Relationship Between Anemia and Mortality Outcomes in a National Acute Coronary Syndrome Cohort: Insights From the UK Myocardial Ischemia National Audit Project Registry

Impact of anemia on outcomes and resource utilization in patients with myocardial infarction: A national database analysis

BACKGROUND

Although anemia is common in patients with myocardial infarction (MI), management remains controversial. We quantified the association of anemia with in-hospital outcomes and resource utilization in patients admitted with MI using a large national database.

METHODS

All hospitalizations with a primary diagnosis code for acute MI in the National Inpatient Sample (NIS) between 2014 and 2018 were identified. Among these hospitalizations, patients with anemia were identified using a secondary diagnosis code. Data on demographic and clinical variables were collected. Outcomes of interest included in-hospital adverse events, length of stay (LOS), and total cost. Multivariable logistic regression and generalized linear models were used to evaluate the relationship between anemia and outcomes.

RESULTS

Among 1,113,181 MI hospitalizations, 254,816 (22.8%) included concomitant anemia. Anemic patients were older and more likely to be women. After adjustment for demographics and comorbidities, anemia was associated with higher mortality (7.1 vs. 4.3%; odds ratio 1.09; 95% confidence interval [CI] 1.07-1.12, p < 0.001). Anemia was also associated with a mean of 2.71 days longer LOS (average marginal effects [AME] 2.71; 95% CI 2.68-2.73, p < 0.05), and $ 9703 mean higher total costs (AME $9703, 95% CI $9577-$9829, p < 0.05). Anemic patients who received blood transfusions had higher mortality as compared with those who did not (8.2% vs. 7.0, p < 0.001).

CONCLUSION

In MI patients, anemia was associated with higher in-hospital mortality, adverse events, total cost, and length of stay. Transfusion was associated with increased mortality, and its role in MI requires further research.

Bleeding risk prediction after acute myocardial infarction-integrating cancer data: the updated PRECISE-DAPT cancer score

BACKGROUND AND AIMS

This study assessed the impact of incorporating cancer as a predictor on performance of the PRECISE-DAPT score.

METHODS

A nationally linked cohort of ST-elevation myocardial infarction patients between 1 January 2005 and 31 March 2019 was derived from the UK Myocardial Ischaemia National Audit Project and the UK Hospital Episode Statistics Admitted Patient Care registries. The primary outcome was major bleeding at 1 year. A new modified score was generated by adding cancer as a binary variable to the PRECISE-DAPT score using a Cox regression model and compared its performance to the original PRECISE-DAPT score.

RESULTS

A total of 216 709 ST-elevation myocardial infarction patients were included, of which 4569 had cancer. The original score showed moderate accuracy (C-statistic .60), and the modified score showed modestly higher discrimination (C-statistics .64; hazard ratio 1.03, 95% confidence interval 1.03-1.04) even in patients without cancer (C-statistics .63; hazard ratio 1.03, 95% confidence interval 1.03-1.04). The net reclassification index was .07. The bleeding rates of the modified score risk categories (high, moderate, low, and very low bleeding risk) were 6.3%, 3.8%, 2.9%, and 2.2%, respectively. According to the original score, 65.5% of cancer patients were classified as high bleeding risk (HBR) and 21.6% were low or very low bleeding risk. According to the modified score, 94.0% of cancer patients were HBR, 6.0% were moderate bleeding risk, and no cancer patient was classified as low or very low bleeding risk.

CONCLUSIONS

Adding cancer to the PRECISE-DAPT score identifies the majority of patients with cancer as HBR and can improve its discrimination ability without undermining its performance in patients without cancer.

Association of anemia with all-cause mortality in Chinese centenarians: a prospective cohort study

OBJECTIVES

This study aimed to examine the relationship between anemia and all-cause mortality in Chinese centenarians.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

We included 1002 Chinese centenarians from the China Hainan Centenarian Cohort Study (CHCCS) MEASUREMENTS: Standard procedures were followed to perform blood analysis, home interviews, and physical examinations. Anemia was defined as a hemoglobin level of less than 130 g/L for men and less than 120 g/L for women.

RESULTS

During the 9-year follow-up period, a total of 929 (92.7%) deaths were identified. Cox proportional hazards regression models revealed that anemia (hazard ratio [HR] 1.289, 95% confidence interval [CI]: 1.117-1.489) was significantly associated with all-cause mortality. There was an apparent dose-response relationship between anemia and all-cause mortality. Centenarians with severe anemia had approximately 1.6 times higher likelihood of all-cause mortality than those without anemia (HR 1.662; 95% CI: 1.154-2.394).

CONCLUSION

Anemia is associated with an increased risk of all-cause mortality in Chinese centenarians. Further research will be needed to collect more comprehensive data on the etiology of anemia and causes of death in centenarians.

Neutrophil-to-lymphocyte ratio and prognosis in patients undergoing percutaneous coronary intervention for acute coronary syndrome

OBJECTIVE

The purpose of this study was to characterize Acute Coronary Syndrome (ACS)-associated inflammation by investigating correlates of the neutrophil-to-lymphocyte ratio (NLR), a surrogate marker of inflammation, and its relation to 1-year mortality in a cohort of patients undergoing percutaneous coronary intervention (PCI) for ACS at a single institution.

METHODS

We performed a single-institution, retrospective, observational study of all-comer ACS patients who underwent PCI and were discharged home before the COVID-19 pandemic between September 23, 2011 and July 31, 2017 for who outcomes data were available.

RESULTS

NLRhigh group tended to be older, white patients, less likely to smoke, more likely to have a history of heart failure and cardiac arrest, higher creatinine values, lower LVEF, and higher CK-MB (a surrogate for infarct size). Linear regression model demonstrated a strong correlation between increasing NLR and white race (B = 1.103, p = 0.001, hemoglobin (B = -0.30, p < 0.001), peak CK-MB (B = 0.004, p = 0.02), LVEF (B = -0.048, p < 0.001), and serum creatinine (B = 0.47, p = 0.03). There were a total of 87 deaths at one year. NLR > 3.4 was associated with worse one-year survival post-PCI (91.4 % vs. 95.4 %, log-rank p < 0.004), which was confirmed on multivariate analysis.

CONCLUSION

Our data confirm the independent prognostic significance of inflammation to mortality after ACS and may provide some insight into the putative benefits of inflammation modulation.

Impact of anaemia and iron deficiency on outcomes in cardiogenic shock complicating acute myocardial infarction

AIMS

Anaemia and iron deficiency (ID) are common comorbidities in cardiovascular patients and are associated with a poor clinical status, as well as a worse outcome in patients with heart failure and acute myocardial infarction (AMI). Nevertheless, data concerning the impact of anaemia and ID on clinical outcomes in patients with cardiogenic shock (CS) are scarce. This study aimed to assess the impact of anaemia and ID on clinical outcomes in patients with CS complicating AMI.

METHODS AND RESULTS

The presence of anaemia (haemoglobin <13 g/dl in men and <12 g/dl in women) or ID (ferritin <100 ng/ml or transferrin saturation <20%) was determined in patients with CS due to AMI from the CULPRIT-SHOCK trial. Blood samples were collected in the catheterization laboratory during initial percutaneous coronary intervention. Clinical outcomes were compared in four groups of patients having neither anaemia nor ID, against patients with anaemia with or without ID and patients with ID only. A total of 427 CS patients were included in this analysis. Anaemia without ID was diagnosed in 93 (21.7%), anaemia with ID in 54 study participants (12.6%), ID without anaemia in 72 patients (16.8%), whereas in 208 patients neither anaemia nor ID was present (48.9%). CS patients with anaemia without ID were older (73 ± 10 years, p = 0.001), had more frequently a history of arterial hypertension (72.8%, p = 0.01), diabetes mellitus (47.8%, p = 0.001), as well as chronic kidney disease (14.1%, p = 0.004) compared to CS patients in other groups. Anaemic CS patients without ID presence were at higher risk to develop a composite from all-cause death or renal replacement therapy at 30-day follow-up (odds ratio [OR] 3.83, 95% confidence interval [CI] 2.23-6.62, p < 0.001) than CS patients without anaemia/ID. The presence of ID in CS patients, with and without concomitant anaemia, did not increase the risk for the primary outcome (OR 1.17, 95% CI 0.64-2.13, p = 0.64; and OR 1.01, 95% CI 0.59-1.73, p = 0.54; respectively) within 30 days of follow-up. In time-to-event Kaplan-Meier analysis, anaemic CS patients without ID had a significantly higher hazard ratio (HR) for the primary outcome (HR 2.11, 95% CI 1.52-2.89, p < 0.001), as well as for death from any cause (HR 1.90, 95% CI 1.36-2.65, p < 0.001) and renal replacement therapy during 30-day follow-up (HR 2.99, 95% CI 1.69-5.31, p < 0.001).

CONCLUSION

Concomitant anaemia without ID presence in patients with CS at hospital presentation is associated with higher risk for death from any cause or renal replacement therapy and the individual components of this composite endpoint within 30 days after hospitalization. ID has no relevant impact on clinical outcomes in patients with CS.

Outcomes of ST elevation myocardial infarction in patients with cancer: a nationwide study

AIMS

To assess processes of care and clinical outcomes in cancer patients with ST elevation myocardial infarction (STEMI) according to cancer type.

METHODS AND RESULTS

This is a national population-based study of patients admitted with STEMI in the UK between January 2005 and March 2019. Data were obtained from the National Heart Attack Myocardial Infarction National Audit Project (MINAP) registry and the Hospital Episode Statistics registry. We identified 353 448 STEMI-indexed admissions between 2005 and 2019. Of those, 8581 (2.4%) had active cancer. Prostate cancer (29% of STEMI patients with cancer) was the most common cancer followed by haematologic malignancies (14%) and lung cancer (13%). Cancer patients were less likely to receive invasive coronary revascularization (60.0% vs. 71.6%, P < 0.001] and had higher in-hospital death [odd ratio (OR) 1.39, 95% confidence interval (CI) 1.25-1.54] and bleeding (OR 1.23, 95% CI 1.03-1.46). Cancer patients had higher mortality at 30 days (HR 2.39, 95% CI 2.19-2.62) and 1 year (HR 3.73, 95% CI 3.58-3.89). Lung cancer was the cancer associated with the highest risk of death in the hospital (OR 1.75, 95% CI 1.39-2.22) and at 1 year (OR 8.08, 95% CI 7.44-8.78). Colon cancer (OR 1.98, 95% CI 1.24-3.14) was the main cancer associated with major bleeding. All common cancer types were associated with higher mortality at 1 year. Cardiovascular death (62%) was the main cause of death in the first 30 days, while cancer (52%) was the main cause of death within 1 year.

CONCLUSION

STEMI patients with cancer have a higher risk of short- and long-term mortality, particularly lung cancer. Colon cancer is the main cancer associated with major bleeding. Cardiovascular disease was the main cause of death in the first month, whereas cancer was the main cause of death within 1 year.

Role of Erythropoiesis-Stimulating Agents in Cardiovascular Protection in CKD Patients: Reappraisal of Their Impact and Mechanisms

Erythropoiesis-stimulating agents (ESAs) have markedly reduced the need for blood transfusion for renal anemia and are included in standard therapies for patients with chronic kidney disease (CKD). Various protective effects of ESAs on the cardiovascular system have been discovered through basic research, and the effects have received much attention because the rates of cardiovascular events and mortality are high in CKD patients. However, randomized clinical trials did not provide strong evidence that ESAs exert cardioprotection in humans, including CKD patients. It is difficult to assess the cardioprotective effects of ESAs in CKD patients through the clinical data that has been reported to date because the relationship between hemoglobin level rather than ESA dose and cardiovascular event rates was examined in most studies. Interestingly, recent studies using a rat model of CKD showed that the infarct size-limiting effect of an ESA was lost when its dose was increased to a level that normalized blood hemoglobin levels, suggesting that the optimal dose of an ESA for myocardial protection is less than the dose required to normalize hemoglobin levels. Furthermore, animal models of traditional coronary risk factors or comorbidities were resistant to the cardioprotective effects of ESAs because of interruptions in signal-mediated mechanisms downstream of erythropoietin receptors. In this review, we briefly discuss basic and clinical data on the impact of anemia on coronary and systemic circulation, the effects of CKD on the cardiovascular system, and the multiple pharmacological actions of ESAs to examine whether the ESAs that are prescribed for renal anemia exert any cardioprotection in patients with CKD.

Investigation of Combined Carotid Endarterectomy and Coronary Artery Bypass Graft Surgery Outcomes and Adverse Event Risk Factors in the Vascular Quality Initiative

OBJECTIVE

The purpose of this study was to investigate outcomes of simultaneous CEA and CABG utilizing the Vascular Quality Initiative (VQI). Additionally, we seek to investigate risks for both perioperative and long-term mortality and adverse neurological outcomes.

METHODS

All carotid endarterectomies in the VQI between January 2003 and May 2022 were queried. We identified 171,816 CEA in the database. We extracted 2 cohorts from these CEA. The first group was patients who underwent simultaneous carotid endarterectomy (CEA) and coronary artery bypass (CABG) (N = 3137). The second group encompassed patients who underwent CABG or percutaneous coronary artery angioplasty/stent within 5 years of ultimately undergoing CEA (N = 27,387). We investigated the following outcomes in a multivariable fashion: 1. Risks for mortality in long term follow-up for both cohorts combined; 2. Risks for ischemic event in the cerebral hemisphere ipsilateral to the CEA site after index hospital admission in follow up for both cohorts combined. Tertiary outcomes are also investigated in the manuscript.

RESULTS

On multivariable analysis, patients undergoing simultaneous combined CEA and CABG had equivalent long-term survival to patients who underwent coronary revascularization within 5 years of ultimately undergoing CEA. Five-year survival is noted to be 84.5% vs 86% with a Cox regression non-significant P-value (.203). Significant multivariable risks for reduced long term survival (P < .03 for all) included: advancing age (HR 2.48/year); smoking history (HR 1.26); Diabetes (HR 1.33); history of CHF (HR 1.66); history of COPD (HR 1.54); baseline renal insufficiency at the time of surgery (HR 1.30); anemia (HR1.64); lack of preoperative aspirin (HR 1.12); and lack of preoperative statin (HR 1.32); lack of patch placement at CEA site (HR 1.16); perioperative MI (HR 2.04); perioperative CHF (1.66); perioperative dysrhythmia (HR 1.36); cerebral reperfusion injury (HR 2.23); perioperative ischemic neurological event (HR 2.48); and lack of statin at discharge (HR 2.04). Amongst patients with documented neurological status in follow up, combined CEA and CABG had over 99% freedom from ischemic cerebral event ipsilateral to the CEA site after discharge.

CONCLUSIONS

Combined CEA and CABG provides excellent long-term mortality prevention in patients with co-existing severe coronary and carotid atherosclerosis. Simultaneous CEA and CABG provides equivalent stroke prevention and long-term survival to both a cohort of patients undergoing coronary revascularization within 5 years of CEA and patients undergoing isolated CEA or CABG in the literature. The two most impactful modifiable risk factors towards long-term stroke and mortality prevention for patients undergoing simultaneous CEA-CABG are patch placement at CEA site and adherence to statin medication therapy.

The predictive value of machine learning for mortality risk in patients with acute coronary syndromes: a systematic review and meta-analysis

BACKGROUND

Acute coronary syndromes (ACS) are the leading cause of global death. Optimizing mortality risk prediction and early identification of high-risk patients is essential for developing targeted prevention strategies. Many researchers have built machine learning (ML) models to predict the mortality risk in ACS patients. Our meta-analysis aimed to evaluate the predictive value of various ML models in predicting death in ACS patients at different times.

METHODS

PubMed, Embase, Web of Science, and Cochrane Library were searched systematically from database establishment to March 12, 2022 for studies developing or validating at least one ML predictive model for death in ACS patients. We used PROBAST to assess the risk of bias in the reported predictive models and a random-effects model to assess the pooled C-index and accuracy of these models.

RESULTS

Fifty papers were included, involving 216 ML prediction models, 119 of which were externally validated. The combined C-index of the ML models in the validation cohort predicting the in-hospital mortality, 30-day mortality, 3- or 6-month mortality, and 1 year or above mortality in ACS patients were 0.8633 (95% CI 0.8467-0.8802), 0.8296 (95% CI 0.8134-0.8462), 0.8205 (95% CI 0.7881-0.8541), and 0.8197 (95% CI 0.8042-0.8354), respectively, with the corresponding combined accuracy of 0.8569 (95% CI 0.8411-0.8715), 0.8282 (95% CI 0.7922-0.8591), 0.7303 (95% CI 0.7184-0.7418), and 0.7837 (95% CI 0.7455-0.8175), indicating that the ML models were relatively excellent in predicting ACS mortality at different times. Furthermore, common predictors of death in ML models included age, sex, systolic blood pressure, serum creatinine, Killip class, heart rate, diastolic blood pressure, blood glucose, and hemoglobin.

CONCLUSIONS

The ML models had excellent predictive power for mortality in ACS, and the methodologies may need to be addressed before they can be used in clinical practice.

The relationship of the hemoglobin to serum creatinine ratio with long-term mortality in patients with acute coronary syndrome: A retrospective study

Acute coronary syndrome (ACS) is an urgent clinical condition of cardiovascular diseases. The present study evaluated the predictive efficacy of the hemoglobin to serum creatinine ratio (Hgb/Cr) on long-term mortality in patients with ACS. The ratio, representing the proportion of the 2 values, is cheap, practical, and very easy to calculate at the bedside. Our study included 475 patients who were admitted to the coronary intensive care unit with a diagnosis of ACS and who underwent coronary angiography. The Hgb/Cr ratio was calculated by dividing the admission hemoglobin by the admission serum creatinine. All patient data were collected from the electronic hospital information system, patient files, and the hospital's archive. A comparison of the patients laboratory findings revealed that the Hgb/Cr ratios differed significantly between the survivor and non-survivor group [16.6 (7.7-49) vs 13.8 (4.91-32.8), respectively; P < .001]. A univariate Cox regression analysis showed that the Hgb/Cr ratio was statistically significant in predicting long-term mortality (0.836; 95% confidence interval [CI]: 0.781-0.895; P < .001). After adjusting the model by adding clinically and statistically significant variables, the Hgb/Cr ratio was still an independent predictor of long-term mortality (0.886; 95% CI: 0.815-0.963; P = .004). The Hgb/Cr ratio's discriminant ability was tested with an receiver operating characteristic curve analysis. The Hgb/Cr ratio's area under the curve value was 0.679 (95% CI: 0.609-0.750; P < .001). A survival analysis using the Kaplan-Meier curve of the 2 Hgb/Cr ratio groups (according to cutoff value) revealed that the low-Hgb/Cr group had a significantly higher mortality rate than high-Hgb/Cr group. The Hgb/Cr ratio was found to be an independent predictor of long-term mortality in ACS patients.

Differential impact of anemia in relation to sex in patients with myocardial infarction

Background

Data on the possible sex-specific effects of anemia on clinical outcome in patients with myocardial infarction are extremely sparse, conflicting, and inconclusive. We investigated the possible sex-specific effects of anemia on outcome in patients with myocardial infarction (MI) who underwent percutaneous coronary intervention (PCI).

Methods

Data from 8,318 patients, who were divided into four groups: men and women with and without anemia on admission, were analyzed. The association between anemia and sex and 30-day and long-term mortality was assessed. The median follow-up time was 7 years (25th, 75th percentile: 4, 11).

Results

Non-anemic men had the lowest 30-day and long-term observed mortality (4.3, 18.7%), followed by non-anemic women (7.0, 25.3%; p < 0.0001, p < 0.0001). Anemic men and women had similar mortality rates (12.8, 46.2%) and (13.4, 45.6%; p = 0.70, p = 0.80), respectively. The anemia/sex groups were independently associated with 30-day and long-term mortality (p = 0.033 and p < 0.0001, respectively). Compared to non-anemic men, non-anemic and anemic women had a similar risk of death at 30 days, but anemic men had a 50% higher risk of death (OR 1.12; 95% CI 0.83-1.52; p = 0.45, OR 1.30; 95% CI 0.94-1.79; p = 0.11, OR 1.50; 95% CI 1.13-1.98; p = 0.004, respectively). In the long term, anemic men had a 46% higher, non-anemic women 15% lower, and anemic women a similar long-term mortality risk to non-anemic men (HR 1.46; 95% CI 1.31-1.63; p < 0.0001, HR 0.85; 95% CI 0.76-0.96; p = 0.011, and HR 1.06; 95% CI 0.93-1.21; p = 0.37, respectively).

Conclusion

Our result suggests that the influence of anemia in patients with MI is different in men and women, with anemia seemingly much more harmful in male than in female patients with MI.

Comparison of Different Risk Scores for Prediction of In-Hospital Mortality in STEMI Patients Treated with PPCI

Background

Several risk scores have been developed to predict and analyze in-hospital mortality and short- and long-term outcomes of ST-elevation myocardial infarction (STEMI) patients after primary percutaneous coronary intervention (PPCI); these can classify patients as having a high or low risk of death or complications.

Objective

To compare the prognostic precision of four risk scores for predicting in-hospital mortality in patients with STEMI treated with PPCI.

Methods

We performed a retrospective cohort analysis of patients with STEMI who underwent PPCI between 2012 and 2019 (N = 1346). GRACE (Global Registry of Acute Cardiac Events), CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications), Zwolle, and TIMI (Thrombolysis in Myocardial Infarction) risk scores were calculated for each patient according to different variables. We evaluated the predictive accuracy of these scores for in-hospital mortality using the C statistic, which was obtained using logistic regression and receiver operating characteristic curves.

Results

The GRACE, CADILLAC, Zwolle, and TIMI risk scores all had good predictive precision for in-hospital mortality, with C statistics ranging from 0.842 to 0.923. The GRACE and CADILLAC risk scores were found to be superior.

Conclusions

All GRACE, CADILLAC, Zwolle, and TIMI risk scores showed a high predictive value for in-hospital mortality due to all causes in patients with STEMI treated with PPCI. The GRACE and CADILLAC risk scores revealed a better accuracy for predicting in-hospital mortality than the Zwolle and TIMI risk scores.

Association of hemoglobin levels with clinical outcomes in acute coronary syndromes in Koreans

Anemia is a well-known risk factor for cardiovascular disease. However, there are limited data on whether anemia on admission is a long-term prognostic factor in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention. We sought to evaluate the prevalence and prognostic consequences of anemia in patients with ACS treated with percutaneous coronary intervention in Korea. We retrospectively enrolled 1930 consecutive patients. Among the anemic population (hemoglobin [Hb] < 13 g/dL in men, and < 12 g/dL in women), we classified patients with Hb ≥ 7 g/dL, <10 d/dL as moderate anemia, other cases classified as mild anemia. Among patients with normal hemoglobin levels, we classified those with Hb > 16.5 g/dL in men, and > 16.0 g/dL in women, as having high hemoglobin. We examined the relationship between anemia with all-cause mortality and secondary outcomes - including cardiovascular mortality, myocardial infarction, stroke, and repeat revascularization. We classified 3.3%, 21.5%, and 5.3% of patients as moderate anemia, mild anemia, and high hemoglobin, respectively. During a median follow-up of 67.2 (interquartile range; 46.8-88.5) months, 74 (3.8%) patients died. Compared with patients with normal hemoglobin, we detected a significantly increased risk for all-cause mortality in patients with anemia (adjusted hazard ratios for moderate and mild anemia, respectively: 8.26 [95% confidence interval: 3.98-17.15], P < .001 and 2.60 [1.54-4.40], P < .001). Among patients with ACS, anemia is prevalent and is strongly associated with increased mortality and cardiovascular events. Clinical trials will prospectively evaluate the efficacy of treatment for anemia on the outcomes of patients with ACS.

Mild haemoglobin drop and clinical outcomes in acute coronary syndrome patients: finding from the BleeMACS registry

BACKGROUND

Haemoglobin drop is common in acute coronary syndrome (ACS) patients and correlates with poor prognosis. However, the association between mild haemoglobin drop and adverse clinical outcome remains insufficiently investigated. This study aimed to examine the association between in-hospital haemoglobin drop and risk for adverse clinical outcomes in ACS patients, especially those with mild drop.

METHODS

Included patients from the BleeMACS (Bleeding complications in a Multicenter registry of patients discharged after an Acute Coronary Syndrome) registry were categorized into three groups by the presence and amount of in-hospital haemoglobin drop (non-drop, mild drop and severe drop). The cut-off point between mild drop and severe drop is ≥ 3 g/dL. Multivariate Cox regression was used to assess the association between haemoglobin drop and major adverse cardiac endpoints (MACE). Patients taking potent P2Y₁₂ inhibitors were selected for the additional analysis. Propensity score matching was used to avoid selective bias in the additional analysis.

RESULTS

Of 6911 patients, 4949 patients (71.6%) experienced in-hospital haemoglobin drop. Compare with non-drop group, patients with haemoglobin drop had higher risk of MACE [adjusted hazard ratio (HR) = 1.36, 95% CI: 1.03-1.80 for mild drop group; adjusted HR = 1.70, 95% CI: 1.07-2.68 for severe drop group]. Patients in mild drop group were less likely to receive potent P2Y₁₂ inhibitors at discharge (mild drop group vs. severe drop group vs. non-drop group: 10.9% vs. 10.7% vs. 23.8%). After propensity score matching adjustment among patients with potent P2Y₁₂ inhibitors, patients in mild drop group were not associated with an increased risk of MACE than those in non-drop group (adjusted HR = 1.52, 95% CI: 0.49-4.72).

CONCLUSIONS

In-hospital haemoglobin drop was common in ACS patients and associated with a higher risk for adverse events. Reduced prescription for potent P2Y₁₂ inhibitors may be responsible for poor prognoses among patients with mild haemoglobin drop.

Impact of hemoglobin levels at admission on outcomes among elderly patients with acute coronary syndrome treated with low-dose Prasugrel or clopidogrel: A sub-study of the ELDERLY ACS 2 trial

Hemoglobin (Hb) levels have emerged as a useful tool for risk stratification and the prediction of outcome after myocardial infarction. We aimed at evaluating the prognostic impact of this parameter among patients in advanced age, where the larger prevalence of anemia and the higher rate of comorbidities could directly impact on the cardiovascular risk.

METHODS

All the patients in the ELDERLY-2 trial, were included in this analysis and stratified according to the values of hemoglobin at admission. The primary endpoint of this study was cardiovascular mortality within one year. The secondary endpoints were all-cause mortality, MI, Bleeding Academic Research Consortium (BARC) type 2-3 or 5 bleeding, any stroke, re-hospitalization for cardiovascular event or stent thrombosis (probable or definite) within 12 months after index admission.

RESULTS

We included in our analysis 1364 patients, divided in quartiles of Hb values (&lt;12.2; 12.2-13.39; 13.44-14.49; ≥ 4.5 g/dl). At a mean follow- up of 330.4 ± 99.9 days cardiovascular mortality was increased in patients with lower Hb (HR[95%CI] = 0.76 [0.59-0.97], p = 0.03). Results were no more significant after correction for baseline differences (adjusted HR[95%CI] = 1.22 [0.41-3.6], p = 0.16). Similar results were observed for overall mortality. At subgroup analysis, (according to Hb median values) a significant interaction was observed only with the type of antiplatelet therapy, but not with major high-risk subsets of patients.

CONCLUSIONS

Among elderly patients with acute coronary syndrome managed invasively, lower hemoglobin at admission is associated with higher cardiovascular and all-cause mortality and major ischemic events, mainly explained by the higher risk profile.

Pharmacological treatment of cardiogenic shock - A state of the art review

Cardiogenic shock is a clinical syndrome of impaired tissue perfusion caused by primary cardiac dysfunction and inadequate cardiac output. It represents one of the most lethal clinical conditions in intensive care medicine with mortality >40%. Management of different clinical presentations of cardiogenic shock includes guidance of cardiac preload, afterload, heart rate and contractility by differential pharmacological modulation of volume, systemic and pulmonary vascular resistance and cardiac output besides reversing the triggering cause. Data from large registries and randomized controlled trials on optimal diagnostic guidance as well as choice of pharmacological agents has accrued significantly in recent years. This state-of-the-art review summarizes the basic concepts of cardiogenic shock, the diagnostic work-up and currently available evidence and guideline recommendations on pharmacological treatment of cardiogenic shock.

The role of anemia on admission in acute coronary syndrome - An umbrella review of systematic reviews and meta-analyses

INTRODUCTION

The role of erythrocytes in the acute coronary syndrome (ACS) is complex. The aim of this review in terms of PICO (P: patients; I: intervention; C: comparison; O: outcome) was to summarize systematic reviews in patients (P) with acute coronary syndrome, evaluating the effects of (I) 1) iron deficiency, 2) administration of an erythropoiesis-stimulating agent (ESA), 3) anemia on admission, 4) red blood cell transfusion, 5) a restrictive transfusion strategy in comparison (C) to 1) no iron deficiency, 2) no ESA 3) no anemia on admission, 4) no red blood cell transfusion, 5) a liberal transfusion strategy on mortality (O).

METHODS

We used AMSTAR2 to assess the methodological quality of systematic reviews and grade the available research. The primary endpoint was all-cause mortality.

RESULTS

Using the data from 2,787,005 patients, the following conditions were associated with worse outcome in patients with ACS: anemia on admission (RR 2.08 95%CI 1.70-2.55) and transfusion (1.93 95%CI 1.12-3.34) of red blood cells. A liberal transfusion (RR 0.86 95%CI 0.70-1-05), administration of ESA (RR 0.55 95%CI 0.22-1.33) and iron deficiency (OR 1.24 95%CI 0.12-13.13) were not associated with altered all-cause mortality.

CONCLUSION

Patients suffering from ACS and anemia on admission are at particular risk for adverse outcome. There is evidence of associations between adverse outcomes and receiving red blood cell transfusions.

Relevance of pre-existing anaemia for patients admitted for acute coronary syndrome to an intensive care unit: a retrospective cohort analysis of 7418 patients

Aims

Patients with acute coronary syndrome (ACS) frequently suffer from anaemia, but its role in patients admitted to an intensive care unit (ICU) is unclear. This analysis evaluates the prognostic relevance of different degrees of anaemia and their specific impact on disease severity and the outcome in critically ill ACS patients.

Methods and results

and results The multi-centre electronic Intensive Care Unit Collaborative Research Database was used, and all patients admitted with ACS were included in a retrospective analysis. Anaemia and its degrees were defined according to the criteria by the World Health Organization. A multi-level logistic regression analysis was used to fit three sequential regression models for the binary primary outcome of hospital mortality. A total of 7418 patients were included; 3437 patients (46%) had anaemia on admission. Patients with anaemia were significantly older [61 (53–70) vs. 70 (61–78) years, P < 0.001], more often female (P < 0.001), and required an increased rate of vasopressor use (P < 0.001) and mechanical ventilation (P < 0.001). With the higher Sequential organ failure assessment score (1 vs. 2; P < 0.001) and Acute Physiology And Chronic Health Evaluation (35 vs. 47; P < 0.001) scores, a higher degree of anaemia was associated with prolonged ICU stay (2 vs. 5 days, P < 0.001). Even patients with mild anaemia needed significantly from more intensive treatment and suffered worse outcome. Intensive care unit and hospital mortality were inversely associated with haemoglobin levels.

Conclusion

Nearly half of critically ill patients with ACS suffer from anaemia, which is associated with increased illness severity, complex ICU procedures, and mortality—even in mild anaemia. Haemoglobin on admission is an independent factor for adverse outcome.

Predicting the Risk of Unplanned Readmission at 30 Days After PCI: Development and Validation of a New Predictive Nomogram

Objective

This study aimed to develop and validate a risk prediction model that can be used to identify percutaneous coronary intervention (PCI) patients at high risk for 30-day unplanned readmission.

Patients and Methods

We developed a prediction model based on a training dataset of 1348 patients after PCI. The data were collected from January 2020 to December 2020. Clinical characteristics, laboratory data and risk factors were collected using the hospital database. The LASSO regression method was applied to filter variables and select predictors, and feature selection for a 30-day readmission risk model was optimized using least absolute shrinkage. Multivariate logistic regression was used to construct a nomogram. The performance and clinical utility of the nomogram were evaluated with a receiver operating characteristic (ROC) curve, a calibration curve, and decision curve analysis (DCA). Internal validation of the predictive accuracy was performed using bootstrapping validation.

Results

The predictors included in the prediction nomogram were medical insurance, length of stay, left ventricular ejection fraction on admission, history of hypertension, the presence of chronic lung disease, the presence of anemia, and serum creatinine level on admission. The area under the receiver operating characteristic curve for the predictive model was 0.735 (95% CI: 0.711–0.759). The P value of the Hosmer–Lemeshow goodness of fit test was 0.326, indicating good calibration, and the calibration curves showed good agreement between the classifications and actual observations. DCA also demonstrated that the nomogram was clinically useful. A high c-index value of 0.723 was obtained during the internal validation.

Conclusion

We developed an easy-to-use nomogram model to predict the risk of readmission 30 days after discharge for PCI patients. This risk prediction model may serve as a guide for screening high-risk patients and allocating resources for PCI patients at the time of hospital discharge and may provide a reference for preventive care interventions.

Prognostic impact of anemia on the mortality of United Arab Emirates nationals with cardiovascular disease

Background: Cardiovascular disease is the leading cause of death worldwide. Multiple risk factors, including low hemoglobin levels, have been associated with poor outcomes in patients with cardiovascular disease. However, the long-term impact of anemia on death has not been investigated in high-risk patients in the United Arab Emirates. Therefore, this study evaluated whether anemia is a significant predictor of mortality in United Arab Emirates nationals with cardiovascular disease over 10 years.

Methods: A retrospective cohort study was conducted in an adult population of United Arab Emirates nationals with a history of cardiovascular disease, recruited from a tertiary healthcare facility. Electronic medical records between April 2008 and December 2008 were reviewed, and follow-up was conducted until December 2019. The survival functions for all-cause mortality in the presence and absence of anemia were compared using univariate Kaplan–Meier analysis with a log-rank test. The association between anemia and all-cause mortality was evaluated using a multivariable Cox regression model.

Results: A total of 224 patients were included in the follow-up for 10.5 years. At baseline, 46% of the patients had anemia, with a mean Hgb level of 105.5 ± 28.0 g/L. Patients with anemia were older (68 vs. 63 years, p = 0.001) and had a higher rate of chronic kidney disease (37.5% vs. 17.5%, p = 0.001) than those without anemia. A total of 77 (34.4%) deaths were recorded by the end of the follow-up period. Risk of all-cause mortality was significantly higher in patients with anemia than in those without (hazard ratio = 2.03, 95% confidence interval = 1.22–3.40, p = 0.006). Age and chronic kidney disease were also statistically significant predictors of death (p < 0.001 and p = 0.001, respectively).

Conclusion: Anemia is an independent predictor of all-cause mortality in United Arab Emirates nationals with underlying cardiovascular disease. Early intervention and treatment for anemia may improve clinical outcomes in this population.

Long-term predictors of death among Tunisian patients presenting for non ST-elevation acute coronary syndrome

BACKGROUND

Coronary artery disease is the leading cause of death in emerging countries. Contemporary data about clinical profile and prognosis in Tunisian patients presenting for non ST-elevation acute coronary syndrome (NSTE-ACS) are lacking.

AIM

We sought to study the risk profile and 3-year mortality predictors in Tunisian patients presenting for NSTE-ACS in the contemporary setting.

METHODS

In this single center study, data about all consecutive patients presenting to our center for NSTE-ACS from April 2014 to July 2016 were extracted and outcomes exhaustively updated. 3-year mortality predictors were determined by multivariable survival analysis.

RESULTS

A total of 340 patients were included, of which 204 (61.8%) were male. Mean age was 63.6 ± 10.3 years. Prevalence of diabetes mellitus, hypertension and smoking was 57.3%, 62.4%, and 45.3%, respectively. In-hospital, 6, 12 and 36-month mortality rate was 2.3%, 3.2%, 7.1% and 15.2%, respectively. In multivariable survival analysis, independent predictors of death were age >75 (HR=5.45, 95% CI: 2.9-10.03, p<0.001), ST-segment deviation (HR=1.86, 95% CI: 1.04-3.33, p=0.036), anemia (HR=2.56, 95% CI: 1.41-4.67, p=0.002), left ventricular ejection fraction (LVEF) <40% (HR=3.5, 95% CI: 1.84-6.67, p<0.001) and a Global Registry of Acute Coronary Events (GRACE) score ≥140 (HR=2.38, 95% CI: 1.02-5.57, p=0.044).

CONCLUSION

In Tunisian patients presenting for NSTE-ACS, long-term mortality was high. Advanced age, ST-segment deviation, anemia, LVEF <40% and a GRACE score ≥140 were independent long-term predictors of death.

Anemia or other comorbidities? using machine learning to reveal deeper insights into the drivers of acute coronary syndromes in hospital admitted patients

Acute coronary syndromes (ACS) are a leading cause of deaths worldwide, yet the diagnosis and treatment of this group of diseases represent a significant challenge for clinicians. The epidemiology of ACS is extremely complex and the relationship between ACS and patient risk factors is typically non-linear and highly variable across patient lifespan. Here, we aim to uncover deeper insights into the factors that shape ACS outcomes in hospitals across four Arabian Gulf countries. Further, because anemia is one of the most observed comorbidities, we explored its role in the prognosis of most prevalent ACS in-hospital outcomes (mortality, heart failure, and bleeding) in the region. We used a robust multi-algorithm interpretable machine learning (ML) pipeline, and 20 relevant risk factors to fit predictive models to 4,044 patients presenting with ACS between 2012 and 2013. We found that in-hospital heart failure followed by anemia was the most important predictor of mortality. However, anemia was the first most important predictor for both in-hospital heart failure, and bleeding. For all in-hospital outcome, anemia had remarkably non-linear relationships with both ACS outcomes and patients' baseline characteristics. With minimal statistical assumptions, our ML models had reasonable predictive performance (AUCs > 0.75) and substantially outperformed commonly used statistical and risk stratification methods. Moreover, our pipeline was able to elucidate ACS risk of individual patients based on their unique risk factors. Fully interpretable ML approaches are rarely used in clinical settings, particularly in the Middle East, but have the potential to improve clinicians' prognostic efforts and guide policymakers in reducing the health and economic burdens of ACS worldwide.

Acute Anemia and Myocardial Infarction

Various studies have established the prognosis of anemia in myocardial infarction (MI). Both chronic and acute anemia lead to poor outcomes in MI. Regardless, the association of anemia with MI and its management varies. In this study, the literature was analyzed to determine the association between acute anemia and MI based on the pathophysiology, outcomes, and management options. Acute anemia results in decreased blood supply and sudden hypoxia to the heart. Additionally, it exacerbates the preexisting compromised coronary blood supply in patients with MI. Thus, there is a disproportionate oxygen supply and demand ratio to the heart. It was found that anemia increases all-cause mortality in acute MI. However, it is unclear whether anemia is the direct contributor to mortality in these patients. For the management of MI, percutaneous coronary intervention (PCI) is commonly used. Increased incidence of hospital-acquired anemia (HAA) is reported in patients after PCI. However, the cause of HAA in these patients is not well established. Antiplatelet therapy in these patients is also considered to be the culprit for HAA. Nonetheless, no clear evidence is available. There is no consensus or criteria for the treatment of acute anemia in MI patients. Researchers have explored management options such as blood transfusion, erythropoietin-stimulating agent, and iron therapy. Further studies are warranted for a better understanding and management of MI in patients with anemia and vice versa.

Prognostic value of novel neutrophil-to-hemoglobin and lymphocyte score in patients with acute myocardial infarction

We developed and assessed whether a novel neutrophil-to-hemoglobin and lymphocyte (NHL) score would improve the ability to predict clinical outcome compared with neutrophil-to-lymphocyte ratio (NLR) and systemic immune-inflammation index (SII) in acute myocardial infarction (AMI). We examined 13,072 AMI patients from the Korean AMI Registry–National Institute of Health database. NHL score was calculated as follows: NHL score (U) = N/(Hb × L), where N, Hb, and L are baseline blood neutrophil, hemoglobin, and lymphocyte count. The primary outcome was the occurrence of major adverse cerebrocardiovascular events (MACCEs) at 2 years. The NLR, SII, and NHL score were independent predictors of 2-year MACCEs. The area under the curve of the NHL score (0.637) for predicting 2-year MACCEs was significantly higher compared with those of SII (0.589) and NLR (0.607). The NHL score significantly improved the reclassification and integrated discrimination compared with NLR ( p < 0.0001) and SII ( p < 0.0001). A high NHL score (≥ 0.35 U) was an independent predictor of 2-year MACCEs (adjusted hazard ratio, 1.41; 95% confidence interval, 1.29–1.55; p < 0.001). The NHL score could be a novel model for predicting long-term MACCEs in patients with AMI.

Impact of extended dual antiplatelet therapy on long-term prognosis in patients with acute coronary syndrome complicated with anemia: A sub-analysis of the real-world OPT-CAD study

OBJECTIVES

To evaluate the impact of extended dual antiplatelet therapy (DAPT) beyond 12 months on long-term prognosis in acute coronary syndrome (ACS) patients complicated with anemia undergoing percutaneous coronary intervention (PCI).

BACKGROUND

Anemia is frequent among ACS patients and is associated with increased risk of adverse clinical outcomes.

METHODS

A total of 6,953 patients were enrolled from the Optimal anti Platelet Therapy for Chinese patients with Coronary Artery Disease (OPT-CAD) study. A landmark analysis comparing extended DAPT versus single antiplatelet therapy (SAPT) at 12-24 months were performed in anemia patients without premature discontinuation of DAPT before 9 months and major clinical adverse events within 12 months. The primary outcome was major adverse cardiovascular and cerebrovascular events (MACCE), defined as a composite of all-cause death, myocardial infarction, and stroke.

RESULTS

Patients with anemia (n = 1,728) had higher rates of MACCE, all-cause mortality, and BARC type 2, 3, 5 bleeding (p < .05) compared to those without anemia (n = 5,225). Anemia patients received extended DAPT (n = 1,010) were associated with a lower risk of stroke (0.3% vs. 1.8%; HR, 0.14; 95% CI, 0.03-0.71; p = .018) compared to those received SAPT (n = 342). The rates of MACCE and all revascularization were lower in patients with extended DAPT, but the differences were not statistically significant. Risk of all-cause mortality and bleeding were comparable between the two groups.

CONCLUSIONS

Extended DAPT beyond 12 months may reduce the incidence of stroke without increasing the risk of bleeding in anemic ACS patients who tolerate 12-month DAPT.

Novel perspectives on redox signaling in red blood cells and platelets in cardiovascular disease

The fundamental physiology of circulating red blood cells (RBCs) and platelets involving regulation of oxygen transport and hemostasis, respectively, are well-described in the literature. Their abundance in the circulation and their interaction with the vascular wall and each other have attracted the attention of other putative physiological and pathophysiological effects of these cells. RBCs and platelets are both important regulators of redox balance harboring powerful pro-oxidant and anti-oxidant (enzymatic and non-enzymatic) capacities. They are also involved in the regulation of vascular tone mainly via export of nitric oxide bioactivity and adenosine triphosphate. Of further importance are emerging observations that these cells undergo functional alterations when exposed to risk factors for cardiovascular disease and during developed cardiometabolic diseases. Under these conditions, the RBCs and platelets contribute to increased oxidative stress by their formation of reactive species including superoxide anion radical, hydrogen peroxide and peroxynitrite. These alterations trigger key changes in the vascular wall characterized by enhanced oxidative stress, reduced nitric oxide bioavailability and endothelial dysfunction. Additional pathophysiological effects are triggered in the heart resulting in increased susceptibility to ischemia-reperfusion injury with impairment in cardiac function. Pharmacological interventions aiming at restoring circulating cell function has been shown to exert marked beneficial effects on cardiovascular function. In this review, we summarize the current knowledge of RBC and platelet biology with special focus on redox biology, their roles in the development of cardiovascular disease and potential therapeutic strategies targeting RBC and platelet dysfunction. Finally, the complex and scarcely understood interaction between RBCs and platelets is discussed.

Association between anemia and mortality in patients with acute coronary syndrome treated with percutaneous coronary intervention and contemporary lipid-lowering therapy

Despite a clear correlation between anemia and mortality in patients with the acute coronary syndrome (ACS), anemia as a mortality predictor in patients with ACS-receiving early invasive strategy and contemporary lipid-lowering therapy has not been examined. Therefore, we aimed to evaluate the association between anemia and mortality in ACS patients treated with acute revascularization and contemporary lipid-lowering treatment. This was a post-hoc study of the Heart Institute of Japan-Proper level of Lipid-Lowering with Pitavastatin and Ezetimibe in acute coronary syndrome study, in which ACS patients with dyslipidemia were randomized to receive either pitavastatin and ezetimibe or pitavastatin monotherapy. The success rate of primary percutaneous coronary intervention (PCI) was 95.2%. Eligible patients were divided into two groups: patients with anemia (anemia group) or without anemia (non-anemia group). Anemia was defined using the World Health Organization definition hemoglobin < 12 g/dL for women and < 13 g/dL for men. We compared the mortality between the two groups using propensity scores derived from 17 baseline variables. We identified 1721 eligible patients, including 420 (24.4%) in the anemia group and 1301 (75.6%) in the non-anemia group. One-to-one propensity score-matching created 381 pairs. Both unmatched and matched analyses found significantly high mortality in the anemia group compared to the non-anemia group (unmatched 12.3% vs. 3.8%, log-rank p < 0.01; matched 11.5% vs. 6.3%, log-rank p = 0.01). In ACS patients treated with an early invasive strategy era with a high PCI success rate and concurrent contemporary lipid-lowering management, all-cause mortality was still significantly higher in anemic patients than in non-anemic patients.Trial registration: Clinical trial registration URL: http://www.umin.ac.jp/ctr . Unique identifier: UMIN00000274.

Risk Factors for Acute Coronary Syndrome in Upper Gastrointestinal Bleeding Patients

Background

Upper gastrointestinal bleeding (UGIB) is a common critical disease with a certain fatality rate. Acute coronary syndrome (ACS), another critical ill condition, is a regular occurrence in the UGIB. We identified risk factors for ACS in UGIB.

Methods

676 patients diagnosed with UGIB were enrolled retrospectively. We assessed the occurrence of ACS in UGIB patients and identified the risk factors for ACS by logistic regression analysis and random forest analysis.

Results

After propensity score matching (PSM), the ACS group (n = 69) and non-ACS group (n = 276) were analyzed. Logistic regression analysis showed that syncope (P = 0.001), coronary heart disease history (P = 0.001), Glasgow Blatchford score (P ≤ 0.001), Rockall risk score (P = 0.004), red blood cell distribution width (RDW) (P ≤ 0.001), total bilirubin (TBil) (P = 0.046), fibrinogen (P ≤ 0.001), and hemoglobin (P = 0.001) had important roles in ACS patients. With Mean Decrease Gini (MDG) sequencing, fibrinogen, RDW, and hemoglobin were ranked the top three risk factors associated with ACS. In ROC analysis, fibrinogen (AUC = 0.841, 95% CI: 0.779-0.903) and RDW (AUC = 0.826, 95% CI: 0.769-0.883) obtained good discrimination performance. According to sensitivity > 80%, the pAUC of fibrinogen and RDW were 0.077 and 0.101, respectively, and there was no significant difference (P = 0.326). However, according to specificity > 80%, the pAUC of fibrinogen was higher than that of RDW (0.126 vs. 0.088, P = 0.018).

Conclusion

Fibrinogen and RDW were important risk factors for ACS in UGIB. Additionally, combination with coronary heart disease, syncope, hemoglobin, and TBil played important roles in the occurrence of ACS. Meanwhile, it was also noted that Rockall score and Glasgow Blatchford score should be performed to predict the risk.

Extreme venous letting and cupping resulting in life-threatening anemia and acute myocardial infarction: A case report

BACKGROUND

Wet cupping (WC) is a traditional therapy of skin suction-assisted bloodletting that is widely used in modern alternative medicine in Asia and the Middle East. Herein, we report the case of a male who presented with ST-elevation myocardial infarction (STEMI) and life-threatening anemia and underwent excessive WC.

CASE SUMMARY

A 55-year-old male presented with chest pain (30 min) and dyspnea (3 wk). His initial electrocardiogram suggested STEMI in the anterior wall. Furthermore, his laboratory results showed severe anemia with a hemoglobin level of 4.1 g/dL. Of note, the patient underwent regular WC therapy for chronic back pain, which he had recently intensified. His WC practice resulted in life-threatening anemia and eventually STEMI. Percutaneous coronary intervention in the left anterior descending artery was performed to treat the STEMI. His dyspnea dramatically improved after the transfusion, and his hemoglobin level returned to 14.8 g/dL within 2 mo after discharge. He has been uneventful for the last seven years of follow-up.

CONCLUSION

The current case demonstrates that excessive WC without adequate medical monitoring can result in severe anemia, which can further develop into STEMI.

Lysophosphatidic acid receptors 2 and 3 regulate erythropoiesis at different hematopoietic stages

Hematopoiesis, the complex developmental process that forms blood components and replenishes the blood system, involves multiple intracellular and extracellular mechanisms. We previously demonstrated that lysophosphatidic acid (LPA), a lipid growth factor, has opposing regulatory effects on erythrocyte differentiation through activation of LPA receptors 2 and 3; yet the mechanisms underlying this process remain unclear. In this study, LPA₂ is observed that highly expressed in common myeloid progenitors (CMP) in murine myeloid cells, whereas the expression of LPA₃ displaces in megakaryocyte-erythroid progenitors (MEP) of later stage of myeloid differentiation. Therefore, we hypothesized that the switching expression of LPA₂ and LPA₃ determine the hematic homeostasis of mammalian megakaryocytic-erythroid lineage. In vitro colony-forming unit assays of murine progenitors reveal that LPA₂ agonist GRI reduces the erythroblast differentiation potential of CMP. In contrast, LPA₃ agonist OMPT increases the production of erythrocytes from megakaryocyte-erythrocyte progenitor cells (MEP). In addition, treatment with GRI reduces the erythroid, CMP, and MEP populations in mice, indicating that LPA₂ predominantly inhibits myeloid differentiation at an early stage. In contrast, activation of LPA₃ increases the production of terminally differentiated erythroid cells through activation of erythropoietic transcriptional factor. We also demonstrate that the LPA₃ signaling is essential for restoration of phenylhydrazine (PHZ)-induced acute hemolytic anemia in mice and correlates to erythropoiesis impairment of Hutchinson-Gilford progeria Symptom (HGPS) premature aging expressed K562 model. Our results reveal the distinct roles of LPA₂ and LPA₃ at different stages of hematopoiesis in vivo, providing potentiated therapeutic strategies of anemia treatment.

Critical Care Society of Southern Africa adult patient blood management guidelines: 2019 Round-table meeting, CCSSA Congress, Durban, 2018

The CCSSA PBM Guidelines have been developed to improve patient blood management in critically ill patients in southern Africa. These consensus recommendations are based on a rigorous process by experts in the field of critical care who are also practicing in South Africa (SA). The process comprised a Delphi process, a round-table meeting (at the CCSSA National Congress, Durban, 2018), and a review of the best available evidence and international guidelines. The guidelines focus on the broader principles of patient blood management and incorporate transfusion medicine (transfusion guidelines), management of anaemia, optimisation of coagulopathy, and administrative and ethical considerations. There are a mix of low-middle and high-income healthcare structures within southern Africa. Blood products are, however, provided by the same not-for-profit non-governmental organisations to both private and public sectors. There are several challenges related to patient blood management in SA due most notably to a high incidence of anaemia, a frequent shortage of blood products, a small donor population, and a healthcare system under financial strain. The rational and equitable use of blood products is important to ensure best care for as many critically ill patients as possible. The summary of the recommendations provides key practice points for the day-to-day management of critically ill patients. A more detailed description of the evidence used to make these recommendations follows in the full clinical guidelines section.

Anaemia is associated with severe RBC dysfunction and a reduced circulating NO pool: vascular and cardiac eNOS are crucial for the adaptation to anaemia

Anaemia is frequently present in patients with acute myocardial infarction (AMI) and contributes to an adverse prognosis. We hypothesised that, besides reduced oxygen carrying capacity, anaemia is associated with (1) red blood cell (RBC) dysfunction and a reduced circulating nitric oxide (NO) pool, (2) compensatory enhancement of vascular and cardiac endothelial nitric oxide synthase (eNOS) activity, and (3) contribution of both, RBC dysfunction and reduced circulatory NO pool to left ventricular (LV) dysfunction and fatal outcome in AMI. In mouse models of subacute and chronic anaemia from repeated mild blood loss the circulating NO pool, RBC, cardiac and vascular function were analysed at baseline and in reperfused AMI. In anaemia, RBC function resulted in profound changes in membrane properties, enhanced turnover, haemolysis, dysregulation of intra-erythrocytotic redox state, and RBC-eNOS. RBC from anaemic mice and from anaemic patients with acute coronary syndrome impaired the recovery of contractile function of isolated mouse hearts following ischaemia/reperfusion. In anaemia, the circulating NO pool was reduced. The cardiac and vascular adaptation to anaemia was characterised by increased arterial eNOS expression and activity and an eNOS-dependent increase of end-diastolic left ventricular volume. Endothelial dysfunction induced through genetic or pharmacologic reduction of eNOS-activity abrogated the anaemia-induced cardio-circulatory compensation. Superimposed AMI was associated with decreased survival. In summary, moderate blood loss anaemia is associated with severe RBC dysfunction and reduced circulating NO pool. Vascular and cardiac eNOS are crucial for the cardio-circulatory adaptation to anaemia. RBC dysfunction together with eNOS dysfunction may contribute to adverse outcomes in AMI.

Incremental Prognostic Value of Anemia in Acute Coronary Syndrome from A Rural Hospital in India

Background:

Anemia is highly prevalent in low- and middle-income countries, where prevalence of acute coronary syndrome (ACS) is also rising. Evidence indicates that baseline anemia status can prognosticate ACS. However, the Global Registry of Acute Coronary Events (GRACE) score that is popularly used all over the world does not include information on anemia.

Objectives:

Our objective was to investigate if anemia at admission, along with the GRACE score, improves the prediction of adverse outcomes within 6 months in rural Indian patients of ACS.

Methods:

We enrolled 200 ACS patients at the Acharya Vinoba Bhave Rural Hospital—a rural, tertiary care hospital in central India. Patients were followed for 6 months for death and major adverse cardiac event (MACE). Improvement in the prediction of adverse events by including anemia in addition to the GRACE score was quantified using area under the receiver operating characteristic curve (AUC), integrated discrimination improvement (IDI) and the net reclassification index (NRI).

Results:

There were 31 deaths due to MACE and an additional 28 non-fatal MACE events during follow-up. Baseline hemoglobin was strongly and independently associated with both outcomes even after adjusting for a multivariable propensity score. For the outcome of death and death/MACE there was a moderate improvement in the AUC of 1% and 6%, respectively. However, for these outcomes the IDI for baseline hemoglobin was 6% (p = 0.03) and 12% (p << 0.0001), respectively, while the NRI was 0.50 (p = 0.01) and 0.78 (p << 0.0001), respectively.

Conclusions:

Inclusion of baseline anemia in addition to the GRACE score improves prognostication of ACS patients.

Impact of Baseline Anemia in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention: A Prespecified Analysis From the VALIDATE-SWEDEHEART Trial

Background

The impact of baseline anemia in a contemporary acute coronary syndrome (ACS) population undergoing percutaneous coronary intervention in the era of predominant radial artery access, potent P2Y12 inhibition, and rare use of glycoprotein IIb/IIIa inhibitors has not been adequately studied.

Methods and Results

ACS patients who underwent percutaneous coronary intervention between 2014 and 2016 in the VALIDATE‐SWEDEHEART (Bivalirudin Versus Heparin in ST‐Segment and Non–ST‐Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy in the Swedish Web System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies Registry) trial without missing values for hemoglobin were included (n=5482). Mortality, myocardial reinfarction, and major bleeding at 180 days were assessed using Cox regression models and propensity score matching. All studied comorbidities were more common in ACS patients who had anemia (n=792). ACS patients with anemia had higher rates of 180‐day mortality (6.9% versus 2.1%; hazard ratio, 1.9; 95% CI, 1.3–2.7; P<0.001), myocardial reinfarction (4.3% versus 1.9%; hazard ratio, 1.7; 95% CI, 1.1–2.7; P=0.013), and major bleeding (13.4% versus 8.2%; hazard ratio, 1.3; 95% CI, 1.0–1.6; P=0.041). The results were most evident in patients with a hemoglobin value <100 g/L, who had a nearly 10 times higher mortality rate.

Conclusions

Baseline anemia in ACS patients undergoing percutaneous coronary intervention, treated according to current practice including routine radial artery access, constitutes a high‐risk feature for both ischemic events, bleeding events, and mortality. A multidisciplinary approach is warranted to maximize benefit and minimize patient risk.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02311231.

Evaluation of a novel score for predicting 2-year outcomes in patients with acute coronary syndrome after percutaneous coronary intervention

BACKGROUND

A novel risk model to predict long-term mortality in patients with acute coronary syndrome (ACS), derived from the EPICOR (long-term follow-up of antithrombotic management patterns in acute coronary syndrome patients) registry, has been released recently and its performance remains to be assessed. The objective is to evaluate the EPICOR score for 2-year mortality risk in ACS patients after percutaneous coronary intervention (PCI).

METHODS

From January to December in 2013, a total of 6087 consecutive patients presenting with ACS who were scheduled for PCI were enrolled. Use online simplified EPICOR calculator to assess the expected risk of death.

RESULTS

Sixty-eight patients (1.1%) died during 2-year follow-up. The areas under the receiver operating characteristics curve for mortality in the overall population, ST-segment elevation myocardial infarction (STEMI), and non-ST-segment elevation ACS were 0.712 (95% CI, 0.650-0.772; p < 0.001), 0.790 (95% CI, 0.676-0.903; p < 0.001), and 0.683 (95% CI, 0.615-0.751; p < 0.001), respectively. Moreover, it was noninferior to the updated Global Registry of Acute Coronary Events (GRACE) risk score. Patients were stratified into three categories: low-risk (n = 3382), medium-risk (n = 2547), and high-risk (n = 158). Kaplan-Meier curve demonstrated significant ongoing divergence in both mortality (0.6% vs 1.3% vs 9.5%; p < 0.001) and major adverse cardiovascular and cerebrovascular events (MACCEs) (11.8% vs 12.3% vs 19.6%; p = 0.014) among them. Multivariate Cox analysis revealed that medium- and high-risk groups predicted 2- and 12-fold hazards of death comparing to the lowest. Yet, it was not a significant predictor for MACCEs after adjusting confounding factors.

CONCLUSION

The simplified EPICOR score showed fair discriminatory power of 2-year mortality in patients with ACS and an improved performance in the STEMI subgroup. It could aid in risk stratification of ACS patients as an independent predictor.

Outcomes of anemic patients presenting with acute coronary syndrome: An analysis of the Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events

BACKGROUND

Anemia commonly accompanies acute coronary syndromes (ACS) and is associated with poorer outcomes. This study examines the associations between anemia, management and outcomes in an Australian ACS population.

METHODS

This analysis of the CONCORDANCE database included 8665 ACS patients presenting to 41 Australian hospitals. Baseline characteristics, management, and outcomes were compared between patients with anemia (Hb ≤ 130 for males, Hb ≤ 120 g/L for females) and non-anemia.

RESULTS

A total of 1880 (21.7%) patients presenting with ACS were anemic. These patients were older (72 years vs 63 years, P < .0001), with higher prevalence of comorbidities. STEMI patients with anemia were less likely to be emergently reperfused with either thrombolytic therapy (22% vs 33%, P < .0001) or primary percutaneous coronary intervention (PCI) (45% vs 51% P = 0.033). For all ACS, anemic patients less frequently received: coronary angiography (63% vs 86%, P < .0001); drug eluting stents if undergoing PCI (50% vs 58%, P < .0001); dual antiplatelet therapy (80% vs 89%, P < .0001) ;and parenteral anticoagulants (82% vs 88%, P < .0001). In hospital complications of heart failure (20% vs 9%, P < .0001), renal failure (13% vs 4%, P < .0001), and re-infarction (4% vs 2%, P = .0006) were more common among anemic patients. There was a near-linear inverse relationship between admission hemoglobin and in hospital mortality.

CONCLUSIONS

Anemic patients with ACS are a high risk group less likely to undergo invasive and antithrombotic therapy. Further investigation is required to determine if more active treatment of anemic patients presenting with ACS will improve their outcomes.

Relations of Anemia With the All-Cause Mortality and Cardiovascular Mortality in General Population: A Meta-Analysis

BACKGROUND

Anemia may be an independent risk factor of death. Therefore, the current meta-analysis aimed to explore the relationship of anemia with all-cause mortality (ACM) and cardiovascular mortality (CVM) to provide evidence-based medical facts.

METHODS

Three major electronic databases, the National Library of Medicine of the USA (PubMed), Cochrane Library and Embase, were searched from inception to October 2018. Relevant studies were screened in strict accordance with the inclusion and exclusion criteria, and the pooled hazard ratios (HRs) together with the 95% confidence intervals (CIs) were performed to assess the statistically significant difference of anemia compared with ACM and CVM.

RESULTS

A total of 15 related studies were included. Our results suggested that among the mixed population regardless of sex, age and cardiovascular diseases (CVD), the ACM and CVM of anemia patients were increased, with the HRs and 95% CIs of 1.41 (1.33, 1.50) and 1.33 (1.23, 1.45), respectively. Meanwhile, the ACM of anemia patients with the mean age of over 65 or below 65 years was increased irrespective of sex and CVD, with the HRs and 95% CIs of 1.43 (1.26, 1.61) and 1.41 (1.32, 1.50), separately. Moreover, the risks of ACM were increased in male, female and mixed sex anemia patients despite age and CVD, with the HRs and 95% CIs of 1.39 (1.29, 1.49), 1.25 (1.20, 1.30) and 1.53 (1.39, 1.68), respectively. All patients with CVD and no CVD were associated with an increased risk of ACM regardless of age and sex, with the HRs and 95% CIs of 1.42 (1.33, 1.51) and 1.38 (1.16, 1.63), respectively.

CONCLUSIONS

Anemia is a risk factor to predict ACM and CVM among the general population, which is independent of sex, age, and history of CVD.

Impact of anemia as risk factor for major bleeding and mortality in patients with acute coronary syndrome

BACKGROUND

Anemia is frequent in acute coronary syndrome (ACS) patients and is associated with worse clinical outcomes. We aimed to investigate the therapeutic strategies, the use of novel P2Y₁₂ inhibitors, and the prognostic implication of anemia in a "real world" cohort of ACS patients.

METHODS

This is an observational and prospective registry including 1717 ACS patients from three tertiary hospitals. During hospitalization we recorded the clinical management and the antiplatelet therapy at discharge. Patients were divided into 2 groups according to the baseline hemoglobin level, i.e. anemic (hemoglobin < 13 g/dL in men and <12 g/dL in women) and non-anemic patients. Bleeding events, mortality and major adverse cardiovascular events (MACEs) were recorded during 1-year of follow-up.

RESULTS

Anemia was present in 445 (25.9%) patients. Cardiac catheterization (83.8% vs. 94.5%, p < .001), and revascularization by percutaneous coronary intervention (53.5% vs. 70.5%, p < .001) were less frequent in these patients. Excluding anticoagulated patients, novel P2Y₁₂ inhibitors were less prescribed in anemic patients (OR 2.80 [95% CI 2.13-3.67], p < .001). Anemia was independently associated with major bleeding (HR 2.26 [95% CI 1.07-4.78], p = .033) and all-cause mortality (HR 1.62 [95% CI 1.03-2.56], p = .038), but not with MACE. At 1-year of follow-up, the risk of mortality in anemic patients taking clopidogrel was higher (HR 2.38 [95% CI 1.01-5.67]; p = .049).

CONCLUSIONS

In this registry involving ACS patients, anemia had influence on clinical management and antiplatelet therapy. Patients suffering from anemia had higher risk for major bleeding and mortality. In particular, anemic patients treated with clopidogrel had even more mortality events.

Outcomes of Percutaneous Coronary Interventions in Patients With Anemia Presenting With Acute Coronary Syndrome

OBJECTIVE

To study the influence of anemia on long-term outcomes of patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI).

PATIENTS AND METHODS

The study included 5668 consecutive unique patients with acute coronary syndrome who underwent PCI at Mayo Clinic from January 1, 2004, through December 31, 2014. The patients were stratified on the basis of the presence (hemoglobin [Hgb] level, <13 g/dL in men and <12 g/dL in women) and severity (moderate to severe Hgb level, <11 g/dL in men and women) of pre-PCI anemia and compared with patients without anemia. The primary outcomes were in-hospital and long-term all-cause mortality after balancing baseline comorbidities using the inverse propensity weighting method.

RESULTS

Unadjusted all-cause in-hospital mortality (4.6% [84 of 1831] vs 2.0% [75 of 3837]) and 5-year follow-up mortality (44.4% [509] vs 15.4% [323]) were higher in patients with anemia than in those without anemia (P<.001 for both). After applying inverse propensity weighting analysis, the all-cause in-hospital mortality (2.0% [37] vs 2.0% [75]; P=.85) and 5-year mortality (17.8% [203] vs 15.4% [323]; P=.05) were not significantly different between patients with and without anemia; however, there were higher rates of all-cause 5-year mortality in patients with moderate to severe anemia (22.3% [113] vs 15.4% [323]; P<.001) compared with patients without anemia. The trend in 5-year mortality was driven by increased noncardiac mortality in patients with anemia (10.2% [91] vs 7.1% [148]; P=.04) and moderate to severe anemia (10.4% [52] vs 7.1% [148]; P=.006) when compared with nonanemic patients.

CONCLUSION

After accounting for differences in risk profiles of anemic and nonanemic patients, anemia appeared to be an independent risk factor for increased long-term all-cause and noncardiac mortality.

Association of Coffee and Tea with Ferritin: Data from the Korean National Health and Nutrition Examination Survey (IV and V)

There have been few studies that have evaluated the association between coffee intake and iron in Korean population. Data from the Korean National Health and Nutrition Examination Survey (IV and V; 2007–2012) was used to investigate the association between coffee and green tea intake and serum ferritin levels in Korean adults. Beverage intake was assessed using a food frequency questionnaire. Multivariate linear regression was performed to evaluate the relationship between coffee and tea intake and serum ferritin levels, after adjusting for age, body mass index, education level, smoking status, alcohol consumption, physical activity, hypertension, diabetes mellitus, and daily iron intake. Coffee intake was negatively related to serum ferritin levels in both sexes. The multivariate-adjusted geometric mean of serum ferritin level was 100.7 ng/mL (95% confidence interval [CI]: 98.2–103.4) in men drinking <1 coffee/day, and 92.2 ng/mL (95% CI: 89.7–94.8) in those drinking ≥3 coffees/day. In women, the equivalent serum ferritin levels were 35.6 ng/mL (95% CI: 34.8–36.4) and 28.9 ng/mL (95% CI: 27.8–30.1). However, green tea intake was not related to serum ferritin levels. In conclusion, coffee consumption was associated with lower serum ferritin levels in Korean adults.

Anemia and acute coronary syndrome: current perspectives

Reference hemoglobin (Hb) values for the definition of anemia are still largely based on the 1968 WHO Scientific Group report, which established a cutoff value of <13 g/dL for adult men and <12 g/dL for adult nonpregnant women. Subsequent studies identified different normal values according to race and age. Estimated prevalence of anemia on admission in the setting of an acute coronary syndrome (ACS) is between 10% and 43% of the patients depending upon the specific population under investigation. Furthermore, up to 57% of ACS patients may develop hospital-acquired anemia (HAA). Both anemia on admission and HAA are associated with worse short- and long-term mortality, even if different mechanisms contribute to their prognostic impact. Baseline anemia can usually be traced back to preexisting disease that should be specifically investigated and corrected whenever possible. HAA is associated with clinical characteristics, medical therapy and interventional procedures, all eliciting cardiovascular adaptive response that can potentially worsen myocardial ischemia. The intrinsic fragility of anemic patients may limit aggressive medical and interventional therapy due to an increased risk of bleeding, and could independently contribute to worse outcome. However, primary angioplasty for ST elevation ACS should not be delayed because of preexisting (and often not diagnosed) anemia; delaying revascularization to allow fast-track anemia diagnosis is usually feasible and justified in non-ST-elevation ACS. Besides identification and treatment of the underlying causes of anemia, the only readily available means to reverse anemia is red blood cell transfusion. The adequate transfusion threshold is still being debated, although solid evidence suggests reserving red blood cell transfusions for patients with Hb level <8 g/dL and considering it in selected cases with Hb levels of between 8 and 10 g/dL. No evidence supports the use of iron supplements and erythropoiesis-stimulating agents in the setting of ACS.

Prognosis of cardiovascular and non-cardiovascular multimorbidity after acute coronary syndrome

Objective

To examine the prognosis of patients with cardiovascular and non-cardiovascular multimorbidity after acute coronary syndrome compared to patients without prior multimorbidity.

Methods

This multicenter prospective cohort study in Switzerland included 5,635 patients hospitalized with acute coronary syndrome between 2009 and 2014, with a one-year follow-up period. We defined cardiovascular and non-cardiovascular multimorbidity as having at least two prior comorbidities before the index hospitalization. Multivariable adjusted Cox proportional models were built to assess the one-year risk of recurrent cardiovascular events, defined as cardiovascular mortality and non-fatal myocardial infarction or stroke. The final model was adjusted for age, gender, body mass index, tobacco consumption, education, and family history of cardiovascular disease, prescription of high-dose statinsat discharge and use of cardiac rehabilitation after discharge.

Results

Overall, 3,664 patients (65%) had no multimorbidity, 1,839 (33%) had cardiovascular multimorbidity, 62 (1%) had non-cardiovascular multimorbidity, and 70 (1%) had both cardiovascular and non-cardiovascular multimorbidity. The multivariate risk of recurrent cardiovascular events was increased among patients with cardiovascular multimorbidity (hazard ratio (HR) 2.05, 95% CI: 1.54–2.73, p<0.001) and patients with non-cardiovascular multimorbidity (HR 2.57, 95% CI: 1.04–6.35, p = 0.04) compared to patients without multimorbidity. Patients with cardiovascular and non-cardiovascular multimorbidity had the highest risk of recurrence with a HR of 5.19, 95% CI: 2.79–9.64, p<0.001, compared to patients without multimorbidity.

Conclusions

Multimorbidity increased by two-fold the risk of cardiovascular events over the year after an acute coronary syndrome. The magnitude of this increased risk was similar for patients with cardiovascular or non-cardiovascular multimorbidity.