking. We analyzed retrospectively 3760 patients diagnosed with STEMI. Mean serum potassium levels were categorized accordingly: <3.0, 3.0 to <3.5, 3.5 to <4.0, 4.0 to <4.5, 4.5 to <5.0, 5.0 to <5.5, and ≥5.5mEq/L. The lowest mortality was determined in patients with serum potassium level of 4 to <4.5mEq/L whereas mortality was higher in patients with serum potassium levels of ≥5.0 and <3.5mEq/L. In a multivariable Cox-proportional regression analysis, the mortality risk was higher for patients with serum potassium levels of ≥5mEq/L [hazard ratio (HR), 2.11; 95% confidence interval (CI) 1.23-4.74 and HR, 4.20; 95% CI 1.08-8.23, for patients with potassium levels of 5 to <5.5mEq/L and ≥5.5mEq/L, respectively]. In-hospital and long-term mortality risks were also higher for patients with serum potassium levels of ≤3.5mEq/L. Conversely, ventricular arrhythmias were higher only for patients with serum potassium level of ≤3.5mEq/L. Furthermore, a significant relationship was found between the patient with serum potassium levels of ≤3.5mEq/L and ventricular arrhythmias.

Can Impaired Elasticity of Aorta Predict the Success of Vardenafil Treatment in Patients with Erectile Dysfunction?

Objective. Vardenafil is used in treatment of erectile dysfunction (ED) but reveals variable clinical outcomes. Here, we aimed to evaluate the role of aortic elasticity in predicting vardenafil success among patients with ED. Methods. Sixty-one consecutive male subjects with primary ED and indication for vardenafil treatment were included. All subjects fulfilled 5-item version of the International Index of Erectile Function (IIEF-5) before the vardenafil treatment. Pretreatment aortic stiffness index (ASI) and aortic distensibility (AD) were obtained echocardiographically. Following two-month vardenafil treatment, the patients were reevaluated with IIEF-5. Pretreatment, posttreatment, and ΔIIEF-5 scores and ASI values were compared. Results. Average age was 54 ± 8 years. Pretreatment and posttreatment IIEF-5 and ΔIIEF-5 scores were 9.1 ± 2.5; 18.5 ± 2.3; and 9.4 ± 3, respectively. Mean ASI and AD values were 3.10 ± 0.54 and 4.13 ± 2.55 1/(10(3) × mmHg) accordingly. ASI value of severe pretreatment ED (n = 15) was significantly higher than that of mild-moderate pretreatment ED (n = 12) (p < 0.001). All pretreatment IIEF-5 scores increased significantly compared to posttreatment IIEF-5 scores (p < 0.001). ASI values were significantly correlated to pretreatment IIEF-5 scores (p < 0.001) and ΔIIEF-5 value (p < 0.001) but not to posttreatment IIEF-5 score. Conclusion. Aortic elasticity was impaired in accordance with degree of ED. The subjects with higher ASI values obtained more benefits from vardenafil.

Assessment of epicardial adipose tissue thickness in patients with resistant hypertension.

OBJECTIVE: Recent studies have shown that epicardial adipose tissue (EAT) thickness is increased in patients with hypertension. In this study, we aimed to investigate the relation of EAT thickness with resistant hypertension (RHT). PARTICIPANTS AND METHODS: Study participants (n=150) were classified into three groups according to their office and ambulatory blood pressure measurements: RHT (n=50), controlled hypertension (CHT, n=50), and normotension (NT, n=50). All patients underwent a transthoracic echocardiographic examination to measure EAT thickness. RESULTS: Clinical and biochemical characteristics of the groups were similar, except the CRP level, which was significantly increased in hypertensive patients compared with patients with NT (P<0.001). EAT thickness differed significantly between groups (P<0.001). The highest values were obtained in the RHT group (4.64±1.24 cm), followed by the CHT (3.3±0.82 cm) and NT (2.6±0.76 cm) groups. Multivariate analysis indicated age, physical activity level, and EAT thickness as independent predictors of RHT. The optimal cut-off value of EAT thickness for detection of RHT was found to be 3.42 cm, with a sensitivity and specificity of 82 and 77%, respectively (AUC=0.87, 95% confidence interval 0.81-0.92, P<0.000). CONCLUSION: EAT can be effective on blood pressure by several mechanisms. In this study, for the first time in the literature, the association of EAT with RHT is reported.

Neutrophil/lymphocyte ratio is associated with right ventricular dysfunction in patients with acute inferior ST-segment elevation myocardial infarction.

BACKGROUND: Acute inferior ST-segment elevation myocardial infarction (STEMI) is associated with increased in-hospital morbidity and mortality particularly among patients with coexisting right ventricular (RV) involvement. High neutrophil to lymphocyte ratio (NLR) is an independent predictor of major adverse cardiac events and mortality in patients with myocardial infarction. This study evaluated the relationship between the NLR and RV dysfunction (RVD) in patients with inferior STEMI who underwent primary percutaneous coronary intervention (PCI). METHODS: A total of 213 subjects with inferior STEMI were divided into two groups according to the presence of RVD. The groups were compared according to NLR and receiver operating characteristic (ROC) analysis was performed to access the predictability of NLR on having RVD. RESULTS: The NLR was significantly higher in the group with RVD compared to that without RVD (p < 0.001). In ROC analysis, NLR > 3.5 predicted RVD with sensitivity of 83% and specificity of 55%. In a multivariate regression analysis, NLR remained an independent predictor of RVD (OR 1.55, 95% CI 1.285-1.750, p < 0.001). CONCLUSIONS: NLR was an independent predictor of RVD in patients with inferior STEMI undergoing primary PCI.