ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction—Executive Summary

Review and Key Takeaways of the 2021 Percutaneous Coronary Intervention Guidelines

The 2021 Percutaneous Coronary Intervention guidelines completed by American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions provide a set of guidelines regarding revascularization strategies. With emphasis on equity of care, multidisciplinary heart team use, revascularization for acute coronary syndrome, and stable ischemic heart disease, the guidelines create a thorough framework with recommendations regarding therapeutic strategies. In this comprehensive review, our aim is to summarize the 2021 revascularization guidelines and analyze key points regarding each recommendation.

Copeptin, miRNA-208, and miRNA-499 as New Biomarkers for Early Detection of Acute Coronary Syndrome

cTn and CK-MB are gold standard biomarkers for acute coronary syndrome (ACS) but are less sensitive in the first 3 h after onset of symptoms. A need thus exists for novel biomarkers for early detection of ACS. We evaluated circulating copeptin, miRNA-208, and miRNA-499 as possible biomarkers for early detection of unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI). Sixty-five patients with probable ACS that presented within 4 h of the onset of chest pain (23 UA and 42 NSTEMI) and 25 apparently healthy individuals were studied. Two sets of blood samples collected in the first 3 h and at 6 h after onset were analyzed for copeptin levels via ELISA and miRNA-208 and miRNA-499 expression via real-time PCR. Copeptin, miRNA-208, and miRNA-499 expression levels were significantly increased in UA and NSTEMI patients compared with controls (p < 0.001) and in NSTEMT compared with UA patients (p < 0.001). Levels were also significantly elevated in UA and NSTEMI patients with negative cardiac troponin in the first 3 h (p < 0.001). ROC curves displayed AUC for prediction of ACS of 0.96 for copeptin, 0.97 for miRNA-208, and 0.97 for miRNA-499. Their combination improved AUC to 0.98. Copeptin and miRNA-208 and miRNA-499 expression are promising biomarkers for UA and NSTEMI that present in the first 3 h of pain onset. A combination of these markers with cTn may increase the accuracy of diagnosis by avoiding the gray zone of cTn as a biomarker.

Preconditioning Effect of High-Intensity Interval Training (HIIT) and Berberine Supplementation on the Gene Expression of Angiogenesis Regulators and Caspase-3 Protein in the Rats with Myocardial Ischemia-Reperfusion (IR) Injury

Objective

It has been shown that angiogenesis is a desirable treatment for patients with ischemic heart disease. We set out to investigate the impact of high-intensity interval training (HIIT) and berberine supplementation on the gene expression of angiogenesis-related factors and caspase-3 protein in rats suffering from myocardial ischemic-reperfusion injury.

Methods

Fifty rats were divided into the following groups: (1) trained, (2) berberine supplemented, (3) combined, and (4) IR. Each cohort underwent five sessions of HIIT per week for a duration of 8 weeks followed by induction of ischemia. Seven days after completion of reperfusion, changes in the gene expression of angiogenesis-related factors and caspase-3 protein were evaluated in the heart tissue.

Results

We observed a significant difference between four groups in the transcript levels of vascular endothelial cell growth factor (VEGF), fibroblast growth factor-2 (FGF2), and thrombospondin-1(TSP-1) (p ≤ 0.05). However, the difference in endostatin (ENDO) levels was not significant among the groups despite a discernible reduction (p ≥ 0.05). Moreover, caspase-3 protein and infarct size were significantly reduced in the intervention groups (p ≤ 0.05), and cardiac function increased in response to these interventions.

Conclusion

The treatments exert their effect, likely, by reducing caspase-3 protein and increasing the expression of angiogenesis-promoting factors, concomitant with a reduction in inhibitors of the process.

High-Risk Chief Complaints I: Chest Pain-The Big Three (an Update)

Nontraumatic chest pain is a frequent concern of emergency department patients, with causes that range from benign to immediately life threatening. Identifying those patients who require immediate/urgent intervention remains challenging and is a high-risk area for emergency medicine physicians where incorrect or delayed diagnosis may lead to significant morbidity and mortality. This article focuses on the 3 most prevalent diagnoses associated with adverse outcomes in patients presenting with nontraumatic chest pain, acute coronary syndrome, thoracic aortic dissection, and pulmonary embolism. Important aspects of clinical evaluation, diagnostic testing, treatment, and disposition and other less common causes of lethal chest pain are also discussed.

Pharmacist role to enhance the prescribing of hospital discharge medications for patients after heart attack

OBJECTIVES

This study aimed to explore the cardiologist adherence with ACC/AHA guidelines on discharge medications for patients admitted with acute coronary syndrome (ACS), assess the predictors of cardiologist non-adherence and measure the impact of pharmacist intervention on improving guideline adherence.

METHODS

The study included two consecutive phases: observation and intervention. It was carried out at Al-Najaf Center for Cardiac Surgery and Catheterization, Iraq, from August through December 2018. In the observation phase, medical records were reviewed retrospectively in order to assess the adherence to guideline. The intervention phase was performed prospectively by the clinical pharmacist, who conducted interventions including auditing, feedback and discussion with every prescriber. The reference of the recommendations was the guideline of American Heart Association/American College of Cardiology guideline (AHA/ACC). The primary outcome was the proportion of patients discharged with optimal treatment. Independent T-test was used to measure the difference in the means of age between the two patient groups. For categorical variables (gender, diagnosis, and comorbidities), chi-square test was used. Binary logistic regression was used to identify patient and disease characteristics associated with receiving optimal discharge regimen.

RESULTS

The observation phase included 100 patients with ACS, while the intervention phase included 105 patients. A total of 50 interventions were performed by pharmacist, of which adding necessary medication was the most frequent (88%), followed by dose optimization (10%), and removing medication duplication (2%). Seventy-four percent of the provided recommendations were accepted by the cardiologists. Pharmacist intervention caused significant (P-value < 0.05) improvement (increasing) in the prescribing of β-blockers, ACE inhibitors/ARBs, statins, and the proportion of patients who received all optimal five therapies (from 35% in observation phase to 80% after intervention).

CONCLUSION

This study showed that pharmacist intervention had a considerable positive impact on the cardiologist prescribing pattern of the essential discharge medications for patients with ACS which could improve patient clinical outcomes.

Predicting 6-Month Mortality for Older Adults Hospitalized With Acute Myocardial Infarction: A Cohort Study

Background

Older adults with acute myocardial infarction (AMI) have higher prevalence of functional impairments, including deficits in cognition, strength, and sensory domains, than their younger counterparts.

Objective

To develop and evaluate the prognostic utility of a risk model for 6-month post-AMI mortality in older adults that incorporates information about functional impairments.

Design

Prospective cohort study. (ClinicalTrials.gov: NCT01755052).

Setting

94 hospitals throughout the United States.

Participants

3006 persons aged 75 years or older who were hospitalized with AMI and discharged alive.

Measurements

Functional impairments were assessed during hospitalization via direct measurement (cognition, mobility, muscle strength) or self-report (vision, hearing). Clinical variables associated with mortality in prior risk models were ascertained by chart review. Seventy-two candidate variables were selected for inclusion, and backward selection and Bayesian model averaging were used to derive (n = 2004 participants) and validate (n = 1002 participants) a model for 6-month mortality.

Results

Participants' mean age was 81.5 years, 44.4% were women, and 10.5% were nonwhite. There were 266 deaths (8.8%) within 6 months. The final risk model included 15 variables, 4 of which were not included in prior risk models: hearing impairment, mobility impairment, weight loss, and lower patient-reported health status. The model was well calibrated (Hosmer-Lemeshow P > 0.05) and showed good discrimination (area under the curve for the validation cohort = 0.84). Adding functional impairments significantly improved model performance, as evidenced by category-free net reclassification improvement indices of 0.21 (P = 0.008) for hearing impairment and 0.26 (P < 0.001) for mobility impairment.

Limitation

The model was not externally validated.

Conclusion

A newly developed model for 6-month post-AMI mortality in older adults was well calibrated and had good discriminatory ability. This model may be useful in decision making at hospital discharge.

Primary Funding Source

National Heart, Lung, and Blood Institute of the National Institutes of Health.

The Association of Frailty With In-Hospital Bleeding Among Older Adults With Acute Myocardial Infarction: Insights From the ACTION Registry

OBJECTIVES

The aim of this study was to determine whether frailty is associated with increased bleeding risk in the setting of acute myocardial infarction (AMI).

BACKGROUND

Frailty is a common syndrome in older adults.

METHODS

Frailty was examined among AMI patients ≥65 years of age treated at 775 U.S. hospitals participating in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry from January 2015 to December 2016. Frailty was classified on the basis of impairments in 3 domains: walking (unassisted, assisted, wheelchair/nonambulatory), cognition (normal, mildly impaired, moderately/severely impaired), and activities of daily living. Impairment in each domain was scored as 0, 1, or 2, and a summary variable consisting of 3 categories was then created: 0 (fit/well), 1 to 2 (vulnerable/mild frailty), and 3 to 6 (moderate-to-severe frailty). Multivariable logistic regression was used to examine the independent association between frailty and bleeding.

RESULTS

Among 129,330 AMI patients, 16.4% had any frailty. Frail patients were older, more often female, and were less likely to undergo cardiac catheterization. Major bleeding increased across categories of frailty (fit/well 6.5%; vulnerable/mild frailty 9.4%; moderate-to-severe frailty 9.9%; p < 0.001). Among patients who underwent catheterization, both frailty categories were independently associated with bleeding risk compared with the non-frail group (vulnerable/mild frailty adjusted odds ratio [OR]: 1.33, 95% confidence interval [CI]: 1.23 to 1.44; moderate-to-severe frailty adjusted OR: 1.40, 95% CI: 1.24 to 1.58). Among patients managed conservatively, there was no association of frailty with bleeding (vulnerable/mild frailty adjusted OR: 1.01, 95% CI: 0.86 to 1.19; moderate-to-severe frailty adjusted OR: 0.96, 95% CI: 0.81 to 1.14).

CONCLUSIONS

Frail patients had lower use of cardiac catheterization and higher risk of major bleeding (when catheterization was performed) than nonfrail patients, making attention to clinical strategies to avoid bleeding imperative in this population.

P2Y12 inhibitors in acute coronary syndrome patients with renal dysfunction: an analysis from the RENAMI and BleeMACS projects

Aims

The aim of the present study was to establish the safety and efficacy profile of prasugrel and ticagrelor in real-life acute coronary syndrome (ACS) patients with renal dysfunction.

Methods and results

All consecutive patients from RENAMI (REgistry of New Antiplatelets in patients with Myocardial Infarction) and BLEEMACS (Bleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coronary Syndrome) registries were stratified according to estimated glomerular filtration rate (eGFR) lower or greater than 60 mL/min/1.73 m2. Death and myocardial infarction (MI) were the primary efficacy endpoints. Major bleedings (MBs), defined as Bleeding Academic Research Consortium bleeding types 3 to 5, constituted the safety endpoint. A total of 19 255 patients were enrolled. Mean age was 63 ± 12; 14 892 (77.3%) were males. A total of 2490 (12.9%) patients had chronic kidney disease (CKD), defined as eGFR &lt;60 mL/min/1.73 m2. Mean follow-up was 13 ± 5 months. Mortality was significantly higher in CKD patients (9.4% vs. 2.6%, P &lt; 0.0001), as well as the incidence of reinfarction (5.8% vs. 2.9%, P &lt; 0.0001) and MB (5.7% vs. 3%, P &lt; 0.0001). At Cox multivariable analysis, potent P2Y12 inhibitors significantly reduced the mortality rate [hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.54–0.96; P = 0.006] and the risk of reinfarction (HR 0.53, 95% CI 0.30–0.95; P = 0.033) in CKD patients as compared to clopidogrel. The reduction of risk of reinfarction was confirmed in patients with preserved renal function. Potent P2Y12 inhibitors did not increase the risk of MB in CKD patients (HR 1.00, 95% CI 0.59–1.68; P = 0.985).

Conclusion

In ACS patients with CKD, prasugrel and ticagrelor are associated with lower risk of death and recurrent MI without increasing the risk of MB.

Effects of Trimetazidine Pretreatment on Endothelial Dysfunction and Myocardial Injury in Unstable Angina Patients Undergoing Percutaneous Coronary Intervention

Objectives

Trimetazidine is an anti-ischemic medication licensed for the treatment of angina pectoris. However, the molecular mechanisms underlying its action remain incompletely elucidated. In this study, therefore, we examined the potential beneficial effects of trimetazidine on myocardial injury and endothelial dysfunction in patients with unstable angina in the perioperative period of percutaneous coronary intervention (PCI).

Methods

A total of 97 patients with unstable angina were randomly divided into trimetazidine (n = 48) and control (n = 49) groups. All subjects received standard medical therapy. The trimetazidine group additionally received 20 mg trimetazidine three times daily 24 hours before and after PCI. Serum levels of creatine kinase-muscle/brain (CK-MB), cardiac troponin I (cTnI), heart-type fatty acid-binding protein (h-FABP), von Willebrand factor (vWF), and nitric oxide (NO) were measured before and the morning following PCI.

Results

In the control group, levels of CK-MB, cTnI, and vWF were significantly elevated (P < 0.05) and NO level was decreased after PCI (P < 0.05). By contrast, no significant changes in the levels of these proteins were observed in the trimetazidine group after PCI (P > 0.05). Moreover, h-FABP levels were not significantly altered after PCI whether in the control or in the trimetazidine group (P > 0.05). Finally, a time-dependent increase in the levels of h-FABP from 0 to 6 hours after PCI, followed by a progressive decline, was observed (P < 0.05).

Conclusions

PCI induces endothelial dysfunction and myocardial damage in patients with unstable angina. Trimetazidine therapy in the perioperative period can reduce this damage.

The high cost of critical care unit over-utilization for patients with NSTE ACS

BACKGROUND

There is substantial variability among hospitals in critical care unit (CCU) utilization for patients admitted with non-ST-Segment Elevation Acute Coronary Syndromes (NSTE ACS). We estimated the potential cost saving if all hospitals adopted low CCU utilization practices for patients with NSTE ACS.

METHODS

National hospital claims data were used to identify all patients with a primary diagnosis of NSTE ACS initially admitted to an acute care hospital between 2007 and 2013. Hospital CCU utilization was classified as low (<30%), medium (30-70%), or high (>70%).

RESULTS

Among the 270,564 NSTE ACS hospitalizations (71.6% non-ST-segment elevation myocardial infarction; 28.4% unstable angina) admitted to 261 hospitals, 41.9% (inter-hospital range 0.3%-95.1%) were admitted to a CCU. The proportion of patients admitted to a CCU in low, medium and high utilization hospitals was 16.3%, 49.5%, and high 81.1%, respectively. No differences in adjusted inpatient mortality were observed by hospital CCU utilization. The overall inpatient costs of caring for NSTE ACS were $1.1 billion. CCU care accounted for 45.2% of all hospitalization costs including 22.6%, 49.9%, and 69.0% (P < .001) of costs in low, medium and high utilization centers. The national potential direct cost savings of medium and high CCU utilization centers adopting low NSTE ACS CCU utilization practices was $113.4 million over the study period.

CONCLUSIONS

In a population-based contemporary cohort, CCU utilization for patients with NSTE ACS varied widely and in-hospital mortality was similar between low, medium and high utilization centers. CCU care accounted for 45% of hospitalization costs; thus, implementing policies and admission practices to align hospital resources with patient care needs have the potential to reduce overall health care costs.

Comparative effectiveness research: what to do when experts disagree about risks

BACKGROUND

Ethical issues related to comparative effectiveness research, or research that compares existing standards of care, have recently received considerable attention. In this paper we focus on how Ethics Review Committees (ERCs) should evaluate the risks of comparative effectiveness research.

MAIN TEXT

We discuss what has been a prominent focus in the debate about comparative effectiveness research, namely that it is justified when "nothing is known" about the comparative effectiveness of the available alternatives. We argue that this focus may be misleading. Rather, we should focus on the fact that some experts believe that the evidence points in favor of one intervention, whereas other experts believe that the evidence favors the alternative(s). We will then introduce a case that illustrates this point, and based on that, discuss how ERCs should deal with such cases of expert disagreement.

CONCLUSION

We argue that ERCs have a duty to assess the range of expert opinions and based on that assessment arrive at a risk judgment about the study under consideration. We also argue that assessment of expert disagreement is important for the assignment of risk level to a clinical trial: what is the basis for expert opinions, how strong is the evidence appealed to by various experts, and how can clinical trial monitoring affect the possible increased risk of clinical trial participation.

Plasma copeptin levels in the patients with gastrointestinal bleeding

INTRODUCTION

Gastrointestinal bleeding is a significant cause of morbidity and mortality worldwide. In addition, it constitutes an important part of health expenditures. In this study, we aimed to determine whether there is a relationship between plasma copeptin levels and the etiology, location and severity of gastrointestinal bleeding.

MATERIALS AND METHODS

This study was performed prospectively in 104 consecutive patients who were admitted to an emergency department with complaints of bloody vomiting or bloody or black stool. To evaluate the level of biochemical parameters such as Full Blood Count (FBC), serum biochemistry, bleeding parameters and copeptin, blood samples were obtained at admission. For the copeptin levels, 2 more blood samples were obtained at the 12th and 24th hours after admission. The values obtained were compared using statistical methods.

RESULTS

In terms of the etiology of bleeding, the copeptin levels in the patients with peptic ulcer were higher than the levels in patients with other gastrointestinal bleeding. However, the difference was not statistically significant. There were no significant differences among all groups' 0th, 12th and 24th hour levels of copeptin.

DISCUSSION

We conclude that copeptin cannot be effectively used as a biochemical parameter in an emergency department to determine the etiology and location of gastrointestinal bleeding. It can, however, be used to make decisions on endoscopy and the hospitalization of patients with suspected gastrointestinal bleeding.

Acute myocardial infarction hospital admissions and deaths in England: a national follow-back and follow-forward record-linkage study

BACKGROUND

Little information is available on how primary and comorbid acute myocardial infarction contribute to the mortality burden of acute myocardial infarction, the share of these deaths that occur during or after a hospital admission, and the reasons for hospital admission of those who died from acute myocardial infarction. Our aim was to fill in these gaps in the knowledge about deaths and hospital admissions due to acute myocardial infarction.

METHODS

We used individually linked national hospital admission and mortality data for England from 2006 to 2010 to identify all primary and comorbid diagnoses of acute myocardial infarction during hospital stay and their associated fatality rates (during or within 28 days of being in hospital). Data were obtained from the UK Small Area Health Statistics Unit and supplied by the Health and Social Care Information Centre (now NHS Digital) and the Office of National Statistics. We calculated event rates (reported as per 100 000 population for relevant age and sex groups) and case-fatality rate for primary acute myocardial infarction diagnosed during the first physician encounter or during subsequent encounters, and acute myocardial infarction diagnosed only as a comorbidity. We also calculated what proportion of deaths from acute myocardial infarction occurred in people who had been in hospital on or within the 28 days preceding death, and whether acute myocardial infarction was one of the recorded diagnoses in such admissions.

FINDINGS

Acute myocardial infarction was diagnosed in the first physician encounter in 307 496 (69%) of 446 744 admissions with a diagnosis of acute myocardial infarction, in the second or later physician encounter in 52 374 (12%) admissions, and recorded only as a comorbidity in 86 874 (19%) admissions. Patients with comorbid diagnoses of acute myocardial infarction had two to three times the case-fatality rate of patients in whom acute myocardial infarction was a primary diagnosis. 135 950 deaths were recorded as being caused by acute myocardial infarction as the underlying cause of death, of which 66 490 (49%) occurred in patients who were in hospital on the day of death or in the 28 days preceding death. AMI was the primary diagnosis in 32 695 (49%) of these 66 490 patients (27 678 [42%] diagnosed in the first physician encounter and 5017 [8%] in a second or subsequent encounter), was a comorbid diagnosis in 12 118 (18%), and was not mentioned at all in the remaining 21 677 (33%). The most common causes of admission in people who did not have an acute myocardial infarction diagnosis but went on to die of acute myocardial infarction as the underlying cause of death were other circulatory conditions (7566 [35%] of 21 677 deaths), symptomatic diagnoses including non-specific chest pain, dyspnoea and syncope (1368 [6%] deaths), and respiratory disorders (2662 [12%] deaths), mainly pneumonia and chronic obstructive airways disease.

INTERPRETATION

As many acute myocardial infarction deaths occurring within 28 days of being in hospital follow a non-acute myocardial infarction admission as follow an acute myocardial infarction admission. These people are often diagnosed with other circulatory disorders or symptoms of circulatory disturbance. Further investigation is needed to establish whether there are symptoms and information that can be used to predict the risk of a fatal acute myocardial infarction in such patients, which can contribute to reducing the mortality burden of acute myocardial infarction.

FUNDING

Wellcome Trust, Medical Research Council, Public Health England, National Institute for Health Research.

Do stable non-ST-segment elevation acute coronary syndromes require admission to coronary care units?

BACKGROUND

Clinical practice guidelines recommend admitting patients with stable non-ST-segment elevation acute coronary syndrome (NSTE ACS) to telemetry units, yet up to two-thirds of patients are admitted to higher-acuity critical care units (CCUs). The outcomes of patients with stable NSTE ACS initially admitted to a CCU vs a cardiology ward with telemetry have not been described.

METHODS

We used population-based data of 7,869 patients hospitalized with NSTE ACS admitted to hospitals in Alberta, Canada, between April 1, 2007, and March 31, 2013. We compared outcomes among patients initially admitted to a CCU (n=5,141) with those admitted to cardiology telemetry wards (n=2,728).

RESULTS

Patients admitted to cardiology telemetry wards were older (median 69 vs 65years, P<.001) and more likely to be female (37.2% vs 32.1%, P<.001) and have a prior myocardial infarction (14.3% vs 11.5%, P<.001) compared with patients admitted to a CCU. Patients admitted directly to cardiology telemetry wards had similar hospital stays (6.2 vs 5.7days, P=.29) and fewer cardiac procedures (40.3% vs 48.5%, P<.001) compared with patients initially admitted to CCUs. There were no differences in the frequency of in-hospital mortality (1.3% vs 1.2%, adjusted odds ratio [aOR] 1.57, 95% CI 0.98-2.52), cardiac arrest (0.7% vs 0.9%, aOR 1.37, 95% CI 0.94-2.00), 30-day all-cause mortality (1.6% vs 1.5%, aOR 1.50, 95% CI 0.82-2.75), or 30-day all-cause postdischarge readmission (10.6% vs 10.8%, aOR 1.07, 95% CI 0.90-1.28) between cardiology telemetry ward and CCU patients. Results were similar across low-, intermediate-, and high-risk Duke Jeopardy Scores, and in patients with non-ST-segment myocardial infarction or unstable angina.

CONCLUSIONS

There were no differences in clinical outcomes observed between patients with NSTE ACS initially admitted to a ward or a CCU. These findings suggest that stable NSTE ACS may be managed appropriately on telemetry wards and presents an opportunity to reduce hospital costs and critical care capacity strain.

Medication Adherence Following Acute Coronary Syndrome: Does One Size Fit All?

Guideline-based management of acute coronary syndrome (ACS) is well established, yet some may challenge that strict implementation of guideline recommendations can limit the individualization of therapy. The use of all recommended medications following ACS places a high burden of responsibility and cost on patients, particularly when these medications have not been previously prescribed. Without close attention to avoiding non-adherence to these medications, the full benefits of the guideline recommendations will not be realized in many patients. Using a case example, we discuss how the recognition of adherence barriers can be an effective and efficient process for identifying patients at risk of non-adherence following ACS. For those identified as at risk, the World Health Organization's model of adherence barriers is explored as a potentially useful tool to assist with individualization of therapy and promotion of adherence.

Barriers to outpatient stress testing follow-up for low-risk chest pain patients presenting to an ED chest pain unit

INTRODUCTION

Outpatient stress testing (OST) after evaluation in the emergency department (ED) is an acceptable evaluation method for patients presenting to the ED with low-risk chest pain (CP). However, not all patients return for OST. Barriers to follow-up evaluation exist and are poorly understood. In this study, we examined the influence of demographic and social characteristics on OST compliance.

METHODS

Data were collected on low-risk CP patients with scheduled OSTs. OST compliance was assessed and then analyzed for correlation with potential barriers including insurance type; age; sex; race; employment status; the distance the patient lived from the hospital; whether or not the patient had a primary care physician; whether or not the patient had a history of hypertension or diabetes; and whether or not the patient had a history of tobacco, alcohol, or illicit drug use.

RESULTS

A total of 275 patients were enrolled over a 5-month period. These patients had an OST follow-up rate of 61.82% within 72hours of discharge from the ED. Patients with Medicaid were statistically less likely (odds ratio [OR], 0.439) to complete OST. Patients with commercial insurance (OR, 1.8225), who were employed (OR, 2.299), or who were retired (OR, 3.44) were more likely to complete OST. All of the other variables analyzed were not statistically significant factors in OST compliance.

CONCLUSION

More than one-third of low-risk CP patients do not follow-up with scheduled OST. Of the variables analyzed, both employment status and insurance type were statistically significant and should be included in risk stratification strategies for OST.

Effect of Beta-Blocker Dose on Survival After Acute Myocardial Infarction

BACKGROUND

Beta-blocker therapy after acute myocardial infarction (MI) improves survival. Beta-blocker doses used in clinical practice are often substantially lower than those used in the randomized trials establishing their efficacy.

OBJECTIVES

This study evaluated the association of beta-blocker dose with survival after acute MI, hypothesizing that higher dose beta-blocker therapy will be associated with increased survival.

METHODS

A multicenter registry enrolled 7,057 consecutive patients with acute MI. Discharge beta-blocker dose was indexed to the target beta-blocker doses used in randomized clinical trials, grouped as >0% to 12.5%, >12.5% to 25%, >25% to 50%, and >50% of target dose. Follow-up vital status was assessed, with the primary endpoint of time-to-death right-censored at 2 years. Multivariable and propensity score analyses were used to account for group differences.

RESULTS

Of 6,682 patients with follow-up (median 2.1 years), 91.5% were discharged on a beta-blocker (mean dose 38.1% of the target dose). Lower mortality was observed with all beta-blocker doses (p < 0.0002) versus no beta-blocker therapy. After multivariable adjustment, hazard ratios for 2-year mortality compared with the >50% dose were 0.862 (95% confidence interval [CI]: 0.677 to 1.098), 0.799 (95% CI: 0.635 to 1.005), and 0.963 (95% CI: 0.765 to 1.213) for the >0% to 12.5%, >12.5% to 25%, and >25% to 50% of target dose groups, respectively. Multivariable analysis with an extended set of covariates and propensity score analysis also demonstrated that higher doses were not associated with better outcome.

CONCLUSIONS

These data do not demonstrate increased survival in patients treated with beta-blocker doses approximating those used in previous randomized clinical trials compared with lower doses. These findings provide the rationale to re-engage in research to establish appropriate beta-blocker dosing after MI to derive optimal benefit from this therapy. (The PACE-MI Registry Study-Outcomes of Beta-blocker Therapy After Myocardial Infarction [OBTAIN]: NCT00430612).

Plaque disruption by coronary computed tomographic angiography in stable patients vs. acute coronary syndrome: a feasibility study

AIMS

This study was designed to determine whether coronary CT angiography (CTA) can detect features of plaque disruption in clinically stable patients and to compare lesion prevalence and features between stable patients and those with acute coronary syndrome (ACS).

METHODS

We retrospectively identified patients undergoing CTA, followed by invasive coronary angiography (ICA) within 60 days. Quantitative 3-vessel CTA lesion analysis was performed on all plaques ≥25% stenosis to assess total plaque volume, low attenuation plaque (LAP, <50 HU) volume, and remodelling index. Plaques were qualitatively assessed for CTA features of disruption, including ulceration and intra-plaque dye penetration (IDP). ICA was employed as a reference standard for disruption. A total of 145 (94 ACS and 51 stable) patients were identified. By CTA, plaque disruption was evident in 77.7% of ACS cases. Although more common among those with ACS, CTA also detected plaque disruption in 37.3% of clinically stable patients (P < 0.0001).

CONCLUSIONS

Clinically stable patients commonly manifest plaques with features of disruption as determined by CTA. Though the prevalence of plaque disruption is less than patients with ACS, these findings support the concept that some clinically stable patients may harbour 'silent' disrupted plaques. These findings may have implications for detection of 'at risk' plaques and patients.

Coronary artery manifestations of fibromuscular dysplasia

Fibromuscular dysplasia (FMD) involving the coronary arteries is an uncommon but important condition that can present as acute coronary syndrome, left ventricular dysfunction, or potentially sudden cardiac death. Although the classic angiographic "string of beads" that may be observed in renal artery FMD does not occur in coronary arteries, potential manifestations include spontaneous coronary artery dissection, distal tapering or long, smooth narrowing that may represent dissection, intramural hematoma, spasm, or tortuosity. Importantly, FMD must be identified in at least one other noncoronary arterial territory to attribute any coronary findings to FMD. Although there is limited evidence to guide treatment, many lesions heal spontaneously; thus, a conservative approach is generally preferred. The etiology is poorly understood, but there are ongoing efforts to better characterize FMD and define its genetic and molecular basis. This report reviews the clinical course of FMD involving the coronary arteries and provides guidance for diagnosis and treatment strategies.

Blood thrombogenicity is independently associated with serum TSH levels in post-non-ST elevation acute coronary syndrome

CONTEXT

Higher serum TSH levels, both within the reference range and in those with subclinical hypothyroidism (SCH), have been associated with increased risk of atherosclerosis and cardiovascular (CV) events in a number of cross-sectional and longitudinal studies.

OBJECTIVE

Our objective was to evaluate blood thrombogenicity in patients post-non-ST elevation acute coronary syndrome (NSTE-ACS) in relation to their thyroid function. DESIGN, PATIENTS, AND OUTCOME MEASURE: At 1 week after troponin-positive NSTE-ACS, 70 patients who had been treated with optimal antiplatelet and secondary prevention therapy were studied. Patients with known thyroid disease or on medications affecting thyroid function were excluded. Blood thrombogenicity was assessed using the ex vivo Badimon perfusion chamber.

RESULTS

Serum TSH was associated with higher thrombus burden (β = .30; P = .01) independent of other well-established CV risk factors. Patients with SCH (n = 12; 17%) had a higher thrombus burden than euthyroid individuals as evidenced by the area of the thrombus: mean (SD) 23 608 (10 498) vs 16 661 (10 902) μm(2)/mm (P = .02). However, this association was not evident when the analysis was limited to patients with serum TSH within the reference range. In addition, neither serum free T4 nor free T3 had any significant association with thrombus area.

CONCLUSION

Serum TSH levels, particularly in the SCH range, are associated with higher thrombus burden despite optimal recommended secondary prevention therapy after NSTE-ACS. This may explain the higher CV risk seen in SCH patients. Future trials to assess the effect of individualized antithrombotic as well as thyroid hormone replacement therapy to reduce atherothrombotic risk in this population are needed.

Early-invasive strategies for the management of coronary heart disease in chronic kidney disease: is acute kidney injury a consideration?

PURPOSE OF REVIEW

People with chronic kidney disease (CKD) are less likely to receive early-invasive management of acute coronary syndrome (ACS). The purpose of this article is to review the risks and outcomes of early-invasive versus conservative strategies, and to consider how contrast-induced acute kidney injury (CI-AKI) should factor in treatment decisions for people with CKD.

RECENT FINDINGS

Numerous observational studies have characterized the prognostic importance of CI-AKI. However, recent studies illustrate that compared to the risk of AKI in individuals treated conservatively, the additional risk of kidney injury associated with invasive coronary procedures is relatively modest. Despite the risk of CI-AKI, early-invasive management of ACS has been associated with important long-term benefits.

SUMMARY

These findings illustrate that the additional short-term risk of AKI associated with invasive management should be considered alongside long-term treatment effects on other clinical outcomes and should not act as a deterrent to their use. Strategies to increase the uptake of an invasive management approach, accompanied by the use of CI-AKI prevention strategies, could benefit high-risk individuals with CKD.

Absence of obesity paradox in Saudi patients admitted with acute coronary syndromes: insights from SPACE registry

BACKGROUND AND OBJECTIVES

To describe the distribution of body mass index (BMI) and its relationship with clinical features, management, and in-hospital outcomes of patients admitted with acute coronary syndromes (ACS).

DESIGN AND SETTINGS

The Saudi Project for Assessment of Coronary Events is a prospective registry. ACS patients admitted to 17 hospitals from December 2005-2007 were included in this study.

METHODS

BMI was available for 3469 patients (68.6%) admitted with ACS and categorized into 4 groups: normal weight, overweight, obese, and morbidly obese.

RESULTS

Of patients admitted with ACS, 72% were either overweight or obese. A high prevalence of diabetes (57%), hypertension (56.6%), dyslipidemia (42%), and smoking (32.4%) was reported. Increasing BMI was significantly associated with diabetes, hypertension, and hyperlipidemia. Overweight and obese patients were significantly younger than the normal-weight group (P=.006). However, normal-weight patients were more likely to be smokers and had 3-vessel coronary artery disease, worse left ventricular dysfunction, and ST elevation myocardial infarction. Glycoprotein IIb-IIIa antagonists were used significantly more in overweight, obese, and morbidly obese ACS patients than in normal-weight patients (P≤.001). Coronary angiography and percutaneous intervention were reported more in overweight and obese patients than in normal-weight patients (P≤.001). In-hospital outcomes were not significantly different among the BMI categories.

CONCLUSION

High BMI is prevalent among Saudi patients with ACS. BMI was not an independent factor for in-hospital outcomes. In contrast with previous reports, high BMI was not associated with improved outcomes, indicating the absence of obesity paradox observed in other studies.

Methamphetamine-associated cardiomyopathy

Methamphetamine and related compounds are now the second most commonly used illicit substance worldwide, after cannabis. Reports of methamphetamine-associated cardiomyopathy (MAC) are increasing, but MAC has not been well reviewed. This analysis of MAC will provide an overview of the pharmacology of methamphetamine, historical perspective and epidemiology, a review of case and clinical studies, and a summary of the proposed mechanisms for MAC. Clinically, many questions remain, including the appropriate therapeutic interventions for MAC, the incidence and prevalence of cardiac pathology in methamphetamine users, risk factors for developing MAC, and prognosis of these patients. In conclusion, recognition of the significance of MAC among physicians and other medical caregivers is important given the growing use of methamphetamine and related stimulants worldwide.

Continuous glucose monitoring in acute coronary syndrome

BACKGROUND

Diabetes mellitus is an independent risk factor for cardiovascular disease.

OBJECTIVE

To compare the efficacy of devices for continuous glucose monitoring and capillary glucose monitoring in hospitalized patients with acute coronary syndrome using the following parameters: time to achieve normoglycemia, period of time in normoglycemia, and episodes of hypoglycemia.

METHODS

We performed a pilot, non-randomized, unblinded clinical trial that included 16 patients with acute coronary artery syndrome, a capillary or venous blood glucose ≥ 140 mg/dl, and treatment with a continuous infusion of fast acting human insulin. These patients were randomized into 2 groups: a conventional group, in which capillary measurement and recording as well as insulin adjustment were made every 4h, and an intervention group, in which measurement and recording as well as insulin adjustment were made every hour with a subcutaneous continuous monitoring system. Student's t-test was applied for mean differences and the X(2) test for qualitative variables.

RESULTS

We observed a statistically significant difference in the mean time for achieving normoglycemia, favoring the conventional group with a P = 0.02.

CONCLUSION

Continuous monitoring systems are as useful as capillary monitoring for achieving normoglycemia.

Comparison of Cockcroft-Gault and Modification of Diet in Renal Disease Formulas as Predictors of Cardiovascular Outcomes in Patients With Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

We prospectively assessed the value of estimated glomerular filtration rate (eGFR) by the Modification of Diet in Renal Disease (MDRD) and Cockcroft-Gault (C-G) equations in predicting inhospital adverse outcomes after primary coronary intervention for acute ST-segment elevation myocardial infarction. We classified 647 patients into 3 categories according to eGFR, <60, 60 to 90, and >90 mL/min/1.73 m2. The eGFRC-G classified 17 patients in the >90 mL/min/1.73 m2 subgroup and 6 and 11 patients in the 60 to 90 and <60 mL/min/1.73 m2 subgroups, respectively. In multivariate analysis, patients with eGFRC-G < 60 mL/min/1.73 m2 had 19.5-fold (95% confidence interval [CI] 1.55-178) higher mortality risk and 5.48-fold (95% CI 1.75-24.21) higher major adverse cardiac events risk compared to patients with eGFRC-G >90 mL/min/1.73 m2 ( P = .01 and P = .01, respectively); the eGFRMDRD was not predictive. Although the MDRD equation more accurately estimates GFR in certain populations, the CG formula may be a better predictor of adverse events.

Bivalirudin in acute coronary syndromes and percutaneous coronary intervention: should we use it?

Major bleeding remains a major risk factor for percutaneous coronary intervention of acute coronary syndromes and is associated with higher morbidity, mortality, prolonged hospital stay and costs. With the recognition that bleeding is an important factor in patient outcomes, the prevention of bleeding has become as important a goal as the prevention of ischaemia. The direct thrombin inhibitor bivalirudin has been shown to reduce ischaemia and importantly, is associated with less bleeding. In this article we review the evidence base that supports the use of bivalirudin across all spectrums of coronary syndromes and percutaneous coronary intervention. An algorithm for the use of bivalirudin in high risk subgroups and coronary syndromes is suggested.

Computing ischemic regions in the heart with the bidomain model--first steps towards validation

We investigate whether it is possible to use the bidomain model and body surface potential maps (BSPMs) to compute the size and position of ischemic regions in the human heart. This leads to a severely ill posed inverse problem for a potential equation. We do not use the classical inverse problems of electrocardiography, in which the unknown sources are the epicardial potential distribution or the activation sequence. Instead we employ the bidomain theory to obtain a model that also enables identification of ischemic regions transmurally. This approach makes it possible to distinguish between subendocardial and transmural cases, only using the BSPM data. The main focus is on testing a previously published algorithm on clinical data, and the results are compared with images taken with perfusion scintigraphy. For the four patients involved in this study, the two modalities produce results that are rather similar: The relative differences between the center of mass and the size of the ischemic regions, suggested by the two modalities, are 10.8% ± 4.4% and 7.1% ± 4.6%, respectively. We also present some simulations which indicate that the methodology is robust with respect to uncertainties in important model parameters. However, in contrast to what has been observed in investigations only involving synthetic data, inequality constraints are needed to obtain sound results.

High-Risk Non-ST Elevation Acute Coronary Syndrome Outcomes in Patients Treated with Unfractionated Heparin Monitored Using Anti-Xa Concentrations Versus Activated Partial Thromboplastin Time

BACKGROUND

While the activated partial thromboplastin time (aPTT) is the most widely used assay to monitor unfractionated heparin (UFH), providing a general measure of the extent of anticoagulation, it does not reliably correlate with the blood concentration of heparin or its antithrombotic effect. While cost and availability have limited the widespread use of UFH in hospitals, monitoring UFH with heparin levels has been shown to reduce both the number of monitoring tests and the time to a therapeutic range.

OBJECTIVES

To compare outcomes in patients with non-ST elevation acute coronary syndrome (ACS) treated with weight-based UFH monitored with anti-Xa concentrations versus aPTT.

METHODS

A retrospective chart review was completed in patients admitted with high-risk ACS and compared to the UFH arm of the SYNERGY trial. The primary outcome included the clinical endpoint of all-cause death or non-fatal myocardial infarction until time of hospital discharge. Safety endpoints evaluated included incidence of stroke and major bleeding.

RESULTS

The primary endpoint occurred in 6.3% of patients in the study cohort compared to 6.5% of patients in the heparin arm of the SYNERGY trial at 48 hours (P = .006). Bleeding was reduced in the study cohort with a significant decrease in GUSTO severe bleeding (P = .007). Additionally the study cohort had significantly fewer patients with an absolute drop in hemoglobin or hematocrit. Thrombolysis in Myocardial Infarction (TIMI) major and minor bleeding, rate of transfusion, and platelet counts were similar between groups.

CONCLUSIONS

Outcomes for high-risk ACS patients receiving heparin monitored by anti-Xa concentrations are noninferior to heparin monitored by aPTT.

Serum extracellular vesicle protein levels are associated with acute coronary syndrome

AIMS

Biomarkers are essential in the early detection of acute coronary syndromes (ACS). Serum extracellular vesicles are small vesicles in the plasma containing protein and RNA and have been shown to be involved in ACS-related processes like apoptosis and coagulation. Therefore, we hypothesized that serum extracellular vesicle protein levels are associated with ACS.

METHODS AND RESULTS

Three serum extracellular vesicle proteins potentially associated with ACS were identified with differential Q-proteomics and were evaluated in 471 frozen serum samples of ACS-suspected patients presenting to the emergency department (30% of whom had an ACS). Protein levels were measured after vesicle isolation using ExoQuick. Mean serum extracellular vesicle concentration of the different proteins was compared between ACS and non-ACS patients. Selected proteins were tested in a univariate logistic regression model, as well as in a multivariate model to adjust for cardiovascular risk factors. A separate analysis was performed in men and women. In the multivariate logistic regression analysis, polygenic immunoglobulin receptor, (pIgR; OR 1.630, p=0.026), cystatin C (OR 1.641, p=0.021), and complement factor C5a (C5a, OR 1.495, p=0.025) were significantly associated with ACS, while total vesicle protein concentration was borderline significant. The association of the individual proteins with ACS was markedly stronger in men.

CONCLUSIONS

These data show that serum extracellular vesicle pIgR, cystatin C, and C5a concentrations are independently associated with ACS and that there are pronounced gender differences. These observations should be validated in a large, prospective study to assess the potential role of vesicle content in the evaluation of patients suspected of having an ACS.

Treatment differences by health insurance among outpatients with coronary artery disease: insights from the national cardiovascular data registry

OBJECTIVES

This study examined the association between insurance status and physicians' adherence with providing evidence-based treatments for coronary artery disease (CAD).

METHODS

Within the PINNACLE (Practice Innovation and Clinical Excellence) registry of the NCDR (National Cardiovascular Data Registry), the authors identified 60,814 outpatients with CAD from 30 U.S. practices. Hierarchical modified Poisson regression models with practice site as a random effect were used to study the association between health insurance (no insurance, public, or private health insurance) and 5 CAD quality measures.

RESULTS

Of 60,814 patients, 5716 patients (9.4%) were uninsured and 11,962 patients (19.7%) had public insurance, whereas 43,136 (70.9%) were privately insured. After accounting for exclusions, uninsured patients with CAD were 9%, 12%, and 6% less likely to receive treatment with a beta-blocker, an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker (ACE-I/ARB), and lipid-lowering therapy, respectively, than privately insured patients, and patients with public insurance were 9% less likely to be prescribed ACE-I/ARB therapy. Most differences by insurance status were attenuated after adjusting for the site providing care. For example, whereas uninsured patients with left ventricular dysfunction and CAD were less likely to receive ACE-I/ARB therapy (unadjusted RR: 0.88; 95% CI: 0.84 to 0.93), this difference was eliminated after adjustment for site (adjusted RR: 0.95; 95% CI: 0.88 to 1.03; p = 0.18).

CONCLUSIONS

Within this national outpatient cardiac registry, uninsured patients were less likely to receive evidence-based medications for CAD. These disparities were explained by the site providing care. Efforts to reduce treatment differences by insurance status among cardiac outpatients may additionally need to focus on improving the rates of evidence-based treatment at sites with high proportions of uninsured patients.

Ticagrelor: the first novel reversible P2Y(12) inhibitor

INTRODUCTION

Dual antiplatelet therapy is a standard of care for treating patients with acute coronary syndrome (ACS). Combination therapy with aspirin and one of the P2Y(12) inhibitors (clopidogrel, prasugrel, or most recently, ticagrelor ) has been recommended by both ACC/AHA and ESC guidelines for ACS patients.

AREAS COVERED

Ticagrelor is the first generation of a new class of reversible P2Y(12) inhibitors, recently added to updated ACC and ESC guidelines for use in patients with ACS. The authors review the studies that evaluate the pharmacokinetics, pharmacodynamics, clinical efficacy and safety of ticagrelor in comparison to currently available antiplatelet agents.

EXPERT OPINION

Ticagrelor 180 mg loading dose followed by 90 mg b.i.d. is significantly more efficacious and, in general, as safe as clopidogrel in the treatment of all patients with an ACS regardless of treatment strategy. In addition, besides aspirin compared to placebo, it is the only pharmaceutical intervention shown to have a cardiovascular mortality benefit within 1 year in a broad ACS population. Whether this surprising benefit is realized in other populations is currently being tested.

The study of LoSmapimod treatment on inflammation and InfarCtSizE (SOLSTICE): design and rationale

The p38 mitogen-activated protein kinase (MAPK) is a nexus point in inflammation, sensing, and stimulating cytokine production and driving cell migration and death. In acute coronary syndromes, p38MAPK inhibition could stabilize ruptured atherosclerotic plaques, pacify active plaques, and improve microvascular function, thereby reducing infarct size and risk of subsequent cardiac events. The SOLSTICE trial is randomized, double-blind, placebo-controlled, parallel group, multicenter phase 2a study of 535 patients that evaluates the safety and efficacy of losmapimod (GW856553), a potent oral p38MAPK inhibitor, vs placebo in patients with non-ST-segment elevation myocardial infarction expected to undergo an invasive strategy. The coprimary end points are reduction in high-sensitivity C-reactive protein at 12 weeks and reduction in infarct size as assessed by troponin area under the curve at 72 hours. A key secondary end point is 72-hour and 12-week B-type natriuretic peptide levels as a measure of cardiac remodeling and ventricular strain. The primary safety assessments are serious and nonserious adverse events, results of liver function testing, and major adverse cardiac events. Cardiac magnetic resonance imaging (N = 117) and coronary flow reserve (N = 13) substudies will assess the effects of losmapimod on infarct size, myocardial function, and coronary vasoregulation. Information gained from the SOLSTICE trial will inform further testing of this agent in larger clinical trials.

Acute coronary syndromes: from the emergency department to the cardiac care unit

Acute coronary syndromes result in a significant burden of morbidity and mortality in the United States. This spectrum of acute coronary thrombosis (including unstable angina, non-ST-segment elevation myocardial infarction, and ST-elevation myocardial infarction) has been well studied in large clinical trials. This review details the initial management of patients presenting with possible acute coronary syndromes in the context of care from the emergency department to the cardiac care unit. The importance of a rapid and focused evaluation, risk stratification, and appropriate therapies are discussed.

The pharmacological differences in anti-anginal effects of long-lasting calcium channel blockers: azelnidipine and amlodipine

ABSTRACT: We examined anti-anginal effects of azelnidipine and amlodipine in an arginine vasopressin (AVP)-induced rat anginal model. Oral administration of azelnidipine or amlodipine produced long-lasting inhibition of AVP-induced ST-segment depression in ECG. The degrees of inhibition with azelnidipine at doses of 1 and 3 mg/kg were comparable to those with amlodipine at 3 and 10 mg/kg. Both drugs lowered mean blood pressure in a dose related manner, while only azelnidipine decreased heart rate. Azelnidipine at 3 mg/kg and amlodipine at 10 mg/kg produced a similar decrease in the rate pressure product, an index for cardiac oxygen consumption. Their inhibitory effects on calcium-induced vascular contraction were compared in isolated porcine coronary arteries. Both drugs produced a slow-developing inhibition of calcium-induced contraction. Although their inhibitory effects were similar, the way the both drugs inhibited calcium-induced contraction differed with each other. After removing the drug from bathing solution, the inhibitory effects of azelnidipine were not blunted but were sustained for a long time which indicates that azelnidipine has high vascular affinity. On the other hand, those of amlodipine were rapidly blunted. These results suggest that the mechanisms underlying anti-anginal effects of azelnidipine differ from those of amlodipine. The anti-anginal effect with azelnidipine may be accounted for by its high affinity to the coronary blood vessels and the heart rate slowing effect, both of which are not shared with amlodipine.