Highlights of the 2002 update to the 2000 American College of Cardiology/American Heart Association acute coronary syndrome guidelines

Association Between Echocardiographic Non-invasive Myocardial Work Indices and Myocardial Fibrosis in Patients With Dilated Cardiomyopathy

Objectives: To analyze the association between global myocardial work indices evaluated by non-invasive left ventricular (LV) pressure-strain loop (PSL) and LV myocardial fibrosis in patients with dilated cardiomyopathy (DCM).

Methods: A total of 57 patients with DCM were included in this prospective study. Global work index (GWI), global constructive work (GCW), global wasted work (GWW), global work efficiency (GWE) and global longitudinal strain (GLS) were measured using LVPSL. LV volumes and LV ejection fraction (LVEF) were evaluated using cardiac magnetic resonance imaging (CMRI), LV myocardial fibrosis was estimated at CMRI by qualitative assessment of late gadolinium enhancement (LGE). According to the CMRI, the studied population was divided into two groups, namely: patients without LGE (LGE-) and patients with LGE (LGE+).

Results: The LGE+ group presented with increased age, LV end systolic volume (LVESV) index and reduced GWI, GCW, GWE, GLS, CMRI-derived LVEF (LVEF_CMRI), the differences between the two groups were statistically significant (P < 0.05). After correcting for age and LVESV index, LVEF_CMRI, GLS, GWI, GCW, and GWE retained independent associations with LV myocardial fibrosis. According to receiver operating characteristics (ROC) analysis, LVEF_CMRI, and GCW showed larger AUC and higher accuracy, sensitivity, and specificity than GLS, the accuracy of predicting LV myocardial fibrosis ranged from high to low as: LVEF_CMRI, GCW, GWE, GWI, and GLS.

Conclusions: LVEF_CMRI, GWI, GCW, GWE, and GLS remained significant predictors of LV myocardial fibrosis. LVEF_CMRI, and GCW appeared to better predict LV myocardial fibrosis compared with GLS.

Interrelationships between ALOX5AP polymorphisms, serum leukotriene B4 level and risk of acute coronary syndrome

BACKGROUND

We investigated the relationships between the ALOX5AP gene rs10507391 and rs4769874 polymorphisms, serum levels of leukotriene (LT) B4, and risk of acute coronary syndrome (ACS).

METHODS

A total of 709 participants, comprising 508 ACS patients (ACS group) and 201 noncoronary artery disease patients with chest pain (control group) were recruited from the Han population of the Changwu region in China. Two polymorphic loci were genotyped using polymerase chain reaction and restriction fragment length polymorphism analysis. Serum LTB4 level was determined by enzyme-linked immunosorbent assay.

RESULTS

Serum LTB4 levels were significantly higher (P<0.001) in the ACS group (median/interquartile range, 470.27/316.32 pg/ml) than in the control group (233.05/226.82 pg/ml). No statistical differences were observed between genotype, allele and haplotype frequencies for the tested loci in either the ACS group or the control group, even after adjustments were made for conventional risk factors by multivariate logistic regression. This suggests there is no association between the ALOX5AP rs10507391 and rs4769874 polymorphisms and ACS risk. Elevated serum LTB4 level was closely linked to ACS risk, and may be independent of traditional risk factors as a risk factor for ACS (P<0.001). There was no significant association between serum LTB4 levels and the two variants in either the ACS group or the control group.

CONCLUSIONS

Rs10507391, rs4769874 and its haplotypes in ALOX5AP are unrelated to ACS risk in the Chinese Han population of Changwu, but elevated serum LTB4 level is strongly associated with ACS risk. Serum LTB4 level is not subject to the influence of either the rs10507391, rs4769874 or the haplotype.

Relation between K469E gene polymorphism of ICAM-1 and recurrence of ACS and cardiovascular mortality

OBJECTIVE

To explore the relation between K469E gene polymorphism of intercellular adhesion molecular-1 (ICAM-1) and the recurrence of ACS and cardiovascular mortality.

METHODS

A total of 185 patients with ACS hospitalized in Department of Cardiology in our hospital from Sep 2007 to Sep 2008 were selected as objectives. Polymerase chain reaction was used to analyze K469E gene polymorphism of ICAM-1. According to the genotypes, they were divided into two groups: group with K allele (KK+KE) and group without K allele (EE). The two groups were followed up prospectively for five years and blood lipid, blood pressure, blood glucose, recurrence and death of ACS were collected when the patients left hospital. The relation between ICAM-1 gene polymorphism and the recurrence of ACS and cardiovascular mortality was analyzed by Logistic regression.

RESULTS

After long-term follow-up, it was found that ACS recurred on 71 cases (38.4%) and 10 cases died, among which 3 cases died of cardiovascular disease. The recurrence of ACS and cardiovascular mortality in group with K allele were remarkably higher than that in group without K allele (P<0.01). After multivariate Logistic regression adjusted ages, gender, weight indexes, TC, LDL-C, TG, smoking, drinking, family history of cardiovascular disease, history of hypertension and the severity of coronary artery disease, the risks of ACS recurrence and cardiovascular mortality in group with genotype KK+KE was 3.31 and 3.53 times of those in group with genotype EE respectively (P<0.01). When the independent variable of hypertension was introduced in regression analysis, the risks of ACS recurrence and cardiovascular mortality in group with K allele both decreased (P<0.05). When the independent variable of HDL-C was introduced, different genotypes of ICAM-1 weren't relevant with ACS recurrence and cardiovascular mortality (P>0.05).

CONCLUSIONS

K469E gene polymorphism of ICAM-1 was related to ACS recurrence and cardiovascular mortality, K allele probably an independent risky factor and hypertension and to which the level of HDL-C were closely related.

Embedded guideline information without patient specificity in a commercial emergency department computerized order-entry system

BACKGROUND

Clinical practice guidelines and computerized provider order entry (CPOE) have potential for improving clinical care. Questions remain about feasibility and effectiveness of CPOE in the emergency department (ED). However, successful implementations in other settings typically incorporate decision support functions that are lacking in many commercially available ED information systems.

OBJECTIVES

To compare acute coronary syndrome (ACS) guideline compliance before and after implementation of a locally implemented ACS guideline, first on paper and then in a commercially available ED information system without patient-specific clinical decision support.

METHODS

Clinical data were abstracted retrospectively on patients seen before and after introduction of paper and, subsequently, CPOE versions of ACS guideline-based order-sets. Order-set use was determined. Risk category assignments were made retrospectively using guideline criteria and compliance with the guideline regarding beta-blockers, heparin, and aspirin was determined. Association between order-set use and compliance was determined.

RESULTS

The authors found increasing use of order-sets over the period of study. However, there was poor association between the order-sets used and risk stratification category. Some association between ED beta-blocker use and use of CPOE order-sets was found, but there was no improvement in overall compliance with any of the guideline recommendations.

CONCLUSIONS

Adherence to an ACS guideline did not improve with implementation of a commercial ED information system without provision for patient-specific decision support. This suggests that the lack of patient-specific decision-support functionality in most current ED information system products may hamper progress in the development of effective decision support.