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Alencar JND, Feres F, Marchi MFND, Franchini KG, Scheffer MK, Felicioni SP, Costa ACM, Fernandes RC, Ramadan HR, Meyers P, Smith SW. Beyond STEMI-NSTEMI Paradigm: Dante Pazzanese's Proposal for Occlusion Myocardial Infarction Diagnosis. Arq Bras Cardiol 2024; 121:e20230733. [PMID: 39016396 PMCID: PMC11216332 DOI: 10.36660/abc.20230733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/11/2024] [Accepted: 03/13/2024] [Indexed: 07/18/2024] Open
Abstract
Although the existing framework for classifying acute myocardial infarction (AMI) into STEMI and NSTEMI has been beneficial, it is now considered to be falling short in addressing the complexity of acute coronary syndromes. The study aims to scrutinize the current STEMI-NSTEMI paradigm and advocate for a more nuanced framework, termed as occlusion myocardial infarction (OMI) and non-occlusion myocardial infarction (NOMI), for a more accurate diagnosis and management of AMI. A comprehensive analysis of existing medical literature was conducted, with a focus on the limitations of the STEMI-NSTEMI model. The study also outlines a new diagnostic approach for patients presenting with chest pain in emergency settings. The traditional STEMI-NSTEMI model falls short in diagnostic precision and effective treatment, especially in identifying acute coronary artery occlusions. The OMI-NOMI framework offers a more anatomically and physiologically accurate model, backed by a wealth of clinical research and expert opinion. It underscores the need for quick ECG assessments and immediate reperfusion therapies for suspected OMI cases, aiming to improve patient outcomes. The OMI-NOMI framework offers a new avenue for future research and clinical application. It advocates for a more comprehensive understanding of the underlying mechanisms of acute coronary syndromes, leading to individualized treatment plans. This novel approach is expected to ignite further scholarly debate and research, particularly in the Brazilian cardiology sector, with the goal of enhancing diagnostic accuracy and treatment effectiveness in AMI patients.
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Affiliation(s)
- José Nunes De Alencar
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Fausto Feres
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | | | - Kleber Gomes Franchini
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Matheus Kiszka Scheffer
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Sandro Pinelli Felicioni
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Ana Carolina Muniz Costa
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Rinaldo Carvalho Fernandes
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Hugo Ribeiro Ramadan
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Pendell Meyers
- Carolinas Medical CenterDepartment of Emergency MedicineCharlotteNCEUACarolinas Medical Center – Department of Emergency Medicine, Charlotte, NC – EUA
| | - Stephen W. Smith
- Department of Emergency Medicine and University of MinnesotaHennepin HealthcareMinneapolisMNEUAHennepin Healthcare, Department of Emergency Medicine and University of Minnesota, Minneapolis, MN – EUA
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Smith SW, Meyers HP. ST Elevation is a poor surrogate for acute coronary occlusion. Let's Replace STEMI with Occlusion MI (OMI)!! Int J Cardiol 2024; 407:131980. [PMID: 38513733 DOI: 10.1016/j.ijcard.2024.131980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 03/17/2024] [Indexed: 03/23/2024]
Affiliation(s)
- Stephen W Smith
- Hennepin Healthcare, ER R-2, 701 S. Park Ave, Minneapolis, MN 55419, United States; Department of Emergency Medicine, Hennepin Healthcare and The University of Minnesota School of Medicine, United States.
| | - H Pendell Meyers
- Hennepin Healthcare, ER R-2, 701 S. Park Ave, Minneapolis, MN 55419, United States
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Kelham M, Vyas R, Ramaseshan R, Rathod K, de Winter RJ, de Winter RW, Bendz B, Thiele H, Hirlekar G, Morici N, Myat A, Michalis LK, Sanchis J, Kunadian V, Berry C, Mathur A, Jones DA. Non-ST-elevation acute coronary syndromes with previous coronary artery bypass grafting: a meta-analysis of invasive vs. conservative management. Eur Heart J 2024; 45:2380-2391. [PMID: 38805681 PMCID: PMC11242441 DOI: 10.1093/eurheartj/ehae245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 03/20/2024] [Accepted: 04/07/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND AND AIMS A routine invasive strategy is recommended in the management of higher risk patients with non-ST-elevation acute coronary syndromes (NSTE-ACSs). However, patients with previous coronary artery bypass graft (CABG) surgery were excluded from key trials that informed these guidelines. Thus, the benefit of a routine invasive strategy is less certain in this specific subgroup. METHODS A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted. A comprehensive search was performed of PubMed, EMBASE, Cochrane, and ClinicalTrials.gov. Eligible studies were RCTs of routine invasive vs. a conservative or selective invasive strategy in patients presenting with NSTE-ACS that included patients with previous CABG. Summary data were collected from the authors of each trial if not previously published. Outcomes assessed were all-cause mortality, cardiac mortality, myocardial infarction, and cardiac-related hospitalization. Using a random-effects model, risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. RESULTS Summary data were obtained from 11 RCTs, including previously unpublished subgroup outcomes of nine trials, comprising 897 patients with previous CABG (477 routine invasive, 420 conservative/selective invasive) followed up for a weighted mean of 2.0 (range 0.5-10) years. A routine invasive strategy did not reduce all-cause mortality (RR 1.12, 95% CI 0.97-1.29), cardiac mortality (RR 1.05, 95% CI 0.70-1.58), myocardial infarction (RR 0.90, 95% CI 0.65-1.23), or cardiac-related hospitalization (RR 1.05, 95% CI 0.78-1.40). CONCLUSIONS This is the first meta-analysis assessing the effect of a routine invasive strategy in patients with prior CABG who present with NSTE-ACS. The results confirm the under-representation of this patient group in RCTs of invasive management in NSTE-ACS and suggest that there is no benefit to a routine invasive strategy compared to a conservative approach with regard to major adverse cardiac events. These findings should be validated in an adequately powered RCT.
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Affiliation(s)
- Matthew Kelham
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Rohan Vyas
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Rohini Ramaseshan
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Krishnaraj Rathod
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Robbert J de Winter
- Department of Cardiology Heart Center, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, The Netherlands
| | - Ruben W de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bjorn Bendz
- Department of Cardiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Geir Hirlekar
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Nuccia Morici
- IRCCS S. Maria Nascente-Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Aung Myat
- Medical Director (Cardiology), Medpace UK, London, UK
| | - Lampros K Michalis
- 2nd Department of Cardiology, Faculty of Medicine, School of Health Sciences, University of Ioannina and University Hospital of Ioannina, University Campus, Ioannina 45110, Greece
| | - Juan Sanchis
- Cardiology Department, University Clinic Hospital of València, INCLIVA University of València, CIBER CV, València, Spain
| | - Vijay Kunadian
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust and Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Colin Berry
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Anthony Mathur
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
- NIHR Barts Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London, UK
| | - Daniel A Jones
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
- NIHR Barts Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London, UK
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Sharma V, Choudhury A, Basavarajaiah S, Rashid M, Yuan M, Jefferey D, Vanezis AP, Sall H, Smith WHT, Parasa R, Kelly P, Kinnaird T, Mamas MA. Chronic total occlusion in non-ST elevation myocardial infarction - A multi-centre observational study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 64:62-67. [PMID: 38395628 DOI: 10.1016/j.carrev.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 02/11/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVES To evaluate the characteristics and outcomes of patients with a chronic total occlusion (CTO) in a Non-ST Elevation Myocardial Infarction (NSTEMI) cohort. BACKGROUND There is limited data on the clinical characteristics, revascularisation strategies and outcomes of patients presenting with a NSTEMI and a CTO. METHODS Retrospective analysis of a six-centre percutaneous coronary intervention (PCI) registry in the UK between January 2015 and December 2020 was performed. Patients with a NSTEMI with and without a CTO were compared for baseline characteristics and outcomes. RESULTS There were 17,355 NSTEMI patients in total of whom 1813 patients had a CTO (10.4 %). Patients with a CTO were more likely to be older (CTO: 67.8 (±11.5) years vs. no CTO: 67.2 (±12) years, p = 0.04), male (CTO: 81.1 % vs.71.9 %, p < 0.0001) with a greater prevalence of cardiovascular risk factors. All-cause mortality at 30 days: HR 2.63, 95 % CI 1.42-4.84, p = 0.002 and at 1 year: HR: 1.87, 95 % CI 1.25-2.81, p = 0.003 was higher in the CTO cohort. CTO patients who underwent revascularisation were younger (Revascularisation 66.4 [±11.7] years vs. no revascularisation 68.4 [±11.4] years, p = 0.001). Patients with failed CTO revascularisation had lower survival (HR 0.21, 95 % CI 0.10-0.42, p < 0.0001). The mean time to revascularisation was 13.4 days. There was variation in attempt at CTO revascularisation between the 6 centres for (16 % to 100 %) with success rates ranging from 65 to 100 %. CONCLUSIONS In conclusion, the presence of a CTO in NSTEMI patients undergoing PCI was associated with worse in-hospital and long-term outcomes.
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Affiliation(s)
- Vinoda Sharma
- Birmingham City Hospital, Birmingham, United Kingdom of Great Britain and Northern Ireland; University of Birmingham, United Kingdom of Great Britain and Northern Ireland.
| | - Anirban Choudhury
- Morriston Cardiac Centre, Swansea, United Kingdom of Great Britain and Northern Ireland
| | - Sandeep Basavarajaiah
- Heartlands Hospital, Birmingham, United Kingdom of Great Britain and Northern Ireland
| | - Muhammad Rashid
- Royal Stoke Hospital, University Hospital North Midlands, Stoke-on-Trent, United Kingdom of Great Britain and Northern Ireland; Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, United Kingdom of Great Britain and Northern Ireland
| | - Mengshi Yuan
- Birmingham City Hospital, Birmingham, United Kingdom of Great Britain and Northern Ireland
| | - Daniel Jefferey
- Morriston Cardiac Centre, Swansea, United Kingdom of Great Britain and Northern Ireland
| | - Andrew P Vanezis
- Trent Cardiac Centre, Nottingham University Hospitals, Nottingham, United Kingdom of Great Britain and Northern Ireland
| | - Hanish Sall
- Trent Cardiac Centre, Nottingham University Hospitals, Nottingham, United Kingdom of Great Britain and Northern Ireland
| | - William H T Smith
- Trent Cardiac Centre, Nottingham University Hospitals, Nottingham, United Kingdom of Great Britain and Northern Ireland
| | - Ramya Parasa
- The Essex Cardiothoracic Centre, Basildon, United Kingdom of Great Britain and Northern Ireland
| | - Paul Kelly
- The Essex Cardiothoracic Centre, Basildon, United Kingdom of Great Britain and Northern Ireland
| | - Tim Kinnaird
- University Hospital Wales, Cardiff, United Kingdom of Great Britain and Northern Ireland
| | - Mamas A Mamas
- Royal Stoke Hospital, University Hospital North Midlands, Stoke-on-Trent, United Kingdom of Great Britain and Northern Ireland; Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, United Kingdom of Great Britain and Northern Ireland
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Lee SD, Kim RB, Seo CO, Kim M, Lee HJ, Kim H, Kim HR, Kim K, Kang MG, Park JR, Hwang SJ, Hwang JY, Jeong MH, Hur SH, Cha KS, Koh JS. Very early vs delayed invasive strategy in high-risk NSTEMI patients without hemodynamic instability: Insight from the KAMIR-NIH. PLoS One 2024; 19:e0304273. [PMID: 38843207 PMCID: PMC11156373 DOI: 10.1371/journal.pone.0304273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 05/09/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND High-risk non-ST-elevation myocardial infarction (NSTEMI) patients' optimal timing for percutaneous coronary intervention (PCI) is debated despite the recommendation for early invasive revascularization. This study aimed to compare outcomes of NSTEMI patients without hemodynamic instability undergoing very early invasive strategy (VEIS, ≤ 12 hours) versus delayed invasive strategy (DIS, >12 hours). METHODS Excluding urgent indications for PCI including initial systolic blood pressure under 90 mmHg, ventricular arrhythmia, or Killip class IV, 4,733 NSTEMI patients were recruited from the Korea Acute Myocardial Infarction Registry-National Institutes of Health (KAMIR-NIH). Patients were divided into low and high- global registry of acute coronary events risk score risk score (GRS) groups based on 140. Both groups were then categorized into VEIS and DIS. Clinical outcomes, including all-cause death (ACD), cardiac death (CD), recurrent MI, and cerebrovascular accident at 12 months, were evaluated. RESULTS Among 4,733 NSTEMI patients, 62% had low GRS, and 38% had high GRS. The proportions of VEIS and DIS were 43% vs. 57% in the low GRS group and 47% vs. 53% in the high GRS group. In the low GRS group, VEIS and DIS demonstrated similar outcomes; however, in the high GRS group, VEIS exhibited worse ACD outcomes compared to DIS (HR = 1.46, P = 0.003). The adverse effect of VEIS was consistent with propensity score matched analysis (HR = 1.34, P = 0.042). CONCLUSION VEIS yielded worse outcomes than DIS in high-risk NSTEMI patients without hemodynamic instability in real-world practice.
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Affiliation(s)
- Seung Do Lee
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Rock Bum Kim
- Department of Preventive Medicine and Institute of Health Sciences, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Chang-Ok Seo
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Moojun Kim
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Hyo Jin Lee
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Hangyul Kim
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Hye Ree Kim
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Kyehwan Kim
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Min Gyu Kang
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Jeong Rang Park
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Suk Jae Hwang
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Jin Yong Hwang
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Myung Ho Jeong
- Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Seung-Ho Hur
- Keimyung University Dongsan Medical Center, Cardiovascular Medicine, Deagu, Republic of Korea
| | - Kwang Soo Cha
- Pusan National University Hospital, Busan, South Korea
| | - Jin-Sin Koh
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
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Lim Y, Kim MC, Ahn JH, Lee SH, Hyun DY, Cho KH, Sim DS, Hong YJ, Kim JH, Jeong MH, Choi IJ, Choo EH, Lim S, Hwang BH, Park MW, Kim CJ, Park CS, Kim HY, Chang K, Ahn Y. Optimal timing of percutaneous coronary intervention for non-ST elevated myocardial infarction with congestive heart failure. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00447-0. [PMID: 38679500 DOI: 10.1016/j.carrev.2024.04.295] [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: 12/18/2023] [Revised: 03/30/2024] [Accepted: 04/23/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVES This study investigated the optimal timing for percutaneous coronary intervention (PCI) in patients with NSTEMI complicated by heart failure (HF). METHODS In total, 762 patients with NSTEMI and HF in a multicenter, prospective registry in South Korea were classified according to the Killip classification (Killip class 2, n = 414 and Killip class 3, n = 348) and underwent early (within 24 h) and delayed (after 24 h) PCI. The primary outcome was all-cause mortality which was further analyzed with landmark analysis with two months as a cut-off. Secondary outcomes were cardiovascular death, in-hospital cardiogenic shock (CS), readmission due to HF, and acute myocardial infarction during follow-up. RESULTS Delayed PCI was associated with lower rates of 2-month mortality (6.1 % vs. 15.8 %, p = 0.007) and in-hospital CS (4.3 % vs. 14.1 %, p = 0.003), along with lower risks of 2-month mortality (hazard ratio [HR] = 0.38, 95 % confidence interval [CI] = 0.18-0.83, p = 0.014), in-hospital CS (HR = 0.29, 95 % CI = 0.12-0.71, p = 0.006) in multivariate Cox models of Killip class 3 patients. There was no statistical difference of incidence and risk of all predefined outcomes according to varying timing of PCI in Killip 2 patients. CONCLUSIONS Based on these results, the timing of PCI in patients with NSTEMI complicated by HF should be determined based on HF severity. Delayed PCI should be considered in patients with NSTEMI and more severe HF.
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Affiliation(s)
- Yongwhan Lim
- Department of Cardiovascular Medicine, Chonnam National University Medical School/Hospital, Gwangju, South Korea
| | - Min Chul Kim
- Department of Cardiovascular Medicine, Chonnam National University Medical School/Hospital, Gwangju, South Korea
| | - Joon Ho Ahn
- Department of Cardiovascular Medicine, Chonnam National University Medical School/Hospital, Gwangju, South Korea
| | - Seung Hun Lee
- Department of Cardiovascular Medicine, Chonnam National University Medical School/Hospital, Gwangju, South Korea
| | - Dae Young Hyun
- Department of Cardiovascular Medicine, Chonnam National University Medical School/Hospital, Gwangju, South Korea
| | - Kyung Hoon Cho
- Department of Cardiovascular Medicine, Chonnam National University Medical School/Hospital, Gwangju, South Korea
| | - Doo Sun Sim
- Department of Cardiovascular Medicine, Chonnam National University Medical School/Hospital, Gwangju, South Korea
| | - Young Joon Hong
- Department of Cardiovascular Medicine, Chonnam National University Medical School/Hospital, Gwangju, South Korea
| | - Ju Han Kim
- Department of Cardiovascular Medicine, Chonnam National University Medical School/Hospital, Gwangju, South Korea
| | - Myung Ho Jeong
- Department of Cardiovascular Medicine, Chonnam National University Medical School/Hospital, Gwangju, South Korea
| | - Ik Jun Choi
- Division of Cardiology, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Eun Ho Choo
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sungmin Lim
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Byung-Hee Hwang
- Division of Cardiology, Department of Internal Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Mahn-Won Park
- Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Chan Joon Kim
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Chul Soo Park
- Division of Cardiology, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hee Yeol Kim
- Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Youngkeun Ahn
- Department of Cardiovascular Medicine, Chonnam National University Medical School/Hospital, Gwangju, South Korea.
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Abdelaziz A, Elsayed H, Atta K, Mechi A, Kadhim H, Aboutaleb AM, Elaraby A, Ellabban MH, Eid M, AboElfarh HE, Ibrahim RA, Zawaneh EA, Ezzat M, Abdelaziz M, Hafez A, Mahmoud A, Ghaith HS, Suppah M. A comprehensive guide on the optimal timing of PCI in the setting of acute coronary syndrome: An updated meta-analysis. Int J Cardiol 2024; 400:131774. [PMID: 38211674 DOI: 10.1016/j.ijcard.2024.131774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 11/19/2023] [Accepted: 01/07/2024] [Indexed: 01/13/2024]
Abstract
BACKGROUND Invasive revascularization is recommended for cohorts of patients with ST-elevation myocardial infarction (STEMI) and non-ST-elevation acute coronary syndrome (NSTE-ACS). However, the optimal timing of invasive revascularization is still controversial and no defined consensus is established. We aim to give a comprehensive appraisal on the optimal timing of invasive strategy in the heterogenous population of ACS. METHODS Relevant studies were assessed through PubMed, Scopus, Web of science, and Cochrane Library from inception until April 2023. Major adverse cardiovascular events (MACE) and all-cause mortality were our primary outcomes of interest, other secondary outcomes were cardiac death, TVR, MI, repeat revascularization, recurrent ischemia, and major bleeding. The data was pooled as odds ratio (OR) with its 95% confidence interval (CI) in a random effect model using STATA 17 MP. RESULTS A total of 26 studies comprising 21,443 patients were included in the analysis. Early intervention was favor to decrease all-cause mortality (OR = 0.79, 95% CI: 0.64 to 0.98, p = 0.03), when compared to delayed intervention. Subgroup analysis showed that early intervention was significantly associated with all-cause mortality reduction in only NSTE-ACS (OR = 0.83, 95% CI [0.7 to 0.99], p = 0.04). However, there was no significant difference between early and delayed intervention in terms of MACE, cardiac death, TVR, MI, repeat revascularization, recurrent ischemia, and major bleeding. CONCLUSION An early intervention was associated with lower mortality rates compared to delayed intervention in NSTE-ACS with no significant difference in other clinical outcomes. PROSPERO registration: CRD42023415574.
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Affiliation(s)
- Ahmed Abdelaziz
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
| | - Hanaa Elsayed
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Karim Atta
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Institute of Medicine, National Research Mordovia State University, Saransk, Russia
| | - Ahmed Mechi
- University of Kufa, Medicine College, Internal Medicine Department, Najaf, Iraq
| | | | - Aya Moustafa Aboutaleb
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed Elaraby
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohamed Hatem Ellabban
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mahmoud Eid
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Hadeer Elsaeed AboElfarh
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Mansoura Manchester Programme for Medical Education, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Rahma AbdElfattah Ibrahim
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Kafr Elsheikh University, Kafr Elsheikh, Egypt
| | - Emad Addin Zawaneh
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of medicine, Jordan university of science and technology, Irbid, Jordan
| | - Mahmoud Ezzat
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Mohamed Abdelaziz
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Abdelrahman Hafez
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ahmed Mahmoud
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Hazem S Ghaith
- Medical Research group of Egypt (MRGE), Cairo, Egypt; Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mustafa Suppah
- Department of Cardiovascular Medicine, Mayo Clinic, 13400 E Shea Boulevard, Scottsdale, AZ 85259, USA
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Elscot JJ, Kakar H, Scarparo P, den Dekker WK, Bennett J, Schotborgh CE, van der Schaaf R, Sabaté M, Moreno R, Ameloot K, van Bommel RJ, Forlani D, Van Reet B, Esposito G, Dirksen MT, Ruifrok WPT, Everaert BRC, Van Mieghem C, Pinar E, Alfonso F, Cummins P, Lenzen M, Brugaletta S, Daemen J, Boersma E, Van Mieghem NM, Diletti R. Timing of Complete Multivessel Revascularization in Patients Presenting With Non-ST-Segment Elevation Acute Coronary Syndrome. JACC Cardiovasc Interv 2024; 17:771-782. [PMID: 38538172 DOI: 10.1016/j.jcin.2024.01.278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Complete revascularization of the culprit and all significant nonculprit lesions in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and multivessel disease (MVD) reduces major adverse cardiac events, but optimal timing of revascularization remains unclear. OBJECTIVES This study aims to compare immediate complete revascularization (ICR) and staged complete revascularization (SCR) in patients presenting with NSTE-ACS and MVD. METHODS This prespecified substudy of the BIOVASC (Percutaneous Complete Revascularization Strategies Using Sirolimus Eluting Biodegradable Polymer Coated Stents in Patients Presenting With Acute Coronary Syndrome and Multivessel Disease) trial included patients with NSTE-ACS and MVD. Risk differences of the primary composite outcome of all-cause mortality, myocardial infarction (MI), unplanned ischemia-driven revascularization (UIDR), or cerebrovascular events and its individual components were compared between ICR and SCR at 1 year. RESULTS The BIOVASC trial enrolled 1,525 patients; 917 patients presented with NSTE-ACS, of whom 459 were allocated to ICR and 458 to SCR. Incidences of the primary composite outcome were similar in the 2 groups (7.9% vs 10.1%; risk difference 2.2%; 95% CI: -1.5 to 6.0; P = 0.15). ICR was associated with a significant reduction of MIs (2.0% vs 5.3%; risk difference 3.3%; 95% CI: 0.9 to 5.7; P = 0.006), which was maintained after exclusion of procedure-related MIs occurring during the index or staged procedure (2.0% vs 4.4%; risk difference 2.4%; 95% CI: 0.1 to 4.7; P = 0.032). UIDRs were also reduced in the ICR group (4.2% vs 7.8%; risk difference 3.5%; 95% CI: 0.4 to 6.6; P = 0.018). CONCLUSIONS ICR is safe in patients with NSTE-ACS and MVD and was associated with a reduction in MIs and UIDRs at 1 year.
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Affiliation(s)
- Jacob J Elscot
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Hala Kakar
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Paola Scarparo
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Wijnand K den Dekker
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Johan Bennett
- Department of Cardiovascular Medicine, University Hospital Leuven, Leuven, Belgium
| | | | - René van der Schaaf
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Manel Sabaté
- Interventional Cardiology Department, Cardiovascular Institute, Hospital Clínic, Barcelona, Spain
| | - Raúl Moreno
- Interventional Cardiology Unit, Cardiology Department, La Paz University Hospital, Madrid, Spain
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos, Belgium
| | | | - Daniele Forlani
- Department of Cardiology, Santo Spirito Hospital, Pescara, Italy
| | - Bert Van Reet
- Department of Cardiology, AZ Turnhout, Turnhout, Belgium
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Maurits T Dirksen
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands
| | | | | | | | - Eduardo Pinar
- Department of Cardiology, Interventional Cardiology Unit, Virgen de la Arrixaca Hospital, Murcia, Spain
| | - Fernando Alfonso
- Department of Cardiology, Hospital Universitario de La Princesa Madrid, Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
| | - Paul Cummins
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Mattie Lenzen
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Joost Daemen
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Eric Boersma
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Roberto Diletti
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands.
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Díez-Delhoyo F, López Lluva MT, Cepas-Guillén P, Jurado-Román A, Bazal-Chacón P, Negreira-Caamaño M, Olavarri-Miguel I, Elorriaga A, Fernández-Sánchez JA, Escribano D, Salinas P, Vaquero-Luna J, Prieto-Lobato A, Pérez-Cebey L, Carrasquer A, Llaóo I, Torres Mezcúa FJ, Giralt-Borrell T, Abellas M, García-Blas S, Matute-Blanco L, Robles-Gamboa C, Martínez-Guisado A, Fernández-Cordón C, González-Maniega C, Díez-Villanueva P. Timing of coronary angiography and use of antiplatelet pretreatment in patients with NSTEACS in Spain. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:234-242. [PMID: 38476000 DOI: 10.1016/j.rec.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/27/2023] [Indexed: 03/14/2024]
Abstract
INTRODUCTION AND OBJECTIVES The optimal timing of coronary angiography in patients admitted with non-ST-segment elevation acute coronary syndrome (NSTEACS) as well as the need for pretreatment are controversial. The main objective of the IMPACT-TIMING-GO registry was to assess the proportion of patients undergoing an early invasive strategy (0-24hours) without dual antiplatelet therapy (no pretreatment strategy) in Spain. METHODS This observational, prospective, and multicenter study included consecutive patients with NSTEACS who underwent coronary angiography that identified a culprit lesion. RESULTS Between April and May 2022, we included 1021 patients diagnosed with NSTEACS, with a mean age of 67±12 years (23.6% women). A total of 87% of the patients were deemed at high risk (elevated troponin; electrocardiogram changes; GRACE score>140) but only 37.8% underwent an early invasive strategy, and 30.3% did not receive pretreatment. Overall, 13.6% of the patients underwent an early invasive strategy without pretreatment, while the most frequent strategy was a deferred angiography under antiplatelet pretreatment (46%). During admission, 9 patients (0.9%) died, while major bleeding occurred in 34 (3.3%). CONCLUSIONS In Spain, only 13.6% of patients with NSTEACS undergoing coronary angiography received an early invasive strategy without pretreatment. The incidence of cardiovascular and severe bleeding events during admission was low.
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Affiliation(s)
| | | | | | | | - Pablo Bazal-Chacón
- Servicio de Cardiología, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain
| | | | - Iván Olavarri-Miguel
- Servicio de Cardiología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain
| | - Ane Elorriaga
- Servicio de Cardiología, Hospital Universitario de Basurto, Bilbao, Vizcaya, Spain
| | | | - David Escribano
- Servicio de Cardiología, Hospital Universitario San Juan de Alicante, San Juan de Alicante, Alicante, Spain
| | - Pablo Salinas
- Servicio de Cardiología, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | | | | | - Lucía Pérez-Cebey
- Servicio de Cardiología, Hospital Universitario de A Coruña, A Coruña, Spain
| | - Anna Carrasquer
- Servicio de Cardiología, Hospital Joan XXIII, Tarragona, Spain
| | - Isaac Llaóo
- Servicio de Cardiología, Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | | | - María Abellas
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Sergio García-Blas
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Lucía Matute-Blanco
- Servicio de Cardiología, Hospital Universitario Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida (IRBLleida), Lleida, Spain
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10
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Liontou C, Kalogera V, Oikonomou D, Stalikas D, Pappas L, Triantafyllou K. Diagnostic performance of quantitative flow ratio in non-ST elevation acute coronary syndromes in comparison to non-hyperemic pressure ratios: a prospective study. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023; 39:2567-2574. [PMID: 37882959 DOI: 10.1007/s10554-023-02967-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 09/21/2023] [Indexed: 10/27/2023]
Abstract
Quantitative flow ratio (QFR) is a new angiography-based coronary physiology tool aimed to evaluate functional relevance of intermediate coronary lesions. Aim of the study is to assess diagnostic performance of QFR in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) in comparison to currently used non-hyperaemic pressure ratios (NHPRs). In this prospective, single-centre study, coronary physiology of intermediate coronary stenoses of non-culprit vessels in patients presenting with NSTE-ACS was evaluated using NHPRs (iFR, DFR or RFR). Subsequently, QFR was computed offline by a QFR analyst blinded to the NHPR results. Diagnostic performance of QFR was assessed in comparison to NHPRs as reference standard. A total of 60 vessels with intermediate coronary stenoses was investigated. The NHPRs were used as follows: RFR 38%, DFR 47% and iFR 15% of the cases. The NHPR result was positive, showing significant lesion, in 19 cases. A significant correlation was found between NHPR and QFR (r = 0.84, p < 0.001). Classification agreement of the two methods (95%) and diagnostic performance of QFR in comparison to NHPR (AUC: 0.962 [0.914-1.00]) were both high. Sensitivity, specificity, positive and negative predictive value of QFR in comparison to NHPR were 84.2%, 100%, 100% and 93.2% respectively. QFR has high diagnostic performance in detecting functionally significant lesions of non-culprit arteries in patients with NSTE-ACS and multivessel disease. Due to its high negative predictive value, it can be used to safely avoid unnecessary invasive physiological assessment of these lesions.
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Affiliation(s)
- Catherine Liontou
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece.
| | - Vasiliki Kalogera
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece
| | - Dimitrios Oikonomou
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece
| | - Dimitrios Stalikas
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece
| | - Loukas Pappas
- 1st Cardiology Department, Evaggelismos General Hospital, Ipsilantou Str. 45-47, 10676, Athens, Greece
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11
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Faro DC, Laudani C, Agnello FG, Ammirabile N, Finocchiaro S, Legnazzi M, Mauro MS, Mazzone PM, Occhipinti G, Rochira C, Scalia L, Spagnolo M, Greco A, Capodanno D. Complete Percutaneous Coronary Revascularization in Acute Coronary Syndromes With Multivessel Coronary Disease: A Systematic Review. JACC Cardiovasc Interv 2023; 16:2347-2364. [PMID: 37821180 DOI: 10.1016/j.jcin.2023.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 06/06/2023] [Accepted: 07/18/2023] [Indexed: 10/13/2023]
Abstract
Multivessel disease (MVD) affects approximately 50% of patients with acute coronary syndromes (ACS) and is significantly burdened by poor outcomes and high mortality. It represents a clinical challenge in patient management and decision making and subtends an evolving research area related to the pathophysiology of unstable plaques and local or systemic inflammation. The benefits of complete revascularization are established in hemodynamically stable ACS patients with MVD, and guidelines provide some reference points to inform clinical practice, based on an evidence level that is solid for ST-segment elevation myocardial infarction and less robust for non-ST-segment elevation myocardial infarction and cardiogenic shock. However, several areas of uncertainty remain, such as the optimal timing for complete revascularization or the best guiding strategy for intermediate stenoses. We performed a systematic review of current evidence in the field of percutaneous revascularization in ACS and MVD, also including future perspectives from ongoing trials that will directly compare different timing strategies and investigate the role of invasive and noninvasive guidance techniques. (Complete percutaneous coronary revascularization in patients with acute myocardial infarction and multivessel disease; CRD42022383123).
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Affiliation(s)
- Denise Cristiana Faro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Federica Giuseppa Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Nicola Ammirabile
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Marco Legnazzi
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Lorenzo Scalia
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico G. Rodolico-San Marco, University of Catania, Catania, Italy.
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12
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Zhao YJ, Sun Y, Wang F, Cai YY, Alolga RN, Qi LW, Xiao P. Comprehensive evaluation of time-varied outcomes for invasive and conservative strategies in patients with NSTE-ACS: a meta-analysis of randomized controlled trials. Front Cardiovasc Med 2023; 10:1197451. [PMID: 37745128 PMCID: PMC10516546 DOI: 10.3389/fcvm.2023.1197451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 08/18/2023] [Indexed: 09/26/2023] Open
Abstract
Background Results from randomized controlled trials (RCTs) and meta-analyses comparing invasive and conservative strategies in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) are highly debatable. We systematically evaluate the efficacy of invasive and conservative strategies in NSTE-ACS based on time-varied outcomes. Methods The RCTs for the invasive versus conservative strategies were identified by searching PubMed, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov. Trial data for studies with a minimum follow-up time of 30 days were included. We categorized the follow-up time into six varied periods, namely, ≤6 months, 1 year, 2 years, 3 years, 5 years, and ≥10 years. The time-varied outcomes were major adverse cardiovascular event (MACE), death, myocardial infarction (MI), rehospitalization, cardiovascular death, bleeding, in-hospital death, and in-hospital bleeding. Risk ratios (RRs) and 95% confidence intervals (Cis) were calculated. The random effects model was used. Results This meta-analysis included 30 articles of 17 RCTs involving 12,331 participants. We found that the invasive strategy did not provide appreciable benefits for NSTE-ACS in terms of MACE, death, and cardiovascular death at all time points compared with the conservative strategy. Although the risk of MI was reduced within 6 months (RR 0.80, 95% CI 0.68-0.94) for the invasive strategy, no significant differences were observed in other periods. The invasive strategy reduced the rehospitalization rate within 6 months (RR 0.69, 95% CI 0.52-0.90), 1 year (RR 0.73, 95% CI 0.63-0.86), and 2 years (RR 0.77, 95% CI 0.60-1.00). Of note, an increased risk of bleeding (RR 1.80, 95% CI 1.28-2.54) and in-hospital bleeding (RR 2.17, 95% CI 1.52-3.10) was observed for the invasive strategy within 6 months. In subgroups stratified by high-risk features, the invasive strategy decreased MACE for patients aged ≥65 years within 6 months (RR 0.68, 95% CI 0.58-0.78) and 1 year (RR 0.75, 95% CI 0.62-0.91) and showed benefits for men within 6 months (RR 0.71, 95% CI 0.55-0.92). In other subgroups stratified according to diabetes, ST-segment deviation, and troponin levels, no significant differences were observed between the two strategies. Conclusions An invasive strategy is superior to a conservative strategy in reducing early events for MI and rehospitalizations, but the invasive strategy did not improve the prognosis in long-term outcomes for patients with NSTE-ACS. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021289579, identifier PROSPERO 2021 CRD42021289579.
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Affiliation(s)
- Yi-Jing Zhao
- State Key Laboratory of Natural Medicines, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, China
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
| | - Yangyang Sun
- Department of Pharmacy, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Fan Wang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Yuan-Yuan Cai
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
| | - Raphael N. Alolga
- State Key Laboratory of Natural Medicines, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, China
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
| | - Lian-Wen Qi
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
- College of Traditional Chinese Medicine and Food Engineering, Shanxi University of Chinese Medicine, Taiyuan, China
| | - Pingxi Xiao
- Department of Cardiology, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Balasubramanian RN, Mills GB, Wilkinson C, Mehran R, Kunadian V. Role and relevance of risk stratification models in the modern-day management of non-ST elevation acute coronary syndromes. Heart 2023; 109:504-510. [PMID: 36104217 DOI: 10.1136/heartjnl-2022-321470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/24/2022] [Indexed: 11/04/2022] Open
Abstract
We summarise the international guidelines surrounding risk stratification as well as discuss new emerging data for future development of a new risk model in the management of patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS). NSTE-ACS accounts for the bulk of acute coronary syndrome presentations in the UK, but management strategies in this group of patients have remained a subject of debate for decades. Patients with NSTE-ACS represent a heterogeneous population with a wide variation in short-term and long-term clinical outcomes, which makes a uniform, standardised treatment approach ineffective and inappropriate. Studies in the modern era have provided some guidance in treating this subset of patients: the provision of early, more potent therapies has been shown to improve outcomes in patients at a particularly elevated risk of adverse outcomes. International guidelines recommend adopting an individualised treatment approach through the use of validated risk prediction models to identify such patients at high risk of adverse outcomes. The present available evidence, however, is based on dated demographics, different diagnostic thresholds and outdated therapies. In particular, the evidence has limited applicability to female patients and older people with frailty. Moreover, the current risk models do not capture key prognostic variables, leading to an inaccurate estimation of patients' baseline risk and subsequent mistreatment. Therefore, the current risk models are no longer fit for purpose and there is a need for risk prediction scores that account for different population demographics, higher sensitivity troponin assays and contemporary treatment options.
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Affiliation(s)
| | - Greg B Mills
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Chris Wilkinson
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vijay Kunadian
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK .,Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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14
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Helber AR, Helfer DR, Ferko AR, Klein DD, Elchediak D, Deaner TS, Slagle D, White WB, Buckler DG, Mitchell OJL, Fiorilli PN, Isenberg DL, Nomura JT, Murphy KA, Sigal A, Saif H, Reihart MJ, Vernon TM, Abella BS. Timing and Outcomes After Coronary Angiography Following Out-of-Hospital Cardiac Arrest Without Signs of ST-Segment Elevation Myocardial Infarction. J Emerg Med 2023; 64:439-447. [PMID: 36997434 DOI: 10.1016/j.jemermed.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/15/2022] [Accepted: 01/06/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND There is broad consensus that resuscitated out-of-hospital cardiac arrest (OHCA) patients with ST-segment elevation myocardial infarction (STEMI) should receive immediate coronary angiography (CAG); however, factors that guide patient selection and optimal timing of CAG for post-arrest patients without evidence of STEMI remain incompletely described. OBJECTIVE We sought to describe the timing of post-arrest CAG in actual practice, patient characteristics associated with decision to perform immediate vs. delayed CAG, and patient outcomes after CAG. METHODS We conducted a retrospective cohort study at seven U.S. academic hospitals. Resuscitated adult patients with OHCA were included if they presented between January 1, 2015 and December 31, 2019 and received CAG during hospitalization. Emergency medical services run sheets and hospital records were analyzed. Patients without evidence of STEMI were grouped and compared based on time from arrival to CAG performance into "early" (≤ 6 h) and "delayed" (> 6 h). RESULTS Two hundred twenty-one patients were included. Median time to CAG was 18.6 h (interquartile range [IQR] 1.5-94.6 h). Early catheterization was performed on 94 patients (42.5%) and delayed catheterization was performed on 127 patients (57.5%). Patients in the early group were older (61 years [IQR 55-70 years] vs. 57 years [IQR 47-65] years) and more likely to be male (79.8% vs. 59.8%). Those in the early group were more likely to have clinically significant lesions (58.5% vs. 39.4%) and receive revascularization (41.5% vs. 19.7%). Patients were more likely to die in the early group (47.9% vs. 33.1%). Among survivors, there was no significant difference in neurologic recovery at discharge. CONCLUSIONS OHCA patients without evidence of STEMI who received early CAG were older and more likely to be male. This group was more likely to have intervenable lesions and receive revascularization.
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Affiliation(s)
- Andrew R Helber
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David R Helfer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Aarika R Ferko
- Department of Emergency Medicine, Reading Hospital, Reading, Pennsylvania
| | - Daniel D Klein
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Daniel Elchediak
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Traci S Deaner
- Department of Emergency Medicine, Reading Hospital, Reading, Pennsylvania
| | - Dustin Slagle
- Department of Emergency Medicine, ChristianaCare, Newark, Delaware
| | - William B White
- Department of Pulmonary and Critical Care, Maine Medical Center, Portland, Maine
| | - David G Buckler
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Oscar J L Mitchell
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul N Fiorilli
- Department of Medicine, Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Derek L Isenberg
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Jason T Nomura
- Department of Emergency Medicine, ChristianaCare, Newark, Delaware
| | | | - Adam Sigal
- Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Emergency Medicine, Reading Hospital, Reading, Pennsylvania
| | - Hassam Saif
- Lehigh Valley Heart and Vascular Institute, Allentown, Pennsylvania
| | - Michael J Reihart
- Department of Emergency Services, Penn State Health, Lancaster Medical Center, Lancaster, Pennsylvania
| | - Tawnya M Vernon
- Penn Medicine Lancaster General Hospital, Lancaster, Pennsylvania
| | - Benjamin S Abella
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Resuscitation Science, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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15
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Wang C, Lang J, Zhang J, Hu Y, Han C, Xu R, Wu J, Liu C, Li W, Li T, Wei A, Qi W, Jin D, Cong H, Wang L. Culprit vessel vs. immediate multivessel vs. out-of-hospital staged intervention for patients with non-ST-segment elevation myocardial infarction and multivessel disease. Front Cardiovasc Med 2022; 9:1033475. [PMID: 36505387 PMCID: PMC9726786 DOI: 10.3389/fcvm.2022.1033475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/09/2022] [Indexed: 11/24/2022] Open
Abstract
Background and aims The optimal interventional strategy remains undetermined in hemodynamically stable patients with NSTEMI and MVD. This study aimed to examine clinical prognosis among culprit vessel, immediate multivessel, and staged percutaneous coronary intervention (PCI) in patients with NSTEMI and MVD. Methods This retrospective, observational, single-center study included 943 hemodynamically stable patients with NSTEMI and MVD who had undergone successful drug-eluting stent (DES) implantation from January 2014 to December 2019. Patients were categorized into culprit lesion-only PCI (CL-PCI), immediate multivessel PCI (MV-PCI), and out-of-hospital staged MV-PCI according to PCI strategy. The primary outcome was the composite of major adverse cardiac events (MACEs), including all-cause death, myocardial infarction (MI), or unplanned repeat revascularization. The secondary outcomes were all-cause death, cardiac death, MI, and unplanned repeat revascularization. Results Over a median follow-up of 59 months, immediate MV-PCI was associated with a lower risk of all-cause death than CL-PCI (HR: 0.591, 95%CI: 0.364-0.960, P = 0.034). Out-of-hospital staged MV-PCI was associated with a reduced risk of MACE (HR: 0.448, 95%CI: 0.314-0.638, P < 0.001) and all-cause death (HR: 0.326, 95%CI: 0.183-0.584, P < 0.001) compared with CL-PCI. The above results were accordant after multivariate COX analysis and propensity score matching. MACE (HR: 0.560, 95%CI: 0.385-0.813, P = 0.002) and repeat revascularization (HR: 0.627, 95%CI: 0.400-0.982, P = 0.041) were significantly less likely to occur with out-of-hospital MV-PCI rather than immediate MV-PCI. However, the incidences of primary and secondary outcomes were comparable between immediate and staged PCI after confounder adjustment using multivariate regression and propensity score matching analysis. For subgroup analyses stratified by synergy between PCI with taxus and cardiac surgery score, staged MV-PCI was found to lower the risk of MACE compared with immediate MV-PCI in patients with more complex coronary disease. Conclusion Hemodynamically stable patients with NSTEMI and MVD benefited from the strategy of MV-PCI. Patients with complex coronary anatomy treated with out-of-hospital staged MV-PCI rather than immediate MV-PCI had lower risks of MACE. These need to be confirmed in the future randomized study.
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Affiliation(s)
- Chen Wang
- Clinical School of Thoracic, Tianjin Medical University, Tianjin, China,Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Jiachun Lang
- Clinical School of Thoracic, Tianjin Medical University, Tianjin, China,Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Jingxia Zhang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Yuecheng Hu
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Chuyi Han
- Clinical School of Thoracic, Tianjin Medical University, Tianjin, China,Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Rongdi Xu
- Clinical School of Thoracic, Tianjin Medical University, Tianjin, China,Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Jikun Wu
- Clinical School of Thoracic, Tianjin Medical University, Tianjin, China,Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Chunwei Liu
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Wenyu Li
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Tingting Li
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Ao Wei
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Wei Qi
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Dongxia Jin
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China
| | - Hongliang Cong
- Clinical School of Thoracic, Tianjin Medical University, Tianjin, China,Department of Cardiology, Tianjin Chest Hospital, Tianjin, China,*Correspondence: Hongliang Cong,
| | - Le Wang
- Department of Cardiology, Tianjin Chest Hospital, Tianjin, China,Le Wang,
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16
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Kong X, Yin J, Chen H, Wu J, Yu X, Zhou N, Ma L. Effect of different revascularization times on intermediate-risk non-ST-elevation acute coronary syndrome. Sci Rep 2022; 12:15714. [PMID: 36127389 PMCID: PMC9489762 DOI: 10.1038/s41598-022-20185-9] [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: 11/30/2021] [Accepted: 09/09/2022] [Indexed: 11/25/2022] Open
Abstract
Non-ST-elevation acute coronary syndrome (NSTE-ACS) is a specific type of acute coronary syndrome. We applied the Thrombolysis in Myocardial Infarction (TIMI) score for risk stratification of patient prognosis. There was uncertainty about the routine revascularization time in patients with intermediate-risk NSTE-ACS. A total of 2835 patients with intermediate-risk NSTE-ACS (TIMI score 3–4) included in the China Acute Myocardial Infarction Registry from November 2014 to January 2017 were analyzed according to the time window from symptom onset to revascularization: within 24 h, Group I (814/28.7%); within 24 to 48 h, Group II (526/18.6%); within 48 to 72 h, Group III (403/14.2%); and after 72 h, Group IV (1092/38.5%). Risk factors, management and in-hospital outcomes were analyzed in the four groups. The results of the chi-square test showed that there was a significant difference in the incidence of in-hospital major adverse cardiovascular events (MACEs) when revascularization was completed within 48 h than when it was completed after 48 h (P < 0.05). The results of revascularization within 48 h were similar, and the incidence of in-hospital MACEs was lower than when revascularization was completed after 48 h. The incidence of in-hospital MACEs among patients who underwent revascularization within 48 h is lower than that of patients who underwent revascularization after 48 h.
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Affiliation(s)
- Xiangyong Kong
- Division of Life Sciences and Medicine, Department of Cardiology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 23001, Anhui, China
| | - Jun Yin
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hongwu Chen
- Division of Life Sciences and Medicine, Department of Cardiology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 23001, Anhui, China
| | - Jiawei Wu
- Division of Life Sciences and Medicine, Department of Cardiology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 23001, Anhui, China
| | - Xiaofan Yu
- Division of Life Sciences and Medicine, Department of Cardiology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 23001, Anhui, China
| | - Ningtian Zhou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.
| | - Likun Ma
- Division of Life Sciences and Medicine, Department of Cardiology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, 23001, Anhui, China.
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17
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Wenzl FA, Kraler S, Ambler G, Weston C, Herzog SA, Räber L, Muller O, Camici GG, Roffi M, Rickli H, Fox KAA, de Belder M, Radovanovic D, Deanfield J, Lüscher TF. Sex-specific evaluation and redevelopment of the GRACE score in non-ST-segment elevation acute coronary syndromes in populations from the UK and Switzerland: a multinational analysis with external cohort validation. Lancet 2022; 400:744-756. [PMID: 36049493 DOI: 10.1016/s0140-6736(22)01483-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/24/2022] [Accepted: 07/25/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND The Global Registry of Acute Coronary Events (GRACE) 2.0 score was developed and validated in predominantly male patient populations. We aimed to assess its sex-specific performance in non-ST-segment elevation acute coronary syndromes (NSTE-ACS) and to develop an improved score (GRACE 3.0) that accounts for sex differences in disease characteristics. METHODS We evaluated the GRACE 2.0 score in 420 781 consecutive patients with NSTE-ACS in contemporary nationwide cohorts from the UK and Switzerland. Machine learning models to predict in-hospital mortality were informed by the GRACE variables and developed in sex-disaggregated data from 386 591 patients from England, Wales, and Northern Ireland (split into a training cohort of 309 083 [80·0%] patients and a validation cohort of 77 508 [20·0%] patients). External validation of the GRACE 3.0 score was done in 20 727 patients from Switzerland. FINDINGS Between Jan 1, 2005, and Aug 27, 2020, 400 054 patients with NSTE-ACS in the UK and 20 727 patients with NSTE-ACS in Switzerland were included in the study. Discrimination of in-hospital death by the GRACE 2.0 score was good in male patients (area under the receiver operating characteristic curve [AUC] 0·86, 95% CI 0·86-0·86) and notably lower in female patients (0·82, 95% CI 0·81-0·82; p<0·0001). The GRACE 2.0 score underestimated in-hospital mortality risk in female patients, favouring their incorrect stratification to the low-to-intermediate risk group, for which the score does not indicate early invasive treatment. Accounting for sex differences, GRACE 3.0 showed superior discrimination and good calibration with an AUC of 0·91 (95% CI 0·89-0·92) in male patients and 0·87 (95% CI 0·84-0·89) in female patients in an external cohort validation. GRACE 3·0 led to a clinically relevant reclassification of female patients to the high-risk group. INTERPRETATION The GRACE 2.0 score has limited discriminatory performance and underestimates in-hospital mortality in female patients with NSTE-ACS. The GRACE 3.0 score performs better in men and women and reduces sex inequalities in risk stratification. FUNDING Swiss National Science Foundation, Swiss Heart Foundation, Lindenhof Foundation, Foundation for Cardiovascular Research, and Theodor-Ida-Herzog-Egli Foundation.
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Affiliation(s)
- Florian A Wenzl
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
| | - Simon Kraler
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | | | - Sereina A Herzog
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Lorenz Räber
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Olivier Muller
- Department of Cardiology, University Hospital of Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Giovanni G Camici
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland; Department of Research and Education, University Hospital Zurich, Zurich, Switzerland
| | - Marco Roffi
- Department of Cardiology, University Hospital Geneva, Geneva, Switzerland
| | - Hans Rickli
- Cardiology Division, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Mark de Belder
- National Institute for Cardiovascular Outcomes Research, Barts Health NHS Trust, London, UK
| | - Dragana Radovanovic
- AMIS Plus Data Center, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - John Deanfield
- Institute of Cardiovascular Sciences, University College London, London, UK
| | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zürich, Schlieren, Switzerland; Royal Brompton and Harefield Hospitals, London, UK; National Heart and Lung Institute, Imperial College, London, UK; School of Cardiovascular Medicine and Sciences, Kings College London, London, UK.
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18
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Almeida I, Chin J, Santos H, Santos M, Miranda H, Almeida S, Sousa C, Almeida L. Optimal timing of intervention in non-ST-elevation acute coronary syndromes without pre-treatment. Rev Port Cardiol 2022. [DOI: 10.1016/j.repc.2021.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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19
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Kite TA, Kurmani SA, Bountziouka V, Cooper NJ, Lock ST, Gale CP, Flather M, Curzen N, Banning AP, McCann GP, Ladwiniec A. Timing of invasive strategy in non-ST-elevation acute coronary syndrome: a meta-analysis of randomized controlled trials. Eur Heart J 2022; 43:3148-3161. [PMID: 35514079 PMCID: PMC9433309 DOI: 10.1093/eurheartj/ehac213] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 03/23/2022] [Accepted: 04/08/2022] [Indexed: 12/03/2022] Open
Abstract
Aims The optimal timing of an invasive strategy (IS) in non-ST-elevation acute coronary syndrome (NSTE-ACS) is controversial. Recent randomized controlled trials (RCTs) and long-term follow-up data have yet to be included in a contemporary meta-analysis. Methods and results A systematic review of RCTs that compared an early IS vs. delayed IS for NSTE-ACS was conducted by searching MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. A meta-analysis was performed by pooling relative risks (RRs) using a random-effects model. The primary outcome was all-cause mortality. Secondary outcomes included myocardial infarction (MI), recurrent ischaemia, admission for heart failure (HF), repeat re-vascularization, major bleeding, stroke, and length of hospital stay. This study was registered with PROSPERO (CRD42021246131). Seventeen RCTs with outcome data from 10 209 patients were included. No significant differences in risk for all-cause mortality [RR: 0.90, 95% confidence interval (CI): 0.78–1.04], MI (RR: 0.86, 95% CI: 0.63–1.16), admission for HF (RR: 0.66, 95% CI: 0.43–1.03), repeat re-vascularization (RR: 1.04, 95% CI: 0.88–1.23), major bleeding (RR: 0.86, 95% CI: 0.68–1.09), or stroke (RR: 0.95, 95% CI: 0.59–1.54) were observed. Recurrent ischaemia (RR: 0.57, 95% CI: 0.40–0.81) and length of stay (median difference: −22 h, 95% CI: −36.7 to −7.5 h) were reduced with an early IS. Conclusion In all-comers with NSTE-ACS, an early IS does not reduce all-cause mortality, MI, admission for HF, repeat re-vascularization, or increase major bleeding or stroke when compared with a delayed IS. Risk of recurrent ischaemia and length of stay are significantly reduced with an early IS.
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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
| | - Sameer A Kurmani
- 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
| | - Vasiliki Bountziouka
- 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
| | - Nicola J Cooper
- 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
| | - Selina T Lock
- 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
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.,Leeds Institute for Data Analytics, University of Leeds, Leeds, UK.,Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Marcus Flather
- Norwich Medical School, University of East Anglia and Norfolk and Norwich University Hospital, Norwich, UK
| | - Nick Curzen
- University Hospital Southampton NHS Foundation Trust and School of Medicine, University of Southampton, Southampton, UK
| | - Adrian P Banning
- Department of Cardiology, Oxford Heart Centre, John Radcliffe Hospital, Oxford, 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
| | - 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
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20
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Kite TA, Banning AS, Ladwiniec A, Gale CP, Greenwood JP, Dalby M, Hobson R, Barber S, Parker E, Berry C, Flather MD, Curzen N, Banning AP, McCann GP, Gershlick AH. Very early invasive angiography versus standard of care in higher-risk non-ST elevation myocardial infarction: study protocol for the prospective multicentre randomised controlled RAPID N-STEMI trial. BMJ Open 2022; 12:e055878. [PMID: 35504645 PMCID: PMC9066091 DOI: 10.1136/bmjopen-2021-055878] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 02/24/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND There are a paucity of randomised data on the optimal timing of invasive coronary angiography (ICA) in higher-risk patients with non-ST elevation myocardial infarction (N-STEMI). International guideline recommendations for early ICA are primarily based on retrospective subgroup analyses of neutral trials. AIMS The RAPID N-STEMI trial aims to determine whether very early percutaneous revascularisation improves clinical outcomes as compared with a standard of care strategy in higher-risk N-STEMI patients. METHODS AND ANALYSIS RAPID N-STEMI is a prospective, multicentre, open-label, randomised-controlled, pragmatic strategy trial. Higher-risk N-STEMI patients, as defined by Global Registry of Acute Coronary Events 2.0 score ≥118, or >90 with at least one additional high-risk feature, were randomised to either: very early ICA±revascularisation or standard of care timing of ICA±revascularisation. The primary outcome is the proportion of participants with at least one of the following events (all-cause mortality, non-fatal myocardial infarction and hospital admission for heart failure) at 12 months. Key secondary outcomes include major bleeding and stroke. A hypothesis generating cardiac magnetic resonance (CMR) substudy will provide mechanistic data on infarct size, myocardial salvage and residual ischaemia post percutaneous coronary intervention. On 7 April 2021, the sponsor discontinued enrolment due to the impact of the COVID-19 pandemic and lower than expected event rates. 425 patients were enrolled, and 61 patients underwent CMR. ETHICS AND DISSEMINATION The trial has been reviewed and approved by the East of England Cambridge East Research Ethics Committee (18/EE/0222). The study results will be submitted for publication within 6 months of completion. TRIAL REGISTRATION NUMBER NCT03707314; Pre-results.
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Affiliation(s)
- Thomas A Kite
- Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, UK
| | - Amerjeet S Banning
- Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, UK
| | - Andrew Ladwiniec
- Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, UK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds and the Department of Cardiology Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - John P Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds and the Department of Cardiology Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Miles Dalby
- Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Rachel Hobson
- Leicester Clinical Trials Unit, University of Leicester, Leicester, Leicestershire, UK
| | - Shaun Barber
- Leicester Clinical Trials Unit, University of Leicester, Leicester, Leicestershire, UK
| | - Emma Parker
- Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, UK
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Nick Curzen
- Faculty of Medicine, University of Southampton and University Hospital Southampton NHS Trust, Southampton, UK
| | - Adrian P Banning
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences, Glenfield Hospital, Leicester, UK
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21
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Sadjadieh G, Kelbæk H, Kofoed KF, Køber LV, Hansen PR, Torp-Pedersen C, Elming H, Gislason G, Høfsten DE, Engstrøm T, Holmvang L. Bleeding Episodes in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome Undergoing Very Early Versus Standard Care Invasive Examination (from the Very EaRly vs Deferred Invasive Evaluation Using Computerised Tomography [VERDICT] Trial). Am J Cardiol 2022; 170:10-16. [PMID: 35221104 DOI: 10.1016/j.amjcard.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 01/13/2022] [Accepted: 01/17/2022] [Indexed: 11/01/2022]
Abstract
Bleeding is known to influence the prognosis in patients with acute coronary syndromes. In this predefined secondary outcome analysis of the Very EaRly vs Deferred Invasive evaluation using Computerized Tomography (VERDICT) trial, we investigated whether a very early invasive coronary angiography (ICA), compared with one performed within 48 to 72 hours (standard care), was associated with fewer serious bleedings. Furthermore, we tested the association between demographic data including GRACE score and serious bleedings as well as bleedings and mortality. In the 2,147 patients included in the main study, bleedings within 30 days of admission were assessed based on Thrombolysis In Myocardial Infarction and Bleeding Academic Research Consortium criteria. Differences were calculated by cumulative incidence methods and Grays test. Variables associated with bleeding and mortality were estimated by Cox proportional hazard models. Serious (Bleeding Academic Research Consortium 3abc) bleeding rates were low (15 [1.4%, standard] vs 12 [1.2%, early], p = 0.56). There were no fatal bleedings or serious bleedings before ICA in either group. By multivariate analysis, there was no difference in bleedings between the 2 groups. Female gender (hazard ratio [HR] 2.7, 95% confidence interval [CI] 1.2 to 6.4; p = 0.02), anemia (HR 7.0, 95% CI 2.8 to 17.0; p <0.001), and increasing blood pressure (HR 1.3, 95% CI 1.1 to 1.5; p = 0.01) were individually associated with serious bleeding, whereas GRACE score >140 was not (HR 1.03, 95% CI 0.4 to 2.9; p = 0.96). In conclusion, serious bleedings were few, and there were none before ICA in either group. A very early invasive strategy did not reduce serious bleedings within 30 days, which was associated with female gender, increasing blood pressure, and anemia.
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22
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Wang JX, Gao J, Xiao JY, Gao MD, Zhang N, Lu PJ, Liu Y. The Relevance of Interventional Time and Clinical Outcomes in Patients with NSTEMI Based on the GRACE Score. Appl Bionics Biomech 2022; 2022:7614619. [PMID: 35528530 PMCID: PMC9076324 DOI: 10.1155/2022/7614619] [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: 03/04/2022] [Revised: 03/22/2022] [Accepted: 03/30/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To investigate the relevance between interventional time and clinical outcomes in non-ST-elevation myocardial infarction (NSTEMI) patients of different risk stratifications, which were divided into different groups according to GRACE scores and the time from admission to percutaneous coronary intervention (PCI). Method Patients were grouped according to the GRACE score and the time from admission to intervention therapy. The Cox multivariate risk regression model was used to analyze the correlation between the GRACE score and the time from admission to intervention therapy with major adverse cardiovascular events (MACEs). Cox interactive item regression was also used to investigate the correlation between the time of intervention therapy and GRACE risk stratification with clinical outcomes and to evaluate the efficacy of intervention therapy in different risk stratifications of patients with NSTEMI. Results Interactive item Cox regression analysis and subgroup analysis show that high-risk NSTEMI patients with a GRACE score > 140 points and the time from admission to intervention < 24 h (p = 0.0004) and 24-72 h (p = 0.0143) have interactive effects on the impact of the MACE event with the reference of intervention time > 72 h and GRACE score < 108 points. The time from admission to intervention < 24 h is an independent protective factor for the occurrence of MACE events (HR = 0.166, 95% CI 0.052-0.532, p = 0.0025). Middle-risk patients with NSTEMI with a GRACE score of 109-140 points and the time from admission to intervention < 24 h (p = 0.0370) and 24-72 h (p = 0.0471) have an interactive effect on the impact of MACE. The time from admission to intervention > 72 h is an independent protective factor for the occurrence of MACE (HR = 0.201, 95% CI 0.045-0.897, p = 0.0355). Conclusion The time from admission to intervention < 24 h could effectively reduce the risk of MACE events within 1 year in high-risk patients with NSTEMI (GRACE score > 140 points); the time from admission to intervention > 72 h can reduce the risk of MACE events within 1 year in low-risk patients with NSTEMI (GRACE score ≤ 108 points).
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Affiliation(s)
- Ji-Xiang Wang
- Cardiology Institute, Tianjin Chest Hospital, Tianjin 300222, China
| | - Jing Gao
- Institute of Cardiovascular Diseases, Tianjin Chest Hospital, Tianjin 300222, China
| | - Jian-Yong Xiao
- Cardiology Institute, Tianjin Chest Hospital, Tianjin 300222, China
| | - Ming-Dong Gao
- Cardiology Institute, Tianjin Chest Hospital, Tianjin 300222, China
| | - Nan Zhang
- Cardiology Institute, Tianjin Chest Hospital, Tianjin 300222, China
| | - Peng-Ju Lu
- Cardiology Institute, Tianjin Chest Hospital, Tianjin 300222, China
| | - Yin Liu
- Cardiology Institute, Tianjin Chest Hospital, Tianjin 300222, China
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23
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Scavelli F, Cartella I, Montalto C, Oreglia JA, Villanova L, Garatti L, Colombo C, Sacco A, Morici N. Percutaneous Coronary Revascularization after Out-of-Hospital Cardiac Arrest: A Review of the Literature and a Case Series. J Clin Med 2022; 11:1395. [PMID: 35268485 PMCID: PMC8911187 DOI: 10.3390/jcm11051395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/15/2022] [Accepted: 03/01/2022] [Indexed: 11/16/2022] Open
Abstract
Out-of-hospital cardiac arrest (OHCA) is still associated with high mortality and severe complications, despite major treatment advances in this field. Ischemic heart disease is a common cause of OHCA, and current guidelines clearly recommend performing immediate coronary angiography (CAG) in patients whose post-resuscitation electrocardiogram shows ST-segment elevation (STE). Contrarily, the optimal approach and the advantage of early revascularization in cases of no STE is less clear, and decisions are often based on the individual experience of the center. Numerous studies have been conducted on this topic and have provided contradictory evidence; however, more recently, results from several randomized clinical trials have suggested that performing early CAG has no impact on overall survival in patients without STE.
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Affiliation(s)
- Francesca Scavelli
- Department of Cardiology and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (F.S.); (I.C.); (C.M.); (J.A.O.); (L.V.); (L.G.); (C.C.); (A.S.)
| | - Iside Cartella
- Department of Cardiology and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (F.S.); (I.C.); (C.M.); (J.A.O.); (L.V.); (L.G.); (C.C.); (A.S.)
- School of Medicine and Surgery, University of Milano Bicocca, 20126 Milan, Italy
| | - Claudio Montalto
- Department of Cardiology and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (F.S.); (I.C.); (C.M.); (J.A.O.); (L.V.); (L.G.); (C.C.); (A.S.)
| | - Jacopo Andrea Oreglia
- Department of Cardiology and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (F.S.); (I.C.); (C.M.); (J.A.O.); (L.V.); (L.G.); (C.C.); (A.S.)
| | - Luca Villanova
- Department of Cardiology and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (F.S.); (I.C.); (C.M.); (J.A.O.); (L.V.); (L.G.); (C.C.); (A.S.)
| | - Laura Garatti
- Department of Cardiology and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (F.S.); (I.C.); (C.M.); (J.A.O.); (L.V.); (L.G.); (C.C.); (A.S.)
| | - Claudia Colombo
- Department of Cardiology and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (F.S.); (I.C.); (C.M.); (J.A.O.); (L.V.); (L.G.); (C.C.); (A.S.)
| | - Alice Sacco
- Department of Cardiology and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (F.S.); (I.C.); (C.M.); (J.A.O.); (L.V.); (L.G.); (C.C.); (A.S.)
| | - Nuccia Morici
- Department of Cardiology and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (F.S.); (I.C.); (C.M.); (J.A.O.); (L.V.); (L.G.); (C.C.); (A.S.)
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Baumann AAW, Tavella R, Air TM, Mishra A, Montarello NJ, Arstall M, Zeitz C, Worthley MI, Beltrame JF, Psaltis PJ. Prevalence and real-world management of NSTEMI with multivessel disease. Cardiovasc Diagn Ther 2022; 12:1-11. [PMID: 35282665 PMCID: PMC8898694 DOI: 10.21037/cdt-21-518] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 01/13/2022] [Indexed: 09/09/2023]
Abstract
BACKGROUND Non-ST elevation myocardial infarction (NSTEMI) has higher post-discharge mortality than ST-elevation myocardial infarction (STEMI). Prognosis worsens in those with multivessel coronary disease (MVD). However, information about the prevalence and extent of MVD in NSTEMI is limited, in turn limiting insights into optimal treatment strategies. This study aimed to define the prevalence and extent of MVD, preferred treatment strategies and the predictors of MVD in a real-world NSTEMI population. METHODS The Coronary Angiogram Database of South Australia (CADOSA) was used to identify consecutive patients presenting to major teaching hospitals with NSTEMI between 2012 and 2016. Obtaining clinical and angiographic details, patients were stratified by the number of significantly diseased vessels (0,1,2,3-VD), defined by a stenosis of ≥70%, or ≥50% in the left main coronary artery. Data was analysed retrospectively. RESULTS The prevalence of MVD (2- or 3-VD) was 42% amongst 3,722 NSTEMI presentations. Multivariate logistic regression modelling showed age, male gender, diabetes, dyslipidaemia and prior myocardial infarction predicted MVD over 1-VD or 0-VD. Percutaneous coronary intervention (PCI) was performed in 42% of patients with MVD. This comprised 61% of 2-VD patients and only 22% of 3-VD patients, with 24% and 66% of each group referred for coronary bypass grafting, respectively. Among MVD patients treated with PCI, 76% had their culprit lesion treated alone in the index admission. CONCLUSIONS In this NSTEMI cohort, over 40% had MVD. Notably, a minority of patients with MVD undergoing PCI received multivessel revascularisation. This real-world practice emphasises that further evaluation is required to determine whether complete revascularisation is beneficial in NSTEMI, as reported for STEMI.
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Affiliation(s)
- Angus A. W. Baumann
- Department of Cardiology, Central Adelaide Local Health Network (CALHN), Adelaide, Australia
- Department of Medicine, Alice Springs Hospital, Alice Springs, Australia
| | - Rosanna Tavella
- Department of Cardiology, Central Adelaide Local Health Network (CALHN), Adelaide, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, Australia
| | - Tracy M. Air
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, Australia
| | - Aashka Mishra
- Department of Cardiology, Central Adelaide Local Health Network (CALHN), Adelaide, Australia
| | - Nicholas J. Montarello
- Department of Cardiology, Central Adelaide Local Health Network (CALHN), Adelaide, Australia
| | - Margaret Arstall
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
- Northern Adelaide Local Health Network (NALHN), Adelaide, Australia
| | - Chris Zeitz
- Department of Cardiology, Central Adelaide Local Health Network (CALHN), Adelaide, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
| | - Matthew I. Worthley
- Department of Cardiology, Central Adelaide Local Health Network (CALHN), Adelaide, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
| | - John F. Beltrame
- Department of Cardiology, Central Adelaide Local Health Network (CALHN), Adelaide, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Woodville South, Australia
| | - Peter J. Psaltis
- Department of Cardiology, Central Adelaide Local Health Network (CALHN), Adelaide, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
- Vascular Research Centre, Lifelong Health Theme, South Australian Health & Medical Research Institute, Adelaide, Australia
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25
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Nef HM, Achenbach S, Birkemeyer R, Bufe A, Dörr O, Elsässer A, Gaede L, Gori T, Hoffmeister HM, Hofmann FJ, Katus HA, Liebetrau C, Massberg S, Pauschinger M, Schmitz T, Süselbeck T, Voelker W, Wiebe J, Zahn R, Hamm C, Zeiher AM, Möllmann H. Manual der Arbeitsgruppe Interventionelle Kardiologie (AGIK) der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung e.V. (DGK). DER KARDIOLOGE 2021. [DOI: 10.1007/s12181-021-00504-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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26
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Shoaib A, Rashid M, Berry C, Curzen N, Kontopantelis E, Timmis A, Ahmad A, Kinnaird T, Mamas MA. Clinical Characteristics, Management Strategies, and Outcomes of Non-ST-Segment-Elevation Myocardial Infarction Patients With and Without Prior Coronary Artery Bypass Grafting. J Am Heart Assoc 2021; 10:e018823. [PMID: 34612049 PMCID: PMC8751868 DOI: 10.1161/jaha.120.018823] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background There are limited data on the management strategies, temporal trends and clinical outcomes of patients who present with non–ST‐segment–elevation myocardial infarction and have a prior history of CABG. Methods and Results We identified 287 658 patients with non–ST‐segment–elevation myocardial infarction between 2010 and 2017 in the United Kingdom Myocardial Infarction National Audit Project database. Clinical and outcome data were analyzed by dividing into 2 groups by prior history of coronary artery bypass grafting (CABG): group 1, no prior CABG (n=262 362); and group 2, prior CABG (n=25 296). Patients in group 2 were older, had higher GRACE (Global Registry of Acute Coronary Events) risk scores and burden of comorbid illnesses. More patients underwent coronary angiography (69% versus 63%) and revascularization (53% versus 40%) in group 1 compared with group 2. Adjusted odds of receiving inpatient coronary angiogram (odds ratio [OR], 0.91; 95% CI, 0.88–0.95; P<0.001) and revascularization (OR, 0.73; 95% CI, 0.70–0.76; P<0.001) were lower in group 2 compared with group 1. Following multivariable logistic regression analyses, the OR of in‐hospital major adverse cardiovascular events (composite of inpatient death and reinfarction; OR, 0.97; 95% CI, 0.90–1.04; P=0.44), all‐cause mortality (OR, 0.96; 95% CI, 0.88–1.04; P=0.31), reinfarction (OR, 1.02; 95% CI, 0.89–1.17; P=0.78), and major bleeding (OR, 1.01; 95% CI, 0.90–1.11; P=0.98) were similar across groups. Lower adjusted risk of inpatient mortality (OR, 0.67; 95% CI, 0.46–0.98; P=0.04) but similar risk of bleeding (OR,1.07; CI, 0.79–1.44; P=0.68) and reinfarction (OR, 1.13; 95% CI, 0.81–1.57; P=0.47) were observed in group 2 patients who underwent percutaneous coronary intervention compared with those managed medically. Conclusions In this national cohort, patients with non–ST‐segment–elevation myocardial infarction with prior CABG had a higher risk profile, but similar risk‐adjusted in‐hospital adverse outcomes compared with patients without prior CABG. Patients with prior CABG who received percutaneous coronary intervention had lower in‐hospital mortality compared with those who received medical management.
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Affiliation(s)
- Ahmad Shoaib
- Keele Cardiovascular Research Group Centre for Prognosis Research Institute for Primary Care and Health Sciences Keele University Stoke-on-Trent UK
| | - Muhammad Rashid
- Keele Cardiovascular Research Group Centre for Prognosis Research Institute for Primary Care and Health Sciences Keele University Stoke-on-Trent UK
| | - Colin Berry
- Institute of Cardiovascular & Medical Sciences University of Glasgow UK
| | - Nick Curzen
- Cardiothoracic Department University Hospital Southampton & Faculty of MedicineUniversity of Southampton UK
| | | | - Adam Timmis
- Barts & the London School of Medicine and Dentistry Queen Mary University London London UK
| | - Ayesha Ahmad
- Keele Cardiovascular Research Group Centre for Prognosis Research Institute for Primary Care and Health Sciences Keele University Stoke-on-Trent UK
| | | | - Mamas A Mamas
- Keele Cardiovascular Research Group Centre for Prognosis Research Institute for Primary Care and Health Sciences Keele University Stoke-on-Trent UK
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27
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Butt JH, Kofoed KF, Kelbæk H, Hansen PR, Torp-Pedersen C, Høfsten D, Holmvang L, Pedersen F, Bang LE, Sigvardsen PE, Clemmensen P, Linde JJ, Heitmann M, Hove JD, Abdulla J, Gislason G, Engstrøm T, Køber L. Importance of Risk Assessment in Timing of Invasive Coronary Evaluation and Treatment of Patients With Non-ST-Segment-Elevation Acute Coronary Syndrome: Insights From the VERDICT Trial. J Am Heart Assoc 2021; 10:e022333. [PMID: 34585591 PMCID: PMC8649124 DOI: 10.1161/jaha.121.022333] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background The optimal timing of invasive examination and treatment of high-risk patients with non-ST-segment-elevation acute coronary syndrome has not been established. We investigated the efficacy of early invasive coronary angiography compared with standard-care invasive coronary angiography on the risk of all-cause mortality according to the GRACE (Global Registry of Acute Coronary Events) risk score in a predefined subgroup analysis of the VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography) trial. Methods and Results Patients with clinical suspicion of non-ST-segment-elevation acute coronary syndrome with ECG changes indicating new ischemia and/or elevated troponin, in whom invasive coronary angiography was clinically indicated and deemed logistically feasible within 12 hours, were eligible for inclusion. Patients were randomized 1:1 to an early (≤12 hours) or standard (48-72 hours) invasive strategy. The primary outcome of the present study was all-cause mortality. Of 2147 patients randomized in the VERDICT trial, 2092 patients had an available GRACE risk score. Of these, 1021 (48.8%) patients had a GRACE score >140. During a median follow-up of 4.1 years, 192 (18.8%) and 54 (5.0%) patients died in the high and low GRACE score groups, respectively. The risk of death with the early invasive strategy was increased in patients with a GRACE score ≤140 (hazard ratio [HR], 2.04 [95% CI, 1.16-3.59]), whereas there was a trend toward a decreased risk of death with the early invasive strategy in patients with a GRACE score >140 (HR, 0.83 [95% CI, 0.63-1.10]) (Pinteraction=0.006). Conclusions In patients with non-ST-segment-elevation acute coronary syndrome, we found a significant interaction between timing of invasive coronary angiography and GRACE score on the risk of death. Randomized clinical trials are warranted to establish the efficacy and safety among high-risk and low-risk patients with non-ST-segment-elevation acute coronary syndrome. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02061891.
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Affiliation(s)
- Jawad H Butt
- Department of Cardiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Klaus F Kofoed
- Department of Cardiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Henning Kelbæk
- Department of Cardiology Zealand University Hospital Roskilde Denmark
| | - Peter R Hansen
- Department of Cardiology Herlev-Gentofte University Hospital Hillerød Denmark
| | | | - Dan Høfsten
- Department of Cardiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Lene Holmvang
- Department of Cardiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Frants Pedersen
- Department of Cardiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Lia E Bang
- Department of Cardiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Per E Sigvardsen
- Department of Cardiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Peter Clemmensen
- Department of Regional Research, Clinical Institute Faculty of Health Sciences University of Southern Denmark Odense Denmark.,Department of Cardiology University Heart Center Hamburg, University Clinic Hamburg-Eppendorf Hamburg Germany
| | - Jesper J Linde
- Department of Cardiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Merete Heitmann
- Department of Cardiology Bispebjerg-Frederiksberg Hospital Bispebjerg Denmark
| | | | - Jawdat Abdulla
- Department of Cardiology Glostrup Hospital Copenhagen University Hospital Glostrup Denmark
| | - Gunnar Gislason
- Department of Cardiology Herlev-Gentofte University Hospital Hillerød Denmark
| | - Thomas Engstrøm
- Department of Cardiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Lars Køber
- Department of Cardiology Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
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28
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Case BC, Weintraub WS. Non-ST-Segment-Elevation Myocardial Infarction: When Is Rapid Revascularization Critical? J Am Heart Assoc 2021; 10:e023645. [PMID: 34585607 PMCID: PMC8649150 DOI: 10.1161/jaha.121.023645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Brian C Case
- Section of Interventional Cardiology MedStar Washington Hospital Center Washington DC
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29
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Murrone A, di Uccio FS, Amodeo V, Aspromonte N, Caldarola P, Casella G, Cipriani M, De Luca L, Di Lenarda A, Domenicucci S, Francese GM, Imazio M, Roncon L, Urbinati S, Valente S, Di Pasquale G, Gulizia MM, Colivicchi F, Gabrielli D. ANMCO POSITION PAPER: Timing of coronary angiography in non-ST-segment elevation acute coronary syndromes. Eur Heart J Suppl 2021; 23:C196-C203. [PMID: 34456646 PMCID: PMC8388606 DOI: 10.1093/eurheartj/suab068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
The European Society of Cardiology guidelines on non-ST-elevation acute coronary syndromes suggest different temporal strategies for the angiographic study depending on the risk profile. The scientific evidence underlying the guideline recommendations and the critical issues currently existing in Italy, that often do not allow either an extended strategy of revascularization within 24 h or the application of the principle of the same day transfer from a spoke to a hub centre, are analysed. The position paper focuses, in particular, on the subgroup of patients with a defined diagnosis of non-ST-elevation myocardial infarction by proposing a timing of coronary angiography/revascularization that takes into account the available scientific evidence and the organizational possibilities of a considerable part of national cardiology services.
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Affiliation(s)
- Adriano Murrone
- Cardiology-ICU Department, Ospedali di Città di Castello e di Gubbio-Gualdo Tadino, AUSL Umbria 1, Via Guerriero Guerra, Perugia 06127, Italy
| | | | - Vincenzo Amodeo
- Cardiology-ICU Department, Ospedale Santa Maria degli Ungheresi, Polistena, RC, Italy
| | - Nadia Aspromonte
- Heart Failure Unit, Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy
| | | | - Gianni Casella
- Cardiology Department, Ospedale Maggiore, Azienda USL di Bologna, Bologna, Italy
| | - Manlio Cipriani
- Cardiology 2-Cardiac Failure and Trasplantation Unit, Cardiotoracovascular Department “A. De Gasperis”, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Leonardo De Luca
- Cardiology Unit, Cardiotoracovascular Department, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
| | - Andrea Di Lenarda
- Cardiovascular and non Cardiovascolular, Cardiovascolular and Sports Medicine Department, Azienda Sanitaria Universitaria Giuliano Isontina-ASUGI, Trieste, Italy
| | | | - Giuseppina Maura Francese
- Cardiology Department, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | - Massimo Imazio
- Cardiology Department, P.O.U. Santa Maria della Misericordia, Udine, Italy
| | - Loris Roncon
- Cardiology Department, Ospedale Santa Maria della Misericordia, Rovigo, Italy
| | - Stefano Urbinati
- Cardiology Department, Ospedale Bellaria, Azienda USL di Bologna, Bologna, Italy
| | - Serafina Valente
- Clinical-Surgical Cardiology and ICU Department, A.O.U. Senese, Ospedale Santa Maria alle Scotte, Siena, Italy
| | | | - Michele Massimo Gulizia
- Cardiology Department, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
- Fondazione per il Tuo cuore—Heart Care Foundation, Firenze, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, Presidio Ospedaliero San Filippo Neri, ASL Roma 1, Roma, Italy
| | - Domenico Gabrielli
- Cardiology Unit, Cardiotoracovascular Department, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
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30
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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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31
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GC. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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32
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Lemkes JS, Spoormans EM, Demirkiran A, Leutscher S, Janssens GN, van der Hoeven NW, Jewbali LSD, Dubois EA, Meuwissen M, Rijpstra TA, Bosker HA, Blans MJ, Bleeker GB, Baak R, Vlachojannis GJ, Eikemans BJW, van der Harst P, van der Horst ICC, Voskuil M, van der Heijden JJ, Beishuizen A, Stoel M, Camaro C, van der Hoeven H, Henriques JP, Vlaar APJ, Vink MA, van den Bogaard B, Heestermans TACM, de Ruijter W, Delnoij TSR, Crijns HJGM, Jessurun GAJ, Oemrawsingh PV, Gosselink MTM, Plomp K, Magro M, Elbers PWG, van de Ven PM, van Loon RB, van Royen N. The effect of immediate coronary angiography after cardiac arrest without ST-segment elevation on left ventricular function. A sub-study of the COACT randomised trial. Resuscitation 2021; 164:93-100. [PMID: 33932485 DOI: 10.1016/j.resuscitation.2021.04.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/09/2021] [Accepted: 04/19/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND The effect of immediate coronary angiography and percutaneous coronary intervention (PCI) in patients who are successfully resuscitated after cardiac arrest in the absence of ST-segment elevation myocardial infarction (STEMI) on left ventricular function is currently unknown. METHODS This prespecified sub-study of a multicentre trial evaluated 552 patients, successfully resuscitated from out-of-hospital cardiac arrest without signs of STEMI. Patients were randomized to either undergo immediate coronary angiography or delayed coronary angiography, after neurologic recovery. All patients underwent PCI if indicated. The main outcomes of this analysis were left ventricular ejection fraction and end-diastolic and systolic volumes assessed by cardiac magnetic resonance imaging or echocardiography. RESULTS Data on left ventricular function was available for 397 patients. The mean (± standard deviation) left ventricular ejection fraction was 45.2% (±12.8) in the immediate angiography group and 48.4% (±13.2) in the delayed angiography group (mean difference: -3.19; 95% confidence interval [CI], -6.75 to 0.37). Median left ventricular end-diastolic volume was 177 ml in the immediate angiography group compared to 169 ml in the delayed angiography group (ratio of geometric means: 1.06; 95% CI, 0.95-1.19). In addition, mean left ventricular end-systolic volume was 90 ml in the immediate angiography group compared to 78 ml in the delayed angiography group (ratio of geometric means: 1.13; 95% CI 0.97-1.32). CONCLUSION In patients successfully resuscitated after out-of-hospital cardiac arrest and without signs of STEMI, immediate coronary angiography was not found to improve left ventricular dimensions or function compared with a delayed angiography strategy. CLINICAL TRIAL REGISTRATION Netherlands Trial Register number, NTR4973.
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Affiliation(s)
- Jorrit S Lemkes
- Department of Cardiology, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands.
| | - Eva M Spoormans
- Department of Cardiology, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands
| | - Ahmet Demirkiran
- Department of Cardiology, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands
| | - Sophie Leutscher
- Department of Cardiology, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands
| | - Gladys N Janssens
- Department of Cardiology, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands
| | - Nina W van der Hoeven
- Department of Cardiology, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands
| | - Lucia S D Jewbali
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Eric A Dubois
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands; Department of Intensive Care Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Tom A Rijpstra
- Department of Intensive Care Medicine, Amphia Hospital, Breda, The Netherlands
| | - Hans A Bosker
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Michiel J Blans
- Department of Intensive Care Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Gabe B Bleeker
- Department of Cardiology, HAGA Hospital, Den Haag, The Netherlands
| | - Rémon Baak
- Department of Intensive Care Medicine, HAGA Hospital, Den Haag, The Netherlands
| | - Georgios J Vlachojannis
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, University Medical Centre Utrecht, The Netherlands
| | - Bob J W Eikemans
- Department of Intensive Care Medicine, Maasstad Hospital, Rotterdam, The Netherlands
| | - Pim van der Harst
- University of Groningen, University Medical Centre Groningen, Department of Cardiology, Groningen, The Netherlands; Department of Cardiology, University Medical Centre Utrecht, The Netherlands
| | - Iwan C C van der Horst
- University of Groningen, University Medical Centre Groningen, Department of Intensive Care Medicine, Groningen, The Netherlands; Department of Intensive Care Medicine, Maastricht University Medical Centre, University Maastricht, Maastricht, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Centre Utrecht, The Netherlands
| | | | - Albertus Beishuizen
- Department of Intensive Care Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Martin Stoel
- Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Cyril Camaro
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Hans van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - José P Henriques
- Department of Cardiology, Amsterdam University Medical Centre, Location AMC, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Centre, Location AMC, Amsterdam, The Netherlands
| | - Maarten A Vink
- Department of Cardiology, OLVG, Amsterdam, The Netherlands
| | | | | | - Wouter de Ruijter
- Department of Intensive care medicine, Noord West Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Thijs S R Delnoij
- Department of Intensive Care Medicine, Maastricht University Medical Centre, University Maastricht, Maastricht, The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | | | | - Koos Plomp
- Department of Cardiology, Ter Gooi Hospital, Blaricum, The Netherlands
| | - Michael Magro
- Department of Cardiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Paul W G Elbers
- Department of Intensive Care Medicine, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands
| | - Peter M van de Ven
- Department of Epidemiology and Data Science, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands
| | - Ramon B van Loon
- Department of Cardiology, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Amsterdam University Medical Centre, Location VUmc, Amsterdam, The Netherlands; Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Comparison of the cost in percutaneous coronary intervention between ST-segment elevation myocardial infarction vs. non-ST-segment elevation myocardial infarction. Cardiovasc Interv Ther 2021; 37:293-303. [PMID: 33884579 DOI: 10.1007/s12928-021-00778-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 04/16/2021] [Indexed: 12/19/2022]
Abstract
Percutaneous coronary intervention (PCI) is a standard strategy for non-ST-segment elevation myocardial infarction (NSTEMI) as well as for ST-segment elevation myocardial infarction (STEMI). The device cost for PCI may be more expensive in NSTEMI, because the culprit lesion morphology may be more complex in NSTEMI. This study aimed to compare the total device cost of PCI between STEMI and NSTEMI. We included 504 patients with acute myocardial infraction (AMI) who underwent PCI, and divided those into a STEMI group (n = 286) and a NSTEMI group (n = 218). We compared the total device cost, the number of used devices, and procedure cost between the 2 groups. The total device cost was significantly higher in the NSTEMI group [¥371,300 (¥320,700-503,350)] than in the STEMI group [¥341,200 (¥314,200-410,475)] (p = 0.001), whereas the procedure cost was significantly higher in the STEMI group [¥343,800 (¥243,800-343,800)] than in the NSTEMI group [¥220,000 (¥216,800-243,800)] (p < 0.001). Drug eluting stent (85.3% vs. 76.1%, p = 0.029) and aspiration catheter (16.8% vs. 2.3%, p < 0.001) were more frequently used in the STEMI group, whereas rotablator (0.7% vs. 8.3%, p < 0.001) were more frequently used in the NSTEMI group. The multivariate logistic regression analysis revealed that NSTEMI was significantly associated with the high device cost (odds ratio 1.899, 95% confidence interval 1.166-3.093, p = 0.01). In conclusion, the total device cost for PCI was significantly higher in the culprit lesions of NSTEMI than in those of STEMI, whereas the procedure cost was significantly higher in the culprit lesions of STEMI than in those of NSTEMI.
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42:1289-1367. [PMID: 32860058 DOI: 10.1093/eurheartj/ehaa575] [Citation(s) in RCA: 2700] [Impact Index Per Article: 900.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Fagel ND, Amoroso G, Vink MA, Slagboom T, van der Schaaf RJ, Herrman JP, Patterson MS, Oosterwerff EF, Vos NS, Verheugt FW, Tijssen JG, de Winter RJ, Riezebos RK. An immediate or early invasive strategy in non-ST-elevation acute coronary syndrome: The OPTIMA-2 randomized controlled trial. Am Heart J 2021; 234:42-50. [PMID: 33422517 DOI: 10.1016/j.ahj.2021.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 01/05/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND In intermediate- and high-risk non-ST elevated acute coronary syndrome (NSTE-ACS) patients, a routine invasive approach is recommended. The timing of coronary angiography remains controversial. To assess whether an immediate (<3 hours) invasive treatment strategy would reduce infarct size and is safe, compared with an early strategy (12-24 hours), for patients admitted with NSTE-ACS while preferably treated with ticagrelor. METHODS In this single-center, prospective, randomized trial an immediate or early invasive strategy was randomly assigned to patients with NSTE-ACS. At admission, the patients were preferably treated with a combination of aspirin, ticagrelor and fondaparinux. The primary endpoint was the infarct size as measured by area under the curve (AUC) of CK-MB in 48 hours. Secondary endpoints were bleeding outcomes and major adverse cardiac events (MACE): composite of all-cause death, MI and unplanned revascularization. Interim analysis showed futility regarding the primary endpoint and trial inclusion was terminated. RESULTS In total 249 patients (71% of planned) were included. The primary endpoint of in-hospital infarct size was a median AUC of CK-MB 186.2 ng/mL in the immediate group (IQR 112-618) and 201.3 ng/mL in the early group (IQR 119-479). Clinical follow-up was 1-year. The MACE-rate was 10% in the immediate and 10% in the early group (hazard ratio [HR] 1.13, 95% CI: 0.52-2.49). CONCLUSIONS In NSTE-ACS patients randomized to either an immediate or an early-invasive strategy the observed median difference in the primary endpoint was about half the magnitude of the expected difference. The trial was terminated early for futility after 71% of the projected enrollment had been randomized into the trial.
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Pendell Meyers H, Bracey A, Lee D, Lichtenheld A, Li WJ, Singer DD, Rollins Z, Kane JA, Dodd KW, Meyers KE, Shroff GR, Singer AJ, Smith SW. Accuracy of OMI ECG findings versus STEMI criteria for diagnosis of acute coronary occlusion myocardial infarction. IJC HEART & VASCULATURE 2021; 33:100767. [PMID: 33912650 PMCID: PMC8065286 DOI: 10.1016/j.ijcha.2021.100767] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/05/2021] [Accepted: 03/16/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE In the STEMI paradigm of Acute Myocardial Infarction (AMI), many NSTEMI patients have unrecognized acute coronary occlusion MI (OMI), may not receive emergent reperfusion, and have higher mortality than NSTEMI patients without occlusion. We have proposed a new OMI vs. Non-Occlusion MI (NOMI) paradigm shift. We sought to compare the diagnostic accuracy of OMI ECG findings vs. formal STEMI criteria for the diagnosis of OMI. We hypothesized that blinded interpretation for predefined OMI ECG findings would be more accurate than STEMI criteria for the diagnosis of OMI. METHODS We performed a retrospective case-control study of patients with suspected acute coronary syndrome. The primary definition of OMI was either 1) acute TIMI 0-2 flow culprit or 2) TIMI 3 flow culprit with peak troponin T ≥ 1.0 ng/mL or I ≥ 10.0 ng/mL. RESULTS 808 patients were included, of whom 49% had AMI (33% OMI; 16% NOMI). Sensitivity, specificity, and accuracy of STEMI criteria vs Interpreter 1 using OMI ECG findings among 808 patients were 41% vs 86%, 94% vs 91%, and 77% vs 89%, and for Interpreter 2 among 250 patients were 36% vs 80%, 91% vs 92%, and 76% vs 89%. STEMI(-) OMI patients had similar infarct size and mortality as STEMI(+) OMI patients, but greater delays to angiography. CONCLUSIONS Blinded interpretation using predefined OMI ECG findings was superior to STEMI criteria for the ECG diagnosis of Occlusion MI. These data support further investigation into the OMI vs. NOMI paradigm and suggest that STEMI(-) OMI patients could be identified rapidly and noninvasively for emergent reperfusion using more accurate ECG interpretation.
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Key Words
- ACS, Acute coronary syndrome
- AMI, acute myocardial infarction
- Acute coronary syndromes
- ECG, Electrocardiogram
- ED, Emergency department
- Electrocardiography
- LBBB, Left Bundle Branch Block
- MIRO, Myocardial Infarction Ruled Out
- MSC, Modified Sgarbossa Criteria
- NOMI, Non-occlusion myocardial infarction
- NSTEMI, Non-ST-segment elevation myocardial infarction
- OMI, Occlusion myocardial infarction
- Occlusion myocardial infarction
- ST elevation myocardial infarction
- STD, ST-segment depression
- STE, ST-segment elevation
- STEMI, ST-segment elevation myocardial infarction
- VPR, Ventricular Paced Rhythm
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Affiliation(s)
- H. Pendell Meyers
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - Alexander Bracey
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
- Department of Emergency Medicine, Albany Medical Center, Albany NY, USA
| | - Daniel Lee
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Andrew Lichtenheld
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Wei J. Li
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Daniel D. Singer
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Zach Rollins
- William Beaumont School of Medicine, Oakland University, Rochester, MI, USA
| | - Jesse A. Kane
- Department of Cardiology, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Kenneth W. Dodd
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Kristen E. Meyers
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Gautam R. Shroff
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Adam J. Singer
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, NY, USA
| | - Stephen W. Smith
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical Center, Minneapolis, MN, USA
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Balbi MM, Scarparo P, Tovar MN, Masdjedi K, Daemen J, Den Dekker W, Ligthart J, Witberg K, Cummins P, Wilschut J, Zijlstra F, Van Mieghem NM, Diletti R. Culprit lesion detection in patients presenting with non-ST elevation acute coronary syndrome and multivessel disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 35:110-118. [PMID: 33839051 DOI: 10.1016/j.carrev.2021.03.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 03/05/2021] [Accepted: 03/17/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND/PURPOSE Identification of the culprit lesion in patients with non-ST elevation acute coronary syndrome (NSTE-ACS) allows appropriate coronary revascularization but may be unclear in patients with multivessel coronary disease (MVD). Therefore, we investigated the rate of culprit lesion identification during coronary angiography in NSTE-ACS and multivessel disease. METHODS/MATERIALS Consecutive patients presenting with NSTE-ACS and MVD, between January 2012 and December 2016 were evaluated. Coronary angiograms, intravascular imaging, and ECGs were analyzed for culprit lesion identification. Long-term clinical outcomes in terms of major adverse cardiac events (MACE) and mortality were reported in patients with or without culprit identification. RESULTS A total of 1107 patients with NSTE-ACS and MVD were included in the analysis, 310 (28.0%) with unstable angina and 797 (72.0%) with non-ST elevation myocardial infarction. The culprit lesion was angiographically identified in 952 (86.0%) patients, while no clear culprit lesion was found in 155 (14.0%) patients. ECG analysis allowed to predict the location of the culprit vessel with low sensitivity (range 28.4%-36.7%) and high specificity (range 90.6%-96.5%). Higher lesion complexity was associated with inability to identify the culprit. Intravascular imaging was applied in 55 patients and helped to identify the culprit lesion in 53 patients (96.4%). There was no difference in all-cause mortality (21.4% vs. 25.8%, p = 0.24) and MACE (39.2% vs. 47.6%, p = 0.07) between the cohorts with or without culprit lesion identification by angiography. CONCLUSIONS The culprit lesion appeared unclear by coronary angiography in >10% of patients with NSTE-ACS and MVD. Complementary invasive imaging substantially enhanced the diagnostic accuracy of culprit lesion detection.
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Affiliation(s)
- Matthew Mercieca Balbi
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Paola Scarparo
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Maria Natalia Tovar
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Kaneshka Masdjedi
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Joost Daemen
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Wijnand Den Dekker
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Jurgen Ligthart
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Karen Witberg
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Paul Cummins
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Jeroen Wilschut
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Felix Zijlstra
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Nicolas M Van Mieghem
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Roberto Diletti
- Department of Interventional Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, the Netherlands.
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Meyers HP, Bracey A, Lee D, Lichtenheld A, Li WJ, Singer DD, Kane JA, Dodd KW, Meyers KE, Thode HC, Shroff GR, Singer AJ, Smith SW. Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI. J Emerg Med 2021; 60:273-284. [DOI: 10.1016/j.jemermed.2020.10.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/30/2020] [Accepted: 10/07/2020] [Indexed: 01/09/2023]
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Aslanger EK, Meyers HP, Smith SW. Time for a new paradigm shift in myocardial infarction. Anatol J Cardiol 2021; 25:156-162. [PMID: 33690129 PMCID: PMC8114732 DOI: 10.5152/anatoljcardiol.2021.89304] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 01/08/2021] [Indexed: 11/22/2022] Open
Abstract
The ST-elevation myocardial infarction (STEMI)/non-STEMI paradigm per the current guidelines has important limitations. It misses a substantial proportion of acute coronary occlusions (ACO) and results in a significant amount of unnecessary catheterization laboratory activations. It is not widely appreciated how poor is the evidence base for the STEMI criteria; the recommended STEMI cutoffs were not derived by comparing those with ACO with those without and not specifically designed for distinguishing patients who would benefit from emergency reperfusion. This review aimed to discuss the origins, evidence base, and limitations of STEMI/non-STEMI paradigm and to call for a new paradigm shift to the occlusion MI (OMI)/non-OMI.
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Affiliation(s)
- Emre K Aslanger
- Department of Cardiology, Marmara University Pendik Training and Research Hospital; İstanbul-Turkey
| | - H Pendell Meyers
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte; North Carolina-United States of America
| | - Stephen W Smith
- Department of Emergency Medicine, University of Minnesota, Hennepin County Medical Center, Minneapolis; Minnesota-United States of America
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Shoaib A, Mohamed M, Rashid M, Khan SU, Parwani P, Contractor T, Shaikh H, Ahmed W, Fahy E, Prior J, Fischman D, Bagur R, Mamas MA. Clinical Characteristics, Management Strategies and Outcomes of Acute Myocardial Infarction Patients With Prior Coronary Artery Bypass Grafting. Mayo Clin Proc 2021; 96:120-131. [PMID: 33413807 DOI: 10.1016/j.mayocp.2020.05.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/13/2020] [Accepted: 05/18/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the management strategies, temporal trends, and clinical outcomes of patients with a history of coronary artery bypass graft (CABG) surgery and presenting with acute myocardial infarction (MI). PATIENTS AND METHODS We undertook a retrospective cohort study using the National Inpatient Sample database from the United States (January 2004-September 2015), identified all inpatient MI admissions (7,250,768 records) and stratified according to history of CABG (group 1, CABG-naive [94%]; group 2, prior CABG [6%]). RESULTS Patients in group 2 were older, less likely to be female, had more comorbidities, and were more likely to present with non-ST-elevation myocardial infarction compared with group 1. More patients underwent coronary angiography (68% vs 48%) and percutaneous coronary intervention (PCI) (44% vs 26%) in group 1 compared with group 2. Following multivariable logistic regression analyses, the adjusted odd ratio (OR) of in-hospital major adverse cardiovascular and cerebrovascular events (OR, 0.98; 95% CI, 0.95 to 1.005; P=.11), all-cause mortality (OR, 1; 95% CI, 0.98 to 1.04; P=.6) and major bleeding (OR, 0.99; 95% CI, 0.94 to 1.03; P=.54) were similar to group 1. Lower adjusted odds of in-hospital major adverse cardiovascular and cerebrovascular events (OR, 0.64; 95% CI, 0.57 to 0.72; P<.001), all-cause mortality (OR, 0.45; 95% CI, 0.38 to 0.53; P<.001), and acute ischemic stroke (OR, 0.71; 95% CI, 0.59 to 0.86; P<.001) were observed in group 2 patients who underwent PCI compared with those managed medically without any increased risk of major bleeding (OR, 1.08; 95% CI, 0.94 to 1.23; P=.26). CONCLUSIONS In this national cohort, MI patients with prior-CABG had a higher risk profile, but similar in-hospital adverse outcomes compared with CABG-naive patients. Prior-CABG patients who received PCI had better in-hospital clinical outcomes compared to those who received medical management.
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Affiliation(s)
- Ahmad Shoaib
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, United Kingdom
| | - Mohamed Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, United Kingdom
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, United Kingdom
| | - Safi U Khan
- Department of Medicine, West Virginia University, Morgantown, WV
| | - Purvi Parwani
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA
| | - Tahmeed Contractor
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA
| | - Hafsa Shaikh
- Department of Medical Sciences, University College London, London, United Kingdom
| | - Waqar Ahmed
- King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Eoin Fahy
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, United Kingdom
| | - James Prior
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, United Kingdom; Midlands Partnership NHS Foundation Trust, Trust Headquarters, St. George's Hospital, Stafford, United Kingdom
| | - David Fischman
- Department of Medicine (Cardiology), Thomas Jefferson University Hospital, Philadelphia, PA
| | - Rodrigo Bagur
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, United Kingdom
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, United Kingdom; Department of Medicine (Cardiology), Thomas Jefferson University Hospital, Philadelphia, PA.
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Variation in treatment strategy for non-ST segment elevation myocardial infarction: A multilevel methodological approach. Int J Cardiol 2020; 328:35-39. [PMID: 33278418 DOI: 10.1016/j.ijcard.2020.11.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 09/17/2020] [Accepted: 11/27/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Variations by hospital and region in the selection of an early invasive strategy (EIS) after non-ST-segment elevation myocardial infarction (NSTEMI) in patients with high-risk criteria are unknown. METHODS We evaluated the data of 7037 patients with NSTEMI from 20 hospitals of 3 regions from the Korean Acute Myocardial Infarction Registry-National Institute of Health database. We used hierarchical generalized linear mixed-models to estimate region- and hospital-level variation in the selection of an EIS after adjusting for patient-level high-risk criteria. We explored the variation using the median rate ratio (MRR), which estimates the relative difference in the risk ratios of two hypothetically identical patients at two different sites. RESULTS An EIS was selected in 84.4% of patients. At the hospital level, the median selection rate was 80.4%. At the region level, the median selection rate was 74.9% in the east region, 81.3% in the north region, and 83.9% in the west region, respectively. After adjusting for patient-level covariates, we found significant hospital- (MRR 2.19, 95% confidence interval [CI]: 1.74-3.03) and region-level (MRR 1.88, 95%CI: 1.26-5.44) variation in the selection of an EIS. Among patient-level factors, male sex, ongoing chest pain, history of coronary artery disease or acute heart failure, and GRACE risk score > 140 were independently associated with the selection of an EIS. CONCLUSIONS We observed significant hospital- and region-level variation in the selection of an EIS after NSTEMI in high-risk patients. Quality improvement efforts are required to standardize decision making and to improve clinical outcomes.
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Lemkes JS, Janssens GN, van der Hoeven NW, Jewbali LSD, Dubois EA, Meuwissen MM, Rijpstra TA, Bosker HA, Blans MJ, Bleeker GB, Baak RR, Vlachojannis GJ, Eikemans BJW, van der Harst P, van der Horst ICC, Voskuil M, van der Heijden JJ, Beishuizen A, Stoel M, Camaro C, van der Hoeven H, Henriques JP, Vlaar APJ, Vink MA, van den Bogaard B, Heestermans TACM, de Ruijter W, Delnoij TSR, Crijns HJGM, Jessurun GAJ, Oemrawsingh PV, Gosselink MTM, Plomp K, Magro M, Elbers PWG, Spoormans EM, van de Ven PM, Oudemans-van Straaten HM, van Royen N. Coronary Angiography After Cardiac Arrest Without ST Segment Elevation: One-Year Outcomes of the COACT Randomized Clinical Trial. JAMA Cardiol 2020; 5:1358-1365. [PMID: 32876654 PMCID: PMC7489423 DOI: 10.1001/jamacardio.2020.3670] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 05/30/2020] [Indexed: 01/10/2023]
Abstract
Importance Ischemic heart disease is a common cause of cardiac arrest. However, randomized data on long-term clinical outcomes of immediate coronary angiography and percutaneous coronary intervention (PCI) in patients successfully resuscitated from cardiac arrest in the absence of ST segment elevation myocardial infarction (STEMI) are lacking. Objective To determine whether immediate coronary angiography improves clinical outcomes at 1 year in patients after cardiac arrest without signs of STEMI, compared with a delayed coronary angiography strategy. Design, Setting, and Participants A prespecified analysis of a multicenter, open-label, randomized clinical trial evaluated 552 patients who were enrolled in 19 Dutch centers between January 8, 2015, and July 17, 2018. The study included patients who experienced out-of-hospital cardiac arrest with a shockable rhythm who were successfully resuscitated without signs of STEMI. Follow-up was performed at 1 year. Data were analyzed, using the intention-to-treat principle, between August 29 and October 10, 2019. Interventions Immediate coronary angiography and PCI if indicated or coronary angiography and PCI if indicated, delayed until after neurologic recovery. Main Outcomes and Measures Survival, myocardial infarction, revascularization, implantable cardiac defibrillator shock, quality of life, hospitalization for heart failure, and the composite of death or myocardial infarction or revascularization after 1 year. Results At 1 year, data on 522 of 552 patients (94.6%) were available for analysis. Of these patients, 413 were men (79.1%); mean (SD) age was 65.4 (12.3) years. A total of 162 of 264 patients (61.4%) in the immediate angiography group and 165 of 258 patients (64.0%) in the delayed angiography group were alive (odds ratio, 0.90; 95% CI, 0.63-1.28). The composite end point of death, myocardial infarction, or repeated revascularization since the index hospitalization was met in 112 patients (42.9%) in the immediate group and 104 patients (40.6%) in the delayed group (odds ratio, 1.10; 95% CI, 0.77-1.56). No significant differences between the groups were observed for the other outcomes at 1-year follow-up. For example, the rate of ICD shocks was 20.4% in the immediate group and 16.2% in the delayed group (odds ratio, 1.32; 95% CI, 0.66-2.64). Conclusions and Relevance In this trial of patients successfully resuscitated after out-of-hospital cardiac arrest and without signs of STEMI, a strategy of immediate angiography was not found to be superior to a strategy of delayed angiography with respect to clinical outcomes at 1 year. Coronary angiography in this patient group can therefore be delayed until after neurologic recovery without affecting outcomes. Trial Registration trialregister.nl Identifier: NTR4973.
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Affiliation(s)
- Jorrit S. Lemkes
- Department of Cardiology, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Gladys N. Janssens
- Department of Cardiology, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Nina W. van der Hoeven
- Department of Cardiology, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | | | - Eric A. Dubois
- Thorax Center, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Topm A. Rijpstra
- Department of Intensive Care Medicine, Amphia Hospital, Breda, the Netherlands
| | - Hans A. Bosker
- Department of Cardiology, Rijnstate Hospital, Arnhem, the Netherlands
| | - Michiel J. Blans
- Department of Intensive Care Medicine, Rijnstate Hospital, Arnhem, the Netherlands
| | - Gabe B. Bleeker
- Department of Cardiology, HAGA Hospital, Den Haag, the Netherlands
| | - Remon R. Baak
- Department of Intensive care medicine, HAGA Hospital, Den Haag, the Netherlands
| | | | - Bob J. W. Eikemans
- Department of Intensive Care Medicine, Maasstad Hospital, Rotterdam, the Netherlands
| | - Pim van der Harst
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Intensive Care Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Iwan C. C. van der Horst
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center, University Maastricht, Maastricht, the Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Joris J. van der Heijden
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Albertus Beishuizen
- Department of Intensive Care Medicine, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Martin Stoel
- Department of Cardiology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Cyril Camaro
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hans van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jose P. Henriques
- Department of Cardiology, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Alexander P. J. Vlaar
- Department of Intensive Care Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | | | | | | | - Wouter de Ruijter
- Department of Intensive Care Medicine, Noord West Ziekenhuisgroep, Alkmaar, the Netherlands
| | - Thijs S. R. Delnoij
- Department of Intensive Care Medicine, Maastricht University Medical Center, University Maastricht, Maastricht, the Netherlands
| | - Harry J. G. M. Crijns
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | | | | | - Koos Plomp
- Department of Cardiology, Ter Gooi Hospital, Blaricum, the Netherlands
| | - Michael Magro
- Department of Cardiology, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands
| | - Paul W. G. Elbers
- Department of Intensive Care Medicine, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Eva M. Spoormans
- Department of Cardiology, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Peter M. van de Ven
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | | | - Niels van Royen
- Department of Cardiology, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
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Yerasi C, Weintraub WS. Non-ST-Segment Elevation Myocardial Infarction Revascularization: Is ≤24 h Early Enough? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 22:8-9. [PMID: 33187896 DOI: 10.1016/j.carrev.2020.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 10/26/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Charan Yerasi
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - William S Weintraub
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America.
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Leiner T, Bogaert J, Friedrich MG, Mohiaddin R, Muthurangu V, Myerson S, Powell AJ, Raman SV, Pennell DJ. SCMR Position Paper (2020) on clinical indications for cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2020; 22:76. [PMID: 33161900 PMCID: PMC7649060 DOI: 10.1186/s12968-020-00682-4] [Citation(s) in RCA: 154] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/18/2020] [Indexed: 12/22/2022] Open
Abstract
The Society for Cardiovascular Magnetic Resonance (SCMR) last published its comprehensive expert panel report of clinical indications for CMR in 2004. This new Consensus Panel report brings those indications up to date for 2020 and includes the very substantial increase in scanning techniques, clinical applicability and adoption of CMR worldwide. We have used a nearly identical grading system for indications as in 2004 to ensure comparability with the previous report but have added the presence of randomized controlled trials as evidence for level 1 indications. In addition to the text, tables of the consensus indication levels are included for rapid assimilation and illustrative figures of some key techniques are provided.
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Affiliation(s)
- Tim Leiner
- Department of Radiology, E.01.132, Utrecht University Medical Center, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands.
| | - Jan Bogaert
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
- Department of Imaging and Pathology, Catholic University Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Matthias G Friedrich
- Departments of Medicine and Diagnostic Radiology, McGill University, 1001 Decarie Blvd., Montreal, QC, H4A 3J1, Canada
| | - Raad Mohiaddin
- Department of Radiology, Royal Brompton Hospital, Sydney Street, Chelsea, London, SW3 6NP, UK
- National Heart and Lung Institute, Imperial College, South Kensington Campus, London, SW7 2AZ, UK
| | - Vivek Muthurangu
- Centre for Cardiovascular Imaging, Science & Great Ormond Street Hospital for Children, UCL Institute of Cardiovascular, Great Ormond Street, London, WC1N 3JH, UK
| | - Saul Myerson
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, Oxford Centre for Clinical Magnetic Resonance Research (OCMR), University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Andrew J Powell
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Farley, 2nd Floor, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Farley, 2nd Floor, Boston, MA, 02115, USA
| | - Subha V Raman
- Krannert Institute of Cardiology, Indiana University School of Medicine, 340 West 10th Street, Fairbanks Hall, Suite 6200, Indianapolis, IN, 46202-3082, USA
| | - Dudley J Pennell
- Royal Brompton Hospital, Sydney Street, Chelsea, London, SW3 6NP, UK
- Imperial College, South Kensington Campus, London, SW7 2AZ, UK
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45
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Mooney M. Angiography of Course, But When? Optimal Post-Cardiac Arrest Care: One Step at a Time. JACC Cardiovasc Interv 2020; 13:2206-2207. [PMID: 33032707 DOI: 10.1016/j.jcin.2020.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 08/19/2020] [Accepted: 08/19/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Michael Mooney
- Minneapolis Cardiology Associates, Minneapolis, Minnesota.
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46
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Li Y, Wang C, Nan Y, Zhao H, Cao Z, Du X, Wang K. Early invasive strategy for non-ST elevation acute coronary syndrome: a meta-analysis of randomized, controlled trials. J Int Med Res 2020; 48:300060520966500. [PMID: 33115315 PMCID: PMC7607294 DOI: 10.1177/0300060520966500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Patients with non-ST elevation acute coronary syndrome (NSTE-ACS) benefit from coronary intervention, but the optimal timing for an invasive strategy is not well defined. This study aimed to determine whether an early invasive strategy (<12 hours) is superior to a delayed invasive strategy. METHODS Twelve studies of nine randomized, controlled trials of 8586 patients were included. RESULTS There were no significant differences in all-cause death (risk ratio [95% confidence interval]) (0.90, [0.77-1.06), re-myocardial infarction (re-MI) (0.95 [0.70-1.29]), major bleeding (0.97 [0.77-1.23]), and refractory ischemia (0.74 [0.53-1.05]) when we compared use of early and delayed invasive strategies. Furthermore, analysis of the effect of the chosen strategy on high-risk patients showed that the rate of composite death or re-MI was significantly decreased in patients with either a Global Registry of Acute Coronary Events (GRACE) risk score >140 or with elevated troponin levels (risk ratio 0.82 [0.72-0.92]; risk ratio 0.84 [0.76-0.93], respectively). CONCLUSIONS This meta-analysis shows that an early angiographic strategy does not improve clinical outcome in patients with NSTE-ACS. An early invasive strategy might reduce the rate of composite death or re-MI in high-risk patients with GRACE risk scores >140 or elevated cardiac markers.
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Affiliation(s)
- Ying Li
- Department of Cardiology, Tianjin Fifth Central Hospital, Tianjin, China
| | - Cuancuan Wang
- Department of Cardiology, Tianjin Fifth Central Hospital, Tianjin, China
| | - Yue Nan
- Department of Cardiology, Tianjin Fifth Central Hospital, Tianjin, China
| | - Hui Zhao
- Department of Cardiology, Tianjin Fifth Central Hospital, Tianjin, China
| | - Zhongnan Cao
- Department of Cardiology, Tianjin Fifth Central Hospital, Tianjin, China
| | - Xinping Du
- Department of Cardiology, Tianjin Fifth Central Hospital, Tianjin, China
| | - Kuan Wang
- Department of Cardiology, Tianjin Fifth Central Hospital, Tianjin, China
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47
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Temporal trends and predictors of time to coronary angiography following non-ST-elevation acute coronary syndrome in the USA. Coron Artery Dis 2020; 30:159-170. [PMID: 30676387 DOI: 10.1097/mca.0000000000000693] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE This study aims to investigate the temporal trends in utilization of invasive coronary angiography (CA) at different time points and changing profiles of patients undergoing CA following non-ST-elevation acute coronary syndrome (NSTEACS). We also describe the association between time to CA and in-hospital clinical outcomes. PATIENTS AND METHODS We queried the National Inpatient Sample to identify all admissions with a primary diagnosis of NSTEACS from 2004 to 2014. Patients were stratified into early (day 0, 1), intermediate (day 2) and late strategy (day≥3) according to time to CA. Multivariable logistic regression was used to investigate the association between time to CA and in-hospital mortality, major bleeding, stroke and Major Adverse Cardiac and Cerebrovascular Events. RESULTS A total of 4 380 827 records were identified with a diagnosis of NSTEACS, out of which 57.5% received CA. The proportion of patients undergoing early CA increased from 65.6 to 72.6%, whereas late CA commensurately declined from 19.6 to 13.5%. Patients receiving early CA were younger (age: 64 vs. 70 years), more likely to be male (63.7 vs. 55.3%) and of Caucasian ethnic background (68.7 vs. 64.7%) compared with late CA group. Similarly, Women, weekend admissions and African Americans remain less likely to receive early CA. In-hospital mortality was lowest in the intermediate group (odds ratio=0.30, 95% confidence interval: 0.28-0.33). CONCLUSION Use of early CA has increased in the management of NSTEACS; however, there remain significant disparities in utilization of an early invasive approach in women, African Americans, admission day and older patients in the USA.
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48
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Baumann AAW, Mishra A, Worthley MI, Nelson AJ, Psaltis PJ. Management of multivessel coronary artery disease in patients with non-ST-elevation myocardial infarction: a complex path to precision medicine. Ther Adv Chronic Dis 2020; 11:2040622320938527. [PMID: 32655848 PMCID: PMC7331770 DOI: 10.1177/2040622320938527] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/26/2020] [Indexed: 12/15/2022] Open
Abstract
Recent analyses suggest the incidence of acute coronary syndrome is declining in high- and middle-income countries. Despite this, overall rates of non-ST-elevation myocardial infarction (NSTEMI) continue to rise. Furthermore, NSTEMI is a greater contributor to mortality after hospital discharge than ST-elevation myocardial infarction (STEMI). Patients with NSTEMI are often older, comorbid and have a high likelihood of multivessel coronary artery disease (MVD), which is associated with worse clinical outcomes. Currently, optimal treatment strategies for MVD in NSTEMI are less well established than for STEMI or stable coronary artery disease. Specifically, in relation to percutaneous coronary intervention (PCI) there is a paucity of randomized, prospective data comparing multivessel and culprit lesion-only PCI. Given the heterogeneous pathological basis for NSTEMI with MVD, an approach of complete revascularization may not be appropriate or necessary in all patients. Recognizing this, this review summarizes the limited evidence base for the interventional management of non-culprit disease in NSTEMI by comparing culprit-only and multivessel PCI strategies. We then explore how a personalized, precise approach to investigation, therapy and follow up may be achieved based on patient-, disease- and lesion-specific factors.
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Affiliation(s)
- Angus A. W. Baumann
- Department of Cardiology, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Aashka Mishra
- Flinders Medical School, Flinders University, Adelaide, South Australia, Australia
| | - Matthew I. Worthley
- Department of Cardiology, Central Adelaide Local Health Network, Adelaide, South Australia, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Adam J. Nelson
- Duke Clinical Research Institute, Durham, NC, USA
- Vascular Research Centre, Lifelong Health Theme, South Australian Health & Medical Research Institute, Adelaide, South Australia, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
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49
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Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2020; 40:87-165. [PMID: 30165437 DOI: 10.1093/eurheartj/ehy394] [Citation(s) in RCA: 3948] [Impact Index Per Article: 987.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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50
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Lindow T, Smith SW. The Search for Strategies to Better Identify Patients With Acute Coronary Occlusion But No ST Elevation Should Not Be Abandoned. Am J Cardiol 2020; 126:108-109. [PMID: 32359716 DOI: 10.1016/j.amjcard.2020.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/03/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Thomas Lindow
- Department of Clinical Physiology, Växjö Central Hospital, Region Kronoberg, Sweden Clinical Physiology, Clinical Sciences, Lund University, Sweden.
| | - Stephen W Smith
- Department of Emergency Medicine, Hennepin County Medical Center and University of Minnesota, Minneapolis, Minnesota, USA
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