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Weintraub WS, Boden WE. Can we measurably improve the prediction of recurrent coronary artery disease events? Eur Heart J 2023; 44:3466-3468. [PMID: 37738645 DOI: 10.1093/eurheartj/ehad464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/24/2023] Open
Affiliation(s)
- William S Weintraub
- MedStar Health Research Institute and Department of Medicine, Georgetown University, Washington, DC 20057, USA
| | - William E Boden
- Department of Medicine, Veterans Affairs Boston Healthcare System and Department of Medicine, Boston University School of Medicine, Boston, MA, USA
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Hernández-Ruiz P, Amezcua-Guerra LM, López-Vidal Y, González-Pacheco H, Pinto-Cardoso S, Amedei A, Aguirre-García MM. Comparative characterization of inflammatory profile and oral microbiome according to an inflammation-based risk score in ST-segment elevation myocardial infarction. Front Cell Infect Microbiol 2023; 13:1095380. [PMID: 36860987 PMCID: PMC9968971 DOI: 10.3389/fcimb.2023.1095380] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/31/2023] [Indexed: 02/15/2023] Open
Abstract
Ischemic heart disease considers the myocardial infarction (MI), either non-ST-segment elevation (non-STEMI) or ST-segment elevation myocardial infarction (STEMI); this represents the main cause of mortality in Mexican population. Regarding to the inflammatory state, this is reported to be a major prognostic factor of mortality for patients with MI. One of the conditions capable of producing systemic inflammation is periodontal disease. It has been proposed that the oral microbiota is translocated through the bloodstream to the liver and intestine, generating intestinal dysbiosis. The aim of this protocol is to assess oral microbiota diversity and circulating inflammatory profile in STEMI patients stratified according to an inflammation-based risk scoring system. We found that Bacteriodetes phylum was the most abundant in STEMI patients, and Prevotella was the most abundant genus, with a higher proportion in periodontitis patients. In fact, Prevotella genus was found to correlate positively and significantly with elevated IL-6 concentration. Our study defined a non-causal association inferred between the cardiovascular risk of STEMI patients, determined by changes in the oral microbiota that influence the development of periodontal disease and its relationship with the exacerbation of the systemic inflammatory response.
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Affiliation(s)
- Paulina Hernández-Ruiz
- Unidad de Investigación UNAM-INC, División de Investigación, Facultad de Medicina, Universidad Nacional Autónoma de México. Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de Mexico, Mexico
| | - Luis M. Amezcua-Guerra
- Departamento de Inmunología, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de Mexico, Mexico
| | - Yolanda López-Vidal
- Programa de Inmunología Molecular Microbiana, Departamento de Microbiología y Parasitología, División de Investigación, Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de Mexico, Mexico
| | - Héctor González-Pacheco
- Unidad de Cuidados Coronarios, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de Mexico, Mexico
| | - Sandra Pinto-Cardoso
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Centro de Investigación en Enfermedades Infecciosas, Ciudad de Mexico, Mexico
| | - Amedeo Amedei
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy,Interdisciplinary Internal Medicine Unit, Careggi University Hospital, Florence, Italy
| | - María Magdalena Aguirre-García
- Unidad de Investigación UNAM-INC, División de Investigación, Facultad de Medicina, Universidad Nacional Autónoma de México. Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de Mexico, Mexico,*Correspondence: María Magdalena Aguirre-García,
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Williams BA, Voyce S, Sidney S, Roger VL, Plante TB, Larson S, LaMonte MJ, Labarthe DR, DeBarmore BM, Chang AR, Chamberlain AM, Benziger CP. Establishing a National Cardiovascular Disease Surveillance System in the United States Using Electronic Health Record Data: Key Strengths and Limitations. J Am Heart Assoc 2022; 11:e024409. [PMID: 35411783 PMCID: PMC9238467 DOI: 10.1161/jaha.121.024409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiovascular disease surveillance involves quantifying the evolving population-level burden of cardiovascular outcomes and risk factors as a data-driven initial step followed by the implementation of interventional strategies designed to alleviate this burden in the target population. Despite widespread acknowledgement of its potential value, a national surveillance system dedicated specifically to cardiovascular disease does not currently exist in the United States. Routinely collected health care data such as from electronic health records (EHRs) are a possible means of achieving national surveillance. Accordingly, this article elaborates on some key strengths and limitations of using EHR data for establishing a national cardiovascular disease surveillance system. Key strengths discussed include the: (1) ubiquity of EHRs and consequent ability to create a more "national" surveillance system, (2) existence of a common data infrastructure underlying the health care enterprise with respect to data domains and the nomenclature by which these data are expressed, (3) longitudinal length and detail that define EHR data when individuals repeatedly patronize a health care organization, and (4) breadth of outcomes capable of being surveilled with EHRs. Key limitations discussed include the: (1) incomplete ascertainment of health information related to health care-seeking behavior and the disconnect of health care data generated at separate health care organizations, (2) suspect data quality resulting from the default information-gathering processes within the clinical enterprise, (3) questionable ability to surveil patients through EHRs in the absence of documented interactions, and (4) the challenge in interpreting temporal trends in health metrics, which can be obscured by changing clinical and administrative processes.
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Grinberg T, Hammer Y, Wiessman M, Perl L, Ovdat T, Tsafrir O, Kogan Y, Beigel R, Orvin K, Kornowski R, Eisen A. Management and outcomes over time of acute coronary syndrome patients at particularly high cardiovascular risk : the ACSIS registry-based retrospective study. BMJ Open 2022; 12:e060953. [PMID: 35410940 PMCID: PMC9003597 DOI: 10.1136/bmjopen-2022-060953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Some patients following acute coronary syndrome (ACS) are at particularly increased risk for recurrent cardiovascular events. We aimed to examine temporal trends in the management and outcomes across the spectrum of these particularly high-risk patients. DESIGN AND SETTING A retrospective study based on the ACS Israeli survey (ACSIS) registry, a multicentre prospective national registry, taking place biennially in 25 cardiology departments in Israel. Temporal trends were examined in the early (2002-2008) and late (2010-2018) time periods. PARTICIPANTS Consecutive patients with ACS enrolled in the ACSIS registry were stratified according to the Thrombolysis in Myocardial Infarction Risk Score for secondary prevention (TRS2°P) to high (TRS2°p=3), very high (TRS2°p=4) or extremely high risk (TRS2°p=5-9). Patients with TRS2°p<3 were excluded. From the initial 15 196 patients enrolled, 5359 patients were eventually included.Clinical outcome measures included 30-day major adverse cardiovascular events (MACE) and 1-year mortality. RESULTS Among 5359 patients (50% high risk, 30% very high risk and 20% extremely high risk), those with a higher risk were older, had more comorbidities, presented more with non-ST elevation myocardial infarction, and were treated less often with guideline-recommended pharmacotherapy and percutaneous coronary intervention. Over time, treatment has improved in all risk strata, and the rate of 30-day MACE has significantly decreased in all risk groups (from 21% to 10%, from 22% to 15%, and from 26% to 16%, in high, very high and extremely high-risk groups, respectively, p<0.001 for each). However, 1-year mortality decreased only among high and very high-risk patients, and not among extremely high-risk patients in whom 1-year mortality rates remained very high (28.7% vs 28.9%, p=1). CONCLUSION Within a particularly high-risk cohort of patients with ACS, treatment has significantly progressed over almost 2 decades. While short-term outcomes have improved in all risk groups, 1-year mortality has remained unchanged in extremely high-risk patients with ACS.
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Affiliation(s)
- Tzlil Grinberg
- Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Hammer
- Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maya Wiessman
- Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leor Perl
- Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Ovdat
- Heart Institute, Sheba Medical Center, Ramat Gan, Israel
| | - Or Tsafrir
- Cardiology Department, Western Galilee Medical Center, Nahariya, Israel
| | - Yoni Kogan
- Cardiology Department, Assuta Medical Center, Ashdod, Israel
| | - Roy Beigel
- Heart Institute, Sheba Medical Center, Ramat Gan, Israel
| | - Katia Orvin
- Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alon Eisen
- Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Constructing Epidemiologic Cohorts from Electronic Health Record Data. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182413193. [PMID: 34948800 PMCID: PMC8701170 DOI: 10.3390/ijerph182413193] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 11/17/2022]
Abstract
In the United States, electronic health records (EHR) are increasingly being incorporated into healthcare organizations to document patient health and services rendered. EHRs serve as a vast repository of demographic, diagnostic, procedural, therapeutic, and laboratory test data generated during the routine provision of health care. The appeal of using EHR data for epidemiologic research is clear: EHRs generate large datasets on real-world patient populations in an easily retrievable form permitting the cost-efficient execution of epidemiologic studies on a wide array of topics. Constructing epidemiologic cohorts from EHR data involves as a defining feature the development of data machinery, which transforms raw EHR data into an epidemiologic dataset from which appropriate inference can be drawn. Though data machinery includes many features, the current report focuses on three aspects of machinery development of high salience to EHR-based epidemiology: (1) selecting study participants; (2) defining “baseline” and assembly of baseline characteristics; and (3) follow-up for future outcomes. For each, the defining features and unique challenges with respect to EHR-based epidemiology are discussed. An ongoing example illustrates key points. EHR-based epidemiology will become more prominent as EHR data sources continue to proliferate. Epidemiologists must continue to improve the methods of EHR-based epidemiology given the relevance of EHRs in today’s healthcare ecosystem.
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Wahrenberg A, Kuja-Halkola R, Magnusson PKE, Häbel H, Warnqvist A, Hambraeus K, Jernberg T, Svensson P. Cardiovascular Family History Increases the Risk of Disease Recurrence After a First Myocardial Infarction. J Am Heart Assoc 2021; 10:e022264. [PMID: 34845931 PMCID: PMC9075368 DOI: 10.1161/jaha.121.022264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Family history of atherosclerotic cardiovascular disease (ASCVD) is easily accessible and captures genetic cardiovascular risk, but its prognostic value in secondary prevention is unknown. Methods and Results We followed 25 615 patients registered in SWEDEHEART (Swedish Web‐System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies) from their 1‐year revisit after a first‐time myocardial infarction during 2005 to 2013, until December 31, 2018. Data on relatives, diagnoses and socioeconomics were extracted from national registers. The association between family history and recurrent ASCVD was studied with Cox proportional‐hazard regression, adjusting for risk factors and socioeconomics. A family history of ASCVD was defined as hospitalization due to myocardial infarction, angina with coronary revascularization, stroke, or cardiovascular death in ≥1 parent or full sibling, with early‐onset defined as disease‐onset before 55 years in men and 65 in women. The additional discriminatory value of family history to Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention was assessed with Harrell’s C‐index difference and reclassification was studied with continuous net reclassification improvement. Family history of early‐onset ASCVD in ≥1 first‐degree relative was present in 2.3% and was associated with recurrent ASCVD (hazard ratio [HR] 1.31; 95% CI, 1.17–1.47), fully adjusted for risk factors (HR, 1.22; 95% CI, 1.05–1.42). Early‐onset family history improved the discriminatory ability of the Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention, with Harrell’s C improving 0.003 points (95% CI, 0.001–0.005) from initial 0.587 (95% CI, 0.576–0.595) and improved reclassification (continuous net reclassification improvement 2.1%, P<0.001). Conclusions Family history of early‐onset ASCVD is associated with recurrent ASCVD after myocardial infarction, independently of traditional risk factors and improves secondary risk prediction. This may identify patients to target for intensified secondary prevention.
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Affiliation(s)
- Agnes Wahrenberg
- Division of Cardiology Department of Clinical Science and Education Karolinska InstitutetSödersjukhuset Stockholm Sweden
| | - Ralf Kuja-Halkola
- Department of Medical Epidemiology and Biostatistics Karolinska Institutet Stockholm Sweden
| | - Patrik K E Magnusson
- Department of Medical Epidemiology and Biostatistics Karolinska Institutet Stockholm Sweden
| | - Henrike Häbel
- Karolinska InstitutetInstitute of Environmental Medicine Stockholm Sweden
| | - Anna Warnqvist
- Karolinska InstitutetInstitute of Environmental Medicine Stockholm Sweden
| | | | - Tomas Jernberg
- Department of Clinical Sciences Karolinska InstitutetDanderyd University Hospital Stockholm Sweden
| | - Per Svensson
- Division of Cardiology Department of Clinical Science and Education Karolinska InstitutetSödersjukhuset Stockholm Sweden
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Ohm J, Jernberg T, Johansson D, Warnqvist A, Leosdottir M, Hambraeus K, Svensson P. Association of clinical trial participation after myocardial infarction with socioeconomic status, clinical characteristics, and outcomes. EUROPEAN HEART JOURNAL OPEN 2021; 1:oeab020. [PMID: 35919264 PMCID: PMC9241569 DOI: 10.1093/ehjopen/oeab020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/17/2021] [Accepted: 08/10/2021] [Indexed: 02/01/2023]
Abstract
Abstract
Aims
To investigate whether participants in clinical trials after myocardial infarction (MI) are representable for the post-MI population concerning characteristics, secondary prevention, and prognosis.
Methods and results
Cohort study on 31 792 attendants to 1-year revisits after MI throughout Sweden (n = 2941 clinical trial participants) between 2008 and 2013 identified in the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART). Individual-level data on socioeconomic status (SES) (disposable income, educational level, and marital status) and outcomes (first recurrent non-fatal MI, coronary heart disease death, fatal or non-fatal stroke until study end 2018) were linked from other national registries. Trial participants were more likely to be men [risk ratio 1.09; 95% confidence interval (CI) 1.07–1.11], and married (1.07; 1.04–1.10), have a highest-quintile income (1.42; 1.36–1.48), and post-secondary education (1.25; 1.18–1.33), while less likely to have a history of MI (0.88; 0.80–0.97), be persistent smokers (0.83; 0.75–0.92) and have left ventricular dysfunction (0.59; 0.44–0.79) compared to non-participants. During a mean 6.7-year follow-up, 5206 outcome events occurred. Risk was lower in trial participants (hazard ratio 0.80; 95% CI 0.72–0.89), also after adjusting for clinical characteristics and post-MI therapies (0.85; 0.77–0.94) and additionally for SES (0.88; 0.79–0.97).
Conclusions
Clinical trial participants post-MI are more often male, have higher SES, a more advantageous risk profile, and better prognosis. Additional unmeasured participation bias was implied. Questionable external validity of post-MI trials highlights the importance of complementary studies using real-world data.
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Affiliation(s)
- Joel Ohm
- Department of Emergency Medicine, Solna, Karolinska University Hospital , Anna Steckséns gata 33 , Stockholm SE-171 76, Sweden
- Department of Medicine, Solna, Karolinska Institutet , Stockholm SE-17177, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet , Stockholm SE-18288, Sweden
| | - David Johansson
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet , Stockholm SE-11883, Sweden
| | - Anna Warnqvist
- Division of Biostatistics, Institute of Environmental Medicine, Nobels väg 13, Karolinska Institutet , Stockholm SE-17177, Sweden
| | - Margrét Leosdottir
- Department of Cardiology, Skåne University Hospital , Jan Waldenströms gata 15, Malmö SE-20502, Sweden
- Department of Clinical Sciences Malmö, Lund University , Box 50332, Malmö SE-20213, Sweden
| | - Kristina Hambraeus
- Department of Cardiology, Falu Hospital , Lasarettsvägen, Falun SE-79182, Sweden
| | - Per Svensson
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet , Stockholm SE-11883, Sweden
- Department of Cardiology, Södersjukhuset , Sjukhusbacken 10, Stockholm SE-11883, Sweden
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Patti G, Fattirolli F, De Luca L, Renda G, Marcucci R, Parodi G, Perna GP, Andreotti F, Ghiglieno C, Fedele F, Marchionni N. Updated antithrombotic strategies to reduce the burden of cardiovascular recurrences in patients with chronic coronary syndrome. Biomed Pharmacother 2021; 140:111783. [PMID: 34102448 DOI: 10.1016/j.biopha.2021.111783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/23/2021] [Accepted: 05/25/2021] [Indexed: 12/24/2022] Open
Abstract
Despite recent achievements in secondary cardiovascular prevention, the risk of further events in patients with chronic coronary syndromes (CCS) remains elevated. Highest risk is seen in patients with recurrent events, comorbidities or multisite atherosclerosis. Optimising antithrombotic strategies in this setting may significantly improve outcomes. The higher the baseline risk, the higher the absolute event reduction with approaches using combined antithrombotic treatments. Tailoring such strategies to the individual patient risk appears crucial to achieve net benefit (i.e., substantial ischaemic event prevention at a limited cost in terms of bleeding). This paper focuses on antithrombotic and non-pharmacological approaches to secondary cardiovascular disease prevention in CCS. In particular, we critically review current evidence on the use of dual antithrombotic therapy, including the newest approach of aspirin plus low-dose anticoagulation and its net clinical outcome according to baseline risk.
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Affiliation(s)
- Giuseppe Patti
- University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy.
| | - Francesco Fattirolli
- Department of Clinical and Experimental Medicine, University of Florence, Careggi Hospital, Florence, Italy
| | - Leonardo De Luca
- Department of Cardiosciences, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
| | - Giulia Renda
- Institute of Cardiology, Department of Neuroscience, Imaging and Clinical Sciences, G. d'Annunzio University, Chieti-Pescara, Italy
| | - Rossella Marcucci
- Department of Clinical and Experimental Medicine, University of Florence, Careggi Hospital, Florence, Italy
| | - Guido Parodi
- Department of Medical Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | | | | | - Chiara Ghiglieno
- University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Francesco Fedele
- Department of Cardiovascular and Respiratory Sciences-Sapienza University of Rome, Rome, Italy
| | - Niccolò Marchionni
- Department of Clinical and Experimental Medicine, University of Florence, Careggi Hospital, Florence, Italy
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Sequential Pattern Mining to Predict Medical In-Hospital Mortality from Administrative Data: Application to Acute Coronary Syndrome. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:5531807. [PMID: 34122784 PMCID: PMC8172301 DOI: 10.1155/2021/5531807] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 05/19/2021] [Indexed: 01/29/2023]
Abstract
Prediction of a medical outcome based on a trajectory of care has generated a lot of interest in medical research. In sequence prediction modeling, models based on machine learning (ML) techniques have proven their efficiency compared to other models. In addition, reducing model complexity is a challenge. Solutions have been proposed by introducing pattern mining techniques. Based on these results, we developed a new method to extract sets of relevant event sequences for medical events' prediction, applied to predict the risk of in-hospital mortality in acute coronary syndrome (ACS). From the French Hospital Discharge Database, we mined sequential patterns. They were further integrated into several predictive models using a text string distance to measure the similarity between patients' patterns of care. We computed combinations of similarity measurements and ML models commonly used. A Support Vector Machine model coupled with edit-based distance appeared as the most effective model. We obtained good results in terms of discrimination with the receiver operating characteristic curve scores ranging from 0.71 to 0.99 with a good overall accuracy. We demonstrated the interest of sequential patterns for event prediction. This could be a first step to a decision-support tool for the prevention of in-hospital death by ACS.
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Validation of the atherothrombotic risk score for secondary prevention in patients with acute myocardial infarction: the J-MINUET study. Heart Vessels 2021; 36:1506-1513. [PMID: 33880614 DOI: 10.1007/s00380-021-01840-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 03/19/2021] [Indexed: 10/21/2022]
Abstract
Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention (TRS2°P) is a contemporary risk scoring system for secondary prevention based on nine clinical factors. However, this scoring system has not been validated in other populations. The aim of this study was to validate the TRS2°P in patients with acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (PCI) in a nationwide registry cohort. Among 3283 consecutive patients with AMI enrolled in the Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET), a total of 2611 patients who underwent primary PCI were included in this study. The performance of the TRS2°P to predict major adverse cardiovascular events (MACE) composed of all-cause death, non-fatal MI, and non-fatal stroke up to 3 years in the present cohort was evaluated. The TRS2°P had modest discriminative performance in this J-MINUET cohort with a c-statistic of 0.63, similar to that in the derived cohort (TRA2°P-TIMI50, c-statistic 0.67). A strong graded relationship between the TRS2°P and 3-year cardiovascular event rates was also observed in the J-MINUET cohort. Age ≥ 75 years, Killip ≥ 2, prior stroke, peripheral artery disease, anemia, and non-ST-elevation myocardial infarction were identified as independent factors for the incidence of MACE. The TRS2°P modestly predicted secondary cardiovascular events among patients with AMI treated by primary PCI in a nationwide cohort of Japan. Further studies are needed to develop a novel risk score better predicting secondary cardiovascular events.
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Nanna MG, Peterson ED, Chiswell K, Overton RA, Nelson AJ, Kong DF, Navar AM. The incremental value of angiographic features for predicting recurrent cardiovascular events: Insights from the Duke Databank for Cardiovascular Disease. Atherosclerosis 2021; 321:1-7. [PMID: 33582446 DOI: 10.1016/j.atherosclerosis.2021.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/25/2021] [Accepted: 02/03/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIMS Identifying patient subgroups with cardiovascular disease (CVD) at highest risk for recurrent events remains challenging. Angiographic features may provide incremental value in risk prediction beyond clinical characteristics. METHODS We included all cardiac catheterization patients from the Duke Databank for Cardiovascular Disease with significant coronary artery disease (CAD; 07/01/2007-12/31/2012) and an outpatient follow-up visit with a primary care physician or cardiologist in the same health system within 3 months post-catheterization. Follow-up occurred for 3 years for the primary major adverse cardiovascular event endpoint (time to all-cause death, myocardial infarction [MI], or stroke). A multivariable model to predict recurrent events was developed based on clinical variables only, then adding angiographic variables from the catheterization. Next, we compared discrimination of clinical vs. clinical plus angiographic risk prediction models. RESULTS Among 3366 patients with angiographically-defined CAD, 633 (19.2%) experienced cardiovascular events (death, MI, or stroke) within 3 years. A multivariable model including 18 baseline clinical factors and initial revascularization had modest ability to predict future atherosclerotic cardiovascular disease events (c-statistic = 0.716). Among angiographic predictors, number of diseased vessels, left main stenosis, left anterior descending stenosis, and the Duke CAD Index had the highest value for secondary risk prediction; however, the clinical plus angiographic model only slightly improved discrimination (c-statistic = 0.724; delta 0.008). The net benefit for angiographic features was also small, with a relative integrated discrimination improvement of 0.05 (95% confidence interval: 0.03-0.08). CONCLUSIONS The inclusion of coronary angiographic features added little incremental value in secondary risk prediction beyond clinical characteristics.
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Affiliation(s)
- Michael G Nanna
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA; Duke University Medical Center, Department of Medicine, Durham, NC, USA.
| | - Eric D Peterson
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Robert A Overton
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Adam J Nelson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - David F Kong
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA; Duke University Medical Center, Department of Medicine, Durham, NC, USA
| | - Ann Marie Navar
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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Nan J, Meng S, Hu H, Jia R, Jin Z. Fibrinolysis Therapy Combined with Deferred PCI versus Primary Angioplasty for STEMI Patients During the COVID-19 Pandemic: Preliminary Results from a Single Center. Int J Gen Med 2021; 14:201-209. [PMID: 33519227 PMCID: PMC7838526 DOI: 10.2147/ijgm.s292901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 12/14/2020] [Indexed: 01/07/2023] Open
Abstract
Introduction The efficacy of fibrinolysis therapy with deferred percutaneous coronary angioplasty (FPCI) versus primary angioplasty (PPCI) during the coronavirus disease 2019 (COVID-19) pandemic is unclear when medical quarantine is needed. Patients and Methods Acute ST segment elevation myocardial infarction (STEMI) patients underwent PPCI after finishing the screening protocol from January 23, 2020 to June 10, 2020 while FPCI was applied when COVID-19-confirmed cases reoccurred in Beijing near our hospital from June 11, 2020 to July 20, 2020. The door-to-balloon time (DTB) or door-to-needle time (DTN) as well as in-hospital adverse clinical outcomes were compared between the two groups. A propensity score-matched (PSM) analysis was performed to diminish the potential influence of confounding factors on the clinical outcomes. Results A total of 126 STEMI patients underwent PPCI after finishing the screening protocol and 17 patients received FPCI before PSM. Patients who received FPCI were younger than patients who underwent PPCI (50.8±14.0 versus 64.1±14.2 years, p=0.001), and chronic kidney disease (CKD) was less common in FPCI patients than in patients who underwent PPCI (0% versus 24.6%, p=0.024). The DTN was significantly shorter than DTB (25.8±4.2 versus 61.1±10.7, p=0.000) before PSM. The DTN was significantly shorter than DTB (26.9±4.2 versus 64.9±23.6, p=0.000); however, the incidence rate of in-hospital ischemia and bleeding adverse clinical outcomes were comparable between the two groups after PSM. Conclusion Fibrinolysis therapy combined with deferred PCI can reduce the ischemia time and has a similar in-hospital adverse clinical outcome rate compared with patients who underwent primary PCI during the COVID-19 pandemic.
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Affiliation(s)
- Jing Nan
- Department of Cardiology and Macrovascular Disease, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Shuai Meng
- Department of Cardiology and Macrovascular Disease, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Hongyu Hu
- Department of Cardiology and Macrovascular Disease, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Ruofei Jia
- Department of Cardiology and Macrovascular Disease, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zening Jin
- Department of Cardiology and Macrovascular Disease, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
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13
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Desjobert E, Tea V, Schiele F, Ferrières J, Simon T, Danchin N, Puymirat E. Clinical outcomes with high-intensity statins according to atherothrombotic risk stratification after acute myocardial infarction: The FAST-MI registries. Arch Cardiovasc Dis 2020; 114:88-95. [PMID: 33011156 DOI: 10.1016/j.acvd.2020.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/10/2020] [Accepted: 06/27/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Current guidelines strongly recommend high-intensity statin therapy after acute myocardial infarction. AIMS To analyse the relationship between prescription of high-intensity statin therapy at discharge and long-term clinical outcomes according to risk level defined by the Thrombolysis In Myocardial Infarction Risk Score for Secondary Prevention (TRS-2P) after acute myocardial infarction. METHODS We used data from the FAST-MI 2005 and 2010 registries - two nationwide French surveys including 7839 consecutive patients with acute myocardial infarction. Level of risk was stratified in three groups using the TRS-2P score: Group 1 (low risk; TRS-2P=0-1); Group 2 (intermediate risk; TRS-2P=2); and Group 3 (high risk; TRS-2P≥3). RESULTS Among the 7348 patients discharged alive with a TRS-2P available, high-intensity statin therapy was used in 41.3% in Group 1, 31.3% in Group 2 and 18.5% in Group 3. After multivariable adjustment, high-intensity statin therapy was associated with a non-significant decrease in major adverse cardiovascular events (death, stroke or recurrent myocardial infarction) at 5 years in the overall population compared with that in patients receiving intermediate- or low-intensity statins or without a statin prescription (14.3% vs 29.6%; hazard ratio 0.94, 95% confidence interval 0.81-1.09; P=0.42). In absolute terms, the decrease in major adverse cardiovascular events was positively correlated with risk level (Group 1: 8.1% vs 10.7%; Group 2: 14.8% vs 21.6%; Group 3: 30.8% vs 51.6%). However, after adjustment, the benefits of high-intensity statin therapy were associated with lower mortality only in high-risk patients (hazard ratio 0.79, 95% confidence interval 0.64-0.97; P=0.02). CONCLUSIONS High-intensity statin therapy at discharge after acute myocardial infarction was associated in absolute terms with fewer major adverse cardiovascular events at 5 years, regardless of atherothrombotic risk stratification, although the highest absolute reduction was found in the high-risk TRS-2P class.
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Affiliation(s)
- Edouard Desjobert
- Department of cardiology, hôpital européen Georges-Pompidou (HEGP), AP-HP, 75015 Paris, France; Université de Paris, 75006 Paris, France
| | - Victoria Tea
- Department of cardiology, hôpital européen Georges-Pompidou (HEGP), AP-HP, 75015 Paris, France; Université de Paris, 75006 Paris, France
| | - François Schiele
- Department of cardiology, university hospital Jean-Minjoz, 25000 Besançon, France
| | - Jean Ferrières
- Department of cardiology, Rangueil hospital, 31400 Toulouse, France
| | - Tabassome Simon
- Department of clinical pharmacology and unité de recherche clinique (URC-Est), hôpital Saint-Antoine, AP-HP, 75012 Paris, France; Université Pierre-et-Marie-Curie (UPMC-Paris 06), 75005 Paris, France
| | - Nicolas Danchin
- Department of cardiology, hôpital européen Georges-Pompidou (HEGP), AP-HP, 75015 Paris, France; Université de Paris, 75006 Paris, France
| | - Etienne Puymirat
- Department of cardiology, hôpital européen Georges-Pompidou (HEGP), AP-HP, 75015 Paris, France; Université de Paris, 75006 Paris, France.
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14
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Boden WE, Hartigan PM, Mancini J, Teo KK, Chaitman BR, Maron DJ, Kostuk WJ, Hartigan JA, Dada M, Spertus JA, Bates ER, Weintraub WS. Risk Prediction Tool for Assessing the Probability of Death or Myocardial Infarction in Patients With Stable Coronary Artery Disease. Am J Cardiol 2020; 130:1-6. [PMID: 32654755 DOI: 10.1016/j.amjcard.2020.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 05/20/2020] [Accepted: 05/25/2020] [Indexed: 11/19/2022]
Abstract
Several risk scores in acute coronary syndromes are available, but few models exist for stable coronary artery disease to guide decision-making and prognosis. A multivariate model was developed using 23 baseline candidate variables from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Therapy EvaluationTrial (n = 2,287 patients). Discrimination of the model was evaluated by the concordance c-index. The procedure was validated using 100 random half samples. We identified 9 independent predictors of death or myocardial infarction (MI) during a 5-year follow-up. The following predictors and points contributing to the risk score were: heart failure (3), number of diseased coronary arteries (1 for each vessel), diabetes (1), age (1 for each 15 years ≥ age 45), previous revascularization (1), current smoking (1), female (1), previous MI (1), and high-density lipoprotein cholesterol (1: 31 to 40 mg/dL; 2: <30 mg/dL). The risk tool had a potential range from 0 to 15, corresponding to 5-year event rates of 5.8% to 56%. C-indices ranged from 0.67 for the full data set to 0.62 for the validating subsamples. Respective observed versus predicted 5-year event rates for 3 predefined risk strata revealed: 30% had a low-risk score of 0 to 3 (9.3% vs 9.3%, or 1.9%/year); 59% had an intermediate-risk score of 4-6 (18.0% vs 18.1%, or 3.6%/year); and 11% had a high-risk score of 7-11 (36% vs 36.5%, or 7.2%/year). This stable coronary artery disease risk score permitted a prognostic assessment of 5-year probability of death or MI with an approximate 4-fold range in event rates from the lowest (9.3%) to the highest (36%) terciles, thus enabling better clinical practice decisions that allow physicians to tailor the intensity of treatment to the level of risk.
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Affiliation(s)
- William E Boden
- Clinical Trials Network, VA New England Healthcare System, Boston University School of Medicine, Boston, Massachusetts.
| | | | - John Mancini
- University of British Columbia, Vancouver, BC, Canada
| | - Koon K Teo
- McMaster University Medical Center, Hamilton, ON, Canada
| | | | - David J Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | | | - John A Hartigan
- Department of Statistics, Yale University, New Haven, Connecticut
| | - Marcin Dada
- Baystate Medical Center, Springfield, Massachusetts
| | | | - Eric R Bates
- University of Michigan Medical Center, Ann Arbor, Michigan
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15
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Arora S, Qamar A, Gupta P, Vaduganathan M, Chauhan I, Tripathi AK, Sharma VY, Bansal A, Fatima A, Jain G, Batra V, Tyagi S, Khandelwal L, Kaul P, Rao SV, Girish MP, Bhatt DL, Gupta MD. Design and rationale of the North Indian ST-Segment Elevation Myocardial Infarction Registry: A prospective cohort study. Clin Cardiol 2019; 42:1140-1146. [PMID: 31593344 PMCID: PMC6906983 DOI: 10.1002/clc.23278] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/16/2019] [Accepted: 09/18/2019] [Indexed: 12/17/2022] Open
Abstract
ST‐segment elevation myocardial infarction (STEMI) is associated with increased mortality and morbidity. Although remarkable progress has been made in the management of STEMI in high‐income countries, contemporary data to evaluate processes and outcomes of STEMI care in India is limited. The North Indian ST‐segment elevation myocardial infarction (NORIN STEMI) registry is a prospective cohort study based at government funded and largely free of cost tertiary medical centers in New Delhi, India. These hospitals serve a large proportion of the patients with lower socioeconomic status presenting from multiple states in India, as many centers in these states lack adequate specialized cardiovascular care. The study has been approved by the Institutional Review Boards of each institution and informed consent has been obtained from study participants. The NORIN STEMI registry aims to provide important insights regarding contemporary risk factors profiles, practice patterns, and prognosis in patients with STEMI in an underserved population in North India. These findings may identify opportunities to improve the outcomes of patients with STEMI in India.
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Affiliation(s)
- Sameer Arora
- Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina.,Preventive Medicine Residency, Department of Family Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Arman Qamar
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Puneet Gupta
- Department of Cardiology, Janakpuri Superspeciality Hospital, New Delhi, India
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Ishit Chauhan
- Department of Cardiology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Ashutosh K Tripathi
- Department of Cardiology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Vinamra Y Sharma
- Department of Cardiology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Ankit Bansal
- Department of Cardiology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Amber Fatima
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Gagan Jain
- Department of Cardiology, Janakpuri Superspeciality Hospital, New Delhi, India
| | - Vishal Batra
- Department of Cardiology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Sanjay Tyagi
- Department of Cardiology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Lokesh Khandelwal
- Department of Cardiology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Prashant Kaul
- Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina.,Piedmont Heart Institute, Atlanta, Georgia
| | - Sunil V Rao
- The Duke Clinical Research Institute, Durham, North Carolina
| | - Meenahalli Palleda Girish
- Department of Cardiology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Mohit D Gupta
- Department of Cardiology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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16
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Outcome associated with prescription of cardiac rehabilitation according to predicted risk after acute myocardial infarction: Insights from the FAST-MI registries. Arch Cardiovasc Dis 2019; 112:459-468. [DOI: 10.1016/j.acvd.2019.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 03/14/2019] [Accepted: 04/02/2019] [Indexed: 11/19/2022]
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17
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Zafrir B, Adawi S, Khalaily M, Jaffe R, Eitan A, Barnett-Griness O, Saliba W. Long-Term Risk Stratification of Patients Undergoing Coronary Angiography According to the Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention. J Am Heart Assoc 2019; 8:e012433. [PMID: 31271083 PMCID: PMC6662136 DOI: 10.1161/jaha.119.012433] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background A risk score for secondary prevention after myocardial infarction (Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention [TRS2P]), based on 9 established clinical factors, was recently developed from the TRA2°P‐TIMI50 (Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events) trial. We aimed to evaluate the performance of TRS2P for predicting long‐term outcomes in real‐world patients presenting for coronary angiography. Methods and Results A retrospective analysis of 13 593 patients referred to angiography for the assessment or treatment of coronary disease was performed. Risk stratification for 10‐year major adverse cardiovascular events was performed using the TRS2P, divided into 6 categories (0 to ≥5 points), and in relation to the presenting coronary syndrome. All clinical variables, except prior coronary artery bypass grafting, were independent risk predictors. The annualized incidence rate of major adverse cardiovascular events increased in a graded manner with increasing TRS2P, ranging from 1.65 to 16.6 per 100 person‐years (Ptrend<0.001). Compared with the lowest‐risk group (risk indicators=0), the hazard ratios (95% CIs) for 10‐year major adverse cardiovascular events were 1.60 (95% CI, 1.36–1.89), 2.58 (95% CI, 2.21–3.02), 4.31 (95% CI, 3.69–5.05), 6.43 (95% CI, 5.47–7.56), and 10.03 (95% CI, 8.52–11.81), in those with 1, 2, 3, 4 and ≥5 risk indicators, respectively. Risk gradation was consistent among individual clinical end points. TRS2P showed reasonable discrimination with C‐statistics of 0.693 for major adverse cardiovascular events and 0.758 for mortality. The graded relationship between the risk score and event rates was observed in both patients presenting with acute and nonacute coronary syndromes. Conclusions The use of TRS2P, a simple risk score based on routinely collected variables, enables risk stratification in patients undergoing coronary angiography. Its predictive value was demonstrated in a real‐world setting with long‐term follow‐up and regardless of the acuity of coronary presentation.
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Affiliation(s)
- Barak Zafrir
- 1 Department of Cardiology Lady Davis Carmel Medical Center Haifa Israel.,4 Faculty of Medicine Technion Israel Institute of Medicine Haifa Israel
| | - Salim Adawi
- 1 Department of Cardiology Lady Davis Carmel Medical Center Haifa Israel.,4 Faculty of Medicine Technion Israel Institute of Medicine Haifa Israel
| | - Marah Khalaily
- 4 Faculty of Medicine Technion Israel Institute of Medicine Haifa Israel
| | - Ronen Jaffe
- 1 Department of Cardiology Lady Davis Carmel Medical Center Haifa Israel.,4 Faculty of Medicine Technion Israel Institute of Medicine Haifa Israel
| | - Amnon Eitan
- 1 Department of Cardiology Lady Davis Carmel Medical Center Haifa Israel
| | - Ofra Barnett-Griness
- 2 Statistical Unit Lady Davis Carmel Medical Center Haifa Israel.,3 Department of Community Medicine and Epidemiology Lady Davis Carmel Medical Center Haifa Israel
| | - Walid Saliba
- 3 Department of Community Medicine and Epidemiology Lady Davis Carmel Medical Center Haifa Israel.,4 Faculty of Medicine Technion Israel Institute of Medicine Haifa Israel
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18
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Ohm J, Hjemdahl P, Skoglund PH, Discacciati A, Sundström J, Hambraeus K, Jernberg T, Svensson P. Lipid levels achieved after a first myocardial infarction and the prediction of recurrent atherosclerotic cardiovascular disease. Int J Cardiol 2019; 296:1-7. [PMID: 31303394 DOI: 10.1016/j.ijcard.2019.07.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 05/22/2019] [Accepted: 07/01/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Low density lipoprotein cholesterol (LDL-C) goals post-myocardial infarction (MI) are debated, and the significance of achieved blood lipid levels for predicting a first recurrent atherosclerotic cardiovascular disease (rASCVD) event post-MI is unclear. METHODS This was a cohort study on first-ever MI survivors aged ≤76 years attending 4-14 week revisits throughout Sweden 2005-2013. Personal-level data was collected from SWEDEHEART and linked national registries. Exposures were quintiles of LDL-C, high density lipoprotein cholesterol (HDL-C), total cholesterol (TC), and triglycerides (TGs) at the revisit. Group level associations with rASCVD (nonfatal MI or coronary heart disease death or fatal or nonfatal ischemic stroke) were estimated in Cox regression models. Predictive capacity was estimated by differences in C-statistic, integrated discriminatory improvement, and net reclassification improvement when adding each blood lipid to a validated risk prediction model. RESULTS 25,643 patients, 96.9% on statin therapy, were followed during a mean of 4.1 years. rASCVD occurred in 2173 patients (8.5%). For LDL-C and TC, moderate associations with rASCVD were observed only in the 5th vs. the lowest (referent) quintiles. For TGs and HDL-C increased risks were observed in quintiles 3-5 vs. the lowest. Minor predictive improvements were observed when lipid fractions were added to the risk model but the discrimination overall was poor (C-statistics <0.6). CONCLUSIONS Our data question the importance of LDL-C levels achieved at first revisit post-MI for decisions on continued treatment intensity considering the weak association with rASCVD observed in this post-MI cohort.
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Affiliation(s)
- Joel Ohm
- Function of Emergency Medicine Solna, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
| | - Paul Hjemdahl
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Per H Skoglund
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Center for Palliative Care, Stiftelsen Stockholms Sjukhem, Stockholm, Sweden
| | - Andrea Discacciati
- Institute of Environmental Medicine, Unit of Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Per Svensson
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Department of Cardiology, Södersjukhuset, Stockholm, Sweden
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19
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Jones-O'Connor M, Natarajan P. Optimal Non-invasive Strategies to Reduce Recurrent Atherosclerotic Cardiovascular Disease Risk. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:38. [PMID: 31254118 PMCID: PMC6739861 DOI: 10.1007/s11936-019-0741-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE OF REVIEW Cardiovascular disease (CVD) remains the leading cause of death worldwide, with coronary artery disease (CAD) responsible for the vast majority of these deaths. Incidence is increasing in developing countries, and prevalence is increasing globally as populations age. Once CAD is manifest, recurrent event risk remains high. RECENT FINDINGS Multiple therapeutic avenues have had significant recent developments, including diet, low-density lipoprotein cholesterol management, triglycerides, hypoglycemic agents, antiplatelet agents, and oral anticoagulants. Combined approaches involving specific, tailored lifestyle, and pharmacological interventions will provide the most effective strategy for reducing the risk of recurrent CVD events. Here, we review risk prediction and non-invasive non-pharmacologic and pharmacologic approaches to mitigate residual coronary artery disease risk.
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Affiliation(s)
- Maeve Jones-O'Connor
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Pradeep Natarajan
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Department of Medicine, Harvard Medical School, Boston, MA, USA.
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Program in Medical and Population Genetics, Broad Institute of Harvard & MIT, Cambridge, MA, USA.
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20
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Biswal A, Erler J, Qari O, Topilow AA, Gupta V, Hossain MA, Asif A, Erler B, Johnson Miller D. The Effect of the New Eighth Edition Breast Cancer Staging System on 100 Consecutive Patients. J Clin Med Res 2019; 11:407-414. [PMID: 31143307 PMCID: PMC6522240 DOI: 10.14740/jocmr3803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 04/05/2019] [Indexed: 11/11/2022] Open
Abstract
Background In October 2016 the American Joint Committee on Cancer published the early eighth edition breast cancer prognostic staging system, incorporating biomarkers into previously accepted staging. The updated and current eighth edition became effective nationwide in January 2018 after a large update to its staging guidelines. This study's aim was to compare patients' anatomic seventh edition (anatomic), early eighth (pre-update, prognostic), and current eighth (post-update, prognostic) pathological stages and to assess the utility of recent inclusions to staging criteria. Additionally, we observed how the aforementioned stage changes aligned with breast cancer histologic subtypes. Methods An Institutional Review Board (IRB)-approved retrospective chart review was performed. Inclusion criteria included female patients between the ages of 35 to 95 years with a diagnosis of invasive ductal or lobular carcinoma of the breast (n = 100) at three Hackensack Meridian Health hospitals. The study evaluated any trends in patients' stage changes between the seventh edition, early eighth edition, and current eighth edition breast cancer staging guidelines. Breast cancer restaging was performed using a novel staging tool on Microsoft Excel. Results Only 26% of patients' stages changed when comparing the seventh edition stage vs. current eighth edition prognostic staging, most of which were downstaged. When comparing the seventh with early eighth edition prognostic staging, 38% of the patients' stages changed, with a majority of them being upstaged. Lastly, 95% of total stage changes were downstages between the early eighth and current eighth edition staging guidelines. Conclusions When comparing the seventh edition vs. current eighth edition staging, few patients (especially those with early stage cancer) underwent a stage change. However, there were significant changes in stage when comparing early eighth vs. current eighth stages. Considering these changes were mostly downstages and many patients reverted to their original seventh edition stage, the current eighth edition is based on a personalized, less radical staging approach, one that is more synonymous with original seventh edition staging.
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Affiliation(s)
- Ashley Biswal
- Office of Research Administration, Jersey Shore University Medical Center, 19 Davis Avenue, Neptune, NJ, USA
| | - Jacqueline Erler
- Office of Research Administration, Jersey Shore University Medical Center, 19 Davis Avenue, Neptune, NJ, USA
| | - Omar Qari
- Office of Research Administration, Jersey Shore University Medical Center, 19 Davis Avenue, Neptune, NJ, USA
| | - Arthur A Topilow
- Office of Research Administration, Jersey Shore University Medical Center, 19 Davis Avenue, Neptune, NJ, USA.,Department of Medicine, Jersey Shore University Medical Center, 1945 Corlies Avenue, Neptune, NJ, USA
| | - Varsha Gupta
- Department of Medicine, Jersey Shore University Medical Center, 1945 Corlies Avenue, Neptune, NJ, USA
| | - Mohammad A Hossain
- Department of Medicine, Jersey Shore University Medical Center, 1945 Corlies Avenue, Neptune, NJ, USA
| | - Arif Asif
- Department of Medicine, Jersey Shore University Medical Center, 1945 Corlies Avenue, Neptune, NJ, USA
| | - Brian Erler
- Department of Pathology, Jersey Shore University Medical Center, 1945 Corlies Avenue, Neptune, NJ, USA
| | - Denise Johnson Miller
- Department of Surgery, Jersey Shore University Medical Center, 1945 Corlies Avenue, Neptune, NJ, USA
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21
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The 2018 Cholesterol Management Guidelines: Topics in Secondary ASCVD Prevention Clinicians Need to Know. Curr Atheroscler Rep 2019; 21:20. [PMID: 30941517 DOI: 10.1007/s11883-019-0784-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW The 2018 ACC/AHA Multisociety blood cholesterol guidelines provide updated recommendations based on contemporary evidence on the management of serum cholesterol for the prevention of atherosclerotic cardiovascular disease (ASCVD) events. This review discusses clinically important topics in the new guidelines related to secondary ASCVD prevention. RECENT FINDINGS Since the 2013 ACC/AHA blood cholesterol guidelines, several large randomized control trials involving ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (evolocumab and alirocumab) have been published. The trials provided evidence that these non-statin, LDL-cholesterol lowering agents are efficacious in reducing risk for ASCVD events in patients with clinical ASCVD. The 2018 guidelines incorporate these new findings into updated clinical recommendations on therapeutic strategies related to the use of ezetimibe and PCSK9 inhibitors. The guidelines also recommend risk stratification of secondary prevention patients to identify those at very high-risk of ASCVD events as these patients would derive the most absolute risk reduction from the addition of non-statin therapies. While high-intensity statins remain the first-line treatment to prevent recurrent ASCVD events in secondary prevention patients, ezetimibe and PCSK9 inhibitors are evidence-based non-statin agents that can be used when residual on top of maximally tolerated statin therapy in patients deemed to be at very-high risk of recurrent ASCVD events.
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22
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Puymirat E, Bonaca M, Fumery M, Tea V, Aissaoui N, Lemesles G, Bonello L, Ducrocq G, Cayla G, Ferrières J, Schiele F, Simon T, Danchin N. Atherothrombotic risk stratification after acute myocardial infarction: The Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention in the light of the French Registry of Acute ST Elevation or non-ST Elevation Myocardial Infarction registries. Clin Cardiol 2018; 42:227-234. [PMID: 30536449 PMCID: PMC6712320 DOI: 10.1002/clc.23131] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/28/2018] [Accepted: 12/04/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Guidelines recommend using risk stratification tools in acute myocardial infarction (AMI) to assist decision-making. The Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention (TRS-2P) has been recently developed to characterize long-term risk in patients with MI. HYPOTHESIS We aimed to assess the TRS-2P in the French Registry of Acute ST Elevation or non-ST elevation MI registries. METHODS We used data from three 1-month French registries, conducted 5 years apart, from 2005 to 2015, including 13 130 patients with AMI (52% ST-elevation myocardial infarction [STEMI]). Atherothrombotic risk stratification was performed using the TRS-2P score. Patients were divided in to three categories: G1 (low-risk, TRS-2P = 0/1); G2 (intermediate-risk, TRS-2P = 2); and G3 (high-risk, TRS-2P ≥ 3). Baseline characteristics and outcomes were analyzed according to TRS-2P categories. RESULTS A total of 12 715 patients (in whom TRS-2P was available) were included. Prevalence of G1, G2, and G3 was 43%, 24%, and 33% respectively. Clinical characteristics and management significantly differed according to TRS-2P categories. TRS-2P successfully defined residual risk of death at 1 year (C-statistic 0.78): 1-year survival was 98% in G1, 94% in G2, and 78.5% in G3 (P < 0.001). Using Cox multivariate analysis, G3 was independently associated with higher risk of death at 1 year (hazard ratio [HR] 4.61; 95% confidence interval [CI]: 3.61-5.89), as G2 (HR 2.08; 95% CI: 1.62-2.65) compared with G1. The score appeared robust and correlated well with mortality in STEMI and NSTEMI populations, as well as in each cohort separately. CONCLUSIONS The TRS-2P appears to be a robust risk score, identifying patients at high risk after AMI irrespective of the type of MI and historical period.
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Affiliation(s)
- Etienne Puymirat
- Department of Cardiology, Hôpital Européen Georges Pompidou (HEGP), Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Marc Bonaca
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Maxime Fumery
- Department of Cardiology, Hôpital Européen Georges Pompidou (HEGP), Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Victoria Tea
- Department of Cardiology, Hôpital Européen Georges Pompidou (HEGP), Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Nadia Aissaoui
- Department of Intensive Care, AP-HP, HEGP, Paris, France
| | - Gilles Lemesles
- Department of Cardiology, Lille Regional University Hospital, Lille, France
| | - Laurent Bonello
- Department of Cardiology, Hôpital Nord, AP-HM, Marseille, France.,Mediterranean Academic Association for Research and Studies in Cardiology (MARS Cardio), INSERM, Aix-Marseille University, Marseille, France
| | - Grégory Ducrocq
- Department of Cardiology, AP-HP, Hôpital Bichat, Paris, France
| | | | - Jean Ferrières
- Department of Cardiology, Rangueil Hospital, Toulouse, France
| | - François Schiele
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France
| | - Tabassome Simon
- Department of Clinical Pharmacology and Unité de Recherche Clinique (URCEST), AP-HP, Hôpital Saint Antoine, Université Pierre et Marie Curie (UPMC-Paris 06), Paris, France
| | - Nicolas Danchin
- Department of Cardiology, Hôpital Européen Georges Pompidou (HEGP), Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
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Tea V, Bonaca M, Chamandi C, Iliou MC, Lhermusier T, Aissaoui N, Cayla G, Angoulvant D, Ferrières J, Schiele F, Simon T, Danchin N, Puymirat E. Appropriate secondary prevention and clinical outcomes after acute myocardial infarction according to atherothrombotic risk stratification: The FAST-MI 2010 registry. Eur J Prev Cardiol 2018; 26:411-419. [PMID: 30354737 DOI: 10.1177/2047487318808638] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Full secondary prevention medication regimen is often under-prescribed after acute myocardial infarction. DESIGN The purpose of this study was to analyse the relationship between prescription of appropriate secondary prevention treatment at discharge and long-term clinical outcomes according to risk level defined by the Thrombolysis In Myocardial Infarction (TIMI) Risk Score for Secondary Prevention (TRS-2P) after acute myocardial infarction. METHODS We used data from the 2010 French Registry of Acute ST-Elevation or non-ST-elevation Myocardial Infarction (FAST-MI) registry, including 4169 consecutive acute myocardial infarction patients admitted to cardiac intensive care units in France. Level of risk was stratified in three groups using the TRS-2P score: group 1 (low-risk; TRS-2P=0/1); group 2 (intermediate-risk; TRS-2P=2); and group 3 (high-risk; TRS-2P≥3). Appropriate secondary prevention treatment was defined according to the latest guidelines (dual antiplatelet therapy and moderate/high dose statins for all; new-P2Y12 inhibitors, angiotensin-converting-enzyme inhibitor/angiotensin-receptor-blockers and beta-blockers as indicated). RESULTS Prevalence of groups 1, 2 and 3 was 46%, 25% and 29% respectively. Appropriate secondary prevention treatment at discharge was used in 39.5%, 37% and 28% of each group, respectively. After multivariate adjustment, evidence-based treatments at discharge were associated with lower rates of major adverse cardiovascular events (death, re-myocardial infarction or stroke) at five years especially in high-risk patients: hazard ratio = 0.82 (95% confidence interval: 0.59-1.12, p = 0.21) in group 1, 0.74 (0.54-1.01; p = 0.06) in group 2, and 0.64 (0.52-0.79, p < 0.001) in group 3. CONCLUSIONS Use of appropriate secondary prevention treatment at discharge was inversely correlated with patient risk. The increased hazard related to lack of prescription of recommended medications was much larger in high-risk patients. Specific efforts should be directed at better prescription of recommended treatment, particularly in high-risk patients.
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Affiliation(s)
- Victoria Tea
- 1 Department of Cardiology, Hôpital Européen Georges Pompidou (HEGP), France
| | - Marc Bonaca
- 2 Division of Cardiovascular Medicine, Brigham and Women's Hospital, USA
| | - Chekrallah Chamandi
- 1 Department of Cardiology, Hôpital Européen Georges Pompidou (HEGP), France
| | | | | | | | - Guillaume Cayla
- 6 Department of Cardiology, University Hospital of Nimes, France
| | - Denis Angoulvant
- 7 Department of Cardiology, CHU Tours & Tours University, France
| | | | - François Schiele
- 8 Department of Cardiology, University Hospital Jean Minjoz, France
| | - Tabassome Simon
- 9 Department of Clinical Pharmacology, Hôpital Saint Antoine, France.,10 Université Pierre et Marie Curie, France
| | - Nicolas Danchin
- 1 Department of Cardiology, Hôpital Européen Georges Pompidou (HEGP), France
| | - Etienne Puymirat
- 1 Department of Cardiology, Hôpital Européen Georges Pompidou (HEGP), France
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Mok Y, Ballew SH, Bash LD, Bhatt DL, Boden WE, Bonaca MP, Carrero JJ, Coresh J, D'Agostino RB, Elley CR, Fowkes FGR, Jee SH, Kovesdy CP, Mahaffey KW, Nadkarni G, Peterson ED, Sang Y, Matsushita K. International Validation of the Thrombolysis in Myocardial Infarction (TIMI) Risk Score for Secondary Prevention in Post-MI Patients: A Collaborative Analysis of the Chronic Kidney Disease Prognosis Consortium and the Risk Validation Scientific Committee. J Am Heart Assoc 2018; 7:e008426. [PMID: 29982232 PMCID: PMC6064832 DOI: 10.1161/jaha.117.008426] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/18/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND The Thrombolysis in Myocardial Infarction (TIMI) Risk Score for Secondary Prevention (TRS2°P), a 0-to-9-point system based on the presence/absence of 9 clinical factors, was developed to classify the risk of major adverse cardiovascular events (MACE) (a composite of cardiovascular death, recurrent myocardial infarction, or ischemic stroke) among patients with a recent myocardial infarction. Its performance has not been examined internationally outside of a clinical trial setting. METHODS AND RESULTS We evaluated the performance of TRS2°P for predicting MACE in 53 599 patients with recent myocardial infarction in 5 international cohorts from New Zealand, South Korea, Sweden, and the United States participating in the Chronic Kidney Disease Prognosis Consortium. Overall, there were 19 444 cases of MACE across 5 cohorts over a mean follow-up of 5 years, and the overall MACE rate ranged from 5.0 to 18.4 (per 100 person-years). The TRS2°P showed modest calibration (Brier score ranged from 0.144 to 0.173) and discrimination (C-statistics >0.61 in all studies except 1 from Korea with 0.55) across cohorts relative to its original Brier score of 0.098 and C-statistic of 0.67 in the derived data set. Although there was some heterogeneity across cohorts, the 9 predictors in the TRS2°P were generally associated with higher MACE risk, with strongest associations observed (meta-analyzed adjusted hazard ratio 1.6-1.7) for history of heart failure, age ≥75 years, and prior stroke, followed by peripheral artery disease, kidney dysfunction, diabetes mellitus, and hypertension (hazard ratio 1.3-1.4). Prior coronary bypass graft surgery and smoking did not reach statistical significance (hazard ratio ≈1.1). CONCLUSIONS TRS2°P, a simple scoring system with 9 routine clinical factors, was modestly predictive of secondary events when applied in patients with recent myocardial infarction from diverse clinical and geographic settings.
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Affiliation(s)
- Yejin Mok
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center Harvard Medical School, Boston, MA
| | - William E Boden
- VA New England Healthcare System and Boston University School of Medicine, Boston, MA
| | - Marc P Bonaca
- Brigham and Women's Hospital Heart & Vascular Center Harvard Medical School, Boston, MA
| | - Juan Jesus Carrero
- Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Josef Coresh
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - C Raina Elley
- School of Population Health, University of Auckland, New Zealand
| | - F Gerry R Fowkes
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom
| | - Sun Ha Jee
- Institute for Health Promotion and Graduate School of Public Health, Yonsei University, Seoul, South Korea
| | - Csaba P Kovesdy
- Memphis Veterans Affairs Medical Center and University of Tennessee Health Science Center, Memphis, TN
| | - Kenneth W Mahaffey
- Department of Medicine, Stanford Center for Clinical Research, Stanford, CA
| | | | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Yingying Sang
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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