[Features of the Reperfusion Therapy for ST-Segment Elevation Myocardial Infarction According to the Russian Registry of Acute Myocardial Infarction - REGION-IM]

AIM

Based on data from the Russian REGION-IM registry, to study the features of reperfusion therapy in patients with ST-segment elevation myocardial infarction (STEMI) in real-life clinical practice.

MATERIAL AND METHODS

REGION-IM is a multicenter prospective observational study. The observational period is divided into 3 stages: during the stay in the hospital and at 6 and 12 months after inclusion in the registry. The patient's records contain demographic and history data; information about the present case of MI, including the time of the first symptom onset, first contact with medical personnel, and admission to the hospital; coronary angiography (CAG) data, percutaneous coronary intervention (PCI) data, and information about the thrombolytic therapy (TLT).

RESULTS

Reperfusion therapy was performed in 88.9 % of patients with STEMI. Primary PCI (pPCI) was performed in 60.6 % of patients. The median time from the onset of symptoms to pPCI was 315 minutes [195; 720]. The median time from ECG to pPCI was 110 minutes [84;150]. Isolated TLT was performed in 7.4 %, pharmaco-invasive treatment tactics were used only in 20.9 % of cases. The median time from ECG to TLT (prehospital and in-hospital) was 30 minutes [10; 59], whereas the median time from ECG to prehospital TLT was 18 minutes [10; 39], and in 63 % of patients, TLT was performed more than 10 minutes after diagnosis. PCI followed TLT in 73 % of patients.

CONCLUSION

The frequency of reperfusion therapy for STEMI in the Russian Federation has increased considerably in recent years. The high frequency of pPCI is noteworthy, but the timing of pPCI does not always comply with clinical guidelines. The results of this registry confirm the high demand for pharmaco-invasive strategies in real-life clinical practice. Taking into account geographical and logistical features, implementing timely myocardial reperfusion requires prehospital TLT. However, the TLT frequency in the Russian Federation is still insufficient despite its proven maximum effectiveness in the shortest possible time from the detection of acute MI.

Contemporary Use of Ticagrelor vs Clopidogrel in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: A GRACE Risk Score Stratification-Based Analysis in a Large-Scale, Real-World Study From China

OBJECTIVE

To evaluate potential gains in outcomes from ticagrelor-based strategy according to risk stratification by Global Registry of Acute Coronary Events (GRACE) score.

METHODS

A total of 19,704 patients discharged alive post-acute coronary syndrome who underwent percutaneous coronary intervention and received ticagrelor or clopidogrel between March 2016 and March 2019 were included in the study. The primary endpoint was ischemic events at 12 months, composed of cardiac death, myocardial infarction, and/or stroke. Secondary outcomes included all-cause mortality and Bleeding Academic Research Consortium type 2 to 5 and 3 to 5 bleeding.

RESULTS

The ticagrelor group comprised 6432 (32.6%) patients and the clopidogrel group comprised 13,272 (67.4%) patients. During the follow-up period, there was a significant reduction in the incidence of ischemic events in patients treated using ticagrelor who had excessive risk of bleeding. According to the GRACE score, among low-risk patients, ticagrelor use compared with clopidogrel was not associated with decreased ischemic events (HR, 0.82; 95% CI, 0.57 to 1.17; P=.27) with excessive risk of Bleeding Academic Research Consortium type 3 to 5 bleeding (HR, 1.59; 95% CI, 1.16 to 2.17; P=.004). The risk of ischemic events (HR, 0.60; 95% CI, 0.41 to 0.89; P=.01) were lower in the intermediate- to high-risk patients treated with ticagrelor without significant difference in BARC type 3 to 5 bleeding risk (HR, 1.11; 95% CI, 0.75 to 1.65; P=.61).

CONCLUSION

There was still a gap between guideline-indicated therapy and the clinical practice in a sizable subset of patients with acute coronary syndrome who underwent percutaneous coronary intervention. The GRACE risk score could identify patients who would derive benefit from the ticagrelor-based antiplatelet strategy.

Establishment of a nomogram model for acute chest pain triage in the chest pain center

Background

Acute myocardial infarction (AMI) is the leading life-threatening disease in the emergency department (ED), so rapid chest pain triage is important. This study aimed to establish a clinical prediction model for the risk stratification of acute chest pain patients based on the Point-of-care (POC) cardiac troponin (cTn) level and other clinical variables.

Methods

We conducted a post-hoc analysis of the database from 6,019 consecutive patients (excluding prehospital-diagnosed non-cardiac chest pain patients) attending a local chest pain center (CPC) in China between October 2016 and January 2019. The plasma concentration of cardiac troponin I (cTnI) was measured using a POC cTnI (Cardio Triage, Alere) assay. All the eligible patients were randomly divided into training and validation cohorts by a 7:3 ratio. We performed multivariable logistic regression to select variables and build a nomogram based on the significant predictive factors. We evaluated the model's generalization ability of diagnostic accuracy in the validation cohort.

Results

We analyzed data from 5,397 patients that were included in this research. The median turnaround time (TAT) of POC cTnI was 16 min. The model was constructed with 6 variables: ECG ischemia, POC cTnI level, hypotension, chest pain symptom, Killip class, and sex. The area under the ROC curve (AUC) in the training and validation cohorts was 0.924 and 0.894, respectively. The diagnostic performance was superior to the GRACE score (AUC: 0.737).

Conclusion

A practical predictive model was created and could be used for rapid and effective triage of acute chest pain patients in the CPC.

Dual versus triple antithrombotic therapy after percutaneous coronary intervention: the prospective multicentre WOEST 2 Study

BACKGROUND

For patients on oral anticoagulants (OAC) undergoing percutaneous coronary intervention (PCI), European guidelines have recently changed their recommendations to dual antithrombotic therapy (DAT; P2Y₁₂ inhibitor and OAC) without aspirin.

AIMS

The prospective WOEST 2 registry was designed to obtain contemporary real-world data on antithrombotic regimens and related outcomes after PCI in patients with an indication for OAC.

METHODS

In this analysis, we compare DAT (P2Y₁₂ inhibitor and OAC) to triple antithrombotic therapy (TAT; aspirin, P2Y₁₂ inhibitor, and OAC) on thrombotic and bleeding outcomes after one year. Clinically relevant bleeding was defined as Bleeding Academic Research Consortium classification (BARC) grade 2, 3, or 5; major bleeding as BARC grade 3 or 5. Major adverse cardiac and cerebrovascular events (MACCE) was defined as a composite of all-cause mortality, myocardial infarction, stent thrombosis, ischaemic stroke, and transient ischaemic attack.

RESULTS

A total of 1,075 patients were included between 2014 and 2021. Patients used OAC for atrial fibrillation (93.6%) or mechanical heart valve prosthesis (4.7%). Non-vitamin K oral anticoagulants (NOAC) were prescribed in 53.1% and vitamin K antagonists in 46.9% of patients. At discharge, 60.9% received DAT, and 39.1% TAT. DAT was associated with less clinically relevant and similar major bleeding (16.8% vs 23.4%; p<0.01 and 7.6% vs 7.7%, not significant), compared to TAT. The difference in MACCE between the two groups was not statistically significant (12.4% vs 9.7%; p=0.17). Multivariable adjustment and propensity score matching confirmed these results.

CONCLUSIONS

Dual antithrombotic therapy is associated with a substantially lower risk of clinically relevant bleeding without a statistically significant penalty in ischaemic events.

Guideline-Directed Medical Therapy in Patients with Chronic Kidney Disease Undergoing Peripheral Vascular Intervention

INTRODUCTION

Guideline-directed medical therapy (GDMT) is imperative to improve cardiovascular and limb outcomes for patients with critical limb ischemia (CLI), especially amongst those at highest risk for poor outcomes, including those with comorbid chronic kidney disease (CKD). Our objective was to examine GDMT prescription rates and their variation across individual sites for patients with CLI undergoing peripheral vascular interventions (PVIs), by their comorbid CKD status.

METHODS

Patients with CLI who underwent PVI (October 2016-April 2019) were included from the Vascular Quality Initiative (VQI) database. CKD was defined as GFR <60 mL/min/1.73 m2. GDMT included the composite use of antiplatelet therapy and a statin, as well as an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker if hypertension was present. The use of GDMT before and after the index procedure was summarized in those with and without CKD. Adjusted median odds ratios (MORs) for site variability were calculated.

RESULTS

The study included 28,652 patients, with a mean age of 69.4 ± 11.7 years, and 40.8% were females. A total of 47.5% had CKD. Patients with CKD versus those without CKD had lower prescription rates both before (31.7% vs. 38.9%) and after (36.5% vs. 48.8%) PVI (p < 0.0001). Significant site variability was observed in the delivery of GDMT in both the non-CKD and CKD groups before and after PVI (adjusted MORs: 1.31-1.41).

DISCUSSION/CONCLUSION

In patients with CLI undergoing PVI, patients with comorbid CKD were less likely to receive GDMT. Significant variability of GDMT was observed across sites. These findings indicate that significant improvements must be made in the medical management of patients with CLI, particularly in patients at high risk for poor clinical outcomes.

Analysis of the relationship between surgeon procedure volume and complications after total knee arthroplasty using a propensity-matched cohort study

Objectives

This study aimed to identify a threshold in annual surgeon volume associated with increased risk of revision (for any cause) and deep infection requiring surgery following primary elective total knee arthroplasty (TKA).

Design

A propensity score matched cohort study.

Setting

Ontario, Canada.

Participants

169 713 persons who received a primary TKA between 2002 and 2016, with 3-year postoperative follow-up.

Main outcome measures

Revision arthroplasty (for any cause), and the occurrence of deep surgical infection requiring surgery.

Results

Based on restricted cubic spline analysis, the threshold for increased probability of revision and deep infection requiring surgery was <70 cases/year. After matching of 51 658 TKA recipients from surgeons performing <70 cases/year to TKA recipients from surgeons with greater than 70 cases/year, patients in the former group had a higher rate of revision (for any cause, 2.23% (95% Confidence Interval (CI) 1.39 to 3.07) vs 1.70% (95% CI 0.85 to 2.55); Hazard Ratio (HR) 1.33, 95% CI 1.21 to 1.47, p<0.0001) and deep infection requiring surgery (1.29% (95% CI 0.44 to 2.14) vs 1.09% (95% CI 0.24 to 1.94); HR 1.33, 95% CI 1.17 to 1.51, p<0.0001).

Conclusions

For primary TKA recipients, cases performed by surgeons who had performed fewer than 70 TKAs in the year prior to the index TKA were at 31% increased relative risk of revision (for any cause), and 18% increased relative risk for deep surgical infection requiring surgery, at 3-year follow-up.

Retrospective study on the possible existence of a treatment paradox in sepsis scores in the emergency department

OBJECTIVE

The quick Sequential Organ Failure Assessment (qSOFA) is developed as a tool to identify patients with infection with increased risk of dying from sepsis in non-intensive care unit settings, like the emergency department (ED). An abnormal score may trigger the initiation of appropriate therapy to reduce that risk. This study assesses the risk of a treatment paradox: the effect of a strong predictor for mortality will be reduced if that predictor also acts as a trigger for initiating treatment to prevent mortality.

DESIGN

Retrospective analysis on data from a large observational cohort.

SETTING

ED of a tertiary medical centre in the Netherlands.

PARTICIPANTS

3178 consecutive patients with suspected infection.

PRIMARY OUTCOME

To evaluate the existence of a treatment paradox by determining the influence of baseline qSOFA on treatment decisions within the first 24 hours after admission.

RESULTS

226 (7.1%) had a qSOFA ≥2, of which 51 (22.6%) died within 30 days. Area under receiver operating characteristics of qSOFA for 30-day mortality was 0.68 (95% CI 0.61 to 0.75). Patients with a qSOFA ≥2 had higher odds of receiving any form of intensive therapy (OR 11.4 (95% CI 7.5 to 17.1)), such as aggressive fluid resuscitation (OR 8.8 95% CI 6.6 to 11.8), fast antibiotic administration (OR 8.5, 95% CI 5.7 to 12.3) or vasopressic therapy (OR 17.3, 95% CI 11.2 to 26.8), compared with patients with qSOFA <2.

CONCLUSION

In ED patients with suspected infection, a qSOFA ≥2 was associated with more intensive treatment. This could lead to inadequate prediction of 30-day mortality due to the presence of a treatment paradox.

TRIAL REGISTRATION NUMBER

6916.

Prevalence and Characteristics of Patients With Primary Severe Hypercholesterolemia in a Multidisciplinary Healthcare System

Severe hypercholesterolemia (SH) includes individuals with LDL-C ≥ 190 mg/dl, regardless of cause. These individuals have a fivefold increased long-term risk for coronary artery disease. Although systematic SH screening can trigger early treatment, current treatment guidelines may not be fully implemented or followed by patients. To further understand this treatment gap, we used electronic health record data to retrospectively assess SH prevalence, characteristics, and treatment in a midwest US healthcare system, between 2009 and 2020. Comorbidities, tobacco exposure, and prescribed lipid-lowering therapies were assessed. Statistical analyses were conducted to identify differences between individuals with primary SH (LDL-C ≥ 190 mg/dl, group 1) and those without primary SH (LDL-C < 190 mg/dl, group 2). Of 265,220 records analyzed, 7.4% met the definition for primary SH. These group 1 cases had more comorbidities than group 2 cases, including premature coronary artery disease (5.8% vs 2.7%). Results showed most individuals in group 1 were treated by primary care providers (43.2% to 45.7%), than by specialty providers (2.5% to 3.3%), and these primary care providers prescribed mainly moderate-intensity statins. Seventy-seven percent of group 1 individuals were treated with a statin, 27% were treated with a high-intensity statin, and 4% were treated with ezetimibe. Fewer young patients (< 40 years) were treated with statins (50% to 58.3%) than older patients (74.0% to 76.3%). Although use of general statins, high-intensity statins, and ezetimibe was higher in individuals with SH than those without SH, treatment remains below guideline recommendations, especially in younger individuals.

Updates in Anti-anginal and Anti-ischemic Therapies for Acute Coronary Syndromes

PURPOSE OF REVIEW

Acute coronary syndrome is a major health problem affecting ~ 1.5 million individuals a year in the USA. We review the contemporary role of anti-anginal and anti-ischemic therapies in the management of an individual presenting with an acute coronary syndrome.

RECENT FINDINGS

Early diagnosis and appropriate evidence-based therapies significantly improve clinical outcomes in acute coronary syndrome patients. Typically, acute coronary syndrome is associated with rupture of an atherosclerotic plaque and either partial or complete thrombotic occlusion of a coronary artery. Management of an acute coronary syndrome is targeted towards this underlying pathophysiology. The last few years have seen significant advances in anti-anginal and anti-ischemic therapies in the management of patients with acute coronary syndrome. It is important to have a team effort to target risk reduction measures and to emphasize medication and dietary compliance. Long-term pharmacotherapy should include aspirin, beta-blocker, DAPT (for at least 1 year), statins, and ACE inhibitors and PCSK9 inhibitors if indicated.

Association between Adherence to Guideline-Recommended Preventive Medications and In-Hospital Mortality among Non-Reperfused ST-Elevation Myocardial Infarction Patients Admitted to a Tertiary Care Academic Center in a Developing Country

Background and aims

Acute ST-elevation myocardial infarction (STEMI) is a potentially fatal presentation of coronary artery disease (CAD). Evidence of the impact of acute pharmacological interventions in non-reperfused STEMI patients on subsequent events is limited. We aimed to assess the association between adherence to guideline-recommended preventive medications and in-hospital mortality among this high-risk patient population.

Methods

We conducted a cohort study using data obtained from the Jakarta Acute Coronary Syndrome (JAC) Registry database from a tertiary care academic hospital in Indonesia. We included 1132 of 2694 patients with STEMI recorded between 1 January 2014 and 31 December 2016 who did not undergo acute reperfusion therapy. Adherence to guideline-recommended preventive medications was defined as the combined administration of aspirin, clopidogrel, anticoagulants and statins after hospital admission. The main outcome measure was in-hospital mortality.

Results

Overall, 778 of 1132 patients (69%) received the combination of preventive medications. The guideline non-adherent group had significantly more patients with earlier onset of STEMI, higher Killip class and thrombolysis in myocardial infarction (TIMI) score. After adjustments for measured characteristics using logistic regression modeling, exposure to the combination of preventive therapies was associated with a statistically significant lower risk for in-hospital mortality (adjusted odds ratio: 0.46, 95% confidence interval: 0.30-0.70).

Conclusions

Adherence to guideline-recommended preventive medications was associated with lower risk of in-hospital mortality in non-reperfused STEMI patients. The predictors of not receiving these medications need to be confirmed in future research.

Invasive and antiplatelet treatment of patients with non-ST-segment elevation myocardial infarction: Understanding and addressing the global risk-treatment paradox

Clinical guidelines for the treatment of patients with non-ST-segment elevation myocardial infarction (NSTEMI) recommend an invasive strategy with cardiac catheterization, revascularization when clinically appropriate, and initiation of dual antiplatelet therapy regardless of whether the patient receives revascularization. However, although patients with NSTEMI have a higher long-term mortality risk than patients with ST-segment elevation myocardial infarction (STEMI), they are often treated less aggressively; with those who have the highest ischemic risk often receiving the least aggressive treatment (the "treatment-risk paradox"). Here, using evidence gathered from across the world, we examine some reasons behind the suboptimal treatment of patients with NSTEMI, and recommend approaches to address this issue in order to improve the standard of healthcare for this group of patients. The challenges for the treatment of patients with NSTEMI can be categorized into four "P" factors that contribute to poor clinical outcomes: patient characteristics being heterogeneous; physicians underestimating the high ischemic risk compared with bleeding risk; procedure availability; and policy within the healthcare system. To address these challenges, potential approaches include: developing guidelines and protocols that incorporate rigorous definitions of NSTEMI; risk assessment and integrated quality assessment measures; providing education to physicians on the management of long-term cardiovascular risk in patients with NSTEMI; and making stents and antiplatelet therapies more accessible to patients.