Incidence of acute coronary syndrome in the general Medicare population, 1992 to 2009: a real-world perspective

Temporal trends in concordance between ICD-coded and cardiac biomarker-classified hospitalisation rates for acute coronary syndromes: a linked hospital and biomarker data study

BACKGROUND

Since 2000, the definition of myocardial infarction (MI) has evolved with reliance on cardiac troponin (cTn) tests. The implications of this change on trends of acute coronary syndrome (ACS) subtypes obtained from routinely collected hospital morbidity data are unclear. Using person-linked hospitalisation data, we compared International Classification of Diseases (ICD)-coded data with biomarker-classified admission rates for ST-segment elevation MI (STEMI), non-STEMI (NSTEMI) and unstable angina (UA) in Western Australia (WA).

METHODS

We used linked hospitalisation data from all WA tertiary hospitals to identify patients with a principal diagnosis of STEMI, NSTEMI or UA between 2002 and 2016. Linked biomarker results were classified as 'diagnostic' for MI according to established criteria. We calculated age-standardised and sex-standardised rates (ASSRs) for ICD-coded versus biomarker-classified admissions by ACS subtypes and estimated annual change in admissions using Poisson regression adjusting for age and sex.

RESULTS

There were 37 272 ACS admissions in 30 683 patients (64.2% male), and 96% of cases had linked biomarker data, predominantly conventional cTn at the start and high-sensitive cTn from late 2013. Despite lower ASSRs, trends in MI classified with a diagnostic biomarker were concordant with ICD-coded admissions rates for both STEMI and NSTEMI. Between 2002 and 2010, STEMI rates declined by 4.1% (95% CI 5.0%, 3.1%) and 3.4% (95% CI 4.6%, 2.3%) in ICD-coded and biomarker-classified admissions, respectively, and both plateaued thereafter. For NSTEMI between 2002 and 2010, the ICD-coded and biomarker-classified rates increased 8.0% per year (95% CI 7.2%, 8.9%) and 8.0% (95% CI 7.0%, 9.0%), respectively, and both subsequently declined. For UA, both ICD-coded and biomarker-classified UA admission rates declined in a steady and concordant manner between 2002 and 2016.

CONCLUSIONS

The present study supports the validity of using administrative data to monitor population trends in ACS subtypes as they appear to generally reflect the redefinition of MI in the troponin era.

The Efficacy of Drug-Coated Balloon for Acute Coronary Syndrome

Background

Percutaneous coronary intervention using a drug-eluting stent (DES) is a common therapeutic option for acute coronary syndrome (ACS). However, stent-associated complications, such as bleeding associated with dual antiplatelet therapy, in-stent restenosis, stent thrombosis, and neoatherosclerosis, remain. Drug-coated balloons (DCBs) are expected to reduce stent-associated complications. This study aimed to assess the efficacy of DCB therapy and compare it with that of DES therapy in patients with ACS.

Materials and Methods

In this single-center, retrospective, observational study, we examined all patients with ACS treated with DCB or DES between July 2014 and November 2020. Patients with left main trunk lesions were excluded. The primary outcome was a composite of major adverse cardiovascular events (MACE: cardiac death, myocardial infarction, and target lesion revascularization) at one year.

Results

Three hundred and seventy-two patients were treated with DES, and 83 patients were treated with DCB. MACE occurred in 10 (12.0%) patients in the DCB group and in 50 (13.4%) patients in the DES group (P=0.73).

Conclusions

DCB is a valuable and effective therapy for patients with ACS. Moreover, DCB may become an alternative therapy for DES in patients with ACS.

Baseline thrombocytopenia in acute coronary syndrome: The lower, the worse

BACKGROUND

Patients with baseline thrombocytopenia can have increased mortality and morbidity, but are typically excluded from randomized clinical trials studying acute coronary syndromes (ACS). We sought to better define the effect thrombocytopenia on clinical outcomes in ACS patients.

METHODS

Patients identified from the NCDR Chest Pain registry at Mayo Clinic Arizona from Oct 2015 to Sep 2018 were retrospectively classified into two groups: TP (platelet <150 × 10³ μL) and control (platelet ≥150 × 10³ μL). The groups were analyzed for the clinical outcome (all-cause mortality, major adverse cardiac events (MACE), and bleeding events). The TP group was divided into moderate-severe thrombocytopenia (TP_mod; platelet 50-100 × 10³ μL) and mild thrombocytopenia (TP_mild; platelet 100-150 × 10³ μL) for further analysis. P-value <0.05 is considered significant.

RESULTS

Five hundred and thirty-six patients were identified, and 72 patients (13%) had thrombocytopenia. The median follow-up time was 1.1 years. The TP group was older (TP vs. control: mean age 73 ± 13 years vs. 70 ± 13 years; P = 0.026). In patients discharged on dual-antiplatelet therapy, the TP group had higher all-cause mortality (23% vs. 7.3%; P = 0.007) but not major bleeding events (11% vs. 5.0%; P = 0.123). Only all-cause mortality increased with the severity of thrombocytopenia (TP_mod vs. TP_mild vs. control: 33% vs. 24% vs. 7.3%; P = 0.007).

CONCLUSIONS

In patients with ACS, baseline thrombocytopenia is associated with increased all-cause mortality and all bleeding events without net MACE benefit. Further study is needed to identify the optimal antiplatelet strategy in this higher risk population.

Evaluating Mortality Rate and Associated Parameters in Patients with Acute Coronary Syndrome

BACKGROUND

Acute coronary syndrome (ACS) is one of the leading causes of mortality worldwide and is characterized by unstable angina or acute myocardial infarction. The aim of this study is to evaluate the clinical characteristics of patients who died of ACS.

METHODS

In this cross-sectional study, 1000 patients presenting ACS were included. Data and records of these patients were evaluated for parameters such as; deceased status, age, gender, diagnosis, ECG, common complaints, associated risk factors, Killip class, pulse, blood pressure, geographic setup (urban or rural), complications and season in which the disease was presented. Statistical analysis was performed on the data obtained using SPSS-win software.

RESULTS

The mortality rate among ACS patients in our study was 7.1%. Of these patients, AMI was the most prevalent diagnosis and chest pain was the most common complaint. Furthermore, low blood pressure, advanced age, increased pulse rate and fall/winter season were associated with the increased risk of mortality. ST deviation was the most seen ECG finding and most of the mortalities were within the 24 hours of admission.

CONCLUSION

Our study reports risk factors associated with mortality in ACS patients. Advanced and timely therapeutic measurements are likely to reduce the incidence of mortality in these patients.

Mild Cognitive Impairment and Receipt of Treatments for Acute Myocardial Infarction in Older Adults

BACKGROUND

Older adults with mild cognitive impairment (MCI) should receive evidence-based treatments when indicated. Providers and patients may overestimate the risk of dementia in patients with MCI leading to potential under-treatment. However, the association between pre-existing MCI and receipt of evidence-based treatments is uncertain.

OBJECTIVE

To compare receipt of treatments for acute myocardial infarction (AMI) between older adults with pre-existing MCI and cognitively normal patients.

DESIGN

Prospective study using data from the nationally representative Health and Retirement Study, Medicare, and American Hospital Association.

PARTICIPANTS

Six hundred nine adults aged 65 or older hospitalized for AMI between 2000 and 2011 and followed through 2012 with pre-existing MCI (defined as modified Telephone Interview for Cognitive Status score of 7-11) and normal cognition (score of 12-27).

MAIN MEASURES

Receipt of cardiac catheterization and coronary revascularization within 30 days and cardiac rehabilitation within 1 year of AMI hospitalization.

KEY RESULTS

Among the survivors of AMI, 19.2% had pre-existing MCI (55.6% were women and 44.4% were male, with a mean [SD] age of 82.3 [7.5] years), and 80.8% had normal cognition (45.7% were women and 54.3% were male, with a mean age of 77.1 [7.1] years). Survivors of AMI with pre-existing MCI were significantly less likely than those with normal cognition to receive cardiac catheterization (50% vs 77%; P < 0.001), coronary revascularization (29% vs 63%; P < 0.001), and cardiac rehabilitation (9% vs 22%; P = 0.001) after AMI. After adjusting for patient and hospital factors, pre-existing MCI remained associated with lower use of cardiac catheterization (adjusted hazard ratio (aHR), 0.65; 95% CI, 0.48-0.89; P = 0.007) and coronary revascularization (aHR, 0.55; 95% CI, 0.37-0.81; P = .003), but not cardiac rehabilitation (aHR, 1.01; 95% CI, 0.49-2.07; P = 0.98).

CONCLUSIONS

Pre-existing MCI is associated with lower use of cardiac catheterization and coronary revascularization but not cardiac rehabilitation after AMI.

Brief Report: Trends in Hospitalizations Due to Acute Coronary Syndromes and Stroke in Patients With Systemic Lupus Erythematosus, 1996 to 2012

OBJECTIVE

Cardiovascular disease (CVD) has been recognized as a major cause of morbidity in patients with systemic lupus erythematosus (SLE), but it is not clear whether increased awareness of these risks has translated into improvements in CVD morbidity at the population level. The aim of this study was to examine trends in hospitalization rates for CVD events in a representative sample of adult patients with SLE in the US from 1996 to 2012.

METHODS

We used the Nationwide Inpatient Sample to estimate the rates of hospitalization for acute myocardial infarction (MI), unstable angina, and ischemic stroke from 1996 to 2012 in patients with SLE. We compared these trends with those in the general population.

RESULTS

During the study years, there were an estimated 31,012 hospitalizations for acute MI, 4,160 hospitalizations for unstable angina, and 26,144 hospitalizations for ischemic stroke among patients with SLE. The rates of hospitalization for acute MI and ischemic stroke increased over time in patients with SLE, while the rates for unstable angina decreased. The rates for all 3 conditions decreased in the general population over these years, with hospitalization rates for unstable angina decreasing faster in the general population than in patients with SLE.

CONCLUSION

Increased awareness of the burden of CVD in patients with SLE has not yet translated into decreased rates of hospitalization for acute MI or stroke. This may be due to barriers in implementation of CVD risk factor modification or to SLE-specific risks that have not yet been identified or effectively targeted.

Report of the European Society of Cardiology Cardiovascular Round Table regulatory workshop update of the evaluation of new agents for the treatment of acute coronary syndrome: Executive summary

Regulatory authorities interpret the results of randomized controlled trials according to published principles. The European Medicines Agency (EMA) is planning a revision of the 2000 and 2003 guidance documents on clinical investigation of new medicinal products for the treatment of acute coronary syndrome (ACS) to achieve consistency with current knowledge in the field. This manuscript summarizes the key output from a collaborative workshop, organized by the Cardiovascular Round Table and the European Affairs Committee of the European Society of Cardiology, involving clinicians, academic researchers, trialists, European and US regulators, and pharmaceutical industry researchers. Specific questions in four key areas were selected as priorities for changes in regulatory guidance: patient selection, endpoints, methodologic issues and issues related to the research for novel agents. Patients with ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) should be studied separately for therapies aimed at the specific pathophysiology of either condition, particularly for treatment of the acute phase, but can be studied together for other treatments, especially long-term therapy. Unstable angina patients should be excluded from acute phase ACS trials. In general, cardiovascular death and reinfarction are recommended for primary efficacy endpoints; other endpoints may be considered if specifically relevant for the therapy under study. New agents or interventions should be tested against a background of evidence-based therapy with expanded follow-up for safety assessment. In conclusion, new guidance documents for randomized controlled trials in ACS should consider changes regarding patient and endpoint selection and definitions, and trial designs. Specific requirements for the evaluation of novel pharmacological therapies need further clarification.

Gender-specific and age-specific differences in unstable angina pectoris admissions: a population-based registry study in Finland

OBJECTIVE

To evaluate gender-specific and age-specific differences in the occurrence of unstable angina pectoris (UAP) caused admissions.

DESIGN

Population-based retrospective registry study in Finland.

PARTICIPANTS

All consecutive patients aged ≥30 years hospitalised with a primary diagnosis of UAP in 22 hospitals with a coronary catheterisation laboratory during 5/2000-10/2009.

PRIMARY OUTCOME MEASURES

Gender-specific and age-specific differences and trends in occurrence of UAP admissions.

RESULTS

The study period included 27 282 admissions caused primarily by UAP. Of these, 61.9% occurred to men and 38.1% to women with age-adjusted relative risk (RR) of 1.85 (CI 1.61 to 2.14) for the male gender (p<0.0001). The standardised incidence rate of UAP during the whole study was 92.8 (CI 91.8 to 93.9)/100,000 person-years. The incidence rate increased gradually from 1.3 in the population aged 30-34 years to 268.0/100,000 in the population aged 75-84 years. Men had a 2.4-fold risk for UAP admission compared with women in the general population (incidence rate ratio 2.39; CI 2.24 to 2.56; p<0.0001). Gender difference was present in all age groups. UAP caused 22.4% of acute coronary syndrome admissions and 4.7% of all cardiovascular admissions. UAP was more likely to be the cause of cardiovascular admission in male patients (RR=1.25; CI 1.21 to 1.30, p<0.0001 compared with female patients), but there was no gender difference in acute coronary syndrome admissions. The incidence rate of UAP hospitalisations in the general population declined by an estimated 8% per study-year (p<0.0001). Declining incidence was evident regardless of gender and age.

CONCLUSIONS

Men have a 2.4-fold overall RR for UAP admission compared to women in the general population. Admissions due to UAP have a declining incidence trend across the adult Finnish population.