Faculty Bibliography

We investigated the association between race/ethnicity on the use of cardiac resources in patients who have acute myocardial infarction that is complicated by cardiogenic shock. The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial examined the effect of reperfusion and revascularization treatment strategies on mortality. Patients screened but not enrolled in the SHOCK Trial (n = 1,189) were entered into the SHOCK registry. Of the patients in the United States registry (n = 538) who had shock due to predominant left ventricular failure, 440 were characterized as white (82%), 42 as Hispanic (8%), 34 as African-American (6%), and 22 as Asian/other (4%). The use of invasive procedures differed significantly by race/ethnicity. Hispanic patients underwent coronary angiography significantly less often than did white patients (38 vs 66%, p = 0.002). Among those patients who underwent coronary angiography, there were no race/ethnicity differences in the proportion of patients who underwent revascularization (p = 0.353). Overall in-hospital mortality (57%) differed significantly by race/ethnicity (p = 0.05), with the highest mortality rate in Hispanic patients (74% vs 65% for African-Americans, 56% for whites, and 41% for Asian/other). After adjustment for patient characteristics and use of revascularization, there were no mortality differences by race/ethnicity (p = 0.262), with all race/ethnicity subgroups benefiting equally by revascularization. In conclusion, the SHOCK registry showed significant differences in the treatment and in-hospital mortality of Hispanic patients who had cardiogenic shock, with these patients being less likely to undergo percutaneous coronary intervention. Therefore, early revascularization should be strongly considered for all patients, independent of race/ethnicity, who develop cardiogenic shock after acute myocardial infarction

Experimental and clinical studies have suggested that late opening of an infarct-related artery (IRA) after myocardial infarction (MI) could improve clinical outcome. However, the suggestive observational data are limited by selection biases. Indeed, most small randomized studies have not demonstrated benefit. Thus, there is no recommendation for routine late opening of the IRA in current national guidelines for management of stable post-MI patients. The OAT is designed to test the hypothesis that opening a totally occluded IRA 3 to 28 days after MI in high-risk asymptomatic patients will improve clinical outcome and be cost-effective. The primary end point is the first occurrence of recurrent MI, hospitalization/treatment of New York Heart Association class IV congestive heart failure, or death. Trial background, design, and preliminary baseline characteristics of 2027 randomized patients are presented. Eligible patients are randomly assigned in equal proportions to optimal evidence-based medical care or optimal care plus late opening of the IRA using percutaneous coronary intervention of the occluded IRA. Treatment groups will be compared using intent-to-treat analysis. The results of OAT should have broad clinical impact by defining an evidence-based approach to the asymptomatic, high-risk, post-MI patient with an occluded IRA. If the efficacy and cost-effectiveness of percutaneous coronary intervention are established, then a policy of routinely seeking and opening persistently occluded IRAs could be advocated. If not, this strategy should be avoided in this large subgroup of post-MI patients

BACKGROUND: Chronic kidney disease (CKD) is highly prevalent in patients with cardiovascular disease. We explored the associations of CKD with outcomes using combined data from two large acute coronary syndrome (ACS) trials. We also explored the associations of CKD with prescription patterns for common cardiovascular medications and the association of these prescription patterns with clinical outcomes. METHODS: Patients were stratified by CKD stage using creatinine clearance (CrCl, ml/min) estimated by the modified MDRD equation using baseline core laboratory creatinine measures. Serum creatinine > or =1.5 mg/dl was an exclusion criterion for the SYMPHONY trials. Baseline characteristics and outcomes across CKD categories were compared and Cox proportional hazards regression was used to assess the relationship of renal insufficiency with clinical outcomes after adjusting for previously identified outcome predictors. Interactions between the use of specific medications and calculated CrCl were tested in the final Cox proportional hazards model predicting time to mortality. RESULTS: Of 13 707 patients analysed, 6840 had CKD stage I (CrCl > or =90 ml/min), 5909 stage II (CrCl 60-89 ml/min), 955 stage III (CrCl 30-59 ml/min) and three stage IV (CrCl <30 ml/min). Patients with more advanced CKD (III) were older, more often female, non-smokers and more likely to have co-morbid diseases including diabetes mellitus, hypertension and congestive heart failure. Cardiovascular medications were used less frequently in patients with CKD. Unadjusted survival was poorer in patients with CKD stages > or =II. In adjusted analyses, for those with CrCl < or =91, each 10 ml/min increase in CrCl was associated with a significantly decreased risk of mortality (hazards ratio 0.897, 95% confidence interval 0.815-0.986) (P = 0.024). The interaction between use of angiotensin-converting enzyme (ACE) inhibitors and CrCl was significantly associated with outcomes; the benefit of drug therapy was greater among patients with CKD. CONCLUSIONS: CKD is an independent predictor of risk among ACS patients, and is associated with less frequent use of proven medical therapies. More aggressive use of conventional cardiovascular therapies in patients with CKD and ACS may be warranted

AIMS: Pexelizumab, a monoclonal antibody inhibiting C5, reduced 90 day mortality and shock in the COMplement inhibition in Myocardial infarction treated with Angioplasty (COMMA) trial without apparent reductions in infarct size. Inflammation is a critical component of ST-elevation myocardial infarction (STEMI); this substudy examines prognostic values of selected markers and treatment effects. METHODS AND RESULTS: C-reactive protein, interleukin-6 (IL-6), and tumour necrosis factor-alpha (TNF-alpha) serum levels were assessed in 337 patients enrolled in either the placebo or the pexelizumab 24 h infusion group. Higher C-reactive protein and IL-6 levels at baseline, 24 h, and 72 h were strongly associated with increased subsequent death (P<0.002 at baseline and 24 h, P<0.02 at 72 h); and all baseline marker levels with death or cardiogenic shock (P<0.03) within 90 days. C-reactive protein and IL-6 levels were similar at baseline, but significantly lower 24 h later with pexelizumab, when compared with placebo (17.1 vs. 25.5 mg/L, P=0.03 and 51.0 vs. 63.8 pg/mL, P=0.04, respectively). At 72 h, corresponding levels were similar, whereas TNF-alpha was slightly higher (P=0.04) in the treated group. CONCLUSION: Inflammation markers and their serial changes predict death and shock in patients with STEMI undergoing primary angioplasty. Pexelizumab reduced C-reactive protein and IL-6, suggesting treatment benefits mediated through anti-inflammatory effects

BACKGROUND: The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial demonstrated the survival advantage of emergency revascularization versus initial medical stabilization in patients developing cardiogenic shock after acute myocardial infarction. The relative merits of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in patients with shock have not been defined. The objective of this analysis was to compare the effects of PCI and CABG on 30-day and 1-year survival in the SHOCK trial. METHODS AND RESULTS: Of the 302 trial patients, 128 with predominant left ventricular failure had emergency revascularization. The selection of revascularization procedures was individualized. Eighty-one patients (63.3%) had PCI, and 47 (36.7%) had CABG. The median time from randomization to intervention was 0.9 hours (interquartile range [IQR], 0.3 to 2.2 hours) for PCI and 2.7 hours (IQR, 1.3 to 5.5 hours) for CABG. Baseline demographics and hemodynamics were similar, except that there were more diabetics (48.9% versus 26.9%; P=0.02), 3-vessel disease (80.4% versus 60.3%; P=0.03), and left main coronary disease (41.3% versus 13.0%; P=0.001) in the CABG group. In the PCI group, 12.3% had 2-vessel and 2.5% had 3-vessel interventions. In the CABG group, 84.8% received > or =2 grafts, 52.2% received > or =3 grafts, and 87.2% were deemed completely revascularized. The survival rates were 55.6% in the PCI group compared with 57.4% in the CABG group at 30 days (P=0.86) and 51.9% compared with 46.8%, respectively, at 1 year (P=0.71). CONCLUSIONS: Among SHOCK trial patients randomized to emergency revascularization, those treated with CABG had a greater prevalence of diabetes and worse coronary disease than those treated with PCI. However, survival rates were similar. Emergency CABG is an important component of an optimal treatment strategy in patients with cardiogenic shock, and should be considered a complementary treatment option in patients with extensive coronary disease