Contemporary management of acute coronary syndromes: does the practice match the evidence? The global registry of acute coronary events (GRACE)

Type of hospitalisations and in-hospital outcomes in the Italian coronary care unit network at the time of COVID-19 pandemic: the BLITZ-COVID19 Registry

OBJECTIVE

The aim of the study was to describe the epidemiology and outcome of patients hospitalised during the COVID-19 pandemic in intensive cardiac care units (ICCs).

DESIGN

Non-interventional, retrospective and prospective, nationwide study.

SETTING

109 private or public ICCs in Italy.

PARTICIPANTS

6054 consecutive patients admitted to Italian ICCs during COVID-19 pandemic.

PRIMARY AND SECONDARY OUTCOME MEASURES

To obtain accurate and up-to-date information on epidemiology and outcome of patients admitted to ICCs during the COVID-19 pandemic, the impact that the COVID-19 infection may have determined on the organisational pathways and in-hospital management of the various clinical conditions being admitted to ICCs.

RESULTS

Acute coronary syndromes were the most frequent ICC discharge diagnoses followed by heart failure and hypokinetic arrhythmias. The prevalence of COVID-19 positivity was approximately 3%. Most patients with a COVID-19 diagnosis at discharge (52%) arrived to ICC from other wards, in particular 22% from non-cardiology ICCs. The overall mortality was 4.2% during ICC and 5.8% during hospital stay. The cause of in-hospital death was cardiac in 74.4% of the cases, non-cardiovascular in 13.5%, vascular in 5.8% and related to COVID-19 in 6.3% of the patients.

CONCLUSIONS

This study provides a unique nationwide picture of current ICC care during COVID-19 pandemic.

TRIAL REGISTRATION NUMBER

NCT04744415.

Changes in demographics, clinical practices and long-term outcomes of patients with ST segment-elevation myocardial infarction who underwent coronary revascularisation in the past two decades: cohort study

OBJECTIVE

To evaluate changes in demographics, clinical practices and long-term clinical outcomes of patients with ST segment-elevation myocardial infarction (STEMI) before and beyond 2010.

DESIGN

Multicentre retrospective cohort study.

SETTING

The Coronary Revascularization Demonstrating Outcome Study in Kyoto (CREDO-Kyoto) AMI Registries Wave-1 (2005-2007, 26 centres) and Wave-2 (2011-2013, 22 centres).

PARTICIPANTS

9001 patients with STEMI who underwent coronary revascularisation (Wave-1: 4278 patients, Wave-2: 4723 patients).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was all-cause death at 3 years. The secondary outcomes were cardiovascular death, cardiac death, sudden cardiac death, non-cardiovascular death, non-cardiac death, myocardial infarction, definite stent thrombosis, stroke, hospitalisation for heart failure, major bleeding, target vessel revascularisation, ischaemia-driven target vessel revascularisation, any coronary revascularisation and any ischaemia-driven coronary revascularisation.

RESULTS

Patients in Wave-2 were older, more often had comorbidities and more often presented with cardiogenic shock than those in Wave-1. Patients in Wave-2 had shorter onset-to-balloon time and door-to-balloon time, were more frequently implanted drug-eluting stents, and received guideline-directed medication than those in Wave-1. The cumulative 3-year incidence of all-cause death was not significantly different between Wave-1 and Wave-2 (15.5% and 15.7%, p=0.77). The adjusted risk of all-cause death in Wave-2 relative to Wave-1 was not significant at 3 years (HR 0.92, 95% CI 0.83 to 1.03, p=0.14), but lower beyond 30 days (HR 0.86, 95% CI 0.75 to 0.98, p=0.03). The adjusted risks of Wave-2 relative to Wave-1 were significantly lower for definite stent thrombosis (HR 0.59, 95% CI 0.43 to 0.81, p=0.001) and for any coronary revascularisation (HR 0.75, 95% CI 0.69 to 0.81, p<0.001), but higher for major bleeding (HR 1.34, 95% CI 1.20 to 1.51, p=0.005).

CONCLUSIONS

We could not demonstrate improvement in 3-year mortality risk from Wave-1 to Wave-2, but we found reduction in mortality risk beyond 30 days. We also found risk reduction for definite stent thrombosis and any coronary revascularisation, but an increase in the risk of major bleeding from Wave-1 to Wave-2.

Creation and Implementation of a Prospective and Multicentric Database of Patients with Acute Myocardial Infarction: RIAM

BACKGROUND

Multicenter registries representing the real world can be a significant source of information, but few studies exist describing the methodology to implement these tools.

OBJECTIVE

To describe the process of implementing a database of ST-segment elevation acute myocardial infarction (STEMI) at a reference hospital, and the application of this process to other centers by means of an online platform.

METHODS

In 2009, our institution implemented an Registry of Acute Myocardial Infarction (RIAM), with the prospective and consecutive inclusion of every patient admitted to the institution who received a diagnosis of STEMI. From March 2014 to April 2016, the registries were uploaded to a web-based system using the REDCap software and the registry was expanded to other centers. Upon subscription, the REDCap platform is a noncommercial software made available by Vanderbilt University to institutions interested in research.

RESULTS

The following steps were taken to improve and expand the registry: 1. Standardization of variables; 2. Implementation of institutional REDCap (Research Electronic Data Capture); 3. Development of data collection forms (Case Report Form - CRF); 4. Expansion of registry to other reference centers using the REDCap software; 5. Training of teams and participating centers following an SOP (Standard Operating Procedure).

CONCLUSION

The description of the methodology used to implement and expand the RIAM may help other centers and researchers to conduct similar studies, share information between institutions, develop new health technologies, and assist public policies regarding cardiovascular diseases. (Arq Bras Cardiol. 2020; 114(3):446-455).

Portuguese Registry of Acute Coronary Syndromes (ProACS): 15 years of a continuous and prospective registry

The Portuguese Registry of Acute Coronary Syndromes (ProACS) has completed 15 years of continuous and prospective activity. We present an overall picture of the data from this powerful tool. Up to 2016, 45 141 records were included, mostly male (71%), and with a mean age of 66 years. Baseline characteristics remained stable over the years. Of the overall population, 44% of cases were ST-elevation myocardial infarction (STEMI). Over the years there was a significant improvement in compliance with international guidelines, in terms of both diagnostic and therapeutic procedures, as well as for medication. In particular, the rate of reperfusion in STEMI increased to 84%, mainly by primary percutaneous coronary intervention (only 5.2% were treated by thrombolysis in 2016). By contrast, timings in STEMI did not change significantly. Improvements in treatment were accompanied by a reduction in in-hospital mortality from 6.7% in 2002 to 2.5% in 2016 in the overall population. This registry enables analysis of the management and results of acute coronary syndromes over time in Portugal, and hence assessment of improvements in quality of care.

Quality Markers in Cardiology. Main Markers to Measure Quality of Results (Outcomes) and Quality Measures Related to Better Results in Clinical Practice (Performance Metrics). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): A SEC/SECTCV Consensus Position Paper

Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries.

Prescription of secondary prevention medications, lifestyle advice, and referral to rehabilitation among acute coronary syndrome inpatients: results from a large prospective audit in Australia and New Zealand

OBJECTIVE

To evaluate the proportion of patients hospitalised with acute coronary syndrome (ACS) in Australia and New Zealand who received optimal inpatient preventive care and to identify factors associated with preventive care.

METHODS

All patients hospitalised bi-nationally with ACS were identified between 14-27 May 2012. Optimal in-hospital preventive care was defined as having received lifestyle advice, referral to rehabilitation, and prescription of secondary prevention pharmacotherapies. Multilevel multivariable logistic regression was used to determine factors associated with receipt of optimal preventive care.

RESULTS

For the 2299 ACS survivors, mean (SD) age was 69 (13) years, 46% were referred to rehabilitation, 65% were discharged on sufficient preventive medications, and 27% received optimal preventive care. Diagnosis of ST elevation myocardial infarction (OR: 2.64 [95% CI: 1.88-3.71]; p<0.001) and non-ST elevation myocardial infarction (OR: 1.99 [95% CI: 1.52-2.61]; p<0.001) compared with a diagnosis of unstable angina, having a percutaneous coronary intervention (PCI) (OR: 4.71 [95% CI: 3.67-6.11]; p<0.001) or coronary bypass (OR: 2.10 [95% CI: 1.21-3.60]; p=0.011) during the admission or history of hypertension (OR:1.36 [95% CI: 1.06-1.75]; p=0.017) were associated with greater exposure to preventive care. Age over 70 years (OR:0.53 [95% CI: 0.35-0.79]; p=0.002) or admission to a private hospital (OR:0.59 [95% CI: 0.42-0.84]; p=0.003) were associated with lower exposure to preventive care.

CONCLUSIONS

Only one-quarter of ACS patients received optimal secondary prevention in-hospital. Patients with UA, who did not have PCI, were over 70 years or were admitted to a private hospital, were less likely to receive optimal care.

Mortality Trends in Patients Hospitalized with the Initial Acute Myocardial Infarction in a Middle Eastern Country over 20 Years

We aimed to define the temporal trend in the initial Acute Myocardial Infarction (AMI) management and outcome during the last two decades in a Middle Eastern country. A total of 10,915 patients were admitted with initial AMI with mean age of 53 ± 11.8 years. Comparing the two decades (1991–2000) to (2001–2010), the use of antiplatelet drugs increased from 84% to 95%, β-blockers increased from 38% to 56%, and angiotensin converting enzyme inhibitors (ACEI) increased from 12% to 36% (P < 0.001 for all). The rates of PCI increased from 2.5% to 14.6% and thrombolytic therapy decreased from 71% to 65% (P < 0.001 for all). While the rate of hospitalization with Initial MI increased from 34% to 66%, and the average length of hospital stay decreased from 6.4 ± 3 to 4.6 ± 3, all hospital outcomes parameters improved significantly including a 39% reduction in in-hospital Mortality. Multivariate logistic regression analysis showed that higher utilization of antiplatelet drugs, β-blockers, and ACEI were the main contributors to better hospital outcomes. Over the study period, there was a significant increase in the hospitalization rate in patients presenting with initial AMI. Evidence-based medical therapies appear to be associated with a substantial improvement in outcome and in-hospital mortality.

Impact of cardiac care variation on ST-elevation myocardial infarction outcomes in Malaysia

Developing countries face challenges in providing the best reperfusion strategy for patients with ST-segment elevation myocardial infarction because of limited resources. This causes wide variation in the provision of cardiac care. The aim of this study was to assess the impact of variation in cardiac care provision and reperfusion strategies on patient outcomes in Malaysia. Data from a prospective national registry of acute coronary syndromes were used. Thirty-day all-cause mortality in 4,562 patients with ST-segment elevation myocardial infarctions was assessed by (1) cardiac care provision (specialist vs nonspecialist centers), and (2) primary reperfusion therapy (thrombolysis or primary percutaneous coronary intervention [P-PCI]). All patients were risk adjusted by Thrombolysis In Myocardial Infarction (TIMI) risk score. Thrombolytic therapy was administered to 75% of patients with ST-segment elevation myocardial infarctions (12% prehospital and 63% in-hospital fibrinolytics), 7.6% underwent P-PCI, and the remainder received conservative management. In-hospital acute reperfusion therapy was administered to 68% and 73% of patients at specialist and nonspecialist cardiac care facilities, respectively. Timely reperfusion was low, at 24% versus 31%, respectively, for in-hospital fibrinolysis and 28% for P-PCI. Specialist centers had statistically significantly higher use of evidence-based treatments. The adjusted 30-day mortality rates for in-hospital fibrinolytics and P-PCI were 7% (95% confidence interval 5% to 9%) and 7% (95% confidence interval 3% to 11%), respectively (p = 0.75). In conclusion, variation in cardiac care provision and reperfusion strategy did not adversely affect patient outcomes. However, to further improve cardiac care, increased use of evidence-based resources, improvement in the quality of P-PCI care, and reduction in door-to-reperfusion times should be achieved.

Predictive models for short- and long-term adverse outcomes following discharge in a contemporary population with acute coronary syndromes

Although numerous risk-prediction models exist in patients presenting with acute coronary syndromes (ACS), they are subject to important short-comings, including lack of contemporary information. Short-term models are frequently biased by in-hospital events. Accordingly, we sought to create contemporary risk-prediction models for clinical outcomes following ACS up to 1 year following discharge. Models were constructed for death at 30 days and 1 year, death/myocardial infarction (MI)/revascularization at 30 days and death/MI at 1 year in consecutive patients presenting with ACS at our institution between 2006 and 2008, and discharged alive. Logistic regression was used to model the 30 day outcomes and Cox proportional hazards were used to model the 1 year outcomes. No linearity assumptions were made for continuous variables. The final model coefficients were used to create a prediction nomogram, which was incorporated into an online risk calculator. A total of 2,681 patients were included, of which about 9.5% presented with ST-elevation MI. All-cause mortality was 2.6% at 30 days and 13% at 1 year. Demographic, past medical history, laboratory, pharmacological and angiographic parameters were identified as being predictive of adverse ischemic outcomes at 30 days and 1 year. The c-indices for these models ranged from 0.73 to 0.82. Our study thus identified risk factors that are predictive of short- and long-term ischemic and revascularization outcomes in contemporary patients with ACS, and incorporated them into an easy-to-use online calculator, with equal or better discriminatory power than currently available models.

Secondary revascularization after CABG surgery

CABG surgery is an effective way to improve symptoms and prognosis in patients with advanced coronary atherosclerotic disease. Despite multiple improvements in surgical technique and patient treatment, graft failure after CABG surgery occurs in a time-dependent fashion, particularly in the second decade after the intervention, in a substantial number of patients because of atherosclerotic progression and saphenous-vein graft (SVG) disease. Until 2010, repeat revascularization by either percutaneous coronary intervention (PCI) or surgical techniques was performed in these high-risk patients in the absence of specific recommendations in clinical practice guidelines, and within a culture of inadequate communication between cardiac surgeons and interventional cardiologists. Indeed, some of the specific technologies developed to reduce procedural risk, such as embolic protection devices for SVG interventions, are largely underused. Additionally, the implementation of secondary prevention, which reduces the need for reintervention in these patients, is still suboptimal. In this Review, graft failure after CABG surgery is examined as a clinical problem from the perspective of holistic patient management. Issues such as the substrate and epidemiology of graft failure, the choice of revascularization modality, the specific problems inherent in repeat CABG surgery and PCI, and the importance of secondary prevention are discussed.

[Early invasive strategy in non-ST-segment elevation acute coronary syndrome. The paradox continues]

OBJECTIVE

Observational studies have reported a paradoxical inverse relationship between the use of an early invasive strategy (EIS) and the risk of events in patients with non-ST-segment elevation acute coronary syndrome (NSTE ACS). The study objectives are: 1) to examine the association between baseline risk in patients with NSTE ACS and the use of EIS; and 2) to identify some of the factors independently associated to the use of EIS.

DESIGN

Retrospective cohort study.

SETTING

Intensive care units participating in the SEMICYUC ARIAM Registry.

PATIENTS

Consecutive patients admitted with a diagnosis of NSTE-ACS within 48 hours of evolution between the months of April-July 2010.

INTERVENTIONS

None.

MAIN OUTCOMES

Coronary angiography with or without angioplasty within 72 hours, risk stratification using the GRACE scale.

RESULTS

We analyzed 543 patients with NSTE-ACS, of which 194 were of low risk, 170 intermediate risk and 179 high risk. The EIS was used in 62.4% of the patients at low risk, in 60.2% of those with intermediate risk, and in 49.7% of those at high risk (p for tendency 0.0144). The EIS was used preferentially in patients with low severity and comorbidity. In the logistic regression model, EIS was independently associated to the availability of a catheterization laboratory (OR 2.22 [CI 95% 1.55 to 3.19]), the presence of ST changes on ECG (OR 1.80 [1.23 to 2.64]), or the existence of a low risk of bleeding (OR 0.76 [0.66 to 0.88)]. Conversely, EIS was less prevalent in patients with diabetes (OR 0.60 [0.41 to 0.88]) or tachycardia upon admission (OR 0.54 [0 36 to 0.82]).

CONCLUSIONS

In 2010 there remained a lesser relative use of EIS in patients at high risk, due in part to an increased risk of bleeding in these patients.

Management of acute coronary syndromes in developing countries: acute coronary events-a multinational survey of current management strategies

BACKGROUND

The burden of cardiovascular diseases is predicted to escalate in developing countries. We investigated the descriptive epidemiology, practice patterns, and outcomes of patients hospitalized with acute coronary syndromes (ACS) in African, Latin American, and Middle Eastern countries.

METHODS

In this prospective observational registry, 12,068 adults hospitalized with a diagnosis of ACS were enrolled between January 2007 and January 2008 at 134 sites in 19 countries in Africa, Latin America, and the Middle East. Data on patient characteristics, treatment, and outcomes were collected.

RESULTS

A total of 11,731 patients with confirmed ACS were enrolled (46% with ST-elevation myocardial infarction [STEMI], 54% with non-ST elevation-ACS). During hospitalization, most patients received aspirin (93%) and a lipid-lowering medication (94%), 78% received a β-blocker, and 68% received an angiotensin-converting enzyme inhibitor. Among patients with STEMI, 39% did not receive fibrinolysis or undergo percutaneous coronary intervention. All-cause death at 12 months was 7.3% and was higher in patients with STEMI versus non-ST elevation-ACS (8.4% vs 6.3%, P < .0001). Clinical factors associated with higher risk of death at 12 months included cardiac arrest, antithrombin treatment, cardiogenic shock, and age >70 years.

CONCLUSIONS

In this observational study of patients with ACS, the use of evidence-based pharmacologic therapies for ACS was quite high, yet 39% of eligible patients with STEMI received no reperfusion therapy. These findings suggest opportunities to further reduce the risk of long-term ischemic events in patients with ACS in developing countries.

Mode of hospital presentation in patients with non-ST-elevation myocardial infarction: implications for strategic management

INTRODUCTION

Contemporary non-ST-elevation myocardial infarction-acute coronary syndrome guidelines emphasize early-risk stratification and optimizing therapy including an invasive strategy in high-risk patients. To assess the feasibility of initiating this strategy in the prehospital environment, we examined how such patients are transported to hospital, their risk profile, and the proportion potentially eligible for such a strategy.

METHODS

Consecutive patients with ST-segment elevation myocardial infarction admitted in Edmonton were studied between September and November 2008 and divided according to their mode of transport to hospital: emergency medical services (EMS) versus self-presenting. Baseline characteristics, GRACE Risk Score, blinded core laboratory electrocardiogram analysis, cardiac biomarkers, in-hospital procedures, and outcomes were analyzed.

RESULTS

Thirty-five percent (93/263) of patients presented via EMS and often to percutaneous coronary intervention hospitals, that is, 64.5% versus 44.1% (P = .0016). They were older (75 vs 62 years, P < .001), more often female (43% vs 28.1%, P < .001), diabetic (34.4% vs 22.9%, P = .045), and hypertensive (72.0% vs 57.1%, P = .017) and had higher GRACE Risk Scores (median 166 vs 130, P < .001). Electrocardiogram analysis revealed more baseline Q waves (38.8% vs 25.5%, P = .031) and ST depression ≥2 mm (P = .027) in EMS-transported patients. Fewer EMS patients underwent cardiac catheterization (60.2% vs 88.2%, P < .001), and a paradoxical relationship existed between catheterization rates and GRACE Risk Score in the total cohort (low-risk: 93.4% vs high-risk: 59.3%, P < .001). The composite of death/re-myocardial infarction/congestive heart failure/shock was greater in EMS patients (unadjusted odds ratio 3.96, 95% CI 1.80-8.69, P = .001); these differences were attenuated after GRACE Risk Score adjustment.

CONCLUSION

Regional strategies using risk-based triage, early medical therapy, and timely triage to percutaneous coronary intervention centers represents an unrealized opportunity to enhance ST-segment elevation myocardial infarction care.

Trends in the Use of Evidence-based Therapies Early in the Course of Acute Myocardial Infarction and its Influence on Short Term Patient Outcomes

AIM

To evaluate changes in management practices and its influence on short term hospital outcomes in patients with acute myocardial infarction (AMI) admitted during two different time periods, 2007 and 2004.

METHODS AND RESULTS

We studied AMI patients from two acute coronary syndrome registries carried out in Kuwait in 2007 and 2004. We included 1872 and 1197 patients from the 2007 and 2004 registries, respectively. When compared with 2004, patients from the 2007 registry had similar baseline clinical characteristics. In 2007 compared to 2004, during the in-hospital period, patients with AMI received significantly more statins (94% vs. 73%%, p<0.0001), Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB) (70% vs. 47%, p<0.001), and Clopidogrel (38% vs. 4%, p<0.001), while beta-blockers use dropped in 2007 compared to 2004 (63% vs. 68%, p=0.0066). The rates of in-hospital mortality and recurrent ischemia were significantly lower in the 2007 cohort compared with the 2004 cohort (for mortality 2.2% vs. 3.9%, P=0.0008, for recurrent ischemia 13.7% vs. 20.4%, P=0<0.0001).Higher utilization of angiotensin converting enzyme inhibitors, angiotensin receptor blockers and statins were the main contributors to the improved in-hospital mortality and morbidity.

IN CONCLUSION

In the acute management of AMI, there was a significant increase in the use of statins, ACE inhibitors and Clopidogrel in 2007 compared to 2004. This was associated with a significant decrease in the in-hospital mortality and recurrent ischemia. Adherence to guidelines recommended therapies improved in-hospital outcomes.

Prediction of persistence of combined evidence-based cardiovascular medications in patients with acute coronary syndrome after hospital discharge using neural networks

In the PREVENIR-5 study, artificial neural networks (NN) were applied to a large sample of patients with recent first acute coronary syndrome (ACS) to identify determinants of persistence of evidence-based cardiovascular medications (EBCM: antithrombotic + beta-blocker + statin + angiotensin converting enzyme inhibitor-ACEI and/or angiotensin-II receptor blocker-ARB). From October 2006 to April 2007, 1,811 general practitioners recruited 4,850 patients with a mean time of ACS occurrence of 24 months. Patient profile for EBCM persistence was determined using automatic rule generation from NN. The prediction accuracy of NN was compared with that of logistic regression (LR) using Area Under Receiver-Operating Characteristics-AUROC. At hospital discharge, EBCM was prescribed to 2,132 patients (44%). EBCM persistence rate, 24 months after ACS, was 86.7%. EBCM persistence profile combined overweight, hypercholesterolemia, no coronary artery bypass grafting and low educational level (Positive Predictive Value = 0.958). AUROC curves showed better predictive accuracy for NN compared to LR models.

Routine early invasive strategy and in-hospital mortality in women with non-ST-elevation myocardial infarction: results from the Berlin Myocardial Infarction Registry (BMIR)

BACKGROUND

It is under discussion whether female patients with non-ST-elevation myocardial infarction (NSTEMI) benefit from routine invasive treatment strategy. We accordingly applied our data from the Berlin Myocardial Infarction Registry (BMIR) to analyze the association between early percutaneous coronary intervention (PCI) and hospital mortality in NSTEMI patients.

METHODS

Data prospectively collected in the BMIR between 2004 and 2008 from 2808 patients (m=1820/w=988) directly admitted to hospitals with 24-h PCI facilities were included in the analysis. After adjustment for confounding variables, we compared in-hospital mortality for patients of both sexes with vs. without early PCI.

RESULTS

Women with NSTEMI were, on average, 7years older than men and demonstrated significantly more comorbidities. A GPIIb/IIIa antagonist was applied in women less often than in men (31.4% vs. 38.4%, p=0.001), and an early PCI was also performed less often in women than in men (64.0% vs. 76.2%, p<0.001). In-hospital mortality was higher in women than in men (5.4% vs. 3.6%, p=0.027). In female patients with NSTEMI, after adjustment for differences in patients' characteristics, hospital mortality did not differ between those treated with early PCI and those managed conservatively (OR: 1.24, 95% CI 0.53-2.91). In contrast, hospital mortality in male patients was lower in those treated with an early PCI (OR: 0.41, 95% CI 0.21-0.78).

CONCLUSION

In our clinical registry, early PCI in female patients with NSTEMI was not associated with lower hospital mortality. Further randomized-controlled trials are needed to better understand which women may benefit from early invasive therapy, and under which conditions such benefits are possible.

Diagnosis of myocardial infarction using the new universal definition: is it enough for risk stratification and guiding decision for revascularization?

Abstract Objectives: Evaluate the new ESC/ACCF/AHA/WHF universal definition of myocardial infarction (MI) in relation to its prognostic implications and the role for guiding decision for revascularization. It was also compared with the multivariable based GRACE Risk Score (GRS).

METHODS

Single centre registry of 389 consecutive patients admitted with non-ST-segment elevation (NSTE) ACS. We calculated the adjusted HR & 95%CI for death/MI at 30-days and one-year follow-up, between the presence or absence of MI using: (1) universal definition: > 99th URL for cTnI (> 0.06 ng/ml) or MBm (> 3.2 ng/ml); (2) MBm > 2 × URL (> 12.2 ng/ml); 3) old WHO: MBact > 2 × URL (> 32U/l). Logistic analysis was performed to test the interaction between tertiles of biomarkers or GRS and the effect of revascularization on the outcome.

RESULTS

The universal definition increased the incidence of MI in 3.5-fold for cTnI, but was not an independent predictor of outcome. The GRS was the only independent predictor of prognosis at 30-days and one-year. The interaction with the prognostic impact of revascularization was only present for the GRS categorized by tertiles.

CONCLUSIONS

In a contemporary unselected population with NSTE-ACS, the universal definition of MI alone was not adequate for risk assessment and revascularization decision making. These purposes were fully addressed with the GRS.

Although women are less likely to be admitted to coronary care units, they are treated equally to men and have better outcome. A prospective cohort study in patients with non ST-elevation acute coronary syndromes

BACKGROUND

The aim of this study was to assess gender differences in admission level of care, management and outcome in patients with non ST-elevation acute coronary syndromes (NSTE-ACS), initially admitted to either coronary care units (CCU) or general wards.

METHOD

Patients admitted to CCUs were routinely registered in the RIKS-HIA registry. In addition, patients admitted to general wards with suspected ACS were also identified and registered. Multivariable regression analysis was used to adjust for baseline differences between the genders.

RESULTS

We included 570 consecutive patients with a discharge diagnosis of NSTE-ACS. Women were less likely to be admitted to coronary care units (56% versus 69%, P=0.002), even after adjustment (odds ratio (OR), 0.65; 95% confidence interval (CI): 0.43-0.98). After adjustment for differences in baseline characteristics, women were treated similarly to men. We found no significant differences in crude short-, or long-term mortality between the genders. However, adjustment for background characteristics revealed lower one-year mortality in women (OR: 0.58; 95% CI: 0.34-0.99).

CONCLUSION

In this study on patients with NSTE-ACS, women were less likely to be admitted to coronary care units. However, the overall treatment was as intensive for women as for men. Moreover, after adjustment, one-year mortality was lower in women.

Antithrombotic therapy in acute coronary syndromes: guidelines translated for the clinician

The use of anticoagulant and antiplatelet therapy during the management of acute coronary syndromes (ACS) has been associated with improvements in short- and long-term clinical outcomes, regardless of whether patients are managed conservatively or with acute coronary revascularization. Translating the existing evidence for selection of the most appropriate antithrombotic strategy has been summarized in available guideline recommendations. Given the breadth of antithrombotic recommendations across existing U.S. and European guidelines, synthesis of these recommendations for practicing clinicians who treat patients with ACS are increasingly desired. Providing a summary of the similarities across guidelines while noting the areas where divergence exists becomes an important facet in translating optimal antithrombotic management in ACS for the treating clinician. This review highlights the important aspects of clinical practice guidelines that practicing physicians should consider when selecting antithrombotic therapies to reduce ischemic risk while minimizing hemorrhagic risk across all ACS subtypes.

Enoxaparin is a cost-effective adjunct to fibrinolytic therapy for ST-elevation myocardial infarction in contemporary practice

INTRODUCTION

In patients receiving fibrinolytic therapy for ST-elevation myocardial infarction (STEMI), adjunct treatment with enoxaparin has been shown to provide superior net clinical benefit compared with unfractionated heparin (UFH) in the Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment - Thrombolysis in Myocardial Infarction (ExTRACT-TIMI) 25 study. The objective of this study was to compare the cost effectiveness of enoxaparin and UFH strategies.

METHODS

A cost-utility analysis was conducted using a two-stage model: (1) A 30-day decision tree analytical model for the acute treatment phase, and (2) a lifetime Markov model (from 30 days post-STEMI until death) populated using patient survival data.

RESULTS

Assuming treatment continuation for 7 days, the mean day 1-30 incremental cost associated with enoxaparin was pound 49 per patient, and mean lifetime incremental cost was pound 592 per patient ( pound 91,091 vs. pound 90,499, respectively). Given an additional 0.048 life years gained per patient with enoxaparin, the cost per life year saved was pound 12,353, and given an additional 0.038 quality-adjusted life years (QALY) per patient with enoxaparin, the cost per QALY was pound 15,413. In an alternative scenario, reflecting contemporary practice assuming early treatment discontinuation at 48 hours, for example following urgent revascularization, the incremental cost per QALY was pound 13,556.

CONCLUSION

The use of an enoxaparin versus UFH strategy in patients receiving fibrinolytic therapy for STEMI, whether continued for 7 days or discontinued early, for example following urgent revascularization, is cost effective at a pound 20,000 willingness-to-pay threshold.

High mortality rates in conservatively managed patients with acute coronary syndrome

OBJECTIVES

The revised diagnostic criteria for the acute coronary syndrome (ACS) have created the need for accurate and representative data on treatment and outcome for the three categories of ACS.

DESIGN

Consecutive patients admitted with a suspected ACS (n = 755) from February 1, 2003 to January 31, 2004 was registered and categorised into five diagnostic groups: 1) ST-elevation myocardial infarction (STEMI) (n = 126), 2) Non-ST-elevation myocardial infarction (NSTEMI) (n = 185), 3) Unstable angina pectoris (UAP) (n = 55), 4) Coronary heart disease (CHD) without ACS (n = 164) and 5) Non-coronary chest pain (n = 225).

RESULTS

All-cause one-year mortality rates were 20%, 32%, 7%, 10% and 3%, in patients with STEMI, NSTEMI, UAP, CHD without ACS and non-coronary chest pain, respectively. In patients with STEMI, 61% received immediate reperfusion therapy (ratio thrombolysis: primary PCI = 18:1). Only 3% of those with NSTEMI had PCI within two days.

CONCLUSION

In this conservatively managed population of consecutive patients with ACS, the one-year mortality rate is significantly higher than seen in most registries and clinical trials.

The use of risk scores for stratification of non-ST elevation acute coronary syndrome patients

OBJECTIVE

To review the methods available for the risk stratification of non-ST elevation (NSTE) acute coronary syndrome (ACS) patients and to evaluate the use of risk scores for their initial risk assessment.

DATA SOURCES

The data of the present review were identified by searching PUBMED and other databases (1996 to 2008) using the key terms "risk stratification", "risk scores", "NSTEMI", "UA" and "acute coronary syndrome".

STUDY SELECTION

Mainly original articles, guidelines and critical reviews written by major pioneer researchers in this field were selected.

RESULT

After evaluation of several risk predictors and risk scores, it was found that estimating risk based on clinical characteristics is challenging and imprecise. Risk predictors, whether used alone or in simple binary combination, lacked sufficient precision because they have high specificity but low sensitivity. Risk scores are more accurate at stratifying NSTE ACS patients into low-, intermediate- or high-risk groups. The Global Registry of Acute Cardiac Events risk score was found to have superior predictive accuracy compared with other risk scores in ACS population. Treatments based according to specific clinical and risk grouping show that certain benefits may be predominantly or exclusively restricted to higher risk patients.

CONCLUSION

Based on the trials in the literature, the Global Registry of Acute Cardiac Events risk score is more advantageous and easier to use than other risk scores. It can categorize a patient's risk of death and/or ischemic events, which can help tailor therapy to match the intensity of the patient's NSTE ACS.

20-year trends in clinical characteristics, therapy and short-term prognosis in acute myocardial infarction according to presenting electrocardiogram: the MONICA/KORA AMI Registry (1985-2004)

OBJECTIVES

To examine the extent to which evidence-based beneficial therapy is applied in practice, whether this is changing over time and is associated with improved outcomes.

BACKGROUND

Randomized trials have proved efficacy of several treatments for acute myocardial infarction (AMI) with ST-elevation (STEMI), non-ST-elevation (NSTEMI) and bundle branch block (BBB).

DESIGN AND SETTING

We prospectively examined all 6748 consecutive patients with AMI aged 25-74 years hospitalized in the study region's major clinic stratified into four time-periods: 1985-1989 (n = 1622), 1990-1994 (n = 1588), 1995-1999 (n = 1450) and 2000-2004 (n = 2088).

RESULTS

The increase in numbers of AMI in the last period was mainly, but not exclusively driven by NSTEMI cases. Evidence-based pharmacological therapy increased steeply over time. Invasive procedures increased mainly in the last period with percutaneous coronary intervention and coronary artery bypass graft performed in 30% and 15% in 1998 and 66.0% and 22%, respectively, in 2004. In-hospital complications and 28-day-case fatality decreased significantly from period 1 to period 4 in all patients with AMI. Marked reductions in 28-day-case fatality were mostly seen in BBB patients during the last period (25.3% vs. 10.3%, P < 0.001). Of interest, the odds in 28-day-case fatality reduction was diminished after correction for recanalization therapy (from 0.35, 95% CI: 0.16-0.74 to 0.52, 95% CI: 0.19-1.45).

CONCLUSIONS

Over the past 20 years, there were substantial changes in pharmacological and interventional therapies in AMI accompanied by reductions in in-hospital complications and 28-day-case fatality in all infarction types with marked reductions in 28-day-case fatality in BBB patients. The latter observation may mainly be because of the increased use of interventional therapy.

Management of acute myocardial infarction in the real world: a summary report from The Ami-Florence Italian Registry

The Florence Acute Myocardial Infarction registry was a population-based, prospective study aimed at identifying the determinants of coronary reperfusion therapy [CRT, by primary coronary intervention (PCI) in more than 95% of cases] utilization and of prognosis in patients with ST-segment elevation myocardial infarction (STEMI). The registry involved one teaching hospital with, and five district hospitals without PCI facilities. Overall, as many as 45.6% of 930 cases of STEMI did not receive any form of CRT. In multivariable analysis, the direct admission to the teaching hospital was the strongest positive predictor, whereas the time delay, older age, and chronic comorbid conditions were negative predictors of CRT utilization. Compared to conservative therapy, CRT was associated with a remarkably reduced 12-month mortality, after adjusting for age, chronic comorbidities and Killip class, which also were significantly associated with long-term prognosis. The higher crude mortality observed in women was accounted for by older age and other age-related factors. The improvement in prognosis with CRT was larger in older patients and/or in those with a greater burden of chronic comorbidity, who less frequently received CRT. These results suggest the need for interdisciplinary reassessing the adherence to therapeutic guidelines and the criteria adopted in the real clinical world to select patients for CRT during STEMI.

Noninvasive, medical management for non-ST-elevation acute coronary syndromes

Despite emphasis on the use of invasive management strategies for patients with non-ST-elevation acute coronary syndromes (NSTE ACS) in recent practice guidelines, 27% to 56% of NSTE ACS patients do not undergo diagnostic angiography, and a further 45% to 78% do not undergo revascularization procedures during the initial hospitalization. These medically managed patients (also termed noninvasive management) have a greater frequency of medical comorbidities and high-risk clinical characteristics and are less likely to receive guideline-recommended medications, compared with patients who undergo revascularization procedures. The rates of short and long-term adverse outcomes are also substantially higher in medically managed NSTE ACS patients, but more widespread implementation of contemporary medical therapies in this population is limited by exclusion of medically managed patients from many randomized clinical trials.

Reduced vascular complications and length of stay with transradial rescue angioplasty for acute myocardial infarction

OBJECTIVES

The aim of this study was to compare clinical outcomes for transradial and transfemoral percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction undergoing rescue angioplasty.

BACKGROUND

Transfemoral percutaneous coronary intervention in patients with acute myocardial infarction treated with systemic thrombolysis is associated with a significant risk of vascular complications. A transradial approach may reduce vascular complications, improve mobilization and facilitate earlier discharge.

METHODS

In a retrospective analysis, clinical outcomes for 287 consecutive patients undergoing rescue angioplasty for acute myocardial infarction were determined. Data were recorded using a standardized proforma and analyzed using SPSS.

RESULTS

Procedural success was similar for the transradial and transfemoral routes (98% vs. 93%; P = 0.3). There was a reduction in vascular complications (0 (0%) vs. 32 (13%); P < 0.01) and post-procedural length of stay (7.0 +/- 7.9 vs. 7.9 +/- 5.6 days; P < 0.005) in the radial group when compared with the femoral group. There were no differences in procedural or in-hospital mortality, procedure duration, or radiation dose between the two groups.

CONCLUSION

Rescue angioplasty performed via the radial artery is safe, effective, and associated with a reduction in vascular complications and length of hospital stay when compared with the femoral approach. These findings suggest that where facilities and experience allow rescue angioplasty in patients with acute myocardial infarction should be performed via the radial artery.

Current management of acute coronary syndromes in Australia: observations from the acute coronary syndromes prospective audit

BACKGROUND

Acute coronary syndromes (ACS) management is now well informed by guidelines extrapolated from clinical trials. However, most of these data have been acquired outside the local context. We sought to describe the current patterns of ACS care in Australia.

METHODS

The Acute Coronary Syndrome Prospective Audit study is a prospective multi-centre registry of ST-segment elevation myocardial infarction (STEMI), high-risk non-ST-segment elevation ACS (NSTEACS-HR) and intermediate-risk non-ST-segment elevation ACS (NSTEACS-IR) patients, involving 39 metropolitan, regional and rural sites. Data included hospital characteristics, geographic and demographic factors, risk stratification, in-hospital management including invasive services, and clinical outcomes.

RESULTS

A cohort of 3402 patients was enrolled; the median age was 65.5 years. Female and non-metropolitan patients comprised 35.5% and 23.9% of the population, respectively. At enrolment, 756 (22.2%) were STEMI patients, 1948 (57.3%) were high-risk NSTEACS patients and 698 (20.5%) were intermediate-risk NSTEACS patients. Evidence-based therapies and invasive management use were highest among suspected STEMI patients compared with other strata (angiography: STEMI 89%, NSTEACS-HR 54%, NSTEACS-IR 34%, P < 0.001) (percutaneous coronary intervention: STEMI 68.1%, NSTEACS-HR 22.2%, NSTEACS-IR 8.1%, P < 0.001). In hospital mortality was low (STEMI 4.0%, NSTEACS-HR 1.8%, NSTEACS-IR 0.1%, P < 0.001), as was recurrent MI (STEMI 2.4%, NSTEACS-HR: 2.8%, NSTEACS-IR 1.2%, P = 0.052).

CONCLUSION

There appears to be an 'evidence-practice gap' in the management of ACS, but this is not matched by an increased risk of in-hospital clinical events. Objective evaluation of local clinical care is a key initial step in developing quality improvement initiatives and this study provides a basis for the improvement in ACS management in Australia.

[Epidemiology of acute coronary syndrome in Europe]

Epidemiological data concerning acute coronary syndromes in Europe are based on national registries, studies by the European Society of Cardiology within the framework of the EuroHeart Survey and on the study of European population sub-groups in large international cohorts. In this article, recently published studies will be reviewed, and the principal developments in different countries as well as the characteristics and particularities of the most recent epidemiological data will be highlighted. In Europe, the presentation of acute coronary syndromes (ACS) has evolved considerably over the last ten years. This evolution is characterized by a reduction in the proportion of acute coronary syndromes with ST-segment elevation (STEMI) and by ageing populations.

Early management of ST elevation myocardial infarction: a review of practice

The last two decades of the 20th century witnessed continuous evolution in the understanding of the pathophysiology of ST elevation myocardial infarction. In parallel, the management of these patients developed steadily throughout this time and into the early years of the 21st century. From humble beginnings involving oxygen therapy, bed rest and analgesia, the relative merits of different strategies to open 'infarct-related arteries' (IRAs) are now being debated: pharmacological reperfusion, mechanical reperfusion or a combination of both these modalities. The current understanding of the process of thrombotic occlusion of the coronary artery has led to the appreciation of the importance of not simply opening the IRA, but also maintaining its patency once opened. Considerable attention is now being afforded to the significant minority of patients who do not achieve early, complete myocardial reperfusion, despite restoration of adequate flow down the epicardial IRA. Those patients who fail to achieve myocardial reperfusion, either due to late presentation or failure of reperfusion therapy, and are left with permanent myocardial scarring can now be considered. This article critically appraises the recent and emerging evidence and clinical implications of the contemporary management of ST elevation myocardial infarction.

Risk assessment after acute coronary syndrome

Lots of potential but will it end up being yet another risk score?

[Clinical pathway "Acute Coronary Syndrome"]

The clinical pathway "acute coronary syndrome" of the university hospital Marburg describes the guideline-conform and consented management of patients with ST-segment elevation infarct (STEMI), non-ST-segment elevation infarct (NSTEMI) and Troponin negative unstable angina. A 12-lead ECG recording is made and read in all patients within 10 minutes. All patients with STEMI undergo immediate revascularisation using primary percutanuous catheter intervention (PCI) after administration of basic medical therapy. Primary PCI is also used in all patients with NSTEMI, persistent chest pain, rhythm or hemodynamic instability. Patients with unstable angina, who became free of symptoms after application of basic medication, but who have additional risk factors undergo cardiac catheterisation within 48 hours. Acute myocardial infarction can be ruled out in patients with twofold negative cardiac troponin levels during 6-12 hours. In the absence of further symptoms, these patiens undergo differential diagnostic evaluation of cardiac and extracardiac causes of chest pain. The introduction of this clinical pathway 2 years ago, which was consented before by the hospital board and the clinical directors, has lead to a remarkable improvement in the clinical decision-making at the emergency room of the hospital and reduced the door to intervention time considerably.

Long term clinical outcome and bleeding complications among hospital survivors with acute coronary syndromes

OBJECTIVE

To examine the 21 month clinical outcome and bleeding complications in hospital survivors with non-ST segment elevation acute coronary syndromes (NSTEACS) who were discharged with combined clopidogrel and aspirin anti-thrombotic therapy, and compare with those having ST segment elevation myocardial infarction (STEMI) who were discharged with aspirin alone.

DESIGN

Observational study.

SETTING

A large university hospital.

PATIENTS

224 patients were admitted to hospital with either NSTEACS or STEMI, and survived to discharge between 1 October 2001 and 31 December 2002.

MAIN OUTCOME MEASURES

Cardiovascular death, total death, new myocardial infarction, unstable angina requiring hospitalisation, stroke or transient ischaemic attack, coronary revascularisation; and fatal, life threatening, major and minor bleeding over 21 months after discharge.

RESULTS

Despite having no or small infarct (median maximum creatine kinase 155 v 1295 u/l; p<0.001) and taking more antianginal drugs, patients with NSTEACS had similar rates of cardiovascular death (9.5% v 8.3%; p = NS), new myocardial infarction (9.5% v 6.5%; p = NS) or unstable angina requiring hospitalisation (15.5% v 10.2%; p = NS) when compared with STEMI. Fatal, life threatening or major bleeding were <1% in both groups (p = NS); and minor bleeding occurred in 4.3% NSTEACS and 2.8% STEMI patients respectively (p = NS).

CONCLUSIONS

Patients with NSTEACS had a similar and unfavourable long term outcome when compared with STEMI. There was no difference in serious bleeding complications between both groups.