Blood pressure screening in Mata Sector, a rural area of Rwanda

In rural sub-Saharan Africa, knowledge of non-communicable diseases such as high blood pressure (BP) is rather limited. This report provides information about a BP screening in Mata Sector, a rural region in Southern Province of Rwanda. Community-based, house-to-house screening was performed between February and July 2020 on more than 7000 inhabitants. The screening was conducted by a local team composed by 20 community health care workers, five community health care supervisors, and one nurse with hypertension surveillance training. BP and heart rate were recorded after 5 min of resting, using a validated automated oscillometric OMRON M6 IT-HEM-7322-E monitor with Intelli Wrap Cuff (HEM-FL31-E) technology. The mean of the second and third value was retained. BP was normal (<140/90 mm Hg) in 6340 (88%) and elevated in 863 (12%) participants with 95% of unawareness. Grade 1 (140-159/90-99 mm Hg) hypertensive BP readings were detected in 697 (81%), grade 2 (160-179/100-109 mm Hg) in 134 (16%), and grade 3 (≥180/≥110 mm Hg) in 32 (3.7%) individuals. The prevalence of hypertensive readings was significantly age-dependent. Additionally, a slightly greater proportion of participants with high BP (14% versus 11%) had a body mass index (BMI) ≥ 25.0 kg/m2. Also resting heart rate was higher in individuals with high BP (82 versus 77 beats/min). Although individuals identified with occasionally elevated BP values need further confirmatory measurements to establish the diagnosis of hypertension, these data suggest that high BP represents a noteworthy and preventable reason of concern within sub-Saharan Africa.

Comparison of office, home and ambulatory blood pressure measurements in hypertensive and suspected hypertensive SWICOS participants

PURPOSE

Hypertension should be confirmed with the use of home BP measurement (HBPM) or 24h ambulatory BP measurement (ABPM). The aim of our study was to compare measurements obtained by OBPM, HBPM and ABPM in individuals with elevated OBPM participating in the population-based Swiss Longitudinal Cohort Study (SWICOS).

MATERIAL AND METHODS

Participants with OBPM ≥140/90 mmHg assessed their BP using HBPM and ABPM. The cut-off for hypertension was ≥135/85 mmHg for HBPM, ≥130/80 mmHg for ABPM. White-coat hypertension (WCH) was defined as normal HPBM and ABPM in participants not taking antihypertensive drugs. Uncontrolled hypertension was defined as hypertension in HBPM or ABPM despite antihypertensive treatment.

RESULTS

Of 72 hypertensive subjects with office BP ≥140/90 mmHg and valid measurements of HBPM and ABPM, 39 were males (aged 62.8 ± 11.8y), 33 were females (aged 57.4 ± 14.2y). Hypertension was confirmed with HBPM and ABPM in 17 participants (24%), with ABPM only in 24 further participants (33%), and with HBPM only in 2 further participants (3%). Participants who had hypertension according to ABPM but not HBPM were younger (59 ± 11 y versus 67 ± 16 y; p < 0.001) and more frequently still working (83% versus 23%; p < 0.001). The prevalence of WCH was 28%. Among the 32 subjects taking antihypertensive drugs, uncontrolled hypertension was found in 49%.

CONCLUSION

This population-based study found a high prevalence of WCH and potential uncontrolled hypertension among individuals with elevated OBPM. This study, therefore, supports the ESH recommendations of complementing OBPM by ABPM or HBPM. The use of HBPM instead of ABPM for the confirmation of hypertension in individuals with elevated OBPM might lead to underdiagnosis and uncontrolled hypertension, in particular in the younger working population. In these individuals, this study suggests using ABPM instead of HBPM.

Twenty-year trends in the prevalence of modifiable cardiovascular risk factors in young acute coronary syndrome patients hospitalized in Switzerland

AIMS

Modifiable cardiovascular risk factors (RFs) play a key role in the development of coronary artery disease. We evaluated 20-year trends in RF prevalence among young adults hospitalized with acute coronary syndromes (ACS) in Switzerland.

METHODS AND RESULTS

Data were analysed from the Acute Myocardial Infarction in Switzerland (AMIS) Plus registry from 2000 to 2019. Young patients were defined as those aged <50 years. Among 58 028 ACS admissions, 7073 (14.1%) were young (median 45.6 years, IQR 42.0-48.0), of which 91.6% had at least one modifiable RF and 59.0% had at least two RFs. Smoking was the most prevalent RF (71.4%), followed by dyslipidaemia (57.3%), hypertension (35.9%), obesity (21.7%), and diabetes (10.1%). Compared with older patients, young patients were more likely to be obese (21.7% vs. 17.4%, P < 0.001) and active smokers (71.4% vs. 33.9%, P < 0.001). Among young patients, between 2000 and 2019, there was a significant increase in the prevalence of hypertension from 29.0% to 51.3% and obesity from 21.2% to 27.1% (both Ptrend < 0.001) but a significant decrease in active smoking from 72.5% to 62.5% (Ptrend = 0.02). There were no significant changes in the prevalence of diabetes (Ptrend = 0.32) or dyslipidaemia (Ptrend = 0.067).

CONCLUSION

Young ACS patients in Switzerland exhibit a high prevalence of RFs and are more likely than older patients to be obese and smokers. Between 2000 and 2019, RF prevalence either increased or remained stable, except for smoking which decreased but still affected approximately two-thirds of young patients in 2019. Public health initiatives targeting RFs in young adults in Switzerland are warranted.

The Perioperative Pain Management Bundle is Feasible: Findings From the PAIN OUT Registry

OBJECTIVES

The quality of postoperative pain management is often poor. A "bundle," a small set of evidence-based interventions, is associated with improved outcomes in different settings. We assessed whether staff caring for surgical patients could implement a "Perioperative Pain Management Bundle" and whether this would be associated with improved multidimensional pain-related patient-reported outcomes (PROs).

METHODS

"PAIN OUT," a perioperative pain registry, offers tools for auditing pain-related PROs and obtaining information about perioperative pain management during the first 24 hours after surgery. Staff from 10 hospitals in Serbia used this methodology to collect data at baseline. They then implemented the "Perioperative Pain Management Bundle" into the clinical routine and collected another round of data. The bundle consists of 4 treatment elements: (1) a full daily dose of 1 to 2 nonopioid analgesics (eg, paracetamol and/or nonsteroidal anti-inflammatory drugs), (2) at least 1 type of local/regional anesthesia, (3) pain assessment by staff, and (4) offering patients information about pain management. The primary endpoint was a multidimensional pain composite score (PCS), evaluating pain intensity, interference, and side effects that was compared between patients who received the full bundle versus not.

RESULTS

Implementation of the complete bundle was associated with a significant reduction in the PCS ( P < 0.001, small-medium effect size [ES]). When each treatment element was evaluated independently, nonopioid analgesics were associated with a higher PCS (ie, poorer outcome, and negligible ES), and the other elements were associated with a lower PCS (all negligible small ES). Individual PROs were consistently better in patients receiving the full bundle compared with 0 to 3 elements. The PCS was not associated with the surgical discipline.

DISCUSSION

We report findings from using a bundle approach for perioperative pain management in patients undergoing mixed surgical procedures. Future work will seek strategies to improve the effect.

Reducing gap in pre-hospital delay between women and men presenting with ST-elevation myocardial infarction

AIMS

This study aimed to analyse changes in pre-hospital delay over time in women and men presenting with ST-elevation myocardial infarction (STEMI) in Switzerland.

METHODS AND RESULTS

AMIS Plus registry data of patients admitted for STEMI between 2002 and 2019 were analysed using multivariable quantile regression including the following covariates: interaction between sex and admission year, age, diabetes, pain at presentation, myocardial infarction (MI) history, heart failure history, hypertension, and renal disease. Among the 15,350 patients included (74.5% men), the median (interquartile range) delay between 2002 and 2019 was 150 (84; 345) min for men and 180 (100; 414) min for women. The unadjusted median pre-hospital delay significantly decreased over time for both sexes but the decreasing trend was stronger for women. Specifically, the unadjusted sex differences in delay decreased from 60 min in 2002 (P = 0.0042) to 40.5 min in 2019 (P = 0.165). The multivariable model revealed a significant interaction between sex and admission year (P = 0.038) indicating that the decrease in delay was stronger for women (-3.3 min per year) than for men (-1.6 min per year) even after adjustment. The adjusted difference between men and women decreased from 26.93 min in 2002 to -1.97 min for women in 2019.

CONCLUSION

Over two decades, delay between symptom onset and hospital admission in STEMI decreased significantly for men and women. The decline was more pronounced in women, leading to the sex gap disappearing in the adjusted analysis for 2019.

Patients With AMI and Severely Reduced LVEF, a Well-Defined, Still Extremely Vulnerable Population (Insights from AMIS Plus Registry)

Left ventricular ejection fraction (LVEF) represents one of the strongest predictors of both in-hospital and long-term prognosis in acute myocardial infarction (AMI). Temporal trends data coming from real-world experiences focused on patients with AMI with severely reduced LVEF (i.e., <30%) are lacking. In a total of 48,543 screened patients with AMI included in the Acute Myocardial Infarction in Switzerland Plus Registry between 2005 and 2020, data on LVEF were available for 23,510 patients. Study patients were classified according to LVEF as patients with AMI with or without severely reduced LVEF (i.e., patients with LVEF <30% and ≥30%, respectively). Overall, 1,657 patients with AMI (7%) displayed severely reduced LVEF. The prevalence of severe LVEF reduction constantly decreased over the study period (from 11% to 4%, p <0.001). In the subgroup of patients with severely reduced LVEF, a significant increase in revascularization rate was observed (from 61% to 84%, p <0.001); however, in-hospital mortality did not significantly decrease and remained well above 20% over the study period (from 23% to 26%, p = 0.65). At discharge, prescription of optimal cardioprotective therapy (defined as an association of renin-angiotensin-aldosterone-system inhibitors, β-blocker, and mineral corticoid receptor antagonist) remained low across the study period (from 17% in 2011 to 20%, p = 0.96). In conclusion, patients with AMI with severely reduced LVEF remain a fragile subgroup of patients with an in-hospital mortality that did not significantly decrease and remained well above 20% over the study period. Moreover, access at discharge to optimal cardioprotective therapy remains suboptimal. Efforts are, therefore, needed to improve prognosis and access to guidelines-directed therapies in this fragile population.

Decade of lung cancer in Serbia: tobacco abuse and gender differences

OBJECTIVE

Lung cancer (LC) is one of the most frequently diagnosed cancers and the leading cause of cancer mortality worldwide. The aim of this study was to get a comprehensive insight into the epidemiology of LC among patients in Vojvodina, the Northern Serbian region, during the ten-year period.

PATIENTS AND METHODS

This retrospective study was performed using LC hospital registry data of the Institute for Pulmonary Diseases of Vojvodina (IPBV) from 2011 to 2020. All patients reported in the registry with a place of residence in Vojvodina were included in this study. The data used in this research were: date of diagnosis, gender, age at diagnosis, place of residence, smoking habits at diagnosis, the intensity of smoking (pack/years), ECOG performance (0-5), histological cancer type, TNM classification and disease stage.

RESULTS

A total of 12,055 LC patients were included, 69.6% of whom were male. The percentage of female LC patients significantly increased, from 26.9% in 2011 to 35.9% in 2020 (p<0.001). Non-small cell lung cancer (NSCLC) was diagnosed in 80.8% of patients, while 15.4% of patients had small cell lung cancer (SCLC). The most common histological type was adenocarcinoma (41.9%), followed by squamous cell carcinoma (30.0%) and SCLC (15.4%).

CONCLUSIONS

The number of diagnosed LC patients in the Northern Serbian region increased over the past decade and is significantly higher in females. There was a strong correlation between smoking habits and LC in both genders. Our results also indicate the importance of introducing and promoting LC screening programs for all risk populations, particularly current and ex-smokers of younger age.

Prognostic value of low heart rates in patients admitted with acute myocardial infarction

INTRODUCTION AND OBJECTIVES

The risk prediction scores adopted in acute coronary syndromes (ACS) use incremental models to estimate mortality for heart rate (HR) above 60 bpm. Nonetheless, previous studies reported a nonlinear relationship between HR and events, suggesting that low HR may have an unrecognized prognostic role. We aimed to assess the prognostic impact of low HR in ACS, defined as admission HR <50 bpm.

METHODS

This study analyzed data from the AMIS Plus registry, a cohort of hospitalized patients with ACS between 1999 and 2021. The primary endpoint was in-hospital all-cause mortality, while a composite of all-cause mortality, major cardiac/cerebrovascular events was set as the secondary endpoint. A multilevel statistical method was used to assess the prognostic role of low HR in ACS.

RESULTS

The study included 51 001 patients. Crude estimates showed a bimodal distribution of primary and secondary endpoints with peaks at low and high HR. A nonlinear relationship between HR and in-hospital mortality was observed on restricted cubic spline analysis. An HR of 50 to 75 bpm showed lower mortality than HR <50 bpm (OR, 0.67; 95%CI, 0.47-0.99) only after primary multivariable analysis, which was not confirmed after multiple sensitivity analyses. After propensity score matching, progressive fading of the prognostic role of HR <50 bpm was evident.

CONCLUSIONS

Low admission HR in ACS is associated with a higher crude rate of adverse events. Nonetheless, after correction for baseline differences, the prognostic role of low HR was not confirmed. Therefore, low HR probably represents a marker of underlying morbidity. These results may be clinically relevant in improving the accuracy of risk scores in ACS.

Influence of allergic status and nasal polyposis on long-term Benralizumab response in eosinophilic severe asthma

Objective

It is unclear whether Benralizumab effectiveness in severe eosinophilic asthma can be influenced by nasal polyposis (NP) or allergic status associations. We evaluated whether Benralizumab long-term efficacy in asthma outcomes could be different in subjects with atopy (SAEA) compared to the effectiveness in those without allergies (SNAEA) and in individuals with NP compared to those without NP.

Methods

This observational retrospective study considered 95 consecutive patients divided into allergic (SAEA; n:65[68.4%]; skin prick tests positive [SPT] and/or IgE values ≥100 UI/mL), and non-allergic (SNAEA; n:30[31.6%], SPT negative and normal IgE levels<100 UI/mL). Overall population was also divided into two groups according to NP presence (NP+:39[41%] and NP-:56[59%]). Benralizumab treatment mean was19.7±7.2 months (range 12-35).

Results

No differences in Benralizumab effectiveness were found in asthma outcomes in patients with/without NP. SNOT-22 improvement was higher in NP+ (-22±24) compared to NP- groups (6.33±15.5;p=0.055). FEV1 (16.33±19.22%), ACT(7.45±3.95) increases and frequency of SABA use (3.37±4.99) reduction were higher in SAEA compared to what obtained in non-allergic subjects (FEV1:8.15±15.6%,p=0.043; ACT:4.89±3.57,p=0.005; SABA use:-1.16±1.84;p=0.015). 93.8% of SAEA patients whereas only 72.2% of SNAEA individuals reduced OC doses at least half after Benralizumab (p=0.035). These results were partially confirmed by linear regression models showing associations between allergic status and FEV1, ACT and SABA use changes (β=8.37;p=0.048, β=2.056;p=0.033 and β=-2.184;p=0.042 respectively).

Conclusion

Benralizumab effectiveness in asthma appears to be independent of NP presence. The allergic eosinophilic disease, compared to just eosinophilic asthma, may be a more severe phenotype. Benralizumab may have greater efficacy in SAEA on some outcomes.

Effect of different doses of remifentanil on the cardiovascular response after endotracheal intubation: a randomized double-blind study

OBJECTIVE

Laryngoscopy and endotracheal intubation (EI) often provoke a marked sympathetic response, which leads to tachycardia and hypertension. The aim of this study was to investigate the effect of different doses of remifentanil on the cardiovascular response to laryngoscopy and EI.

PATIENTS AND METHODS

100 patients were included in this randomized study. The participants were divided into four groups of 25 patients each. The patients in the control group did not receive remifentanil. The patients from other three groups received remifentanil prior to induction of anesthesia at doses of 0.5 µg/kg, 1 µg/kg, and 1.5 µg/kg. Hemodynamic parameters were measured before and after administration of remifentanil, after induction of anesthesia and one minute after EI.

RESULTS

After administration of remifentanil and induction of anesthesia, a decrease in arterial pressure and heart rate occurred in most patients. After EI, an increase in arterial pressure and heart rate was observed in most patients. The largest increase was recorded in the group of patients who did not receive remifentanil. The best hemodynamic response was observed in patients who received 1 and 1.5 µg/kg of remifentanil.

CONCLUSIONS

Remifentanil at the doses of 1-1.5 µg/kg is absolutely safe for co-induction of anesthesia with thiopental. Such dosing regimen provides optimal conditions for reducing hemodynamic response to laryngoscopy and EI.

Impact of Cardiovascular Risk Factors on Arterial Stiffness in a Countryside Area of Switzerland: Insights from the Swiss Longitudinal Cohort Study

INTRODUCTION

Cardiovascular disease is the leading cause of morbidity and mortality. Besides traditional cardiovascular risk factors, arterial stiffness is a recognized predictor of cardiovascular risk.

METHODS

We investigated the relationship between traditional cardiovascular risk factors, sex, and aortic pulse wave velocity in subjects living in a countryside area of Southern Switzerland. For this aim, we performed a cross-sectional analysis of data from adult participants of the Swiss Longitudinal Cohort Study, which, initiated in 2015, follows health status and disease risk factors in a Swiss countryside cohort at least 6 years of age.

RESULTS

A total of 387 people (205 women and 182 men) were included. Hyperlipidemia, overweight, and obesity were more common (p ≤ 0.001) and LDL-cholesterol, triglycerides, and hemoglobin A1c were higher (p < 0.03) in men than women. Systolic and diastolic brachial and aortic blood pressures were higher in men (p < 0.02), whereas aortic pulse wave velocity and aortic pulse pressure were higher in women (p < 0.05). The aortic pulse wave velocity was significantly higher in subjects with hypertension, hyperlipidemia, diabetes, and obesity, and significantly increased with age (p < 0.0001). Multiple linear regression analysis showed a significant correlation between pulse wave velocity and age, female sex, brachial systolic blood pressure, and heart rate (p < 0.005).

CONCLUSION

Also in a countryside area, the aortic pulse wave velocity is higher in subjects with hypertension, hyperlipidemia, diabetes and obesity, and significantly increases with age. Furthermore, with advancing age, aortic pulse wave velocity is higher in women than men.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT02282748.

Oxidative stress and viral Infections: rationale, experiences, and perspectives on N-acetylcysteine

This article explores current evidence on the role of oxidative stress in viral infections, and on the use of antioxidant drugs as adjunctive treatment. MEDLINE/PubMed was searched for appropriate keywords, and preclinical and clinical studies with reviews were retrieved and examined by authors. Old and current evidence shows that GSH content reduction is the main mechanism of redox imbalance in viral-infected cells. Clinical studies found that GSH levels are depleted in patients with viral infections such as HIV and SARS-CoV. Viral infections activate inflammation through different pathways, and several of these mechanisms are related to oxidative stress. NAC is a precursor of GSH, and many of its intracellular effects are mediated by GSH replenishment, but it also activates some anti-inflammatory mechanisms. NAC has an excellent safety profile and better oral and topical bioavailability than GSH. These characteristics make NAC a suitable option as a repurposed drug. Adjunctive antioxidant treatment may improve the outcomes of antiviral therapies. Current evidence supports the rationale for this practice and some clinical experience showed encouraging results.

Sex inequities in the performance of the GRACE 2.0 score in non-ST-segment elevation acute coronary syndromes: a multinational observational study in contemporary cohorts from four European countries

Background

The Global Registry of Acute Coronary Events (GRACE) score was developed and validated in predominantly male patient populations. Growing evidence indicates distinct pathophysiologic and clinical characteristics of non-ST-segment elevation acute coronary syndromes (NSTE-ACS) in women and men.

Purpose

We aimed to assess sex differences in the performance of the GRACE score in NSTE-ACS in contemporary populations.

Methods

We calculated GRACE 2.0 risk estimates for patients with NSTE-ACS in contemporary nation-wide ACS cohorts from England, Wales, and Northern Ireland (MINAP, 2005–2017, n=400,054) and from Switzerland (AMIS Plus, 2005–2020, n=20,727; SPUM-ACS, 2009–2017, n=2,239). Sex disaggregated analyses were stratified according to the mortality endpoint of the score (in-hospital death, death at 6 months, death at 1 year), the clinical setting (calculated at admission and calculated for hospital survivors, respectively), the geographic region (United Kingdom and Switzerland, respectively) and the level of care (all hospitals and PCI-capable university hospitals, respectively). The area under the receiver operating characteristic curve (AUC), the average prediction error (APE), and the misclassification rate (MCR) were compared between women and men.

Results

The discriminatory performance of GRACE 2.0 for in-hospital death was lower and the APE and MCR were higher in women as compared to men in the United Kingdom (AUC female: 80.4%, 95% confidence interval [CI], 80.0 to 80.8, AUC male: 84.7%, 95% CI, 84.4 to 85.1, p&lt;0.001; APE female: 0.0512, 95% CI, 0.0501–0.0522, APE male: 0.0357, 95% CI, 0.0351 to 0.0363; MCR female: 5.81%, 95% CI, 5.68 to 5.94, MCR male: 3.96, 95% CI, 3.89 to 4.03) and in Switzerland (AUC female: 84.2%, 95% CI, 81.4 to 86.8, AUC male: 88.5%, 95% CI 87.1–89.7, p=0.003; APE female: 0.0420, 95% CI 0.0376 to 0.0465, APE male: 0.0312, 95% CI 0.0289 to 0.0335; MCR female: 4.98%, 95% CI 4.39 to 5.56, MCR male: 3.69%, 95% CI, 3.39 to 4.00). Similar results were obtained for 6-month death and 1-year death endpoints across clinical settings, geographic regions, and levels of care. The risk of in-hospital death relative to males was increased in females that GRACE 2.0 classified as low-to-intermediate risk (suggesting no early invasive management strategy) in the United Kingdom (relative risk [RR]: 1.61, 95% CI, 1.50 to 1.74, p&lt;0.001) and in Switzerland (RR: 1.84, 95% CI, 1.28 to 2.64, p&lt;0.001).

Conclusion

Thus far, this is the largest investigation on the GRACE risk score. We confirmed good overall score performance and found decreased performance in contemporary female patients with NSTE-ACS irrespective of the mortality endpoint, the clinical setting, the geographic region, and the level of care.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science FoundationSwiss Heart Foundation

Sex differences in acute coronary syndromes: a never ending same old story or sign for improvement

Introduction

We previously described sex differences in baseline characteristics, interventional therapy and mortality in patients admitted for acute coronary syndromes (ASC) in Swiss hospitals and enrolled in the AMIS Plus registry between 1997 and 2006 (1). This present analysis aimed to reassess whether anything changed over the last 15 years.

Method

All AMIS Plus patients enrolled between 2007 and 2021 were included. Baseline characteristics, therapy and outcome were analysed according to sex and age groups. Multivariate analyses were performed to assess independent predictors of in-hospital mortality.

Results

Among 42,471 patients, 10,825 (25.5%) were women. Women were still older (71.6±12.6y vs. 64.2±12.6y for men), had more comorbidities (Charlson Comorbidity Index&gt;1: 26.5% vs. 21.7%), were less likely to receive drug therapy (e.g., P2Y12 inhibitors 83.3% vs. 89.2% or statins 73.0% vs. 78.5%) and underwent percutaneous coronary intervention (PCI) less frequently (OR 0.77; 95% CI 0.73–0.83). These findings paralleled our observations for the period 1997–2006. However, the increase in PCI use over the years, particularly in women, led to a marked decrease in differences between men and women with respect to revascularization, from 16.6% in 2006 down to 2.0% in 2020. Unadjusted in-hospital mortality was higher in women (OR 1.55; 95% CI 1.41–1.70), but this significance disappeared after adjustment for baseline differences (OR 1.07; (95% CI 0.96–1.20)). However, in women under the age of 50 years, crude mortality (3.1% versus 1.6%) was significantly higher than in same-aged men; adjusted OR 1.78 (95% CI 0.99–3.20).

Conclusions

Sex differences in the baseline characteristics of ACS patients and the use of evidence-based drugs persisted but the sex gap in PCI access slowly but surely diminished. Female sex per se was not an independent predictor of in-hospital mortality in the overall population but it showed a strong trend among patients younger than 50 years of age.

Funding Acknowledgement

Type of funding sources: None.

Heart rate and mortality in myocardial infarction: incremental or bimodal correlation?

Introduction

Risk prediction scores adopted in acute coronary syndromes use incremental models to estimate mortality for heart rate (HR) above 60 bpm. Nonetheless, a non-linear, bimodal relationship, with higher event rates at low or high HR, has been described, potentially hampering risk prediction accuracy.

Purpose

Our aim was to assess the prognostic impact of bradycardia, defined as admission HR &lt;50 bpm, in myocardial infarction (MI) among patients enrolled in a large nationwide registry.

Methods

Data of patients enrolled between 1999 and 2021 stratified by admission HR were retrospectively analysed. The primary endpoint was in-hospital mortality. The secondary endpoint was a composite of death, cerebrovascular event, and reinfarction. Associations between HR and outcomes were assessed at univariate and multivariable logistic regression analyses, then verified after sequential propensity-score matchings among HR groups.

Results

51001 patients (median age 66 years, IQR 56–76) were included. Crude estimates showed a bimodal distribution of primary and secondary endpoints with peaks at low and high HR. Association of HR &lt;50 bpm with mortality was recognised only at primary multivariable logistic regression analysis (OR 1.49; 95% CI 1.01–2.13 p=0.038) but not at multiple sensitivity analyses after exclusion of patients on negative chronotropic therapy. Three sequential propensity-score matching were performed among patients with HR &lt;50 bpm at admission and those with HR 50–75 bpm, HR 76–100 bpm and HR &gt;100 bpm at admission, identifying 1159, 1159 and 1158 matched pairs, respectively. After propensity-score matching, rates of primary and secondary endpoints equalled among groups with HR &lt;100 bpm.

Conclusions

Bradycardia (HR &lt;50 bpm) at admission in patients with MI identified a group with higher crude rate of adverse events. Nonetheless, the signal supporting an independent association between bradycardia at admission and short-term mortality is weak and was not confirmed after correction for relevant baseline differences by propensity score matching. These findings support the hypothesis that lower HR might not be causative for the worse outcomes, but rather serves as a marker of underlying morbidity.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The AMIS Plus registry is funded by unrestricted grants from the Swiss Heart Foundation and from Abbot AG, Amgen AG, AstraZeneca AG, Bayer (Schweiz) AG, Biotronik AG, Boston Scientific AG, B. Braun Medical AG, Daiichi-Sankyo/Lilly AG, Cordis Cardinal Health GmbH, Medtronic AG, Novartis Pharma Schweiz AG, Sanofi-Aventis (Schweiz) AG, SIS Medical AG, Terumo AG, Vascular Medical GmbH, all in Switzerland, and the Swiss Working Group for Interventional Cardiology. The sponsors did not play any role in the design, data collection, analysis, or interpretation of data.

Treatment and outcome of patients with acute myocardial infarction and chronic lung disease: insights from the nationwide AMIS Plus registry

Introduction

Little is known about patients with acute myocardial infarction (AMI) and chronic lung disease (CLD). The aim of our study was to analyze risk factors, treatment, and outcome of AMI patients with CLD over the last 20 years using the nationwide AMIS Plus registry.

Methods

All AMI patients enrolled in the AMIS Plus registry with data on CLD between January 2002 and December 2021 were included. Chronic lung disease was determined according to the definition used in the Charlson Comorbidity Index. Data on baseline characteristics, regular medication, immediate therapy within 24 hours, in-hospital interventions and treatments, in-hospital outcome, complications and discharge medication were analyzed using descriptive statistics and logistic regression.

Results

Among 53,680 AMI patients, 5.8% had a CLD. The CLD group included 26.6% female and 73.4% male patients. Gender distribution was similar in patients with and without CLD. Patients with CLD were significantly older (71.2 vs. 65.8 y; p&lt;0.001), more frequently diagnosed with NSTEMI, had more comorbidities and were less frequently never smokers (17.4% vs. 35.3%; p&lt;0.001) compared to patients without CLD. In addition, CLD patients were less likely to receive aspirin, P2Y12 inhibitors, beta-blockers, ACE inhibitors and statins (all p&lt;0.001), and were also less likely to undergo percutaneous coronary interventions (68.7% vs. 82.5%; p&lt;0.001). Median length of stay was 2 days longer for CLD patients. Patients with CLD had more major adverse cardiac and cerebrovascular events in-hospital (10.3% vs. 5.9%; p&lt;0.001) and higher crude in-hospital mortality (8.3% vs. 4.7%; p&lt;0.001). However, multivariable regression analysis showed that CLD was not an independent predictor for in-hospital mortality (OR 1.19 (95% CI 0.98–1.45), p=0.081).

Conclusion

Patients with CLD were less likely to receive evidence-based medicine and had a worse in-hospital outcome compared to those without CLD. However, after adjustment, CLD was not an independent predictor of in-hospital mortality.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): AstraZeneca AG, Biotronik (Schweiz) AG

Bleeding risk in patients hospitalized for non-ST-segment elevation acute coronary syndromes in Switzerland: performance of the CRUSADE score

Background

Evaluation of bleeding risk is critical to the management of patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). The CRUSADE score is the most established tool to estimate major bleeding events following the index NSTE-ACS.

Purpose

We aimed to assess the performance of the CRUSADE score and the predictive utility of the individual score variables in contemporary European populations.

Methods

The CRUSADE score was studied in prospectively recruited Swiss patients with NSTE-ACS included in the multicentre SPUM-ACS study (n=4'787) and main findings were validated in the nation-wide AMIS Plus registry (n=46'939). Major bleeding during hospitalization was defined as Bleeding Academic Research Consortium (BARC) class IIIB, IIIC, IV, or V. Discrimination was evaluated by the area under the receiver operating characteristic curve (AUC). Multivariable-adjusted risk ratios (adj RR) were estimated for each of the 8 score variables. Hematocrit estimates were based on hemoglobin concentrations in AMIS Plus. Analyses were performed on complete and imputed data (multiple imputation using chained equations).

Results

CRUSADE showed poor discriminatory performance (SPUM-ACS: AUC, 0.65; 95% CI 0.57 to 0.72) and low balanced accuracy (SPUM-ACS: 0.50). Risk predicted by CRUSADE exceeded the observed risk across all predefined risk categories (very low, low, moderate, high, and very high). Decision curve analyses suggested little to no net benefit from using the score. Adjusting for other score variables, signs of heart failure (adj RR, 3.83; 95% CI, 1.93 to 7.37), low hematocrit (adj RR, 2.16; 95% CI, 0.55 to 7.70; &lt;31% vs. &gt;40%), and low systolic blood pressure (adj RR, 2.70; 95% CI, 1.14 to 6.16; &lt;100 mmHg vs. &gt;121 mmHg) were the strongest predictors of major in-hospital bleeds in SPUM-ACS. These findings were similarly observed in AMIS Plus.

Conclusion

The CRUSADE score overestimates bleeding risk in NSTE-ACS. Among all 8 score variables, signs of heart failure, low hematocrit, and low systolic blood pressure are the strongest predictors of major in-hospital bleeds in contemporary patients with NSTE-ACS.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Swiss National Science FoundationSwiss Heart Foundation

Acute myocardial infarction and work inability: insights from the AMIS Plus registry

Introduction

The impact of acute myocardial infarction (AMI) on the ability to pursue professional life is not well defined. Using a nationwide database, we aimed to describe the ability to return to work after AMI in Switzerland and identify factors associated therewith.

Methods

AMI patients of working-age enrolled in the AMIS Plus registry between 01/2006 and 09/2020 with data on self-reported work status before and 12 months after AMI were included. Using the Kruskal-Wallis rank sum test or Fisher's exact test we compared patient characteristics between those who did not reduce work hours, those who reduced, and those no longer working 12 months after the AMI.

Results

Of 4315 AMI patients (median (IQR) age 54 (49, 59)), 3204 (74.3%) did not reduce work, 592 (13.7%) reduced and 519 (12.0%) stopped working. Patients not reducing were youngest (median age (IQR)): 54y (49y, 58y), those who reduced: 56y (51y, 60y), those who stopped: 56y (51y, 61y), p&lt;0.001) and more often men (no reduction: 90%, reduced: 80%, stopped: 82%, p&lt;0.001). Patients who reduced showed worst cardiac function at AMI reflected in the highest rates of Killip class&gt;2 (no reduction: 1.8%, reduced: 5.2%, stopped: 3.3%, p&lt;0.001) and resuscitation before admission (no reduction: 4.1%, reduced: 6.9%, stopped: 4.0%, p=0.008). Patients who stopped work had the most comorbidities such as past AMI (no reduction: 8.6%, reduced: 10%, stopped: 13%, p=0.003), hypertension (no reduction: 45%, reduced: 50%, stopped: 54%, p&lt;0.001), diabetes (no reduction: 10%, reduced: 13%, stopped: 16%, p&lt;0.001) and cerebrovascular disease (no reduction: 0.8%, reduced: 1.2%, stopped: 2.3%, p=0.007). There was no significant difference for rehabilitation participation during follow up (no reduction: 84%, reduced: 86%, stopped: 84%, n.s. for all group comparisons). Multivariable regression showed that the reduction group had a higher proportion of women (OR 2.30; 95% CI 1.80–2.93 p&lt;0.001) and were more likely to have a Killip class &gt;2 at admission (OR 2.58; 95% CI 1.54–4.31 p&lt;0.001) as compared to the no reduction group whereas the comparison between no reduction and work stop identified comorbidities (past MI (OR 1.46; 95% CI 1.07–1.94 p=0.016), diabetes (OR 1.59; 95% CI 1.21–2.09 p=0.001), cerebrovascular disease (OR 2.53; 95% CI 1.22–5.25 p=0.013)) and being female (OR 1.98; 95% CI 1.51–2.58 p&lt;0.001) as major predictors for work stop.

Conclusion

Our data showed that 1:7 had reduced and 1:8 stopped professional activity 1 year after AMI. Younger age, being male and lower rates of comorbidities such as a past AMI, hypertension, diabetes and cerebrovascular disease were important factors associated with returning to work after AMI. Work reduction was significantly related with worse cardiac function whereas work stop was more related with comorbidities.

Funding Acknowledgement

Type of funding sources: None.

Where do we stand with acute myocardial infarction patients with severely reduced left ventricular ejection fraction? insights from AMIS Plus Registry

Background

Left ventricular ejection fraction (LVEF) represents one of the strongest predictors of both in-hospital and long-term prognosis in acute myocardial infarction (AMI). Temporal trends data coming from real-word experiences focused on AMI patients with severely reduced LVEF (i.e. &lt;30%) are lacking.

Purpose

The present study aims at providing a comprehensive picture on temporal trends in AMI patients with severely reduced LVEF, with a particular focus on prevalence, in-hospital management/prognosis and pharmacological therapy at discharge. These data could shed light on the implementation in the clinical arena of guideline-directed therapies in this fragile subgroup of patients and on their effect on real-word short-term prognosis.

Methods

On a total of 48,543 screened AMI patients included in AMIS Plus Registry between 2005 and 2020, data on LVEF were available for 23,510 patients. Study patients were classified according to LVEF as AMI patients with or without severely reduced LVEF (i.e. patients with LVEF &lt;30% and ≤30%, respectively).

Results

Overall, 1657 AMI patients (7%) presented with severely reduced LVEF. Prevalence of severe LVEF reduction constantly decreased over the study period (from 11% to 4%, p&lt;0.001; Figure 1). In the subgroup of patients with severely reduced LVEF a significant increase in revascularisation (percutaneous and/or surgical) rate was observed (from 61% to 84%, p&lt;0.001); in-hospital access to advanced short-term mechanical circulatory support (both ECMO and/or Impella) significantly increased from 0% in 2011 to 17% (p=0.05). Rate of cardiogenic shock developed during hospitalization remained stable over time (from 21% to 16%, p=0.7); in-hospital mortality did not significantly decrease and remained well above 20% all over the study period (from 23% to 26%, p=0.65; Figure 2). At discharge, prescription of optimal anti-ischaemic therapy (defined as an association of dual antiplatelet therapy and statine) significantly increased (from 47% to 75%, p&lt;0.001), mainly driven by an increase in dual antiplatelet therapy prescription; however, prescription of optimal cardio-protective therapy (defined as an association of renin-angiotensin-aldosterone-system inhibitors, beta-blocker and mineralcorticoid receptor antagonist) remained low across the study period (from 17% in 2011 to 20%, p=0.96).

Conclusion

AMI patients with severely reduced ejection fraction still remain a fragile subgroup of patients; in-hospital mortality did not significantly decrease and remained exceedingly high and well above 20% all over the study period; efforts are, therefore, urgently needed to develop therapeutic strategies focused on this subgroup of patients and aiming at improving short-term prognosis. Moreover, access at discharge to optimal cardio-protective therapy remains suboptimal; efforts are needed to improve access to guidelines-directed therapy both at discharge and follow-up in this fragile population.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Swiss Heart Fundation

Severe asthma and long-term Benralizumab effectiveness in real-life

OBJECTIVE

Long-term efficacy of Benralizumab in real life is not clearly known. We assessed the long-term effectiveness persistence to anti-IL-5R treatment in a group of severe eosinophilic asthmatics.

PATIENTS AND METHODS

We retrospectively analyzed 95 individuals affected by severe asthma (36 males  ̶ 37.9%; mean age 58.1 ± 12.2) treated with Benralizumab (mean time 19.7 ± 7.2 months, range 12-35). Outcomes were evaluated at the beginning and at the end of patients' treatment periods.

RESULTS

Mean baseline blood eosinophils were 897.5 ± 720.1 cells/μL (11 ± 5.6%) decreasing to 7.4 ± 20.6 cells/μL (0.97 ± 0.26%; p < 0.0001) after Benralizumab. FENO likewise decreased from 63.9 ± 68.4 to 28.4 ± 23.6 ppb, while FEV1% significantly improved (p < 0.0001). Mean FEF25-75 also increased from 45.8 ± 24.6% to 60.7 ± 24.6%, whereas RAW dropped from 202.15 ± 109.6% to 135.2 ± 54.75% (p < 0.0001). Also, lung volumes greatly decreased. ACT/ACQ significantly improved, while exacerbations number fell from 4.1 ± 2.4, before anti-IL-5R, to 0.33 ± 0.77, after treatment (p < 0.0001). Rhinitis severity levels and SNOT-22 also changed favorably. Patients that took long-term OCs were 71.6% before treatment, decreasing to 23.2% after Benralizumab (p < 0.0001), with an OCs dose reduction from 14.8 ± 8.9 to 1.45 ± 2.8 mg/day (p < 0.0001). 51.6% of subjects used SABA as needed before Benralizumab, falling to 4.2% after treatment. Several patients showed a reduction of ICS doses, SABA use and maintenance therapy step-down. Clinical/biological response with anti-IL-5R remained constant or even improved in terms of exacerbations or maintenance therapy reductions over time. On the contrary, FEF25-75% improvement slowed down in the long-term. No relationship was found between baseline blood eosinophil number and therapeutic response.

CONCLUSIONS

Long-term Benralizumab effectiveness persistence in all outcomes in real life was confirmed.

Sex-specific evaluation and redevelopment of the GRACE score in non-ST-segment elevation acute coronary syndromes in populations from the UK and Switzerland: a multinational analysis with external cohort validation

BACKGROUND

The Global Registry of Acute Coronary Events (GRACE) 2.0 score was developed and validated in predominantly male patient populations. We aimed to assess its sex-specific performance in non-ST-segment elevation acute coronary syndromes (NSTE-ACS) and to develop an improved score (GRACE 3.0) that accounts for sex differences in disease characteristics.

METHODS

We evaluated the GRACE 2.0 score in 420 781 consecutive patients with NSTE-ACS in contemporary nationwide cohorts from the UK and Switzerland. Machine learning models to predict in-hospital mortality were informed by the GRACE variables and developed in sex-disaggregated data from 386 591 patients from England, Wales, and Northern Ireland (split into a training cohort of 309 083 [80·0%] patients and a validation cohort of 77 508 [20·0%] patients). External validation of the GRACE 3.0 score was done in 20 727 patients from Switzerland.

FINDINGS

Between Jan 1, 2005, and Aug 27, 2020, 400 054 patients with NSTE-ACS in the UK and 20 727 patients with NSTE-ACS in Switzerland were included in the study. Discrimination of in-hospital death by the GRACE 2.0 score was good in male patients (area under the receiver operating characteristic curve [AUC] 0·86, 95% CI 0·86-0·86) and notably lower in female patients (0·82, 95% CI 0·81-0·82; p<0·0001). The GRACE 2.0 score underestimated in-hospital mortality risk in female patients, favouring their incorrect stratification to the low-to-intermediate risk group, for which the score does not indicate early invasive treatment. Accounting for sex differences, GRACE 3.0 showed superior discrimination and good calibration with an AUC of 0·91 (95% CI 0·89-0·92) in male patients and 0·87 (95% CI 0·84-0·89) in female patients in an external cohort validation. GRACE 3·0 led to a clinically relevant reclassification of female patients to the high-risk group.

INTERPRETATION

The GRACE 2.0 score has limited discriminatory performance and underestimates in-hospital mortality in female patients with NSTE-ACS. The GRACE 3.0 score performs better in men and women and reduces sex inequalities in risk stratification.

FUNDING

Swiss National Science Foundation, Swiss Heart Foundation, Lindenhof Foundation, Foundation for Cardiovascular Research, and Theodor-Ida-Herzog-Egli Foundation.

Occupational radiation dose of personnel involved in sentinel node biopsy procedure

INTRODUCTION

Sentinel node biopsy is a procedure used for axillary nodal staging in breast cancer surgery. The process uses radioactive ^99mTc isotope for mapping the sentinel node(s) and all the staff involved in the procedure is potentially exposed to ionizing radiation. The colloid for radiolabelling (antimone-sulphide) with ^99mTc isotope (half-life 6 h) is injected into the patient breast. The injection has activity of 18.5 MBq. The surgeon removes the primary tumor and detects active lymph nodes with gamma detection unit. The tumor as well as the active nodal tissue is transferred to pathologist for the definitive findings. The aim of the study was to measure dose equivalents to extremities and whole body for all staff and suggest practice improvement in order to minimize exposure risk.

MATERIALS AND METHODS

The measurements of the following operational quantities were performed: Hp(10) personal dose equivalent to whole body and Hp(0.07) to extremities for staff as well as ambiental dose for operating theatre and during injection. Hp(0.07) were measured at surgeon's finger by ring thermoluminescent dosimeter (TLD) type MTS-N, and reader RADOS RE2000. Surgeon and nurse were wearing TLD personal dosimeter at the chest level. Anesthesiologist and anesthetist were wearing electronic personal dosimeters, while pathologist was wearing ring TLD while manipulating tissue samples. Electronic dosimeters used were manufactured by Polimaster, type PM1610. All TLD and electronic dosimeters data were reported, including background radiation. Background radiation was also monitored separately. Personal TLDs are standard for this type of personal monitoring, provided by accredited laboratory. Measurements of ambiental dose in workplaces of other staff involved around the patient was performed before the surgery took place, by calibrated survey meters manufactured by Atomtex, type 1667. The study involved two surgeons and one pathologist, two anesthesiologists and three anesthetists during two months period.

RESULTS AND DISCUSSION

The doses received by all staff are evaluated using passive and active personal dosimeters and ambiental dose monitors and practice was improved based on results collected. Average annual whole body dose for all staff involved in the procedure was less than 0.8 mSv. Extremity dose equivalents to surgeon and pathologist were far below the limits set for professionally exposed (surgeon) and for public (pathologist).

CONCLUSIONS

Although has proven to be very safe for all staff, additional measures for radiation protection, in accordance to ALARA principle (As Low As Reasonably Achievable) should be conducted. The recommendations for practice improvement with respect to radiation protection were issued.

Dual antiplatelet therapy is under-prescribed in patients with surgically treated acute myocardial infarction

OBJECTIVES

Despite guideline recommendations, previous reports, coming mainly from outside Europe, showed low rates of prescriptions for dual antiplatelet therapy (DAPT) in patients with acute myocardial infarction (AMI) undergoing surgical revascularization. The present study assesses this issue in the era of potent P2Y12 inhibitors in Switzerland.

METHODS

All patients with a diagnosis of AMI included in the Acute Myocardial Infarction in Switzerland Plus Registry from January 2014 to December 2019 were screened; 9050 patients undergoing either percutaneous (8727, 96.5%) or surgical (323, 3.5%) revascularization were included in the analysis.

RESULTS

Surgically treated patients were significantly less likely to receive DAPT at discharge (56.3% vs 96.7%; P < 0.001). Even when discharged with a prescription for DAPT, those patients were significantly less likely to receive a regimen containing a new P2Y12 inhibitor (67/182 [36.8%] vs 6945/8440 [83.2%]; P < 0.001). At multivariate analysis, surgical revascularization was independently associated with a lower likelihood of receiving a prescription for DAPT at discharge (odds ratio 0.03, 95% confidence interval 0.02-0.06).

CONCLUSIONS

DAPT prescriptions for patients with AMI undergoing surgical revascularization are not in line with current guideline recommendations. Efforts are necessary to clarify the role of DAPT for secondary prevention in these patients and increase the confidence of treating physicians in guideline recommendations.

CLINICAL TRIAL REGISTRATION

Acute Myocardial Infarction in Switzerland Plus Registry; registration number at ClinicalTrials.gov: NCT01305785.

Long-term trends in treatment and outcomes of patients with diabetes and acute coronary syndromes: insights from the nationwide AMIS plus registry

Background

Although impressive advances in the treatment of patients with acute coronary syndromes (ACS) have been achieved over the last decades, morbidity and mortality of patients with diabetes and ACS remain substantial. This study aimed at investigating long-term trends in treatment and outcomes of patients with diabetes and ACS, using data from a large, prospective, nation-wide database.

Methods

Patients with ST segment elevation myocardial infarction (STEMI) or non-ST segment elevation myocardial infarction (NSTEMI) enrolled in the prospective AMIS Plus registry between 01/2003 and 12/2018 and available data on diabetes diagnosis were included in the analysis. Major adverse cardiovascular events (MACE), a composite of all-cause death, non-fatal myocardial infarction, and cerebrovascular events were assessed for each 3-year period.

Results

Out of 49'413 ACS patients, 10'200 (20.6%) had diabetes (29.4% women). In diabetic patients, the percentage of women decreased from 32.3% in 2002–2004 to 25.9% in 2017–2019 (p&lt;0.001). Diabetic patients were older (p&lt;0.001), more frequently women (p&lt;0.001), and had a higher body mass index (p&lt;0.001). They less often underwent percutaneous coronary intervention (p&lt;0.001) and were more frequently treated by coronary artery bypass grafting (p&lt;0.001). Over the 18-year period, the percentage of diabetic patients undergoing PCI or CABG increased (p&lt;0.001). While treatment with glycoprotein IIb/IIIa inhibitors, low-molecular weight heparin, and beta blockers decreased over time, administration of aspirin, P2Y12 inhibitors, lipid-lowering drugs, and unfractionated heparin increased. Rates of MACE were 9.5% and 5.2% in diabetic and non-diabetic patients (p&lt;0.001). Rates of mortality (7.7% versus 4.1%, p&lt;0.001), recurrent myocardial infarction (1.5% versus 0.9%, p&lt;0.001), and cerebrovascular events (1.2% versus 0.6%, p&lt;0.001) were higher in diabetic as compared with non-diabetic patients, with highest rates of MACE, mortality, and myocardial infarction observed in diabetic women. Rates of MACE decreased from 11.8% in 2002–2004 to 7.5% in 2017–2019 in diabetic patients (p for trend &lt;0.001). While rates of mortality (9.4% to 5.9%, p for trend =0.001) and rates of recurrent myocardial infarction (3.4% to 0.9%, p for trend &lt;0.001) decreased over time, rates of cerebrovascular events remained stable (p for trend =0.34). Trends were the same in diabetic women and men.

Conclusions

Rates of MACE significantly decreased over the 18-year period in both diabetic women and men, with highest rates observed in diabetic women. Despite the observed improvements, rates of MACE remained 50% higher in diabetic as compared with non-diabetic patients. These findings emphasize that advanced strategies particularly targeting the vulnerable high-risk diabetic patient population are warranted to further improve quality of care in ACS.

Funding Acknowledgement

Type of funding sources: None.

Achievement of guideline recommended LDL-C goals in patients with acute myocardial infarction (AMI) in Switzerland

Background

In 2016 and subsequently again in 2019 the ESC/EAS Guidelines for the Management of Dyslipidaemia established a more intensive reduction of LDL cholesterol (LDL-C) treatment recommendations. We aim to characterize patients with acute myocardial infarction (AMI) with regards to achievement of recommended LDL-C goals and their current lipid lowering therapy.

Methods

We retrospectively analysed patients with AMI admitted to Swiss hospitals between 2016 and 2020. Patients were classified as “very high risk” due to prior atherosclerotic cardiovascular disease (ACSVD) events including at least one of the following: Myocardial infarction (MI), stroke, peripheral arterial disease (PAD) and type 2 diabetes mellitus with target organ damage. The remaining patients were classified as “other risk”. LDL-C treatment recommendation goals for the “very high risk” population were set to 1.8mmol/L (2016 ESC/EAS Guidelines) or 1.4mmol/L (2019 ESC/EAS Guidelines) and for the “other risk” population to 2.6mmol/L or 1.8mmol/L. To identify differences between the two groups the Mann-Whitney test was used and for differences within a group the Kruskal-Wallis test. In-hospital outcomes were summarised as major adverse cardiac and cerebrovascular events (MACCE).

Results

Among 7114 patients included, 18.4% were categorized as “very high risk” and 81.6% as “other risk” (p&lt;0.001). In general, the “very high risk” patients were older (69.2y vs. 63.6y, p&lt;0.001), more likely to be men (78.8% vs. 75.3%, p=0.007), had poorer in-hospital outcomes (6.0% vs. 3.4%, p&lt;0.001) and were more often on lipid lowering treatment (statin/ezetimibe/combination) (LLT) prior to admission (64.8% vs 14.0%, p&lt;0.001). The overall LDL-C median for the “very high risk” population was significantly lower than for the “other risk” population (2.4mmol/L vs. 3.5mmol/L, p&lt;0.001). In addition, median (IQR) LDL-C increased in the “other risk” group over the years from 3.5mmol/L (2.7; 4.2) in 2016 to 3.7mmol/L (3.1; 4.4) in 2020. In contrast, no change in LDL-C was observed in the patients at higher risk (Fig. 1).

Patients in the “other risk” group were more likely to miss the recommended LDL-C goals (2016 Guidelines: 80.0% vs. 75.4%, 2019 Guidelines: 94.2% vs. 89.1%). Patients without LLT prior to admission had a higher chance of not reaching the recommendations compared to patients with LLT prior to admission (without LLT: 2016: 85.3% vs. 91.0%, 2019: 96.1% vs. 96.6%), (with LLT: 2016: 50.8% vs. 66.8%, 2019: 83.2% vs.85.2%) (Fig. 2).

Conclusion

Median LDL-C levels have tended to increase in recent years in patients with very high CV risk and AMI admitted to Swiss hospitals. Despite existing lipid lowering therapies only few patients met guideline recommended LDL-C goals. Our results indicate that clinical implementation of guidelines remains to be optimised with regards to achievement of LDL-C goals to reduce CV risk and improve outcomes.

Funding Acknowledgement

Type of funding sources: None. Figure 1. LDL-C developmentFigure 2. Recommended LDL-C goal achievement

The impact of the COVID-19 pandemic on the management and outcomes of STEMI patients in Switzerland

Introduction

The COVID-19 pandemic has placed unprecedented strain on healthcare systems around the world, with potential repercussions on the quality of care of patients with other diseases. From a cardiological perspective, there have been concerns that the pandemic may have impacted the management of the most acute cardiovascular conditions.

Purpose

We evaluated the impact of the COVID-19 pandemic on the management of ST-elevation myocardial infarction (STEMI) in Switzerland by assessing a range of quality-of-care metrics during the first year of the pandemic, as compared with the preceding year.

Methods

Data on STEMI patients hospitalised in Switzerland from 1st January 2019 to 31st December 2020 were obtained from the Acute Myocardial Infarction in Switzerland (AMIS) registry. Symptom-to-first-medical-contact (symptom-to-FMC) time, symptom-to-door time, and door-to-balloon (DTB) time were compared between 2020 and 2019 in an analysis by year and by month. Additionally, rates of in-hospital all-cause mortality and in-hospital major adverse cardiovascular events (MACE: all-cause mortality, MI, stroke) were compared.

Results

Data on 2192 STEMI patients were available. Compared with the preceding 12 months, the first year of the pandemic was not associated with a significant change in median symptom-to-FMC time (2020: 90 minutes vs 2019: 95 minutes, p=0.32) or median symptom-to-door time (2020: 145 min vs 2019: 157 min, p=0.51). In 2020, February (start of the pandemic) and March (start of national lockdown) were associated with increased DTB times as compared with the same months of 2019 (+7 minutes, +10 minutes, respectively). However, overall median door-to-balloon times remained stable (2020: 40 min vs 2019: 39 min, p=0.06). Furthermore, there was no significant difference in the proportion of patients undergoing percutaneous coronary intervention (2020: 95.6% vs 2019: 95.1%, p=0.54). Finally, there were no significant differences in median length of stay (2020: 4 days vs 2019: 157 min, p=0.51), in-hospital all-cause mortality (2020: 4.9% vs. 2019: 4.2%, p=0.41) or MACE (2020: 6.2% vs. 2019: 5.6%, p=0.52).

Conclusions

Although there are some limitations associated with the present study inherent to its retrospective observational design (for instance, a potentially important number of late comers may not have been included in the registry), the data suggest that despite the impact of COVID-19 on the healthcare system in Switzerland in 2020, STEMI management as defined by a range of quality-of-care metrics remained effective and efficient.

Funding Acknowledgement

Type of funding sources: None.

Prevalence of ideal cardiovascular health in a community-based population - results from the Swiss Longitudinal Cohort Study (SWICOS)

AIMS OF THE STUDY

The American Heart Association (AHA) developed a concept to measure cardiovascular health in populations. We aimed to analyse participants in the Swiss Longitudinal Cohort Study (SWICOS) according to the AHA concept.

METHODS

We analysed cardiovascular health according to the AHA concept in all 474 participants of the prospective, population-based SWICOS study who were 18 years or older. The AHA concept uses seven health metrics of known cardiovascular risk factors (blood pressure, total cholesterol, blood glucose, smoking, body weight, physical activity and diet), and classifies each health metric according to three levels (ideal, intermediate and poor) using pre-defined cut-offs.

RESULTS

Ideal cardiovascular health for three or more of the seven health metrics was found in 259 participants (54.9%; 95% confidence interval [CI] 50.1-59.4%), but a relevant number of participants (n = 213, 45.1%, 95% CI 40.6-49.7%) showed ideal cardiovascular health for only two or fewer of the seven health metrics. Poor cardiovascular health for three or more of the seven health metrics was found in 40 participants (8.5%; 95% CI 6.1-11.4%); a majority of 432 participants (91.5%; 95% CI 88.6-93.9%) showed a poor level for only two or fewer of the seven health metrics.

CONCLUSIONS

Overall, we found favourable results for cardiovascular health in the population-based SWICOS cohort. Nevertheless, we see the need for further health prevention campaigns given the fact that a relevant proportion of the participants could optimise their cardiovascular health.

Age-Dependency of Cardiometabolic Risk and Protective Factors in Females Living in a Countryside Area of Switzerland

We investigated the effect of age on cardiometabolic risk and protective factors in females living in a countryside area of Switzerland. For this cross-sectional analysis, data from 268 female adults, who live in two neighboring countryside villages in Italian-speaking Switzerland were retained. 89 study participants were premenopausal, 82 climacteric and 97 postmenopausal. Television viewing time, short duration of sleep, overweight, blood pressure, levels of atherogenic lipids and glycated hemoglobin significantly increased with age. Walking time also significantly increased with age. Tobacco smoking was more common among premenopausal women. It is concluded that in these countryside villages climacteric and postmenopausal women generally have an unfavorable cardiometabolic risk profile. On the other side, low physical activity and smoking are, compared to premenopausal and climacteric women, less prevalent in postmenopausal women.

Temporal trends in cardiovascular risk factors' prevalence in patients with myocardial infarction

INTRODUCTION AND OBJECTIVES

Little is known about changes in cardiovascular risk factors (CVRF) profile over time in patients presenting with acute myocardial infarction (AMI).

METHODS

We assessed changes in age and CVRF profile in consecutive AMI patients enrolled in the Swiss nationwide AMIS Plus registry between 1 January 1997 and 31 December 2018.

RESULTS

A total of 57 995 AMI patients were included in the analysis. Mean age at presentation was 71.5 ± 11.3 years for women and 63.9 ± 12.8 years for men and did not change over time. Overall, the mean (standard deviation) number of CVRF increased from 1.76 (1.07) in 1997/98 to 2.26 (1.10) in 2017/18 in men (P_trend  < .001), while the corresponding rates in females were 1.83 (1.11) and 2.24 (1.08) (P_trend  < .001). In terms of active smoking, no significant trend was detected for males, while there was a significant increase in females (P < .001). As a result, the gap in smoking rates between men and women presenting with AMI decreased from 19.9% (45.3% vs 25.4%) in 1997/98 to 7.9% (41.2% vs 33.3%) in 2017/18. Reassuring was the stability in terms of diabetes prevalence for both genders. Obesity was more prevalent over time in men, while the prevalence of hypertension and dyslipidemia increased in both genders.

CONCLUSION

Among patients with AMI in Switzerland over two decades, age at presentation remained stable, while the mean number of CVRF increased in both men and women. Striking was the increase in the prevalence of smoking in women, leading to a reduction of the gender gap over time.

Cocaine consumption and acute coronary syndromes: a cross sectional study from the Swiss registry AMIS Plus

INTRODUCTION Cocaine abuse is a relevant public health issue which causes medical, psychological and social drawbacks. Only limited data are currently available on outcomes of acute coronary syndromes (ACS) in cocaine-addicted patients. The aim of this study was to evaluate the cardiovascular impact of cocaine in a population of patients enrolled in the Swiss nationwide AMIS Plus registry, with a focus on in-hospital outcomes. METHODS We retrospectively analysed data of patients enrolled in the Swiss AMIS Plus registry from 1 January 2007 to 31 December 2018. Baseline and in-hospital data of ACS patients with self-reported regular cocaine abuse were compared with the remaining AMIS Plus population and a sex and age-matched group of non-cocaine user ACS patients (ratio 1:5, 540 patients). Primary endpoints were in-hospital death and major adverse cardiac and cardiovascular events (MACCEs). RESULTS A total of 20,036 patients were included in the AMIS Plus registry for ACS in the study period, of whom 110 (0.5%) reported regular cocaine abuse. As compared with the remaining AMIS population, cocaine users were significantly younger (46.4 ± 10.8 vs 66.4 ± 13.2 years, p <0.001), presented more frequently with out-of-hospital cardiac arrest (11.8% vs 4.7%, p <0.001) and ST-elevation myocardial infarction (68.2% vs 54.7%, p = 0.007). Of the traditional cardiovascular risk factors, there was a higher incidence of positive family history and active smoking, but a lower incidence of arterial hypertension, diabetes and obesity. In-hospital mortality (3.6% vs 4.4%, p = 1) and MACCEs (5.4% vs 5.5%, p = 0.83) were comparable. When compared with an age-matched non-cocaine user ACS population, cocaine users were more frequently smokers (87.6% vs 63.6%, p <0.001) but less frequently obese (10.4% vs 25.6%, p = 0.001). Clinical presentation was comparable between the two groups. However, cocaine abuse was associated with a higher incidence of in-hospital death (3.7% vs 0.7%, p <0.05) and MACCEs (5.6% vs 1.3%, p <0.05). CONCLUSION Cocaine abuse increases the risk of mortality by a factor of 5 and the risk of major adverse cardiac and cardiovascular events by a factor of 4 as compared with a sex and age-matched population hospitalised after an acute coronary syndrome.

Going beyond the mean: economic benefits of myocardial infarction secondary prevention

BACKGROUND

Using the example of secondary prophylaxis of myocardial infarction (MI), our aim was to establish a framework for assessing cost consequences of compliance with clinical guidelines; thereby taking cost trajectories and cost distributions into account.

METHODS

Swiss mandatory health insurance claims from 1840 persons with hospitalization for MI in 2014 were analysed. Included persons were predominantly male (74%), had a median age of 73 years, and 71% were pre-exposed to drugs for secondary prophylaxis, prior to index hospitalization. Guideline compliance was defined as being prescribed recommended 4-class drug prophylaxis including drugs from the following four classes: beta-blockers, statins, aspirin or P2Y₁₂ inhibitors, and angiotension-converting enzyme inhibitors or angiotensin receptor blockers. Health care expenditures (HCE) accrued over 1 year after index hospitalization were compared by compliance status using two-part regression, trajectory analysis, and counterfactual decomposition analysis.

RESULTS

Only 32% of persons received recommended 4-class prophylaxis. Compliant persons had lower HCE (- 4865 Swiss Francs [95% confidence interval - 8027; - 1703]) and were more likely to belong to the most favorable HCE trajectory (with 6245 Swiss Francs average annual HCE and comprising 78% of all studied persons). Distributional analyses showed that compliance-associated HCE reductions were more pronounced among persons with HCE above the median.

CONCLUSIONS

Compliance with recommended prophylaxis was robustly associated with lower HCE and more favorable cost trajectories, but mainly among persons with high health care expenditures. The analysis framework is easily transferrable to other diseases and provides more comprehensive information on HCE consequences of non-compliance than mean-based regressions alone.

Differences in presentation and clinical outcomes between left or right bundle branch block and ST segment elevation in patients with acute myocardial infarction

Background:

In patients with acute myocardial infarction, the presence of a left bundle branch block or right bundle branch block may be associated with worse prognosis compared to isolated ST segment elevation. However, specificities in clinical presentation and outcomes of acute myocardial infarction patients with left bundle branch block or right bundle branch block are poorly characterized.

Methods:

We analysed acute myocardial infarction patients with left bundle branch block (n=880), right bundle branch block (n=732) or ST segment elevation without bundle branch block (n=15,852) included in the Acute Myocardial Infarction in Switzerland-Plus registry between 2008–2019.

Results:

Acute myocardial infarction patients with bundle branch block were older and had more pre-existing cardiovascular conditions compared to ST segment elevation. Pulmonary oedema and cardiogenic shock were most frequent in patients with left bundle branch block (18.8% vs 12.0% for right bundle branch block and 7.9% for ST segment elevation, p&lt;0.001). Acute myocardial infarction patients with bundle branch block had more three-vessel (40.6% vs 25.3%, p&lt;0.001 vs ST segment elevation) and left main disease (5.6% vs 2.0%, p&lt;0.001 vs ST segment elevation). Major adverse cardiac and cerebrovascular events, a composite of reinfarction, stroke/transient ischaemic attack, and death during hospitalization, were highest in acute myocardial infarction patients with left bundle branch block (13.9% vs 9.9% for right bundle branch block and 6.7% for ST segment elevation, p&lt;0.05), which was driven by hospital mortality. After multivariate adjustment, however, mortality was similar in patients with left bundle branch block and lower in patients with right bundle branch block, respectively, when compared to ST segment elevation. Mortality was only increased when a right bundle branch block with concomitant STE was present (odds ratio 1.77, 95% confidence interval 1.19–2.64, p&lt;0.01 vs ST segment elevation).

Conclusions:

Compared to ST segment elevation, an isolated bundle branch block reflects high-risk clinical characteristics but does not independently determine increased hospital mortality in acute myocardial infarction.

Temporal trends in treatment and outcomes of patients with acute coronary syndrome and concomitant moderate to severe renal failure

Introduction

Limited information about the management and outcomes of patients with acute coronary syndromes (ACS) and moderate to severe renal failure (RF) is available owing to underrepresentation of this population in most studies.

Methods

We evaluated the use of guideline-recommended therapies and in-hospital outcomes of totally 49'191 ACS patients with normal-mild renal failure (RF) (defined as eGFR &gt;45ml/min/m2) versus moderate-severe RF (eGFR &lt;45ml/min/m2) enrolled in the prospective Acute Myocardial Infarction in Switzerland (AMIS) cohort between 2002 and 2019 according to 2-year periods.

Results

Overall, 3'478 (7.1%) patients had moderate-severe RF. They were older (65.2+12.9 versus 77.2+10.6 years) and had significantly more comorbidities (including heart failure, cerebrovascular and peripheral vascular disease). Moderate-severe RF patients received less frequently guideline-recommended drugs, including P2Y12 inhibitors, ACEI/ARBs and statins (p&lt;0.0001). Between the first and last 2-year periods, the number of patients with moderate-severe RF and number of performed percutaneous coronary interventions (PCI) increased in this cohort (p-for-trend=0.001). At the same time, in-hospital mortality significantly decreased among ACS patients with and without RF (17.5% to 10.5% and 6.0% to 3.9%, respectively, p-for-trend=0.001 for both, see Figure). Similar trends were observed for other complications, namely cardiogenic shock and reinfarction. However, major bleedings increased significantly over time in patients with and without RF (p-for-trend=0.038 and &lt;0.001, respectively).

Conclusions

Outcomes of ACS patients with moderate to severe RF improved over the last two decades. Even though the rate of PCI increased in ACS patients with moderate-severe RF, they were less likely to receive guideline-recommended therapies and still suffer a high in-hospitality mortality (&gt;10%). With respect to the increasing burden of ACS patients with RF, our study implicates that more efforts should be undertaken to further improve outcomes of those patients.

Funding Acknowledgement

Type of funding source: None

Heavy drinking habits are associated with worse in-hospital outcomes in patients with acute coronary syndrome

Introduction

The association between alcohol consumption and the occurrence of coronary heart disease is well described in literature. Data regarding the impact of regular alcohol consumption on in-hospital outcomes in the setting of acute coronary syndrome (ACS) are lacking.

Purpose

We aimed to evaluate the impact of self-reported alcohol consumption on in-hospital outcomes in patients with ACS.

Methods

Data derived from patients enrolled between 2007 and 2019 in the Acute Myocardial Infarction in Switzerland (AMIS) Plus registry were retrospectively analyzed. The primary endpoint was all-cause in-hospital mortality, while secondary endpoints were set as incidence of major adverse cardiac and cerebrovascular events (MACCEs). Outcomes comparisons according to quantity of daily alcohol intake were also performed.

Results

Records concerning alcohol consumption were available in 25707 patients; 5298 of them (21%) fulfilled the criteria of regular alcohol consumption. Daily alcohol intake was reported in 4059 (77%), of these patients (regular drinkers) with 2640 light drinkers (≤2 drinks/day) and 1419 heavy drinkers (&gt;2 drinks/day). Regular drinkers were predominantly male, younger, smokers, more comorbid and with a worse clinical presentation as compared to abstainers/occasional drinkers.

In-hospital mortality and MACCEs of heavy drinkers were significantly higher compared to light drinkers (5.4% vs. 3.3% and 7.0% vs. 4.4%, both p=0.001). When tested together with GRACE risk score parameters, heavy alcohol consumption was independently associated to in-hospital mortality (p=0.004).

Conclusions

Heavy alcohol consumption is an additional independent predictor of in-hospital mortality in patients presenting with ACS.

Figure 1. Study flowchart.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Swiss Heart Foundation

Delay between symptom onset and hospital admission in patients with ST-elevation myocardial infarction: different trends in men and women

Introduction

The aim of this study was to analyse whether prehospital delay in ST-elevation myocardial infarction (STEMI) has changed in men and women since 2002.

Methods

We used data from the AMIS Plus registry of patients who were admitted for STEMI between 2002 and 2019. Patients who were transferred from another hospital or were resuscitated before admission were excluded. Patient delay was defined as the difference between symptom onset and hospital admission time. Trends in delay according to gender were depicted by medians per year with a 95% confidence interval. Differences between men and women were tested using the Mann-Whitney test. To analyse the adjusted effect of gender on delay, multivariable quantile regression was applied including the interaction between gender and admission year as well as the covariates age, diabetes, pain at presentation and myocardial infarction (MI) history.

Results

Among the 15,154 patients included (74.5% men), the overall median (IQR) delay between 2002 and 2019 was 150 (84; 345) minutes for men and 180 (100; 415) for women. Women were older (71.3y vs. 62.8y, p&lt;0.001), had more often diabetes (20.0% vs. 16.9%, p&lt;0.001), but less often MI history (11.2% vs. 14.9%, p&lt;0.001) and less often pain at presentation (92.0% vs. 94.8%, p&lt;0.001).

The unadjusted median delay decreased over the admission years. The decreasing trend was stronger in women than men: the unadjusted difference in delay between men and women decreased from 60 min in 2002 (p=0.003) to 15 min in 2019 (p=0.155) (Fig 1). The multivariable model confirmed a significant interaction between gender and admission year (p=0.042) indicating that the decrease in delay was stronger for women (−3.1 min per year) than for men (−1.4 min per year) even after adjustment. The adjusted difference between men and women decreased from 27.4 min in 2002 to −1.6 min for women in 2019. Additional independent predictors of longer delay were the covariates age (+1.6 min per additional year, p&lt;0.001) and diabetes (+27.1 min, p&lt;0.001). Conversely, pain at admission (−46.3 min, p&lt;0.001) and MI history (−32.9 min, p&lt;0.001) predicted a shorter delay.

Conclusions

The difference in delay between symptom onset and hospital admission in STEMI patients between men and women steadily diminished from 2002 to 2019. This might indicate that the public and health professionals' awareness of STEMI in women has ameliorated over time.

Unadjusted delay according to gender

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): AMIS Plus Foundation

Multisite vascular disease in acute coronary syndromes: increased in-hospital mortality and no improvement over time

Introduction:

Limited data are available on the impact of multisite artery disease in patients with acute coronary syndromes. In particular, it is unknown whether the outcomes of those high-risk patients have improved over time. Therefore, we addressed the multisite artery disease patient population enrolled in the Swiss nationwide prospective acute coronary syndromes cohort study AMIS Plus over two decades.

Methods:

All patients enrolled from January 1999 to October 2016 were stratified according to the presence of isolated coronary artery disease or multisite artery disease, defined as coronary artery disease with known concomitant vascular disease (i.e. cerebrovascular disease and/or peripheral artery disease). Multisite artery disease 1 (MSAD1) and multisite artery disease 2 (MSAD2) defined patients with one and two additional vascular conditions, respectively. Primary outcome measures were in-hospital mortality and major adverse cardiovascular events (defined as re-infarction, stroke or death).

Results:

Among a total of 44,157 patients, 39,613 (89.7%) had coronary artery disease only while 4544 (10.3%) had multisite artery disease (4097 (9.3%) had MSAD1 and 447 (1.0%) had MSAD2). Compared with patients with coronary artery disease only, multisite artery disease patients were older, had a longer delay from symptom onset to hospital admission, had more frequently atypical presentation, presented more frequently with non-ST-segment elevation acute coronary syndromes, were more frequently in Killip class III/IV, had higher Charlson comorbidity index, more frequently had three-vessel coronary artery disease and were treated less frequently with evidence-based treatments such as aspirin, P2Y12 inhibitors, or beta-blockers. Similarly, multisite artery disease benefitted less frequently from coronary angiography as well as percutaneous coronary revascularisation. In-hospital mortality was 10.9% in multisite artery disease patients and 4.4% in coronary artery disease-only patients (P&lt;0.001). Corresponding major adverse cardiovascular events rates were 13.4% and 5.4% (P&lt;0.001). Cardiogenic shock, re-infarction and cerebrovascular events were significantly more frequent in multisite artery disease patients compared with coronary artery disease-only patients. In multivariable logistic regression analysis, multisite artery disease was identified as an independent predictor of in-hospital mortality (odds ratio 1.69, 95% confidence interval 1.47–1.94, P&lt;0.001). Among multisite artery disease patients, mortality was the highest in MSAD2 individuals (15.4% vs. 10.4% among MSAD1 patients, P=0.001), the same was true for the major adverse cardiovascular events rates (19.1% in MSAD2 patients vs. 12.7% in MSAD1 patients, P&lt;0.001). When stratified for the decade of enrollment, no improvement in mortality or major adverse cardiovascular events rates was observed in multisite artery disease patients.

Conclusion:

Patients presenting with multisite artery disease were less likely to receive evidence-based therapies than coronary artery disease-only patients and had increased in-hospital morbidity and mortality, with no improvement over time. The worse outcomes were observed among MSAD2 patients. These results should prompt awareness for multisite artery disease as a high-risk condition in the setting of multisite artery disease.

Heavy Drinking Habits Are Associated with Worse In-Hospital Outcomes in Patients with Acute Coronary Syndrome: An Insight from the AMIS Plus Registry

BACKGROUND

The association between alcohol consumption and the occurrence of coronary heart disease is well described in the literature, while data regarding the impact of regular alcohol consumption on in-hospital outcomes in the setting of acute coronary syndrome (ACS) are lacking. We aimed to evaluate the impact of self-reported alcohol consumption on in-hospital outcomes in patients with ACS.

METHODS

Data derived from patients enrolled between 2007 and 2019 in the Acute Myocardial Infarction in Switzerland (AMIS) Plus registry were retrospectively analyzed. Patients were stratified based on alcohol drinking pattern. Primary outcome was all-cause in-hospital mortality, while secondary outcomes were set as incidence of major adverse cardiac and cerebrovascular events (MACCEs). Outcome comparisons according to quantity of daily alcohol intake were also performed.

RESULTS

Records concerning alcohol consumption were available in 25,707 patients; 5,298 of them (21%) fulfilled the criteria of regular alcohol consumption. Regular drinkers were predominantly male, younger, smokers, more comorbid and with a worse clinical presentation as compared with abstainers/occasional drinkers. Daily alcohol intake was reported in 4,059 (77%) of these patients (regular drinkers). Among them, 2,640 were light drinkers (≤2 drinks/day) and 1,419 heavy drinkers (>2 drinks/day). In-hospital mortality and MACCEs of heavy drinkers were significantly higher compared with those of light drinkers (5.4 vs. 3.3% and 7.0 vs. 4.4%, both p = 0.001). When tested together with Global Registry of Acute Coronary Events risk score parameters, heavy alcohol consumption was independently associated with in-hospital mortality (p = 0.004).

CONCLUSIONS

Our results support that heavy alcohol consumption is an independent predictor of in-hospital mortality in patients presenting with ACS.

Temporal trends in in-hospital complications of acute coronary syndromes: Insights from the nationwide AMIS Plus registry

BACKGROUND

Acute coronary syndrome (ACS)-related morbidity and mortality remain substantial. Data on temporal trends in in-hospital complications of ACS patients are scarce. This study sought to investigate whether the incidence of in-hospital complications of ACS patients changed over time.

METHODS

Acute coronary syndrome patients prospectively enrolled in the National Registry of Acute Myocardial Infarction in Switzerland (AMIS Plus) between 2003 and 2018 and with available data on in-hospital complications were included in the analysis. Rates of in-hospital complications, including recurrent angina, recurrent myocardial infarction, cerebrovascular events, cardiogenic shock, bleeding, acute renal failure, sepsis/systemic inflammatory response syndrome (SIRS)/multiorgan dysfunction syndrome (MODS), AV block needing pacing and new-onset atrial fibrillation, were assessed for each 2-year period.

RESULTS

Among 47,845 ACS patients, in-hospital complications significantly decreased from 22.0% in 2003/2004 to 18.9% in 2017/2018 (p for trend <0.001). An initial decline in rates of in-hospital complications to 15.7% in 2009/2010 (p for trend <0.001) was followed by a constant increase thereafter (p for trend = 0.002). While rates of recurrent angina, recurrent myocardial infarction, and cardiogenic shock decreased over time, rates of bleeding events, acute renal failure, sepsis/SIRS/MODS, and new-onset atrial fibrillation increased. Rates of in-hospital complications were higher in women, mainly due to a constantly increased risk of bleeding and AV block needing pacing.

CONCLUSIONS

The decrease in ischemic complications was paralleled by a concomitant increase in non-ischemic events. These findings emphasize that advanced strategies targeting non-ischemic complications are warranted to further improve quality of care of ACS patients.

Implementation of an EMR integrated pathway for the management of malignant bowel obstruction

813

Background: Despite published evidence based interventions for malignant bowel obstruction (MBO), implementation of a standard pathway is challenging. We hypothesized that using industrial engineering techniques and a modified dynamic sustainability framework for implementation, we can implement an electronic medical record (EMR) based pathway in the management of MBO. Methods: A workflow in the management of MBO was developed using iterative meetings from 8/2018 to 4/2019 including gateway stakeholders (surgical oncology, gynecological oncology and medical oncology), interventional stakeholders (gastroenterology, interventional radiology) and supportive stakeholders (hospital medicine, palliative care, nutrition, nursing). Industrial engineers were utilized to study human factors, and perform a method study. EMR integration was performed using EPIC systems Agile MD pathway and educational materials were created. Interventions such as early placement of gastrostomy tubes, total parenteral nutrition and medications were protocolized. Results: Since implementation, over 6 months the pathway and order set has been activated 56 times. Orders have been employed 21 times through the AgileMD pathway demonstrating a pathway drift of 62.5%. Educational materials have been accessed routinely during this time. Conclusions: Feasibility of implementing an EMR integrated MBO pathway is demonstrated with early suggestion of pathway drift. Utilizing tools of implementation science are necessary to facilitate widespread adoption of evidence based interventions in the management of patients with MBO.

Comparison of P2Y12 receptor inhibitors in patients with ST-elevation myocardial infarction in clinical practice: a propensity score analysis of five contemporary European registries

Aims

Among acute coronary syndromes (ACS), ST-segment elevation myocardial infarction (STEMI) has the most severe early clinical course. Recent randomized clinical trials have demonstrated that novel antithrombotic therapies improve in-hospital outcomes in STEMI patients. We aimed to describe the effectiveness and safety of P₂Y₁₂ receptor inhibitors in clinical practice in patients with STEMI based on data from contemporary European ACS registries.

Methods and results

Five registries from the PIRAEUS initiative (AAPCI/ADPAT, ALKK-PIC, AMIS Plus, Belgium STEMI, and EYESHOT) provided data for the assessment of P₂Y₁₂ receptor inhibitor-based dual antiplatelet therapy. Registries were heterogeneous in terms of setting, patient characteristics, and treatment selection. Matched pair analysis and propensity score matching were used to assess all-cause in-hospital death rates based on data from 25 250 patients (8577 patients on prasugrel, 5995 on ticagrelor, and 10 678 on clopidogrel). The odds ratio (OR) for the death of any cause when compared with clopidogrel was 0.72 [95% confidence interval (CI) 0.62–0.84, P < 0.001] in favour of the new P₂Y₁₂ receptor inhibitors (prasugrel and ticagrelor combined). In the comparison between prasugrel and ticagrelor, there were no relevant differences (OR 0.97, 95% CI 0.77–1.23; P = 0.81). Event rates of cardiovascular death and stroke were also substantially lower for the new P₂Y₁₂ receptor inhibitors. The differences between clopidogrel and prasugrel or ticagrelor on major bleeding were numerically in the same order as for death of any cause but were not statistically significant. No differences in ischaemic and bleeding outcomes were observed between prasugrel and ticagrelor.

Conclusion

This analysis suggests that the prasugrel or ticagrelor compared with clopidogrel have favourable outcomes in clinical practice while not being inferior in terms of safety.

Temporal trends in latecomer STEMI patients: insights from the AMIS Plus registry 1997-2017

INTRODUCTION AND OBJECTIVES

A substantial proportion of patients experiencing ST-segment elevation myocardial infarction (STEMI) have a late presentation. There is a lack of temporal trends drawn from large real-word scenarios in these patients.

METHODS

All STEMI patients included in the AMIS Plus registry from January 1997 to December 2017 were screened and patient-related delay was assessed. STEMI patients were classified as early or latecomers according to patient-related delay (≤ or> 12hours, respectively).

RESULTS

A total of 27 231 STEMI patients were available for the analysis. During the study period, the prevalence of late presentation decreased from 22% to 12.3% (P <.001). In latecomer STEMI patients, there was a gradual uptake of evidence-based pharmacological treatments (rate of P2Y₁₂ inhibitors at discharge, from 6% to 90.6%, P <.001) and a marked increase in the use of percutaneous coronary intervention (PCI), particularly in 12- to 48-hour latecomers (from 11.9%-87.9%; P <.001). In-hospital mortality was reduced from 12.4% to 4.5% (P <.001). On multivariate analysis, PCI had a strong independent protective effect on in-hospital mortality in 12- to 48-hour latecomers (OR, 0.29; 95%CI, 0.15-0.55).

CONCLUSIONS

During the 20-year study period, there was a progressive reduction in the prevalence of late presentation, a gradual uptake of main evidence-based pharmacological treatments, and a marked increase in PCI rate in latecomer STEMI patients. In-hospital mortality was reduced to a third (to an absolute rate of 4.5%); in 12- to 48-hour latecomers, this reduction seemed to be mainly associated with the increasing implementation of PCI.

463Temporal trends in latecomer ST-segment elevation myocardial infarction patients: Insights from the AMIS Plus Registry 1997–2017

Introduction

A relevant proportion of patients experiencing ST-segment elevation myocardial infarction (STEMI) has a late presentation after symptoms onset. Temporal trends deriving from a large real-word scenario for this subgroup of patients are lacking.

Purpose

The aim of the present study was to provide a comprehensive analysis of temporal trends in latecomer STEMI patients, with particular regard to implementation of evidence-based treatments in this population and major in-hospital outcomes.

Methods

All STEMI patients included in the AMIS Plus Registry from January 1997 to December 2017 were included and patient-related delay was assessed: 27 231 patients were available for the final analysis. STEMI patients were classified as early or latecomers according to patient-related delay (≤ or >12 hours, respectively).

Results

22 928 patients were earlycomers (84%) and 4303 patients were classified as latecomers (16%). Across the study period we observed a significant decrease in prevalence of late presentation from 22% to 12.3% (p<0.001, Figure 1). In latecomer STEMI patients there was a gradual uptake of evidence-based pharmacological treatments with an increase in discharge prescription of P2Y12 inhibitors from 6% to 90.7% (p<0.001). Similarly, a marked increase in percutaneous coronary intervention (PCI) rate was observed (12.1–86.6%; p<0.001). Across this 20-year period, in-hospital mortality was reduced to a third (to an absolute rate of 4.5%, p<0.001) and a significant reduction in prevalence of both cardiogenic shock (14.6–4.3%) and re-infarction (5.4–0.2%) during the index hospitalisation was observed (p<0.001 for both variables). Length of hospitalisation in acute care facilities significantly decreased from 10 (6,14) days to 4 (1,7) days (p<0.001). At multivariate analysis, PCI had a strong independent protective effect toward in-hospital mortality (odds ratio 0.3, 95% confidence interval 0.187 to 0.480).

Figure 1

Conclusion

The present study provides a comprehensive picture of temporal trends in late presentation in STEMI over the last 20 years in Switzerland. During the study period in latecomer STEMI population there was a gradual uptake of evidence-based pharmacological treatments and a marked increase in PCI rate. In-hospital mortality was reduced to a third (to an absolute rate of 4.5%) and this reduction seems to be mainly associated with the increasing implementation of PCI.

P3625Cocaine consumption and acute coronary syndrome: an analysis from the Swiss registry AMIS Plus

Introduction

The aim of this study is to evaluate the cardiovascular impact of cocaine in a population of patients enrolled in the Swiss nationwide AMIS Plus registry with a focus on in-hospital outcomes.

Methods

We retrospectively analysed data of patients enrolled in the Swiss AMIS Plus registry from 2007 to 2018. Baseline and in-hospital data of patients with ACS and cocaine use were compared with the remaining AMIS population as well as to a sex and aged matched ACS patients (1:5 ratio, 540 patients) without history of cocaine consumption. Primary endpoints were death and major adverse cardiac and cardiovascular events (MACCE).

Results

A total of 20'981 patients had been included in the AMIS Plus registry for ACS in the study period, of them 110 (0.5%) were cocaine user.

As compared to the remaining AMIS population, cocaine abusers were significantly younger (46.4±10.8 vs 66.4±13.2 years; p<0.001), presented more frequently with out of hospital cardiac arrest (11.8% vs 4.7%, p<0.001) and STEMI (68,2% vs 54.7%, p=0.007). Apart from active smoke and family history, had a lower burden of CV risk factors. In hospital mortality (3.6% vs 4.4%; p=1) and MACCE (5.4% vs 5.5%; p=0.83) were comparable.

When compared to the age matched ACS population without history of cocaine consumption, cocaine abusers were more frequently smokers (87.6% vs 63.6%, p<0.001) but less frequently obese (10.4% vs 25.6%, p=0,001). Clinical presentation was comparable among the two groups, nonetheless cocaine abuse was associated with a higher incidence of death (3.7% vs 0.7%, p<0.05) and MACCE (5.6% vs 1.3%, p<0.05).

Conclusion

This analysis presents the largest series of cocaine associated ACS available in literature. Cocaine abuse increases by 5 the risk of mortality and by 4 the risk of MACCE as compared to an age matched ACS population. No differences where observed in outcomes when compared to a 20 years older population.

P4391Cardiovascular risk factor trends over two decades in patients presenting with acute myocardial infarction: a failure of smoking control, especially in women

Background

Hypertension, diabetes, dyslipidemia and smoking are established cardiovascular risk factors (CVRF). Little is known about the changes of risk factor profiles over time in patients presenting with acute myocardial infarction (AMI).

Purpose

To analyze the temporal trends of CVRF in patients presenting with AMI over the last 22 years in Switzerland.

Methods

We included data of all AMI patients enrolled between 1997 and 2018 in the Swiss nationwide AMIS Plus registry. The rates of hypertension, diabetes, dyslipidemia and smoking at presentation were descriptively analyzed dividing the data into 2-year periods. Trend analyses were performed using the CHI-square-test and ANOVA. A p-value of <0.005 was considered as statistically significant.

Results

A total of 57,995 patients were included in the analysis (73.6% male). The mean age was 66.0 years (males: 64.0 years, females 71.6 years) and did not differ over the study period. The mean CVRF rates over the study period were as follows: diabetes 20.5% (males: 19.4%, females: 23.6%), hypertension 60.2% (males: 57.0%, females: 69.0%), dyslipidemia 59.4% (males: 60.5%, females: 56.4%), and smoking 39.3% (males: 43.0%, females: 28.7%). While there was no significant change over time in the rates of diabetes for both genders, there were significant increases in the rates of hypertension and dyslipidemia for both males and females (p<0.001 for all comparisons). In terms of smoking, there was no significant trend for males while there was a significant increase in the rate of smoking for females (p<0.001). As a result, the gap in smoking rates between men and women decreased from 19.9% (45.3% vs. 25.4%) in 1997/98 to 7.9% (41.2% vs. 33.3%) in 2017/18.

Trends in the rate of smokers

Conclusions

Among patients presenting with AMI in Switzerland over two decades, the prevalence of hypertension and dyslipidemia increased in both men and women, while diabetes at presentation did not change over the years. We documented a failure of smoking control, with a lack of a reduction in the smoking prevalence among males and a striking increase among women.