BACKGROUND Guidelines recommend nonstatin lipid-lowering agents in patients at very high risk for major adverse cardiovascular events (MACE) if low-density lipoprotein cholesterol (LDL-C) remains ≥70 mg/dL on maximum tolerated statin treatment. It is uncertain if this approach benefits patients with LDL-C near 70 mg/dL. Lipoprotein(a) levels may influence residual risk. OBJECTIVES In a post hoc analysis of the ODYSSEY Outcomes (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab) trial, the authors evaluated the benefit of adding the proprotein subtilisin/kexin type 9 inhibitor alirocumab to optimized statin treatment in patients with LDL-C levels near 70 mg/dL. Effects were evaluated according to concurrent lipoprotein(a) levels. METHODS ODYSSEY Outcomes compared alirocumab with placebo in 18,924 patients with recent acute coronary syndromes receiving optimized statin treatment. In 4,351 patients (23.0%), screening or randomization LDL-C was <70 mg/dL (median 69.4 mg/dL; interquartile range: 64.3–74.0 mg/dL); in 14,573 patients (77.0%), both determinations were ≥70 mg/dL (median 94.0 mg/dL; interquartile range: 83.2–111.0 mg/dL). RESULTS In the lower LDL-C subgroup, MACE rates were 4.2 and 3.1 per 100 patient-years among placebo-treated patients with baseline lipoprotein(a) greater than or less than or equal to the median (13.7 mg/dL). Corresponding adjusted treatment hazard ratios were 0.68 (95% confidence interval [Cl]: 0.52–0.90) and 1.11 (95% Cl: 0.83–1.49), with treatment-lipoprotein(a) interaction on MACE ( P interaction = 0.017). In the higher LDL-C subgroup, MACE rates were 4.7 and 3.8 per 100 patient-years among placebo-treated patients with lipoprotein(a) >13.7 mg/dL or ≤13.7 mg/dL; corresponding adjusted treatment hazard ratios were 0.82 (95% Cl: 0.72–0.92) and 0.89 (95% Cl: 0.75–1.06), with P interaction = 0.43. CONCLUSIONS In patients with recent acute coronary syndromes and LDL-C near 70 mg/dL on optimized statin therapy, proprotein subtilisin/kexin type 9 inhibition provides incremental clinical benefit only when lipoprotein(a) concentration is at least mildly elevated. (ODYSSEY Outcomes: Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab; NCT01663402 )
The aim – to analyze the endocrine status of high-risk patients with coronary artery disease in cardiac surgery.Materials and methods. Retrospective analysis of data from random 354 high-risk patients who were operated on and discharged from M.M. Amosov National Institute of Cardiovascular Surgery of NAMS of Ukraine in the period from 2009 to 2019. The mean age of patients was 61.9±9.7 years. All patients underwent ECG, ECHO, coronary angiography and surgical myocardial revascularization with correction of concomitant cardiac pathology, if necessary. In the perioperative period all patients underwent general clinical and biochemical blood tests. Stratifying the risk according to the EuroSCORE II scale, patients belonged to the high risk group and had > 5 % probability of mortality.Results and discussion. All patients had hemodynamically significant stenosis of the coronary arteries that required surgical revascularization of the myocardium. The analysis showed that 287 (81.07 %) patients were overweight, 281 (79.3 %) – had metabolic syndrome, 90 (25.4 %) – type 2 diabetes mellitus (type 2 DM), 161 (45.45 %) – impaired glucose tolerance. Thyroid disease was diagnosed in 37 (10.4 %) patients, 11 (3.1 %) patients had hypothyroidism. In the postoperative period, paroxysms of atrial fibrillation occurred in 83 (23.4 %) patients, of whom 70 (84.3 %) had type 2 DM and impaired glucose tolerance. Deep sternal infection occurred in 4 (4.4 %) patients with type 2 DM, for 3 (3.3 %) of them sternoplasty performed. Neurological complications – stroke and transient ischemic attack had 10 (2.8 %) patients among which 9 (90 %) had glucose metabolism disturbance. Acute renal failure occurred in 10 (2.8 %) patients, of whom 8 (80 %) had type 2 DM and pre-DM.Conclusions. Despite the high predicted mortality on the EuroSCORE II scale – 8.82 %, the operative mortality in the study group was 0 %, which indicates a coordinated highly skilled Heart-team work, timely verification of comorbid conditions and the involvement of related specialists.
Objective. To determine the impact of the mitral valve insufficiency in patients, suffering ischemic heart disease with lowered contractility of left ventricle and methods of its treatment. Materials and methods. During 01.01.2015-31.12.2018 yrs period in the Amosov National Institute of Cardiovascular Surgery there were conducted 2267 consecutive operations of coronary shunting, of them 190 (8.4%) - in patients, suffering the ischemic heart disease with lowered contractility of left ventricle. Reduction of the output fraction of left ventricle down to 35% and lower have served as criterion of inclusion of the patients into the Group. There were 170 (89.5%) men and 20 (10.5%) women. The patients’ age have constituted 29 - 83 yrs old, (61.1 ± 8.9) yrs old at average. Results. In 47.9% of the patients the lowering of the left ventricle contractility after myocardial infarction was followed by occurrence of regurgitation on a mitral valve. At the same time it was noted, that the regurgitation value have had correlated with degree of the left ventricle contractility lowered: in reduction of values of the left ventricle output fracture down to 25% and lower a moderate regurgitation on a mitral valve was registered up to 2 times, a significant one - in 2.5 times, and the pronounced one - in 1.5 times more frequently, than in values of the left ventricle output fracture, exceeding 25%. Occurrence of a mitral insufficiency in 18.7% patients was caused by direct damage of valvular apparatus, while in 81.3% patients the consequences of the heart cavities were present in disorder of contractile function of myocardium. Presence of postinfarction mitral insufficiency enhances the risk of an acute cardiac insufficiency in 1.7 times and necessitates intraoperative correction in values of the regurgitation fraction over 30%. Conclusion. The own data obtained witness, that noncorrected mitral insufficiency in the ischemic heart disease worsens significantly the postoperative period course after performance of coronary shunting, enhancing rate of an acute cardiac, respiratory and renal insufficiency. Thus, taking into account a negative impact of concomitant mitral valve insufficiency on efficacy of surgical interventions in the lowered contractility of left ventricle the need emerges to perform complex reconstructive intervention in patients, suffering ischemic heart disease with lowered contractility of left ventricle.
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