Diana E. CRETU, Cristian A. UDROIU, Claudiu I. STOICESCU, Gabriel TATU-CHITOIU and Dragos VINEREANU

ABSTRACT

Background: ST-segment elevation myocardial infarction (STEMI) remains a leading cause of morbidity and mortality worldwide. Primary percutaneous coronary intervention (pPCI) is the preferred therapy for STEMI if it is done within 120 min from the first medical contact, by an experienced team in a high-volume center. The aim of this study was to assess the clinical characteristics and predictors of in-hospital mortality of patients with STEMI treated by percutaneous coronary interventions (PCIs).

Methods: We analyzed data from 15,076 STEMI patients enrolled in the RO-STEMI registry (ROmanian ST-Elevation Myocardial Infarction registry). Patients were divided into 2 groups: PCI (11.669; 77%) and conservative treated (3.407; 23%). PCI group includes both pPCI treated patients (84.3%), and patients undergoing rescue PCI (6.4%) and late PCI (9.3%).

Results: The mean age of STEMI patients was 62.7+/-12.7 years. 70% were males. Patients treated by PCI were younger (61.4+/-12.2 versus 67.2+/-13.3, p<0.0001) and more often men (80% versus 71%, p<0.0001). They were less likely to have acute heart failure (Killip class II-IV) at admission (p<0.0001). During admission, patients treated by PCI received more often dual antiplatelet therapy (97.6% versus 90.8%, p<0.0001), statins (96.3% versus 87.5%, p<0.0001), beta-blockers (83.8% versus 73.2%, p<0.0001), and RAAS blockers (82.6% versus 66.4%, p<0.0001). Overall in-hospital mortality was 7.1%: 4.1% in the PCI group and 15.7% in the conservative treated group. Multivariate analysis showed that, after adjusting for all clinical variables, Killip class II-IV at admission (OR: 9.2; 95%CI: 6.2-13.6; p<0.0001), LVEF<35% (OR: 3.8; 95%CI: 2.6-5.4; p<0.0001), age older than 65 years (OR: 2.2; 95%CI: 1.5-3.2; p<0.0001), and anterior location of myocardial infarction (OR: 2.1; 95% CI: 1.5-3; p<0.0001) remained independent predictors for in-hospital mortality for STEMI patients treated interventionally.

Conclusion: Advanced Killip class, depressed LVEF, advanced age, and anterior location were the most powerful independent predictors of in-hospital mortality in STEMI patients who underwent interventional treatment.

Keywords: STEMI, percutaneous coronary interventions, mortality

Full text | PDF

Claudiu STOICESCU, Vlad VINTILA, Cristian UDROIU, Nicolae FLORESCU, Aws DAWOOD, Mircea CINTEZA and Dragos VINEREANU

ABSTRACT

Background: Stent thrombosis (ST) is a rare, but extremely severe complication of PCI. Outside clinical trials, data are limited regarding the risks and the impact of this phenomenon.

Aims: To assess prevalence, predictors, and clinical outcome of ST after implantation of drug eluting stents (DES) compared with bare metal stents (BMS), in a large case-control study in a real world scenario, as well as the relation between ST and duration of combined antiplatelet treatment.

Methods: In a case-control registry we included 475 patients who received at least 1 DES (sirolimus, zotarolimus, everolimus, paclitaxel), compared with a group of 475 patients who received at least 1 BMS. We used 1.22 DES/patient vs. 1.26 BMS/patient (p=ns), treating 1.02 DES/lesion vs. 1.05 BMS/ lesion (p=ns). Main outcome was ST defined by the Academic Research Consortium (ARC) as definite (acute, sub-acute, late), probable, and possible.

Results: At 15 months we found 0.8% (4) patients in the DES group vs. 1.1% (5) patients in the BMS group with definite ST (ns); 0.4% (2) patients from each group had acute ST, while 0.4% (2) vs. 0.7% (3) patients had sub-acute ST (both comparisons were ns). None of the patients from the DES group died, whereas two patients with definite ST from the BMS group died, with a case fatality rate of 40% (2/5). 0.2% (1) patient from each group had probable ST (ns) and 0.6% (3) vs. 0.4% (2) patients had possible ST (ns). Independent predictors of stent thrombosis in merged groups were antiplatelet therapy discontinuation (HR 3.8; 95%CI 1.9-7.6; p<0.01), diabetes (HR 2.15; 95%CI 1.4-5.1; p<0.01), a lower left ventricular ejection fraction (EF) (HR 1.1; 95%CI 1.0-1.9; p<0.01 for each 10% decrease), and LAD lesions (HR 1.0; 95%CI, 0.93-1.9; P<0.01).

Conclusions: ST is a rare complication (0.95%), similar after DES or BMS implantation. Premature discontinuation of antiplatelet therapy, followed by diabetes and a lower LVEF, are the independent predictors of ST.

Full text | PDF

Leonida GHERASIM, Andrea O. CIOBANU, Carmen Lucia GHERGHINESCU, Raluca DULGHERU, Stefania MAGDA, Ruxandra DRAGOI GALRINHO, Maria FLORESCU, Suzana GUBERNA, Mircea CINTEZA and Dragos VINEREANU

ABSTRACT

Background: Blood pressure variability (BPV) was proved as a cardiovascular risk factor. One of its mechanisms is related to arterial stiffness and ventriculo-arterial coupling; however its impact on subclinical cardiovascular dysfunction has not been evaluated yet.

Objectives: To assess the relationship between BPV on 24 hours, and subclinical left ventricle (LV), renal, and vascular dysfunction in diabetic and hypertensive patients. Material and methods: We studied 56 patients (57±9 years, 29 men) with mild-to-moderate hypertension and type 2 diabetes, no cardiovascular disease, normal ejection fraction and normal renal function. 24 hours ambulatory blood pressure monitoring (ABPM) was used to assess BPV, daytime (d) and night time (n), by: 1. mean (M); 2. standard deviation of mean (SD); 3. variance (Vr); 4. coefficient of variation (CV); 5. day/night variation: reverse dippers, non-dippers, dippers and extreme dippers; conventional and 2D speckle tracking echo to assess LV function; myocardial deformation was measured as global longitudinal strain (GLS). Endothelial (flow mediated dilation, FMD) and arterial function (intima media-thickness, IMT; pulse wave velocity, PWV), microalbuminuria were tested.

Outcomes: Daytime BPV correlates inversely with subclinical myocardial function evaluated through GLS. Daytime systolic BPV correlates positively with IMT (all rho > 0.30, all p < 0.05). Also, there is a significantly inverse correlation between mean BP and GLS. We found a direct correlation between mean BP, but not BPV, and microalbuminuria (all rho > - 0.30 and all p < 0.05). We found no correlation between BPV and FMD, PWV. There were no differences for GLS, microalbuminuria and FMD between dipper groups.

Conclusions: In diabetic patients with mild-to-moderate hypertension, increased daytime blood pressure variability correlates with subclinical left ventricular dysfunction and arterial function (IMT), while microalbuminuria correlates with elevated blood pressure, but not with blood pressure variability.

Keywords: blood pressure variability, ventricular dysfunction, diabetes, hypertension

Full text | PDF

Mircea CINTEZA, Bogdan PANA, Emil COCHINO, Maria FLORESCU, Andrei MARGULESCU, Anca FLORIAN and Dragos VINEREANU

Background. Cardiovascular disease (CVD) – including Coronary Artery Disease, Stroke, or Peripheral Arterial Disease – is the leading cause of mortality in Romania. Several risk factors (obesity – OB, smoking – SM, hypertension – HT, diabetes mellitus – DM, or hypercholesterolemia – Hchol) are associated with the development of CVD and their prevalence may vary by region of the country. However, there are few estimates of CVD risk factors burden or of its control status in Romania.

Aims. 1) to evaluate the prevalence of CVD and its risk factors in a general practitioners population among different regions in Romania and 2) to assess the status of control of CVD risk factors in this population.

Design. A cross-sectional study was conducted among an 8 EURO-regions in Romania (Bucharest, Muntenia, Oltenia, Banat, Crisana, Transilvania, Moldova and Dobrogea) between April and June 2006. From 17,330 questionnaires, 3,124 eligible individuals aged between 18 – 85 year old, 61 % female, were randomly selected to create a representative sample to respect age, gender and regional population distribution.

Methods. The following were standardly assessed: weight and height for calculation of body mass index, smoking status, arterial pressure, blood sample for measuring basal glucose and total cholesterol, history of angina and medical history questionnaire.

Results. The global prevalence of major CV risk factors (95% CI) was: HT – 39.1%, known DM – 11.8%, Hchol 31.4%, and SM – 21.7%. The general prevalence of the obesity was 26.3%, while the presence of other risk factors significantly increased the prevalence of OB (43% in diabetics vs 24% in nondiabetics, p<0.05). There was not significant difference of the CV risk factors prevalence among the EUROregions, except Banat, where the prevalence of OB and HT was higher (38.3%, respectively 42.7%) and Muntenia, where the prevalence of diabetes was higher (22.6%). The presence of history of angina and stroke was significantly increased in diabetics when compared with non-diabetics (34.2% vs 11.5%, p<0.05 and 9.3% vs 2.5%, p<0.05). Despite the treatment, adequate control of blood pressure, blood glucose or total cholesterol was present in only 22.3% of patients with HT, 19.6% of patients with DM, and 39% of those with Hchol.

Conclusions. 1. General prevalence of CVD and its risk factors in Romania is high and there are no important differences in risk factors among the 8 EURO-regions. 2. Effective risk factors control among the general practitioners population is still poor.

Full text | PDF

Claudiu STOICESCU, Alexandru BURLACU, Vlad VINTILA, Cristian UDROIU, Nicolae FLORESCU, Octavian PARVU, Mircea CINTEZA and Dragos VINEREANU

Background. Medium-term outcome of patients with percutaneous coronary interventions (PCIs) is related to in-stent restenosis, which represents the main drawback for PCIs. Recent clinical studies have shown a decrease of restenosis rate from 25% to less than 10%, using sirolimus eluting stents (DES). However, “real-life” DES restenosis, by comparison with similar patients receiving BMS, has not been enough reported.

Methods. We performed a controlled registry study (“case control study”) over a period of 44 months, including all patients who received ≥ 1 sirolimus eluting stent, comparing them to a control group of patients who received ≥ 1 bare metal stent (BMS). Primary end-point was the clinical restenosis (defined clinically and/or by ECG exercise test); when clinical restenosis was suspected, coronary angiography was repeated. Secondary end-points were major adverse cardiac events (MACE).

Results. 448 patients were included into the controlled registry study: 224 DES patients (58±10 years, 75% males), compared to 224 age- and sex-matched BMS patients. 268 DES were used in 260 lesions, versus (vs.) 298 BMS used in 278 lesions. Major cardiovascular risk factors prevalence was: diabetes mellitus 26% vs. 11%, p=0.0001; arterial hypertension 79% vs. 72%, p=0.065; hypercholesterolemia 90% vs. 79%, p=0.001, in DES and BMS groups, respectively. 52% vs. 40% patients (p=0.005) associated at least 3 risk factors, and 16% vs. 3.5% patients had four major risk factors. 71% vs. 43% patients (p=0.0001) had previous myocardial infarction. 8% vs. 0.3% (p=0.001) stents were used for intrastent restenosis. Target vessel was LAD in 66% vs. 45% patients (p=0.003); left circumflex in 12% vs. 24% (p=0.012); and RCA in 20% vs. 31% (p=0.05). 71% vs. 41% (p= 0.0001) were lesions with RVD ≤ 3 mm, and 88% vs. 51% (p= 0.0001) were lesions longer than 15 mm. 3 cases of clinical restenosis were suspected in the DES group, confirmed by coronary angiography in 2 patients (0.9%), whereas 20 cases of clinical restenosis were suspected in the BMS group, confirmed by coronary angiography in 16 patients (7.0%) (p=0.001). 2.7% patients from the DES group had MACE, compared with 8.9% from the BMS group (p= 0.007). Myocardial infarction and total death did not differ significantly between the two groups.

Conclusions. By comparison with patients receiving BMS, patients who benefit from DES had more diabetes mellitus, more than 3 major cardiovascular risk factors, mainly LAD lesions, small and/or long vessel lesions. Clinically-driven in-stent restenosis was reduced from 7% to less than 1%, with a significant decrease of MACE.

Full text | PDF

Ruxandra DRAGOI GALRINHO, Andrea Olivia CIOBANU, Roxana Cristina RIMBAS, Catalin Gabriel MANOLE, Bogdan MARINESCU and Dragos VINEREANU

ABSTRACT

Background: The rat infarct model was used extensively to study the pathophysiology of myocardial infarction and to evaluate different therapies. Transthoracic echocardiography is used in rats in order to assess cardiac anatomy and function, being a safe and reliable non-invasive technique. However, studies combining conventional with new echo techniques, such as tissue Doppler imaging (TDI) and speckletracking echocardiography (STE), are lacking.

Objectives: To validate a protocol using the available conventional and new echocardiographic techniques (TDI and STE) for a comprehensive assessment of cardiac remodelling and function, after myocardial infarction in rats.

Methods: Ten Wistar (W) and five Sprague Dawley (SD) male rats (aged 21±2 weeks, mean weight 355±43 g) were evaluated by echocardiography, before and 24 hours post-ligation of the left coronary artery, with previous anaesthesia. Left ventricular (LV) structure was assessed by end-diastolic and endsystolic anterior wall thickness and LV diameters (from the SAX view), while LV function by fractional shortening (FS) and ejection fraction (EF) (by area-length formula), septal mitral annular plane systolic excursion (MAPSE), cardiac output (CO), myocardial performance index (MPI), septal mitral annular systolic velocity (S’, by TDI), and global circumferential and radial systolic strain (GCS, GRS) and strain rate (GCSr, GRSr) by STE, from the SAX view at the level of papillary muscles.

Results: Feasibility of measuring the above mentioned parameters was 100%. Twenty-four hours after myocardial infarction, rats had lower heart rate (373±44 vs. 351±32 bpm, p<0.05) and thinner LV anterior wall, while LV diameters and volumes were significantly higher. FS (54±7 vs. 33±9%), EF (72±9vs. 47±10%), septal MAPSE (2.02±0.17 vs. 1.44±0.22 mm), CO (76±15 vs. 48±12 ml/min), MPI (0.33±0.11 vs. 0.50±0.14), S’ (5.58±1.20 vs. 3.84±1.06 cm/s), and LV strain and strain rate (GCS: -23.52±2.44 vs. -13.33±1.51% and GRS: 50.45±13.11 vs. 17.27±5.2%, GCSr: -8.42±0.85 vs. -4.68±0.53; and GRSr: 11.93±2.39 vs. 4.89±1.18 1/s) were significantly lower, all p<0.01.

Conclusion: Our echocardiographic protocol of experimental myocardial infarction in rats is feasible. The impact of myocardial infarction in rats could be more extensively assessed using a comprehensive echocardiographic protocol of conventional and specific myocardial parameters, measured by TDI and STE, in order to quantify better the LV structure and function. Therefore, we suggest that this protocol may be used in order to assess the effect of different regenerative therapies in experimental myocardial infarction in rats.

Keywords: Wistar, Sprague Dawley, myocardial infarction, echocardiography, speckle tracking

Full text | PDF