Treatment adherence in patients without ST-elevation acute coronary syndrome

BACKGROUND

Despite progress during the last decades, patients with coronary artery disease (CAD) remain with a high residual risk due to multiple reasons. Optimal medical treatment (OMT) provides a decrease of recurrent ischemic events after acute coronary syndrome (ACS). Therefore, treatment adherence results crucial to reduce further outcomes after the index event. No recent data are available in Argentinian population; the main objective of our study was to evaluate the adherence at 6 and 15 months in post non-ST elevation acute coronary syndrome (NST-ACS) consecutive patients. Secondary objective was to evaluate the relationship of adherence with 15-month events.

METHODS

A prespecified sub-analysis in the prospective registry Buenos Aires I was performed. The adherence was evaluated using the modified Morisky-Green Scale.

RESULTS

A number of 872 patients had information about adherence profile. Of them 76.4% were classified as adherents at month 6 and 83.6% at 15 (P=0.06). We did not find any difference in baseline characteristic between the adherent and non-adherent patients at 6 months. The adjusted analysis showed that non-adherent patients had a rate of ischemic events at 15th month of 20% (27/135) vs. 11.5% (52/452) in adherent patients (P=0.001). The bleeding events defined were of 3.6% in the non-adherent group vs. 5% in the adherent group without a statistical difference (P=0.238).

CONCLUSIONS

Adherence to treatment is still a major issue as almost 25% of patients should be considered as non-adherent to OMT. No clinical predictor of this phenomenon was identified but our criteria were not exhaustive. Good adherence to treatment was highly associated to a reduction of ischemic events, whereas no impact on bleeding events was found. These data support a better network and collaboration with shared decision between healthcare professionals with patients and family members to improve acceptance and adherence to optimal medical strategies.

[Use of parenteral anticoagulants in patients with coronary syndrome]

Anticoagulant treatment, together with antiplatelet therapy, plays an important role in the treatment of acute coronary syndromes. Its use is associated with a reduction in new ischemic events, stent thrombosis, and lower mortality. However, in clinical practice there is great heterogeneity in its use, leading to suboptimal results in treatment. This paper conducts a narrative review on the use of parenteral anticoagulants in patients with acute coronary syndromes, depending on the clinical scenario, as well as the revascularization strategy used and the bleeding risk. The different anticoagulant schemes available in acute coronary syndromes with and without segment ST elevation are addressed, based on the updated evidence. Finally, evidence-based strategies for risk stratification for bleeding and therapeutic management are developed.

P5016Usefulness of different electrocardiographic patterns as predictors of in-hospital mortality in acute pulmonary embolism

Background

Many electrocardiographic (ECG) patterns may be present in acute pulmonary embolism (PE), but their prevalence and association with in hospital mortality (IHM) are less well established.

Objective

Assess the correlation between different ECG patterns and IHM in patients (Pts) with PE using a whole country dataset.

Methods

Prospective multicenter registry which included Pts with acute PE hospitalized in 75 academic centers from October 2016 to November 2017. We considered the following ECG patterns: sinus tachycardia, pulmonary P waves, Q waves in DII-aVF leads, negative T waves in V1-V4, ST segment elevation in aVR and V1, atrial fibrillation or atrial flutter (AF/AF), right bundle branch block (RBBB), ST segment depression, S1Q3T3 pattern or Qr in V1. Statistical analysis was carried out using de STATA version 13.1. A value of p<0.0.5 was considered statistically significant.

Results

We included 684 Pts; mean age 63.8±16.7 years (43% male). Global IHM was 12%. The most prevalent ECG patterns were sinus tachycardia (51.7%), S1Q3T3 (24.5%), negative T waves in V1- V4 (16%), RBBB (9.9%), AF/AF (8.6%). Four ECG patterns remained statistically significant predictors of IHM on multivariate analysis: AF/AF (OR: 3.81; CI 95% 1.82–7.95, p<0.01), pulmonary P waves (OR: 3.81; CI 95% 1.2–12, p<0.04), RBBB (OR: 2.71; CI 95% 1.39–5.30, p<0.01) and sinus tachycardia (OR: 2.05; CI 95% 1.18–3.54, p<0.04).

ECG pattern and in-hospital mortality.Multivariate analysis Electrocardiographic pattern OR CI 95% p value AF/AF 3.81 1.82–7.95 <0.01 Pulmonary P waves 3.81 1.20–12.00 <0.04 RBBB 2.71 1.39–5.30 <0.01 Sinus tachycardia 2.05 1.18–3.54 <0.04 Q waves in DII-aVF 0.93 0.32–2.64 0.89 ST segment depression 1.07 0.39–2.96 0.80 Negative T waves in V1-V4 0.93 0.47–1.81 0.83 S1Q3T3 pattern 0.75 0.39–1.41 0.37 Qr in V1 2.07 0.63–6.73 0.22 ST segment elevation in aVR 2.38 0.79–7.15 0.12

Conclusions

We corroborate the usefulness of the ECG as a prognostic tool in acute PE. Four simple ECG patterns (AF/AF, Pulmonary P waves, RBBB and sinus tachycardia) were associated with a higher IHM and therefore should be considered for PE risk stratification.