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Bardooli F, Kumar D, Hasan J, Mengal N, Iqbal Bhatti K, Makwana D, Rai K, Maheswari L. Prognostic Significance of Electrocardiography, Echocardiography, and Troponin in Patients Admitted With Non-ST Elevation Myocardial Infarction. Cureus 2023; 15:e37629. [PMID: 37200672 PMCID: PMC10186068 DOI: 10.7759/cureus.37629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND Non-ST segment elevation myocardial infarction (NSTEMI) is a clinical condition characterized by typical symptoms of myocardial ischemia along with electrocardiographic changes and a positive value of troponin. After presentation in the emergency department, these patients have their troponin I value and electrocardiography done. Echocardiography (echo) should also be performed on these patients. This study was conducted to determine the prognostic significance of ECG, echo, and troponin. METHODS This observational study was conducted at a tertiary care cardiac hospital on 221 diagnosed patients of NSTEMI. Electrocardiography was performed to see any particular resting ECG findings and the peak values of cardiospecific troponin were analyzed for associations with major adverse events after a six-month period of follow-up. On echo, the left ventricular ejection fraction was divided into two categories: left ventricular ejection fraction (LVEF) <40% and LVEF >40%. RESULTS The most frequent finding on presenting ECG was ST depression in anterior leads (V1-V6) in 27.6%. Median troponin I at presentation was 3.2 ng/dl and the median ejection fraction was 45%. The overall all-cause mortality rate at six months was observed to be 8.6%; re-infarction in 5%, re-hospitalization in 16.3%, and heart failure in 25.3% were observed. However, mortality was higher for patients with baseline ECG findings of A-fib, generalized ST-depression, poor R-wave progression, Wellens sign, and T-wave inversion in inferior; the mortality rate was also relatively higher among patients with poor LVEF (<30%). CONCLUSION ECG and echo were prognostically significant and with the combined incidence of adverse events. However, troponin lacks prognostic significance at six months.
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Affiliation(s)
- Fawaz Bardooli
- Interventional Cardiology, Mohammed Bin Khalifa Bin Salman Al Khalifa Specialist Cardiac Centre, Awali, BHR
| | - Dileep Kumar
- Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Jehangir Hasan
- Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Naeem Mengal
- Interventional Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
| | | | - Dayaram Makwana
- Cardiology, Mohammed Bin Khalifa Bin Salman Al Khalifa Specialist Cardiac Centre, Awali, BHR
| | - Kelash Rai
- Internal Medicine, Wayne State University School of Medicine, Rochester Hills, USA
| | - Lalit Maheswari
- Medicine, Global Medical Solutions Hospital Management LLC, Abu Dhabi, ARE
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Schmitz T, Wein B, Methe H, Linseisen J, Heier M, Peters A, Meisinger C. Association between admission ECG changes and long-term mortality in patients with an incidental myocardial infarction: Results from the KORA myocardial infarction registry. Eur J Intern Med 2022; 100:69-76. [PMID: 35317964 DOI: 10.1016/j.ejim.2022.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/01/2022] [Accepted: 03/08/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND The aim of this study was to examine the predictive value of specific changes in admission ECG on long-term outcome in acute myocardial infarction (AMI). METHODS From 2000 until 2017 all AMI cases (n = 9,689) in the study area of Augsburg, Germany, were prospectively recorded. For this study, all patients with a first-time AMI, who survived the first 28 days, were considered. Median observational time was 6.7 years (IQR: 3.6-10.9). Each case was assigned to one of the following groups according to the admission ECG: 'ST-segment elevation', 'ST-segment depression', 'T-wave inversion', 'unspecific changes', 'normal ECG' and 'bundle branch block' (BBB). Multivariable adjusted COX regression models were calculated to compare long-term all-cause mortality. RESULTS The final regression model revealed a significantly higher mortality among patients with BBB (HR: 1.52 [1.34-1.73], p-value: < 0.001) and 'ST-segment depression' (HR: 1.16 [1.03-1.29], p-value: 0.01252) compared to the STEMI group (reference group). The 'normal ECG' group (HR: 0.76 [0.66-0.87], p-value: < 0.001) on the other hand was associated with significantly lower long-term mortality. The 'T-wave inversion' group (HR: 1.08 [0.96-1.21]) and the 'unspecific changes' group (HR: 1.05 [0.94-1.17]) did not differ significantly from the STEMI group. CONCLUSION ST-segment depressions and BBB admission ECGs go along with higher long-term mortality in AMI patients compared to STEMI cases. This should be taken into account by physicians when treating patients with NSTEMIs. Only the complete absence of AMI-related ECG changes predicts a more favorable outcome.
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Affiliation(s)
- Timo Schmitz
- Chair of Epidemiology, University of Augsburg, University Hospital Augsburg, Stenglinstraße 2, 86156 Augsburg, Germany.
| | - Bastian Wein
- Department of Cardiology, University Hospital of Augsburg, Germany
| | - Heiko Methe
- Department of Cardiology, Kliniken an der Paar, Krankenhaus Aichach, Aichach, Germany
| | - Jakob Linseisen
- Chair of Epidemiology, University of Augsburg, University Hospital Augsburg, Stenglinstraße 2, 86156 Augsburg, Germany; IRG Clinical Epidemiology, Helmholtz Zentrum München, Germany
| | - Margit Heier
- KORA Study Centre, University Hospital of Augsburg, Germany; Institute of Epidemiology, Helmholtz Zentrum München, Germany
| | - Annette Peters
- Institute of Epidemiology, Helmholtz Zentrum München, Germany; German Center for Diabetes Research (DZD) Neuherberg, Germany
| | - Christa Meisinger
- Chair of Epidemiology, University of Augsburg, University Hospital Augsburg, Stenglinstraße 2, 86156 Augsburg, Germany
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Risk Stratification of Patients with Acute Coronary Syndrome. J Clin Med 2021; 10:jcm10194574. [PMID: 34640592 PMCID: PMC8509298 DOI: 10.3390/jcm10194574] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 12/17/2022] Open
Abstract
Defining the risk factors affecting the prognosis of patients with acute coronary syndrome (ACS) has been a challenge. Many individual biomarkers and risk scores that predict outcomes during different periods following ACS have been proposed. This review evaluates known outcome predictors supported by clinical data in light of the development of new treatment strategies for ACS patients during the last three decades.
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Kite TA, Ladwiniec A, Arnold JR, McCann GP, Moss AJ. Early invasive versus non-invasive assessment in patients with suspected non-ST-elevation acute coronary syndrome. Heart 2021; 108:500-506. [PMID: 34234006 DOI: 10.1136/heartjnl-2020-318778] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/22/2021] [Indexed: 11/04/2022] Open
Abstract
Non-ST-elevation acute coronary syndrome (NSTE-ACS) comprises a broad spectrum of disease ranging from unstable angina to myocardial infarction. International guidelines recommend a routine invasive strategy for managing patients with NSTE-ACS at high to very high-risk, supported by evidence of improved composite ischaemic outcomes as compared with a selective invasive strategy. However, accurate diagnosis of NSTE-ACS in the acute setting is challenging due to the spectrum of non-coronary disease that can manifest with similar symptoms. Heterogeneous clinical presentations and limited uptake of risk prediction tools can confound physician decision-making regarding the use and timing of invasive coronary angiography (ICA). Large proportions of patients with suspected NSTE-ACS do not require revascularisation but may unnecessarily undergo ICA with its attendant risks and associated costs. Advances in coronary CT angiography and cardiac MRI have prompted evaluation of whether non-invasive strategies may improve patient selection, or whether tailored approaches are better suited to specific subgroups. Future directions include (1) better understanding of risk stratification as a guide to investigation and therapy in suspected NSTE-ACS, (2) randomised clinical trials of non-invasive imaging versus standard of care approaches prior to ICA and (3) defining the optimal timing of very early ICA in high-risk NSTE-ACS.
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Affiliation(s)
- Thomas A Kite
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Andrew Ladwiniec
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - J Ranjit Arnold
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Alastair J Moss
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
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Nicolau JC, Feitosa Filho GS, Petriz JL, Furtado RHDM, Précoma DB, Lemke W, Lopes RD, Timerman A, Marin Neto JA, Bezerra Neto L, Gomes BFDO, Santos ECL, Piegas LS, Soeiro ADM, Negri AJDA, Franci A, Markman Filho B, Baccaro BM, Montenegro CEL, Rochitte CE, Barbosa CJDG, Virgens CMBD, Stefanini E, Manenti ERF, Lima FG, Monteiro Júnior FDC, Correa Filho H, Pena HPM, Pinto IMF, Falcão JLDAA, Sena JP, Peixoto JM, Souza JAD, Silva LSD, Maia LN, Ohe LN, Baracioli LM, Dallan LADO, Dallan LAP, Mattos LAPE, Bodanese LC, Ritt LEF, Canesin MF, Rivas MBDS, Franken M, Magalhães MJG, Oliveira Júnior MTD, Filgueiras Filho NM, Dutra OP, Coelho OR, Leães PE, Rossi PRF, Soares PR, Lemos Neto PA, Farsky PS, Cavalcanti RRC, Alves RJ, Kalil RAK, Esporcatte R, Marino RL, Giraldez RRCV, Meneghelo RS, Lima RDSL, Ramos RF, Falcão SNDRS, Dalçóquio TF, Lemke VDMG, Chalela WA, Mathias Júnior W. Brazilian Society of Cardiology Guidelines on Unstable Angina and Acute Myocardial Infarction without ST-Segment Elevation - 2021. Arq Bras Cardiol 2021; 117:181-264. [PMID: 34320090 PMCID: PMC8294740 DOI: 10.36660/abc.20210180] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- José Carlos Nicolau
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Gilson Soares Feitosa Filho
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brasil
- Centro Universitário de Tecnologia e Ciência (UniFTC), Salvador, BA - Brasil
| | - João Luiz Petriz
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
| | | | | | - Walmor Lemke
- Clínica Cardiocare, Curitiba, PR - Brasil
- Hospital das Nações, Curitiba, PR - Brasil
| | | | - Ari Timerman
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | - José A Marin Neto
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Ribeirão Preto, SP - Brasil
| | | | - Bruno Ferraz de Oliveira Gomes
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | | | | | - Carlos Eduardo Rochitte
- Hospital do Coração (HCor), São Paulo, SP - Brasil
- Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Edson Stefanini
- Escola Paulista de Medicina da Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
| | | | - Felipe Gallego Lima
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | | | - José Maria Peixoto
- Universidade José do Rosário Vellano (UNIFENAS), Belo Horizonte, MG - Brasil
| | - Juliana Ascenção de Souza
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Lilia Nigro Maia
- Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP - Brasil
| | | | - Luciano Moreira Baracioli
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luís Alberto de Oliveira Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luis Augusto Palma Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Luiz Carlos Bodanese
- Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, RS - Brasil
| | | | | | - Marcelo Bueno da Silva Rivas
- Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | - Múcio Tavares de Oliveira Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Nivaldo Menezes Filgueiras Filho
- Universidade do Estado da Bahia (UNEB), Salvador, BA - Brasil
- Universidade Salvador (UNIFACS), Salvador, BA - Brasil
- Hospital EMEC, Salvador, BA - Brasil
| | - Oscar Pereira Dutra
- Instituto de Cardiologia - Fundação Universitária de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brasil
| | - Otávio Rizzi Coelho
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP - Brasil
| | | | | | - Paulo Rogério Soares
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | - Roberto Esporcatte
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | - Talia Falcão Dalçóquio
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - William Azem Chalela
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Wilson Mathias Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
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6
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Mould SJ, Soliman EZ, Bertoni AG, Bhave PD, Yeboah J, Singleton MJ. Association of T-wave abnormalities with major cardiovascular events in diabetes: the ACCORD trial. Diabetologia 2021; 64:504-511. [PMID: 33420509 DOI: 10.1007/s00125-020-05337-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/15/2020] [Indexed: 12/07/2022]
Abstract
AIMS/HYPOTHESIS T-wave abnormalities (TWA) are often found on ECG and signify abnormal ventricular repolarisation. While TWA have been shown to be associated with subclinical atherosclerosis, the relationship between TWA and hard cardiovascular endpoints is less clear and may differ in the presence of diabetes, so we sought to explore these associations in participants from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. METHODS TWA were operationally defined as the presence of any Minnesota Codes 5-1 through 5-4 in any lead distribution. Multivariable Cox proportional hazards models were constructed to examine relationships between TWA and clinical cardiovascular events. Secondary analyses explored the risks conferred by major vs minor TWA, differential effects of TWA by anatomic localisation (anterolateral, inferior or anterior lead distributions), and differing associations in those with or without prevalent CVD. RESULTS Among 8176 eligible participants (mean 62.1 ± 6.3 SD years, 61.4% male), there were 3759 cardiovascular events, including 1430 deaths (473 of a cardiovascular aetiology), 474 heart failure events, 1452 major CHD events and 403 strokes. Participants with TWA had increased risks of all-cause mortality (HR 1.45 [95% CI 1.30, 1.62], p < 0.0001), cardiovascular mortality (HR 1.93 [1.59, 2.34], p = 0.0001), congestive heart failure (HR 2.04 [1.69, 2.48], p < 0.0001) and major CHD (HR 1.40 [1.26, 1.57], p < 0.0001), but no increased risk of stroke (HR 0.99 [0.80, 1.23], p = 0.95). Major TWA conferred a higher risk than minor TWA. When TWA were added to the UK Prospective Diabetes Study risk engine, there was improved discrimination for incident CHD events, but only for those with prevalent CVD (area under the receiver operating characteristic curve 0.5744 and 0.6030 with p = 0.0067). Adding TWA to the risk engine yielded improvements in reclassification that were of greater magnitude in those with prevalent CVD (net reclassification improvement [NRI] 0.24 [95% CI 0.16, 0.32] in those with prevalent CVD, NRI 0.14 [95% CI 0.07, 0.22] in those without prevalent CVD). CONCLUSIONS/INTERPRETATION The presence and magnitude of TWA are associated with increased risk of clinical cardiovascular events and mortality in individuals with diabetes and may have value in refining risk, particularly in those with prevalent CVD. Graphical abstract.
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Affiliation(s)
- Steven J Mould
- Section of Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Elsayed Z Soliman
- Section of Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Epidemiological Cardiology Research Center, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Alain G Bertoni
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Prashant D Bhave
- Section of Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Joseph Yeboah
- Section of Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Matthew J Singleton
- Section of Cardiology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.
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7
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Predictive Value of Serial ECGs in Patients with Suspected Myocardial Infarction. J Clin Med 2020; 9:jcm9072303. [PMID: 32698466 PMCID: PMC7408822 DOI: 10.3390/jcm9072303] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 12/15/2022] Open
Abstract
The electrocardiogram (ECG) is an important diagnostic tool for patients with suspected acute myocardial infarction (AMI). Current guidelines recommend serial ECGs in case of persisting symptoms. We aimed to analyze the predictive value of ischemic ECG-signs in patients with suspected AMI. Patients presenting to the emergency department with suspected AMI were included. All patients with ST-elevation AMI were excluded from analyses. Patients received 12-lead-ECG and high-sensitive Troponin T (hs-TnT)-measurement at admission and after 3 h. Four groups were defined: no ischemic signs in either ECG; new ischemic signs in the second ECG; resolved ischemic signs in the second ECG; and persistent ischemic signs in both ECGs. Patients were followed for 2 years to assess the composite endpoint of all-cause-mortality, AMI, and coronary revascularization. Using a 30-day landmark analysis, a Cox regression with ischemic signs as the variable of interest, adjusted by cardiovascular risk factors, was calculated. Of 1675 patients, 1321 showed no ischemic signs, in 25 new-, in 92 resolved- and in 237 patients, persistent ischemic signs were documented. Patients with persistent ischemic signs had significantly worse outcomes, compared to those without. Compared to no ischemic signs, adjusted hazard ratios for the combined endpoint were 0.81 (95% CI 0.20, 3.31; p-value = 0.77) for new-, 0.59 (95% CI 0.26, 1.34; p-value = 0.21) for resolved-, and 1.47 (95% CI 1.102, 2.13; p-value = 0.041) for persistent ischemic signs. In patients with suspected AMI, persistent ischemic ECG-signs are predictive of a higher rate of all-cause-mortality, AMI, and revascularization.
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Wu CJ, Yeh KH, Wang HT, Liu WH, Chen HC, Chai HT, Chung WJ, Hsueh S, Chen CJ, Fang HY, Chen YL. Impact of electrocardiographic morphology on clinical outcomes in patients with non-ST elevation myocardial infarction receiving coronary angiography and intervention: a retrospective study. PeerJ 2020; 8:e8796. [PMID: 32419982 PMCID: PMC7211404 DOI: 10.7717/peerj.8796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/25/2020] [Indexed: 11/20/2022] Open
Abstract
Background
The impact of electrocardiography (ECG) morphology on clinical outcomes in patients with non-ST segment elevation myocardial infarction (NSTEMI) receiving percutaneous coronary intervention (PCI) is unknown. This study investigated whether different ST morphologies had different clinical outcomes in patients with NSTEMI receiving PCI.
Methods
This retrospective study analyzed record-linked data of 362 patients who had received PCI for NSTEMI between January 2008 and December 2010. ECG revealed ST depression in 67 patients, inverted T wave in 91 patients, and no significant ST-T changes in 204 patients. The primary endpoint was long-term all-cause mortality. The secondary endpoint was long-term cardiac death and non-fatal major adverse cardiac events.
Results
Compared to those patients whose ECG showed an inverted T wave and non-specific ST-T changes, patients whose ECG showed ST depression had more diabetes mellitus, advanced chronic kidney disease (CKD) and left main artery disease, as well as more in-hospital mortality, cardiac death and pulmonary edema during hospitalization. Patients with ST depression had a significantly higher rate of long-term total mortality and cardiac death. Finally, multiple stepwise Cox regression analysis showed that an advanced Killip score, age, advanced CKD, prior percutaneous transluminal coronary angioplasty and ST depression were independent predictors of the primary endpoint.
Conclusions
Among NSTEMI patients undergoing coronary angiography, those with ST depression had more in-hospital mortality and cardiac death. Long-term follow-up of patients with ST depression consistently reveals poor outcomes.
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Affiliation(s)
- Chiung-Jen Wu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Kuo-Ho Yeh
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Hui-Ting Wang
- Emergency Department, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Wen-Hao Liu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Huang-Chung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Han-Tan Chai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Wen-Jung Chung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Shukai Hsueh
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chien-Jen Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Hsiu-Yu Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yung-Lung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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9
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Chen PF, Tang L, Pei JY, Yi JL, Xing ZH, Fang ZF, Zhou SH, Hu XQ. Prognostic value of admission electrocardiographic findings in non-ST-segment elevation myocardial infarction. Clin Cardiol 2020; 43:574-580. [PMID: 32125713 PMCID: PMC7299002 DOI: 10.1002/clc.23349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/24/2020] [Accepted: 02/14/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Admission electrocardiographic (ECG) findings of non-ST-segment elevation myocardial infarction (NSTEMI) include transient ST-segment elevation (TSTE), ST-segment depression (STD), T-wave inversion (TWI), and no ischemic changes (NIC). HYPOTHESIS This study aimed to assess the prognostic value of qualitative ECG findings at presentation and to clarify the influence of invasive treatment on the prognostic value of admission ECG findings. METHODS We analyzed the Acute Coronary Syndrome Quality Improvement in Kerala (ACS QUIK) study post hoc. NSTEMI patients were included and classified into four groups per ECG findings. Study endpoints were in-hospital and 30-day mortality rates and major adverse events (MAE). We performed multivariate logistic regression, adjusting for covariates in the Global Registry of Acute Coronary Events risk model, with subset analyses of patients treated with or without invasive management. RESULTS STD patients had significantly higher in-hospital and 30-day mortality rates/MAE than TWI patients, which had lower in-hospital mortality rate/MAE than the NIC group. TSTE patients had intermediate outcomes. In multivariate logistic regression using the TWI group as the reference, STD and NIC remained independently associated with worse outcomes. Subset analysis showed prognostic value of admission ECG in non-invasively managed but not in invasively managed patients. CONCLUSIONS STD was associated with adverse outcomes, TWI with benign prognoses. NIC should not be taken to indicate low risk. Qualitative analysis of admission ECG is suitable for rapid risk stratification of NSTMI patients at presentation. However, it may not be predictive of short-term outcomes of NSTEMI patients after invasive management.
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Affiliation(s)
- Peng-Fei Chen
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, China
| | - Liang Tang
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, China
| | - Jun-Yu Pei
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, China
| | - Jun-Lin Yi
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, China
| | - Zhen-Hua Xing
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, China
| | - Zhen-Fei Fang
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, China
| | - Sheng-Hua Zhou
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, China
| | - Xin-Qun Hu
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, China
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Burak C, Yesin M, Tanık VO, Çağdaş M, Rencüzoğulları İ, Karabağ Y, Hamideyin Ş, İliş D, Çınar T, Altıntaş B, Baysal E. Prolonged P wave peak time is associated with the severity of coronary artery disease in patients with non-ST segment elevation myocardial infarction. J Electrocardiol 2019; 55:138-143. [PMID: 31185366 DOI: 10.1016/j.jelectrocard.2019.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/15/2019] [Accepted: 05/29/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Multi-vessel coronary artery disease (CAD) is associated with worse outcome in non-ST segment elevation myocardial infarction (NSTEMI) patients. Depending on the severity of CAD, there may be prolongation of atrial depolarization time as a result of left ventricular dysfunction and atrial ischemia. Therefore, we aimed to study whether the severity of CAD can be predicted with the P wave peak time (PWPT) in the electrocardiography (ECG) obtained during the diagnosis in NSTEMI patients. METHOD A total of 162 patients were included. The coronary angiography records of all patients were analyzed and SYNTAX scores were calculated. Patients were divided into two groups, according to CAD severity. In addition to well-known P wave parameters, PWPT, defined as the time from the beginning of the P wave to its peak, was measured in the leads DII and V1. RESULTS The PWPTs in the leads DII and V1 were significantly longer in the group with severe CAD (71 ± 13 vs. 61 ± 12, p < 0.001, 63 ± 24 vs. 53 ± 18, p = 0.024, respectively). PWPT was found to be an independent predictor of severe CAD and the best cut-off value of PWPT in the lead DII was 69.6 ms with sensitivity of 58.3% and specificity of 78.9%. CONCLUSION Our findings show that prolonged PWPT, which is a parameter easily obtainable from the ECG, is associated with severe CAD. Recognition of NSTEMI patients with severe CAD at the time of diagnosis before performing coronary angiography may be important for the planning of treatment.
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Affiliation(s)
- Cengiz Burak
- Kafkas University, Medical Faculty, Department of Cardiology, Kars, Turkey.
| | - Mahmut Yesin
- Kars Harakani State Hospital, Cardiology, Kars, Turkey
| | - Veysel Ozan Tanık
- Dışkapı Yıldırım Beyazıt Training and Research Hospital, Cardiology, Ankara, Turkey
| | - Metin Çağdaş
- Kafkas University, Medical Faculty, Department of Cardiology, Kars, Turkey
| | | | - Yavuz Karabağ
- Kafkas University, Medical Faculty, Department of Cardiology, Kars, Turkey
| | - Şerif Hamideyin
- Kafkas University, Medical Faculty, Department of Cardiology, Kars, Turkey
| | - Doğan İliş
- Kafkas University, Medical Faculty, Department of Cardiology, Kars, Turkey
| | - Tufan Çınar
- Health Science University, Sultan Abdulhamid han Training and Research Hospital, Cardiology, Istanbul, Turkey
| | - Bernas Altıntaş
- Gazi Yaşargil Training and Research Hospital, Cardiology, Diyarbakır, Turkey
| | - Erkan Baysal
- Gazi Yaşargil Training and Research Hospital, Cardiology, Diyarbakır, Turkey
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11
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Nakahashi T, Tada H, Sakata K, Nomura A, Ohira M, Mori M, Takamura M, Hayashi K, Yamagishi M, Kawashiri MA. Additive Prognostic Value of Carotid Plaque Score to Enhance the Age, Creatinine, and Ejection Fraction Score in Patients with Acute Coronary Syndrome. J Atheroscler Thromb 2018; 25:709-719. [PMID: 29375083 PMCID: PMC6099068 DOI: 10.5551/jat.42317] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Aim: To assess whether combining measurements obtained from carotid ultrasonography in addition to the age, creatinine, and ejection fraction (ACEF) score would improve the predictive ability of outcome in patients with acute coronary syndrome (ACS). Methods: We examined 264 patients with ACS (194 men; mean age: 68 ± 11 years) who underwent percutaneous coronary intervention. The carotid plaque score (cPS) and intima–media thickness (cIMT) were determined by carotid ultrasonography. The modified ACEF score was calculated using the following formula: (age/left ventricular ejection fraction) +1 point for every 10 mL/min reduction in creatinine clearance below 60 mL/min per 1.73 m2. The endpoint of this study was major adverse cardiovascular and cerebrovascular events (MACEs), defined as all-cause death, myocardial infarction, stoke, and target vessel revascularization. Results: During the median 4-year follow-up, there were 121 incidents of MACEs. Multivariate Cox proportional hazard regression analysis revealed that cPS ≥ 9.8 (hazard ratio [HR], 1.52; 95% confidence interval [CI], 1.01–2.31) and ACEF score ≥ 1.20 (HR, 1.62; 95% CI, 1.11–2.39) were significantly associated with MACEs, whereas cIMT was not. When the new combined risk score was calculated by multiplying the cPS by the modified ACEF score, the freedom from MACEs at 5 years was 71% and 31% for the lower and higher scores, respectively (p < 0.001). The area under the receiver-operating characteristic curve for MACEs for the ACEF score, cPS, and combined risk score were 0.65, 0.66, and 0.71, respectively (p < 0.05). Conclusion: The cPS offers an incremental predictive value when combined to the simple ACEF score in ACS.
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Affiliation(s)
- Takuya Nakahashi
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine
| | - Hayato Tada
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine
| | - Kenji Sakata
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine
| | - Akihiro Nomura
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine
| | - Miho Ohira
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine
| | - Mika Mori
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine
| | - Masayuki Takamura
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University
| | - Kenshi Hayashi
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine
| | - Masakazu Yamagishi
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine
| | - Masa-Aki Kawashiri
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine
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12
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Stähli BE, Wischnewsky MB, Jakob P, Klingenberg R, Obeid S, Heg D, Räber L, Windecker S, Roffi M, Mach F, Gencer B, Nanchen D, Jüni P, Landmesser U, Matter CM, Lüscher TF, Maier W. Predictive value of the age, creatinine, and ejection fraction (ACEF) score in patients with acute coronary syndromes. Int J Cardiol 2018; 270:7-13. [PMID: 29885826 DOI: 10.1016/j.ijcard.2018.05.134] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 05/27/2018] [Accepted: 05/31/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND This study sought to investigate the predictive value of the age, creatinine, and ejection fraction (ACEF) score in patients with acute coronary syndromes (ACS). The ACEF score (age/left ventricular ejection fraction +1 [if creatinine > 176 μmol/L]) has been established in patients evaluated for coronary artery bypass surgery. Data on its predictive value in all-comer ACS patients undergoing percutaneous coronary intervention are scarce. METHODS A total of 1901 patients prospectively enrolled in the Swiss ACS Cohort were included in the analysis. Optimal ACEF score cut-off values were calculated by decision tree analysis, and patients divided into low-risk (≤1.45), intermediate-risk (>1.45 and ≤2.0), and high-risk groups (>2.0). The primary endpoint was all-cause mortality. Major adverse cardiac and cerebrovascular events (MACCE) included all-cause death, non-fatal myocardial infarction, clinically indicated repeat coronary revascularization, definite stent thrombosis, and transient ischemic attack/stroke. RESULTS One-year rates of all-cause death increased across ACEF score groups (1.6% versus 5.6% versus 23.0%, p < 0.001). In multivariate analysis, the ACEF score was related with an increased risk of all-cause mortality (adjusted HR 3.53, 95% CI 2.90-4.31, p < 0.001), MACCE (adjusted HR 2.23, 95% CI 1.88-2.65, p < 0.001), and transient ischemic attack/stroke (adjusted HR 2.58, 95% CI 1.71-3.89, p < 0.001) at 1 year. Rates of Thrombolysis in Myocardial Infarction (TIMI) major and Global use of Strategies to Open Occluded Coronary Arteries (GUSTO) severe bleeding paralleled the increased ischemic risk across the groups (p < 0.001). CONCLUSIONS The ACEF score is a simple and useful risk stratification tool in patients with ACS referred for coronary revascularization.
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Affiliation(s)
- Barbara E Stähli
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland; Department of Cardiology, Charité Berlin - University Medicine, Campus Benjamin Franklin, Berlin, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.
| | | | - Philipp Jakob
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland; Department of Cardiology, Charité Berlin - University Medicine, Campus Benjamin Franklin, Berlin, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Roland Klingenberg
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Slayman Obeid
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Dik Heg
- Clinical Trials Unit, Department of Clinical Research, Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Cardiovascular Center, University Hospital Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Cardiovascular Center, University Hospital Bern, Bern, Switzerland
| | - Marco Roffi
- Division of Cardiology, Cardiovascular Center, University Hospital Geneva, Geneva, Switzerland
| | - François Mach
- Division of Cardiology, Cardiovascular Center, University Hospital Geneva, Geneva, Switzerland
| | - Baris Gencer
- Division of Cardiology, Cardiovascular Center, University Hospital Geneva, Geneva, Switzerland
| | - David Nanchen
- Department of Ambulatory Care and Community Medicine, Lausanne University, Lausanne, Switzerland
| | - Peter Jüni
- Clinical Trials Unit, Department of Clinical Research, Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Ulf Landmesser
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland; Department of Cardiology, Charité Berlin - University Medicine, Campus Benjamin Franklin, Berlin, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Christian M Matter
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Thomas F Lüscher
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland; Cardiology, Royal Brompton and Harefield Hospitals and Imperial College, London, UK
| | - Willibald Maier
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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13
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Cost-Effectiveness of Simvastatin Plus Ezetimibe for Cardiovascular Prevention in Patients With a History of Acute Coronary Syndrome: Analysis of Results of the IMPROVE-IT Trial. Heart Lung Circ 2018; 27:656-665. [DOI: 10.1016/j.hlc.2017.05.139] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 05/11/2017] [Accepted: 05/25/2017] [Indexed: 12/24/2022]
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14
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Two-year Follow-up of Patients With Unstable Angina/Non-ST Segment Elevation Myocardial Infarction Undergoing Early Invasive Strategy: Predictors of Normal or Near-Normal Coronary Angiography and Mortality. Crit Pathw Cardiol 2018; 17:47-52. [PMID: 29432377 DOI: 10.1097/hpc.0000000000000108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Predictors of normal or near-normal coronary angiography (NONCAG) in patients with unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) and their importance regarding the prognosis are not understood. Accordingly, we determined these predictors as well as mortality risk factors at 2-year follow-up of UA/NSTEMI patients managed by the early invasive strategy. METHODS We prospectively studied consecutive patients with UA/NSTEMI managed with the early invasive strategy at Tehran Heart Center, in 1-year period. Echocardiography was performed before coronary angiography (CAG) for all the patients. Baseline characteristics, laboratory parameters, echocardiographic findings, invasive treatment modalities, and survival status after 2 years of follow-up were collected. We identified the predictors of NONCAG in the first phase of the study and then the risk factors of mortality in the second phase. RESULTS In the study period, 298 patients including 211 (71%) males, with the age of 59.31 ± 10.72 years were enrolled. The following factors were predictors of NONCAG: the female sex (P < 0.001); negative family history of CAD (P = 0.028); Thrombolysis in Myocardial Infarction (TIMI) risk score (P < 0.001); and early transmitral flow velocity/mean mitral annular velocity (E/E'mean) (P = 0.003). The following items were significant protective factors against mortality: percutaneous coronary intervention (PCI) (P = 0.012), age (P = 0.001), and E/E'mean (P = 0.020). CONCLUSION Patients' baseline characteristics as well as echocardiographic data could help in predicting those with NONCAG and PCI can be considered as the treatment of strategy with the most protection against mortality.
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15
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Nakahashi T, Tada H, Sakata K, Yakuta Y, Tanaka Y, Nomura A, Gamou T, Terai H, Horita Y, Ikeda M, Namura M, Takamura M, Hayashi K, Yamagishi M, Kawashiri MA. Paradoxical impact of decreased low-density lipoprotein cholesterol level at baseline on the long-term prognosis in patients with acute coronary syndrome. Heart Vessels 2017; 33:695-705. [PMID: 29288404 DOI: 10.1007/s00380-017-1111-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 12/22/2017] [Indexed: 11/30/2022]
Abstract
Although statin therapy is beneficial in the setting of acute coronary syndrome (ACS), a substantial proportion of patients with ACS still do not receive the guideline-recommended lipid management in contemporary practice. We hypothesize that the low-density lipoprotein cholesterol (LDL-C) level at the time of admission might affect patient management and the subsequent outcome. Nine-hundred and forty-two consecutive patients with ACS who underwent percutaneous coronary intervention were analyzed retrospectively. The study patients were first divided into two groups based on the LDL-C level on admission: group A (n = 267), with LDL-C < 100 mg/dL; and group B (n = 675), with LDL-C ≥ 100 mg/dL. Each group was then further divided into those who were prescribed statins or not at the time of discharge from the hospital. The primary endpoint was all-cause death. In addition, we analyzed the serial changes of LDL-C within 1 year. Patients in group A were significantly older and more likely to have multiple comorbidities compared with group B. The proportion of patients who were prescribed statin at discharge was significantly smaller in group A compared with group B (57.7 vs. 77.3%, p < 0.001). During the median 4-year follow-up, there were 122 incidents of all-cause death. Multivariate Cox proportional hazard analysis revealed that LDL-C < 100 mg/dL on admission [hazard ratio (HR), 1.61; 95% confidence interval (CI), 1.09-2.39; p < 0.05] and prescription of statins at discharge (HR, 0.52; 95% CI, 0.36-0.76; p < 0.001) were associated significantly with all-cause death. Under these conditions, increasing LDL-C levels were documented during follow-up in those patients in group A when no statins were prescribed at discharge (79 ± 15-96 ± 29 mg/dL, p < 0.001), whereas these remained unchanged when statins were prescribed at discharge (79 ± 15-77 ± 22 mg/dL, p = 0.30). These results demonstrate that decreased LDL-C on admission in ACS led to less prescription for statins, which could result in increased death, probably due to underestimation of the baseline LDL-C.
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Affiliation(s)
- Takuya Nakahashi
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Hayato Tada
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Kenji Sakata
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Yohei Yakuta
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | - Yoshihiro Tanaka
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Akihiro Nomura
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Tadatsugu Gamou
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Hidenobu Terai
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | - Yuki Horita
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | - Masatoshi Ikeda
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | - Masanobu Namura
- Department of Cardiology, Kanazawa Cardiovascular Hospital, Kanazawa, Japan
| | - Masayuki Takamura
- Department of Disease Control and Homeostasis, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Kenshi Hayashi
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Masakazu Yamagishi
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan.
| | - Masa-Aki Kawashiri
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
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16
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Dechamps M, Castanares-Zapatero D, Berghe PV, Meert P, Manara A. Comparison of clinical-based and ECG-based triage of acute chest pain in the Emergency Department. Intern Emerg Med 2017; 12:1245-1251. [PMID: 27796707 DOI: 10.1007/s11739-016-1558-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 10/20/2016] [Indexed: 01/23/2023]
Abstract
In the Emergency Department, chest pain triage systems are based on either clinical features or ECG recording. In this prospective, single-center, observational study, we aimed to compare the diagnostic performance of these triage systems in distinguishing acute coronary syndromes (ACS) from diseases of mild severity. Patients were sorted into the triage systems based on collected data at admission and on a systematic 12-lead ECG performed at triage. The final diagnosis was determined after a 30-day follow-up. For ACS, we determined a high-acuity triage score (Level 1 or 2) as being adequate, and for mild severity diseases a low-acuity triage score (Level 3, 4 or 5) as being adequate. The diagnostic performance of all studied systems was moderate (AUC from 0.644 to 0.694), with no statistically significant difference found between them. However, characteristics of the systems differed because the clinical-based systems had a higher sensitivity (87-91%) but lower specificity (32-39%) compared with the ECG-based system (sensitivity 62% and specificity 64%). A higher sensitivity limits the risk of a patient with acute coronary syndrome staying unsafely in the waiting room, while a higher specificity prevents overcrowding. ECG at triage also ensures that no STEMIs or high-risk NSTEMIs are missed. Based on these findings, each Emergency Depatment could more accurately select the triage system that fits their local particularities.
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Affiliation(s)
- Melanie Dechamps
- Emergency Department, Clinique Universitaire Saint Luc, Université Catholique de Louvain, 1200, Brussels, Belgium.
- Emergency Department, Universitair Zienkenhuis Gent, Universiteit Gent, 9000, Ghent, Belgium.
| | - Diego Castanares-Zapatero
- Intensive Care Unit, Clinique Universitaire Saint Luc, Université Catholique de Louvain, 1200, Brussels, Belgium
| | - Patrick Vanden Berghe
- Emergency Department, Clinique Universitaire Saint Luc, Université Catholique de Louvain, 1200, Brussels, Belgium
| | - Philippe Meert
- Emergency Department, Clinique Universitaire Saint Luc, Université Catholique de Louvain, 1200, Brussels, Belgium
| | - Alessandro Manara
- Emergency Department, Clinique Universitaire Saint Luc, Université Catholique de Louvain, 1200, Brussels, Belgium
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17
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The association between electrocardiographic R wave peak time and coronary artery disease severity in patients with non-ST segment elevation myocardial infarction and unstable angina pectoris. J Electrocardiol 2017; 51:230-235. [PMID: 29108790 DOI: 10.1016/j.jelectrocard.2017.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND We aimed to evaluate possible association between QRS duration (QRSD), R wave peak time (RWPT), and coronary artery disease severity identified using the SYNTAX score (SS) in patients with unstable angina pectoris (USAP) or non-ST segment elevation myocardial infarction (NSTEMI). METHOD A total of 176 USAP/NSTEMI patients were enrolled in the study. RESULTS The high SS group (>22, n:45) patients had a higher prevalence of diabetes mellitus (DM); presence of ST segment depression ≥0.5 mm and 1 mm; ST segment elevation in the AVR lead (AVRSTE); longer QRSD and RWPT; and lower left ventricular ejection fraction (LVEF) than the low SS group (≤22, n: 131). The LVEF, AVRSTE, and RWPT (OR: 1.035, 95% CI: 1.003-1.067; p = 0.030) were independent predictors of high SS. CONCLUSION The present study demonstrated that RWPT and AVRSTE could be used as predictors of high SS.
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18
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Machine Learning Improves Risk Stratification After Acute Coronary Syndrome. Sci Rep 2017; 7:12692. [PMID: 28978948 PMCID: PMC5627253 DOI: 10.1038/s41598-017-12951-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 09/12/2017] [Indexed: 02/07/2023] Open
Abstract
The accurate assessment of a patient’s risk of adverse events remains a mainstay of clinical care. Commonly used risk metrics have been based on logistic regression models that incorporate aspects of the medical history, presenting signs and symptoms, and lab values. More sophisticated methods, such as Artificial Neural Networks (ANN), form an attractive platform to build risk metrics because they can easily incorporate disparate pieces of data, yielding classifiers with improved performance. Using two cohorts consisting of patients admitted with a non-ST-segment elevation acute coronary syndrome, we constructed an ANN that identifies patients at high risk of cardiovascular death (CVD). The ANN was trained and tested using patient subsets derived from a cohort containing 4395 patients (Area Under the Curve (AUC) 0.743) and validated on an independent holdout set containing 861 patients (AUC 0.767). The ANN 1-year Hazard Ratio for CVD was 3.72 (95% confidence interval 1.04–14.3) after adjusting for the TIMI Risk Score, left ventricular ejection fraction, and B-type natriuretic peptide. A unique feature of our approach is that it captures small changes in the ST segment over time that cannot be detected by visual inspection. These findings highlight the important role that ANNs can play in risk stratification.
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19
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Sanaani A, Yandrapalli S, Jolly G, Paudel R, Cooper HA, Aronow WS. Correlation between electrocardiographic changes and coronary findings in patients with acute myocardial infarction and single-vessel disease. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:347. [PMID: 28936441 DOI: 10.21037/atm.2017.06.33] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Correlation of ST-segment elevation on the 12-lead electrocardiogram (ECG) with the expected affected coronary territory is established in patients with ST-elevation myocardial infarction (STEMI). In patients with non-ST-elevation myocardial infarction (NSTEMI), correlation of ischemic ECG abnormalities with the affected coronary territory has not been well-established. We sought to investigate the correlation of electrocardiographic abnormalities with the location of 1-vessel obstructive coronary artery disease (CAD) in patients with both STEMI and NSTEMI. METHODS In this retrospective study, the charts of all patients referred for coronary angiography in 2012 were reviewed. Patients with a single obstructive coronary artery plus angina-equivalent symptoms and an elevated cardiac troponin I was included. Available ECGs were interpreted by an experienced cardiologist (WSA) blinded to the result of angiography. Patients with complete bundle branch block or ventricular pacing were excluded. Ischemic ECG changes were correlated to a coronary territory based on predefined criteria. RESULTS Of 131 included patients (mean age 64±13 years; 74% male), 29 had STEMI and 102 had NSTEMI. Eleven of 11 patients (100%) with anterior STEMI had left anterior descending artery (LAD) obstructive CAD. Of 18 patients with inferior STEMI, 14 (78%) had right coronary artery (RCA) obstructive CAD, 3 (17%) had left circumflex artery (LCX) artery obstructive CAD, and 1 (5%) had LAD obstructive CAD. Of 102 NSTEMI patients, 53 (52%) had definite ECG ischemic abnormalities. Of 31 patients with anterior definite ECG ischemic abnormalities, 30 (97%) had LAD obstructive CAD, and 1 (3%) had RCA obstructive CAD. Of 22 patients with inferior definite ECG ischemic abnormalities, 14 (64%) had RCA obstructive CAD, 5 (23%) had LCX obstructive CAD, and 3 (14%) had LAD obstructive CAD. CONCLUSIONS Patients with anterior STEMI had LAD obstructive CAD. Patients with inferior STEMI were highly likely to have RCA or LCX obstructive CAD. Only half of NSTEMI patients had definite ischemic ECG abnormalities. When present, anterior ischemic ECG changes in patients with single vessel CAD with NSTEMI were predictive of LAD obstructive CAD.
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Affiliation(s)
- Abdallah Sanaani
- Division of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Srikanth Yandrapalli
- Department of Internal Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - George Jolly
- Department of Internal Medicine, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Rajiv Paudel
- Heart and Vascular Institute of Texas, San Antonio, TX, USA
| | - Howard A Cooper
- Division of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Wilbert S Aronow
- Division of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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20
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Bang WD, Kim K, Lee YH, Kwon H, Park Y, Pak HN, Ko YG, Lee M, Joung B. Repolarization Heterogeneity of Magnetocardiography Predicts Long-Term Prognosis in Patients with Acute Myocardial Infarction. Yonsei Med J 2016; 57:1339-46. [PMID: 27593860 PMCID: PMC5011264 DOI: 10.3349/ymj.2016.57.6.1339] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/25/2016] [Accepted: 04/25/2016] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Magnetocardiography (MCG) has been proposed as a noninvasive, diagnostic tool for risk-stratifying patients with acute myocardial infarction (AMI). This study evaluated whether MCG predicts long-term prognosis in AMI. MATERIALS AND METHODS In 124 AMI patients (95 males, mean age 60±11 years), including 39 with ST-elevation myocardial infarction, a 64-channel MCG was performed within 2 days after AMI. During a mean follow-up period of 6.1 years, major adverse cardiac events (MACE) were evaluated. RESULTS MACE occurred in 31 (25%) patients, including 20 revascularizations, 8 deaths, and 3 re-infarctions. Non-dipole patterns were observed at the end of the T wave in every patients. However, they were observed at T-peak in 77% (24/31) and 54% (50/93) of patients with and without MACE, respectively (p=0.03). Maximum current, field map angles, and distance dynamics were not different between groups. In the multivariate analysis, patients with non-dipole patterns at T-peak had increased age- and gender-adjusted hazard ratios for MACE (hazard ratio 2.89, 95% confidence interval 1.20-6.97, p=0.02) and lower cumulative MACE-free survival than those with dipole patterns (p=0.02). CONCLUSION Non-dipole patterns at T-peak were more frequently observed in patients with MACE and were related to poor long-term prognosis. Thus, repolarization heterogeneity measured by MCG may be a useful predictor for AMI prognosis.
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Affiliation(s)
- Woo Dae Bang
- Cardiology Division, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Department of Cardiology, University of Ulsan College of Medicine, Gangneung Asan Hospital, Gangneung, Korea
| | - Kiwoong Kim
- Bio-Signal Research Center, Korea Research Institute of Standards and Science, Daejeon, Korea
| | - Yong Ho Lee
- Bio-Signal Research Center, Korea Research Institute of Standards and Science, Daejeon, Korea
| | - Hyukchan Kwon
- Bio-Signal Research Center, Korea Research Institute of Standards and Science, Daejeon, Korea
| | - Yongki Park
- Bio-Signal Research Center, Korea Research Institute of Standards and Science, Daejeon, Korea
| | - Hui Nam Pak
- Cardiology Division, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young Guk Ko
- Cardiology Division, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Moonhyoung Lee
- Cardiology Division, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Boyoung Joung
- Cardiology Division, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
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Jin ES, Park CB, Kim DH, Hwang HJ, Cho JM, Sohn IS, Kim CJ. Comparative clinical implications of admission electrocardiographic findings for patients with non-ST-segment elevation myocardial infarction. Medicine (Baltimore) 2016; 95:e4862. [PMID: 27631250 PMCID: PMC5402593 DOI: 10.1097/md.0000000000004862] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Early risk stratification is crucial for appropriate management using invasive strategies in non-ST elevation myocardial infarction (NSTEMI), and electrocardiography (ECG) has been widely used for risk stratification. However, ECG findings in NSTEMI vary, and there is a need to define the clinical characteristics and outcomes according to ECG.We analyzed the admission ECGs of 345 NSTEMI patients who underwent coronary angiography from 2006 to 2013. Demographics, procedural characteristics, and clinical outcomes were analyzed.The ST-segment depression, T-wave inversion, and no ECG change groups included 114, 90, and 141 patients, respectively. The ST-segment depression group trended toward older, nonsmoking, and female, with a lower body mass index (BMI) and a higher incidence of comorbidities, than the no ECG change group. The ST-segment depression group also had a higher Killip class, a lower left ventricular ejection fraction, a higher regional wall motion score index (RWMSI), and 3-vessel coronary artery disease angiographically, than the no ECG change group. Patients with T-wave inversion trended toward older, female, lower BMI, less smoking, lower creatine kinase MB, and more left anterior descending (LAD) artery involvement, than the no ECG change group. In clinical outcomes, the ST-segment depression group had a higher mortality rate at 30 days and 12 months after the index procedure than the no ECG change group, whereas the T-wave inversion group showed similar clinical outcomes.Patients with ST-segment depression have a greater burden of comorbidities with risk factors and worse clinical outcomes, whereas patients with T-wave inversion have an intermediate number of risk factors but similar outcomes, compared with the no ECG change group. Further study is necessary to evaluate the prognostic impact of the baseline ECG on admission.
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Affiliation(s)
| | - Chang-Bum Park
- Department of Internal Medicine, Kyung Hee University, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
- Correspondence: Chang-Bum Park, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, Seoul 134-727, Republic of Korea (e-mail: )
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Cerit L. Chicken or the egg: ST elevation in lead aVR or SYNTAX score. Cardiovasc J Afr 2016; 28:100-103. [PMID: 27276224 PMCID: PMC5488054 DOI: 10.5830/cvja-2016-062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 05/12/2016] [Indexed: 11/15/2022] Open
Abstract
Background: ST-segment elevation in lead aVR (STEaVR) anticipates left main and/or three-vessel disease (LM/3VD) in patients with acute coronary syndromes. STEaVR is generally reciprocal to and accompanied by ST-segment depression (STD) in the precordial leads. SYNTAX score (SS) is an angiographic scoring system and is widely used to evaluate the severity and complexity of coronary artery disease. The purpose of our study was to assess the relationship between STEaVR and SS. Methods: We performed a retrospective analysis of 117 patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). Electrocardiograms at presentation were reviewed, especially for ST-segment elevation of ≥ 0.05 mV in lead aVR and STD of ≥ 0.05 mV in more than two contiguous leads. All lesions causing ≥ 50% stenosis in a coronary artery with a diameter of ≥ 1.5 mm were included in the SS calculation. SS was divided into two groups: ≥ 23: high, < 23: low. Results: Among the 117 patients, 80 (68.4%) had STEaVR and 37 (31.6%) did not. Patients with STEaVR had a higher SS and higher rate of LM/3VD (85 vs 67.6%, p < 0.001; 86.2 vs 72.9%, p = 0.03, respectively) than those without STEaVR. On multivariate analysis, STEaVR [odds ratio (OR) 1.85; 95% confidence interval (CI): 1.20–3.97, p = 0.03] and STD in leads V1–V4 (OR 2.14; 95% CI: 1.46–4.23, p = 0.002) were independent predictors of a high SS. Conclusion: This study demonstrated that STEaVR was an independent predictor of a high SS.
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Fanning JP, Nyong J, Scott IA, Aroney CN, Walters DL. Routine invasive strategies versus selective invasive strategies for unstable angina and non-ST elevation myocardial infarction in the stent era. Cochrane Database Syst Rev 2016; 2016:CD004815. [PMID: 27226069 PMCID: PMC8568369 DOI: 10.1002/14651858.cd004815.pub4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND People with unstable angina and non-ST elevation myocardial infarction (UA/NSTEMI) are managed with a combination of medical therapy, invasive angiography and revascularisation. Specifically, two approaches have evolved: either a 'routine invasive' strategy whereby all patients undergo coronary angiography shortly after admission and, if indicated, coronary revascularisation; or a 'selective invasive' (also referred to as 'conservative') strategy in which medical therapy alone is used initially, with a selection of patients for angiography based upon evidence of persistent myocardial ischaemia. Uncertainty exists as to which strategy provides the best outcomes for these patients. This Cochrane review is an update of a Cochrane review originally published in 2006, to provide a robust comparison of these two strategies in the early management of patients with UA/NSTEMI. OBJECTIVES To determine the benefits and harms associated with the following.1. A routine invasive versus a conservative or 'selective invasive' strategy for the management of UA/NSTEMI in the stent era.2. A routine invasive strategy with and without glycoprotein IIb/IIIa receptor antagonists versus a conservative strategy for the management of UA/NSTEMI in the stent era. SEARCH METHODS We searched the following databases and additional resources up to 25 August 2015: the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, MEDLINE and EMBASE, with no language restrictions. SELECTION CRITERIA We included prospective randomised controlled trials (RCTs) that compared invasive with conservative or 'selective invasive' strategies in participants with acute UA/NSTEMI. DATA COLLECTION AND ANALYSIS Two review authors screened the records and extracted data in duplicate. Using intention-to-treat analysis with random-effects models, we calculated summary estimates of the risk ratio (RR) with 95% confidence intervals (CIs) for the primary endpoints of all-cause death, fatal and non-fatal myocardial infarction (MI), combined all-cause death or non-fatal MI, refractory angina and re-hospitalisation. We performed further analysis of included studies based on whether glycoprotein IIb/IIIa receptor antagonists were used routinely. We assessed the heterogeneity of included trials using Pearson χ² (Chi² test) and variance (I² statistic) analysis. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, we assessed the quality of the evidence and the GRADE profiler (GRADEPRO) was used to import data from Review Manager 5.3 (Review Manager) to create Summary of findings (SoF) tables. MAIN RESULTS Eight RCTs with a total of 8915 participants (4545 invasive strategies, 4370 conservative strategies) were eligible for inclusion. We included three new studies and 1099 additional participants in this review update. In the all-study analysis, evidence did not show appreciable risk reductions in all-cause mortality (RR 0.87, 95% CI 0.64 to 1.18; eight studies, 8915 participants; low quality evidence) and death or non-fatal MI (RR 0.93, 95% CI 0.71 to 1.2; seven studies, 7715 participants; low quality evidence) with invasive strategies compared to conservative (selective invasive) strategies at six to 12 months follow-up. There was appreciable risk reduction in MI (RR 0.79, 95% CI 0.63 to 1.00; eight studies, 8915 participants; moderate quality evidence), refractory angina (RR 0.64, 95% CI 0.52 to 0.79; five studies, 8287 participants; moderate quality evidence) and re-hospitalisation (RR 0.77, 95% CI 0.63 to 0.94; six studies, 6921 participants; moderate quality evidence) with routine invasive strategies compared to conservative (selective invasive) strategies also at six to 12 months follow-up.Evidence also showed increased risks in bleeding (RR 1.73, 95% CI 1.30 to 2.31; six studies, 7584 participants; moderate quality evidence) and procedure-related MI (RR 1.87, 95% CI 1.47 to 2.37; five studies, 6380 participants; moderate quality evidence) with routine invasive strategies compared to conservative (selective invasive) strategies.The low quality evidence were as a result of serious risk of bias and imprecision in the estimate of effect while moderate quality evidence was only due to serious risk of bias. AUTHORS' CONCLUSIONS In the all-study analysis, the evidence failed to show appreciable benefit with routine invasive strategies for unstable angina and non-ST elevation MI compared to conservative strategies in all-cause mortality and death or non-fatal MI at six to 12 months. There was evidence of risk reduction in MI, refractory angina and re-hospitalisation with routine invasive strategies compared to conservative (selective invasive) strategies at six to 12 months follow-up. However, routine invasive strategies were associated with a relatively high risk (almost double the risk) of procedure-related MI, and increased risk of bleeding complications. This systematic analysis of published RCTs supports the conclusion that, in patients with UA/NSTEMI, a selectively invasive (conservative) strategy based on clinical risk for recurrent events is the preferred management strategy.
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Affiliation(s)
- Jonathon P Fanning
- The Prince Charles HospitalSchool of Medicine, The University of QueenslandRode RoadChermsideBrisbaneAustralia4032
| | - Jonathan Nyong
- FARR Institute UCLClinical Epidemiology222 Euston RoadLondonGreater LondonUKNW1 2DA
| | - Ian A Scott
- Princess Alexandra HospitalInternal Medicine Department and Clinical Services Evaluation UnitBrisbaneAustralia
| | - Constantine N Aroney
- The Prince Charles HospitalDepartment of CardiologyRode RdChermsideBrisbaneAustralia
| | - Darren L Walters
- The Prince Charles HospitalExecutive Chair Prince Charles Heart and Lung InstituteRoad RdBrisbaneQueenslandAustralia4032
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Sarak B, Goodman SG, Yan RT, Tan MK, Steg PG, Tan NS, Fox KAA, Udell JA, Brieger D, Welsh RC, Gale CP, Yan AT. Prognostic value of dynamic electrocardiographic T wave changes in non-ST elevation acute coronary syndrome. Heart 2016; 102:1396-402. [DOI: 10.1136/heartjnl-2015-309161] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 03/24/2016] [Indexed: 02/07/2023] Open
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Brandão RM, Samesima N, Pastore CA, Staniak HL, Lotufo PA, Bensenor IM, Goulart AC, Santos IS. ST-segment abnormalities are associated with long-term prognosis in non-ST-segment elevation acute coronary syndromes: The ERICO-ECG study. J Electrocardiol 2016; 49:411-6. [PMID: 26874565 DOI: 10.1016/j.jelectrocard.2016.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Indexed: 01/30/2023]
Abstract
INTRODUCTION We aimed to identify whether ST-segment abnormalities, in the admission or during in-hospital stay, are associated with survival and/or new incident myocardial infarction (MI) in 623 non-ST-elevation acute coronary syndrome participants of the Strategy of Registry of Acute Coronary Syndrome (ERICO) study. MATERIALS AND METHODS ERICO is conducted in a community-based hospital. ST-segment analysis was based on the Minnesota Code. We built Cox regression models to study whether ECG was an independent predictor for clinical outcomes. RESULTS Median follow-up was 3years. We found higher risk of death due to MI in individuals with ST-segment abnormalities in the final ECG (adjusted hazard ratio: 2.68; 95% confidence interval: 1.14-6.28). Individuals with ST-segment abnormalities in any tracing had a non-significant trend toward a higher risk of fatal or new non-fatal MI (p=0.088). CONCLUSIONS ST-segment abnormalities after the initial tracing added long-term prognostic information.
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Affiliation(s)
- Rodrigo M Brandão
- Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da Universidade de São Paulo, Brazil
| | - Nelson Samesima
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Carlos A Pastore
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Henrique L Staniak
- Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da Universidade de São Paulo, Brazil
| | - Paulo A Lotufo
- Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da Universidade de São Paulo, Brazil; Departamento de Clínica Médica da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Isabela M Bensenor
- Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da Universidade de São Paulo, Brazil; Departamento de Clínica Médica da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Alessandra C Goulart
- Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da Universidade de São Paulo, Brazil
| | - Itamar S Santos
- Centro de Pesquisa Clínica e Epidemiológica do Hospital Universitário da Universidade de São Paulo, Brazil; Departamento de Clínica Médica da Faculdade de Medicina da Universidade de São Paulo, Brazil.
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Abstract
This article discusses the approach to the management of myocardial infarction (MI) in the intensive care unit setting. It includes an overview of the definition, classification, and underlying pathologic conditions of acute MI and specifically discusses the diagnosis and management of unstable angina, non-ST elevation MI, and ST-segment elevation MI. Diagnosis and treatment of the acute complications of MI are also reviewed.
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Affiliation(s)
- Akram W Ibrahim
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Emory University Hospital Midtown, Medical Office Tower, 550 Peachtree Street, Atlanta, GA 30308, USA
| | - Thomas C Riddell
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Emory University Hospital Midtown, Medical Office Tower, 550 Peachtree Street, Atlanta, GA 30308, USA
| | - Chandan M Devireddy
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Emory University Hospital Midtown, Medical Office Tower, 550 Peachtree Street, Atlanta, GA 30308, USA.
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27
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Tan NS, Goodman SG, Yan RT, Tan MK, Fox KA, Gore JM, Brieger D, Steg PG, Langer A, Yan AT. Prognostic significance of low QRS voltage on the admission electrocardiogram in acute coronary syndromes. Int J Cardiol 2015; 190:34-9. [DOI: 10.1016/j.ijcard.2015.04.085] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 04/05/2015] [Accepted: 04/12/2015] [Indexed: 12/22/2022]
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Misumida N, Kobayashi A, Fox JT, Hanon S, Schweitzer P, Kanei Y. Predictive Value of ST-Segment Elevation in Lead aVR for Left Main and/or Three-Vessel Disease in Non-ST-Segment Elevation Myocardial Infarction. Ann Noninvasive Electrocardiol 2015; 21:91-7. [PMID: 25884447 DOI: 10.1111/anec.12272] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND ST-segment elevation in lead aVR predicts left main and/or three-vessel disease (LM/3VD) in patients with acute coronary syndromes. ST-segment elevation in lead aVR is generally reciprocal to and accompanied by ST-segment depression in precordial leads. Previous studies have assessed the independent predictive value of ST-segment elevation in lead aVR for LM/3VD in non-ST-segment elevation acute coronary syndrome and have reported conflicting results. METHODS We performed a retrospective analysis of 379 patients with non-ST-segment elevation myocardial infarction (NSTEMI). Electrocardiograms on presentation were reviewed especially for ST-segment elevation ≥0.05 mV in lead aVR and ST-segment depression ≥0.05 mV in more than two contiguous leads in any other leads. RESULTS Among 379 patients, 97 (26%) patients had ST-segment elevation in lead aVR and 88 (23%) patients had LM/3VD. Patients with ST-segment elevation in lead aVR had a higher rate of LM/3VD (39% vs. 18%; P < 0.001) and in-hospital revascularization (73% vs. 60%; P = 0.02) driven by a higher rate of in-hospital coronary artery bypass grafting (19% vs. 7%; P < 0.001) than those without ST-segment elevation in lead aVR. On multivariate analysis, ST-segment elevation in lead aVR (odds ratio [OR] 2.05; 95% confidence interval [CI] 1.10-3.77; P = 0.02) and ST-segment depression in leads V1 -V4 (OR 2.99; 95% CI 1.46-6.15; P = 0.003) were independent predictors of LM/3VD. CONCLUSION This study demonstrates that ST-segment elevation in lead aVR is an independent predictor of LM/3VD in patients with NSTEMI.
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Affiliation(s)
| | | | - John T Fox
- Department of Cardiology, Mount Sinai Beth Israel, New York, NY
| | - Sam Hanon
- Department of Cardiology, Mount Sinai Beth Israel, New York, NY
| | - Paul Schweitzer
- Department of Cardiology, Mount Sinai Beth Israel, New York, NY
| | - Yumiko Kanei
- Department of Cardiology, Mount Sinai Beth Israel, New York, NY
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Nikus K, Järvinen O, Sclarovsky S, Huhtala H, Tarkka M, Eskola M. Electrocardiographic Presentation of Left Main Disease in Patients Undergoing Urgent or Emergent Coronary Artery Bypass Grafting. Postgrad Med 2015; 123:42-8. [DOI: 10.3810/pgm.2011.03.2262] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Farré N, Mercè J, Camprubí M, Mohandes M, Guarinos J, Fernández F, Oliva X, Bardají A. Prevalence and outcome of patients with left bundle branch block and suspected acute myocardial infarction. Int J Cardiol 2015; 182:164-5. [DOI: 10.1016/j.ijcard.2014.12.123] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 12/29/2014] [Indexed: 11/29/2022]
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Affiliation(s)
- Konstantinos C. Koskinas
- First Cardiology Department, AHEPA Hospital, Aristotle University Medical School, Thessaloniki, Greece
| | - Antonios Ziakas
- First Cardiology Department, AHEPA Hospital, Aristotle University Medical School, Thessaloniki, Greece
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Swahn E, Alfredsson J. Invasive treatment of non-ST-segment elevation acute coronary syndrome: cardiac catheterization/revascularization for all? ACTA ACUST UNITED AC 2014; 67:218-21. [PMID: 24774397 DOI: 10.1016/j.rec.2013.11.004] [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: 11/05/2013] [Accepted: 11/05/2013] [Indexed: 11/28/2022]
Abstract
Patients admitted to hospital with symptoms and signs of non-ST-segment elevation acute coronary syndromes have different risk profiles and are in need of an individualized approach that takes into consideration not only age and sex but also comorbidities such as diabetes, renal failure, hypertension, heart failure, peripheral artery disease, earlier revascularization, etc. According to evidence-based medicine and as documented in current guidelines, there is currently evidence for early catheterization and, if feasible, revascularization in high-risk patients, especially in men. Nevertheless, because of a lack of definitive evidence, there is uncertainty about treating women in the same way. Because women are usually older and have more comorbidities, they are frailer and revascularization should be indicated with greater caution. There is no evidence that catheterization as such is worse for women than for men; however, for both men and women with low risk, a less invasive approach, such as coronary computed tomography angiography, could be considered as a first diagnostic tool.
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Affiliation(s)
- Eva Swahn
- Faculty of Health Sciences, Linkoping University Hospital, Linkoping, Sweden.
| | - Joakim Alfredsson
- Faculty of Health Sciences, Linkoping University Hospital, Linkoping, Sweden
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Shams-Vahdati S, Vand-Rajavpour Z, Paknezhad SP, Piri R, Moghaddasi-Ghezeljeh E, Mirabolfathi S, Naghavi-Behzad M. Cost-effectiveness of cardiac biomarkers as screening test in acute chest pain. J Cardiovasc Thorac Res 2014; 6:29-33. [PMID: 24753829 PMCID: PMC3992729 DOI: 10.5681/jcvtr.2014.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 02/21/2014] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Acute chest pain is an important and frequently occurring symptom in patients. Chest pain is often a sign of ischemic heart disease. Associated findings of electrocardiograph (ECG) are rather heterogeneous, and traditional cardiac biomarkers such as Creatine Kinase-MB (CK-MB) suffer from low cardiac specificity and sensitivity. In this study cost effectiveness of cardiac biomarkers single quantitative measurement was examined. METHODS The present descriptive-analytic study conducted on patients who were asked for troponin I and CK-MB. All patients who referred to Emergency unit of Tabriz Imam Reza educational-medical center during January 2012 to July the 2013 were included in study. All patients included in the study were documented in terms of age, sex, working shift of referring, main complaint of patient, symptoms in referring, ECG findings, and results of troponin I and CK-MB tests. RESULTS In this study, 2900 patients were studied including 1440 (49.7%) males and 1460 (50.3%) females. Mean age of patients was 62.91 (SD=14.36). Of all patients 1880 (64.8%) of patients referred during 8 a.m. to 8 p.m. and 1020 (35.2%) patients were referred during 8 p.m. to 8 a.m. The sensitivity of cardiac biomarkers' test in diagnosing Acute Coronary Syndrome (ACS) disease was calculated as 44.8% and its specificity was 86.6%. For diagnosing Acute Myocardial Infarction (AMI), sensitivity of cardiac biomarkers' test was 72.2% and its specificity was 86%. None of patients who were finally underwent unstable angina diagnosis showed increase in cardiac enzymes. CONCLUSION In conclusion, cardiac biomarkers can be used for screening acute chest pains, also cost effectiveness of cardiac biomarkers, appropriate specificity and sensitivity can guarantee their usefulness in emergency room.
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Affiliation(s)
- Samad Shams-Vahdati
- Department of Emergency Medicine, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Zahra Vand-Rajavpour
- Students’ Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Reza Piri
- Students’ Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Saba Mirabolfathi
- Students’ Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Naghavi-Behzad
- Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Tratamiento invasivo del síndrome coronario agudo sin elevación del segmento ST: ¿cateterismo cardiaco/revascularización en todos los casos? Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2013.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Liu Q, Wang T, Chen R, Liu C, Yue W, Hong J, Jia R. Mean platelet volume predicts left descending artery occlusion in patients with non-ST-elevation myocardial infarction. Platelets 2013; 25:246-51. [PMID: 24102229 DOI: 10.3109/09537104.2013.810332] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Platelets play an important role in atherothrombosis. As the most common site plaque occurs, left anterior descending artery (LAD) infarct location always associate with poor prognosis. We sought to assess whether mean platelet volume (MPV) could predict LAD infarct location and short-term clinical outcome. In this study, 190 consecutive patients with non-ST-elevation myocardial infarction (NSTEMI) were enrolled. Clinical, electrocardiography and laboratory characteristics were measured. All patients underwent coronary angiography examination and had definite culprit vessel during hospitalization. The results showed that MPV was smaller in patients with a LAD infarct location than that of left circumflex artery or right coronary artery (9.0 ± 1.5 versus 9.8 ± 1.6, p<0.001). Multivariate analysis also showed that MPV was the only independent factor to predict LAD infarct location [Odds ratio (OR)=0.65, 95% confidence interval (CI) 0.53-0.80, p<0.0001] in patients with NSTEMI. B-type natriuretic peptide and electrocardiography were unreliable predictive factors to locate culprit vessel. Receiver operating characteristic curve analysis showed MPV (area under the curve: 0.65, 95% CI 0.56-0.74, p<0.01) could reliably discriminate those patients with NSTEMI who had a major in-hospital event. Multivariate regression analyses also showed that MPV (OR=1.46, 95% CI 1.15-1.86, p<0.01) were predictors of major in-hospital events. In conclusion, MPV was the only factor independently associated with LAD infarct location in patients with non-ST-elevation myocardial infarction.
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Affiliation(s)
- Qiang Liu
- Department of Cardiology, The Fourth People's Hospital of Jinan, Medical school, Tai Shan Medical College , Jinan , PR China and
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Diosmin exhibits anti-hyperlipidemic effects in isoproterenol induced myocardial infarcted rats. Eur J Pharmacol 2013; 718:213-8. [DOI: 10.1016/j.ejphar.2013.08.031] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Revised: 08/15/2013] [Accepted: 08/30/2013] [Indexed: 11/22/2022]
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Figueras J, Barrabés JA, Evangelista A, Lidón RM, Gutierrez L, Garcia del Blanco B, Garcia-Dorado D. Admission Wall Motion Score and Quantitative ST-Segment Depression in the Assessment of 30-Day Mortality in Patients with First Non–ST-Segment Elevation Acute Coronary Syndromes. J Am Soc Echocardiogr 2013; 26:885-92. [DOI: 10.1016/j.echo.2013.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Indexed: 11/17/2022]
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Tan NS, Goodman SG, Yan RT, Elbarouni B, Budaj A, Fox KA, Gore JM, Brieger D, López-Sendón J, Langer A, van de Werf F, Steg PG, Yan AT. Comparative prognostic value of T-wave inversion and ST-segment depression on the admission electrocardiogram in non-ST-segment elevation acute coronary syndromes. Am Heart J 2013; 166:290-7. [PMID: 23895812 DOI: 10.1016/j.ahj.2013.04.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 04/17/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND ST-segment depression (STD) is predictive of adverse outcomes in non-ST-segment elevation acute coronary syndromes (NSTE-ACS), but there are conflicting data on the incremental prognostic value of T-wave inversions (TWIs) on the admission electrocardiogram. METHODS Admission electrocardiograms of 7,343 patients with NSTE-ACS from the Global Registry of Acute Coronary Events (GRACE) and ACS I registry were independently analyzed at a core laboratory and stratified by TWI and STD status. We performed multivariable analyses to determine the independent prognostic significance of TWI and tested for interaction between TWI and STD for adverse outcomes. RESULTS Patients with TWI and/or STD had a higher prevalence of cardiovascular risk factors, higher Killip class, and higher GRACE risk scores. Among the 2,708 patients with available angiographic data, rates of 3-vessel or left main disease were similar between patients with TWI and those without TWI/STD. After adjusting for other established prognosticators, TWI did not independently predict in-hospital (adjusted odds ratio 1.03, 95% CI 0.75-1.42, P = .85) or 6-month mortality (adjusted odds ratio 1.02, 95% CI 0.80-1.30, P = .88); STD remained a strong independent predictor. There was no interaction between TWI and STD for these outcomes. No contiguous lead groups or cumulative number of leads with TWI provided independent prognostic information. CONCLUSIONS TWI is associated with other high-risk clinical features but is not an independent predictor of adverse short- and long-term mortality in NSTE-ACS. T-wave inversion does not provide additional prognostication beyond the GRACE risk model, and its concomitant presence does not alter the prognostic value of STD.
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Zoghbi WA, Arend TE, Oetgen WJ, May C, Bradfield L, Keller S, Ramadhan E, Tomaselli GF, Brown N, Robertson RM, Whitman GR, Bezanson JL, Hundley J. 2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. Circulation 2013; 127:e663-828. [DOI: 10.1161/cir.0b013e31828478ac] [Citation(s) in RCA: 181] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Jneid H, Ettinger SM, Ganiats TG, Philippides GJ, Jacobs AK, Halperin JL, Albert NM, Creager MA, DeMets D, Guyton RA, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013; 61:e179-347. [PMID: 23639841 DOI: 10.1016/j.jacc.2013.01.014] [Citation(s) in RCA: 373] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Brown AJ, Hoole SP, McCormick LM, Malone-Lee M, Cacciottolo PJ, Schofield PM, West NEJ. Left bundle branch block with acute thrombotic occlusion is associated with increased myocardial jeopardy score and poor clinical outcomes in primary percutaneous coronary intervention activations. Heart 2013; 99:774-8. [DOI: 10.1136/heartjnl-2012-303194] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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Neeland IJ, Kontos MC, de Lemos JA. Evolving considerations in the management of patients with left bundle branch block and suspected myocardial infarction. J Am Coll Cardiol 2012; 60:96-105. [PMID: 22766335 DOI: 10.1016/j.jacc.2012.02.054] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 02/17/2012] [Accepted: 02/27/2012] [Indexed: 01/09/2023]
Abstract
Patients with a suspected acute coronary syndrome and left bundle branch block (LBBB) present a unique diagnostic and therapeutic challenge to the clinician. Although current guidelines recommend that patients with new or presumed new LBBB undergo early reperfusion therapy, data suggest that only a minority of patients with LBBB are ultimately diagnosed with acute myocardial infarction, regardless of LBBB chronicity, and that a significant proportion of patients will not have an occluded culprit artery at cardiac catheterization. The current treatment approach exposes a significant proportion of patients to the risks of fibrinolytic therapy without the likelihood of significant benefit and leads to increased rates of false-positive cardiac catheterization laboratory activation, unnecessary risks, and costs. Therefore, alternative strategies to those for patients with ST-segment elevation myocardial infarction are needed to guide selection of appropriate patients with a suspected acute coronary syndrome and LBBB for urgent reperfusion therapy. In this article, we describe the evolving epidemiology of LBBB in acute coronary syndromes and discuss controversies related to current clinical practice. We propose a more judicious diagnostic approach among clinically stable patients with LBBB who do not have electrocardiographic findings highly specific for ST-segment elevation myocardial infarction.
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Affiliation(s)
- Ian J Neeland
- Donald W. Reynolds Cardiovascular Clinical Research Center, Dallas, TX, USA
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Gadaleta F, Llois S, Kaski JC. Corrected QT interval: a prognostic marker in patients with non-ST-segment elevation acute coronary syndrome? Trends Cardiovasc Med 2012; 21:129-35. [PMID: 22732547 DOI: 10.1016/j.tcm.2012.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Over many decades, the corrected QT (QTc) has become an established clinical tool for the prediction of sudden cardiac death and life-threatening ventricular arrhythmias and for monitoring adverse effects of pharmacological agents capable of triggering serious ventricular arrhythmias mainly associated with QTc prolongation. Recent evidence also suggests that QTc prolongation is a predictor of poor clinical outcome in patients with coronary artery disease, particularly in the setting of the acute coronary syndrome. Indeed, in the past few years, studies assessing the predictive role of QTc measurements have provided important information in this regard and suggest a potential role of the QTc in patient risk stratification. The incorporation of biomarkers of myocardial damage (ie cardiac troponins), clinical risk scores, and other biochemical and angiographic markers in the past two decades has considerably improved the risk stratification of patients presenting with acute coronary syndrome, but further refinement of our prognostic armamentarium is still required. This article reviews the information available regarding the potential role of the QTc as a marker of increased risk in patients with acute presentations of coronary artery disease.
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Affiliation(s)
- Francisco Gadaleta
- Coronary Care Unit, Department of Cardiology, Eva Perón General Hospital, Buenos Aires, Argentina
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Bakhoya VN, Kurl S, Laukkanen JA. T-wave inversion on electrocardiogram is related to the risk of acute coronary syndrome in the general population. Eur J Prev Cardiol 2012; 21:500-6. [PMID: 22952285 DOI: 10.1177/2047487312460022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND T-wave inversion (TWI) is a frequently encountered electrocardiographic (ECG) finding during routine medical examination of asymptomatic individuals, and of patients with various clinical conditions. However, the role of isolated TWI in the prediction of acute coronary syndrome (ACS) in the community has not been extensively studied. We investigated the relationship between TWI in routine ECG and the risk for ACS in the general population. METHODS This study is based on a random sample of 1997 men aged 42-60 years in Eastern Finland. Electrocardiograms recorded at rest were classified using the Minnesota codes. The association between isolated TWI and ACS was determined using a multivariable adjusted Cox proportional hazard model. RESULTS Negative T-waves were present in 3.6% of the participants. During an average follow-up of 20 years, a total of 493 ACS events were registered. After adjusting for age, TWI was associated with a 3.10-fold (95% confidence interval (CI) 2.21-4.32) risk for ACS. After additional adjustment for previously known coronary risk factors, TWI remained statistically significant in predicting ACS (relative risk 2.23; 95% CI 1.57-3.15). Negative T-waves was one of the strongest risk markers for ACS compared with other ECG-based variables such as left ventricular hypertrophy, previous Q-wave and prolonged QRS duration. CONCLUSION TWI has a strong and independent predictive value for ACS in the general population.
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Affiliation(s)
- Victor N Bakhoya
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio Campus, Finland
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Pradhan R, Chaudhary A, Donato AA. Predictive accuracy of ST depression during rapid atrial fibrillation on the presence of obstructive coronary artery disease. Am J Emerg Med 2012; 30:1042-7. [DOI: 10.1016/j.ajem.2011.06.027] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2011] [Revised: 06/26/2011] [Accepted: 06/27/2011] [Indexed: 11/29/2022] Open
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Ferencik M, Schlett CL, Bamberg F, Truong QA, Nichols JH, Pena AJ, Shapiro MD, Rogers IS, Seneviratne S, Parry BA, Cury RC, Brady TJ, Brown DF, Nagurney JT, Hoffmann U. Comparison of traditional cardiovascular risk models and coronary atherosclerotic plaque as detected by computed tomography for prediction of acute coronary syndrome in patients with acute chest pain. Acad Emerg Med 2012; 19:934-42. [PMID: 22849339 DOI: 10.1111/j.1553-2712.2012.01417.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES The objective was to determine the association of four clinical risk scores and coronary plaque burden as detected by computed tomography (CT) with the outcome of acute coronary syndrome (ACS) in patients with acute chest pain. The hypothesis was that the combination of risk scores and plaque burden improved the discriminatory capacity for the diagnosis of ACS. METHODS The study was a subanalysis of the Rule Out Myocardial Infarction Using Computer-Assisted Tomography (ROMICAT) trial-a prospective observational cohort study. The authors enrolled patients presenting to the emergency department (ED) with a chief complaint of acute chest pain, inconclusive initial evaluation (negative biomarkers, nondiagnostic electrocardiogram [ECG]), and no history of coronary artery disease (CAD). Patients underwent contrast-enhanced 64-multidetector-row cardiac CT and received standard clinical care (serial ECG, cardiac biomarkers, and subsequent diagnostic testing, such as exercise treadmill testing, nuclear stress perfusion imaging, and/or invasive coronary angiography), as deemed clinically appropriate. The clinical providers were blinded to CT results. The chest pain score was calculated and the results were dichotomized to ≥10 (high-risk) and <10 (low-risk). Three risk scores were calculated, Goldman, Sanchis, and Thrombolysis in Myocardial Infarction (TIMI), and each patient was assigned to a low-, intermediate-, or high-risk category. Because of the low number of subjects in the high-risk group, the intermediate- and high-risk groups were combined into one. CT images were evaluated for the presence of plaque in 17 coronary segments. Plaque burden was stratified into none, intermediate, and high (zero, one to four, and more than four segments with plaque). An outcome panel of two physicians (blinded to CT findings) established the primary outcome of ACS (defined as either an acute myocardial infarction or unstable angina) during the index hospitalization (from the presentation to the ED to the discharge from the hospital). Logistic regression modeling was performed to examine the association of risk scores and coronary plaque burden to the outcome of ACS. Unadjusted models were individually fitted for the coronary plaque burden and for Goldman, Sanchis, TIMI, and chest pain scores. In adjusted analyses, the authors tested whether the association between risk scores and ACS persisted after controlling for the coronary plaque burden. The prognostic discriminatory capacity of the risk scores and plaque burden for ACS was assessed using c-statistics. The differences in area under the receiver-operating characteristic curve (AUC) and c-statistics were tested by performing the -2 log likelihood ratio test of nested models. A p value <0.05 was considered statistically significant. RESULTS Among 368 subjects, 31 (8%) subjects were diagnosed with ACS. Goldman (AUC = 0.61), Sanchis (AUC = 0.71), and TIMI (AUC = 0.63) had modest discriminatory capacity for the diagnosis of ACS. Plaque burden was the strongest predictor of ACS (AUC = 0.86; p < 0.05 for all comparisons with individual risk scores). The combination of plaque burden and risk scores improved prediction of ACS (plaque + Goldman AUC = 0.88, plaque + Sanchis AUC = 0.90, plaque + TIMI AUC = 0.88; p < 0.01 for all comparisons with coronary plaque burden alone). CONCLUSIONS Risk scores (Goldman, Sanchis, TIMI) have modest discriminatory capacity and coronary plaque burden has good discriminatory capacity for the diagnosis of ACS in patients with acute chest pain. The combined information of risk scores and plaque burden significantly improves the discriminatory capacity for the diagnosis of ACS.
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Affiliation(s)
- Maros Ferencik
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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Nikus KC, Sclarovsky S, Huhtala H, Niemelä K, Karhunen P, Eskola MJ. Electrocardiographic presentation of global ischemia in acute coronary syndrome predicts poor outcome. Ann Med 2012; 44:494-502. [PMID: 21679105 DOI: 10.3109/07853890.2011.585345] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Global ischemia (GI) electrocardiogram (ECG), wide-spread ST depression with inverted T waves maximally in leads V(4-5), and lead aVR ST elevation (STE), is a marker of an adverse outcome in patients with non-ST elevation acute coronary syndromes (ACS), perhaps because this pattern is indicative of left main stenosis. The prognostic value of this ECG pattern has not been established. AIMS The distribution of ECG changes and the prognostic value of the GI ECG were studied. METHODS ECGs of consecutive patients admitted with suspected ACS (n = 1,188) were classified into seven ECG categories: STE, Q waves without STE, left bundle branch block, left ventricular hypertrophy, GI ECG, other ST depression and/or T wave inversion, and other findings. RESULTS The GI ECG pattern predicted a high rate (48%) of composite end-points (mortality, re-infarction, unstable angina, resuscitation, or stroke) at 10-month follow-up compared to the other ECG categories (36%) (HR 1.78; CI 95% 1.31-2.41; P < 0.001). In multivariate analysis, the GI ECG pattern was associated with a higher rate of composite end-points (HR 1.40; CI 95% 1.02-1.91; P = 0.035). The multivariate analysis furthermore identified age, creatinine level, and diabetes as independent predictors of prognosis. CONCLUSIONS The GI ECG pattern predicted an unfavorable outcome, when compared to other ECG patterns in patients with ACS.
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Affiliation(s)
- Kjell C Nikus
- Heart Center, Department of Cardiology, Tampere University Hospital, Tampere, Finland
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Risk stratification and timing of revascularization: which patients benefit from early versus later revascularization? Curr Cardiol Rep 2012; 14:510-20. [PMID: 22581166 DOI: 10.1007/s11886-012-0279-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
In acute coronary syndromes, risk stratification is essential, particularly in patients without ST elevation, and is based upon clinical, electrocardiogram (ECG), and biological markers. Among them, recent and repeated attacks of angina, ST-segment deviation from baseline on the admission ECG as well as elevated markers of myonecrosis (particularly increased troponin levels), myocardial dysfunction (B-type natriuretic peptide [BNP]; N-terminal prohormone of BNP[NT-proBNP]), and inflammation (high-sensitivity C-reactive protein) are predictors of an adverse outcome. These variables can be incorporated into broader risk predictive scores, among which the TIMI (Thrombolysis in Myocardial Infarction) and GRACE (Global Registry of Acute Coronary Events) scores are the most widely used. Two general therapeutic strategies (routine invasive vs conservative or selective invasive) are employed in the treatment of non-ST-segment elevation acute coronary syndrome (NSTEACS). Evidence-based analysis and the current American College of Cardiology/American Heart Association/Society for Cardiac Angiography and Interventions clinical practice guidelines recommend an early invasive treatment strategy (8-24 h) for intermediate or high clinical risk patients with NSTEACS.
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Conti A, Poggioni C, Viviani G, Luzzi M, Vicidomini S, Zanobetti M, Innocenti F, Pini R, Padeletti L, Gensini GF. Short- and long-term cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram. Am J Emerg Med 2012; 30:1698-705. [PMID: 22425002 DOI: 10.1016/j.ajem.2012.01.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 01/12/2012] [Accepted: 01/14/2012] [Indexed: 11/30/2022] Open
Abstract
AIM The aim of this study is to evaluate incidence of adverse cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram (ECG) and initial troponin. METHODS Prospective, nonrandomized study enrolled low-risk patients with normal ECG and troponin on admission who underwent observation and/or stress testing by unstandardized clinical judgment. Patients who experienced recurrent angina or positive ECGs or positive troponins during observation or patients with positive stress testing were admitted; otherwise, they were discharged. END POINT The end points are cardiac events at short- and long-term follow-up including cardiovascular death, myocardial infarction, unstable angina, and revascularization. RESULTS Of 5656 patients considered, 1732 with ischemic ECG were initially admitted and, therefore, excluded from the analysis; 2860 with pleuritic chest pain and normal ECG were discharged; 1064 with visceral chest pain and normal ECG were enrolled. Patients with known coronary disease (45%) were older and likely presented known vascular disease. Patients with known vascular disease, older age, female sex, diabetes mellitus, and lower chest pain score were likely managed with observation. In patients with known coronary disease as compared with patients without, overall cardiac events account for 35% vs 14%, respectively (P < .001), as follows: in-hospital, 23% vs 10%, (P < .001); 1 month, 4% vs 2% (P = .133); and 9.9 ± 4.9 months, 8% vs 2%, respectively (P < .001). CONCLUSIONS One-third of patients with chest pain with known coronary disease, negative ECG, and biomarkers were subsequently found to have adverse cardiac events. The value of this research for an emergency medicine audience could be extended to all clinicians and general practitioners beyond cardiologists.
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Affiliation(s)
- Alberto Conti
- Department of Critical Care Medicine and Surgery, Careggi University Hospital, Florence, Italy.
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Palmerini T, Caixeta A, Genereux P, Cristea E, Lansky A, Mehran R, Dangas G, Lazar D, Sanchez R, Fahy M, Xu K, Stone GW. Comparison of clinical and angiographic prognostic risk scores in patients with acute coronary syndromes: Analysis from the Acute Catheterization and Urgent Intervention Triage StrategY (ACUITY) trial. Am Heart J 2012; 163:383-91, 391.e1-5. [PMID: 22424008 DOI: 10.1016/j.ahj.2011.11.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 11/07/2011] [Indexed: 01/16/2023]
Abstract
BACKGROUND Several prognostic risk scores have been developed for patients with coronary artery disease, but their comparative use in patients with non-ST-segment elevation acute coronary syndromes (NSTEACS) undergoing percutaneous coronary intervention (PCI) has not been examined. We therefore investigated the accuracy of the Synergy Between PCI With Taxus and Cardiac Surgery (SYNTAX) score, Clinical Synergy Between PCI With Taxus and Cardiac Surgery score (CSS), New Risk Stratification (NERS) score (NERS), Age, Creatinine, Ejection Fraction (ACEF) score, Global Registry for Acute Coronary Events (GRACE) score, and Thrombolysis in Myocardial Infarction (TIMI) score for risk assessment of 1-year mortality, cardiac mortality, myocardial infarction, target vessel revascularization, and stent thrombosis in patients with NSTEACS undergoing PCI. METHODS The 6 scores were determined in 2,094 patients with NSTEACS treated with PCI enrolled in the angiographic substudy of the ACUITY trial. The prognostic accuracy of the 6 scores was assessed using the c statistic for discrimination and the Hosmer-Lemeshow test for calibration. The index of separation and net reclassification improvement (NRI) were also determined. RESULTS Scores incorporating clinical and angiographic variables (CSS and NERS) showed the best tradeoff between discrimination and calibration for most end points, with the best discrimination for all end points and good calibration for most of them. The CSS had the best index of separation for most ischemic endpoints and displayed an NRI for cardiac death and myocardial infarction (MI) compared to the other scores, whereas NERS displayed an NRI for all-cause death and target vessel revascularization. The 3 scores-CSS, NERS, and SYNTAX-were the only scores to have both good discrimination and calibration for cardiac mortality. CONCLUSIONS In patients with NSTEACS undergoing PCI, risk scores incorporating clinical and angiographic variables had the highest predictive accuracy for a broad spectrum of ischemic end points.
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