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B-type natriuretic peptide at presentation and prognosis in patients with ST-segment elevation myocardial infarction: An ENTIRE-TIMI-23 substudy
B-Type Natriuretic Peptide at Presentation and Prognosis in Patients With ST-Segment Elevation Myocardial Infarction: An ENTIRE–TIMI-23 Substudy
65 years of age or older who have had an acute myocardial infarction (MI). Methods: This retrospective cohort study used linked hospital discharge and prescription databases containing information on 18,453 patients 65 years of age or older who were admitted for an acute MI between April 1, 1996, and March 31, 2000. The association between specific drugs and clinical outcomes was measured using the Cox proportional hazards model, with adjustment for demographic, clinical, physician, and hospital variables and dosage categories, represented by time-dependent variables. Results: Enalapril, fosinopril, captopril, quinapril and lisinopril, were associated with higher mortality than was ramipril; the adjusted hazard ratios (HRs) and 95% CIs were 1.47 (95% CI, 1.14 –1.89), 1.71 (CI 1.29 –2.25), 1.56 (CI 1.13–2.15), 1.58 (CI, 1.10 –2.82) and 1.28 (CI, 0.98 – 1.67), respectively. The adjusted HR associated with perindopril was 0.98 (CI, 0.60 –1.60). Conclusions: The authors concluded that survival benefits in the first year after acute MI in patients 65 years of age or older seem to differ according to the specific ACE inhibitor prescribed. Ramipril was associated with lower mortality than most other ACE inhibitors. Perspective: The study suggests that not all drugs within the class of ACE inhibitors should be considered to have the same effect. At currently used dosages, elderly patients who filled prescriptions for ramipril had statistically significant lower mortality within the first year after acute MI than did users of several other ACE inhibitors. The exact mechanisms causing these differences are unclear, although they may be related to the structural and pharmacologic characteristics of the individual drugs. However, this was a retrospective, observational study of administrative databases, and large randomized clinical trials or prospective clinical studies are needed to confirm these results. DM
Mega JL, Morrow DA, de Lemos JA, et al. J Am Coll Cardiol 2004;44:335–9. Study Question: Investigators sought to evaluate B-type natriuretic peptide (BNP), alone and in comparison to cardiac troponin I (cTnI) and high-sensitivity C-reactive protein (hs-CRP), for risk assessment at initial presentation with ST-segment elevation myocardial infarction (STEMI). Methods: Investigators obtained samples from 438 patients presenting within 6 h of STEMI enrolled in the Enoxaparin Tenecteplase-Tissue-Type Plasminogen Activator With or Without Glycoprotein IIb/IIIa Inhibitor as Reperfusion Strategy in ST-Segment Elevation Myocardial Infarction (ENTIRE)–Thrombolysis in Myocardial Infarction (TIMI)-23 trial. Outcomes were assessed through 30 days. Results: Median BNP was higher in patients who died (89 pg/mL, 25th to 75th percentile: 40 –192), compared with survivors (15 pg/mL, 25th to 75th percentile: 8.8 –32; p⬍0.0001). Patients with BNP ⬎80 pg/mL were at significantly higher risk of death (17.4% vs. 1.8%; p⬍0.0001). Cardiac troponin established a gradient of mortality between the highest and lowest quartile (7.9% vs. 0%; p⫽0.007). C-reactive protein was not associated with outcome. After adjustment for cTnI, hs-CRP, and major clinical predictors, including age, heart failure, anterior myocardial infarction (MI) location, heart rate, and blood pressure, a BNP level ⬎80 pg/mL was associated with a seven-fold higher mortality risk ([OR] 7.2, 95% confidence interval 2.1–24.5; p⫽0.001). Patients with BNP ⬎80 pg/mL were also more likely to have impaired coronary flow (p⫽0.049) and incomplete resolution of ST-segment elevation (p⫽0.05). Conclusions: The authors concluded that increased concentrations of BNP at initial presentation of patients with STEMI are associated with impaired reperfusion after fibrinolysis and higher short-term risk of mortality. Perspective: In patients with STEMI, elevated levels of BNP at initial presentation were associated with impaired reperfusion after fibrinolysis and increased risk of short-term mortality. These data support the value of combining markers of hemodynamic stress, such as BNP, with established biomarkers of necrosis, for risk assessment at the time of presentation with acute MI. DM
Incidence and Follow-up of Inflammatory Cardiac Complications After Smallpox Vaccination Eckart RE, Love SS, Atwood JE, et al. J Am Coll Cardiol 2004;44: 201–5. Study Question: What is the outcome of vaccinia-associated myocarditis? Methods: Between December 2002 and December 2003, the U.S. Department of Defense Smallpox Vaccination Program immunized 540,824 military personnel (New York City Board of Health strain) to counter the potential release of variola virus as an act of terrorism against U.S. military forces. Cases of myopericarditis were identified through sentinel reporting to military headquarters, systematic surveillance and spontaneous reports. Results: A total of 67 cases of myopericarditis were identified 10.4⫾3.6 days after vaccination. All 67 cases presented initially with chest pain or substernal pressure. ST-segment elevation was noted in 57%; mean troponin on admission
Mortality Rates in Elderly Patients Who Take Different Angiotensin-Converting Enzyme Inhibitors After Acute Myocardial Infarction: A Class Effect? Pilote L, Abrahamowicz M, Rodrigues E, Eisenberg MJ, Rahme E. Ann Intern Med 2004;141:102–12. Study Question: The investigators evaluated whether all ACE inhibitors are associated with similar mortality in patients
ACC CURRENT JOURNAL REVIEW Oct 2004
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65 years of age or older who have had an acute myocardial infarction (MI). Methods: This retrospective cohort study used linked hospital discharge and prescription databases containing information on 18,453 patients 65 years of age or older who were admitted for an acute MI between April 1, 1996, and March 31, 2000. The association between specific drugs and clinical outcomes was measured using the Cox proportional hazards model, with adjustment for demographic, clinical, physician, and hospital variables and dosage categories, represented by time-dependent variables. Results: Enalapril, fosinopril, captopril, quinapril and lisinopril, were associated with higher mortality than was ramipril; the adjusted hazard ratios (HRs) and 95% CIs were 1.47 (95% CI, 1.14 –1.89), 1.71 (CI 1.29 –2.25), 1.56 (CI 1.13–2.15), 1.58 (CI, 1.10 –2.82) and 1.28 (CI, 0.98 – 1.67), respectively. The adjusted HR associated with perindopril was 0.98 (CI, 0.60 –1.60). Conclusions: The authors concluded that survival benefits in the first year after acute MI in patients 65 years of age or older seem to differ according to the specific ACE inhibitor prescribed. Ramipril was associated with lower mortality than most other ACE inhibitors. Perspective: The study suggests that not all drugs within the class of ACE inhibitors should be considered to have the same effect. At currently used dosages, elderly patients who filled prescriptions for ramipril had statistically significant lower mortality within the first year after acute MI than did users of several other ACE inhibitors. The exact mechanisms causing these differences are unclear, although they may be related to the structural and pharmacologic characteristics of the individual drugs. However, this was a retrospective, observational study of administrative databases, and large randomized clinical trials or prospective clinical studies are needed to confirm these results. DM
Mega JL, Morrow DA, de Lemos JA, et al. J Am Coll Cardiol 2004;44:335–9. Study Question: Investigators sought to evaluate B-type natriuretic peptide (BNP), alone and in comparison to cardiac troponin I (cTnI) and high-sensitivity C-reactive protein (hs-CRP), for risk assessment at initial presentation with ST-segment elevation myocardial infarction (STEMI). Methods: Investigators obtained samples from 438 patients presenting within 6 h of STEMI enrolled in the Enoxaparin Tenecteplase-Tissue-Type Plasminogen Activator With or Without Glycoprotein IIb/IIIa Inhibitor as Reperfusion Strategy in ST-Segment Elevation Myocardial Infarction (ENTIRE)–Thrombolysis in Myocardial Infarction (TIMI)-23 trial. Outcomes were assessed through 30 days. Results: Median BNP was higher in patients who died (89 pg/mL, 25th to 75th percentile: 40 –192), compared with survivors (15 pg/mL, 25th to 75th percentile: 8.8 –32; p⬍0.0001). Patients with BNP ⬎80 pg/mL were at significantly higher risk of death (17.4% vs. 1.8%; p⬍0.0001). Cardiac troponin established a gradient of mortality between the highest and lowest quartile (7.9% vs. 0%; p⫽0.007). C-reactive protein was not associated with outcome. After adjustment for cTnI, hs-CRP, and major clinical predictors, including age, heart failure, anterior myocardial infarction (MI) location, heart rate, and blood pressure, a BNP level ⬎80 pg/mL was associated with a seven-fold higher mortality risk ([OR] 7.2, 95% confidence interval 2.1–24.5; p⫽0.001). Patients with BNP ⬎80 pg/mL were also more likely to have impaired coronary flow (p⫽0.049) and incomplete resolution of ST-segment elevation (p⫽0.05). Conclusions: The authors concluded that increased concentrations of BNP at initial presentation of patients with STEMI are associated with impaired reperfusion after fibrinolysis and higher short-term risk of mortality. Perspective: In patients with STEMI, elevated levels of BNP at initial presentation were associated with impaired reperfusion after fibrinolysis and increased risk of short-term mortality. These data support the value of combining markers of hemodynamic stress, such as BNP, with established biomarkers of necrosis, for risk assessment at the time of presentation with acute MI. DM
Incidence and Follow-up of Inflammatory Cardiac Complications After Smallpox Vaccination Eckart RE, Love SS, Atwood JE, et al. J Am Coll Cardiol 2004;44: 201–5. Study Question: What is the outcome of vaccinia-associated myocarditis? Methods: Between December 2002 and December 2003, the U.S. Department of Defense Smallpox Vaccination Program immunized 540,824 military personnel (New York City Board of Health strain) to counter the potential release of variola virus as an act of terrorism against U.S. military forces. Cases of myopericarditis were identified through sentinel reporting to military headquarters, systematic surveillance and spontaneous reports. Results: A total of 67 cases of myopericarditis were identified 10.4⫾3.6 days after vaccination. All 67 cases presented initially with chest pain or substernal pressure. ST-segment elevation was noted in 57%; mean troponin on admission
Mortality Rates in Elderly Patients Who Take Different Angiotensin-Converting Enzyme Inhibitors After Acute Myocardial Infarction: A Class Effect? Pilote L, Abrahamowicz M, Rodrigues E, Eisenberg MJ, Rahme E. Ann Intern Med 2004;141:102–12. Study Question: The investigators evaluated whether all ACE inhibitors are associated with similar mortality in patients
ACC CURRENT JOURNAL REVIEW Oct 2004
11