The Significance of Apolipoprotein-A in the Long-Term Death of Patients with STEMI

Objective. To analyze apolipoprotein-A for its predictive value for long-term death in individuals suffering from acute ST-segment elevation myocardial infarction following percutaneous coronary intervention. Methods. We selected patients suffering from acute ST-segment elevation myocardial infarction who underwent emergency PCI at the Affiliated Hospital of Putian University from January 2017 to August 2019. The patients were divided into a high-Apo-A group and low-Apo-A group, and we observed all-cause deaths of patients in the 2 groups within 2 years. Results. The ROC curve analysis indicated the best critical value for predicting 2-year mortality as 0.8150 (area under the curve was 0.626, sensitivity 75.1%, and specificity 51.9%). There was no statistical difference among the two groups in gender, age, lesion vessel, and comorbidities. The two groups had statistically significant differences in apolipoprotein-B/A, high-density lipoprotein, apolipoprotein-A, and hypersensitivity C-reactive protein. Correlation analysis showed a significant negative correlation between apolipoprotein-A and hypersensitive C-reactive protein. The results of the 24-month analysis indicated the incidence of all-cause mortality as higher in the low-Apo-A group, and Kaplan–Meier survival analysis showed the same trend. Conclusion. Apolipoprotein-A can predict the potential for long-term mortality among individuals having acute ST-segment elevation myocardial infarction.

Qrs-Complex Fragmentations and Right Ventricular Infarction in the Presence of Inferior Infarction with Triple-Vessels Disease; Bad Initials but a Good Outcome

Rationale: The term “fragmentation of the QRS complex” denotes the existence of high-frequency potentials (spikes) in the QRS-complex. It is either a marker for cardiac structural diseases inducing biventricular hypertrophy or any condition interfering with the normally homogeneous depolarization status inside the myocardium. An associated right ventricular infarction with inferior infarction maybe carry a risk impact and serious complications. Patient concerns: A 64-year-old married, farmer, heavy smoker, Egyptian male patient presented with acute severe chest pain and inferior with right ventricular ST-segment elevation myocardial infarction and fragmentation of the QRS complex. Diagnosis: QRS-complex fragmentations and right ventricular infarction in the presence of inferior infarction with the triple-vessels disease. Interventions: Electrocardiography, oxygenation, streptokinase intravenous infusion, echocardiography, and percutaneous transluminal coronary angioplasty. Outcomes: Dramatic response of acute inferior with right ventricular ST-segment elevation myocardial infarction and QRS-complex fragmentations to streptokinase. Lessons: Despite the presence of inferior and right ventricular ST-segment elevation myocardial infarction with QRS-complex fragmentations, but there is no correlation with the severity of the disease. Dramatic clinical and electrocardiographic response signifying the role of streptokinase and fibrinolytic. The presence of fragmentation of the QRS-complex may have a bidirectional impact from seriousness to complications.

Safety and Efficacy of Drug-Coated Balloons Versus Drug-Eluting Stents in Acute Coronary Syndromes: A Prespecified Analysis of BASKET-SMALL 2

Background: Drug-coated balloons (DCBs) are an established treatment strategy for coronary artery disease. Randomized data on the application of DCBs in patients with an acute coronary syndrome (ACS) are limited. We evaluated the impact of clinical presentation (ACS versus chronic coronary syndrome) on clinical outcomes in patients undergoing DCB or drug-eluting stent (DES) treatment in a prespecified analysis of the BASKET-SMALL 2 trial (Basel Kosten Effektivitäts Trial–Drug-Coated Balloons Versus Drug-Eluting Stents in Small Vessel Interventions). Methods: BASKET-SMALL 2 randomized 758 patients with small vessel coronary artery disease to DCB or DES treatment and followed them for 3 years regarding major adverse cardiac events (cardiac death, nonfatal myocardial infarction, and target vessel revascularization). Results: Among 758 patients, 214 patients (28.2%) presented with an ACS (15 patients [7%], ST-segment–elevation myocardial infarction; 109 patients [50.9%], non–ST-segment–elevation myocardial infarction; 90 patients [42.1%], unstable angina pectoris). At 1-year follow-up, there was no significant difference in the incidence of the primary end point by randomized treatment in patients with ACS (hazard ratio, 0.50 [95% CI, 0.19–1.26] for DCB versus DES) or chronic coronary syndrome (hazard ratio, 1.29 [95% CI, 0.67–2.47] for DCB versus DES). There was no significant interaction between clinical presentation and treatment effect ( P for interaction, 0.088). For cardiac death ( P for interaction, 0.049) and nonfatal myocardial infarction ( P for interaction, 0.010), a significant interaction between clinical presentation and treatment was seen at 1 year with lower rates of these secondary end points in patients with ACS treated by DCB. At 3 years, there were similar major adverse cardiac event rates throughout groups without significant interaction between clinical presentation and treatment ( P for interaction, 0.301). All-cause mortality was higher in ACS compared with chronic coronary syndrome; however, there was no difference between DCB and DES irrespective of clinical presentation. Conclusions: In this subgroup analysis of the BASKET-SMALL 2 trial, there was no interaction between indication for percutaneous coronary intervention (acute versus chronic coronary syndrome) and treatment effect of DCB versus DES in patients with small vessel coronary artery disease. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01574534.

Higher Plasma Pentraxin-3 Level Predicts Adverse Clinical Outcomes in Patients With Coronary Artery Disease: A Meta-Analysis of Cohort Studies

Background: Association between plasma pentraxin-3 (PTX-3) and clinical outcomes in patients with coronary artery disease (CAD) remains not fully determined. An updated meta-analysis of cohort studies was performed to systematically evaluate the association.Methods: Cohort studies evaluating the association between plasma PTX-3 and adverse outcomes [mortality and major adverse cardiovascular events (MACEs)] in adults with CAD were identified by systematic search of PubMed, Embase, and Web of Science databases. Only studies with multivariate analysis were included. A random-effects model incorporating the potential intrastudy heterogeneity was used for the meta-analysis.Results: A total of 16 studies including 11,007 patients were included. Pooled results showed that patients with highest level of PTX-3 were independently associated with higher risk of mortality [adjusted risk ratio (RR): 2.09, 95% CI: 1.60 to 2.74, p < 0.001; I2 = 50%] and MACEs (adjusted RR: 1.80, 95% CI: 1.43 to 2.28, p < 0.001; I2 = 49%). Subgroup analyses showed that the associations between PTX-3 and poor prognosis in CAD were consistent in patients with ST-segment elevation myocardial infraction, non-ST-segment elevation acute coronary syndrome, and stable CAD (p < 0.05 for each subgroup). Besides, the association between PTX-3 and increased incidence of mortality and MACEs were consistent in short-term (within 1 year) and long-term (over 1 year) studies and in studies with or without adjustment of C-reactive protein (CRP) (p < 0.05 for each subgroup).Conclusion: Higher plasma PTX-3 is associated with poor prognosis in patients with CAD, which may be independent of the CAD subtype, follow-up durations, and adjustment of CRP.

Tenecteplase use in the management of acute ischemic stroke: Literature review and clinical considerations

Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose Several research articles have been published within the last decade comparing the use of tenecteplase to alteplase in ischemic stroke management. Prior reporting on the comparative therapeutic efficacy and safety profiles of tenecteplase and alteplase is reviewed. Summary Tenecteplase is a variant of native tissue-type plasminogen activator, which rapidly promotes thrombolysis by catalyzing formation of the serine protease plasmin. Tenecteplase has theoretical advantages over alteplase as it has greater fibrin specificity and has a longer half-life than alteplase. This allows the administration of a single bolus over 5 to 10 seconds, as opposed to a bolus followed by a 1-hour infusion with alteplase. While currently approved by the Food and Drug Administration for the treatment of ST-segment elevation myocardial infarction, tenecteplase has also been studied in the treatment of acute ischemic stroke and has extensive data for this off-label indication. The most comprehensive trials to date evaluating the use of tenecteplase in acute ischemic stroke include the TNK-S2B, Australian TNK, ATTEST, Nor-Test, and EXTEND-IA TNK trials. Findings from these randomized controlled studies suggest that tenecteplase is at least as efficacious as alteplase in terms of neurological outcomes. The majority of these studies also reported a trend toward improved safety profiles with the use of tenecteplase. Conclusion Current clinical evidence shows that tenecteplase is not inferior to alteplase for the treatment of ischemic stroke and suggests that tenecteplase may have a superior safety profile. Furthermore, tenecteplase also has practical advantages in terms of its administration. This can potentially lead to a decrease in medication errors and improvement in door to thrombolytic time.

IMPACT OF GENDER ON THE CLINICAL FEATURES, ANGIOGRAPHIC FINDINGS, AND OUTCOMES OF YOUNG PATIENTS PRESENTED WITH ACUTE CORONARY SYNDROME

Objectives: Acute coronary syndrome (ACS) at a younger age is now becoming a crucial problem. This study determined the effect of gender on the clinical findings and outcomes of young patients (≤ 45 years) with ACS. Methodology: In this descriptive cross sectional study, young patients (≤45 years) who presented with ACS and underwent coronary angiography were recruited. The comparison of clinical profile, angiographic findings, in-hospital, and 90-days mortality between genders were made. Results: A total of 335 young patients with ACS were included, 80.6% of whom were men. A significant difference was found between men and women in terms of mean age: 38±6 vs. 40±5 (p=0.014), hypertension: 37.8% vs. 58.5% (p=0.002), diabetes: 17.4% vs. 35.4% (p=0.001), smoking: 50.4% vs. 6.2% (p≤0.001), use of smokeless tobacco: 14.1% vs. 4.6% (p=0.037), median time from symptom onset to first medical contact: 270 [420–165] minutes vs. 346 [499.5–240] minutes (p=0.047), ST-segment elevation myocardial infarction (STEMI) 89.6% vs. 78.5% (p=0.015), non-ST-elevation myocardial infarction (NSTEMI) 8.5% vs. 18.5% (p=0.019), and three-vessel disease (3VD) 10.7% vs. 21.5% (p=0.019), respectively. In-hospital and 90-day mortality rates were 0.4% vs. 3.1% (p=0.097) and 1.5% vs. 4.6% (p=0.136) for men and women, respectively. Conclusion: Women tended to have a higher age at presentation, more frequent traditional risk factors, late presentation after symptom onset, frequent NSTEMI, and 3VD, whereas men were distinct with frequent STEMI and higher tobacco use. In addition, women trended to have a higher in-hospital as well as short-term mortality than men did.