Recent developments in diagnosis and risk stratification of non-ST-elevation acute coronary syndrome

Design of a new mortality indicator in acute coronary syndrome on admission to the Intensive Care Unit

OBJECTIVE

To design a mortality indicator in acute coronary syndrome (ACS) in the intensive care unit (ICU).

DESIGN

A multicenter, observational descriptive study was carried out.

PARTICIPANTS

Patients with ACS admitted to the ICUs included in the ARIAM-SEMICYUC registry between January 2013 and April 2019.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

Demographic parameters, time of access to the healthcare system, and clinical condition. Revascularization therapy, drugs and mortality were analyzed. Cox regression analysis was performed, followed by the design of a neural network. A receiver operating characteristic curve (ROC) was plotted to calculate the power of the new score. Lastly, the clinical utility or relevance of the ARIAM indicator (ARIAM's) was assessed using a Fagan test.

RESULTS

A total of 17,258 patients were included in the study, with a mortality rate of 3.5% (n = 605) at discharge from the ICU. The variables showing statistical significance (P < .001) were entered into the supervised predictive model, an artificial neural network. The new ARIAM's yielded a mean of 0.0257 (95%CI: 0.0245-0.0267) in patients discharged from the ICU versus 0.27085 (95%CI: 0.2533-0.2886) in those who died (P < .001). The area under the ROC curve of the model was 0.918 (95%CI: 0.907-0.930). Based on the Fagan test, the ARIAM's showed the mortality risk to be 19% (95%CI: 18%-20%) when positive and 0.9% (95%CI: 0.8%-1.01%) when negative.

CONCLUSIONS

A new mortality indicator for ACS in the ICU can be established that is more accurate and reproducible, and periodically updated.

Risk Stratification of Acute-Onset Chest Pain: SVEAT Score Versus HEART and TIMI Scores

Introduction Acute chest pain is a frequently encountered symptom in the emergency department. Despite the availability of various chest pain risk scores, their effectiveness in identifying low-risk patients suitable for safe and early discharge is inadequate. Moreover, clinical data collected at the initial stage, which has valuable discriminatory ability, is often underutilized. This study aims to assess the effectiveness of the Symptoms, history of Vascular disease, ECG, Age, and Troponin I (SVEAT) score in predicting major adverse cardiovascular events (MACE) in acute-onset chest pain, compared with the pre-existing History, ECG, Age, Risk factors, and Troponin I (HEART) and Thrombolysis In Myocardial Infarction (TIMI) scores. Methodology This prospective study utilizing non-probability convenience sampling was conducted in the emergency medicine department of a tertiary care hospital in Rawalpindi, Pakistan, for a period of five months from July 2022 to November 2022. The study included patients aged >45 years who presented primarily with chest pain lasting for at least five minutes but less than 24 hours and with a lack of acute ECG changes indicative of ST-elevation acute coronary syndrome (STE-ACS). Patients who were hemodynamically unstable were excluded. All patients were assessed for the calculation of SVEAT, TIMI, and HEART scores. All patients were followed for a period of 30 days to assess the incidence of MACE. Results A total of 60 patients were included. The mean age was 61.5±9.1 years while 31 (51.7%) patients were females. Diabetes was the most prevalent comorbidity (n=32; 53.3%). Regarding MACE, nine (15%) patients developed ACS and underwent percutaneous coronary intervention (PCI). Two patients (3.3%) experienced heart failure. Six (10%) patients also underwent PCI in the absence of ACS while two (3.3%) patients developed sudden cardiac death. Area-under-curve (AUC) values were determined for SVEAT (0.843; 95%CI: 0.74-0.94), TIMI (0.742; 95%CI: 0.62-0.86), and HEART scores (0.840; 95%CI: 0.74-0.94). A cut-off level of 3.5 SVEAT points obtained a sensitivity of 63.2% and specificity of 75.6% in predicting 30-day MACE. Conclusion SVEAT score potentially lacks the appropriate sensitivity level to predict a significant number of major adverse cardiovascular events compared to contemporary risk stratification scores. Therefore, the SVEAT criteria need re-evaluation as a screening tool for risk assessment in acute chest pain.

Point-of-care high-sensitivity troponin-I analysis in capillary blood for acute coronary syndrome diagnostics point-of-care troponin-I for ACS diagnostics

OBJECTIVES

Patients with acute coronary syndrome (ACS) should be referred promptly to the hospital to reduce mortality and morbidity. Differentiating between low-risk and high-risk patients remains a diagnostic challenge. Point-of-care testing can contribute to earlier disposition decisions for patients excluded from ACS. This study describes the validation of the Atellica^® VTLi. Patient-side Immunoassay Analyzer for high-sensitivity troponin point-of-care (POC) analysis. (The Atellica VTLi is not available for sale in the USA. The products/features (mentioned herein) are not commercially available in all countries. Their future availability cannot be guaranteed).

METHODS

A total of 152 patients with acute chest pain admitted at the cardiac emergency department (ED) were included in the study. Capillary blood was compared with a whole blood and plasma sample obtained by venipuncture. All samples were analyzed using the Atellica VTLi Patient-side Immunoassay Analyzer; in addition, plasma was analyzed by a central lab immunoassay analyzer.

RESULTS

No significant difference was observed between venous whole blood vs. plasma analyzed by the Atellica VTLi Patient-side Immunoassay Analyzer. The difference between capillary blood and venous blood showed a constant bias of 7.1%, for which a correction factor has been implemented. No clinically relevant differences were observed for the capillary POC results compared to plasma analyzed with a standard immunoassay analyzer.

CONCLUSIONS

The Atellica VTLi Patient-side Immunoassay Analyzer for high-sensitivity troponin analysis shows equivalent results for all sample types, including capillary blood. No clinically relevant discordances were observed between capillary POC and central laboratory results. With additional studies, this could pave the way towards rapid testing of high-sensitivity troponin in the ambulance or the general practitioner's office without the need for hospitalization of patients with acute chest pain.

Serum Levels of Growth Differentiation Factor-15 as an Inflammatory Marker in Patients with Unstable Angina Pectoris

Background: Growth differentiation factor-15 (GDF-15), a member of transforming growth factors, is a stress-responsive marker whose levels may significantly increase in response to pathological stresses associated with inflammatory tissue injuries such as unstable angina pectoris (USAP). This study evaluated the diagnostic value of GDF-15 in patients with USAP.

Methods: The present cross-sectional study recruited 39 patients with USAP criteria and 30 patients with stable angina pectoris (SAP), referred to Shahid Beheshti Hospital, Kashan, Iran. All the patients with USAP had at least 1 coronary artery stenosis (>50%) in angiography. The control group comprised 42 healthy individuals. The serum levels of GDF-15 were measured in all the participants by ELISA. Also analyzed were the relationship between GDF-15 levels and thrombolysis in myocardial infarction (TIMI) and the Global Registry of Acute Coronary Events (GRACE) risk scores in the patients with USAP to determine the severity of the disease.

Result: The study population consisted of 111 subjects, 62 women and 49 men, divided into 3 groups of USAP (n=39, mean age=60.07±14.10 y), SAP (n=30, mean age=67.56±9.88 y), and control (n=42, mean age=61.21±7.76 y). The mean serum level of GDF-15 in the USAP group was significantly different from the other 2 groups (P<0.001), while no significant difference was observed in this regard between the SAP and control groups (P=0.797). No correlation was found between the mean GDF-15 serum level and the GRACE (P=0.816) and TIMI (P=0.359) risk scores in the USAP group.

Conclusion: The mean serum level of GDF-15 exhibited a rise in our patients with USAP. GDF-15 may be a diagnostic biomarker of USAP and its severity.

Triglyceride-Glukose Index Predicts Adverse Events in Patients with Acute Coronary Syndrome: A Meta-Analysis of Cohort Studies

The triglyceride-glucose (TyG) index, a recently proposed indicator for insulin resistance, has been related with cardiovascular risks. We aimed to summarize the association between TyG index and incidence of major adverse cardiovascular events (MACEs) in patients with acute coronary syndrome (ACS). Cohort studies demonstrating the association between TyG index and incidence of MACEs in ACS patients with multivariate adjusted analyses were identified by search of PubMed, Embase, and Web of Science databases. A random-effekt model incorporating the heterogeneity was applied to pool the results. Eight cohort studies with 19 611 participants were included. Results showed that compared to those with the lowest category of TyG index, ACS patients with the highest category of TyG index were independently associated with higher risk of MACEs [risk ratio (RR): 1.94, 95% confidence interval (CI): 1.47-2.56, I²=85%, p <0.001). Subgroup analyses showed consistent results in patients with ST-segment elevated myocardial infarction or non-ST segment elevated ACS, in patients with or without diabetes, and in patients after percutaneous coronary intervention. Results were consistent in studies with TyG index analyzed as continuous variable (RR for per standard deviation increment of TyG index: 1.59, 95% CI: 1.38-1.83, I²=24%, p <0.001). In conclusion, higher TyG index may be independently associated with higher incidence of MACEs in patients with ACS.