Acute Coronary Episode Research Articles

Author's reply: An unusual case of two acute coronary syndrome episodes caused by allergic and non-allergic coronary artery dissection with potential coronary vasospasm association: a case report.

Author's reply: An unusual case of two acute coronary syndrome episodes caused by allergic and non-allergic coronary artery dissection with potential coronary vasospasm association: a case report.

Stenting the unprotected left main coronary artery- mid-term outcomes of the observational registry

Abstract Background New imaging modalities such as IVUS had improved results of Stenting of the unprotected left main coronary artery (UPLM). The results of stenting UPLM without these new modalities but with meticulous care need to be studied more. Methods This prospective and retrospective study was performed in multiple local centers. The local ethics committee approved the study, and the patients signed informed consent. In addition, the local heart team, including a cardiac surgeon, was consulted for a joint decision agreement. In the last five years, one hundred twenty patients with left main disease >50% were subjected to stenting with drug- eluted stents.All patients were subjected to detailed history taking with particular emphasis on acute coronary syndrome, angina duration, class, previous coronary interventions, and medications. In addition, 12 lead ECGs were revised with an evaluation of ST/T changes and any old infarction. An echocardiographic examination was done on all patients. Relevant laboratory tests were done.Risk assessment was calculated for every patient, including Euro SCORE and Syntax score. Patient selection: Consecutive patients arriving for primary Stenting or acute coronary episode were included. Medications: All patients received clopidogrel and aspirin before the planned procedure. Anticoagulation with unfractionated heparin in a dose of 10000 IU was given at the beginning of the PCI. Post PCI, all patients received B blockers, ACE inhibitors, statins, and dual antiplatelets in the guidelines recommended doses. Calcification was assessed by angiographic imaging only. We estimated the vessel diameter as 2/3 diameter of the branches. PCI technique: A steerable guidewire was advanced in LAD, followed by PCI with pre-dilatation or direct Stenting according to the operator’s discretion. One or two stent strategy was utilized according to the situation of the lesions. Results 92 patients (77.3%) presented with ACS, of which 65 patients (54.6%) had no Previous Intervention, and 27 patients (22.7%) had a previous PCI. Left ventricular ejection fraction significantly correlates with the complication at six months follow-up; all 16 patients with reported complications (100%) had baseline LVEF of <40% (P-value = 0.023). Syntax score 11 patients (55%) with a high score of more than 32 had adverse events, P = 0.004. Residual syntax shows a less significant correlation with a mean value of 7.3 in the complication group vs. 4.9 in the other group (P = 0.016). Final kissing balloon inflation shows no statistically significant difference. Conclusions PCI in UPLM is a safe, feasible option with a high technical success rate and acceptable outcome at follow-up, even without the utilization of IVUS

Predictors of Readmission after the First Acute Coronary Syndrome and the Risk of Recurrent Cardiovascular Events-Seven Years of Patient Follow-Up.

Recurrent hospitalization after acute coronary syndromes (ACS) is common. Identifying risk factors associated with subsequent cardiovascular events and hospitalization is essential for the management of these patients. Our research consisted in observing the outcomes of subjects after they suffered an acute coronary event and identifying the factors that can predict rehospitalization in the first 12 months and the recurrence of another acute coronary episode. Data from 362 patients admitted with ACS during 2013 were studied. Recurrent hospitalizations were retrospectively reviewed from medical charts and electronic hospital archives over a period of seven years. The mean age of the studied population was 64.57 ± 11.79 years, 64.36% of them being males. The diagnosis of ACS without ST elevation was registered in 53.87% of the patients at index hospitalization. More than half had recurrent hospitalization in the first year after the first ACS episode. Patients with lower ejection fraction (39.20 ± 6.85 vs. 42.24 ± 6.26, p < 0.001), acute pulmonary edema during the first hospitalization (6.47% vs. 1.24%, p = 0.022), coexistent valvular heart disease (69.15% vs. 55.90%, p = 0.017), and three-vessel disease (18.90% vs. 7.45%, p = 0.002) were more frequently readmitted in the following twelve months after their first acute coronary event, while those with complete revascularization were less frequently admitted (24.87% vs. 34.78%, p = 0.005). In multiple regression, complete revascularization during the index event (HR = 0.58, 95% CI 0.35-0.95, p = 0.03) and a higher LVEF (left ventricular ejection fraction) (HR = 0.95, 95% CI 0.92-0.988, p = 0.009) remained independent predictors of fewer early readmissions. Complete revascularization of the coronary lesions at the time of the first event and a preserved LVEF were found to be the predictors of reduced hospitalizations in the first year after an acute coronary event.

Thromboembolic Complications in COVID-19 Patients Hospitalized in Italian Ordinary Wards: Data from the Multicenter Observational START-COVID Register.

Background Coronavirus disease 2019 (COVID-19) infection causes acute respiratory insufficiency with severe interstitial pneumonia and extrapulmonary complications; in particular, it may predispose to thromboembolic disease. The reported incidence of thromboembolic complications varies from 5 to 30% of cases. Aim We conducted a multicenter, Italian, retrospective, observational study on COVID-19 patients admitted to ordinary wards, to describe the clinical characteristics of patients at admission and bleeding and thrombotic events occurring during the hospital stay. Results The number of hospitalized patients included in the START-COVID-19 Register was 1,135, and the number of hospitalized patients in ordinary wards included in the study was 1,091, with 653 (59.9%) being males and 71 years (interquartile range 59–82 years) being the median age. During the observation, two (0.2%) patients had acute coronary syndrome episodes and one patient (0.1%) had an ischemic stroke; no other arterial thrombotic events were recorded. Fifty-nine patients had symptomatic venous thromboembolism (VTE) (5.4%) events, 18 (30.5%) deep vein thrombosis (DVT), 39 (66.1%) pulmonary embolism (PE), and 2 (3.4%) DVT+PE. Among patients with DVT, eight (44.4%) were isolated distal DVT and two cases were jugular thrombosis. Among patients with PE, seven (17.9%) events were limited to subsegmental arteries. No fatal PE was recorded. Major bleeding events occurred in nine (1.2%) patients and clinically relevant nonmajor bleeding events in nine (1.2%) patients. All bleeding events occurred among patients receiving thromboprophylaxis, more frequently when treated with subtherapeutic or therapeutic dosages. Conclusion Our findings confirm that patients admitted to ordinary wards for COVID-19 infection are at high risk for thromboembolic events. VTE recorded among these patients is mainly isolated PE, suggesting a peculiar characteristic of VTE in these patients.

Effect of exercise-based cardiac rehabilitation program on mental health at patients after myocardial infarction

Objective: The aim of the present review is to evaluate the effect of an exercise-based CR program on mental health at patients after myocardial infarction. Materials and Methods: PubMed/Medline and Scopus/Elsevier electronic databases were searched for English control trials with no publication date limitation. Results: The articles that finally met all the inclusion criteria and were analyzed, after the screening of the title, the summary and the whole text, were 3. A total of 488 patients who received exercise-based CR were examined in this review. Discussion: The review demonstrated that exercise in the CR improves the psychological parameters of patients after an acute coronary episode. Systematic exercise of various types and moderate intensity, in supervised CR programs of 2-3 months, reduced the levels of adverse characteristics at all ages and in both sexes, while in fact no individualized psychological help was given to any patient during the intervention. Among those who have experienced OEM for the first time, there are increased levels of fear - avoidance of exercise that can lead to restriction of movement and activity, thus worsening their condition and making it difficult for them to recover. Participating in a 4-month exercise program significantly reduced the levels of these beliefs, while increasing the physical activity levels of these patients.

Cost-Effectiveness, Burden of Disease and Budget Impact of Inclisiran: Dynamic Cohort Modelling of a Real-World Population with Cardiovascular Disease.

ObjectiveWe aimed to estimate the cost-effectiveness, burden of disease and budget impact of inclisiran added to standard-of-care lipid-lowering therapy in the real-world secondary cardiovascular prevention population in Switzerland.MethodsAn open-cohort Markov model captured event risks by sex, age and low-density lipoprotein cholesterol based on epidemiological and real-world data. Low-density lipoprotein cholesterol reduction with add-on inclisiran was based on trial results and translated to meta-analysis-based relative risks of cardiovascular events. Unit costs for 2018 were based on publicly available sources, adopting a Swiss healthcare system perspective. Price assumptions of Swiss francs (CHF) 500 and CHF 3,000 per dose of inclisiran were evaluated, combined with uptake assumptions for burden of disease and budget impact. The assessment of cost-effectiveness used a discount rate of 3% per year. We performed deterministic and probabilistic sensitivity analyses, and extensive scenario analyses.ResultsPatients treated with inclisiran gained a 0.291 qualityadjusted life-year at an incremental cost per QALY gained of CHF 21,107/228,040 (life-long time horizon, discount rate 3%) under the lower/higher price. Inclisiran prevented 1025 cardiovascular deaths, 3425 acute coronary syndrome episodes, and 1961 strokes in 48,823 patients ever treated during 10 years; the 5-year budget impact was CHF 49.3/573.4 million under the lower/higher price. Estimates were sensitive to calibration targets and treatment eligibility; burden of disease/budget impact results also to uptake. Limitations included uncertainties about model assumptions and the size and characteristics of the population modelled.ConclusionsInclisiran may be cost-effective at a willingness to pay of CHF 30,000 if priced at CHF 500; a threshold upwards of CHF 250,000 will be required if priced at CHF 3000. Inclisiran could enable important reductions in cardiovascular burden particularly under broader eligibility with a budget impact range from moderate to high depending on price.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40273-022-01152-8.

Management of Psychiatric Disorders in Patients with Cardiovascular Diseases.

Management of Psychiatric Disorders in Patients with Cardiovascular Diseases.

Polymorphism of TNF gene in acute coronary syndrome patients: data from the registries ORACLE I and ORACLE II

Aim . To analyze possible association of the risk of adverse outcomes development in patients post acute coronary episode (ACS), with the polymorphism of gene TNF. Material and methods . To the study, patients included, that were under observation in 2 registry studies ORACLE I and II (Exacerbation of coronary heart disease: logic-probability ways of course prediction and treatment optimization). In overall, 2012 ACS patients assessed. Mean age 64,7±12,69 y.o. There were 1205 males (59,8%) and 807 females (40,2%). 741 patients (36,8%) included with ST elevation ACS, 1271 (63,2%) — with non-ST elevation ACS. Follow-up started at the 10th day from clinical stabilization. Clinical outcomes were gathered based on phone calls with the patients and their relatives, as during the outpatient office visits. Assessment of polymorphisms of gene TNF done with PCR. Results . In the assessed group, the frequency of alleles and gene TNF genotypes were measured: 18 patients carried genotype АА (0,9%), 561 patients — AG (279%), 1433 — GG (71,2%). In those with the allele А gene TNF, more commonly the episodes of SCD were noted (9,8% comparing to 6,6% of GG carriers, p&lt;0,001); rate of non-cardiac death did not differ significantly (3,5% and 3,1%, respectively). There were no significant differences in the rate of fatal and non-fatal strokes, number of non-complicated cases of peripheral atherosclerosis. In the group of patients with allele A, there were more common the repeated ACS episodes (21,4% vs 12,8% in GG carriers, p&lt;0,001). The rate of repeated after discharge interventions did not differ significantly. Independent factors for any adverse outcome (death, ACS, stroke, complicated atherosclerosis, repeated coronary interventions) were myocardial infarction (OR 1,235 (1,041-1,464)) and heart failure (OR 1,22 (1,02-1,44)) in anamnesis, decreased GFR (OR 1,04 (0,87-1,43)) and carriage of АА and AG gene TNF (OR 1,35 (1,14-1,60)). Conclusion . Carriage of the rare A allele of polymorphic marker G(-308)A gene TNF is associated with more common development of adverse outcomes in patients after exacerbation of CHD.

P4493Predictors of returning to work in the long-run after an acute coronary syndrome episode

P4493Predictors of returning to work in the long-run after an acute coronary syndrome episode

Prolonging Ticagrelor Beyond a Year of Acute Coronary Syndrome: Worth or Harmful?

Platelet activation plays a central role in triggering and complicating acute coronary syndromes, especially in case of stent thrombosis and myocardial infarction. On top of aspirin, P2Y12- inhibitors are successfully used to treat and prevent these events for a duration of one year after an acute coronary episode or 6 months after drug-eluting stent implantation. However, patients with acute coronary syndromes remain at heightened risk for recurrent ischemic events after the recommended durations of P2Y12-inhibitors and therefore, prolonging treatment is often considered in clinical practice. However, the higher risk for bleeding limits the utility of such approach to a restricted group who is still poorly defined by available measures. This review aims to discuss potential benefits and highlight important pitfalls of prolonged treatment with P2Y12-inhibitors, with a focus on ticagrelor, an attractive reversible P2Y12-inhibitor in patients after myocardial infarction.

The New 2016 European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines: Enough Guidance? Enough Evidence?

For the first time, the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery have joined forces to develop consensus guidelines for the management of atrial fibrillation (AF). One of the main issues is the integrated care of patients with AF, with emphasis on multidisciplinary teams of general physicians, cardiologists, stroke specialists and surgeons, together with the patient's involvement for better management of AF. These guidelines also help in the detection of risk factors and concomitant cardiovascular diseases, stroke prevention therapies, including anticoagulation and antiplatelet therapies after acute coronary episodes, major haemorrhages or strokes. In the field of ablation, surgery plays an important role as concomitant with other surgical procedures, and it should be considered in symptomatic patients with the highest level of evidence. Asymptomatic patients with mitral insufficiency should also be considered for combined mitral and AF surgery if they have new-onset AF. In patients with stand-alone AF, recommendations for minimally invasive ablation have an increased level of recommendation and should be considered as the same level as catheter ablation in patients with persistent or long-standing persistent AF or with paroxysmal AF who fail catheter ablation. Surgical occlusion or exclusion of the left atrial appendage may be considered for stroke prevention in patients with AF about to have surgery. Nevertheless, not enough is known to avoid long-term anticoagulation in patients at risk of stroke even if the left atrial appendage has been excluded. These Guidelines provide a full spectrum of recommendations on the management of patients with AF including prevention, treatment and complications based on the latest published evidence.

A Mini-Review on Hyperlipidemia: Common Clinical Problem

The results of the randomized, PARADIGM-HF trial led to the insertion of the sacubitril/valsartan combination, as a replacement therapy of Angiotensin Converting Enzyme-inhibitors (ACEi) to further reduce the risk of HF hospitalization and death of patients suffering from heart failure with reduced ejection fraction and remain symptomatic despite optimal therapy. The current indication for the sacubitril/valsartan combination in this patient category is class I, with level of evidence B. In this case report we describe our own clinical experience on the remarkable clinical recovery of a patient suffering from ischemic heart failure, whose functional status deteriorated from NYHA II to NYHA IV, after his second acute coronary episode and during his index hospitalization. 42 days later and after only 4 days of the ''off-label'' initiation of the low-dose sacubitril/valsartan combination the patient exhibited remarkable clinical improvement.

Evaluation of Cardiovascular Risk Factors in Tunisian Coronary Patients

Introduction: Ischemic heart disease ranked among the leading causes of death worldwide. Several biological and genetic risk factors associated with acute coronary syndrome. By addressing the risk factors, it is possible to prevent most of the cardiovascular diseases and contribute to the reduction of complications of acute coronary syndrome. Material and Methods: Our study is a prospective study that was conducted to the main military hospital of instruction of Tunis. Recruitment involved 122 coronary (n = 122) and 705 controls (n = 705) totaling a population of 827 subjects. Data collection concerned socio-demographic characteristics, anthropometric measurements, habits and lifestyle, health status and biological assessment. Results: Our study reported a high prevalence of cardiovascular classic risk factor particularly overweight (62.3%), diabetes (63.1%) and hypertension (50%). In 55% of coronary patients, moderate to intermediate hyperhomocysteinemia was found, but it appears to be an independent risk factor. The results of our study show a significant difference in the genotypic frequencies of the C677T mutation in the MTHFR gene between the two populations, cases and controls. Conclusion: Acute coronary syndromes are the leading cause of sudden death in adults. The evaluation of risk factors after acute coronary syndrome episode is essential for a better management according to the recommendations of learned societies and standards of good practice.

Left ventricular diastolic dysfunction in patients with ST-elevation myocardial infarction following early and late reperfusion by coronary intervention

BackgroundThis study prospectively assessed the left ventricular (LV) diastolic function changes in patients with ST-elevation myocardial infarction (STEMI) and determined if the early revascularization of the infarct-related coronary artery in acute phase achieve a better recovery of diastolic function than late recanalization. MethodsForty-five consecutive patients (61.20±11.37years, 8 females) presenting with STEMI and treated with PCI were prospectively enrolled in this study. The important inclusion criteria were first acute coronary syndrome episode and LV ejection fraction exceeded 45%. The patients were divided to two different groups by total ischemia time (TIT): early reperfusion (TIT<6h) and late reperfusion group (TIT≥6h). Transthoracic echocardiography were performed within the first week after PCI, and data were compared between groups. Evaluation of diastolic function was based on integrated assessment of trans-mitral Doppler flow pattern, tissue Doppler, and color M-mode ECT. ResultsA normal diastolic filling pattern was seen in only 9 patients, and the other 80% patients had abnormal filling patterns: 16 impaired relaxation, 14 pseudonormal, and 6 restrictive filling patterns. The e′septal velocity was lower in early reperfusion group compared to late reperfusion group (5.52±1.67cm/s vs 7.11±2.14cm/s, P<0.05), but no statistical difference was found in E/e′ average (11.99±4.30 vs 9.85±3.47, P>0.05). There was also no statistical difference for left atrial volume index and mitral annulus propagation velocity between groups. ConclusionsLV diastolic dysfunction was present in most of acute MI patients even after successful PCI. It seemed STEMI patients receiving early myocardial reperfusion had no better diastolic functions compared with late-reperfused patients within the acute phase.

Complex Data-driven Predictive Modeling in Personalized Clinical Decision Support for Acute Coronary Syndrome Episodes

The objective of this paper is to demonstrate the development of complex model of clinical episode, based on data-driven approach, for decision support in treatment of ACS (Acute Coronary Syndrome). The idea is aimed at improving predictive capability of a data-driven model by combining different models within a composite data-driven model. It can be implemented either hierarchical or alternative combination of models. Three examples of data-driven models are described: simple classifier, outcome prediction based on reanimation time and states-based prediction model, to be used as part of complex model of episodes. To implement the proposed approach, a generalized architecture of data-driven clinical decision support systems was developed. The solution is developed as a part of complex clinical decision support system for cardiac diseases for Federal Almazov North-West Medical Research Centre in Saint Petersburg, Russia.

Acute coronary syndromes in patients with atrial fibrillation and heart failure. Could novel oral anticoagulants be the solution of the optimal antithrombotic therapy puzzle?

The patients experiencing an acute coronary event are exposed to increased risk of thromboembolic events. That risk becomes substantially greater when AF fibrillation and heart failure are present as well. Dual antiplatelet therapy remains the gold standard in the treatment of patients with ACS. The combination of an oral anticoagulant agent with dual antiplatelet therapy is proven to be more effective in prevention of further antithrombotic events but is followed by increased risks of clinically significant bleeding thus it is not suggested in the treatment of ACS. However, it has been proven beneficial in patients with AF who present with an acute coronary episode. NOACs have proved to be at least as effective as vitamin K antagonists in protecting patients with atrial fibrillation from thromboembolic events without increased risk of major bleeding. However, only data on the effectiveness of NOACS in patients with ACS and AF have been quite contradictory. Even more, the data on the effect of NOACS in patients with concomitant HF and AF who present with an acute coronary event is almost lacking from current bibliography. In this review, we attempt to describe the available data of the use of NOACS in patients with AF and HF who experience an ACS and to address the need for further studies in this area.

Higher prevalence of morphometric vertebral fractures in patients with recent coronary events independently of BMD measurements

Cardiovascular disease and osteoporosis are important causes of morbi-mortality in the elderly and may be mutually related. Low bone mineral density (BMD) may be associated with increased risk of cardiovascular events. We investigated the prevalence of low bone mass and fractures in metabolic syndrome patients with acute coronary events. A case–control study was conducted with 150 individuals (30–80years-old) with metabolic syndrome. Seventy-one patients had had an acute coronary syndrome episode in the last 6months (cases) and the remaining 79 had no coronary event (controls). Cases and controls were matched for gender, BMI and age. DXA measurements and body composition were performed while spine radiographs surveyed for vertebral fractures and vascular calcification. Biochemical bone and metabolic parameters were measured in all patients. No statistically significant difference in BMD and the prevalence of osteopenia, osteoporosis and non-vertebral fractures was observed between cases and controls. The prevalence of vertebral fractures and all fractures was higher in the cases (14.1 versus 1.3%, p=0.003 and 22.5versus7.6%, p=0.010, respectively). Male gender (OR=0.22 95% CI 0.58 to 0.83, p=0.026) and daily intake of more than 3 portions of dairy products (OR=0.19 95% CI 0.49 to 0.75, p=0.017) were associated with lower prevalence of fractures. Cases had higher risk for fractures (OR=4.97, 95% CI 1.17 to 30.30, p=0.031). Bone mass and body composition parameters were not associated with cardiovascular risk factors or bone mineral metabolism. Patients with fragility fractures had higher OPG serum levels than those without fractures (p<0.001). Our findings demonstrated that patients with recent coronary events have a higher prevalence of vertebral fractures independently of BMD.

A 50-year-old woman with syncope

A 50-year-old postmenopausal woman with no prior comorbidity, was brought to the emergency department with two weeks history of exertional dyspnoea, syncope and generalised weakness. There was no associated chest pain or cough. She had experienced three episodes of syncope characterised by loss of consciousness, each episode lasting for 2–3 mins. On examination, she was a middle-aged woman with a pulse of 100 beats·min−1, blood pressure of 120/80 mmHg, respiratory rate of 20 breaths·min−1, room air oxygen saturation of 95% and jugular venous pressure within the normal range. Leg veins were prominent with minimal pedal oedema. Respiratory examination revealed an elliptical chest, normal vesicular breathing and occasional wheeze. Cardiovascular examination revealed a right ventricular heave, audible heart sounds with a systolic murmur audible at the tricuspid area and palpable peripheral pulses. The chest radiograph (CXR) from a local hospital is shown in figure 1. Figure 1 Chest radiograph. ### Task 1 What does the chest radiograph demonstrate? ### Answer 1 An electrocardiogram (EKG) revealed right ventricular strain with no evidence of an acute coronary episode. Initial investigations at our hospital showed a haemoglobin level of 14.9 mg·dL−1 (11.5–13.8 mg·dL−1), total white cell count of 13.2×109 cells·L−1 (4.0–10.0×109 cells·L−1) and platelets of 174×109 cells·L−1 (150–400×109 cells·L−1). Arterial blood gases showed pH 7.53, oxygen tension 65.9, carbon dioxide tension 27.2, HCO3- 22.7 …

388 Prescription of Antiplatelet and Gastroprotective Medications After an Acute Coronary Episode: Influence of a History of Peptic Ulcer Disease

388 Prescription of Antiplatelet and Gastroprotective Medications After an Acute Coronary Episode: Influence of a History of Peptic Ulcer Disease

Friable but treatable

Vascular Ehlers-Danlos syndrome is a rare connective tissue disorder associated with arterial dissection or rupture. Percutaneous coronary intervention (PCI) is often critical in patients with this syndrome because their coronary arteries are prone to dissection, enhancing the risk of stent borders dissection when conventional stent deployment pressures are used. Coronary artery bypass graft (CABG) treatment for these patients may also raise concerns because the left internal mammary artery is probably friable. Therefore, coronary artery revascularization in vascular Ehlers-Danlos syndrome either using PCI or CABG is challenging due to the arteries friability. A small number of cases have been published describing the friability of the vessels and associated complications; nevertheless, the optimum treatment remains unclear. We report the case of a 54-year-old woman treated successfully with PCI and CABG in two different acute coronary syndrome episodes, in which specific technical issues related to both procedures were decisive.