Comparative study of ticagrelor and clopidogrel in therapeutic effect of acute myocardial infarction patients undergoing percutaneous coronary intervention

ObjectivesComparison of Ticagrelor vs clopidogrel in antiplatelet therapeutic effect of acute myocardial infarction patients undergoing percutaneous coronary intervention.MethodsThe study focused on 2000 acute myocardial infarction patients undergoing percutaneous coronary intervention (PCI) in our hospital from January 2013 to December 2015. To reduce the formation of acute stent thrombosis caused by clopidogrel resistance, we had two options, one was to double the dosage of clopidogrel, and the other was to substitute ticagrelor for clopidogrel. Based on random number table method, the 2000 patients were divided into experimental group and control group, each containing 1,000 patients. The patients in experimental group took 180 mg ticagrelor before PCI and 90 mg ticagrelor twice a day after PCI (Gu, 2016). In contrast, the patients control group took 600 mg clopidogrel before PCI and 150 mg clopidogrel once a day after PCI. Both groups were drawn 2.7 ml of fasting venous blood for platelet aggregation rate test before PCI and 2 h, 24 h, 7 days after PCI respectively. Turbidimetric method was used to measure the ADP-induced platelet aggregation rate and observe change of platelet aggregation rate and success rate. Incidence of liver and kidney malfunction and adverse actions were monitored. All patients accepted a 6-month of follow-up examination to record and compare incidences of major adverse cardiac and cerebrovascular events. The statistical results of both groups are analyzed and compared.ResultsThe platelet aggregation rate of experimental group before PCI and 2 h, 24 h, 7 days after PCI was 59.71% ± 7.24%, 59.20% ± 7.70%, 48.66% ± 7.80% and 43.39% ± 8.28%; The control group was 58.04% ± 5.61%, 56.25% ± 6.02%, 55.68% ± 3.14%, 53.94% ± 5.30%; Comparing the platelet aggregation rate of different time, P was less than 0.05. The success rate of platelet aggregation of experimental group and control group was 80.56% and 46.86% respectively. There were significant differences between the two groups and the P was less than .05. The postoperative serum creatinine level of experimental group was higher than that in the control group (P < .05). The incidence of adverse reactions in the experimental group was significantly lower than that of the control group. There were significant differences between the two groups and the difference was of statistical significance (P < .05). According to the 5-month follow-up examination: the incidence of major adverse cardiac and cerebrovascular events in experimental group was 2.60% (52/2000) ,while the control group was 13.00% (260/2000) . There were significant differences between the two groups and the difference was of statistical significance (P < .05).ConclusionsCompared with clopidogrel, ticagrelor can achieve better n antiplatelet effect for patients with acute myocardial infarction undergoing percutaneous coronary intervention (PCI). It can effectively reduce the incidence of postoperative adverse cardiac and cerebrovascular events and control the rate of adverse reactions within the acceptable range.     

Prospective register of primary percutaneous coronary interventions in patients with acute myocardial infarction

The present study has evaluated the immediate angiographic results of primary percutaneous interventions (PCI) in patients with acute myocardial infarction, as well as hospital and 6-month clinical outcomes. The analysis covered a total of 265 patients (females (23%) and males (77%)); their mean age was 57+/-11 years. The mean time before the first balloon dilatation during PCI was 278+/-135 minutes after the development of the pain syndrome or 109+/-94 minutes after hospital admission. PCI proved to be effective in 96% of the patients, as evidenced by angiography. TIMI 3 blood flow was achieved in 83% of cases during PCI. After primary PCI, hospital mortality was 98.9% and 95% survived 6 months. At 6-month follow-up, 22% patients had positive exercise tests, recurrent angina pectoris and/or more than 50% luminal stenosis of the infarct-related artery. Control angiography made less than 6 months later showed 11% restenosis. This prospective study has demonstrated the high immediate and long effectiveness and safety of primary interventions in acute myocardial infarction.     

Association of admission testosterone level with ST-segment resolution in male patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

Background

Low level of testosterone may be associated with cardiovascular diseases in men, as some evidence suggests a protective role for testosterone in cardiovascular system. Little is known about the possible role of serum testosterone in response to reperfusion therapy in ST-elevation myocardial infarction (STEMI) and its relationship with ST-segment recovery. The present study was conducted to evaluate the association of serum testosterone levels with ST-segment resolution following primary percutaneous coronary intervention (PPCI) in male patients with acute STEMI.

Methods

Forty-eight men (mean age 54.55 ± 12.20) with STEMI undergoing PPCI were enrolled prospectively. Single-lead ST segment resolution in the lead with maximum baseline ST-elevation was measured and patients were divided into two groups according to the degree of ST-segment resolution: complete (> or =50%) or incomplete (<50%). The basic and demographic data of all patients, their left ventricular ejection fraction (LVEF) and laboratory findings including serum levels of free testosterone and cardiac enzymes were recorded along with angiographic finding and baseline TIMI (Thrombolysis in Myocardial Infarction) flow and also in-hospital complications and then these variables were compared between two groups.

Results

A complete ST-resolution (≥50%) was observed in 72.9% of the patients. The serum levels of free testosterone (P = 0.04), peak cardiac troponin (P = 0.03) were significantly higher and hs-CRP (P = 0.02) were lower in patients with complete ST-resolution compared to those with incomplete ST-resolution. In-hospital complications were observed in 31.2% of patients. The patients with a lower baseline TIMI flow (P = 0.03) and those who developed complications (P = 0.04) had lower levels of free testosterone. A significant positive correlation was observed between the left ventricular function and serum levels of free testosterone (P = 0.01 and r = +0.362).

Conclusion

This study suggests that in men with STEMI undergoing PPCI, higher serum levels of testosterone are associated with a better reperfusion response, fewer complications and a better left ventricular function.

     

Effect of primary percutaneous coronary intervention on stress hyperglycaemia in myocardial infarction

Diabet. Med. 29, 1317-1320 (2012) ABSTRACT: Aim To measure the effect of primary percutaneous coronary intervention on stress hyperglycaemia induced by ST segment elevation myocardial infarction. Methods We measured blood glucose before primary percutaneous coronary intervention and 1?h after intervention in all patients presenting with ST segment elevation myocardial infarction for 2?months in our unit. A paired t-test was used for a statistical analysis. Results From 157 patients accepted for primary percutaneous coronary intervention, 90 patients were included in the analysis. Blood glucose before intervention was 8.4?±?2.46?mmol/l (mean?±?SD) and after intervention was 7.9?±?2.0?mmol/l (mean?±?sd) (P?=?0.003). In the subset of 15 patients with hyperglycaemia (glucose greater than 10?mmol/l), glucose before intervention was 12.7?±?2.62?mmol/l (mean?±?SD) and after intervention was 9.8?±?3.42?mmol/l (mean?±?sd) (P?=?0.0002). Conclusions Blood glucose in patients with ST segment elevation myocardial infarction is significantly lower after primary percutaneous coronary intervention and this reduction is most marked in patients with hyperglycaemia. Waiting for the stress response to diminish means that 11.1% of patients' glucose levels fell below the treatment threshold of 10?mmol/l. Using the post-intervention blood glucose level avoids the need for treatment with insulin in this population. Further randomized studies are warranted to investigate the impact on mortality and morbidity of administering insulin triggered by pre-invention blood glucose vs. post-intervention blood glucose.     

A 60-s postconditioning protocol by percutaneous coronary intervention inhibits myocardial apoptosis in patients with acute myocardial infarction

Different postconditioning (Postcon) methods have been demonstrated to protect heart from ischemia/reperfusion injury. The relationship between Postcon by percutaneous coronary intervention (PCI) and apoptosis is not clear. Our objective was to test whether Postcon by PCI in patients with acute myocardial infarction (AMI) reduces myocardial apoptosis. Seventy-five patients were randomly assigned to one of three groups before stenting. The Routine group (n = 26) received no Postcon intervention prior to the onset of reperfusion; Postcon-30s (n = 25) and Postcon-60s groups (n = 24) underwent three cycles of 30- or 60-s balloon deflation and 30- or 60-s inflation. Additionally, 34 normal controls (NC) were enrolled in the study. Plasma concentrations of soluble Fas/APO-1 ([sFas]) and Fas ligand ([sFasL]) were determined at baseline and 7 days after PCI via ELISA. The [sFas] and [sFasL] in AMI patients were significantly elevated at baseline as compared with NC (P < 0.01), and showed an upward trend in the Routine group, a slightly upward trend in Postcon-30s, and a downward trend in Postcon-60s at 7 days. Comparison among the three groups showed significant differences (P < 0.05, 3.8 vs. 4.6 vs. 5.1 ng ml⁻¹). The [sFasL] in Postcon-60s was significantly decreased at 7 days (P < 0.05, 3.9 vs. 3.1 ng ml⁻¹) compared with baseline, but not Postcon-30s and Routine. More importantly, Postcon-60s group had the lowest [sFasL], followed by Postcon-30s, which had a lower value than Routine at 7 days (P < 0.05, 3.1 vs.3.7 vs. 4.2 ng ml⁻¹). Our results suggest that Postcon-60s was visibly better than Postcon-30s, which in turn was better than Routine for inhibition of the effects of myocardial apoptosis and reduction of reperfusion injury in patients with acute myocardial infarction.     

Conditions mimicking acute ST-segment elevation myocardial infarction in patients referred for primary percutaneous coronary intervention

Background/Objectives. A rapid diagnosis of ST-segment elevation myocardial infarction (STEMI) is mandatory for optimal treatment. However, a small proportion of patients with suspected STEMI suffer from other conditions. Although case reports have described these conditions, a contemporary systematic analysis is lacking. We report the incidence, clinical characteristics and outcome of patients with suspected STEMI referred for primary percutaneous coronary intervention (PCI) with a final diagnosis other than STEMI. Methods. From January 2004 to July 2005, 820 consecutive patients were included with suspected STEMI who were referred for primary PCI to a university medical centre, based on a predefined protocol. Clinical characteristics, final diagnosis and outcome were obtained from patient charts and databases. Results. In 19 patients (2.3%), a final diagnosis other than myocardial infarction was established: coronary aneurysm (n=1), (myo)pericarditis (n=5), cardiomyopathy (n=2), Brugada syndrome (n=1), aortic stenosis (n=1), aortic dissection (n=3), subarachnoidal haemorrhage (n=2), pneumonia (n=1), chronic obstructive pulmonary disease (n=1), mediastinal tumour (n=1), and peritonitis after recent abdominal surgery (n=1). These patients less often reported previous symptoms of angina (p<0.001), smoking (p<0.05) and a positive family history of cardiovascular diseases (p<0.05) than STEMI patients. Mortality at 30 days was 16%. Conclusion. A 2.3% incidence of conditions mimicking STEMI was found in patients referred for primary PCI. A high clinical suspicion of conditions mimicking STEMI remains necessary. (Neth Heart J 2008;16:325-31.)     

冠脉内注射替罗非班不同给药方式对急性心肌梗死介入治疗术中血流异常的影响

目的：比较急性心肌梗死介入治疗中冠脉内常规给予以及必要时给予血小板膜糖蛋白（GP）Ⅱb／Ⅲa受体拮抗剂替罗非班两种给药方式对冠脉血流异常的影响,寻找较好的替罗非班用药方式。方法：入选九四医院2005年1月至2008年10月急性心肌梗死直接PCI患者58例,随机分成常规给药组（血管开通前所有患者冠状动脉内均注射替罗非班,n=30）与必要时给药组（血管开通后即时造影显示TIMI血流≤2级者冠脉内注射替罗非班,TIMI血流3级者不给药,n=28）,观察支架植入后30分钟TIMI血流、30天内主要不良心血管事件（MACE）、出血以及血小板减少情况。结果：必要给药组冠脉内给药可显著改善冠脉血流（TIMI3级给药前46．4％,给药后75％,P〈0．05）,常规给药组支架植入后30分钟TIMI3级获得率高于必要给药组（96．7％比75％,P〈0．05）,MACE、出血和血小板减少事件两组之间差异无统计学意义。结论：冠脉内给予替罗非班可有效降低急性心肌梗死PCI术中血流异常情况,血管开通前冠脉内常规给药方式优于必要时给药方式。     

MRI discriminates thrombus composition and ST resolution after percutaneous coronary intervention in patients with ST-elevation myocardial infarction

Histological composition of material obtained by thrombus aspiration during percutaneous coronary intervention (PCI) in patients with ST-segment elevation acute myocardial infarction (STEMI) is highly variable. We aimed to characterize this material using magnetic resonance imaging (MRI) and to correlate MRI findings with the success of PCI in terms of ST-segment resolution. Thrombus aspiration during primary or rescue PCI was attempted in 100 consecutive STEMI patients, of whom enough material for MRI was obtained in 59. MR images were obtained at 9.4T and T1 and T2 values were measured. Patients with (n = 31) and without (n = 28) adequate ST resolution 120 min after PCI (≥70% of pre-PCI value) had similar baseline characteristics except for a higher prevalence of diabetes mellitus in the latter (10 vs. 43%, p = 0.003). T1 values were similar in both groups (1248±112 vs. 1307±85 ms, respectively, p = 0.7). T2 values averaged 31.2±10.3 and 36.6±12.2 ms; in thrombus from patients with and without adequate ST resolution (p = 0.09). After adjusting for diabetes and other baseline characteristics, lower T2 values were significantly associated with inadequate ST resolution (odds ratio for 1 ms increase 1.08, CI 95% 1.01–1.16, p = 0.027). Histology classified thrombus in 3 groups: coagulated blood (n = 38), fibrin rich (n = 9) and lipid-rich (n = 3). Thrombi composed mostly of coagulated blood were characterized as being of short (n = 10), intermediate (n = 15) or long evolution (n = 13), T2 values being 34.0±13.2, 31.9±8.3 and 31.5±7.9 ms respectively (p = NS). In this subgroup, T2 was significantly higher in specimens from patients with inadequate perfusion (35.9±10.3 versus 28.6±6.7 ms, p = 0.02). This can be of clinical interest as it provides information on the probability of adequate ST resolution, a surrogate for effective myocardial reperfusion.     

Increased 30-day and 1-year mortality rates and lower coronary revascularisation rates following acute myocardial infarction in patients with autoimmune rheumatic disease

IntroductionIt is now well-recognised that patients with autoimmune rheumatic disease (AIRD) have a predisposition to cardiovascular disease that results in increased morbidity and mortality. Following myocardial infarction (MI), patients with rheumatoid arthritis have been shown to have an increased case fatality rate; however, this has not been demonstrated in other forms of AIRD. The aim of this study was to compare case fatality rates following a first MI in patients with AIRD versus the general population. The secondary aim was to compare revascularisation treatment following MI in patients with AIRD versus the general population.MethodsA retrospective cohort study using two population-based linked databases was undertaken. Cases of first MI from July 2001 to June 2007 were identified based on International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification, codes. Thirty-day and one-year mortality rates were calculated (all-cause and cardiovascular causes of death). Logistic regression models were fitted to calculate the odds of mortality by AIRD status with adjustment for relevant characteristics.ResultsThere were 79,390 individuals with a first MI, of whom 1,409 (1.8%) had AIRD. After adjusting for relevant covariates, the odds ratio (OR) for 30-day cardiovascular mortality in patients with AIRD was 1.44 (95% confidence interval (CI): 1.25 to 1.66), and the OR for 12-month cardiovascular mortality was 1.71 (95% CI: 1.51 to 1.94). The 90-day adjusted odds of percutaneous transluminal coronary angioplasty and coronary artery bypass graft were significantly lower in the AIRD group compared with controls (OR: 0.81, 95% CI: 0.70 to 0.94, and OR: 0.52, 95% CI: 0.39 to 0.69, respectively).ConclusionsWe identified a higher risk-adjusted mortality rate for the majority of patients with AIRD at 30 days and 12 months after first MI. We also identified lower post-MI revascularisation rates in the AIRD group, suggesting there may be current gaps in cardiovascular treatment for patients with AIRD.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0552-2) contains supplementary material, which is available to authorized users.     

Relationship between time of day and periprocedural myocardial infarction after elective angioplasty

Objectives: To test if the time of day significantly influences the occurrence of type 4A myocardial infarction in elective patients undergoing percutaneous coronary intervention (PCI).

Background: Recent studies have suggested an influence of circadian rhythms on myocardial infarction size and mortality among patients with ST-elevation myocardial infarction. The aim of the study is to investigate whether periprocedural myocardial infarction (PMI) is influenced by the time of day in elective patients undergoing PCI.

Methods: All consecutive patients undergoing elective PCI between 2007 and 2011 at our institutions with known post-interventional troponin were retrospectively included. Patients (n?=?1021) were divided into two groups according to the starting time of the PCI: the morning group (n?=?651) between 07:00 and 11:59, and the afternoon group (n?=?370) between 12:00 and 18:59. Baseline and procedural characteristics as well as clinical outcome defined as the occurrence of PMI were compared between groups. In order to limit selection bias, all analyses were equally performed in 308 pairs using propensity score (PS) matching.

Results: In the overall population, the rate of PMI was statistically lower in the morning group compared to the afternoon group (20% vs. 30%, p?<?0.001). This difference remained statistically significant after PS-matching (21% vs. 29%, p?=?0.03). Multivariate analysis shows that being treated in the afternoon independently increases the risk for PMI with an odds ratio of 2.0 (95%CI: 1.1–3.4; p?=?0.02).

Conclusions: This observational PS-matched study suggests that the timing of an elective PCI influences the rate of PMI.     

Prophylactic veno-arterial extracorporeal membrane oxygenation in patients undergoing high-risk percutaneous coronary intervention

Netherlands Heart Journal - Complex high-risk percutaneous coronary intervention (PCI) is challenging and frequently accompanied by haemodynamic instability. Veno-arterial extracorporeal membrane...     

Dynamic changes in serum angiopoietin-1, angiopoietin-2, and angiopoietin-2/angiopoietin-1 ratio in acute myocardial infarction patients treated with primary percutaneous coronary intervention

Context: Angiopoietin-1 (Ang-1) and angiopoietin-2 (Ang-2) play divergent roles in myocardial ischemia and reperfusion injury.

Objective: To investigate serum Ang-1 and Ang-2 levels in ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PCI).

Methods: Serum Ang-1 and Ang-2 were measured in 85 STEMI patients in the first week after PCI.

Results: Ang-1, Ang-2 and Ang-2/Ang-1 ratio (Ang-2/1) were all increased at admission, and had dynamic changes after PCI. Ang-2 and Ang-2/1 at admission and 2 h after PCI were positively correlated with peak cardiac troponin T levels.

Conclusion: The extent of myocardial damage may be linked to circulating Ang-2 and Ang-2/1.     

Effect of obesity on repeat revascularization in patients undergoing percutaneous coronary intervention with drug-eluting stents

Obesity is a major risk factor for developing coronary artery disease. The impact of obesity on prognosis among those with established coronary disease is less clear. The objective of this study was to evaluate the effect of obesity on repeat revascularization in patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES). We examined 6,083 patients who were divided into three groups according to BMI: normal (BMI 18.5-24.9 kg/m(2), n = 1,592); overweight (BMI 25-29.9 kg/m(2), n = 3,026) and obese (BMI >30 kg/m(2), n = 1,465). The follow-up focused on clinical-driven repeat revascularization, including target lesion revascularization (TLR) and nonTLR. Median follow-up was 26 months (interquartile range 20-32). There was no significant difference in the incidence of TLR among normal, overweight, and obese patients (6.3% vs. 6.1% vs. 7.1%; P = 0.423). In contrast, the incidence of nonTLR was significantly higher in obese patients compared with normal and overweight (8.4% vs. 6.0% vs. 5.8%, P = 0.003). Multivariate analysis showed that obesity was an independent predictor of nonTLR during follow-up (hazard ratio = 1.39; 95% confidence interval = 1.06-1.83; P = 0.019), along with diabetes and hypercholesterolemia. Concomitant use of statins was independently associated with decreased risk of nonTLR (hazard ratio = 0.75; 95% confidence interval = 0.62-0.92; P = 0.005). In conclusion, among patients undergoing PCI with DES, obesity was not associated with TLR, but was associated with a higher risk of nonTLR.     

The impact of adjunctive eptifibatide therapy with percutaneous coronary intervention for acute myocardial infarction

The role of small molecules anti-glycoprotein (GP) IIb/IIIa pharmacotherapy during acute myocardial infarction (AMI) has not been established. The purpose of our study was to evaluate the clinical outcomes of patients sustaining AMI who underwent emergent percutaneous coronary intervention (PCI) and who were distinguished by the use of the anti-GP IIb/IIIa agent eptifibatide. We studied a consecutive group of 216 patients who underwent PCI for acute ST-elevation myocardial infarction and compared the outcomes of patients who received eptifibatide just prior and following the procedure (n=167) to those who were not on anti GP IIb/IIIa inhibitors (n=49). On average, patients treated using eptifibatide were younger and were more likely to be men, hypertensive, and smokers. The eptifibatide treated patients were less likely to have diabetes and renal failure and had worse angiographic characteristics. There were no significant differences between the groups in any of the clinical outcomes, including the composite endpoint (e.g. death, MI, repeat revascularization) and the rate of sub-acute stent thrombosis. Nonetheless, there was a non-significant trend towards lower 30 day mortality in the eptifibatide group (4.8% versus 12%, P=0.09). We concluded that in our comparative study of periprocedural administration of eptifibatide during emergent AMI angioplasty, there was a non-significant trend towards better short-term survival among eptifibatide treated patients although the composite endpoint did not differ between patients distinguished by the use of anti GP IIb/IIIa small molecule pharmacotherapy.     

PCI围术期消化道出血患者抗血小板治疗调整及近期疗效

目的:探讨经皮冠状动脉介入治疗(PCI)围术期发生消化道出血(GIB)患者抗血小板治疗的调整,评价其安全性及近期疗效。方法:回顾性分析2005年1月至2008年12月PCI围术期发生GIB的40例患者的临床资料,其中急性心肌梗死(AMI)22例(55%),不稳定型心绞痛18例(45%)。PCI围术期发生GIB的患者,除扩容、输血、抑酸、保护胃粘膜等支持疗法外,依据临床情况调整抗血小板药物。观察住院期间及术后3个月后主要不良心脑事件(MACCE:包括心绞痛、非致死性心肌梗死、心性死亡、再次血管重建、支架内血栓形成、缺血性卒中)及消化道再次出血的发生率。结果:40例患者PCI成功39例(病例成功率97.5%),1例慢性完全闭塞(CTO)病变导丝未通过,1例(2.5%)AMI患者PCI术后第5天发生支架内亚急性血栓(SAT)。出院后3月内,2例未完全血运重建的患者有心绞痛发作,无死亡,所有患者均无消化道再次出血,MACCE发生率(7.5%)。结论:PCI围术期发生GIB的患者,依据临床情况调整抗血小板药物,不增加MACCE风险及消化道再次出血发生率。