ACS Patients Research Articles

Optimizing Post-Acute Coronary Syndrome Dyslipidemia Management: Insights from the North American Acute Coronary Syndrome Reflective III

Introduction: Despite contemporary practice guidelines, a substantial number of post-acute coronary syndrome (ACS) patients fail to achieve guideline-recommended LDL-C thresholds. Our study aimed to investigate this guideline recommendations-to-practice care gap. Specifically, we aimed to identify opportunities where additional lipid-lowering therapies are indicated and explore reasons for the non-prescription of guideline-recommended therapies. Methods: ACS patients with LDL-C ≥1.81 mmol/L (70 mg/dL) despite maximally tolerated statin ± ezetimibe therapy (including those intolerant of ≥2 statins) were enrolled 1–12 months post-event from 27 Canadian and US sites from September 2018 to October 2020 and followed up for three visits during the 12 months post-event. We determined the proportion of patients who did not achieve Canadian/US guideline-recommended LDL-C thresholds, the number of patients who would have been eligible for additional lipid-lowering therapies, and reasons behind lack of escalation in lipid-lowering therapies when indicated. Individual patient and aggregate practice feedback, including guideline-recommended intensification suggestions, were provided to each physician. Results: Of the 248 patients enrolled in the pilot study (median age 64 [57, 73] years, 31.5% female and STEMI 27.4%), 75.4% were on high-intensity statins on the first visit. A total of 18.5% of those who attended all 3 visits had an LDL-C measured only at the first visit which was above the threshold. After 1 year of follow-up, 51.9% of patients achieved LDL-C thresholds at either visit 2 or 3. In the context of feedback reminding physicians about guideline-directed LDL-C-modifying therapy in their individual participating patients, we observed an increase in the use of ezetimibe and PCSK9 inhibitor therapy at 3–12 months. This was associated with a significant lowering of the mean LDL-C (from 2.93 mmol/L [baseline] to 2.09 mmol/L [3–6 months] to 1.87 mmol/L [6–12 months]) and a significantly greater proportion of patients (from 0% [baseline] to 38.6% [3–6 months] to 53.4% [6–12 months]) achieving guideline-recommended LDL-C thresholds. The most prevalent reasons behind the non-intensification of LDL-C-lowering therapy with ezetimibe and/or PCSK9i were LDL-C levels being close to target, the pre-existing use of other lipid-lowering therapies, patient refusal, and cost. Conclusion: Although most patients post-ACS were on high-intensity statin therapy, almost 50% failed to achieve guideline-recommended LDL-C thresholds by 1-year follow-up. Furthermore, additional lipid-lowering therapies in this high-risk group were underprescribed, and this might be linked to several factors including potential gaps in physician knowledge, treatment inertia, patient refusal, and cost.

Home-based cognitive bias modification training for reducing maladaptive fear in patients with suspected acute coronary syndrome: a pilot randomized clinical trial

BackgroundPatients evaluated in an emergency department for suspected acute coronary syndromes (ACS; e.g., myocardial infarction) often experience a lingering fear of recurrence, which may adversely affect their mental health and adherence to recommended health behaviors. Cognitive bias modification training (CBMT) is an acceptable, easy-to-use intervention that reduces fear of recurrence in cancer patients, and reduces fear and anxiety in other populations, providing an alternative to psychotherapy or counseling-based approaches. Feasibility testing is needed to assess whether a cardiac-related version of CBMT is acceptable to patients with elevated threat perceptions related to their suspected ACS.MethodsWe developed a tablet-based CBMT intervention tailored to reduce cardiac-related fear of recurrence. In this double-blinded feasibility trial, patients with elevated threat perceptions related to a recent suspected ACS were randomized either to a 4-week, 8-session, tablet-delivered intervention (CBMT) group or to a sham attention control group. Feasibility outcomes included the proportion of eligible patients who enrolled, drop-out rate, intervention compliance rate, acceptability/pleasantness and usability ratings, and task engagement (i.e., accuracy, response time).ResultsOf 49 eligible patients with suspected ACS and elevated threat perceptions recruited from NewYork-Presbyterian Hospital, over half (53.1%) enrolled after receiving a description of study procedures. Of the 26 randomized patients (mean age 59.15 years, 50% women), 2 patients (7.7%) dropped out. Additionally, 4 (15.4%) enrolled patients were not able to complete the tablet tasks, either due to difficulties with the technology or an inability to process the visually presented linguistic information at a sufficient speed. Still, among patients who returned the tablets (19 returned/20 received; 95%), most completed all assigned tablet tasks (intervention or control; 10/19; 52.6%), reporting that the tablets were easy to use and that the tasks were pleasant to complete.ConclusionCurrent findings suggest that cardiac-related CBMT is a promising and generally acceptable intervention for suspected ACS patients with cardiac-related threat perceptions which are akin to fear of recurrence. Nevertheless, challenges related to tablet usage indicate that the intervention user-experience should be further refined to optimize usability.Trial registrationRegistered at ClinicalTrials.gov on 2/25/2019; NCT03853213. Registered with the Open Science Framework on 11/20/2017; https://osf.io/k7g8c/.

A Study on Statin Compliance and Influencing Factors in ACS Patients after PCI in Xiangxi Region

A Study on Statin Compliance and Influencing Factors in ACS Patients after PCI in Xiangxi Region

Relationship between Lymphocyte to Monocyte Ratio and Contrast-Induced Nephropathy in Acute Coronary Syndrome patients treated with Percutaneous Coronary Intervention

Aim: This study aimed to evaluate lymphocyte to monocyte ratio (LMR) for risk of CIN in patients with ACS undergoing PCI. Methods: A total of 1001 ACS patients between 2017 and 2021 were included in the study. CIN was defined as an increase in serum creatinine level of ≥0.5 mg/dL or ≥ 25% above baseline within 72 hours after the procedure. Patients were divided into two groups: patients with and without CIN. Demographics, clinical risk factors, angiographic and laboratory parameters, CIN incidence, and other in hospital clinical outcomes were compared between two groups. Results: LMR at baseline was significantly lower in patients who developed CIN compared to those who did not (2.1±0.9 and 3.9±1.7, respectively; P < 0.001). In receiver operating characteristic analysis showed that at a cutoff of ≤3, the value of LMR exhibited 80.17 % sensitivity and 70.96% specificity for detecting CIN. At multivariate analyses, LMR ≤3 value (OR 5.525, 95% CI 2.518-12.123; P < 0.001) was one of significant independent predictors of CIN. Conclusion: Our study suggested that LMR level on admission was independently associated with the development of CIN after PCI in patients with ACS.

Prognostic implications of obstructive sleep apnea in patients with acute coronary syndrome stratified by homocysteine level: a prospective cohort study

BackgroundSporadic studies have examined the impact of OSA on ACS patients by homocysteine (Hcy) level. This study attempted to comprehensively evaluate the effects of the interaction between Hcy and OSA on long-term cardiovascular outcomes in ACS patients.MethodsIn this prospective, large-scale cohort study, 2160 patients admitted for ACS were recruited to undergo overnight sleep monitoring. OSA was diagnosed when apnea–hypopnea index ≥ 15 events/h. Patients with normohomocysteinemia (NHcy) were defined as having serum Hcy ≤ 15 μmol/L, and the others had hyperhomocysteinemia (HHcy). The primary endpoint was major adverse cerebrocardiovascular event (MACCE), a composite of cardiovascular death, myocardial infarction, stroke, ischemia-driven revascularization and hospitalization for unstable angina and heart failure.ResultsA total of 1553 eligible ACS patients (average age: 56.3 ± 10.5 years) were enrolled, among which 819 (52.7%) had OSA, and 988 (63.6%) were with NHcy. OSA did not significantly affect the level of Hcy. During a median follow-up of 2.9 (1.6, 3.5) years, after adjustment for clinical confounders, OSA was associated with increased risk for MACCE occurrence versus non-OSA ones in ACS patients with NHcy (adjusted hazard ratio [HR] = 1.36, 95% confidence interval [CI] 1.02–1.83, P = 0.039), but not in those with HHcy (adjusted HR = 0.92, 95%CI 0.62–1.36, P = 0.668). There was an absence of interaction between homocysteine level and OSA in relation to MACCE (interaction P = 0.106).ConclusionsOSA was independently associated with worse prognosis in ACS patients with NHcy. Our study emphasized the necessity to identify potential presence of OSA in such a population.Trial registration: ClinicalTrials.gov; Number: NCT03362385; URL: www.clinicaltrials.gov.

Subtyping treatment response of tirofiban in acute ischemic stroke based on neuroimaging features.

In a previously published clinical trial, we demonstrated that tirofiban was effective and safe in acute ischemic stroke (AIS) patients who did not undergo early recanalization treatments. We aimed to evaluate neuroimaging characteristics and their clinical significance to guide tirofiban treatment. In this post hoc analysis, location of infarcts (anterior circulation stroke [ACS] vs. posterior circulation stroke [PCS]), degree of cerebral artery stenosis (≤69% vs. ≥70% or occlusion), total infarct volume, and ASPECTS were used to predict the treatment effects of tirofiban, defined as the proportions of excellent and favorable functional outcome (modified Rankin Scale [mRS] score of 0-1, 0-2) at 90 days. ACS patients were more likely to achieve excellent (OR 2.08; 95% CI 1.25-3.45; p = 0.004) and favorable functional outcome (OR 2.28; 95% CI 1.24-4.22; p = 0.008) when treated with tirofiban. However, there was no significant difference in PCS patients between tirofiban and the control group. For patients with severe stenosis (≥70% or occlusion), tirofiban treatment improved the proportion of good outcomes (OR 2.84; 95% CI 1.44-5.60; p = 0.002 for mRS 0-1; OR 2.42; 95% CI 1.22-4.77; p = 0.011 for mRS 0-2). Meanwhile, we found that tirofiban improved outcome in patients with ASPECTS 8-10 and was independent of total infarct volume. These findings support the hypothesis that patients with ACS and severe stenosis may be recommended for tirofiban treatment, which can be predicted independent of total infarct volume.

Triglyceride-glucose index is an independent predictor of MACE in diabetic ACS patients < 50 years - Improving on the YCAD (Young CAD) risk score

Triglyceride-glucose index is an independent predictor of MACE in diabetic ACS patients < 50 years - Improving on the YCAD (Young CAD) risk score

Prediction of short- and long-term mortality in Asian ACS patients using stacked ensemble learning

Prediction of short- and long-term mortality in Asian ACS patients using stacked ensemble learning

Correlation of Hba1c with Severity of Coronary Artery Disease in Non-Diabetic ACS Patients: A Crossectional Study in a Tertiary Care Hospital, Odisha

Correlation of Hba1c with Severity of Coronary Artery Disease in Non-Diabetic ACS Patients: A Crossectional Study in a Tertiary Care Hospital, Odisha

A retrospective analysis of ACS patients who had undergone PCI on attainment of LDL-C goals as per ESC 2019 guidelines

A retrospective analysis of ACS patients who had undergone PCI on attainment of LDL-C goals as per ESC 2019 guidelines

The potential future role of extensive lipid lowering in ACS patients with the use of PCSK9 inhibitors: early bird catches the worm.

The potential future role of extensive lipid lowering in ACS patients with the use of PCSK9 inhibitors: early bird catches the worm.

Long-term functional cardiac changes in takotsubo syndrome

Abstract Background Takotsubo syndrome has long been thought to be a benign condition once the acute event has been overcome. However, an increasing number of studies suggest that there might be long-term consequences. The aim of the present study was to evaluate long term functional cardiac changes in patients after Takotsubo Syndrome. Methods In the present study, a total of 131 TTS patients were prospectively included and age and gender matched with 131 ACS patients. Out of this cohort, a total of 66 patients (TTS: N=33, ACS: N=33) without any known respiratory diseases (e.g. Asthma or COPD) had a follow-up examination one to six months after the index event, including cardiopulmonary exercise testing (CPET) and echocardiography. CPET indices were compared between TTS and ACS patients in those who achieved an RER of at least 1.05. Results Mean age of patients was 65.4 in the TTS group and 65.0 in the ACS group (p=0.541). In each group, 118 (90%) patients were female. At follow-up, TTS patients had a significantly higher LVEF (%, TTS: 59 [56 to 63] vs ACS: 56.5 [51 to 60], p&amp;lt;0.001) and significantly lower levels of BNP (ULN, TTS: 0.5 [0.2 to 0.9] vs ACS: 1.0 [0.5 to 2.6], p&amp;lt;0001), compared to TTS patients. TTS patients were significantly more frequently suffering from persistent symptoms compared to ACS patients (TTS: 78 [60%] vs. ACS: 60 [45.8%], p=0.035, figure 1). Twenty-four TTS Patients (72%) had an RER over 1.05 and were age and gender matched with 24 ACS patients. VO2max was comparable between the two groups (TTS: 20.2 [±5.4] vs ACS: 18.9 [±7.6], p=0.47) as well as Peak Mets (TTS: 5.7 (±1.6) vs ACS: 5.5 (±1.9), p=0.68). However, there was a trend towards a lower oxygen pulse in TTS compared to ACS patients (TTS: 9.4 [±2.2] vs ACS: 10.9 [±3.1], p=0.055) and a significant higher oxygen cost of work (ΔV’O2/ΔW, TTS: 12.9 [11.3 to 15.5] vs ACS: 10.9 [9.7 to 12.2], p=0.019). Conclusion TTS patients were more frequently suffering from persistent symptoms compared to ACS patients. Moreover, TTS patients demonstrated long-term functional cardiac changes reflected in impaired CPET parameters comparable to or worse than those of ACS patients. These findings highlight the long-term consequences of TTS and further challenge the concept that TTS is a benign disease.

Lipid lowering treatment after percutaneous coronary intervention: data from the large contemporary ZON-HR registry

Abstract Background Low density lipoprotein-C (LDL-C) reduction in patients who underwent percutaneous coronary intervention (PCI) is recommended by ESC guidelines to prevent ischemic events. This is mainly achieved by secondary prevention with lipid lowering treatment. The ‘’Zuid-Oost Nederland Heart Registry’’ (ZON-HR) is a multicentre prospective registry designed to improve secondary prevention after PCI by a patient-tailored approach. Purpose To describe the use of lipid lowering treatment in patients who underwent PCI in the ZON-HR. Methods Since November 2020 data from all 4628 patients who underwent PCI were included in four hospitals. Patient characteristics, LDL-C values at baseline and medication at discharge were collected. The association between predefined variables and lipid lowering treatment was assessed with multivariable logistic regression. Results LDL-C at baseline was available in 2325 patients. The mean age was 67.8 year and 73.5% was male (table 1). ACS patients had a significantly higher baseline LDL-C value compared with CCS patients (2.81 mmol/l vs 2.45 mmol/l). However, even in CCS patients LDL-C values were &amp;gt;2 mmol/L. There was a different pattern in lipid lowering treatment at discharge after ACS or CCS. Statins were prescribed significantly more frequent in ACS patients, while ezetimibe was prescribed significantly more frequent in CCS patients compared to ACS patients. Mono and combination therapy was prescribed more often in ACS patients compared to CCS patients. Increasing age and CCS indication for PCI were predictors for not receiving any lipid lowering medication at discharge. Also, patients with a higher LDL-C baseline value had a smaller chance to receive lipid lowering medication at discharge. Conclusion LDL-C reduction is the cornerstone of secondary prevention after PCI for CCS and ACS. 8.9% of ACS and 18.2% of CCS patients receive no lipid lowering treatment. Also, patients with scheduled PCI (CCS) had LDL-C values above target. Age and CCS are independent predictors for not receiving lipid lowering treatment. ZON-HR will develop and integrate initiatives to improve lipid lowering secondary prevention.Baseline characteristicsPredictors lipid lowering medication

Impact of the infarct-related coronary artery on inflammatory profiles and outcomes in patients presenting with acute coronary syndromes: insights from a prospective multicenter real-world cohort

Abstract Background Patients with a total coronary occlusion (TCO) of the infarct-related artery (IRA) frequently present as ST-segment elevation myocardial infarction (STEMI). However, patients presenting as non-ST-segment elevation acute coronary syndromes (NSTE-ACS) on a routine ECG may actually have TCO at angiography, typically involving left circumflex (LCx) or right coronary artery (RCA) as the IRA. These patients might be at higher risk of MACE due to a delayed diagnosis and, consequently, an inappropriately prolonged time window to revascularization. Herein, we aimed to describe clinical characteristics and outcomes of IRA location in patients presenting with ACS enrolled in a real-world prospective cohort. Methods Between 2009 and 2017, 4,787 ACS patients were prospectively recruited in the SPUM-ACS prospective study. The primary outcome measure was major adverse cardiovascular events (MACE), a composite of all-cause death, non-fatal myocardial infarction and non-fatal stroke at one year. Multivariable-adjusted Cox regression models were fit using backward selection. Coronary angiographies were reviewed by operators of each site to assess the IRA location and TCO was defined in the presence of TIMI 0 flow. Results 4,542 ACS patients (95% of the total cohort) had angiographic studies available. Patients with left main (n=75) and bypass graft (n=55) as culprit artery were excluded and a final sample size of 4,412 patients were included in the present analysis; 56% (n=2469) presented with ST-elevation myocardial infarction (STEMI) and 44% (n=1943) with NSTE-ACS. Overall, the IRA was the right coronary artery (RCA) in 33.9% (n=1494), the left-anterior descending coronary artery (LAD) in 45.6% (n=2013) and the left circumflex (LCx) in 20.5% (n=905). In those presenting with STEMI, patients with LAD as IRA had an increased risk of MACE (1.43, 95% CI 1.02-2.00, p = 0.04) as compared to those with RCA and LCx. In those presenting with NSTE-ACS, LCx and RCA as IRA had more frequently a TCO compared to the LAD (27% and 24%, respectively, vs. 9%, p&amp;lt;0.001). Features of patients with NSTE-ACS associated with TCO of the IRA included elevated lymphocyte and neutrophil counts, higher hs-CRP and hs-TnT, lower eGFR, and absent history of MI. Among patients with NSTE-ACS, LCx as IRA but not LAD and RCA was associated with an increased risk of MACE at one 1 year (fully adjusted HR 1.68, 95% CI 1.10-2.59, p=0.02; reference: RCA and LAD). Conclusion Among all ACS patients included in the SPUM-ACS, those with NSTE-ACS at initial ECG and RCA and LCx involvement had more often a TCO of the IRA, but only LCx as IRA was an independent predictor of MACE during follow-up. Hs-CRP levels, lymphocytes and neutrophils counts, hs-TnT, eGFR and history of MI at admission were found to be independent predictors of IRA occlusion at angiography. Thus, NSTE-ACS patients showing such features should further be evaluated for timely PCI.

Temporal trends in intra-aortic balloon pump use

Abstract Background Intra-aortic balloon pump (IABP) is still the most accessible and available mechanical support solution in acute myocardial infarction patients, especially in cardiogenic shock. Although studies from the last decade failed to prove benefit for routine IABP use in this indication, the benefit of IABP utilization in selected cases is still unknown. Purpose To follow temporal trends in IABP use in a large-scale, real-world cohort of ACS patients. Methods We evaluated IABP utilization and patient’s outcome form the ACS Israel Survey (ACSIS) between 2000-2021. Temporal trends and compared rates of mortality and MACE (comprising death, myocardial infarction, stroke, target vessel revascularization and/or coronary bypass surgery) with IABP at 2 time periods were set: early (2000-2010) and late (2013-2021). Subgroup analysis for cardiogenic shock patients was performed as well. Results Out of 18,662 admitted ACS patients, 692 (3.7%) patients were treated with IABP. The rate of IABP use stood at about 4.5% (511 patients) in the early period and decreased to ∼2.5% (181 patients) in the late period. Patients treated with IABP in the early period had more frequently moderately and severely reduced ejection fraction on admission (64.5% vs 53.2%, p&amp;lt;0.01) and were mostly STEMI patients (71.0% vs 62.4%, p=0.04). On admission and in hospital cardiogenic shock (Killip 4) were presented equally in both periods (14.6% vs. 17.1%, p= 0.66 and 42.8% vs. 41.9%, p=0.90, respectively). 30-day mortality and MACE were comparable between time periods (28% vs 30.7%, p=0.547 and 43.6%vs. 44.1%, p=0.978, respectively) however major bleeding complication was significantly higher in the later period (4.8% vs 11.2%, p=0.04). These observations were consistent also in patients with baseline Killip class 3/4. Conclusions Our real-world data based prospective study demonstrated poor prognosis with IABP during all time periods, suggesting poor outcome in routine as well as selective use.

Successful ESC recommended LDL-C reduction after percutaneous coronary intervention: real-world data from the contemporary ZON-HR registry

Abstract Background Low density lipoprotein-cholesterol (LDL-C) reduction in patients who underwent percutaneous coronary intervention (PCI) is recommended by ESC guidelines to prevent secondary events. Lipid lowering treatment is indicated to reach a LDL-C of less than 1.4mmol/l in these very high risk patients. The ‘’Zuid-Oost Nederland Heart Registry’’ (ZON-HR) is a multicentre prospective registry designed to improve secondary prevention after PCI by a patient-tailored approach. Purpose Cholesterol management in patients after percutaneous coronary intervention (PCI) from the ZON-HR was evaluated. Methods Since November 2020 real-world data from 4628 patients who underwent PCI were collected in four hospitals. Patient characteristics, LDL-C values at baseline and after 30 days and medication at discharge were collected. The association between predefined variables and a LDL-C &amp;lt;1.4 mmol/l was assessed in multivariable logistic regression. Results LDL-C at baseline and one-month follow-up was complete in 306 patients. This number is limited, because LDL-C was not routinely tested in every patient at baseline and during 30 day follow-up. Patients with a chronic coronary syndrome (CCS) undergoing PCI were significantly older compared to patients with ACS (66.8 vs 63.9 years)(table 1). After one month, the LDL-C value decreased significantly both in ACS as well as CCS patients. No significant differences in cholesterol lowering medication at discharge between CCS and ACS patients were observed. Statins (87.8%) were most frequent prescribed, with low numbers of new therapies (8.2% ezetimibe, 2.6% PCSK-9 inhibitor). The goal LDL &amp;lt;1.4 mmol/l was reached in 33% of patients. Lower LDL-C levels at baseline, ACS indication for PCI, and a combination of lipid lowering treatment were independent predictors for achieving the goal LDL-C &amp;lt;1.4 (table 2). Conclusion Our contemporary registry reveals the following important observations: 1) LDL-C assessment at one month follow-up is performed in a minority of patients. 2) The LDL-C goal of 1.4 mmol/l is reached in a minority of patients. 3) Predictors for reaching the ESC recommended target include an ACS indication and combination lipid lowering treatment, emphasizing the importance of secondary prevention.Baseline characteristicsPredictors reaching LDL-C target value

A meta-analysis on the efficacy of ticagrelor monotherapy after 3 months of dual antiplatelet therapy vs ticagrelor plus aspirin dual therapy on patients with ACS who underwent PCI

Abstract Background Major adverse cardiovascular events remain the major cause of mortality and morbidity after acute coronary syndrome, including patients who underwent percutaneous coronary intervention. Several studies have shown increased incidence of re-infarction, cardiac death, stroke, stent thrombosis, and all-cause mortality among these patients. The use of dual antiplatelet therapy has been recommended for post-procedural patients, according to guidelines. However, prolonged exposure to dual antiplatelets raised concerns on risk of bleeding. Our study aims to determine whether short term dual antiplatelet therapy followed with Ticagrelor monotherapy will benefit patients who are at higher risk of bleeding. Objective To determine the efficacy of Ticagrelor monotherapy after three months of Dual Antiplatelet Therapy versus 12 months of Ticagrelor plus Aspirin dual therapy in the prevention of MACE and bleeding among patients who had ACS and have undergone PCI. METHODOLOGY Randomized controlled trials on Ticagrelor monotherapy vs Ticagrelor + Aspirin Dual Therapy with outcomes on myocardial infarction, cardiac death, stroke, stent thrombosis, bleeding, all-cause mortality, were searched through PubMed. Results A total of 10,175 participants who had Acute Coronary Syndrome who have undergone Percutaneous Coronary Intervention were included in this analysis. Our results showed that discontinuing Aspirin after 3 months of Dual antiplatelet was not associated with significant increase in the risk of Major Adverse Cardiovascular Events: Myocardial Infarction (RR 0.96 95% CI 0.73-1.25), Cardiac Death (RR 0.92 95% CI 0.74-1.14), Stroke (RR 1.27 95% CI 0.69 -2.31), Stent Thrombosis (RR 0.87, 95% CI 0.48-1.59), Bleeding (RR 0.58 , 95% CI 0.49- 0.69) and All Cause Death (RR 0.77, 95% CI 0.52 – 1.14). Discontinuing Aspirin 3 months was associated with lower risk of bleeding (RR 0.58, 95% CI 0.49 - 0.69). Conclusion Minimizing the duration of exposure to antiplatelet agents with the use of Ticagrelor monotherapy after three months of DAPT among ACS patients who underwent PCI significantly reduced the incidence of bleeding, particularly among those who are at higher risk of bleeding. There is no significant difference in the risk for myocardial infarction, cardiac-related deaths, stroke, stent thrombosis, and all-cause mortality between the two groups.

Comparison of ticagrelor and prasugrel just before PCI in NSTE acute coronary syndromes, LIKE-ACCOAST analysis

Abstract Background Recommendations for the preference of prasugrel over ticagrelor just before PCI in NSTE ACS are based on limited and controversial evidence. Furthermore, prasugrel can’t be used in patients after a stroke/TIA, and the risk of bleeding in older and low-weight patients annuls its benefit. Purpose We aimed to add to the current evidence comparing the benefit of prasugrel and ticagrelor just before PCI (without pretreatment) in NSTE ACS patients. Methods The prasugrel population comprised the ACCOAST study non-pretreatment arm undergoing PCI (N 1372) (ref 1). The ticagrelor study population was selected from the long-term all-comers National Registry of Cardiovascular Surgery and Interventions: Module of Cardiovascular interventions of Institute of Health Information and Statistics of the Czech Republic (N 15126)who were 1) undergoing PCI for NSTE ACS, 2) received ticagrelor loading dose 180 mg just before the procedure, 3) fulfilled the inclusion and exclusion criteria of the ACCOAST trial (N 1370). The endpoint (identically to the ACCOAST primary EP) was a composite of cardiovascular death, myocardial infarction, stroke, urgent revascularization, or glycoprotein IIb/IIIa bailout seven days after PCI. The data were matched to the structure of published ACCOAST no pre-treatment group using R with maic package, which provides a generalized workflow for the generation of subject weights to be used in Matching-Adjusted Indirect Comparison (MAIC) (Ref 3,4). In MAIC, unbiased comparison between outcomes of two trials is facilitated by weighting the subject-level outcomes of one trial with weights derived such that the weighted aggregate measures of the prognostic or effect modifying variables are equal to those of the sample in the comparator trial. Results The study population characteristics are presented in Table. We did not find any difference in the efficacy endpoint at seven and 30 days after PCI between the groups treated with prasugrel and ticagrelor (Figure). Conclusion Prasugrel and ticagrelor given just before PCI for NSTE ACS are equally effective in reducing ischemic risk.Table.Efficacy endpoint occurence.

Thrombotic profile of East Asian and Western ACS patients and relationship to cardiovascular outcomes

Abstract Background East Asian patients compared to Westerners, have a lower risk of ischemic heart disease and a higher risk of bleeding with antithrombotic medications. The underlying mechanisms are incompletely understood. Genetic differences may underlie lower coagulant and inflammation levels in EA compared to W populations. Objectives We sought to compare thrombotic profiles of East Asian and Western patients with myocardial infarction (MI) and relate these to cardiovascular outcomes. Methods In a 2 centre, prospective, observational study in the U.K. and Korea, blood samples from patients (n=515) with ST- or non-ST-elevation MI (STEMI and NSTEMI) were assessed using the Global Thrombosis Test, measuring thrombotic occlusion (OT) and endogenous fibrinolysis (LT) times. In STEMI patients, blood samples were taken immediately upon arrival, whilst in NSTEMI patients, blood samples were taken after DAPT loading. Patients were followed for 1 year for major adverse cardiovascular events and major bleeding. Results Major adverse cardiovascular events occurred significantly more frequently in Western than in East Asian patients (6.27% vs. 1.92%, p=0.014), driven by a higher rate of cardiovascular death (3.53% vs. 0.38%, p=0.01), with minimal major bleeding events (0.39% vs. 0.38%, p=1.0). East Asian patients showed reduced platelet reactivity (longer OT) compared to Western patients (646s [470-818] vs. 436s [320-580], p&amp;lt;0.001), with similar LT. In STEMI, OT (588s [440-759] vs. 361s [274-462], p&amp;lt;0.001) and LT (1854s [1389-2729] vs. 1338s [1104-1788], p&amp;lt;0.001) were longer in East Asian patients than Westerners. In NSTEMI, OT was longer (OT 734s [541-866] vs. 580s [474-712], p&amp;lt;0.001) and LT shorter (1519s [1058-2508] vs. 1898s [1614-2806], p=0.004) in East Asian than Western patients. While OT was unrelated, LT was a strong independent predictor of MACE after adjustment for risk factors (HR 3.70, 95% CI 1.43-9.57, p=0.007), predominantly in Western patients, and more so in STEMI than NSTEMI. Conclusion East Asian patients exhibit different global thrombotic profiles to Westerners, associated with a lower rate of cardiovascular events. The lower platelet reactivity in East Asian STEMI patients, even before antiplatelet therapy, may explain contribute to the lower risk of subsequent adverse ischaemic events.

Abstract 18795: Low Density Lipoprotein Cholesterol Levels at Baseline and the Need for Additional Non Statin Lipid Lowering Therapy for Attaining Lipid Targets in Patients Presenting With Acute Coronary Syndromes- A Retrospective Study

Introduction: CAD is the leading cause of death globally, with more than 17.3 million deaths per year. Multiple modifiable and non-modifiable factors may contribute to cardiovascular risk; among them, LDL-C levels play a crucial role in the pathophysiology of ACS. Objectives: To study the baseline LDL in ACS patients and Predict the need for additional lipid lowering therapies other than high-dose statins for attaining LDL-C goals. Methods: This is a single-centre retrospective study analysing LDL-C levels at the time of admission for ACS. Results: A total of 1880 ACS patients were enrolled (75.3% STEMI &amp; 19.7% NSTEMI) with a mean age of 56±11.79 years (82% males).The mean LDL-C was 74.73mg/dL, with 79 % of patients having LDL less than 100 mg/dL and 89% of patients having LDL-C levels less than 130 mg/dL. Patients less than 40 years of age had a mean LDL of 88.01 mg/dL, while individuals over 60 years had 69.03 mg/dL (p- &lt;0.001). No significant correlation was observed between angiographic severity and LDL-C levels in 1259 patients who underwent coronary angiography. Most patients (96%) received high-dose statin (Atorvastatin 80 mg and Rosuvastatin 40 mg) on discharge. Considering the expected LDL-C reduction by 50 % with high intensity statins alone, the target LDL-C goals as prescribed by ESC guidelines (&lt; 55 mg/dl) and ACC/AHA guidelines (&lt; 70 mg/dl) would be attained by 79% &amp; 89% of patients respectively on follow up. With high intensity statin plus ezetimibe combination (with an expected 65% LDL-C reduction), 89% patients could achieve LDL-C goal by ESC guidelines criteria and &gt; 99% would attain LDL targets set by ACC/AHA guidelines. Conclusions: In this south Asian cohort of ACS patients, the LDL-C levels at presentation were lower compared to western studies and more than three quarters could potentially achieve their LDL-C targets by high intensity statin alone. The results could have potential implications for non-statin therapy utilization.