Faculty of Medicine

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Predictors of early rehospitalization in patients with acute coronary syndrome
(2014-10)
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Chaparovska Emilija
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Pocesta Bekim
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Shehu Enes
Purpose:To analyze early rehospitalization rate (defined as 90 days after the acute event) in patients with ACS, and to identify predictors of risk for readmission. Methods:463 randomly selected patients with ACS,were retrospectively analyzed.Analyzed variables:type of ACS(STEMI/NSTEMI/APNS),location of MI,gender,age,risk factors:HTA,HLP,DM,COPD,CAD,PVD,CVD,EF,type of treatment(PCI vs. noninvasive),extensiveness of coronary disease,GRACE and TIMI risk score, type of morbidity,and reason for rehospitalization.Comparative analysis was performed between patients with early rehospitalisation and others.Statistical analysis:t-test,Chi square,univariate and multivariate linear regression. Results:463 patients were enrolled:68.9% males mean age 60.4±10.9, and 31.1% females mean age 64.94±12.0(p 0.000).MI type:STEMI 75.8%,NSTEMI 11.2%,APNS 13%; MI location:40.2% anterior,39,7% inferior,3% lateral and 3.7% multiple locations(p 0.000).Risk profile:15.3% HCAD,27% HF,62% HTA,28.1% DM,5.8% PVD,2.6% COPD.Mean BMI was 27±2.9,mean SBP 138.8±28.5mmHg,mean HR 84.3±24.2,mean EF (in 208 pts.) 50.2±10.4%, mean GRACE score(in 72 pts.) was 148.9±60.6,mean TIMI score(in 263 pts.) was 3.9±2.3. 87.5% were treated with PCI procedure, with mean disease’s CA 1.84(range 1-5), median 1(p 0.000). Hospital morbidity was present in 16% of pts.,6.9% minor, 3% major bleeding complications, 2.4% acute HF, 1.9% pericardial effusion, and 1.1% early stent thrombosis.Early rehospitalization rate was 6.3% (29/463):14 ischemic/trombotic events;9 acute heart failures, 3 malignant arrhythmias, and three fatal events. Univariate predictors of RH: HR(R square 0.014, p 0.014, beta .116, r -.217, p 0.002);EF(%) (R square 0.055, p 0.001, beta -.234, r -.231, p 0.001).HTA was significantly associated with reduced hospitalization risk (Chi square 4.28, p 0.039, exp B .405, p 0.054),diabetes(Chi square 10.04, p 0.002, exp B 3.45, p 0.001),PVD (expB 2.85, p 0.070),early in-hospital morbidity(expB 2.12, p 0.084),and NSTEMI pts. had OR 1.3, and APNS pts. OR 1.16 for rehospitalization(higher but not significantly in comparison to STEMI pts.). Multivariate model with variables that were found significantly associated with HR, identified two strong independent predictors of early rehospitalization(mean square.424, sig 0.000),EF(beta -.220, p 0.001),and diabetes(t 2.52, p 0.012) Conclusions:LV systolic dysfunction was again proven to be a strong predictor of clinical outcome in terms of early hospital readmission in ACS patients no matter how they were treated for ACS, and diabetes was the single strong independent predictor-risk factor for this event.
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Anemia,renal impairment and intrahospital mortality in acute worsening chronic heart failure patients
(2014-06)
Bojovski Ivica
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Caparovska Emilija
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Pocesta Bekim
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Shehu Enes
im of the study: To analyze the impact of anemia and renal impairment on in-hospital mortality(IHD), in patients with acute worsening chronic heart failure. Methods: 232 randomly selected patients with symptoms of HF were retrospectively analyzed. Analyzed variables: gender, age, risk factors and co-morbidities: HTA, HLP, DM, COPD, CAD, PVD, CVD, anemia(defined as Hgb ≤10mg/dl), renal failure. Measured variables: systolic and diastolic BP, Hgb, sodium, BUN, creatinine, length of hospital stay and IHD. Comparative analysis was performed between patients with in-hospital mortality(IHD) and survivors, as a function of anemia and renal impairment. Statistical analysis: descriptive and comparative analysis, t-test, Chi square, univariate (binary logistic and linear regression and multivariate linear regression(stepwise backward). Results: Mean age 69.6±11.4, 102(44%)females and 130(56%) males, with females being significantly older 72.6±12.5 vs. 67.7±10.2(p=0.002), with significantly higher SBP, DBP and sodium level (p=0.003; 0.002 and 0.028 respectively), and males having HTA more often OR 1.3; p=0.017. Mean hospital stay was 6.8±5.8 days, with significant difference between IHD and non IHD group(7.9±4.5 vs. 3.8±7.9; p=0.000), with the highest mortality during the first (37.3%) and second hospital day (44.1%). 44 pts.(19%) had anemia, 31(13.4%) had known Chronic Renal Failure(CRF), and 59(25.4%) had IHD. Anemia was significantly associated with IHD (Chi square 6,36, sig 0.012, Exp B 2.48, sig 0.010), meaning pts. with anemia had 2,5 times greater risk for IHD. CRF per se, was not associated with IHD. Univariate linear regression identified creatinine(R square .032, beta .180, sig 0.006), and BUN(R square .034, beta .184, sig 0.005), as predictors of IHD. Multivariate stepwise regression model(anemia, HRF, Hgb, BUN, creatinine, sodium) at step 3(mean square .799, sig 0.002), identified two independent predictors Hgb(beta -.148, sig 0.028), and BUN(beta .163, sig 0.055). Multivariate model that included other known predictors of IHD(EF%, SBP, DBP, HRF, CAD, anemia, Hgb, BUN, creatinine, sodium) at step 8(mean square 1.537, sig 0.000), identified four independent predictors: EF%(beta -.204, sig 0.002), SBP(beta -.130, sig 0.052) as markers of systolic dysfunction and again anemia(Exp B 2.2.06, sig 0.041), and BUN(beta .200, sig 0.002). Conclusion: Anemia and renal impairment are well known comorbidities associated with HF that have great impact on course of HF. We confirmed that anemia and BUN, are significantly independent predictors of in hospital mortality in acute worsening CHF
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Mid-term clinical outcome of patients treated for acute coronary syndrome-data from the registry
(2016-10)
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Bekim Pocesta
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Taravari Hajber
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Shehu Enes
Aim of the study: what are the prognosticators of mid-term outcome in patients treated because of acute coronary syndrome. Methods: Longitudinal retrospective-prospective single center study that analyze, type of ACS (STEMI/NSTEMI/APNS), hemodynamic parameters (heart rate and SBP on the admition), type of treatment (PCI vs medical), LV ejection fraction, extent and severity of CAD, medication used, medications post discharge, type and time to event. Statistical analyze: descriptive and comparative analyze, uni and multivariate regression analyze, Caplan-Meier event free survival analyze. Results: 364 patients treated for ACS, at mean age 63,1±11,1 y., 246(67,4%) males and 119(32,6%) females, were followed up for mean 18.6±10,4 months. A total of 95 cardiac events (CE) in 94(25,8%) patients during the 364pts./563.7 y. follow up were registered, or 17.6% annually. 8 (2.2%) cardiac deaths (CD) were registered, or 1.5% annually death rate. Ischemic events were the most frequent (59-15,7%): angina-14(3,9%), scheduled revascularization after ACS because of multivassel CAD-31(8.5%), and acute ischemic event leading to re-revascularization-12(3.3%) pts. Symptomatic heart failure-20(5.5%) pts. leading to CD in 5, 7(1,4%), ischemic CVI with one fatal event, atrial arrhythmias in 8(2,2%) and malignant ventricular arrhythmias in 4(1,1%) pts. one with fatal ending, and one sudden CD. 58(61,7%) out of 94 events occurred during the first 6 months after the ACS. Univariate predictors were: medications used: DAPT: beta -2.147, p=0.000, expB 0.117; beta blockers: beta -.952, p=0,004, exp(B) 0,386; BB+RAAS inhibitors: beta -.765, p=0,015, exp(B) 0,465; diuretics: beta 1,189, p=0,007; exp(B) 3.284; ASA prior the first event: beta -1.055, p=0,000; exp(B) 0.345; diabetes: beta .788, p=0.006, exp(B) 2.199; anemia: beta1,090, p=0,006, exp(B) 2.975; age: beta.155, t 2.198, p=0.029; HR beta.155, t 3.274, p=0.001; number of lesions: beta.105, t 2.009, p=0.045; In a backword conditional logistic regression model six independent predictors were identified: ASA prior the first event exp(B) .537, p=0.049; DAPT exp(B) 2.245, p=0.000; BB+RAAS exp(B) .492, p=0.046; diuretics exp(B) 3.087, p=0.18; DM exp(B), p=0.014; Conclusion: The prevalence of CE during the mid-term follow up in ACS patients was 17.6%, with 1.5% death rate annually. Diabetes is a powerful independent predictor of mid-term outcome in patients treated for ACS. But taking aspirin therapy prior to the event, DAPT, combined BB+RAAS inhibitor after the treatment for ACS are significant positive prognosticators, as opposite taking diuretic therapy is a negative prognosticator of mid-term outcome in these patients.
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Incidence of Major Gastrointestinal Bleeding in Patients with Acute Coronary Syndrome treated with dual antiplatelet and anticoagulant therapy-Data from the Registry.
(2017)
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Bekim Pocesta
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Hajber Taravari
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Shehu Enes
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Kitanoski Darko
Aim of the study: To investigate the incidence, predictors and prognosis of gastrointestinal bleeding in patients treated for acute coronary syndrome. Materials and Methods: A retrospective study with data gathered from the registry. We analyzed different variables of STEMI, NSTEMI and unstable angina treated patients: clinical, angiographic, treatment type, medications use, in-hospital outcome. Upper gastrointestinal bleeding was defined as hematemesis and/or melena with Hgb reduction, requiring cessation of antiplatelet or anti-coagulant therapy and administration of erythrocyte transfusion and, if needed, upper GIT endoscopy. Statistical Analysis: Descriptive, comparative, univariate and multivariate linear and/or binary logistic regression analysis. Statistical significance was determined at a 0,05 level. Results: 874 patients (66,6% males and 33,4% females, mean age 65,7 ± 11,04 y) were analyzed. 75,4% of the patients had STE-MI, 12.5% had NSTEMI and 12,1% APNS. The predominant risk factors were: HTA (59.9%), smoking (56,9%), overweight/obesity (66,7%) and DM (27,8%). 11% had previous MI, 11,3% revascularization, 5,3% CVI and 5% had previous GIT symptomatology. Mean eGFR was 93 ml/min, although 16,4% of the patients had eGFR < 60ml/min. Preexisting anemia was registered in 9,7%. 93,6% of STEMI, and 91,6% of NSTEMI/APNS patients received PCI. Regarding the patients medications, 98,4% were treated with ASA, 70% with 600 mg loading dose Clopidogrel, 90,4% with UFH and 18% received H 2 blockers or PPI. For the in-hospital morbidity, 5,6% of the patients had acute heart failure, 2,8% A-V block, 2,6% acute renal failure, 5,4% supraventricular arrhythmias, 6,4% ventricular arrhythmias, 0,8% in-stent thrombosis, and 0,3% of the patients had ischemic CVI. The most frequent bleeding complications were: 9,2% at the vascular access site, 1,5% GI bleedings and 1,6% UG bleedings. Hospital mortality was 6,8%, and the death Hazard Ratio among patients with GIB was 9,34 (CI 2,95-29,5). Univariate predictors of GIB were: age (beta ,085), BMI (beta-,073), eGFR < 60ml/min (beta-,081), Crusade bleeding risk score (beta ,141), Hgb (beta-,225), urea (beta ,386), old MI (OR 3,715), GPIIb/IIIa inhibitors (OR 9,267), H2/PPI (OR 10,840), anemia (OR 11,712), eGFR < 60 ml/min (OR 6,390), ARF (OR 7645), and supraventricular arrhythmias (OR 5,440). Previous MI (p = 0,010), use of GPIIb/IIIa inhibitors (p=0,031); H2 or PPI (p = 0,000); eGFR < 60 ml/min (p = 0,050); supraventricular arrhythmias (p = 0,002), and anemia prior ACS (p = 0,042) were identified as independent predictors. Conclusion: GIB is one of the most frequent bleeding complications in patients treated for acute coronary syndrome, associated with a significant in-hospital mortality risk.
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QT prolongation, QT dispersion and ventricular arrhythmias in patients with acute coronary syndrome treated with percutaneous coronary intervention
(2018-03)
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Bekim Pocesta
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Taravari Hajber
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Bojovski Ivica
The QT interval prolongation which happens during acute coronary syndrome is a dynamic parameter which changes at different points-reaches the peak point 24h after PCI and gets back in the normal range after 72h. QT dispersion follows this trend of change as well. Theres no difference of these changes between patients who present with STEMI, and patients with NSTEMI, except for the value of QT dispersion at admission which is shorter in the STEMI group. These patients have increased risk of malignant arrhythmias and should be closely monitored

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