1
|
Santos JD, Dawson S, Conefrey C, Isaacs T, Khanum M, Faisal S, Paramasivan S. Most UK cardiovascular disease trial protocols feature criteria that exclude ethnic minority participants: a systematic review. J Clin Epidemiol 2024; 167:111259. [PMID: 38215800 DOI: 10.1016/j.jclinepi.2024.111259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 12/12/2023] [Accepted: 01/08/2024] [Indexed: 01/14/2024]
Abstract
OBJECTIVES We systematically reviewed UK cardiovascular disease (CVD) randomized controlled trial (RCT) protocols to identify the proportion featuring eligibility criteria that may disproportionately exclude ethnic minority (EM) participants. METHODS We searched MEDLINE, Embase, and Cochrane Library databases, January 2014-June 2022, to identify UK CVD RCT protocols. We extracted nonclinical eligibility criteria from trial protocols and inductively categorized the trials by their language, consent, and broad (ambiguous) criteria. Findings are narratively reported. RESULTS Of the seventy included RCT protocols, most (87.1%; 61/70) mentioned consent within the eligibility criteria, with more than two-thirds (68.9%; 42/61) indicating a requirement for 'written' consent. Alternative consent pathways that can aid EM participation were absent. English language requirement was present in 22.9% (16/70) of the studies and 37.1% (26/70) featured broad criteria that are open to interpretation and subject to recruiter bias. Only 4.3% (3/70) protocols mentioned the provision of translation services. CONCLUSION Most UK CVD trial protocols feature eligibility criteria that potentially exclude EM groups. Trial eligibility criteria must be situated within a larger inclusive recruitment framework, where ethnicity is considered alongside other intersecting and disadvantaging identities.
Collapse
Affiliation(s)
- Jhulia Dos Santos
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shoba Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Carmel Conefrey
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Talia Isaacs
- UCL Centre for Applied Linguistics, IOE, UCL's Faculty of Education and Society, University College London, London, UK
| | - Mahwar Khanum
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Saba Faisal
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sangeetha Paramasivan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| |
Collapse
|
2
|
Parco C, Tröstler J, Brockmeyer M, Hoss A, Lin Y, Quade J, Heinen Y, Schulze V, Jung C, Icks A, Kelm M, Wolff G. Risk-adjusted management in catheterization procedures for non-ST-segment elevation myocardial infarction: A standard operating procedure pilot study. Int J Cardiol 2023; 388:131111. [PMID: 37302420 DOI: 10.1016/j.ijcard.2023.06.002] [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: 05/23/2023] [Accepted: 06/02/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND The effects of standardized risk-adjusted periprocedural management of cardiac catheterization procedures in Non-ST segment elevation myocardial infarction (NSTEMI) remain unknown. We implemented a standard operating procedure (SOP) specifying risk assessment (RA, using National Cardiovascular Data Registry (NCDR) risk models) and risk-adjusted management (RM, e.g. intensified monitoring) in 2018 and aimed to investigate staff SOP adherence and associations with patient outcomes. METHODS AND RESULTS All 430 invasively managed NSTEMI patients (mean age 72y; 70.9% male) in 2018 were analyzed for staff SOP adherence and in-hospital clinical outcomes. 207 patients (48.1%; RM+) received both RA and RM; 92 patients (21.4%; RM-) received RA but no RM; 131 patients (30.5%; RA-) received neither RA nor RM. Lower staff adherence to RA was associated with emergency settings (51.9% (RA-) vs. 22.1% (RA+); p<0.01), presentation in cardiogenic shock (17.6% (RA-) vs. 6.4% (RA+); p<0.01) and invasive mechanical ventilation (12.2% (RA-) vs. 3.3% (RA+); p<0.01). Early sheath removal (87.9% (RM+) vs. 56.5% (RM-); p<0.01) and intensified monitoring (p<0.01) were more frequent in the RM+ group. All-cause mortality was not different (1.4% (RM+) vs. 4.3% (RM-); p=0.13), but there were fewer major bleeding events with associated with RM (2.4% (RM+) vs. 12% (RM-); p<0.01), which remained independently associated with RM in a multivariate logistic regression model correcting for confounders (p<0.01). CONCLUSION In an all-comer patient cohort with NSTEMI, staff adherence to risk-adjusted periprocedural management was independently associated with fewer major bleeding events. Staff adherence to SOP-specified risk assessment was frequently neglected in more critical clinical situations.
Collapse
Affiliation(s)
- Claudio Parco
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Jennifer Tröstler
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Maximilian Brockmeyer
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Alexander Hoss
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Yingfeng Lin
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Julia Quade
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Yvonne Heinen
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Volker Schulze
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Christian Jung
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Andrea Icks
- Institute for Health Services Research and Health Economics, German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany; CARID, Cardiovascular Research Institute Düsseldorf, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Georg Wolff
- Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
| |
Collapse
|
3
|
Nadarajah R, Farooq M, Raveendra K, Nakao YM, Nakao K, Wilkinson C, Wu J, Gale CP. Inequalities in care delivery and outcomes for myocardial infarction, heart failure, atrial fibrillation, and aortic stenosis in the United Kingdom. THE LANCET REGIONAL HEALTH. EUROPE 2023; 33:100719. [PMID: 37953996 PMCID: PMC10636273 DOI: 10.1016/j.lanepe.2023.100719] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/19/2023] [Accepted: 08/02/2023] [Indexed: 11/14/2023]
Abstract
Cardiovascular diseases are a leading cause of death and disability globally, with inequalities in burden and care delivery evident in Europe. To address this challenge, The Lancet Regional Health-Europe convened experts from a range of countries to summarise the current state of knowledge on cardiovascular disease inequalities across Europe. This Series paper presents evidence from nationwide secondary care registries and primary care healthcare records regarding inequalities in care delivery and outcomes for myocardial infarction, heart failure, atrial fibrillation, and aortic stenosis in the National Health Service (NHS) across the United Kingdom (UK) by age, sex, ethnicity and geographical location. Data suggest that women and older people less frequently receive guideline-recommended treatment than men and younger people. There are limited publications about ethnicity in the UK for the studied disease areas. Finally, there is inter-healthcare provider variation in cardiovascular care provision, especially for transcatheter aortic valve implantation, which is associated with differing outcomes for patients with the same disease. Providing equitable care is a founding principle of the UK NHS, which is well positioned to deliver innovative policy responses to reverse observed inequalities. Understanding differences in care may enable the implementation of appropriate strategies to mitigate differences in outcomes.
Collapse
Affiliation(s)
- Ramesh Nadarajah
- Leeds Institute of Data Analytics, University of Leeds, UK
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Maryum Farooq
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Yoko M. Nakao
- Leeds Institute of Data Analytics, University of Leeds, UK
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, UK
| | - Kazuhiro Nakao
- Leeds Institute of Data Analytics, University of Leeds, UK
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, UK
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, UK
| | - Chris Wilkinson
- Academic Cardiovascular Unit, South Tees NHS Foundation Trust, Middlesbrough, UK
- Hull York Medical School, University of York, York, UK
| | - Jianhua Wu
- Wolfson Institute of Population Health, Queen Mary University of London, UK
| | - Chris P. Gale
- Leeds Institute of Data Analytics, University of Leeds, UK
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| |
Collapse
|
4
|
Krause KR, Tay J, Douglas WA, Sammy A, Baba A, Goren K, Thombs BD, Howie AH, Oskoui M, Frøbert O, Trakadis Y, Little J, Potter BK, Butcher NJ, Offringa M. Paper II: thematic framework analysis of registry-based randomized controlled trials provided insights for designing trial ready registries. J Clin Epidemiol 2023; 159:330-343. [PMID: 37146660 DOI: 10.1016/j.jclinepi.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 04/12/2023] [Accepted: 04/26/2023] [Indexed: 05/07/2023]
Abstract
OBJECTIVES Registry-based randomized controlled trials (RRCTs) are increasingly used, promising to address challenges associated with traditional randomized controlled trials. We identified strengths and limitations reported in planned and completed RRCTs to inform future RRCTs. STUDY DESIGN AND SETTING We conducted an environmental scan of literature discussing conceptual or methodological strengths and limitations of using registries for trial design and conduct (n = 12), followed by an analysis of RRCT protocols (n = 13) and reports (n = 77) identified from a scoping review. Using framework analysis, we developed and refined a conceptual framework of RRCT-specific strengths and limitations. We mapped and interpreted strengths and limitations discussed by authors of RRCT articles using framework codes and quantified the frequencies at which these were mentioned. RESULTS Our conceptual framework identified six main RRCT strengths and four main RRCT limitations. Considering implications for RRCT conduct and design, we formulated ten recommendations for registry designers, administrators, and trialists planning future RRCTs. CONCLUSION Consideration and application of empirically underpinned recommendations for future registry design and trial conduct may help trialists utilize registries and RRCTs to their full potential.
Collapse
Affiliation(s)
- Karolin R Krause
- Cundill Centre for Child and Youth Depression, Centre for Addiction and Mental Health, 1000 Queen Street W, Toronto, Ontario, Canada M6J 1H4
| | - Joanne Tay
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Peter Gilgan Centre for Research and Learning, 686 Bay Street, Toronto, Ontario, Canada M5G 0A4
| | - William A Douglas
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Peter Gilgan Centre for Research and Learning, 686 Bay Street, Toronto, Ontario, Canada M5G 0A4
| | - Adrian Sammy
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Peter Gilgan Centre for Research and Learning, 686 Bay Street, Toronto, Ontario, Canada M5G 0A4
| | - Ami Baba
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Peter Gilgan Centre for Research and Learning, 686 Bay Street, Toronto, Ontario, Canada M5G 0A4
| | - Katherine Goren
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Peter Gilgan Centre for Research and Learning, 686 Bay Street, Toronto, Ontario, Canada M5G 0A4
| | - Brett D Thombs
- Lady Davis Institute for Medical Research, Jewish General Hospital, 3755 Chem. de la Côte-Sainte-Catherine, Montréal, Quebec, Canada H3T 1E2; Departments of Psychiatry; Epidemiology, Biostatistics, and Occupational Health; Medicine; Psychology; and Biomedical Ethics Unit, McGill University, 845 Sherbrooke St W, Montreal, Quebec, Canada H3A 0G4
| | - Alison H Howie
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, Ontario, Canada K1G 5Z3
| | - Maryam Oskoui
- Department of Pediatrics, Faculty of Medicine and Health Sciences, McGill University, 3605 Rue de la Montagne, Montréal, Quebec, Canada H3G 2M1
| | - Ole Frøbert
- Department of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden
| | - Yannis Trakadis
- Department of Human Genetics, Faculty of Medicine and Health Sciences, McGill University, Montréal, Quebec, Canada H3G 1A4
| | - Julian Little
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, Ontario, Canada K1G 5Z3
| | - Beth K Potter
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, Ontario, Canada K1G 5Z3
| | - Nancy J Butcher
- Cundill Centre for Child and Youth Depression, Centre for Addiction and Mental Health, 1000 Queen Street W, Toronto, Ontario, Canada M6J 1H4; Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Peter Gilgan Centre for Research and Learning, 686 Bay Street, Toronto, Ontario, Canada M5G 0A4; Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, Ontario, Canada M5T 1R8
| | - Martin Offringa
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Peter Gilgan Centre for Research and Learning, 686 Bay Street, Toronto, Ontario, Canada M5G 0A4; Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St 4th Floor, Toronto, Ontario, Canada M5T 3M6; Division of Neonatology, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario, Canada M5G 1X8.
| |
Collapse
|
5
|
Gale CP, Stocken DD, Aktaa S, Reynolds C, Gilberts R, Brieger D, Carruthers K, Chew DP, Goodman SG, Fernandez C, Sharples LD, Yan AT, Fox K. Effectiveness of GRACE risk score in patients admitted to hospital with non-ST elevation acute coronary syndrome (UKGRIS): parallel group cluster randomised controlled trial. BMJ 2023; 381:e073843. [PMID: 37315959 PMCID: PMC10265221 DOI: 10.1136/bmj-2022-073843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To determine the effectiveness of risk stratification using the Global Registry of Acute Coronary Events (GRACE) risk score (GRS) for patients presenting to hospital with suspected non-ST elevation acute coronary syndrome. DESIGN Parallel group cluster randomised controlled trial. SETTING Patients presenting with suspected non-ST elevation acute coronary syndrome to 42 hospitals in England between 9 March 2017 and 30 December 2019. PARTICIPANTS Patients aged ≥18 years with a minimum follow-up of 12 months. INTERVENTION Hospitals were randomised (1:1) to patient management by standard care or according to the GRS and associated guidelines. MAIN OUTCOME MEASURES Primary outcome measures were use of guideline recommended management and time to the composite of cardiovascular death, non-fatal myocardial infarction, new onset heart failure hospital admission, and readmission for cardiovascular event. Secondary measures included the duration of hospital stay, EQ-5D-5L (five domain, five level version of the EuroQoL index), and the composite endpoint components. RESULTS 3050 participants (1440 GRS, 1610 standard care) were recruited in 38 UK clusters (20 GRS, 18 standard care). The mean age was 65.7 years (standard deviation 12), 69% were male, and the mean baseline GRACE scores were 119.5 (standard deviation 31.4) and 125.7 (34.4) for GRS and standard care, respectively. The uptake of guideline recommended processes was 77.3% for GRS and 75.3% for standard care (odds ratio 1.16, 95% confidence interval 0.70 to 1.92, P=0.56). The time to the first composite cardiac event was not significantly improved by the GRS (hazard ratio 0.89, 95% confidence interval 0.68 to 1.16, P=0.37). Baseline adjusted EQ-5D-5L utility at 12 months (difference -0.01, 95% confidence interval -0.06 to 0.04) and the duration of hospital admission within 12 months (mean 11.2 days, standard deviation 18 days v 11.8 days, 19 days) were similar for GRS and standard care. CONCLUSIONS In adults presenting to hospital with suspected non-ST elevation acute coronary syndrome, the GRS did not improve adherence to guideline recommended management or reduce cardiovascular events at 12 months. TRIAL REGISTRATION ISRCTN 29731761.
Collapse
Affiliation(s)
- 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
| | - Deborah D Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, UK
| | - Suleman Aktaa
- 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
| | - Catherine Reynolds
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Leeds Institute of Clinical Trials Research, University of Leeds, UK
| | - Rachael Gilberts
- Leeds Institute of Clinical Trials Research, University of Leeds, UK
| | - David Brieger
- Cardiology Department, Concord Repatriation General Hospital, Sydney, Australia
| | - Kathryn Carruthers
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Derek P Chew
- College of Medicine and Public Health of Medicine, Flinders University of South Australia, Adelaide, Australia
| | - Shaun G Goodman
- Canadian VIGOUR Centre, Department of Medicine, University of Alberta, Edmonton, Canada
| | | | - Linda D Sharples
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Andrew T Yan
- St Michael's Hospital, Department of Medicine, University of Toronto, Toronto, Canada
| | - Keith Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
6
|
Ferenci T, Hári P, Vájer P, Jánosi A. External validation of the GRACE risk score in patients with myocardial infarction in Hungary. IJC HEART & VASCULATURE 2023; 46:101210. [PMID: 37168416 PMCID: PMC10164882 DOI: 10.1016/j.ijcha.2023.101210] [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: 02/09/2023] [Revised: 04/03/2023] [Accepted: 04/13/2023] [Indexed: 05/13/2023]
Abstract
Background Literature confirms that the Global Registry of Acute Coronary Events (GRACE) risk score provides a better risk evaluation than clinical judgment in patients with acute myocardial infarction. We aimed to externally validate the GRACE risk score in unselected patients with myocardial infarction in Hungary. Methods Data from the comprehensive Hungarian Myocardial Infarction Registry (HUMIR), a national registry that collects data on consecutive acute myocardial infarction (AMI) patients, were used. Hospitals registered 102,939 infarction events in the HUMIR between January 1, 2014, and December 31, 2020. The data required to calculate GRACE risk score were available for 75,199 events. We studied the 6-months, 1-year, and 3-year outcomes. We calculated widely used metrics to characterise calibration (calibration curve, calibration intercept and slope, Eavg, Emax, and E90) and discrimination (c-score, equivalent to AUC, and Somer's Dxy). Results The risk of low-risk patients was underestimated, and the risk of high-risk patients was overestimated. However, the deviation was small, especially for the three-year survival (E90 was 0.15, 0.22, and 0.08). Discrimination was good, with an AUC of approximately 0.8, and was very similar in all the periods. Conclusions These data confirmed the usefulness of GRACE risk score in selecting high-risk patients with myocardial infarction in the Hungarian population.
Collapse
Affiliation(s)
- Tamás Ferenci
- Physiological Controls Research Center, Óbuda University, Budapest, Hungary
- Department of Statistics, Corvinus University of Budapest, Budapest, Hungary
- Corresponding author at: Physiological Controls Research Center, Óbuda University, Budapest, Hungary.
| | | | - Péter Vájer
- Gottsegen National Cardiovascular Center, Budapest Hungary, Hungarian Myocardial Infarction Registry, Budapest, Hungary
| | - András Jánosi
- Gottsegen National Cardiovascular Center, Budapest Hungary, Hungarian Myocardial Infarction Registry, Budapest, Hungary
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Doherty DA, Tong SYC, Reilly J, Shrapnel J, McDonald S, Ahern S, Harris I, Tam CS, Brennan AL, Hodgson C, Wilcox L, Balagurunathan A, Butcher BE, Reid CM. Registry randomised trials: a methodological perspective. BMJ Open 2023; 13:e068057. [PMID: 36858472 PMCID: PMC9980340 DOI: 10.1136/bmjopen-2022-068057] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
Registry randomised clinical trials (RRCTs) have the potential to provide pragmatic answers to important clinical questions. RRCTs can be embedded into large population-based registries or smaller single site registries to provide timely answers at a reduced cost compared with traditional randomised controlled trials. RRCTs can take a number of forms in addition to the traditional individual-level randomised trial, including parallel group trials, platform or adaptive trials, cluster randomised trials and cluster randomised stepped-wedge trials. From an implementation perspective, initially it is advantageous to embed RRCT into well-established registries as these have typically already overcome any issues with end point validation and adjudication. With advances in data linkage and data quality, RRCTs can play an important role in answering clinical questions in a pragmatic, cost-effective way.
Collapse
Affiliation(s)
- Dorota A Doherty
- UWA Medical School, The University of Western Australia, Perth, Western Australia, Australia
- Biostatistics and Research Design Unit, King Edward Memorial Hospital for Women Perth, Subiaco, Western Australia, Australia
| | - Steven Y C Tong
- The Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Menzies School of Health Research, Casuarina, Nothern Territory, Australia
| | - Jennifer Reilly
- Anaesthesiology & Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jane Shrapnel
- The Sydney Children's Hospitals Network, Westmead, New South Wales, Australia
| | - Stephen McDonald
- Central Northern Adelaide Dialysis, The University of Adelaide, Adelaide, South Australia, Australia
- Australia and New Zealand Dialysis and Transplant Registry, South Australian Health and Medical Research Institute Limited, Adelaide, South Australia, Australia
| | - Susannah Ahern
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ian Harris
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW, Sydney, New South Wales, Australia
| | - Charmaine S Tam
- Northern Clinical School, Centre for Translational Data Science, The University of Sydney, Sydney, New South Wales, Australia
| | - Angela L Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Carol Hodgson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Leonie Wilcox
- Australasian Bone Marrow Transplant Recipient Registry, St Vincent's Health Australia Ltd, Sydney, New South Wales, Australia
| | | | - Belinda E Butcher
- WriteSource Medical Pty Ltd, Lane Cove, New South Wales, Australia
- University of New South Wales Faculty of Medicine, Sydney, New South Wales, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Population Health, Curtin University, Perth, Western Australia, Australia
| |
Collapse
|
9
|
Sato T, Saito Y, Kitahara H, Kobayashi Y. Relation of GRACE Risk Score to Coronary Lipid Core Plaques in Patients with Acute Coronary Syndrome. Life (Basel) 2023; 13:life13030630. [PMID: 36983786 PMCID: PMC10054497 DOI: 10.3390/life13030630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/12/2023] [Accepted: 02/22/2023] [Indexed: 02/26/2023] Open
Abstract
The GRACE risk score is established to predict thrombotic events in patients with acute coronary syndrome (ACS). Although thrombotic events including myocardial infarction after ACS are mainly attributable to vulnerable plaque formation, whether the GRACE score correlates with coronary lipid-rich plaque is unclear. A total of 54 patients with ACS undergoing primary percutaneous coronary intervention under near-infrared spectroscopy intravascular ultrasound (NIRS-IVUS) guidance were included in a prospective manner. Patients were divided into two groups according to the median of the GRACE risk score. Coronary lipid plaques in the target vessel were assessed by NIRS-IVUS with lipid core burden index (LCBI) and a maximum LCBI in 4 mm (maxLCBI4mm). The receiver operating characteristics (ROC) curve analysis was performed based on the major adverse cardiovascular events as an exploratory analysis. The GRACE risk score was significantly and positively correlated with LCBI (r = 0.31, p = 0.03) and maxLCBI4mm (r = 0.38, p = 0.006). LCBI (111.7 ± 85.7 vs. 169.0 ± 83.5, p = 0.02) and maxLCBI4mm (428.5 ± 227.1 vs. 600.6 ± 227.7, p = 0.009) in the target vessel were significantly higher in the high GRACE risk score group than their counterpart. In the ROC curve analysis, LCBI and maxLCBI4mm were predictive for clinical events. In conclusion, the higher GRACE risk score may serve as a discriminator of risk comprising more lipid-rich plaques as an underlying mechanism of an increased risk of thrombotic events after ACS. In patients with ACS, the higher GRACE risk score was significantly and modestly associated with greater coronary lipid plaques in the target vessel.
Collapse
|
10
|
Saito Y, Oyama K, Tsujita K, Yasuda S, Kobayashi Y. Treatment strategies of acute myocardial infarction: updates on revascularization, pharmacological therapy, and beyond. J Cardiol 2023; 81:168-178. [PMID: 35882613 DOI: 10.1016/j.jjcc.2022.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 07/06/2022] [Indexed: 10/16/2022]
Abstract
Owing to recent advances in early reperfusion strategies, pharmacological therapy, standardized care, and the identification of vulnerable patient subsets, the prognosis of acute myocardial infarction has improved. However, there is still considerable room for improvement. This review article summarizes the latest evidence concerning clinical diagnosis and treatment of acute myocardial infarction.
Collapse
Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Kazuma Oyama
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| |
Collapse
|
11
|
Asaria P, Bennett JE, Elliott P, Rashid T, Iyathooray Daby H, Douglass M, Francis DP, Fecht D, Ezzati M. Contributions of event rates, pre-hospital deaths, and deaths following hospitalisation to variations in myocardial infarction mortality in 326 districts in England: a spatial analysis of linked hospitalisation and mortality data. Lancet Public Health 2022; 7:e813-e824. [PMID: 35850144 PMCID: PMC10506182 DOI: 10.1016/s2468-2667(22)00108-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/11/2022] [Accepted: 04/19/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Myocardial infarction mortality varies substantially within high-income countries. There is limited guidance on what interventions-including primary and secondary prevention, or improvement of care pathways and quality-can reduce myocardial infarction mortality. Our aim was to understand the contributions of incidence (event rate), pre-hospital deaths, and hospital case fatality to the variations in myocardial infarction mortality within England. METHODS We used linked data from national databases on hospitalisations and deaths with acute myocardial infarction (ICD-10 codes I21 and I22) as a primary hospital diagnosis or underlying cause of death, from Jan 1, 2015, to Dec 31, 2018. We used geographical identifiers to estimate myocardial infarction event rate (number of events per 100 000 population), death rate (number of deaths per 100 000 population), total case fatality (proportion of events that resulted in death), pre-hospital fatality (proportion of events that resulted in pre-hospital death), and hospital case fatality (proportion of admissions due to myocardial infarction that resulted in death within 28 days of admission) for men and women aged 45 years and older across 326 districts in England. Data were analysed in a Bayesian spatial model that accounted for similarities and differences in spatial patterns of fatal and non-fatal myocardial infarction. Age-standardised rates were calculated by weighting age-specific rates by the corresponding national share of the appropriate denominator for each measure. FINDINGS From 2015 to 2018, national age-standardised death rates were 63 per 100 000 population in women and 126 per 100 000 in men, and event rates were 233 per 100 000 in women and 512 per 100 000 in men. After age-standardisation, 15·0% of events in women and 16·9% in men resulted in death before hospitalisation, and hospital case fatality was 10·8% in women and 10·6% in men. Across districts, the 99th-to-1st percentile ratio of age-standardised myocardial infarction death rates was 2·63 (95% credible interval 2·45-2·83) in women and 2·56 (2·37-2·76) in men, with death rates highest in parts of northern England. The main contributor to this variation was myocardial infarction event rate, with a 99th-to-1st percentile ratio of 2·55 (2·39-2·72) in women and 2·17 (2·08-2·27) in men across districts. Pre-hospital fatality was greater than hospital case fatality in every district. Pre-hospital fatality had a 99th-to-1st percentile ratio of 1·60 (1·50-1·70) in women and 1·75 (1·66-1·86) in men across districts, and made a greater contribution to variation in total case fatality than did hospital case fatality (99th-to-1st percentile ratio 1·39 [1·29-1·49] and 1·49 [1·39-1·60]). The contribution of case fatality to variation in deaths across districts was largest in women aged 55-64 and 65-74 years and in men aged 55-64, 65-74, and 75-84 years. Pre-hospital fatality was slightly higher in men than in women in most districts and age groups, whereas hospital case fatality was higher in women in virtually all districts at ages up to and including 65-74 years. INTERPRETATION Most of the variation in myocardial infarction mortality in England is due to variation in myocardial infarction event rate, with a smaller role for case fatality. Most variation in case fatality occurs before rather than after hospital admission. Reducing subnational variations in myocardial infarction mortality requires interventions that reduce event rate and pre-hospital deaths. FUNDING Wellcome Trust, British Heart Foundation, Medical Research Council (UK Research and Innovation), and National Institute for Health Research (UK).
Collapse
Affiliation(s)
- Perviz Asaria
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK; MRC Centre for Environment and Health, School of Public Health, Imperial College London, London, UK; Department of Cardiology, Imperial College NHS Trust, London, UK
| | - James E Bennett
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK; MRC Centre for Environment and Health, School of Public Health, Imperial College London, London, UK
| | - Paul Elliott
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK; MRC Centre for Environment and Health, School of Public Health, Imperial College London, London, UK; UK Small Area Health Statistics Unit, School of Public Health, Imperial College London, London, UK
| | - Theo Rashid
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK; MRC Centre for Environment and Health, School of Public Health, Imperial College London, London, UK
| | - Hima Iyathooray Daby
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK; MRC Centre for Environment and Health, School of Public Health, Imperial College London, London, UK; UK Small Area Health Statistics Unit, School of Public Health, Imperial College London, London, UK
| | - Margaret Douglass
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK; MRC Centre for Environment and Health, School of Public Health, Imperial College London, London, UK; UK Small Area Health Statistics Unit, School of Public Health, Imperial College London, London, UK
| | - Darrel P Francis
- Department of Cardiology, Imperial College NHS Trust, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Daniela Fecht
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK; MRC Centre for Environment and Health, School of Public Health, Imperial College London, London, UK; UK Small Area Health Statistics Unit, School of Public Health, Imperial College London, London, UK
| | - Majid Ezzati
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK; MRC Centre for Environment and Health, School of Public Health, Imperial College London, London, UK; Regional Institute for Population Studies, University of Ghana, Accra, Ghana.
| |
Collapse
|
12
|
OUP accepted manuscript. Eur Heart J 2022; 43:2300-2302. [DOI: 10.1093/eurheartj/ehac027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
|
13
|
Umadat G, Moktan V, Shapiro B. 61-Year-Old Man With Nausea and Vomiting. Mayo Clin Proc 2022; 97:170-175. [PMID: 34862073 DOI: 10.1016/j.mayocp.2021.04.031] [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: 03/09/2021] [Revised: 04/09/2021] [Accepted: 04/26/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Goyal Umadat
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Varun Moktan
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Brian Shapiro
- Advisor to residents and Consultant in Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL.
| |
Collapse
|
14
|
Mohammad MA, Olesen KKW, Koul S, Gale CP, Rylance R, Jernberg T, Baron T, Spaak J, James S, Lindahl B, Maeng M, Erlinge D. Development and validation of an artificial neural network algorithm to predict mortality and admission to hospital for heart failure after myocardial infarction: a nationwide population-based study. Lancet Digit Health 2021; 4:e37-e45. [PMID: 34952674 DOI: 10.1016/s2589-7500(21)00228-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 08/28/2021] [Accepted: 09/10/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients have an estimated mortality of 15-20% within the first year following myocardial infarction and one in four patients who survive myocardial infarction will develop heart failure, severely reducing quality of life and increasing the risk of long-term mortality. We aimed to establish the accuracy of an artificial neural network (ANN) algorithm in predicting 1-year mortality and admission to hospital for heart failure after myocardial infarction. METHODS In this nationwide population-based study, we used data for all patients admitted to hospital for myocardial infarction and discharged alive from a coronary care unit in Sweden (n=139 288) between Jan 1, 2008, and April 1, 2017, from the Swedish Web system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART) nationwide registry; these patients were randomly divided into training (80%) and testing (20%) datasets. We developed an ANN using 21 variables (including age, sex, medical history, previous medications, in-hospital characteristics, and discharge medications) associated with the outcomes of interest with a back-propagation algorithm in the training dataset and tested it in the testing dataset. The ANN algorithm was then validated in patients with incident myocardial infarction enrolled in the Western Denmark Heart Registry (external validation cohort) between Jan 1, 2008, and Dec 31, 2016. The predictive ability of the model was evaluated using area under the receiver operating characteristic curve (AUROC) and Youden's index was established as a means of identifying an empirical dichotomous cutoff, allowing further evaluation of model performance. FINDINGS 139 288 patients who were admitted to hospital for myocardial infarction in the SWEDEHEART registry were randomly divided into a training dataset of 111 558 (80%) patients and a testing dataset of 27 730 (20%) patients. 30 971 patients with myocardial infarction who were enrolled in the Western Denmark Heart Registry were included in the external validation cohort. A first event, either all-cause mortality or admission to hospital for heart failure 1 year after myocardial infarction, occurred in 32 308 (23·2%) patients in the testing and training cohorts only. For 1-year all-cause mortality, the ANN had an AUROC of 0·85 (95% CI 0·84-0·85) in the testing dataset and 0·84 (0·83-0·84) in the external validation cohort. The AUROC for admission to hospital for heart failure within 1 year was 0·82 (0·81-0·82) in the testing dataset and 0·78 (0·77-0·79) in the external validation dataset. With an empirical cutoff the ANN algorithm correctly classified 73·6% of patients with regard to all-cause mortality and 61·5% of patients with regard to admission to hospital for heart failure in the external validation cohort, ruling out adverse outcomes with 97·1-98·7% probability in the external validation cohort. INTERPRETATION Identifying patients at a high risk of developing heart failure or death after myocardial infarction could result in tailored therapies and monitoring by the allocation of resources to those at greatest risk. FUNDING The Swedish Heart and Lung Foundation, Swedish Scientific Research Council, Swedish Foundation for Strategic Research, Knut and Alice Wallenberg Foundation, ALF Agreement on Medical Education and Research, Skane University Hospital, The Bundy Academy, the Märta Winkler Foundation, the Anna-Lisa and Sven-Eric Lundgren Foundation for Medical Research.
Collapse
Affiliation(s)
- Moman A Mohammad
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden.
| | - Kevin K W Olesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Rebecca Rylance
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Tomas Jernberg
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Tomasz Baron
- Department of Medical Sciences and Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
| | - Jonas Spaak
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| |
Collapse
|
15
|
Moledina SM, Rashid M, Nolan J, Nakao K, Sun LY, Velagapudi P, Wilton SB, Volgman AS, Gale CP, Mamas MA. Addressing disparities of care in non-ST-segment elevation myocardial infarction patients without standard modifiable risk factors: insights from a nationwide cohort study. Eur J Prev Cardiol 2021; 29:1084-1092. [PMID: 34897399 DOI: 10.1093/eurjpc/zwab200] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/09/2021] [Accepted: 11/09/2021] [Indexed: 12/14/2022]
Abstract
AIMS The importance of standard modifiable cardiovascular risk factors (SMuRFs) in preventing non-ST-segment elevation myocardial infarction (NSTEMI) is established. However, NSTEMI may present in the absence of SMuRFs, and little is known about their outcomes. METHODS AND RESULTS We analysed 176 083 adult (≥18 years) hospitalizations with NSTEMI using data from the United Kingdom (UK) Myocardial Infarction National Audit Project (MINAP). Clinical characteristics and all-cause in-hospital mortality were analysed according to SMuRF status, with 135 223 patients presenting with at least one of diabetes, hypertension, hypercholesterolaemia, or current smoking status and 40 860 patients without any SMuRFs. Those with a history of coronary artery disease were excluded. Patients without SMuRFs were more frequently older (median age 72 year vs. 71 years, P < 0.001), male (62% vs. 61%, P < 0.001), and Caucasian (95% vs. 92%, P < 0.001). Those without SMuRFs less frequently received statins (71% vs. 81%, P < 0.001), had their left ventricular (LV) function recorded (62% vs. 65%, P < 0.001) or for those with moderate or severe LV systolic dysfunction were prescribed angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (80% vs. 85%, P < 0.001). Following propensity score matching the odds of all-cause mortality [odds ratio (OR): 0.85, 95% confidence interval (CI): 0.77-0.93], cardiac mortality (OR: 0.85, 95% CI: 0.76-0.94), and major adverse cardiovascular events (MACE) (OR: 0.85, 95% CI: 0.77-0.93) were lower in patients without SMuRFs. CONCLUSION More than one in five patients presenting with NSTEMI had no SMuRFs, who were less frequently received guideline-recommended management and had lower in-hospital (all-cause and cardiac) mortality and MACE than patients with SMuRFs.
Collapse
Affiliation(s)
- Saadiq M Moledina
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, Keele Road, Newcastle ST5 5BG, UK.,Division of Cardiology, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, Keele Road, Newcastle ST5 5BG, UK.,Division of Cardiology, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - James Nolan
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, Keele Road, Newcastle ST5 5BG, UK.,Division of Cardiology, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| | - Kazuhiro Nakao
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Claredon Way, Leeds LS2 9NL, UK.,Leeds Institute of Data Analytics, University of Leeds, Claredon Way, Leeds LS2 9NL, UK.,Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Great Georde St, Leeds LS1 3EX, UK
| | - Louise Y Sun
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, and School of Epidemiology and Public Health, University of Ottawa, Ruskin Street, Ottawa, ON K1Y 4W7, Canada
| | - Poonam Velagapudi
- Division of Cardiology, University of Nebraska Medical Center, Emile St, Omaha, NE 68198, USA
| | - Stephen B Wilton
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Hospital Drive, NW T2N 4N, Alberta, Canada
| | | | - Chris P Gale
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Claredon Way, Leeds LS2 9NL, UK.,Leeds Institute of Data Analytics, University of Leeds, Claredon Way, Leeds LS2 9NL, UK.,Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Great Georde St, Leeds LS1 3EX, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, Keele Road, Newcastle ST5 5BG, UK.,Division of Cardiology, Royal Stoke University Hospital, Newcastle Road, Stoke-on-Trent, ST4 6QG, UK
| |
Collapse
|
16
|
Korol S, Wsol A, Reshetnik A, Krasyuk A, Marushchenko K, Puchalska L. Evaluation and Comparison of the STIMUL Extended and Simplified Risk Scores for Predicting Two-Year Death in Patients Following ST-Segment Elevation Myocardial Infarction. Medicina (B Aires) 2021; 57:medicina57121349. [PMID: 34946294 PMCID: PMC8707946 DOI: 10.3390/medicina57121349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/30/2021] [Accepted: 12/08/2021] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: The management of ST-segment elevation myocardial infarction (STEMI) requires a patient’s long-term risk to be estimated. The objective of this study was to develop extended and simplified models of two-year death risk estimation following STEMI that include and exclude cardiac troponins as prognostic factors and to compare their performance with each other. Materials and Methods: Extended and simplified multivariable logistic regression models were elaborated using 1103 patients with STEMI enrolled and followed up in the STIMUL (ST-segment elevation Myocardial Infarctions in Ukraine and their Lethality) registry. Results: The extended STIMUL risk score includes seven independent risk factors: age; Killip class ≥ II at admission; resuscitated cardiac arrest; non-reperfused infarct-related artery; troponin I ≥ 150.0 ng/L; diabetes mellitus; and history of congestive heart failure. The exclusion of cardiac troponin in the simplified model did not influence the predictive value of each factor. Both models divide patients into low, moderate, and high risk groups with a C-statistic of 0.89 (95% CI 0.84–0.93; p < 0.001) for the extended STIMUL model and a C-statistic of 0.86 (95% CI 0.83–0.99; p < 0.001) for the simplified model. However, the addition of the level of troponin I to the model increased its prognostic value by 10.7%. Conclusions: The STIMUL extended and simplified risk estimation models perform well in the prediction of two-year death risk following STEMI. The simplified version may be useful when clinicians do not know the value of cardiac troponins among the population of STEMI patients.
Collapse
Affiliation(s)
- Svitlana Korol
- Department of Military Therapy of the Ukrainian Military Medical Academy, 01015 Kyiv, Ukraine; (S.K.); (A.K.); (K.M.)
| | - Agnieszka Wsol
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, 02-091 Warsaw, Poland;
- Correspondence: ; Tel.: +48-22-116-6113
| | - Alexander Reshetnik
- Department of Nephrology and Intensive Care Medicine, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany;
| | - Alexander Krasyuk
- Department of Military Therapy of the Ukrainian Military Medical Academy, 01015 Kyiv, Ukraine; (S.K.); (A.K.); (K.M.)
| | - Kateryna Marushchenko
- Department of Military Therapy of the Ukrainian Military Medical Academy, 01015 Kyiv, Ukraine; (S.K.); (A.K.); (K.M.)
| | - Liana Puchalska
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, 02-091 Warsaw, Poland;
| |
Collapse
|
17
|
Chunawala ZS, Hall ME, Arora S, Dai X, Menon V, Smith SC, Matsushita K, Caughey MC. Prognostic value of shock index in patients admitted with non-ST-segment elevation myocardial infarction: the ARIC study community surveillance. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:869-877. [PMID: 34263294 PMCID: PMC8557437 DOI: 10.1093/ehjacc/zuab050] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/03/2021] [Accepted: 06/17/2021] [Indexed: 02/07/2023]
Abstract
AIMS Shock index (SI), defined as the ratio of heart rate (HR) to systolic blood pressure (SBP), is easily obtained and predictive of mortality in patients with ST-segment elevation myocardial infarction. However, large-scale evaluations of SI in patients with non-ST-segment elevation myocardial infarction (NSTEMI) are lacking. METHODS AND RESULTS Hospitalizations for acute myocardial infarction were sampled from four US areas by the Atherosclerosis Risk in Communities (ARIC) study and classified by physician review. Shock index was derived from the HR and SBP at first presentation and considered high when ≥0.7. From 2000 to 2014, 18 301 weighted hospitalizations for NSTEMI were sampled and had vitals successfully obtained. Of these, 5753 (31%) had high SI (≥0.7). Patients with high SI were more often female (46% vs. 39%) and had more prevalent chronic kidney disease (40% vs. 32%). TIMI (Thrombolysis in Myocardial Infarction) risk scores were similar between the groups (4.3 vs. 4.2), but GRACE (Global Registry of Acute Coronary Syndrome) score was higher with high SI (140 vs. 118). Angiography, revascularization, and guideline-directed medications were less often administered to patients with high SI, and the 28-day mortality was higher (13% vs. 5%). Prediction of 28-day mortality by SI as a continuous measurement [area under the curve (AUC): 0.68] was intermediate to that of the GRACE score (AUC: 0.87) and the TIMI score (AUC: 0.54). After adjustments, patients with high SI had twice the odds of 28-day mortality (odds ratio = 2.02; 95% confidence interval: 1.46-2.80). CONCLUSION The SI is easily obtainable, performs moderately well as a predictor of short-term mortality in patients hospitalized with NSTEMI, and may be useful for risk stratification in emergency settings.
Collapse
Affiliation(s)
- Zainali S Chunawala
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Michael E Hall
- Department of Medicine, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS, 39216, USA
| | - Sameer Arora
- Department of Medicine, Division of Cardiology, University of North Carolina School of Medicine, 160 Dental Circle, Chapel Hill, NC, 27599, USA
| | - Xuming Dai
- Department of Cardiology, Lang Research Center, New York Presbyterian Queens Hospital, 56-45 Main St., Flushing, NY, 11355, USA
| | - Venu Menon
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA
| | - Sidney C Smith
- Department of Medicine, Division of Cardiology, University of North Carolina School of Medicine, 160 Dental Circle, Chapel Hill, NC, 27599, USA
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument St., Baltimore, MD, 21287, USA
| | - Melissa C Caughey
- Joint Department of Biomedical Engineering, University of North Carolina and North Carolina State University, 104 Mason Farm Rd., Chapel Hill, NC 27599, USA
| |
Collapse
|
18
|
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.
Collapse
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
| |
Collapse
|
19
|
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]
|
20
|
Haghbayan H, Gale CP, Chew DP, Brieger D, Fox KA, Goodman SG, Yan AT. Clinical risk prediction models for the prognosis and management of acute coronary syndromes. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 7:222-228. [PMID: 33693493 DOI: 10.1093/ehjqcco/qcab018] [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: 01/30/2021] [Accepted: 03/04/2021] [Indexed: 06/12/2023]
Abstract
Patients with acute coronary syndromes (ACS), particularly non-ST-segment elevation ACS, represent a spectrum of patients at variable risk of short- and long-term adverse clinical outcomes. Accurate prognostic assessment in this population requires the simultaneous consideration of multiple clinical and laboratory variables which may be under-recognized by the treating physicians, leading to an observed risk-treatment paradox in the use of invasive and pharmacological therapies. The routine application of established clinical risk scores, such as the Global Registry of Acute Coronary Events risk score, is recommended by major international clinical practice guidelines for structured risk stratification at the time of presentation, but uptake remains inconsistent. This article discusses the methodology of designing, deriving, and validating clinical risk scores, reviews the major validated risk scores for assessing prognosis in ACS, and examines their role in guiding clinical decision-making in ACS management, especially the timing of invasive coronary angiography. We also discuss emerging data on the impact of the routine use of such risk scores on patient management and clinical outcomes, as well as future directions for investigation in this field.
Collapse
Affiliation(s)
- Hourmazd Haghbayan
- Division of Cardiology, Department of Medicine, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto M5B 1W8,Ontario, Canada
| | - Chris P Gale
- School of Medicine, Faculty of Medicine and Health, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - David Brieger
- Faculty of Medicine and Health, Concord Hospital, University of Sydney, Sydney,NSW 2050 Australia
| | - Keith A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Shaun G Goodman
- Division of Cardiology, Department of Medicine, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto M5B 1W8,Ontario, Canada
| | - Andrew T Yan
- Division of Cardiology, Department of Medicine, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto M5B 1W8,Ontario, Canada
| |
Collapse
|
21
|
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
|
22
|
Kumar D, Ashok A, Saghir T, Khan N, Solangi BA, Ahmed T, Karim M, Abid K, Bai R, Kumari R, Kumar H. Prognostic value of GRACE score for in-hospital and 6 months outcomes after non-ST elevation acute coronary syndrome. Egypt Heart J 2021; 73:22. [PMID: 33677742 PMCID: PMC7937004 DOI: 10.1186/s43044-021-00146-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 02/23/2021] [Indexed: 12/22/2022] Open
Abstract
Background The aim of this study was to determine the predictive value of the Global Registry of Acute Coronary Events (GRACE) score for predicting in-hospital and 6 months mortality after non-ST elevation acute coronary syndrome (NSTE-ACS). Results In this observational study, 300 patients with NSTE-ACS of age more than 30 years were included; 16 patients died during the hospital stay (5.3%). Of 284 patients at 6 months assessment, 10 patients died (3.5%), 240 survived (84.5%), and 34 were lost to follow-up (12%) respectively. In high risk category, 10.5% of the patients died within hospital stay and 11.8% died within 6 months (p = 0.001 and p = 0.013). In univariate analysis, gender, diabetes mellitus, family history, smoking, and GRACE score were significantly associated with in-hospital mortality whereas age, obesity, dyslipidemia, and GRACE were significantly associated with 6 months mortality. After adjustment, diabetes mellitus, family history, and GRACE score remained significantly associated with in-hospital mortality (p ≤ 0.05) and age remained significantly associated with 6 months mortality. Conclusion GRACE risk score has good predictive value for the prediction of in-hospital mortality and 6 months mortality among patients with NSTE-ACS.
Collapse
Affiliation(s)
- Dileep Kumar
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan.
| | - Arti Ashok
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Tahir Saghir
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Naveedullah Khan
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | | | - Tariq Ahmed
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Musa Karim
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Khadijah Abid
- College of Physicians and Surgeons Pakistan (CPSP), Karachi, Pakistan
| | - Reeta Bai
- Dow University of Health Sciences, Karachi, Pakistan
| | | | | |
Collapse
|
23
|
Chew DP, Hyun K, Morton E, Horsfall M, Hillis GS, Chow CK, Quinn S, D’Souza M, Yan AT, Gale CP, Goodman SG, Fox K, Brieger D. Objective Risk Assessment vs Standard Care for Acute Coronary Syndromes: A Randomized Clinical Trial. JAMA Cardiol 2021; 6:304-313. [PMID: 33295965 PMCID: PMC7726696 DOI: 10.1001/jamacardio.2020.6314] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/22/2020] [Indexed: 11/14/2022]
Abstract
Importance Although international guidelines recommend use of the Global Registries of Acute Coronary Events (GRACE) risk score (GRS) to guide acute coronary syndrome (ACS) treatment decisions, the prospective utility of the GRS in improving care and outcomes is unproven. Objective To assess the effect of routine GRS implementation on guideline-indicated treatments and clinical outcomes of hospitalized patients with ACS. Design, Setting, and Participants Prospective cluster (hospital-level) randomized open-label blinded end point (PROBE) clinical trial using a multicenter ACS registry of acute care cardiology services. Fixed sampling of the first 10 patients within calendar month, with either ST-segment elevation or non-ST-segment elevation ACS. The study enrolled patients from June 2014 to March 2018, and data were analyzed between February 2020 and April 2020. Interventions Implementation of routine risk stratification using the GRS and guideline recommendations. Main Outcomes and Measures The primary outcome was a performance score based on receipt of early invasive treatment, discharge prescription of 4 of 5 guideline-recommended pharmacotherapies, and cardiac rehabilitation referral. Clinical outcomes included a composite of all-cause death and/or myocardial infarction (MI) within 1 year. Results This study enrolled 2318 patients from 24 hospitals and was stopped prematurely owing to futility. Of the patients enrolled, median age was 65 years (interquartile range, 56-74 years), 29.5% were women (n = 684), and 62.9% were considered high risk (n = 1433). Provision of all 3 measures among high-risk patients did not differ between the randomized arms (GRS: 424 of 717 [59.9%] vs control: 376 of 681 [55.2%]; odds ratio [OR], 1.04; 95% CI, 0.63-1.71; P = .88). The provision of early invasive treatment was increased compared with the control arm (GRS: 1042 of 1135 [91.8%] vs control: 989 of 1183 [83.6%]; OR, 2.26; 95% CI, 1.30-3.96; P = .004). Prescription of 4 of 5 guideline-recommended pharmacotherapies (GRS: 864 of 1135 [76.7%] vs control: 893 of 1183 [77.5%]; OR, 0.97; 95% CI, 0.68-1.38) and cardiac rehabilitation (GRS: 855 of 1135 [75.1%] vs control: 861 of 1183 [72.8%]; OR, 0.68; 95% CI, 0.32-1.44) were not different. By 12 months, GRS intervention was not associated with a significant reduction in death or MI compared with the control group (GRS: 96 of 1044 [9.2%] vs control: 146 of 1087 [13.4%]; OR, 0.66; 95% CI, 0.38-1.14). Conclusions and Relevance Routine GRS implementation in cardiology services with high levels of clinical care was associated with an increase in early invasive treatment but not other aspects of care. Low event rates and premature study discontinuation indicates the need for further, larger scale randomized studies. Trial Registration anzctr.org.au Identifier: ACTRN12614000550606.
Collapse
Affiliation(s)
- Derek P. Chew
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Karice Hyun
- Westmead Applied Research Centre, Faulty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - Erin Morton
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Matt Horsfall
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Graham S. Hillis
- School of Medicine, University of Western Australia, Perth, Australia
| | - Clara K. Chow
- Westmead Applied Research Centre, Faulty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Stephen Quinn
- Department of Health Science and Biostatistics, Swinburne University of Technology, Melbourne, Australia
| | - Mario D’Souza
- Westmead Applied Research Centre, Faulty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Andrew T. Yan
- St Michael’s Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Chris P. Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, England
| | - Shaun G. Goodman
- St Michael’s Hospital, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Keith Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland
| | - David Brieger
- Cardiology Department, Concord Repatriation General Hospital, Sydney, Australia
| |
Collapse
|
24
|
Parco C, Brockmeyer M, Kosejian L, Quade J, Tröstler J, Bader S, Lin Y, Karathanos A, Krieger T, Heinen Y, Schulze V, Icks A, Jung C, Kelm M, Wolff G. Modern NCDR and ACTION risk models outperform the GRACE model for prediction of in-hospital mortality in acute coronary syndrome in a German cohort. Int J Cardiol 2021; 329:28-35. [PMID: 33412182 DOI: 10.1016/j.ijcard.2020.12.085] [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: 08/27/2020] [Revised: 11/18/2020] [Accepted: 12/28/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Risk prediction with the Global Registry of Acute Coronary Events (GRACE) risk model is guideline-recommended in acute coronary syndrome (ACS) patients. However, the performance of more contemporary scores derived from ACTION (Acute Coronary Treatment and Intervention Outcomes Network) and National Cardiovascular Data (NCDR) registries remains incompletely understood. We aimed to compare these models in German ACS patients. METHODS AND RESULTS A total of 1567 patients with (Non-)ST-segment elevation myocardial infarction (NSTEMI: 1002 patients, STEMI: 565 patients) undergoing invasive management at University Hospital Düsseldorf (Germany) from 2014 to 2018 were included. Overall in-hospital mortality was 7.5% (NSTEMI 3.7%, STEMI 14.5%). Parameters for calculation of GRACE 1.0, GRACE 2.0, ACTION and NCDR risk models and in-hospital mortality were assessed and risk model performance was compared. The GRACE 1.0 risk model for prediction of in-hospital mortality discriminated risk superior (c-index 0.84) to its successor GRACE 2.0 (c-index 0.79, pGRACE1.0vsGRACE2.0 = 0.0008). The NCDR model performed best in discrimination of risk in ACS overall (c-index 0.89; pACTIONvsNCDR < 0.0001; pGRACEvsNCDR < 0.0001) and showed superior performance compared to GRACE in NSTEMI and STEMI subgroups (pGRACEvsNCDR both < 0.02). ACTION and GRACE risk models performed comparable to each other (both c-index 0.84, pGRACEvsACTION = 0.68), with advantages for ACTION in NSTEMI patients (c-index 0.87 vs. 0.84 (GRACE); pGRACEvsACTION = 0.02). ACTION and GRACE 2.0 showed the most accurate calibration of all models. CONCLUSIONS In a contemporary German patient population with ACS, modern NCDR and ACTION risk models showed superior performance in prediction of in-hospital mortality compared to the gold-standard GRACE model.
Collapse
Affiliation(s)
- Claudio Parco
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany.
| | - Maximilian Brockmeyer
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Lucin Kosejian
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Julia Quade
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Jennifer Tröstler
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Selina Bader
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Yingfeng Lin
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Athanasios Karathanos
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Torben Krieger
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Yvonne Heinen
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Volker Schulze
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Andrea Icks
- Institute for Health Services Research and Health Economics, Heinrich-Heine-University, Düsseldorf, Germany
| | - Christian Jung
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Malte Kelm
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Georg Wolff
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| |
Collapse
|
25
|
Chan Pin Yin D, Azzahhafi J, James S. Risk Assessment Using Risk Scores in Patients with Acute Coronary Syndrome. J Clin Med 2020; 9:E3039. [PMID: 32967247 PMCID: PMC7565031 DOI: 10.3390/jcm9093039] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/18/2020] [Indexed: 02/07/2023] Open
Abstract
Risk scores are widely used in patients with acute coronary syndrome (ACS) prior to treatment decision-making at different points in time. At initial hospital presentation, risk scores are used to assess the risk for developing major adverse cardiac events (MACE) and can guide clinicians in either discharging the patients at low risk or swiftly admitting and treating the patients at high risk for MACE. During hospital admission, risk assessment is performed to estimate mortality, residual ischemic and bleeding risk to guide further in-hospital management (e.g., timing of coronary angiography) and post-discharge management (e.g., duration of dual antiplatelet therapy). In the months and years following ACS, long term risk can also be assessed to evaluate current treatment strategies (e.g., intensify or reduce pharmaceutical treatment options). As multiple risk scores have been developed over the last decades, this review summarizes the most relevant risk scores used in ACS patients.
Collapse
Affiliation(s)
- Dean Chan Pin Yin
- Department of Cardiology, St. Antonius Hospital Nieuwegein, 3435CM Nieuwegein, The Netherlands;
| | - Jaouad Azzahhafi
- Department of Cardiology, St. Antonius Hospital Nieuwegein, 3435CM Nieuwegein, The Netherlands;
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University Hospital, 751 85 Uppsala, Sweden;
| |
Collapse
|
26
|
Comparison of the CAMI-NSTEMI and GRACE Risk Model for Predicting In-Hospital Mortality in Chinese Non-ST-Segment Elevation Myocardial Infarction Patients. Cardiol Res Pract 2020; 2020:2469281. [PMID: 32774913 PMCID: PMC7396005 DOI: 10.1155/2020/2469281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/13/2020] [Accepted: 06/18/2020] [Indexed: 02/07/2023] Open
Abstract
Introduction The ability of risk models to predict in-hospital mortality and the influence on downstream therapeutic strategy has not been fully investigated in Chinese Non-ST-segment elevation myocardial infarction (NSTEMI) patients. Thus, we sought to validate and compare the performance of the Global Registry of Acute Coronary Events risk model (GRM) and China Acute Myocardial Infarction risk model (CRM) and investigate impacts of the two models on the selection of downstream therapeutic strategies among these patients. Methods We identified 2587 consecutive patients with NSTEMI. The primary endpoint was in-hospital death. For each patient, the predicted mortality was calculated according to GRM and CRM, respectively. The area under the receiver operating characteristic curve (AUC), Hosmer–Lemeshow (H–L) test, and net reclassification improvement (NRI) were used to assess the performance of models. Results In-hospital death occurred in 4.89% (126/2587) patients. Compared to GRM, CRM demonstrated a larger AUC (0.809 versus 0.752, p < 0.0001), less discrepancy between observed and predicted mortality (H–L χ2: 22.71 for GRM, p=0.0038 and 10.25 for CRM, p=0.2479), and positive NRI (0.3311, p < 0.0001), resulting in a significant change of downstream therapeutic strategy. Conclusion In Chinese NSTEMI patients, the CRM provided a more accurate estimation for in-hospital mortality, and application of the CRM instead of the GRM changes the downstream therapeutic strategy remarkably.
Collapse
|