TP44 334. Strategies for the optimization of antithrombotic therapy and reduction events after coronary artery bypass graft surgery: stop events cabg trial

IntroducciónLa doble antiagregación (aspirina/clopidogrel) parece disminuir el riesgo de eventos adversos tras una cirugía de revascularización coronaria (CRC). La falta de unanimidad científica al respecto puede deberse a la variabilidad de la respuesta al clopidogrel y al diseño de los estudios publicados hasta la fecha. Prasugrel es una nueva tienopiridina con efecto interindividual más uniforme que podría proteger a los pacientes sometidos a CRC de futuros eventos cardiovasculares.ObjetivosPresentamos un estudio cuyo fin es comparar la doble antiagregación con aspirina (100mg/24 h) y prasugrel (5 o 10mg/24 h, según peso) frente a aspirina en la incidencia del fallo (oclusión o pérdida luminal ≥ 50%) del injerto venoso a 3 meses y el riesgo de eventos hemorrágicos tras CRC.MétodosSe ha diseñado un estudio prospectivo, aleatorizado, doble ciego y multicéntrico. Se incluirán pacientes sometidos a CRC que reciban injertos venosos. Se aleatorizarán los sujetos en dos grupos: antiagregación con ácido acetilsalicílico (AAS) o AAS + prasugrel (inicio en primeras 24h postoperatorias). Se registrarán los eventos hemorrágicos, y se medirá la permeabilidad de los injertos mediante tomografía computarizada (TC) multicorte a los 3 meses. Otros eventos: muerte, accidente cerebrovascular (ACV), infarto, reintervención coronaria, fallo del injerto previo a los 3 meses. Estudio bilateral, riesgo α: 0,05, potencia (1-ß): 80%. Diferencia a detectar: 6%. Pérdidas estimadas: 15%. Número de injertos por brazo: 490. Número de pacientes por brazo: 250. Análisis intermedio con 150 sujetos en cada brazo

Analysis of right ventricle echocardiographic function parameters for the prediction of outcomes in significant functional tricuspid regurgitation

Abstract Introduction Functional tricuspid regurgitation is a common disease that significantly impairs survival and quality of life. The role of echocardiographic right ventricular (RV) function parameters to detect patients with worse prognosis that may benefit from invasive treatment is still under debate. Methods 121 consecutive patients with grade III and IV functional tricuspid regurgitation were evaluated. RV function parameters and clinical variables were assessed at baseline, and then patients were prospectively followed-up. The primary endpoint was the combination of death or heart failure (HF) admissions. Comparison of imaging parameters was done using receiver-operating characteristics (ROC) curves. Multivariate logistic regression analysis was preformed to establish independent predictors of outcomes. Results Median follow up was 27.3 months. 73.6% of the patients were female, and mean age was 80.4 years. 63.6% were grade IV tricuspid regurgitation. In the univariate analysis using the area under the ROC curve (AUC), RV-free wall strain (RVS, AUC=0.633) and pulmonary artery systolic pressure (PASP, AUC=0.605) were the best predictors of death and HF admissions, although the individual diagnostic performance was weak. In the multivariate analysis including either clinical and echocardiographic variables, independent predictors of death and HF admissions were Age (OR 1.07, p=0.029), RVS &amp;gt;−16 (OR 5.0, p=0.001), Diabetes mellitus (OR 3.0, p=0.011), eGFR (ml/min, OR 0.96, p=0.001) and Hemoglobin (g/dL, OR=0.74, p=0.048). The model including these variables was superior than RVS and PASP alone (AUC 0.884, p&amp;lt;0.001) (graph 1), showing high sensitivity (78.8%) and specificity (67.3%). Conclusions In patients with significant functional tricuspid regurgitation, RVS and PASP show the best performance for the detection of death and HF admissions. A multivariate model including age, diabetes, eGFR, hemoglobin and RVS was superior than the individual imaging parameters. Funding Acknowledgement Type of funding sources: None. Table 1Graph 1 </jats:sec

P25 330. Remodelado del aneurisma aterosclerótico aórtico tras tratamiento endovascular

ObjetivoAnalizar los resultados del tratamiento endovascular en aneurismas ateroscleróticos de aorta torácica (TEVAR). La exclusión del aneurisma aórtico de la circulación sistémica supone la despresurización del saco aneurismático y la reducción de diámetro del mismo.Material y métodosRevisión retrospectiva del tratamiento endovascular de los aneurismas ateroscleróticos de aorta torácica descendente realizados desde 2002–2011. Dieciséis pacientes (87,5% varones, edad media 70,6±5,5 años, 56,3% con vasculopatía periférica y EuroSCORE medio 24,7±19,1%) fueron tratados mediante TEVAR: 2 aneurismas saculares aorta torácica descendente, 10 aneurismas toracoabdominales Crawford I, 2 aneurismas toracoabdominales Crawford II, 2 aneurismas de aorta ascendente, arco y aorta descendente. La media del diámetro mayor de los aneurismas y número de stents fue 65±13,3mm y 1,7±0,7, respectivamente. La mediana de seguimiento fue 47 meses (rango 0–86 meses). Se realizó control mediante TC multidetector a 1 mes y a 1 año en todos los pacientes.ResultadosÉxito técnico mostrando exclusión completa del aneurisma en 15 pacientes (1 endoleak tipo I y tipo III precoz). Mortalidad intrahospitalaria 6,3%. El diámetro aórtico se redujo menos de un 10% en 12 pacientes, más de un 10% en 3 y aumentó más 10% en 1 paciente durante el seguimiento. Supervivencia a 5 años 93,7%.ConclusionesEl tratamiento endovascular se ha consolidado como un método seguro y efectivo en el tratamiento de la patología aórtica, con buenos resultados a corto y medio plazo. En nuestro centro, se ha convertido en el tratamiento de elección de los aneurismas de aorta torácica descendente

Kounis syndrome after ingestion of undercooked fish: New role of intracoronary imaging techniques

Depto. de MedicinaFac. de MedicinaTRUEpu

Platelet function in Takotsubo cardiomyopathy

Estudio observacional prospectivo donde se evaluó en 32 pacientes diagnosticados de miocardiopatía de estrés (Takotsubo) la reactividad plaquetaria, en comparación con pacientes con un síndrome coronario agudo “convencional” y voluntarios sanos. Los pacientes con Takotsubo presentaron mayores niveles de adrenalina, pero no hubo diferencias en la reactividad plaquetaria tras ajustar según el tratamiento antiagregante. Takotsubo cardiomyopathy (TK) includes a transient left ventricular dysfunction without obstructive coronary disease, sometimes after stressful situations with elevated cathecolamines. Since catecholamines activate platelets we aimed to study the platelet influence in a TK setting. We included 32 patients with a TK diagnosis, 13 with an acute coronary syndrome (ACS) and 18 healthy volunteers. Once consent informed was obtained, blood samples were extracted and processed (at admission and after 3 months follow-up). Clinical, ecg, echocardiographic and angiographic features were thoroughly recorded.Previous treatment before admission was similar between groups. No differences were observed in clinical features or any of the acute markers studied regarding platelet reactivity between TK compared to ACS. After follow-up, aggregation levels and platelet reactivity showed differences, mainly due to the antithrombotic therapy prescribed at discharge, but similar to volunteers. Circulating epinephrine during the acute phase was significantly higher in TK (p < 0.001). Patients with higher levels of epinephrine had elevated platelet activation and aggregation after 3 months. No differences were observed in Takotsubo acute platelet aggregation compared to patients with ACS, in spite of higher blood levels of adrenaline. Takotsubo patients had elevated platelet aggregation and activation compared with ACS patients at 3 months follow-up because they were less frequently on chronic clopidogrel and ASA. However, they had similar platelet aggregation and activation levels to healthy volunteers despite treatment with low-dose ASA. Takotsubo patients who had higher levels of adrenaline in the acute phase displayed increased platelet reactivity during follow-up.Depto. de MedicinaFac. de MedicinaTRUEpu

Is “one size fits all” anti-aggregation really effective? Variability in the response to P2Y12 receptor inhibitors in obese patients

Abstract Background Different “ex vivo” studies have shown both a greater platelet activation and higher rates of resistance to clopidogrel in obese patients. Although there is less evidence, less prasugrel activity has also been observed in these patients. Our aim was to study the variability of the response to clopidogrel, ticagrelor and prasugrel in obese patients, defined as a body mass index ≥30. Methods Prospective, multicenter, observational, pharmacodynamic study, conducted in a Spanish population of patients with an acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI) and double anti-aggregation with acetylsalicylic acid and a P2Y12 receptor inhibitor. Platelet function tests were performed the morning after the ICP and 30 days after it, including: 1) VerifyNow P2Y12 assay; 2) multiple electrode aggreometry (Multiplate); and 3) VASP analysis. Results Of the total patients included (988), 300 were obese (30.3%). The obese group was younger (62.8±12 years vs 64.9±12), had a higher incidence of arterial hypertension (76.3% vs. 56.7%), diabetes mellitus (35% vs. 27.5%); and lower incidence of chronic kidney disease (7.7% vs. 17%). There were no differences in the acute phase (day 1 after PCI) in the pharmacodynamic response to any of the P2Y12 inhibitors used. After 30 days, greater platelet aggregation (decreased response) was documented in obese patients treated with prasugrel according to VASP tests (PRI in non-obese 23.9±13% vs. 30.4±14.7% in obese, p 0.035) and MEA (area under the aggregation units curve in non-obese 251.7±104.1 vs 320±166.7 in obese, p 0.007) and a numerical trend with VerifyNow. A trend in the same direction was also observed in patients treated with clopidogrel that did not reach statistical significance with all the platelet function tests used. No differences were observed in the ticagrelor group. Conclusion Obese patients with an ACS treated with PCI have a worse response to thienopyridines than non-obese patients in the maintenance phase of antiaggregant treatment, while the response to ticagrelor is not affected by obesity. Completing the clinical follow-up proposed by the registry is necessary to know if these differences have an implication in cardiovascular events. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Fondo de Investigaciones Sanitarias (FIS) </jats:sec

Impact of smoking habit on platelet reactivity in a cohort of patients admitted due to an acute coronary syndrome

Abstract Background Several pharmacodynamic studies have shown the impact of smoking habit on platelet reactivity; with a reduction on platelet aggregation. Wether this inhibition in platelet reactivity is due to tobacco effects in platelet signaling pathways or due to a pharmacodynamic interaction with antiplatelet therapies is not well stablished. Purpose Our aim was to study the influence of smoking habit in platelet reactivity and in the response to P2Y12 inhibitors. Methods Patients admitted in four tertiary care hospitals due to an acute coronary syndrome that undergone percutaneous coronary intervention (PCI) were consecutively and prospectively recruited. All the patients received dual antiplatelet therapy with aspirin and a P2Y12 inhibitor following current European Guidelines. Platelet function was assessed at day 1 and day 30 post-PCI by VerifyNow P2Y12, VASP (Vasodilator-stimulated phosphoprotein) y MEA (Multiple electrode aggregometry). Results A total of 1000 patients were enrolled, of whom 12 had to be excluded due to inaccurate processing of blood samples. 372 patients (37,6%) had smoking habit. Non-smoking patients showed higher prevalence of high blood pressure [423 (68.7%) vs 196 (52.7%)] and diabetes mellitus [213 (34.6%) vs 81 (21.8%)]. Smoking patients were younger [57.3 (9,6) years old vs 68.4 (11.1)], with higher incidence of acute coronary syndrome with ST segment elevation [184 patients (49,5%) vs 241 (39.1%), p&amp;lt;0,001]. There were no differences in platelet function at day 1. When analysing platelet function 30 days post-PCI, a lower inhibition of platelet reactivity in non-smoking patients as compared with smoking patients was observed in those treated with clopidogrel, with higher prevalence of clopidogrel-resistance in non-smoking patients (VerifyNow, 51,2% prevalence of high platelet reactivity in non-smoking patients vs 34,9% 30 days after PCI, p=0,023). On the other hand, smoking patients that received ticagrelor did not show any differences. Patients with smoking habit treated with prasugrel showed a lower response of borderline statistical significance. Conclusion Smoking habit was associated with a lower response to prasugrel of borderline significance, and with higher response to clopidogrel, according with previous studies suggesting a pharmacodynamics interaction between tobacco use and P2Y12 inhibitors. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Fondo de Investigaciones Sanitarias (FIS) </jats:sec

Stress neuropeptide levels in adults with chest pain due to coronary artery disease: potential implications for clinical assessment

: Substance P (SP) and neuropeptide Y (NPY) are neuropeptides involved in nociception. The study of biochemical markers of pain in communicating critically ill coronary patients may provide insight for pain assessment and management in critical care. Purpose of the study was to to explore potential associations between plasma neuropeptide levels and reported pain intensity in coronary critical care adults, in order to test the reliability of SP measurements for objective pain assessment in critical care