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Looi JL, Chan C, Pemberton J, Nankivell A, McLeod P, Webster M, To A, Lee M, Kerr AJ. External Validation of a Clinical Score to Differentiate Takotsubo Syndrome From Non-ST-Elevation Myocardial Infarction in Women. Heart Lung Circ 2023:S1443-9506(23)00164-6. [PMID: 37121882 DOI: 10.1016/j.hlc.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 03/26/2023] [Accepted: 04/02/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND AND AIMS Clinical presentation of Takotsubo Syndrome (TS) mimics acute coronary syndrome (ACS). A score to differentiate TS from ACS would be helpful to facilitate appropriate investigation and management. We have previously developed a clinical score (NSTE-Takotsubo Score) to distinguish women with non-ST-segment elevation myocardial infarction (NSTEMI) from TS with non-ST-segment elevation (NSTE-TS). This study sought to assess the diagnostic validity of this score in an external validation cohort. METHODS The external cohort consisted of women with NSTE-TS (n=110) and NSTEMI (n=113) from two major tertiary hospitals in New Zealand. The five variables in the arithmetic score (range -6 to +5) and their relative weights are: T-wave inversion (TWI) in ≥6 leads (3 points), recent stress (2 points), diabetes mellitus (DM) (-1 point), prior cardiovascular disease (CVD) (-2 points) and presence of ST depression (-3 points). Two clinicians blinded to the diagnoses calculated the score using clinical and electrocardiogram (ECG) data on day 1 post-admission. RESULTS The NSTE-Takotsubo Score discriminated well between NSTE-TS and NSTEMI. The sensitivity and specificity of a score ≥1 to distinguish NSTE-TS from NSTEMI were 78% and 85%, respectively. The area under the receiver operator curve was 0.78 (95% CI 0.72 to 0.84). CONCLUSION In an external validation cohort, the NSTE-Takotsubo Score was easy to apply and useful to identify women likely to have NSTE-TS on day 1 post-admission.
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Affiliation(s)
- Jen-Li Looi
- Department of Cardiology, Middlemore Hospital, Otahuhu, Auckland, New Zealand.
| | - Christina Chan
- Department of Cardiology, Christchurch Hospital, Riccarton Avenue, Christchurch, New Zealand
| | - James Pemberton
- Department of Cardiology, Dunedin Hospital, Dunedin, New Zealand
| | - Alison Nankivell
- Department of Cardiology, Christchurch Hospital, Riccarton Avenue, Christchurch, New Zealand
| | - Peter McLeod
- Department of Cardiology, Dunedin Hospital, Dunedin, New Zealand
| | - Mark Webster
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Andrew To
- Cardiovascular Division, North Shore Hospital, Takapuna, Auckland, New Zealand
| | - Mildred Lee
- Department of Cardiology, Middlemore Hospital, Otahuhu, Auckland, New Zealand
| | - Andrew J Kerr
- Department of Cardiology, Middlemore Hospital, Otahuhu, Auckland, New Zealand; Department of Medicine and School of Population Health, University of Auckland, Auckland, New Zealand
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Higher mortality in acute coronary syndrome patients without standard modifiable risk factors: Results from a global meta-analysis of 1,285,722 patients. Int J Cardiol 2023; 371:432-440. [PMID: 36179904 DOI: 10.1016/j.ijcard.2022.09.062] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Standard modifiable cardiovascular risk factors (SMuRF), comprising diabetes, hyperlipidemia, hypertension, and smoking, are used for risk stratification in acute coronary syndrome (ACS). Recent studies showed an increasing proportion of SMuRF-less ACS patients. METHODS Embase, Medline and Pubmed were searched for studies comparing SMuRF-less and SMuRF patients with first presentation of ACS. We conducted single-arm analyses to determine the proportion of SMuRF-less patients in the ACS cohort, and compared the clinical presentation and outcomes of these patients. RESULTS Of 1,285,722 patients from 15 studies, 11.56% were SMuRF-less. A total of 7.44% of non-ST-segment-elevation ACS patients and 12.87% of ST-segment-elevation myocardial infarction (STEMI) patients were SMuRF-less. The proportion of SMuRF-less patients presenting with STEMI (60.71%) tended to be higher than those with SMuRFs (49.21%). Despite lower body mass index and fewer comorbidities such as chronic kidney disease, peripheral arterial disease, stroke and heart failure, SMuRF-less patients had increased in-hospital mortality (RR:1.57, 95%CI:1.38 to 1.80) and cardiogenic shock (RR:1.39, 95%CI:1.18 to 1.65), but lower risk of heart failure (RR:0.91, 95%CI:0.83 to 0.99). On discharge, SMuRF-less patients were prescribed less statins (RR:0.93, 95%CI:0.91 to 0.95), beta-blockers (RR:0.94, 95%CI:0.92 to 0.96), P2Y12 inhibitors (RR: 0.98, 95%CI: 0.96 to 0.99), and angiotensin-converting-enzyme inhibitor or angiotensin-receptor blocker (RR:0.92, 95%CI:0.75 to 0.91). CONCLUSION In this study level meta-analysis, SMuRF-less ACS patients demonstrate higher mortality compared with patients with at least one traditional atherosclerotic risk factor. Underuse of guideline-directed medical therapy amongst SMuRF-less patients is concerning. Unraveling novel risk factors amongst SMuRF-less individuals is the next important step. SUMMARY Standard modifiable cardiovascular risk factors (SMuRF), comprising diabetes mellitus, hyperlipidemia, hypertension, and smoking, are often used for risk stratification in acute coronary syndrome (ACS). Recent studies showed an increasing proportion of SMuRF-less ACS patients. Of 1,285,722 ACS patients, 11.56% were SMuRF-less. Despite lower body mass index and fewer comorbidities, SMuRF-less patients had increased in-hospital mortality and cardiogenic shock. However, despite worse outcomes, SMuRF-less patients were prescribed less guideline-directed medical therapies on discharge.
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Zykov MV, Dyachenko NV, Velieva RM, Kashtalap VV, Barbarash OL. Combined use of the GRACE ACS risk score and comorbidity indices to increase the effectiveness of hospital mortality risk assessment in patients with acute coronary syndrome. TERAPEVT ARKH 2022; 94:816-821. [DOI: 10.26442/00403660.2022.07.201742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/09/2022] [Indexed: 11/22/2022]
Abstract
Aim. To assess the possibilities of using comorbidity indices together with the GRACE (Global Registry of Acute Coronary Events) scale to assess the risk of hospital mortality in acute coronary syndrome (ACS).
Materials and methods. The registry study included 2,305 patients with ACS. The frequency of coronary angiography was 54.0%, percutaneous coronary intervention (PCI) 26.9%. Hospital mortality with ACS was 4.8%, with myocardial infarction 9.4%. All patients underwent a comorbidity assessment according to the CIRS system (Cumulative Illness Rating Scale), according to the CCI (Charlson Comorbidity Index) and the CDS (Chronic Disease Score) scale, according to their own scale, which is based on the summation of 9 diseases (diabetes mellitus, atrial fibrillation, stroke, arterial hypertension, obesity, peripheral atherosclerosis, thrombocytopenia, anemia, chronic kidney disease). All patients underwent a mortality risk assessment using the GRACE ACS Risk scale.
Results. It was found that the CDS and CIRS indices are not associated with the risk of hospital mortality. With CCI3, the frequency of death outcomes increased from 4.1 to 6.1% (2=4.12, p=0.042). With an increase in the severity of comorbidity from minimal (no more than 1 disease) to severe (4 or more diseases) according to its own scale, hospital mortality increased from 1.2 to 7.4% (2=23.8, p0.0001). In contrast to other scales of comorbidity, our own model more efficiently estimates the hospital prognosis both in the conservative treatment group (2=8.0, p=0.018) and in the PCI group (2=28.5, p=0.00001). It was in the PCI subgroup that the comorbidity factors included in their own model made it possible to increase the area under the ROC curve of the GRACE scale from 0.80 (0.740.87) to 0.90 (0.850.95).
Conclusion. CCI and its own comorbidity model, but not CDS and CIRS, are associated with the risk of hospital mortality. The model for assessing comorbidity on a 9-point scale, but not CCI, CDS and CIRS, can significantly improve the predictive value of the GRACE scale.
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Van Dyke TE, El Kholy K, Ishai A, Takx RA, Mezue K, Abohashem SM, Ali A, Yuan N, Hsue P, Osborne MT, Tawakol A. Inflammation of the periodontium associates with risk of future cardiovascular events. J Periodontol 2021; 92:348-358. [PMID: 33512014 PMCID: PMC8080258 DOI: 10.1002/jper.19-0441] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 09/10/2020] [Accepted: 09/25/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND While growing evidence suggests a link between periodontal disease (PD) and cardiovascular disease (CVD), the independence of this association and the pathway remain unclear. Herein, we tested the hypotheses that: (1) inflammation of the periodontium (PDinflammation ) predicts future CVD independently of disease risk factors shared between CVD and PD, and (2) the mechanism linking the two diseases involves heightened arterial inflammation. METHODS 18 F-fluorodeoxyglucose positron emission tomography/computed tomography (18 F-FDG-PET/CT) imaging was performed in 304 individuals (median age 54 years; 42.4% male) largely for cancer screening; individuals without active cancer were included. PDinflammation and arterial inflammation were quantified using validated 18 F-FDG-PET/CT methods. Additionally, we evaluated the relationship between PDinflammation and subsequent major adverse cardiovascular events (MACE) using Cox models and log-rank tests. RESULTS Thirteen individuals developed MACE during follow-up (median 4.1 years). PDinflammation associated with arterial inflammation, remaining significant after adjusting for PD and CVD risk factors (standardized β [95% CI]: 0.30 [0.20-0.40], P < 0.001). PDinflammation predicted subsequent MACE (standardized HR [95% CI]: 2.25 [1.47 to 3.44], P <0.001, remaining significant in multivariable models), while periodontal bone loss did not. Furthermore, mediation analysis suggested that arterial inflammation accounts for 80% of the relationship between PDinflammation and MACE (standardized log odds ratio [95% CI]: 0.438 [0.019-0.880], P = 0.022). CONCLUSION PDinflammation is independently associated with MACE via a mechanism that may involve increased arterial inflammation. These findings provide important support for an independent relationship between PDinflammation and CVD.
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Affiliation(s)
- Thomas E. Van Dyke
- Forsyth Institute, Cambridge, MA
- Harvard School of Dental Medicine, Boston, MA
| | - Karim El Kholy
- Forsyth Institute, Cambridge, MA
- Harvard School of Dental Medicine, Boston, MA
| | | | | | - Kene Mezue
- Cardiovascular Imaging Research Center, Boston, MA
- Nuclear Cardiology, Boston, MA
- Cardiology Division, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Shady M. Abohashem
- Cardiovascular Imaging Research Center, Boston, MA
- Nuclear Cardiology, Boston, MA
- Cardiology Division, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | | | - Neal Yuan
- San Francisco General Hospital and the University of California San Francisco, San Francisco, CA
| | - Priscilla Hsue
- San Francisco General Hospital and the University of California San Francisco, San Francisco, CA
| | - Michael T. Osborne
- Cardiovascular Imaging Research Center, Boston, MA
- Nuclear Cardiology, Boston, MA
- Cardiology Division, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Ahmed Tawakol
- Cardiovascular Imaging Research Center, Boston, MA
- Nuclear Cardiology, Boston, MA
- Cardiology Division, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
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Looi JL, Poppe K, Lee M, Gilmore J, Webster M, To A, Kerr AJ. A Score to differentiate Takotsubo syndrome from non-ST-elevation myocardial nfarction in women at the bedside. Open Heart 2020; 7:e001197. [PMID: 32201588 PMCID: PMC7066633 DOI: 10.1136/openhrt-2019-001197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/02/2020] [Accepted: 02/03/2020] [Indexed: 12/22/2022] Open
Abstract
Objective A score to distinguish Takotsubo syndrome (TS) from acute coronary syndrome would be useful to facilitate appropriate patient investigation and management. This study sought to derive and validate a simple score using demographic, clinical and ECG data to distinguish women with non-ST elevation myocardial infarction (NSTEMI) from NSTE-TS. Methods The derivation cohort consisted of women with NSTE-TS (n=100) and NSTEMI (n=100). Logistic regression was used to derive the score using ECG values available on the postacute ward round on day 1 post-hospital admission. The score was then temporally validated in subsequent consecutive patients with NSTE-TS (n=40) and NSTEMI (n=70). Results The five variables in the score and their relative weights were: T-wave inversion in ≥6 leads (+3), recent stress (+2), diabetes (−1), prior cardiovascular disease (−2) and ST-depression in any lead (−3). When calculated using ECG values obtained at admission, discrimination between conditions was very good (area under the curve (AUC) 0.87 95% CI 0.83 to 0.92). The optimal score cut-point of ≥1 to predict NSTE-TS had 73% sensitivity and 90% specificity. When applied to the validation cohort at admission, AUC was 0.82 (95% CI 0.75 to 0.90) and positive and negative predictive values were 78% and 81%, respectively. On day 1 post-admission, AUC was 0.92 (95% CI 0.87 to 0.97), with positive and negative predictive values of 77% and 91%, respectively. Conclusion This NSTE-TS score is easy to use and may prove useful in clinical practice to distinguish women with NSTE-TS from NSTEMI. Further validation in external cohorts is needed.
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Affiliation(s)
- Jen-Li Looi
- Cardiology, Middlemore Hospital, Auckland, New Zealand
| | - Katrina Poppe
- Epidemiology & Biostatistics, University of Auckland, Auckland, New Zealand
| | - Mildred Lee
- Cardiology, Middlemore Hospital, Auckland, New Zealand
| | - Jill Gilmore
- Cardiology, Middlemore Hospital, Auckland, New Zealand
| | - Mark Webster
- Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
| | - Andrew To
- Lakeview Cardiology Centre, North Shore Hospital, Auckland, New Zealand
| | - Andrew J Kerr
- Cardiology, Middlemore Hospital, Auckland, New Zealand
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Abstract
Acute coronary syndrome (ACS) is associated with both short- and long-term unfavorable prognosis. Therefore, medical societies developed risk scores for predicting mortality and assessing decision-making regarding early aggressive treatment in patients presenting an ACS. The Thrombolysis In Myocardial Infarction and the Global Registry of Acute Coronary Events risk scores are the most extensively investigated scores for ACS. Clinical judgment is also important. Significant differences in aggressive treatment of ACS still exist with respect to gender, age, and ethnicity. The reasons for these discrepancies need to be further elucidated in future studies. Therefore, generalizability of stratifications and risk scores in certain populations should be performed with caution.
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Affiliation(s)
| | - Niki Katsiki
- Second Propaedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
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Jukema JW, Lettino M, Widimský P, Danchin N, Bardaji A, Barrabes JA, Cequier A, Claeys MJ, De Luca L, Dörler J, Erlinge D, Erne P, Goldstein P, Koul SM, Lemesle G, Lüscher TF, Matter CM, Montalescot G, Radovanovic D, Lopez-Sendón J, Tousek P, Weidinger F, Weston CF, Zaman A, Zeymer U. Contemporary registries on P2Y12 inhibitors in patients with acute coronary syndromes in Europe: overview and methodological considerations: Table 1. EUROPEAN HEART JOURNAL - CARDIOVASCULAR PHARMACOTHERAPY 2015; 1:232-244. [DOI: 10.1093/ehjcvp/pvv024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Jernberg T, Hasvold P, Henriksson M, Hjelm H, Thuresson M, Janzon M. Cardiovascular risk in post-myocardial infarction patients: nationwide real world data demonstrate the importance of a long-term perspective. Eur Heart J 2015; 36:1163-70. [DOI: 10.1093/eurheartj/ehu505] [Citation(s) in RCA: 472] [Impact Index Per Article: 52.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 12/16/2014] [Indexed: 01/04/2023] Open
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