Complications in acute coronary syndrome with contemporary care, and predictors of high risk

Abstract

Abstract Introduction With the implementation of early reperfusion therapy, the number of complications in patients with acute coronary syndrome (ACS) has diminished significantly. However, ACS patients are still routinely admitted to units with high-level monitoring such as the coronary or intensive care unit (CCU/ICU). The cost of these admissions is high and there is often a shortage of beds. Purpose The aim of this study was to map the complications in contemporary ACS patients, and to explore the possibility of creating simple decision rules for risk assessment. Methods This observational study included 26547 chest pain patients ≥18 years at five Swedish emergency departments (ED) from the ESC-TROP trial. Complications were defined as the following within 30 days: Death, cardiac arrest, cardiogenic shock, respiratory failure, ventricular arrythmia, high-degree AV-block that required a pacemaker, and mechanical complications such as ventricular septum defects (VSD). Logistic regression including age, sex, history of myocardial infarction, hypertension, hypercholesterolemia, angina pectoris, diabetes mellitus was used to identify factors predicting high risk of complications. Results Of all 26547 patients, 2463 (9.3%) were diagnosed with ACS, and 146 of these (5.9%) suffered any complication within 30 days. Mean age was higher in patients with (78.9 years) than without (69.4 years) complications, and more were female (39.7% vs 33.1%). Seventy-nine (3.2%) patients died, 33 (1.3%) had cardiac arrest, 10 (0.4%) cardiogenic shock, 20 (0.9%) respiratory failure, 6 (0.2%) ventricular arrythmia, 13 (0.5%) high-degree AV block, and 2 (<0.1%) VSD. More than 40% of the complications were present already at the ED, and 40% of patients with complications were not admitted to the CCU/ICU. Only 78 (53%) of the patients with complications underwent coronary angiography and 62 were revascularized (PCI or CABG). Sixty-two patients (42%) were managed without coronary angiography and 6 (4%) had palliative care from the start. Only age >80 years (OR 4.8, p<0.001) appeared to be a significant factor for increased risk of complications. Conclusion With current care, serious complications occurred in only 6 out of 100 ACS patients, and the complications were often present already at the ED. Many patients with complications were not admitted to the CCU/ICU and did not undergo coronary angiography. Algorithms to improve the identification of ACS patients with a need of high-level monitoring could help optimize the use of hospital resources. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ALF research grantSwedish Research Council