Diagnosis, risk stratification, and early management of non-ST-segment elevation acute coronary syndrome.

Objectives: We sought to assess whether plasma neopterin predicts adverse clinical outcomes in patients with NSTEACS. Background: Circulating C reactive protein (CRP), a marker of inflammation, correlates with events in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). High neopterin levels - a marker of macrophage activation - predict cardiovascular events in stable angina patients but their prognostic role in NSTEACS has not been systematically evaluated. Methods: We prospectively assessed 397 patients (74 % men) admitted with NSTEACS: 169 (42.5%) had unstable angina and 228 (57.5%) non-ST-segment elevation myocardial infarction (NSTEMI). Blood samples for neopterin and CRP assessment were obtained at admission. TIMI risk score was also assessed among other clinical and biochemical variables. The study end point was the composite of cardiac death, acute myocardial infarction and recurrent angina at 180-days. Results: Baseline neopterin concentrations (nmol/L) were similar in unstable angina and NSTEMI patients (8.3 [6.5–10.6] vs 8.0 [6.2–11.1], p = 0.54). Fifty-nine patients (14.9 %) had events during follow-up (highest third (%) 21.5 vs 1 st and 2 nd thirds 11.5, log rank 7.341, p = 0.007). On multivariable hazard Cox regression, only neopterin (highest vs 1 st and 2 nd thirds, HR 2.15, 95 % CI [1.21–3.81]) was independently associated with the combined endpoint.CRP levels, however, were not significantly different in patients with events compared to those without events (adjusted HR = 0.98, p = 0.89, 95% CI 0.80 –1.21). Conclusion: Increased neopterin levels are an independent predictor of 180-day adverse cardiac events in patients with NSTEACS.

Comparison of prognostic value of high-sensitivity and conventional troponin T in patients with non-ST-segment elevation acute coronary syndromes

To assess the anticoagulant therapy for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in China and to offer the rationale for establishing reasonable strategies to improve the prognosis of NSTE-ACS. A total of 1,502 patients with NSTE-ACS were recruited from 28 third-grade hospitals distributed in 14 provinces and cities in China from December 2009 to December 2011. The strategies for diagnosis and treatment, decided by each hospital respectively, were used for further analysis and comparison of medication, percutaneous coronary intervention (PCI), and end points for efficacy and safety assessment at 9 and 30 days following PCI. A lower incidence rate (P < 0.05) was noted for efficacy and safety in patients with unstable angina (UA) than those with non-ST-segment elevation myocardial infarction (NSTE-MI). The prescription rate of unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), fondaparinux, PCI, and single medication was 0.61%, 66.42%, 30.61%, 69.64%, and 70.74%, respectively. Compared with NSTE-MI, UA is featured with better prognosis, less severity, and different outcome. However, in clinical practice, the therapies for NSTE-MI and UA show no differences, which deserves great attention. In China, the most common anticoagulant therapies for NSTE-ACS are single medication, mainly based on LMWH and PCI.

Platelets play an important role in both initiation and propagation of acute coronary syndromes. We sought to evaluate the predictive value of mean platelet volume (MPV) in young patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). This is a retrospective observational study; evaluating the MPV values of 79 NSTE-ACS patients aged under 45 years and 45 control subjects having normal coronary anatomy. NSTE-ACS group was composed of 41 non-ST elevation myocardial infarction (NSTEMI) and 38 unstable angina pectoris (USAP) patients. MPV was measured using an automated hematologic analyzer called Coulter counter. The predictive value of MPV was evaluated using logistic regression analysis and comparison of MPV between NSTE-ACS and control groups was performed by Mann-Whitney U test. The MPV was found to be significantly higher in the NSTE-ACS compared with control group (8.49±1.22 versus 7.78±0.65 fL, p=0.001). In logistic regression analysis, MPV was found to be an independent predictor of NSTE-ACS (OR=3.1, 95% CI 1.2-8.2, p=0.022). The MPV values of NSTEMI group were not significantly different from USAP group (8.78±1.38 versus 8.17±0.95 fL, p=0.66). Similarly, the MPV values of the 3 groups (Control, USAP and NSTEMI) were found to be significantly different (7.78±0.65, 8.18±0.95, 8.78±1.38 fL respectively, p=0.001). In conclusion, MPV was found to be elevated in NSTE-ACS patients compared with control subjects in young population. In addition, increased MPV was established to be an independent predictor of NSTE-ACS.

### Learning objectives Upon completion of this module, the reader will be able to: Non-ST-segment elevation acute coronary syndromes (NSTE-ACS) comprise unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI). Among...

This study explored the early diagnosis and prognostic value of copeptin in non-ST-segment elevation acute coronary syndrome (NSTE-ACS). 171 patients with chest pain or myocardial ischemia symptoms were enrolled. Patients with NSTE-ACS were further divided into the non-ST-elevation myocardial infarction (NSTEMI) and unstable angina (UA). All NSTE-ACS patients were followed up to record the occurrence of Major Adverse Cardiovascular Events (MACEs). Serum copeptin concentration in the NSTE-ACS group was significantly higher than that in the control group. The Area under the curve (AUC) value of copeptin in the diagnosis of NSTE-ACS was 0.798. The combined AUC value of copeptin and hypersensitive troponin I (hs-TnI) to NSTE-ACS increased to 0.930. In addition, copeptin and hs-TnI have been proven to be independent risk factors for MACEs in patients with NSTE-ACS. The use of copeptin in combination with conventional myocardial markers contributes to the early diagnosis and short-term prognosis assessment of NSTE-ACS.

Acute coronary syndromes, characterized by the rupture of unstable plaque and the subsequent thrombotic process involving platelets, have been increasing in relative frequency. The central role of platelet activation has long been noticed in this pathophysiology; hence, many therapies have been directed against it. In this study, we have aimed to search prospectively the value of mean platelet volume (MPV), which is a simple and accurate measure of the functional status of platelets, in patients hospitalized with diagnosis of acute coronary syndromes (ACS). A total of 216 consecutive patients (156 male, 60 female) hospitalized with the diagnosis of non-ST segment elevation (NSTE) ACS within the first 24 h of their chest pain were enrolled. One hundred and twenty patients, matched according to sex and age, with stable coronary heart disease (CHD) (85 male, 35 female) were enrolled as a control group. Patients were classified into two group: those with unstable angina (USAP, n = 105) and those with non-ST segment elevation myocardial infarction (NSTEMI, n = 111). MPVs were 10.4 +/- 0.6 fL, 10 +/- 0.7 fL, 8.9 +/- 0.7 fL consecutively for NSTEMI, USAP and stable CHD with significant differences. Patients with ischemic attacks in the first day of hospitalization accompanied by >0.05 mV ST segment shift had significantly higher MPV compared to those without such attacks (P = 0.001). Multivariable logistic regression analysis yielded that MPV (P = 0.016), platelet count (P < 0.001), and the presence of >0.05 mV ST segment depression at admission (P = 0.002) were independent predictors of development of NSTEMI in patients presenting with NSTE ACS. In patients presenting with NSTE ACS, higher MPV, though there are overlaps among subgroups, indicates not only more risk of having NSTEMI but also ischemic complications.

Non-ST-segment elevation acute coronary syndromes (NSTE-ACS) are responsible for almost 1 million admissions in the U.S. annually (1), and represent a spectrum of clinical conditions ranging from unstable angina (UA) to non-ST-segment elevation myocardial infarction (NSTEMI). The most important cause is intraluminal thrombosis due to atherosclerotic plaque rupture, which impairs distal blood flow and may lead to myocardial ischemia or infarction.

To investigate factors that influence annual prognosis in patients with non-ST-segment elevation acute coronary syndrome ((NSTEACS) concurrent with type 2 diabetes mellitus (DM2). The registry of patients with NSTEACS (non-ST-segment elevation myocardial infarction (NSTEMI), unstable angina) included 415 patients, of them 335 had no carbohydrate metabolic disorders, 80 had DM2. The follow-up period, during which the prognosis was evaluated in the patients, was one year after hospital discharge following the index NSTEACS event. Lipidogram readings and the serum levels of endothelin-1 (ET-1), sP-selectin, sE-selectin, and sPECAM were determined on day 10 after admission to hospital. All the patients underwent coronary angiography (CA), Doppler ultrasound of peripheral arteries during their hospital stay. The patients with DM2 versus those without diabetes proved to be significantly older and to have a higher body mass index; among them there were more women, they were noted to have more frequently hypertension and less frequently smoked. The presence of DM2 was associated with significantly increased intima-media thickness and higher GRACE scores (p=0.013) as compared to those in the patients with normal carbohydrate metabolism. There were significant differences in high-density lipoprotein levels that were lower, as well as in triglyceride levels and atherogenic index, which were higher in patients with DM2 than in those without this condition. In addition, there were significant differences in ET-1, sP-selectin, sE-selectin, and sPECAM levels that were significantly higher in the DM2 group. Moreover, the levels of ET-1 and sPECAM were above normal in both the DM and non-DM2 groups. Assessment of poor outcomes at one year of the observation established that cardiovascular mortality rates were significantly higher and coronary angiography was performed much less frequently in the DM2 group. The most significant prognostic factors associated with a poor prognosis were as follows: multifocal atherosclerosis, reduced left ventricular ejection fraction (LVEF) less than 51%, and increased ET-1 levels more than 0.87 fmol/ml. The register-based study has shown that the presence of DM2 statistically significantly increases cardiovascular mortality rates during a year after the index ACS event; the patients of this category are less commonly referred for CA for the estimation of the degree of coronary bed lesion. The most important factors of recurrent cardiovascular events in patients with DM2 within a year after prior ACS are multifocal atherosclerosis, reduced myocardial contractility (LVEF less than 51%), and increased vasospastic endothelial function (an increase in ET-1 levels more than 0.87 fmol/ml).

Thirty days clinical outcomes following stent implantation with aspirin-free prasugrel monotherapy in non-ST segment elevation myocardial infarction. Interim report from ASET-Japan pilot study

Renal dysfunction is frequent in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Chronic kidney disease (CKD) is associated with very poor prognosis and is an independent predictor of early and late mortality and major bleeding in patients with NSTE-ACS. Patients with NSTE-ACS and CKD are still rarely treated according to guidelines. Medical registers reveal that patients with CKD are usually treated with too high doses of antithrombotics, especially anticoagulants and inhibitors of platelet glycoprotein (GP) IIb/IIIa receptors, and therefore they are more prone to bleeding. Drugs which are excreted mainly or exclusively by the kidney should be administered in a reduced dose or discontinued in patients with CKD. These drugs include enoxaparin, fondaparinux, bivalirudin, and small molecule inhibitors of GP IIb/IIIa inhibitors. In long-term treatment of patients after myocardial infarction, anti-platelet therapy, lipid-lowering therapy and β-blockers are used. Chronic kidney disease patients before qualification for coronary interventions should be carefully selected in order to avoid their use in the group of patients who could not benefit from such procedures. This paper presents schemes of non-ST and ST-segment elevation myocardial infarction treatment in CKD patients in accordance with the current recommendations of the European Society of Cardiology (ESC).

Acute coronary syndrome (ACS) poses a pervasive threat to individuals grappling with cardiovascular afflictions, manifesting as unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), ST-segment elevation myocardial infarction (STEMI), or sudden cardiac death, depending on vascular obstruction’s extent and location. NSTEMI, closely linked to substantial morbidity and mortality, has become the primary cause of hospitalization in ischemic heart disease patients. Swift prognostication of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is crucial, necessitating the identification of precise markers. This study, conducted from January 2020 to March 2021, explored the correlation between serum visfatin levels and NSTE-ACS severity. A total of 164 patients undergoing coronary angiography were enrolled, with a control group (n = 55) exhibiting less than 50% coronary stenosis. NSTE-ACS patients were categorized based on angiography outcomes into single-vessel (n = 41), double-vessel (n = 28), and multivessel (n = 40) groups. Serum visfatin levels, meticulously quantified, showed significant elevation in NSTE-ACS patients (n = 109) compared to the control group (n = 55) (P&lt;0.01). Visfatin correlated positively with the GRACE score (r = 0.397, P&lt;0.01). In the multivessel disease group, visfatin levels were notably higher (P&lt;0.01). After adjusting for cardiovascular risk factors, visfatin emerged as an independent predictor of affected coronary arteries (OR 0.205; 95% CI 0.032–0.378; P=0.02). Receiver-operating characteristic (ROC) curves demonstrated enhanced prognostic ability when combining visfatin with age, hypertension, and diabetes for multivessel disease (AUC: 0.839, sensitivity: 65.0%, specificity: 89.7%, P&lt;0.001). Elevated serum visfatin in NSTE-ACS patients suggests its role as an independent harbinger for the number of affected coronary arteries, potentially indicating severity in NSTE-ACS patients.

We examined the impact of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) on clinical outcomes in patients with bifurcation lesions treated with drug-eluting stents. We hypothesized that NSTE-ACS would be attributable to the increased risk of major adverse cardiac events (MACE) in bifurcation percutaneous coronary intervention. We enrolled 1668 patients, using data from a multicenter real-world bifurcation registry. The primary objective was to compare the 2-year cumulative risk of MACE in patients with NSTE-ACS to those with stable angina. Major adverse cardiac events were defined as the composite endpoint of cardiac death, myocardial infarction (MI), and target-lesion revascularization. Non-ST-segment elevation acute coronary syndrome was seen in 969 (58.1%) patients and stable angina in 699. Major adverse cardiac events occurred in 7.3% of NSTE-ACS patients and in 5.2% with stable angina (P = 0.042). However, cardiac death, MI, and target-lesion revascularization were similar between the 2 groups. We stratified patients with NSTE-ACS into those with non-ST-segment elevation MI and those with unstable angina. Cumulative risks of 2-year MACEs were 7.0% in non-ST-segment elevation MI patients and 7.5% in unstable angina patients (P = 0.87). In the NSTE-ACS cohort, the baseline lesion length in the side branch (adjusted hazard ratio [HR]: 1.04, 95% confidence interval [CI]: 1.01-1.07, P = 0.022), paclitaxel-eluting stents in the main vessel (adjusted HR: 2.02, 95% CI: 1.21-3.40, P = 0.008), and final kissing ballooning (adjusted HR: 1.88, 95% CI: 1.10-3.21, P = 0.021) were independent predictors of MACE. Compared with stable angina patients, the NSTE-ACS patients who underwent bifurcation percutaneous coronary intervention had an increased risk of MACE during the 2-year follow-up.

Introduction Non-ST-segment elevation acute coronary syndromes (NSTE-ACS), including non-ST-segment-elevation myocardial infarction (NSTEMI) and unstable angina, represent a leading cause of mortality worldwide, with important socio-economic consequences. NSTEMI accounts for the majority of acute coronary syndromes and usually develops on the background of a nonocclusive thrombus. We searched for relevant literature in the field in PubMed and clinicaltrials.gov as of July 2022. Areas covered A number of pharmacotherapies are currently available for treatment and secondary prevention, mainly including antithrombotic, lipid-lowering and anti-inflammatory drugs. Pretreatment with aspirin, anticoagulant and statin therapy is of key importance in the preprocedural phase, while pretreating with an oral P2Y12 inhibitor is not routinely indicated in patients undergoing early invasive management. For patients undergoing percutaneous coronary revascularization, pharmacotherapy essentially consists of antithrombotic drugs, which should be carefully selected. Finally, antithrombotic, lipid-lowering and anti-inflammatory drugs are important components of long-term secondary prevention after a NSTE-ACS. Expert opinion This article reviews the evidence supporting recommendation on pharmacotherapy in patients presenting with a NSTE-ACS. Several randomized clinical trials are still ongoing and are expected to further inform scientific knowledge and clinical practice, with the final aim to improve the treatment of NSTE-ACS patients.

Implementation of cardiac troponin (cTn) assays has revolutionized the diagnosis, risk stratification, triage and management of patients with suspected myocardial infarction (MI). The Universal Definition of MI brought about a shift in the diagnostics of MI, from an approach primarily based on electrocardiography (ECG) to one primarily based on biomarkers. Currently, detection of a rise and/or fall in concentration or activity of myocardial necrosis biomarkers, preferentially cTns, with at least one value above the 99th percentile upper reference limit (URL), is the essential component for the diagnosis of MI. High-sensitivity cardiac troponin (hs-cTn) assays with their superior analytical performance were designed to further facilitate clinical decision making. The ability of hs-cTn assays to detect measurable cTn concentrations in at least 50% of healthy individuals, along with their improved precision (expressed as coefficient of variation ≤10% at the 99th percentile URL) associated with increased recognition of changing values, leads to enhanced risk stratification of patients with suspected MI, and also enables them to be used as prognostic tools potentially useful in other patient subsets. In this comprehensive review, we aim to integrate updated laboratory and clinical knowledge regarding hs-cTn assays in order to promote their optimal use in daily practice. We primarily focus on the role of hs-cTn assays in patients with suspected MI, discussing recommended diagnostic algorithms and result interpretation. Emphasis is also placed on the release of cTns following myocardial injury, the characteristics of antibodies used in available cTn immunoassays, and analytical performance of hs-cTn assays. In this paper, we also review potential challenges related to the selection of a healthy reference population in determining 99th percentile values, biological variation of hs-cTns, inequality between hs-cTn assays, and outline the current status of cTnI standardization. Finally, we discuss in detail the diagnostic and prognostic value of hs-cTn assays, including non-coronary causes of cTn elevation, the potential benefits and risks of point-of-care testing, and the unjustified skepticism of some clinicians regarding implementation of hs-cTn assays. In everyday clinical practice, hs-cTn assays are an important diagnostic advance, predominantly for patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), with suspected non-ST-segment elevation myocardial infarction (NSTEMI). In the NSTE-ACS setting, recently introduced short diagnostic algorithms using hs-cTn assays integrated with careful clinical and ECG assessment were found to substantially reduce the time to final diagnosis, shorten visits to the emergency department and allow earlier safe discharge of low risk subjects. Hs-cTn assays have significantly higher sensitivity and negative predictive value for NSTEMI in comparison to contemporary cTn tests, particularly in early NSTE-ACS presenters. However, due to frequently occurring mild hs-cTn elevations, they are also associated with lower specificity and reduced positive predictive value when compared to previous generations of assays. Our review underscores the need for the education of clinicians and medical laboratory professionals regarding appropriate use and interpretation of hs-cTn assays. Adequate training and clinical experience in using these tests are essential to translate the improved analytical performance of hs-cTn assays into enhanced risk stratification and hopefully better patient outcomes.