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    Chronic nitrate therapy is associated with different presentation and evolution of acute coronary syndromes: insights from 52,693 patients in the Global Registry of Acute Coronary Events

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    Authors
    Ambrosio, Giuseppe
    Del Pinto, Maurizio
    Tritto, Isabella
    Agnelli, Giancarlo
    Bentivoglio, Maurizio
    Zuchi, Cinzia
    Anderson, Frederick A. Jr.
    Gore, Joel M.
    Lopez-Sendon, Jose
    Wyman, Allison
    Kennelly, Brian M.
    Fox, Keith A. A.
    Show allShow less
    UMass Chan Affiliations
    Department of Medicine, Division of Cardiovascular Medicine
    Center for Outcomes Research
    Document Type
    Journal Article
    Publication Date
    2010-02-12
    Keywords
    Acute Coronary Syndrome
    Adolescent
    Adult
    Aged
    Cardiotonic Agents
    Female
    Hospital Mortality
    Humans
    Ischemic Preconditioning, Myocardial
    Male
    Middle Aged
    Muscle Cells
    Myocardial Infarction
    Necrosis
    Nitrates
    Prospective Studies
    Treatment Outcome
    Young Adult
    Health Services Research
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    Link to Full Text
    http://dx.doi.org/10.1093/eurheartj/ehp457
    Abstract
    AIMS: Brief episode(s) of ischaemia may increase cardiac tolerance to a subsequent major ischaemic insult ('preconditioning'). Nitrates can pharmacologically mimic ischaemic preconditioning in animals. In this study, we investigated whether antecedent nitrate therapy affords protection toward acute ischaemic events using data from the Global Registry of Acute Coronary Events. METHODS AND RESULTS: The dataset comprised 52,693 patients from 123 centres in 14 countries: 42,138 (80%) were nitrate-naive and 10,555 (20%) were on chronic nitrates at admission. In nitrate-naive patients, admission diagnosis was ST-segment elevation myocardial infarction (STEMI) in 41%, whereas 59% presented with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). In contrast, only 18% nitrate users showed STEMI, whereas 82% presented with NSTE-ACS. Thus, among nitrate users clinical presentation was tilted toward NSTE-ACS by more than four-fold, STEMI occurring in less than one of five patients (P < 0.0001). After adjustment (age, sex, medical history, prior therapy, revascularization, previous angina), chronic nitrate use remained independent predictor of NSTE-ACS (OR 1.36; 95% CI 1.26-1.46; P < 0.0001). Furthermore, regardless of presentation, within both STEMI and NSTEMI populations, antecedent nitrate use was associated with significantly lower levels of CK-MB and troponin (P < 0.0001 for all). CONCLUSION: In this large multinational registry, chronic nitrate use was associated with a shift away from STEMI in favour of NSTE-ACS and with less release of markers of cardiac necrosis. These findings suggest that in nitrate users acute coronary events may develop to a smaller extent. Randomized, placebo-controlled trials are warranted to establish whether nitrate therapy may pharmacologically precondition the heart toward ischaemic episodes.
    Source
    Eur Heart J. 2010 Feb;31(4):430-8. Epub 2009 Nov 10. Link to article on publisher's site
    DOI
    10.1093/eurheartj/ehp457
    Permanent Link to this Item
    http://hdl.handle.net/20.500.14038/27198
    PubMed ID
    19903682
    Related Resources
    Link to Article in PubMed
    ae974a485f413a2113503eed53cd6c53
    10.1093/eurheartj/ehp457
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