ESC Congress 2016 - 20

clINIcAl TRIAl HIgHlIgHTs significance was not adjusted for multiple testing. Use of CPAP significantly improved scores on the ESS (P < .001), the Hospital Anxiety (P = .002) and Depression Scale (P < .001), and the SF-36 Health Survey physical (P = .002) and mental (P < .001) components, and significantly reduced work days lost because of ill-health (P < .001). There were no serious adverse events or accidents due to sleepiness. A subanalysis confined to patients with good CPAP compliance (> 4 hr/night) and matched patients from the usual care group (n = 561 each group) showed a trend toward a reduced risk of stroke (P = .05) and a composite of cerebral events (P = .02), although the authors cautioned that this is a preliminary finding that will requires confirmation from future randomized studies specifically designed to investigate the impact of OSA treatment on cerebrovascular risk. In conclusion, CPAP for secondary prevention of CV disease in patients with moderate-to-severe OSA may be of no benefit to prevent recurrent CV events. Unfortunately, due to many logistical and other challenges, the SAVE trial ultimately was underpowered to definitively test the efficacy of CPAP for secondary prevention. NACIAM: N-acetylcysteine Added to Glyceryl Trinitrate Reduces Infarct Size in STEMI Written by Toni Rizzo The size of the myocardial infarction in patients with acute STEMI is a major determinant of patient outcomes following the event. Infarct size is determined by the duration of ischemia, size of the myocardium supplied by that vascular territory, and the extent of reperfusion injury. Prior, small clinical studies have shown that n-acetylcysteine (NAC), a sulfhydryl donor, has antioxidant properties and may reduce infarct size when added to glyceryl trinitrate (GTN), which has vasodilator effects and may decrease platelet aggregation. The aim of NACIAM, a randomized controlled trial that was presented by Sivabaskari Pasupathy, University of Adelaide, Adelaide, Australia, was designed as a pilot study to assess the efficacy of adding high-dose intravenous NAC to low-dose intravenous GTN in patients with acute STEMI undergoing percutaneous coronary intervention (PCI). A total of 112 patients who presented within 12 hours of onset of symptoms and received intravenous GTN 2.5 µg/min were randomized to either NAC (n = 53) or placebo (n = 59). NAC was given at 20 mg/min for the first hour and 10 mg/min for the next 47 hours. The placebo was saline, administered for 48 hours. The primary efficacy endpoint was MI infarct size as determined by cardiac magnetic resonance imaging (cMRI). 20 October 2016 Other endpoints included myocardial salvage on MRI, left ventricular ejection fraction (LVEF) on MRI, creatine kinase area under the curve (AUC), and safety. MRI was done on Day 5 (mean) and again at a mean of 3 months. The patients were followed for 2 years. MRI was performed at Day 5 in 37 NAC patients and 38 placebo patients. Follow-up MRI at 3 months was performed in 26 NAC patients and 29 placebo patients. The results showed that myocardial infarct size was reduced by 5.5% of the total LV mass in the NAC group compared with the placebo group (95% CI, 1% to 10%; P = .02). Patients treated with NAC had significantly increased myocardial salvage (P = .001), reduced transmural infarct (P = .02), and reduced infarct size at late MRI (P = .02) compared with placebo patients (Table 1). The beneficial effect of NAC on myocardial salvage was marginally reduced with longer periods of ischemia such that the effects of NAC on myocardial salvage were greater in patients with a shorter duration of ischemia. LVEF and creatine kinase AUC were not significantly different between the NAC and placebo groups. The creatine kinase AUC were 22,000 IU/L/h in the NAC group compared with 40,000 IU/L/h in the placebo group (P = .08). Table 1. Results of MRI Studies MRI Parameter Placebo (n = 38) NAC (n = 37) P Value Anterior infarct 39% 35% .81 Microvascular obstruction 1.1 ± 1.8 0.95 ± 1.8 .66 27% (14% - 41%) 60% (37% - 79%) .001 79% 54% .02 10% (7% - 15%) 5% (1% - 12%) .02 Myocardial salvage Transmural infarct Infarct size at late MRI Percentages as median and interquartile range (IQR). There were no significant differences in the occurrence of death (P = .49), hypotension (P = 1.00), bleeding (P = 1.00), or renal dysfunction (P = .72) between the NAC and placebo groups. Deaths and cardiac readmissions over 2 years were significantly lower in the NAC group (6%) compared with the placebo group (27%; P = .02). The authors noted that further study is needed to better evaluate different doses of NAC and to investigate the mechanism of action. In addition, they noted that the study had a small sample size; thus, there is a need for a larger, well-powered study on the impact of NAC on clinical outcomes. The investigators concluded that the addition of NAC to GTN was safe, reduced infarct size, and increased myocardial salvage. medicom-publishers.com/mcr http://www.medicom-publishers.com/mcr

Table of Contents for the Digital Edition of ESC Congress 2016