History Of Acute Coronary Syndrome Research Articles

Effect of statin on long-term outcomes in persistent tobacco users receiving percutaneous coronary intervention: A longitudinal, retrospective cohort study.

The role of statins in improving cardiovascular outcomes is well established, but little is known about their impacts on long-term outcomes in persistent tobacco users with stable coronary artery disease (CAD) who receive percutaneous coronary intervention (PCI). A population of persistent smokers with CAD treated by PCI was analyzed. From 2012 through 2019, a cohort of 907 persistent tobacco users with stable CAD undergoing PCI were enrolled from the inpatient department of Taichung Tzu Chi Hospital, Taiwan. We surveyed statin users and non-statin users after index PCI, and general characteristics, major risk factors, angiographic findings, and long-term clinical outcome were compared. Kaplan-Meier curve was used to compare the survival difference and Cox proportional hazard model was used to analyze the predictors for all-cause mortality and major adverse cardiovascular events, including cardiovascular (CV) mortality, myocardial infarction, and repeated PCI procedures. The statin group had a higher average total cholesterol (P < .01) and low-density lipoprotein cholesterol (LDL-C) level (P < .01) and was younger (P < .01) than the non-statin group. Ninety-six point one percent patients in the statin group had a LDL-C level below 100 mg/dL after treatment. They also had a more frequent history of acute coronary syndrome and lower prevalence of chronic kidney disease than the non-statin group (both P < .01). Freedom from all-cause and CV mortality were lower in the non-statin group than the statin group (both P < .01). After adjustment for age and chronic kidney disease, statin treatment no longer reduced the risk of CV mortality (hazard ratio: 0.32, 95% confidence interval = 0.07-1.49), but was still associated with a reduction in all-cause mortality (hazard ratio: 0.27, 95% confidence interval = 0.10-0.75). In persistent tobacco users undergoing PCI, patients treated with statin for LDL-C values above 100 mg/dL had a similar level of cardiovascular protection as those with LDL-C below 100 mg/dL and without statin treatment. Therefore, smoking attenuates pleiotropic effect of statin. Nevertheless, statin therapy was still associated with a reduction of all-cause mortality.

Clinical profile and prognosis of Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) in patients with previous Acute Coronary Syndrome (ACS)

Abstract Introduction Myocardial infarction with non-obstructed coronary arteries (MINOCA) may occur in patients with a personal history of ischaemic heart disease, making diagnosis even more difficult. In addition, the role of cardiovascular risk factors, which are well known in patients with acute myocardial infarction with obstructed arteries (MICAD), is less well defined in MINOCA. The aim of this study is to define the clinical characteristics, risk factors and long-term prognosis in patients with MINOCA and previous acute coronary syndrome (ACS). Methods A prospective, analytical, observational study was designed. Included all patients admitted to our centre with ACS between 2016 and 2023 in which a coronary angiography was performed. Patients were classified as MINOCA according to the definition of the 2020 European ACS guidelines. MINOCA patients with and without a history of previous ischaemic heart disease were compared. At follow-up, MACE was defined as all-cause death, hospitalisation, reinfarction and stroke. The median follow-up was 43 [IQR 20-71]. Results A total of 136 patients were included, of whom 17 had a history of ACS. The proportion of men was significantly higher in the group with previous ACS (82% vs 48%; p=0.008). Patients with a history of ACS had higher rates of smoking (71% vs 51%, p=0.139), more night work (80% vs 39%, p=0.017) and less stress (33% vs 61%, p=0.152). They also had more peripheral vascular disease (24% vs 3%, p=0.005), diabetes (41% vs 19%, p=0.042), dyslipidaemia (71% vs 43%, p=0.04) and a higher rate of atrial fibrillation (29% vs 9%, p=0.032). However, despite a higher rate of previous ventricular dysfunction (24% vs 3%, p=0.005), they had lower troponin levels on admission (62 [IQR 37-368] vs 152 [IQR 49-424]). We found no differences in the other comorbidities analysed (Table 1). On admission, patients with previous ACS had significantly more non-ST-segment elevation (29% vs 10%, P=0.05) and received more beta-blocker treatment (82% vs 57%, p=0.046). When analysing the mechanism of infarction, patients without previous ACS were more likely to have vasospasm and coronary embolism. However, there was a significantly higher rate of type II AMI (41% vs 18%, p=0.044) in the group with previous ACS. During follow-up, patients with a history of ACS are more likely to have a new infarction (7% vs 3%, p=0.3) or stroke (14% vs 6%, p=0.2). There was also a trend towards a higher incidence of MACE in patients with prior ACS, although this did not reach statistical significance (HR 2.379, 95% IC 0,883-6,405) (Table 2). Conclusion MINOCA patients with a history of ACS have distinct and worse epidemiological features in which classic cardiovascular risk factors play a significant role, with more ventricular dysfunction and atrial fibrillation. In addition, they appear to have a worse prognosis with increased cardiovascular complications. That might suggest a more MICAD-like profile.

Development of an Initial Screening Scale to Detect Patients With Chest Pain From Acute Coronary Syndrome in the Emergency Department.

Identifying patients with chest pain potentially due to acute coronary syndrome (ACS) early is crucial for triage nurses. They need a reliable, validated screening tool. This study aims to develop an initial screening scale to detect ACS in patients presenting with chest pain in the emergency department. We analyzed electronic medical records of 3131 chest pain patients from 103,041 emergency department visits between January 2018 and December 2019. ACS diagnosis was confirmed by cardiologists through clinical symptoms, electrocardiograms, and cardiac enzyme levels. The study proceeded in four stages: (1) identifying potential ACS predictors through a literature review, (2) validating these predictors with experts, (3) comparing data between ACS and non-ACS patients and (4) developing a screening scale based on identified predictors. Statistical methods included univariate analysis and binary logistic regression. The scale's accuracy was assessed using ROC curve analysis and compared to existing tools. Eight significant ACS predictors were identified: male sex, age over 49 for males and over 65 for females, typical symptoms, initial pain scale score of 6 or higher, pain duration of at least 10 min, history of ACS, hypertension, and dyslipidemia. Each predictor was scored, with typical symptoms and severe pain receiving higher scores, totaling up to 10 points. A score of 6 or more indicated high ACS risk, demonstrating accuracy comparable to the HEART and TIMI score systems. This study developed a new ACS screening scale for use by triage nurses in emergency departments. This scale can facilitate early detection and intervention for patients at high risk of ACS.

Study on Heparin-Induced Thrombocytopenia and Blood Group among Individuals Suffering from Acute Coronary Syndrome

Background: Clinicians confront heparin-induced thrombocytopenia (HIT) as the most pertinent pathological relationship. Antibodies directed against complexes of heparin molecules and platelet factor 4 (PF4) are the cause of this immune-mediated phenomena. HIT is a significant adverse event that affects individuals with acute coronary syndromes (ACS). Objective: To assess the frequency of HIT in patients presenting with ACS. Materials and Methods: This study was carried out the Northeast Medical College's Department of Cardiology in Sylhet from June 2021 to December 2022. A total of 234 individuals aged 40 to 70 years old presented with ACS within 24 hours of symptom onset. This study excluded patients with idiopathic thrombocytopenic purpura (ITP), aplastic anemia, myeloproliferative diseases, or pre-existing thrombocytopenia. Thrombocytopenia was evaluated using medical records and a full blood count (CBC), with isolated thrombocytopenia (platelets &lt;150 x109/L) prior to heparin administration. Results: Diabetes mellitus, hypertension, a history of ACS, and obesity were the most frequent comorbidities, accounting for 41.03%, 33.76%, 43.16%, and 14.96%, respectively. The incidence of HIT in NSTEMI and STEMI was higher than in unstable angina, although still comparable. The delayed presentation of ACS &gt; 12 hours was also strongly correlated with the occurrence of HIT (p&lt;0.05). Unstable angina and middle age (50–60 years) were found to have a significant relationship with HIT (p&lt;0.05). Conclusion: HIT is more common in patients who have had a myocardial infarction or who have had symptoms for more than 12 hours at the time of hospitalization. Cardiologists and internal medicine experts must take extra precautions when administering heparin to high-risk patients to prevent problems.

The Economic Burden of Atherosclerotic Cardiovascular Disease in Italy.

Atherosclerotic cardiovascular diseases remain the primary cause of mortality in Italy. Individuals with a history of acute coronary syndrome, peripheral arterial disease, and ischemic stroke/transient ischemic attack face an elevated risk of recurrent major adverse cardiovascular events, including mortality. The population aging, coupled with increasing risk factors such as diabetes mellitus and obesity, exacerbates the disease's economic impact. This study aims to comprehensively assess the economic burden of atherosclerotic cardiovascular diseases in Italy, specifically focusing on direct healthcare costs. We analyzed real-world data from administrative databases in the Marche region and Local Health Unit Umbria 2. The economic burden of patients discharged with acute coronary syndrome, peripheral arterial disease, and ischemic stroke/transient ischemic attack was evaluated, with a focus on direct costs associated with hospitalizations, drugs, and outpatient visits. Results were stratified by age, sex, comorbidities at baseline, and adherence to lipid-lowering therapy and antihypertensive agents. Annually, nearly 350,000 patients were hospitalized for peripheral arterial disease, acute coronary syndrome, or ischemic stroke/transient ischemic attack. Direct health costs averaged €7190 per patient over a 2-year follow-up, with hospitalizations accounting for nearly 70% of the total. Male patients incurred significantly higher costs (€7467) than female patients (€6625). Costs correlated positively with age and with the number of baseline comorbidities, with a range from €5259 (0-1 comorbidities) to €17,095 (4+ comorbidities). Costs were significantly lower in adherent subjects (€6813) compared with non-adherent subjects (€7757). This study provides valuable insights into the economic implications of atherosclerotic cardiovascular diseases in Italy, emphasizing the necessity of a comprehensive approach to preventive measures, optimal medication adherence, and lifestyle modifications to mitigate its impact.

Patients With Non-Obstructive Coronary Artery Disease and Polyvascular Disease. Sub-Analysis of the Real-World Registry KAMMA (Clinical Registry on Patient Population With Polyvascular Disease in the Russian Federation and Eurasian Countries).

To study the clinical status and data of laboratory and instrumental examination of patients with non-obstructive ischemic heart disease (IHD) and multifocal atherosclerosis (MFA) included in the KAMMA registry. The subanalysis included 1,893 IHD patients who underwent coronary angiography (CAG) and ultrasonic examination of peripheral arteries. Based on the CAG data, patients were divided into two groups: group 1, patients with obstructive coronary atherosclerosis (CA) (maximum stenosis ≥50% and/or history of percutaneous coronary intervention/coronary artery bypass grafting, n=1728; 91.3%) and group 2, patients with non-obstructive CA (maximum stenosis &lt;50%, n = 165; 8.7%). A comparative analysis based on the degree of coronary obstruction in patients with verified IHD who were included in the KAMMA registry showed that 8.7% of them had coronary artery stenosis of less than 50%. The overwhelming majority of patients with non-obstructive CA had MFA affecting the brachiocephalic arteries in 94.3% and the lower extremity arteries in 40.2%. Among patients with non-obstructive IHD, women predominated; risk factors such as smoking and type 2 diabetes mellitus were less frequent in this group than in the obstructive IHD group. Patients with non-obstructive CA more frequently had a history of dyslipidemia; they had higher total cholesterol and non-high-density lipoprotein cholesterol; and they more frequently received moderate-intensity statin therapy than patients with obstructive CA (55.8% vs. 34.5%). Characteristic features of patients with non-obstructive CA were less severe IHD and less frequent history of acute coronary syndrome. However, the incidence of stroke, peripheral arterial thrombosis, and chronic arterial insufficiency of the lower extremities did not differ in groups 1 and 2, whereas the incidence of paroxysmal atrial fibrillation was higher in the non-obstructive IHD group. IHD patients without coronary obstruction also require assessment of the peripheral arterial status, as they may have advanced MFA, which should be taken into account when choosing the "aggressiveness" of therapy.

THE ROLE OF PATIENT SCREENING AND RISK STRATIFICATION IN THE PREOPERATIVE PREPARATION OF PATIENTS WITH ANTERIOR ABDOMINAL WALL HERNIAS

Introduction. Lifestyle, poor physical condition, bad habits, malnutrition and adverse psychological factors reduce the body's resistance to overcome the physiological stress of surgery. Abdominal wall hernia repair is one of the most common surgical operations. A high body mass index, smoking, diabetes and immunosuppression are risk factors for the development of postoperative hernia, and in the case of its surgical correction, these factors significantly worsen the perioperative prognosis. Assessing the risk of serious complications and death during the perioperative period is crucial for the patient. Aim. To assess the role and necessity of patient screening and risk stratification in the complex of preoperative preparation of patients with anterior abdominal wall hernias. Materials and methods. In the research took part 91 patients who underwent surgical treatment of abdominal wall hernias. They were divided into 3 groups according to the type of anesthesia (general, neuraxial and fascial blocks of the abdominal wall). The analysis was carried out according to comorbidity, the presence of lifestyle risks, the risk of cardiovascular complications (LI index), the risk of anesthesia according to the ASA (American Society of Anesthesiologist's) scale and the risk of thromboembolic complications according to the Caprini scale, factors that affect the frequency postoperative nausea, vomiting and their prevention. Results and discussions. It was determined that the most common concomitant pathology in patients of 1, 2 and 3 study groups was arterial hypertension. Ischemic heart disease was most often observed in patients of group 3. Patients with a history of acute coronary syndrome dominated in the 3rd observation group. Patients were also noted to have diabetes mellitus, chronic obstructive pulmonary disease, and a history of impaired cerebral circulation. It was determined that many patients in the studied groups did not have additional risk factors, but all of them smoked and were overweight. Many patients had anesthetic risk according to ASA II or III. Patients received combined prophylaxis of postoperative nausea and vomiting. Conclusions. All groups were dominated by patients with an average and high risk of developing perioperative complications. Careful examination, identification of potential risk factors related to comorbidities and lifestyle are important to reduce the risk of complications in patients with abdominal wall hernias in the complex of preoperative preparation. Patients with a high risk of developing perioperative complications are recommended to choose neuraxial or regional anesthesia to prevent the development of postoperative complications.

Exploring shared frailty models for cluster-specific risk estimation: A study on diabetes patients with a history of acute coronary syndrome

This study proposes the use of semiparametric log-normal shared frailty models to analyze time-to-event data for individuals with similar features referred to as clusters. Shared frailty models are useful for modeling and estimating common risk in the lifetimes of individuals in these clusters. While various methods have been proposed for estimating shared frailty models, few studies have explored the use of the pseudo-full-likelihood method. In this study, the pseudo-full-likelihood and hierarchical likelihood approaches were used to construct and estimate parameter estimates and check for asymptotic properties via simulations. Log-normal semiparametric frailty model was used to obtain cluster-specific frailty based on the semiparametric log-normal shared frailty distribution. The results of both methods were compared, and prediction intervals for a random effect were obtained. To further investigate the existence of shared frailty in diabetes patients and a history of acute coronary syndrome (STEMI and NSTEMI), data from UK Biobank was used. The results suggest the presence of frailty within the clusters and indicate cluster time dependence in the study population. Overall, this study highlights the potential benefits of using the pseudo-full-likelihood method in shared frailty modeling and provides insights into the impact of observed variabilities on hazards within clusters.

The Correlation of Reverse Redistribution Pattern with Coronary Angiography: A Conundrum Revisited

Abstract Objective The reverse redistribution (RR) pattern is a phenomenon whose etiology, pathophysiology, and clinical implications are not well understood. The studies examining this pattern date back to days when timely coronary interventions and anti-ischemic therapies were not widely used, so we aimed to reinvestigate any relationship between RR and coronary angiography (CA) findings in today's contemporary clinical settings. Methods All patients with an RR pattern on the Tc99m-MIBI (technetium-99m sestamibi) scan between 2021 and 2023 were screened. Information on demographics, history of acute coronary syndrome, revascularization, comorbidities, and risk factors was collected. The CA findings were compared to RR regions. The physician's decision in the case of the RR pattern was grouped. Results In a total of 67 patients (men 83%, aged 63.6 ± 10.5), the RR pattern was most commonly seen in the inferior-posterior wall (n = 41, 31.3%), followed by the apex (n = 19, 14.5%) and anterior (n = 12, 9.2%). Most patients with RR pattern had normal/nonobstructive coronary angiograms (61.1%, n = 22); significant stenoses in 1, 2, and 3 vessels were present in 19.4% (n = 7), 13.8% (n = 5), and 5.5% (n = 2) of patients, respectively. There was no correlation between the regions of the RR pattern and significant stenosis detected on CA (p = 0.6, p = 0.5, p = 0.6, respectively, for left anterior descending artery, circumflex artery, and right coronary artery). Conclusion In this study, no evidence of a relationship between RR patterns and CA findings was found. The 60% of the patients with RR pattern had normal/nonobstructive coronaries, so the decision to proceed with CA should not be made based solely on this finding.

Papillary Fibroelastoma of the Aortic Valve:Acute Coronary Syndrome Due to Dynamic Obstruction of the Right Coronary Artery Ostium.

A 59-year-old woman, who had a history of acute coronary syndrome (ACS) but without obstructive coronary lesions 2 years previously, presented with vertigo. MRI revealed a left cerebellar embolism. TEE detected a mobile aortic valve tumor, suggesting a papillary fibroelastoma (PFE). Reviewing previous echocardiograms, it was discovered that the tumor was present at the time of the ACS event. At surgery, the PFE was present on the right coronary cusp. When the aortic valve was opened, it was found that the tumor was obstructing the right coronary artery (RCA) ostium. ACS was probably caused by PFE's dynamic obstruction of the RCA ostium.

Feasibility and Safety of Bridging Antiplatelet Therapy with Cangrelor in Neuro-Oncology: A Preliminary Experience.

Antiplatelet therapy is mandatory for prevention of thrombotic events in patients with a recent history of acute coronary syndromes and/or percutaneous coronary interventions. However, if an urgent surgery is required during antiplatelet therapy, a compromise between the ischemic/thrombotic and hemorrhagic risk has to be reached. Different bridging schemes are reported in the literature, but there is no clear consensus on the optimal treatment strategy in terms of efficacy and safety. Although some indications about the perioperative management of antiplatelet therapy regarding specific surgical specializations are available, balancing the thrombotic and hemorrhagic risk on an individual basis, no evidence referring to neurosurgical or neuro-oncologic procedures is reported. Herein, we present our preliminary experience in the perioperative management of a patient who underwent a neurosurgical procedure for the resection of a primary malignant brain tumor using an intravenous P2Y12 inhibitor (cangrelor) as bridging therapy after a recent acute myocardial infarction treated with primary percutaneous coronary intervention and stenting. The oral P2Y12 inhibitor (clopidogrel) was withdrawn 5 days prior to the surgical procedure and continuous infusion of cangrelor was started 3 days before the surgery at a dose of 0.75 μg/kg/min. Cangrelor was discontinued 2 hours before surgery and resumed 72 hours after tumor resection for further 60 hours. Neither cangrelor-related bleeding nor cardiac ischemic events were observed in the perioperative period and the following 90 days, supporting data regarding the feasibility and safety of this bridging scheme. Further studies are needed to confirm our promising results.

Assessment of Carotid Plaque Enhancement on Contrast-Enhanced Ultrasound as a Predictor for Severe Coronary Artery Disease.

Background and Aim Contrast-enhanced ultrasound (CEUS) can reliably identify vulnerable plaques. As atherosclerosis is a systemic disease, we evaluated whether contrast enhancement of carotid plaque (CECP) can predict severe coronary artery disease (CAD) by comparing CECP in patients who have had acute coronary syndromes (ACS) recently with asymptomatic individuals. Settings and Design This case-control study was done at a tertiary care center during 2022. Materials and Methods Fourteen participants were recruited in each group, after screening in-patients for carotid plaques and inclusion and exclusion criteria. Those who had history of ACS were enrolled as cases, while those who did not were enrolled as controls. All these patients underwent grayscale, Doppler, and CEUS examination for characterization of the carotid plaque. For cases, findings on CEUS were also compared with the severity of CAD on catheter coronary angiography. Statistical Analysis Diagnostic parameters including sensitivity, specificity, and diagnostic accuracy were calculated and proportions were compared by using Fisher's exact test. Results Eight out of 28 patients showed CECP. CECP and CAD were positively associated with p -Value of 0.033. Eighty-three percent patients with triple vessel disease and 50% patients with double vessel disease on coronary angiography showed CECP. Sensitivity and specificity of CECP for prediction of CAD were 50 and 92.9%, respectively. Conclusion CECP on CEUS can predict CAD and is a more reliable indicator of severe CAD than plaque characteristics on grayscale and Doppler imaging; making it useful for screening of patients at risk of having CAD.

Elevated neutrophyl-to-lymphocyte ratioand smoking are associated with chronic total occlusion in patients with ST elevation myocardial infarction

BackgroundAtherosclerosis is a progressive disease characterized by the build-up of lipids and connective tissue in the large arteries. Some patients experience chronic total occlusion (CTO). Inflammation plays a key role in the development and complications of atherosclerosis. Neutrophil-to-lymphocyte ratio (NLR) is a marker of systemic inflammation associated with the development of acute coronary syndrome (ACS). We aimed to assess the relationship between NLR and CTO in ACS patients with ST elevated myocardial infarction (STEMI) in Indonesia.MethodsThis cross-sectional study was performed with secondary data obtained from patient medical records at Cipto Mangunkusumo National Central Hospital, Jakarta. Inclusion criteria were patients with ACS and STEMI who underwent coronary angiography in 2015–2018.ResultsA total of 98 patients were enrolled in the analysis. Most subjects with CTO were male, elderly (> 60), smoking, had no history of diabetes mellitus (DM) or hypertension, no family history of coronary heart disease (CHD), but had a history of ACS and had never consumed statin or antiplatelet medications. Bivariate logistic regression analysis revealed that male gender (PR = 1.820; 95%CI 0.871–3.805; p = 0.025) and smoking (PR = 1.781; 95%CI 1.028–3.086; p = 0.004) were significantly correlated with CTO. Receiver operator characteristic (ROC) curve revealed that higher NLR (≥ 6.42) could predict a CTO diagnosis with positive predictive value (PPV) of 91%. Multivariate analysis revealed that NLR was correlated with an 11.2-fold increase in occurrence of CTO (95%CI 3.250-38.303; p < 0.001). Additionally, smoking was correlated with a 7-fold increase in CTO (95% CI 1.791–30.508; p = 0.006).ConclusionNLR value of ≥ 6.42 is potentially useful as a marker of CTO in STEMI patients. In addition, smoking increases the risk of CTO in ACS/STEMI patients.

Coronary artery disease in older adults with congenital heart defects: risk factors and pharmacotherapy.

With advancing age, adults with congenital heart disease (ACHD) are at a higher risk of developing atherosclerotic coronary artery disease (CAD). We aimed to determine the prevalence of CAD, its risk factors, and use of guideline‑directed pharmacotherapy among older patients with ACHD. Patients and methods: We studied all ACHD patients aged 60 years or older hospitalized in our department between the years 2013 and 2020. CAD was defined as a history of acute coronary syndrome or coronary revascularization, or more than 50% diameter stenosis on coronary angiography. Data regarding the underlying heart defect, prevalence of cardiovascular risk factors, and drug prescriptions were collected. A total of 198 patients with known coronary artery status (mean [SD] age, 66.2 [5.3] years; 43.3% men) were included in the analysis. Of them, 54 (27.3%) had CAD. The individuals with CAD were more often men, and they were more likely to have a mild heart defect, dyslipidemia, and a history of hypertension and tobacco use. Multivariable analysis showed that male sex (P = 0.001), dyslipidemia (P = 0.003), and hypertension (P = 0.04) were positive independent predictors of CAD, whereas overweight / obesity was identified as a negative independent predictor (P = 0.04). The proportion of CAD patients on antiplatelet and / or anticoagulant drugs was 92.6%. β‑Blockers were prescribed to 87% of the patients, and a lipid‑lowering agent to 96% of the study population. CAD is common in older patients with ACHD. Our results underline the importance of identification and treatment of modifiable CAD risk factors in individuals with ACHD. The obesity paradox might also play a role in this population. The rate of guideline‑recommended pharmacotherapy implementation seems to be satisfactory.

Hibernation of the Conduction System and Atrioventricular Block Reversibility Following Revascularization in Patients without Acute Coronary Syndrome.

Although myocardial infarction (MI) is a reversible cause of atrioventricular (AV) block, the association of ischemia other than MI with AV block is unclear. The purpose of this study is to investigate this relationship. Among patients nominated for pacemaker implantation due to AV block in two centers from 2017-2020, 120 patients with significant coronary artery disease (CAD) in angiography were included in the study. Patients were divided into two equal groups based on their CAD treatment approach: drug therapy and revascularization. Coronary lesions were divided into three types based on location: left anterior descending artery (type 1), dominant coronary with AV node branch (type 2), and a combination of both (type 3). After coronary disease treatment, all patients were followed up with for 14 months, and AV block reversibility was assessed. There were 7 cases of block reversibility in the revascularization group (11.7%) and 1 case in the medical group (1.7%), which differed significantly (P = .02). A history of acute coronary syndrome, smoking, opium use, chronic kidney disease, hypertension, age, sex, and chronic obstructive pulmonary disease were not significantly associated with reversible block. Also, the type of coronary obstruction had no significant relationship with block reversibility (P = .3, .5, and .8 for type 1, type 2, and type 3, respectively). Hibernation due to ischemia can be a reversible cause of an AV blockage. Therefore, it is recommended that significant coronary artery lesions be revascularized before pacemaker implantation.

Can the Use of Cardiology Medical Record to Deliver Educational Intervention Improve Care? On Behalf of TAPP Program: Thinking Approach Towards Physician Support in Patient Management

Background: Despite clear and concise practice guidelines, strategies for lowering LDL-C are often poorly adopted in clinical practice, and many patients fail to reach guideline-recommended levels despite physician education and quality improvement programs. We studied whether physician focussed, guideline-based practice level educational intervention can improve lipid lowering management. Methods: Cardiologists or internal medicine specialists from the province of Ontario, Canada who were using a cardiology specific EMR (CEREBRUM, WELL Health Technologies Corporation) were invited to participate. Practice level data of patients with history of acute coronary syndromes (ACS) and lipid profile were studied. Physicians were alerted when patients in their practice were not treated according to recommendations. The primary endpoint was proportion of patients achieving the recommended LDL-C level of below 1.8 mmol/L. Results: Of the invited 378 specialists, 178 agreed to participate and shared their practice involving 7,683 ACS patients who were 70.4 ± 10.3 years of age and 27.2% were women. Overall, 57.7% of patients had LDL-C &lt; 1.8 mmol/L at the start of the program (1.84 ± 0.87 mmol/L) and 63.0% (1.75 ± 0.79 mmol/L) at the end of the program (p&lt;0.0001). With respect to the lipid lowering therapy, statin therapy was used in 52.9% of patients at the start of the program and increased to 72.1% at the end (p&lt;0.0001). The use of ezetimibe increased from 12.6% to 19.0% (p&lt;0.0001) and the use of PCSK9i from 1.2% to 2.4% (p&lt;0.0001). Conclusion: The results indicate the feasibility of using EMR as a platform to deliver educational intervention and overcoming treatment inertia and improving LDL-C lowering.

Rupture of a Spinal Dural Arteriovenous Fistula as a Differential Diagnosis of a Coronary Syndrome: Case Report

BACKGROUND AND IMPORTANCE: Spinal dural arteriovenous fistulas (SDAVFs) are the most common vascular malformation of the spine and can lead to progressive paraplegia if left untreated. However, because of their nonspecific clinical presentation, they are often misdiagnosed as other pathologies, such as discopathies or degenerative neuropathies, which can result in delayed diagnosis and treatment. CLINICAL PRESENTATION: A case of a 73-year-old female with a history of acute coronary syndrome who presented to the emergency department with sudden onset chest pain suggestive of an acute myocardial infarction is presented. Further evaluation revealed a subdural hematoma at T2-T5 and T8-L5, caused by a ruptured SDAVF at the T12-L1 level. The patient required emergency decompression surgery, but because of late diagnosis, she suffered a spinal cord injury with an ASIA-A classification. CONCLUSION: SDAVF is a disease with nonspecific initial symptoms, which can easily be mistaken for other pathologies. However, early recognition of the presence of the fistula, especially in cases of rupture, can improve prognosis and increase the chance of better outcomes. It is important to keep this condition in mind when evaluating patients with unexplained neurological symptoms and consider SDAVF as a differential diagnosis of acute coronary syndrome.

SICI-GISE/SICOA Consensus document: Clinical follow-up of patients after acute coronary syndrome or percutaneous coronary intervention

In the last decades, advances in percutaneous coronary intervention (PCI) strategies have significantly reduced the risk of procedural complications and in-hospital mortality of patients with acute coronary syndromes (ACS), thus increasing the population of stable post-ACS patients. This novel epidemiological scenario emphasizes the importance of implementing secondary preventive and follow-up strategies. The follow-up of patients after ACS or elective PCI should be based on common pathways and on the close collaboration between hospital cardiologists and primary care physicians. However, the follow-up strategies of these patients are still poorly standardized. This SICI-GISE/SICOA consensus document was conceived as a proposal for the long-term management of post-ACS or post-PCI patients based on their individual residual risk of cardiovascular adverse events. We defined five patient risk classes and five follow-up strategies including medical visits and examinations according to a specific time schedule. We also provided a short guidance for the selection of the appropriate imaging technique for the assessment of left ventricular ejection fraction and of non-invasive anatomical or functional tests for the detection of obstructive coronary artery disease. Physical and pharmacological stress echocardiography was identified as the first-line imaging technique in most of cases, while cardiovascular magnetic resonance should be preferred when an accurate evaluation of left ventricular ejection fraction is needed. The standardization of the follow-up pathways of patients with a history of ACS or elective PCI, shared between hospital doctors and primary care physicians, could result in a more cost-effective use of resources and potentially improve patient's long-term outcome.

Statin Therapy After Myocardial Infarction in Patients With Renal Failure: The Longer, the Merrier!

Among the ongoing clinical challenges for cardiologists in the 21 th century, there is the necessity of being able to cope with multimorbidity and polypharmacy. Irrespectively, beneficial drugs should be continued long-term, to ensure mortality and morbidity benefits continue to be accrued. This is evidently the case for the use of statins to improve long-term outcomes in chronic kidney disease (CKD) patients with acute coronary syndromes (ACS), as the combination of CKD and ACS represents a veritable crucible of adverse risk factors. Furthermore, statins have pleiotropic effects, including anti-inflammatory, antioxidant and endothelial-protective effects. Even though these effects are debated in CKD patients, it is biologically plausible that statins may reduce the inflammatory burden and improve glomerular hemodynamics. Awaiting for further clinical studies, for instance focused on the identification of possible biomarkers of statins action on renal function, it is pivotal to maintain our CKD patients with history of ACS on lifesaving medications such as statins.

Vitamin D deficiency in persons over 50 years of age with and without carotid artery atherosclerosis: a cross-sectional outpatient study

Highlights. The association between vitamin D levels and estimated glomerular filtration rate and triglyceride levels was revealed in people with cardiovascular risk factors aged older than 50 years. Vitamin D deficiency was more frequently noted in patients with acute coronary syndrome. They also were more likely to have abdominal obesity and type 2 diabetes mellitus, indicating the association between vitamin D deficiency and metabolic syndrome. The high prevalence of both vitamin D deficiency and metabolic syndrome in the population necessitates further larger-scale studies to identify the relationship between vitamin D levels and cardiovascular risk factors.Aim. To assess the level of vitamin D in people older than 50 years with the presence/ absence of carotid artery atherosclerosis.Methods. The single-stage observational study was conducted, the study included 70 outpatients over 50 years of age, of which 17 (24%) were men and 53 (76%) were women. The mean age of the patients was 66 (60; 72) years. All examined patients underwent history taking, anthropometry, biochemical examination of blood plasma with the determination of lipid spectrum, glucose, creatinine and estimated glomerular filtration rate, echocardiographic examination. The presence of carotid atherosclerosis was determined by ultrasound examination of the carotid arteries. The study of the level of 25-OH vitamin D in blood serum was carried out by enzyme immunoassay (25-OH vitamin D ELISA).Results. It was found that about half (46%) of the examined persons have insufficient levels of vitamin D in the blood plasma, while its deficiency (less than 20 ng/mL) was determined in 9% of patients. Individuals with carotid atherosclerosis had slightly lower levels of vitamin D than those without it, but the differences did not reach statistical significance. In acute coronary syndrome survivors, there was a statistically significant decrease in vitamin D levels, the vast majority of these patients had diabetes mellitus and abdominal obesity. Statistically significant moderate relationships were found between vitamin D levels and triglyceride levels (r = –0.33; p&lt;0.05) and estimated glomerular filtration rate (r = 0.26; p&lt;0.05), which confirms the association of vitamin D deficiency with metabolic syndrome. No statistical regularity was found between the level of vitamin D and other laboratory biochemical parameters, as well as morphological changes in the heart and blood vessels.Conclusion. Insufficient content of vitamin D in blood plasma is more common in individuals with a history of acute coronary syndrome, among them diabetes mellitus and abdominal obesity are more often detected, which confirms the relationship of vitamin D deficiency with metabolic syndrome.