Usefulness of the QRS Score as a Strong Prognostic Marker in Patients Discharged After Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction.

Am J Cardiol. 2010 Sep 1;106(5):630-634

Authors: Tjandrawidjaja MC, Fu Y, Westerhout CM, Wagner GS, Granger CB, Armstrong PW,

The prognostic value of myocardial infarct size estimation by QRS scoring in patients with ST-segment elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI) is unclear. The standard 32-point Selvester QRS score on the discharge electrocardiogram (each point approximately 3% left ventricular mass) was calculated in 4,113 patients with STEMI who underwent primary PCI and survived to hospital discharge in the APEX-AMI trial. QRS scores were divided into tertiles, i.e., </=3 (<10% myocardium), 4 to 7 (10% to 21% myocardium), and >/=8 (>21% myocardium). Adjusted associations between QRS score and 90-day outcomes (death and composite of death/congestive heart failure (CHF)/shock) were examined. Higher QRS scores were associated with male gender, higher heart rate, worse Killip class, noninferior infarct location, greater ST-segment deviation, and longer times to reperfusion. Higher QRS scores were also associated with impaired culprit artery flow before and after PCI and more frequent multivessel disease. Adverse outcomes occurred more often in patients with higher QRS scores (90-day death: 1.9%, QRS score 0 to 3; 3.4%, 4 to 7; 4.9%, >/=8; 90-day death/shock/CHF: 4.5%, 0-3; 7.8%, 4 to 7; 12.1%, >/=8). After multivariable adjustment, patients with higher QRS scores remained more likely to develop an adverse outcome versus those with QRS scores </=3 (score 4 to 7, hazard ratios [HR] for death 2.08, 95% confidence interval [CI] 1.26 to 3.41; HR for death/CHF/shock 2.00, 95% CI 1.26 to 3.17; score >/=8, HR for death 2.57, 95% CI 1.56 to 4.24, HR for death/CHF/shock 2.93, 95% CI 1.84 to 4.67). In conclusion, infarct size as estimated by QRS scoring at hospital discharge is an independent and prognostically relevant metric in patients with STEMI undergoing primary PCI.

PMID: 20723636 [PubMed - as supplied by publisher]

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A Novel Percutaneous Coronary Intervention Risk Score to Predict One-Year Mortality.

Am J Cardiol. 2010 Sep 1;106(5):641-645

Authors: Maluenda G, Delhaye C, Gaglia MA, Ben-Dor I, Gonzalez MA, Hanna NN, Collins SD, Wakabayashi K, Torguson R, Xue Z, Satler LF, Pichard AD, Waksman R

Clinical and angiographic risk factors associated with adverse outcomes after percutaneous coronary intervention (PCI) have been included in previous validated risk scores. Complications after PCI are known to increase mortality and morbidity but have not been included in any model. Records of 6,932 consecutive patients who underwent PCI from 2000 to 2005 were reviewed. Patients presenting with cardiogenic shock were excluded. Logistic regression and bootstrap methods were used to build an integer risk score for estimating risk of death at 1 year after PCI using baseline, angiographic, and procedural characteristics and postprocedural complications. This risk score was validated in a set of consecutive patients who underwent PCI from 2006 to 2007. The following 8 variables were significantly correlated with outcome: older age, history of diabetes mellitus, chronic renal failure, heart failure, left main coronary artery disease, lower baseline hematocrit, greater hematocrit decrease after PCI, and Thrombolysis In Myocardial Infarction grade <3 flow after PCI. In the validation population (n = 973), average receiver operating characteristic curve area was 0.836. In conclusion, we developed and validated a simple integer risk score, including postprocedural variables that closely predict long-term mortality after PCI. This model emphasizes the significant impact of complications occurring after PCI on long-term outcomes.

PMID: 20723638 [PubMed - as supplied by publisher]

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Emergence of Blood Urea Nitrogen as a Biomarker of Neurohormonal Activation in Heart Failure.

Am J Cardiol. 2010 Sep 1;106(5):694-700

Authors: Kazory A

The nonosmotic release of arginine vasopressin, concurrent with the activation of the sympathetic nervous system and renin-angiotensin-aldosterone system, is thought to represent the maladaptive response that is central to the pathophysiology of heart failure (HF). The degree of neurohormonal activation correlates with the severity of the disease and can predict the outcomes. However, quantification of components of neurohormonal axis (e.g., serum arginine vasopressin level) is mainly reserved for research purposes rather than routine practice. The results of several recent HF trials have shed light on the differential role of blood urea nitrogen (BUN) and creatinine in predicting the outcomes in this setting. These studies suggest that BUN could indeed represent a surrogate marker for “renal response” to neurohormonal activation in this setting, above and beyond its role in the estimation of renal function. In this report, the relevant physiologic mechanisms underlying urea and water transport in the kidney are first reviewed. Then, the activation of the neurohormonal axis and the impact of its components on renal urea transport, independent of changes in renal function, are explained. Finally, the unique role of BUN as a biomarker of neurohormonal activation in the setting of HF is discussed, and the potential clinical implication of this novel concept is emphasized. In conclusion, this review explains the pathophysiologic basis for the emerging role of BUN as a biomarker in HF.

PMID: 20723648 [PubMed - as supplied by publisher]

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Legal Risks of “Curbside” Consults.

Am J Cardiol. 2010 Jul 1;106(1):135-138

Authors: Cotton VR

“Curbside” consults, in which physicians informally solicit one another’s opinions, are an integral part of our medical culture and invaluable to the care of our patients. Unfortunately, there is widespread uncertainly as to the degree of legal risk they pose and growing concern in the risk management community that curbside consults should be limited in scope if not eliminated entirely. This places curbside consultants in a quandary, seemingly forced to choose among their ethical obligation to patients, their sense of duty to colleagues, and their own legal well-being. The author evaluates the legal aspects of curbside consults, distinguishes them from clinical interactions with which they must not be confused, and then provides guidance for conducting curbside consults. In conclusion, curbside consults should occur as often as needed and to whatever degree is necessary for proper patient care.

PMID: 20609661 [PubMed - as supplied by publisher]

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Do Calcium Channel Blockers Increase the Diagnosis of Heart Failure in Patients With Hypertension?

Am J Cardiol. 2010 Jul 15;106(2):228-235

Authors: Shibata MC, León H, Chatterley T, Dorgan M, Vandermeer B

Calcium channel blockers (CCBs) are widely used to control hypertension. Previous work suggested that their use could increase heart failure (HF), which is 1 of the consequences of uncontrolled hypertension. Information about the effect of CCBs on incident HF in patients with hypertension is scarce. A systematic review was conducted to evaluate patients with hypertension treated with CCBs and incident HF. An electronic search of publications was conducted using 8 major databases. Studies were eligible if they (1) were randomized clinical trials, (2) performed comparisons of CCBs versus active control, (3) randomized >200 patients, (4) had follow-up periods >6 months, and (5) provided data regarding incident HF. Trials of renal transplantation patients, placebo-controlled trials, and HF trials were excluded. A total of 156,766 patients were randomized to CCBs or control, with a total of 5,049 events. The analysis indicated a significant increase in the diagnosis of HF in patients allocated to CCBs (odds ratio 1.18, 95% confidence interval 1.07 to 1.31). The effect observed was independent of incident myocardial infarction. Subgroup analyses indicated that patients with diabetes were at higher risk for developing HF (odds ratio 1.71, 95% confidence interval 1.21 to 2.41). In conclusion, the results suggest that patients with hypertension treated with CCBs have increased incident HF.

PMID: 20599008 [PubMed - as supplied by publisher]

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Association Between Statin Use and the Incidence of Atrial Fibrillation Following Hospitalization for Coronary Artery Disease.

Am J Cardiol. 2010 Jun 15;105(12):1655-1660

Authors: Kulik A, Singh JP, Levin R, Avorn J, Choudhry NK

Mounting evidence suggests that statins possess antiarrhythmic properties and inhibit atrial fibrillation (AF). The goal of this study was to evaluate the relation between statin use and new-onset AF in a large cohort of patients with coronary artery disease. We identified all Medicare beneficiaries >/=65 years old who had been hospitalized for acute myocardial infarction or coronary revascularization from 1995 to 2004 and participated in 1 of 2 government-sponsored medication benefit programs. Patients with a history of AF before and during hospitalization were excluded. This yielded a cohort of 29,088. The incidence of new AF was compared between patients who were (n = 8,450) and were not (n = 20,638) prescribed statins within 1 month of hospital discharge after their cardiac event. New-onset AFs within 5 and 10 years were 32.6% and 51.2%, respectively, in patients who received statins compared to 38.3% and 58.0% in patients who did not receive statins (unadjusted hazard ratio 0.82, 95% confidence interval 0.78 to 0.86). Multivariable analysis controlling for demographic and clinical confounders indicated that statin use independently decreased the risk of developing new-onset AF compared to nonusers (adjusted hazard ratio 0.90, 95% confidence interval 0.85 to 0.94). Adjustment for propensity-score and health-seeking behaviors yielded nearly identical results. In conclusion, statin therapy initiated within 1 month after hospital discharge is independently associated with a decrease in the risk of new-onset AF after myocardial infarction or coronary revascularization. These findings lend support to the antiarrhythmic effects of statins and suggest another benefit for their use in patients with coronary artery disease.

PMID: 20538110 [PubMed - as supplied by publisher]

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Risk of Adverse Outcomes in Taiwan Associated With Concomitant Use of Clopidogrel and Proton Pump Inhibitors in Patients Who Received Percutaneous Coronary Intervention.

Am J Cardiol. 2010 Jun 15;105(12):1705-1709

Authors: Huang CC, Chen YC, Leu HB, Chen TJ, Lin SJ, Chan WL, Chen JW

Recent studies have suggested that proton pump inhibitors (PPIs) might reduce the inhibitory effect of clopidogrel on platelet aggregation, possibly through inhibition of the hepatic cytochrome P450 2C19 (CYP2C19) isoenzyme. The prevalence of CYP2C19 loss-of-function alleles is much greater among East Asians than among other populations. Thus, potential drug interactions might be more apparent. Therefore, we conducted a nationwide, population-based study using the Taiwan National Health Insurance database. We identified 3,278 patients (mean age 65.9 +/- 11.9 years, 71.9% men) with coronary artery disease who had taken clopidogrel after percutaneous coronary intervention from the 1 million sampling cohort data set since January 1, 2002. Of the 3,278 patients, 572 had received concomitant PPIs for underlying gastrointestinal disease and 2,706 had not used PPIs. To the end of 2007, 1,410 patients had been rehospitalized, 970 patients had undergone revascularization, and 499 patients had died. According to the Kaplan-Meier analysis, the incidence of rehospitalization (p = 0.001) and mortality (p <0.001) was significantly greater for the patients with concomitant PPI use than for those without concomitant PPI use. However, the incidence of revascularization was similar in the 2 groups. Multivariate analyses showed that concomitant PPI use was associated with an increased risk of rehospitalization (hazard ratio 1.23, 95% confidence interval 1.07 to 1.41, p = 0.003) and mortality (hazard ratio 1.65, 95% confidence interval 1.35 to 2.01, p <0.001). In conclusion, the concomitant use of clopidogrel and PPIs should be done with care to avoid adverse outcome in East Asians patients who have undergone percutaneous coronary intervention.

PMID: 20538118 [PubMed - as supplied by publisher]

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Comparison of Long-Term (4-Year) Outcomes of Patients With Unprotected Left Main Coronary Artery Narrowing Treated With Drug-Eluting Stents Versus Coronary-Artery Bypass Grafting.

Am J Cardiol. 2010 Jun 15;105(12):1728-1734

Authors: Wu X, Chen Y, Liu H, Teirstein PS, Kirtane AJ, Ge C, Song X, Chen X, Gu C, Huang F, Lv S

Percutaneous coronary intervention with drug-eluting stents (DES) may achieve midterm outcomes comparable to coronary artery bypass grafting (CABG) for unprotected left main coronary artery disease, but few real-world, long-term studies have been reported. In this study, 376 patients with unprotected left main coronary artery disease who underwent DES implantation (n = 131) or CABG (n = 245) were evaluated, and outcomes were compared using propensity analyses to adjust for baseline differences. Overall, 367 patients (98%) had complete clinical follow-up for a median of 4.0 years (interquartile range 3.2 to 4.7). Although the overall sample size was limited, there was a trend toward lower mortality with DES versus CABG in unadjusted (hazard ratio [HR] 0.50, 95% confidence interval [CI] 0.20 to 1.22, p = 0.13), multivariate-adjusted (HR 0.37, 95% CI 0.13 to 1.09, p = 0.07), and propensity score-adjusted (HR 0.34, 95% CI 0.12 to 1.03, p = 0.06) analyses. Treatment with DES was associated with a higher rate of target-vessel revascularization (TVR; 18% vs 9%, p = 0.02). However, ischemic TVR was not significantly different between the 2 groups (25% vs 39%, p = 0.15) in patients who received angiographic follow-up. No differences were detected in the occurrence of composite major adverse cardiac and cerebrovascular events between DES and CABG (27% vs 22%, p = 0.42). In conclusion, during 4-year follow-up, overall composite major adverse cardiac and cerebrovascular events were similar after DES and CABG treatment of unprotected left main coronary artery disease, with a trend toward lower mortality after percutaneous coronary intervention with DES. DES were associated with a higher rate of TVR compared to CABG, but ischemic TVR was not significantly different between the 2 groups.

PMID: 20538122 [PubMed - as supplied by publisher]

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Impact of Lipid-Lowering Therapy on Outcomes in Atrial Fibrillation.

Am J Cardiol. 2010 Jun 15;105(12):1768-1772

Authors: Badheka AO, Rathod A, Kizilbash MA, Garg N, Mohamad T, Afonso L, Jacob S

Lipid-lowering therapy (LLT) decreases mortality in select patient populations. LLT has also been shown to have antiarrhythmic effects, thus favorably influencing the incidence and recurrence of atrial fibrillation (AF). However, data are lacking regarding the effect of LLT on mortality in patients with AF. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study was the one of the largest multicenter trials comprising of 4,060 patients with AF at high risk for stroke and death. This is a post hoc analysis of the National Heart, Lung, and Blood Institute limited-access dataset of AFFIRM patients who were on LLT at the time of randomization (n = 913). The control group consisted of AFFIRM patients who were not on LLT (n = 3,147). Cox proportional hazards analysis was performed controlling for baseline differences. The end point was all-cause mortality, cardiovascular mortality, and ischemic stroke. A separate analysis was carried out for the combined end point of death, ventricular tachycardia, ventricular fibrillation, cardiac arrest, ischemic stroke, major bleeding, systemic embolism, pulmonary embolism, and myocardial infarction. Patients on LLT were younger and on more cardioactive medications but also had more cardiovascular morbidities. On multivariate analysis, LLT use was associated with lower all-cause mortality (hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.62 to 0.95, p = 0.01), cardiovascular mortality (HR 0.71, 95% CI 0.53 to 0.95, p = 0.02), ischemic stroke (HR 0.56, 95% CI 0.36 to 0.89, p = 0.01), and combined end point (HR 0.81, 95% CI 0.69 to 0.96, p = 0.01). In conclusion, a decrease in mortality and adverse cardiovascular events was observed using LLT in AF.

PMID: 20538128 [PubMed - as supplied by publisher]

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Long-Term Outcomes of Medicare Beneficiaries With Worsening Renal Function During Hospitalization for Heart Failure.

Am J Cardiol. 2010 Jun 15;105(12):1786-1793

Authors: Kociol RD, Greiner MA, Hammill BG, Phatak H, Fonarow GC, Curtis LH, Hernandez AF

We examined whether worsening renal function (RF) was associated with long-term mortality, readmission, and inpatient costs in Medicare beneficiaries hospitalized with heart failure (HF). Baseline renal insufficiency in patients hospitalized for HF is associated with increased risk of morbidity and mortality. However, the relation between worsening RF and long-term clinical outcomes is unclear. We linked clinical registry data to Medicare inpatient claims to identify 1-year outcomes of patients >/=65 years of age hospitalized with HF. Worsening RF was defined as a change in serum creatinine >/=0.3 mg/dl. Relations between worsening RF and 1-year mortality and readmission were evaluated with multivariable Cox proportional hazards models with robust SEs; associations with inpatient costs were evaluated with generalized linear models with a log-link and Poisson distribution. Of 20,063 patients hospitalized with HF and discharged alive, 3,581 (17.8%) had worsening RF during the index hospitalization. One year after discharge, 35.4% of these patients died, 64.5% were readmitted, and average costs at 1 year were $14,829 (interquartile range 0 to 19,366). After adjustment for patient characteristics, baseline RF, and comorbid conditions, worsening RF was independently associated with 1-year mortality (hazard ratio 1.12, 95% confidence interval 1.04 to 1.20) but not readmission or total inpatient costs. In conclusion, worsening RF in patients hospitalized with HF was independently associated with long-term mortality.

PMID: 20538131 [PubMed - as supplied by publisher]

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Continuous Versus Bolus Dosing of Furosemide for Patients Hospitalized for Heart Failure.

Am J Cardiol. 2010 Jun 15;105(12):1794-1797

Authors: Allen LA, Turer AT, Dewald T, Stough WG, Cotter G, O’Connor CM

Intravenous diuretics are the cornerstone of management for patients hospitalized for heart failure. Physiologic data suggest that intermittent high-dose furosemide promotes neurohormonal activation, which a slow continuous infusion might remediate. However, the limited clinical data comparing dosing schemes are confounded. This study was a randomized, open-label, single-center trial of twice-daily bolus injection versus continuous infusion furosemide in patients hospitalized with heart failure and volume overload. The primary outcome was change in creatinine from admission to hospital day 3 or discharge. Twenty-one patients were randomized to bolus injection and 20 patients to continuous infusion. Baseline characteristics were balanced between study arms except for gender, with a mean age of 60 +/- 15 years, a mean ejection fraction of 35 +/- 19%, and a mean creatinine level of 1.9 +/- 1.2 mg/dl. The mean doses of furosemide were similar between arms over the first 48 hours (162 +/- 48 and 162 +/- 52 mg/24 hours). None of the outcomes differed significantly between bolus and continuous dosing from admission to hospital day 3 or discharge (mean change in creatinine -0.02 vs 0.13 mg/dl, p = 0.18; urine output 5,113 vs 4,894 ml, p = 0.78; length of stay 8.8 vs 9.9 days, p = 0.69). All patients survived to discharge. In conclusion, there were no substantial differences between bolus injection and continuous infusion of equal doses of furosemide for the treatment of patients hospitalized with heart failure. Given the high prevalence of heart failure hospitalization and the disparate results of small studies regarding optimal dosing of loop diuretics to treat these patients, larger multicenter blinded studies are needed.

PMID: 20538132 [PubMed - as supplied by publisher]

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Prognostic implications of bundle branch block in patients undergoing primary coronary angioplasty in the stent era.

Am J Cardiol. 2010 May 1;105(9):1276-83

Authors: Vivas D, Pérez-Vizcayno MJ, Hernández-Antolín R, Fernández-Ortiz A, Bañuelos C, Escaned J, Jiménez-Quevedo P, De Agustín JA, Núñez-Gil I, González-Ferrer JJ, Macaya C, Alfonso F

The presence of bundle branch block (BBB) in patients with ST-segment elevation myocardial infarction has been associated with a poor outcome. However, the implications of BBB in patients undergoing primary angioplasty in the stent era are poorly established. Furthermore, the prognostic implications of BBB type (right vs left and previous vs transient or persistent) remain unknown. We analyzed the data from 913 consecutive patients with ST-segment elevation myocardial infarction treated with primary angioplasty. All clinical, electrocardiographic, and angiographic data were prospectively collected. The median follow-up period was 19 months. The primary end point was the combined outcome of death and reinfarction. BBB was documented in 140 patients (15%). Right BBB (RBBB) was present in 119 patients (13%) and was previous in 27 (23%), persistent in 45 (38%), and transient in 47 (39%). Left BBB (LBBB) was present in 21 patients (2%) and was previous in 8 (38%), persistent in 9 (43%), and transient in 4 (19%). Patients with BBB were older, and more frequently had diabetes, anterior infarctions, a greater Killip class, a lower left ventricular ejection fraction, and greater mortality (all p <0.005) than patients without BBB. The short- and long-term primary outcome occurred more frequently in patients with persistent RBBB/LBBB than in those with previous or transient RBBB/LBBB. On multivariate analysis, persistent RBBB/LBBB emerged as an independent predictor of death and reinfarction. In conclusion, in patients undergoing primary angioplasty in the stent era, BBB is associated with poor short- and long-term prognosis. This risk appears to be particularly high among patients with persistent BBB.

PMID: 20403479 [PubMed - in process]

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Accuracy of noninvasively determined pulmonary artery systolic pressure.

Am J Cardiol. 2010 Apr 15;105(8):1192-7

Authors: Testani JM, St John Sutton MG, Wiegers SE, Khera AV, Shannon RP, Kirkpatrick JN

The noninvasive estimation of pulmonary artery systolic pressure (PASP) has become a standard component of the echocardiographic examination. Our aim was to evaluate the accuracy of this modality in a large series of unselected studies obtained in clinical practice. All right heart catheterizations during a 4-year period were reviewed. Studies with echocardiographic findings available within 48 hours were evaluated for PASP agreement. In an effort to mirror clinical practice, the right heart catheterization findings were used as the reference standard and the PASP values were taken directly from the respective clinical reports. Overall, 792 right heart catheterization-echocardiogram pairs were identified. Echocardiographic PASP could not be estimated in 174 of these studies (22.0%). The correlation between modalities was moderate, but agreement was poor (bias 9.0%, 95% limits of agreement -53.2% to 71.2%, r = 0.52, p <0.001). Misclassification of clinical PASP categories occurred more often than not (54.4%). Multivariate analysis using multiple potential sources of error could only account for 3.2% of the total variation in the discrepancy between the study modalities (p = 0.003). In conclusion, noninvasively estimated PASP had limited agreement with the invasively determined PASP, and misclassification of PASP clinical categories occurred frequently. Given the widespread use of echocardiographically determined PASP, these data are in need of replication in a large prospective study.

PMID: 20381676 [PubMed - in process]

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Comparison of bivalirudin and unfractionated heparin plus protamine in patients with coronary heart disease undergoing percutaneous coronary intervention (from the Antithrombotic Regimens aNd Outcome [ARNO] trial).

Am J Cardiol. 2010 Apr 15;105(8):1053-9

Authors: Parodi G, Migliorini A, Valenti R, Bellandi B, Signorini U, Moschi G, Buonamici P, Cerisano G, Antoniucci D

Previous studies have compared bivalirudin and unfractionated heparin (UFH) plus the routine use of glycoprotein IIb/IIIa inhibitors. They have demonstrated that bivalirudin can decrease bleeding complications without a significant increase in ischemic complications, resulting in a better net clinical outcome, as defined by the efficacy (ischemic complications) or safety (bleeding complications) end point. The aim of the present study was to compare bivalirudin and UFH plus protamine in patients undergoing elective percutaneous coronary intervention and pretreated with clopidogrel and aspirin. We randomly assigned 850 patients with stable or unstable coronary artery disease to bivalirudin or UFH followed by protamine at the end of the percutaneous coronary intervention. The primary end point was in-hospital major bleeding. The main secondary end points were the 1-month composite of death, myocardial infarction, unplanned target vessel revascularization; and the 1-month net clinical outcome. The rate of major bleeding (primary end point) was 0.5% in patients randomized to bivalirudin and 2.1% in patients randomized to UFH (p = 0.033). At 30 days, the rate of major bleeding was 0.9% in the bivalirudin arm and 2.8% in the UFH arm (p = 0.043). The composite of death, myocardial infarction, and target vessel revascularization rate and the net clinical outcome rate was 2.8% and 6.4% (p = 0.014) and 3.3% and 7.8% (p = 0.004), respectively, in the bivalirudin and UFH arms. In conclusion, in percutaneous coronary intervention patients pretreated with clopidogrel and aspirin, bivalirudin was associated with less major bleeding and fewer ischemic complications and a better net clinical outcome than UFH.

PMID: 20381652 [PubMed - in process]

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Comparison of the usefulness of N-terminal pro-brain natriuretic peptide to other serum biomarkers as an early predictor of ST-segment recovery after primary percutaneous coronary intervention.

Am J Cardiol. 2010 Apr 15;105(8):1047-52

Authors: Verouden NJ, Haeck JD, Kuijt WJ, van Geloven N, Koch KT, Henriques JP, Baan J, Vis MM, van Straalen JP, Fischer J, Piek JJ, Tijssen JG, de Winter RJ

Data on the ability of serum biomarkers to predict microvascular obstruction by ST-segment recovery after primary percutaneous coronary intervention (PCI) is largely absent. Therefore, we determined the association between 5 serum biomarkers, obtained before emergency coronary angiography, and immediate ST-segment recovery in patients who had undergone primary PCI for ST-segment elevation myocardial infarction. We measured N-terminal pro-brain natriuretic peptide (NT-pro-BNP), cardiac troponin T, creatinine kinase-MB fraction, high-sensitivity C-reactive protein, and serum creatinine from blood samples obtained through the arterial sheath at the start of primary PCI. Serial 12-lead electrocardiograms were recorded in the catheterization laboratory before arterial puncture and at the end of the PCI. ST-segment recovery was defined as incomplete if <50%. Of 662 included patients with ST-segment elevation myocardial infarction, 338 (51%) had incomplete ST-segment recovery. An elevated NT-pro-BNP level (> or = 608 ng/L) was the strongest predictor of incomplete ST-segment recovery (adjusted odds ratio 2.6, 95% confidence interval 1.6 to 4.1; p <0.001) compared to other serum biomarkers and clinical predictors. An elevated NT-pro-BNP level was more strongly predictive in patients without a history of coronary artery disease or hypertension (adjusted odds ratio 4.7, 95% confidence interval 2.4 to 9.2; p <0.001). NT-pro-BNP was the best contributor to both net reclassification (0.43; p <0.001) and integrated discrimination improvement (0.04; p <0.001) when added to a multivariate model with clinical predictors of incomplete ST-segment recovery. In conclusion, NT-pro-BNP was the strongest independent predictor of ST-segment recovery at the end of primary PCI for ST-segment elevation myocardial infarction compared to the other serum biomarkers reflecting myocardial cell damage, renal function, and inflammation.

PMID: 20381651 [PubMed - in process]

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