Acute Coronary Syndrome Pts Research Articles

Analyzing the economic ramifications of the broad implementation of generic prasugrel

Abstract Introduction The 2023 European Acute Coronary Syndrome (ACS) guidelines state that prasugrel (PRG) should be considered in preference to ticagrelor (TCG) in patients (pts) who proceed to percutaneous coronary angioplasty (PCI). In Portugal, PRG is less available due to earlier evidence considering pretreatment and contraindications for each drug. PRG (10mg) is currently a generic drug, while TCG is not. We aimed to evaluate the proportion of pts that could be switched from TCG to PRG, and the economic impact of a widespread national adoption. Methods To determine eligibility for generic PRG 10mg, we examined a single center prospective database of consecutive ACS pts undergoing PCI in a full year. Eligibility for TCG and PRG was based on drug specific contraindications, previous stroke for PRG and chronic liver disease (CLD) for TCG, and indication for PRG dose reduction (≤60 kg and ≥75 years). To estimate hospital costs we used the price per pill indicated by the pharmacy (0.98€ TCG, 0.67€ PRG). To obtain post-discharge and NHS savings we used the INFARMED public information. We estimated 3500 PCIs per year on a national level, based on published data. Results A total of 780 pts were included, median age 68±10.4years, 523 (67.1%) were male, 51.9% (n=406) had non-ST elevation ACS. Mean admission time was 8.36 days. Considering PRG and TCG contraindications, 157 pts (20.3%) had a previous history of stroke and 20pts (2.6%) had CLD. 150 pts (19.2%) had PRG dose reduction criteria. Eligible for PRG 10mg and TCG 90mg were 434 pts (57.8% of total PCI pts). Cost per admission would be 33 697.35€ for TCG and 17 617.28€ for PRG. At a national level, hospital costs can be reduced by 16080.07€. Considering the 1-year outpatient setting and a widespread generic PRG 10mg adoption, NHS savings are estimated in 898 323.59€, and patient savings in 401248.25€ (198.38€ per patient). Conclusions ACS pts in real-world scenarios exhibit both eligibility for PRG and TCG. Considering the lower cost, the NHS can potentially save 914 403,66€ (figure 1) annually through the widespread adoption of generic PRG 10mg.

What is the prognosis for patients who develop new-onset atrial fibrillation in the first 48 hours after an acute coronary syndrome?

Abstract Atrial fibrillation (AF) is a common complication in acute coronary syndrome (ACS). However, treating patients (pts) with new-onset AF (NOAF) after an ACS remains a challenge. Although it seems intuitive that pts who develop AF within the first 48h have increased morbidity and mortality, your prognosis is unclear because there are no robust studies in the literature to confirm this association. Aim To characterize the population of pts who developed NOAF in the first 48 hours after an ACS and to compare the prognosis between these pts and pts who didn't develop AF. Methods 2916 ACS pts admitted consecutively in our coronary care unit during 6 years were analyzed retrospectively. Of these pts, 343 (11.7%) had AF within the first 48h, of which 99 (3.4%) had pre-existing AF and 243 (8.3%) presented NOAF. Pts were divided into two groups: group 1 -ACS pts who developed NOAF in the first 48h (n=243; 8.8%); group 2 – ACS pts who did not develop AF (n=2517; 91.2%). Pts with pre-existing AF were excluded (n=156; 5.4%). Primary endpoint were the occurrence of death at 6 months; follow-up was completed in 95.8% of pts. Results Group 1 pts were older (72±12 vs 62±13, p<0.001), with higher proportion of women (30,9% vs 20,9%, p<0.001), hypertensive (78,5% vs 60,7%, p<0.001), smokers (17,4% vs 32,6%, p<0.001), previous CABG (7,9% vs 3,8%, p=0.06) and stroke (10,7% vs 6,8%, p=0.035). Group 1 had a higher proportion of STEMI pts (58,5% vs 46,5%, p<0.001) and, during hospitalization, had more often respiratory infection (p<0.001), malignant arrhythmias (p<0.001), heart failure (p<0.001), stroke (p=0.001), higher values of NT-proBNP (p<0.001) increased C-reactive protein levels (p<0.001), leukocytes (p=0.020), peak of TropI (p=0.029) and creatinine (p<0.001). On echocardiography, group1 had greater LA diameter (45±6 VS 41±5mm, p<0.001), more frequent significant mitral regurgitation (13,9% vs 2,9%, p<0.001), worst LVEF (41±10% vs 46±10%, p<0.001) and a higher value of pulmonary artery pressure (39±12 vs 24±10, p<0.001). Group 1 were less likely to have undergone coronary revascularization (84% vs 74%, p=0.005). In multivariate analysis, age ≥75 (OR 1.05, p<0.001), LVEF ≤40% (OR 2.50, p<0.001), LA diameter (OR 1.59, p=0.027), more significant mitral regurgitation (OR 2.49, p=0.001) and Killip class >1 (OR 1.51, p=0.015) remained independent predictors of NOAF. In multivariate analysis and after adjusting for different baseline characteristics, pts with NOAF have the same risk of 6-months mortality compared to those who didn't develop AF [OR 1.03, p=0.91]. Conclusion The incidence of NOAF was 8.8% in our population, which is similar to the literature. Age, LVEF, LA diameter, a significant mitral regurgitation and Killip class >1 were independent predictors of NOAF after ACS. Pts with NOAF in the first 48h after an ACS had worse clinical manifestations during hospitalization but no higher 6-months mortality risk. Funding Acknowledgement Type of funding source: None

Prognostic impact of severe anemia (hemoglobin <10g/dL) during treatment with dual antiplatelet therapy after hospital discharge for acute coronary syndrome

Abstract Introduction In recent years, the use of invasive strategies has become the generalized approach in the management of patients with acute coronary syndrome (ACS), justified by the associated prognostic benefit due to reduced mortality and the evolution of percutaneous coronary intervention (PCI). However, the benefits of an invasive approach in ACS are unclear in the population with significant anemia, as anemia is strongly associated with increased risk of morbidity and mortality in these patients. Aim To determine the ischaemic vs. bleeding risks from patients with severe anemia (hemoglobin <10 g/dL) during treatment with Dual Antiplatelet Therapy (DAPT) after an ACS undergoing PCI. Methods From a national multicentre registry, we analyzed 17 370 ACS pts. Pts were divided into two groups: group 1 - pts with severe anemia (hemoglobin <10g/dL) (n=557, 3.2%); group 2 - pts without severe anemia (hemoglobin 10g/dL) (n=16813, 96.8%). Primary endpoint was the occurrence of a composite of death and adverse cardiovascular events (stroke, reinfarction, and rehospitalization of cardiovascular etiology) at 1 year. Results The sample consisted in 73.4% men and 26.6% women, with mean age of 66±14 years. The incidence of severe anemia was 3.2%. Group 1 pts were older (75±12 vs 66±14, p<0.001), had a higher proportion of women (47.6% vs 25.9%, p<0.001), diabetes (55% vs 30.6%, p<0.001), hypertension (81.8% vs 68.2%, p<0.001) and chronic kidney disease (29.2% vs 5.2%, p<0.001). During hospitalization, group 1 had more heart failure (35.3% vs 15.1%, p<0.001), worst LVEF (27.3% vs 17.3%, p<0,001), bleeding (7.6%% vs 1.3%, p<0.001) and transfusion (23.4% vs 1%, p<0.001). During hospitalization, group 2 pts were more likely to undergo revascularization (82.9% vs 89.4%, p<0.001) and double antiaggregation (82.5% vs 95%, p<0.001). A multivariate analysis identified age [OR 1.48, 95% CI 1.32 to 1.89; p<0.001] and feminine sex [OR 2.21, 95% CI 1.89 to 3.61; p<0.001] as independent predictors of severe anemia during hospitalization. Patients with severe anemia had longer hospital stay (9 days vs 6 days; p<0.001), and higher 6-month mortality (8.7% vs. 2.9%; p<0.001). In multivariate analysis and after adjusting for different baseline characteristics, pts with severe anemia had higher occurrence of a composite of death and adverse cardiovascular events at 1-year compared to those without severe anemia [OR 3.04, 95% CI 1.21 to 5.04; p=0.029]. Conclusion We objected a low prevalence of ACS patients with severe anemia undergoing PCI (52.2%) but the incidence of ICP in these complex patients has increased in recent years, mainly due to the evolution of PCI over the last 40 years. Severe anemia was strongly associated with increased risk of morbidity and mortality in ACS pts. Funding Acknowledgement Type of funding source: None

Ticagrelor monotherapy vs clopidogrel monotherapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention

Abstract Background P2Y12 inhibitor monotherapy with either clopidogrel or ticagrelor becomes an alternative antiplatelet strategy in patients (pts) undergoing percutaneous coronary intervention (PCI). The purpose of this study was to compare the efficacy and safety of clopidogrel vs. ticagrelor monotherapy in pts with acute coronary syndrome (ACS) undergoing PCI who cannot tolerate aspirin. Methods and results From January 1, 2014 to December 31, 2018, a total of 610 ACS pts (mean age 70.4±13.1 years, 72.1% men, 28.5% STEMI) that aspirin was stopped prematurely for various reasons and received either clopidogrel (n=369) or ticagrelor (n=241) monotherapy were included from 8 major hospitals in Taiwan. The duration (median and the 25th and 75th percentile) of aspirin treatment was 9 (1.39–37.00) days in the clopidogrel group and 10 (1.00–55.00) days in the ticagrelor group (p=0.514). Gastrointestinal bleeding (36.9%) was the most common reason to stop aspirin in both groups. The primary endpoint is the composite of all-cause mortality, recurrent ACS or unplanned revascularization, and stroke within 12 months after discharge. The safety endpoint was the major bleeding defined as BARC 3 or 5 bleedings. The covariates were balanced between groups after using inverse probability of treatment weighting. Overall, 84 patients developed events of primary endpoint, with 57 (15.4%) in the clopidogrel group and 27 (11.2%) in the ticagrelor group. After multivariate adjustment in the Cox proportional-hazards models, ticagrelor was associated with a lower risk of primary endpoint compared with clopidogrel (adjusted hazard ratio [aHR] 0.67, 95% CI 0.49–0.93). Among the primary endpoint, ticagrelor significantly reduced the risk of recurrent ACS or unplanned revascularization (aHR 0.46, 95% CI 0.28–0.75). There was no significant difference of all-cause mortality between the 2 groups (aHR 0.92, 95% CI 0.52–1.61). The risk of BARC 3 or 5 bleeding was also similar (aHR 0.71, 95% CI 0.35–1.45). Conclusions Among ACS patients undergoing PCI who cannot tolerate aspirin, ticagrelor monotherapy was associated with a significantly lower risk of a composite of cardiovascular events compared to clopidogrel monotherapy. The major bleeding risk was similar between groups. Funding Acknowledgement Type of funding source: None

Abstract 304: Characteristics of Acute Coronary Syndrome Patients Referred to the Bridge Transitional Care Clinic By Time to Readmission

Introduction: Prompt follow-up post-discharge is recommended by many readmission reduction initiatives. Identifying predictors of early readmission may inform discharge planning. We compared characteristics of acute coronary syndrome (ACS) patients (pts) based on time to readmission to determine factors associated with early readmission. Methods: Pts referred to the BRIDGE transitional care clinic following index admission for ACS from 2008-2017 were eligible. Demographics and inpatient clinical characteristics were compared between pts readmitted early (0-7 days post-discharge) versus late (8-30 days post-discharge). Multivariable logistic regression models were created to identify independent predictors of early readmission. Results: Of 1220 ACS pts, 198 were readmitted within 30 days; 70 (35.4%) were readmitted early, and 10.0% of these were readmitted for ACS. Early readmissions were more likely to be female, have an ED visit prior to readmission, and have an index ICU admission. Female sex [OR: 2.26, 95% CI: 1.23, 4.16] and ICU admission [OR: 2.20, 95% CI: 1.14, 4.24] were both independent predictors of early readmission. Conclusion: Female sex and ICU admission during index were associated with roughly twice the odds of early readmission. Non-white pts were also more often readmitted early (p=0.05), suggesting potential care disparities in this population. Future studies to identify pts at increased risk of early readmission and efforts to reduce disparities are warranted.

VISIT-TO-VISIT BLOOD PRESSURE VARIABILITY AND RISK OF ALL-CAUSE DEATH

Objective:The purpose of the study to elucidate possible association of visit-to-visit blood pressure variability with unfavorable outcome in patients with acute coronary syndrome (ACS) in real practice.Design and method:1502 ACS pts in the 4 PCI centers were included into ORACLE II (ObseRvation aft

TCT-367 Evolution of Plaque Volume and Lesion Morphology in Patients with Non-culprit Lesion-related Events: A serial VH-IVUS analysis from the PROSPECT study

Serial evolution in untreated coronary lesion morphology associated with and without cardiac events has not previously been prospectively described. In PROSPECT, 3-vessel grayscale and virtual histology intravascular ultrasound (VH)-IVUS was performed in 697 acute coronary syndrome pts following

Abstract 12492: Multimodality Intravascular Imaging Assessment of Plaque Erosion vs Plaque Rupture in Patients With Acute Coronary Syndrome

We used optical coherent tomography (OCT) and virtual histology intravascular ultrasound (VH-IVUS) to assess culprit lesions in 146 Korean pts with acute coronary syndrome (ACS). Methods: Culprit lesion plaque rupture (PR) or plaque erosion (PE) was diagnosed with OCT; and IVUS was used to determine arterial remodeling. PE (n=56) was the presence of intracoronary thrombus attached to the luminal surface with no detectable signs of fibrous cap rupture that was seen in 90 ACS pts with PR. Positive remodeling was a remodeling index (lesion/reference EEM [external elastic membrane] area) >1.05. Results: Pt age was 60±12 yrs in PR and 62±11 yrs in PE; 19% of PR vs 18% of PE were females. Overall, 25% (14/56) of PE had non-ST elevation myocardial infarction (NSTEMI) and 34% (19/56) had STEMI; conversely, 14.4% (13/90) of PR had NSTEMI and 71% (64/90) had STEMI (p<0.0001). Vessel size, minimal lumen area, and lumen area at the PR or PE site were similar; however, lesion length was longer in PR. Plaque area was smaller with negative remodeling in PE while PR showed positive remodeling with a larger necrotic core area by VH-IVUS (Table). By OCT, PE were fibrotic in 50% (28/56), fibrocalcific in 16% (9/56), and lipidic in 32.1% (18/56, all but one of which was a thick cap fibroatheroma). Conclusion: Multimodality intravascular imaging with OCT and VH-IVUS showed fundamentally different pathoanatomic substrates underlying plaque rupture and erosion in Asian pts.

TCT-377 Multimodality intravascular imaging assessment of plaque erosion vs plaque rupture in patients with acute coronary syndrome

We used optical coherent tomography (OCT) and virtual histology intravascular ultrasound (VH-IVUS) to assess culprit lesions in 146 Korean pts with acute coronary syndrome (ACS). Methods: Culprit lesion plaque rupture (PR) or plaque erosion (PE) was diagnosed with OCT; and IVUS was used to determine arterial remodeling. PE (n=56) was the presence of intracoronary thrombus attached to the luminal surface with no detectable signs of fibrous cap rupture that was seen in 90 ACS pts with PR. Positive remodeling was a remodeling index (lesion/reference EEM [external elastic membrane] area) >1.05. Results: Pt age was 60±12 yrs in PR and 62±11 yrs in PE; 19% of PR vs 18% of PE were females. Overall, 25% (14/56) of PE had non-ST elevation myocardial infarction (NSTEMI) and 34% (19/56) had STEMI; conversely, 14.4% (13/90) of PR had NSTEMI and 71% (64/90) had STEMI (p Conclusion: Multimodality intravascular imaging with OCT and VH-IVUS showed fundamentally different pathoanatomic substrates underlying plaque rupture and erosion in Asian pts.

Management of non ST-elevation acute coronary syndrome (NSTEACS) patients in New Zealand (NZ): A longitudinal analysis. Results from the NZACS national audits of 2002, 2007 and 2012

Background: The first New Zealand Acute Coronary Syndrome (ACS) National audit of 2002 was a collaborative effort between Clinicians and Nurses and demonstrated important limitations to NSTEACS patient (pt) care. A momentum for change was created. Subsequent audits in 2007 and 2012 allow assessment over time. Methods: Over 14 days, in May 2002, 2007 and 2012, pts with suspected ACS admitted to a hospital in NZ were audited. ‘Definite’ ACS pts were determined at discharge, after in-hospital investigations; we reviewed NSTEACS pts. Results: From 2002, more pts underwent risk stratification with assessment of left ventricular function (echocardiogram) and coronary anatomy (cardiac angiogram). Evidence-based in-hospital medical treatments and revascularisation have also increased over the decade (Table).Tabled 1200220072012PN (%*% of all ‘definite’ ACS Pts seen during the audit window.)620 (86%)742(90%)432 (81%)Hospital InvestigationsChest X-ray534 (86%)650 (88%)399 (92%)0.0067Echocardiogram115 (19%)116 (16%)139 (32%)<0.0001Exercise test (ETT)138 (22%)182 (25%)85 (20%)0.15Angiogram128 (21%)241 (32%)197 (46%)<0.0001No ETT/Angiogram383 (62%)362 (49%)187 (43%)<0.0001Hospital TreatmentsAspirin496 (80%)531 (72%)405 (94%)<0.0001Other anti-platelet56 (9%)248 (33%)318 (73%)<0.0001Any heparin369 (60%)403 (54%)312 (72%)<0.0001PCI**Percutaneous coronary intervention.37 (6%)118 (16%)99 (23%)<0.0001CABG***Coronary artery bypass graft. surgery21 (3%)19 (3%)24 (6%)0.027Times/OutcomesTime to angiogram (hr)72 (48,120)100 (62, 151)65 (32, 96)<0.0001Length of Stay (days)3 (2, 6)4.2 (2.6, 6.3)3.5 (1.8, 6.0)0.78In-hospital deaths12 (2%)8 (1%)10 (2.3%)0.23* % of all ‘definite’ ACS Pts seen during the audit window.** Percutaneous coronary intervention.*** Coronary artery bypass graft. Open table in a new tab Conclusion: Over a ten year period, evidence-based care for pts presenting with a NSTEACS event in NZ has improved. However, considerable room remains to optimise management particularly with prompt referral and delivery of angiography in these high-risk pts. CSANZ NZ AbstractsHeart, Lung and CirculationVol. 23Preview Full-Text PDF

Ivabradin treatment in patients with acute coronary syndrome

Purpose: To assess the efficacy and safety of early administration of ivabradin in addition to metoprolol in patients (pts) with acute coronary syndrome (ACS). Methods: The study included 98 ACS pts (64% men), mean age 72 (60; 76) years, with sinus rhythm and heart failure Killip class I. Pts were randomly assigned to metoprolol+ivabradin (M+Iv) group (n=50) and metoprolol (M) group (n=48) dose up-titration for 14 days. Mean doses were 100 (75; 125) mg for M and 10 (10; 10) mg for Iv in M+Iv group pts and 100 (100; 150) mg in M group pts. We evaluated heart rate (HR) at rest, systolic and diastolic blood pressure (BP), ECG parameters, incidence and duration of myocardial ischemia during 24 hour ECG monitoring and treadmill test, 6-minute walk test (6-MWT). The primary end point of efficacy was achievement of target HR less 60 bpm at the 14th day of treatment. The primary combined end point of safety included incidence of arterial hypotension, sinoatrial and atrioventricular conduction disturbance, bronchial obstruction and visual disturbance. Results: At the 14th day target HR by ECG measuring was achieved in 45 (90%) pts of M+Iv group and 40 (83%) pts of M group (p=0.33). Mean HR less 60 bpm measured by 24 hour ECG monitoring was observed in 38 (76%) and 30 (63%) respectively (p=0.14). There were no significant differences in BP level, incidence and duration ischemic episodes and result of 6-MWT. The primary combined end point of safety was documented in 9 (18%) pts of M+Iv group and 18 (38%) pts of M group (p=0.03). Conclusion: Combined treatment with metoprolol and ivabradine showed a favorable safety profile and same antiischemic activity compared with metoprolol up-titration regimen in ACS pts.

Adherence to guidelines on management of acute coronary syndrome in Russian hospitals is better in lower risk patients and this is associated with better outcomes of hospitalization

Purpose: It is known that following guidelines for management of acute coronary syndrome (ACS) is associated with better outcomes and that guidelines are more strictly followed in lower risk patients. We attempted to assess relationship between degree of adherence to guidelines and in-hospital outcomes irrespective of initial estimation of risk. Methods: Each key statement of guidelines issued in 2008-2011 (13 for STEACS, 12 for NSTEACS) was given weight of 1. Sum of these units constituted index of guideline adherence (IGA). IGA was retrospectively calculated for 1656 patients (pts) included in Russian ACS registry RECORD-2 (duration 04.2009 -04.2011). Pts were divided into 2 groups by quartiles of IGA distribution: 1) low adherence (quartiles I-II); 2) high adherence (quartiles III-IV). Results: In low compared with high adherence group there were more pts ≥65 years (p=0.0007), with chronic heart failure [CHF] (p<0.0001), previous stroke (p<0.0001), atrial fibrillation [AF] (p=0.0002), Killip class ≥II (p=0.0065), high risk of death by GRACE score (p=0.035). Mortality was 9.3 and 2.4% in low and high adherence group, respectively (p<0.0001). Belonging to IGA quartiles I-II was an independent predictor of death (odds ratio [OR] 4.0; 95% confidence interval [CI] 2.3-7.1; p<0.0001). From groups with low and high adherence to guidelines we selected pairs of pts (n=588) with similar age, ACS type, GRACE score, Killip class, other important risk factors, and formed 2 equal subgroups without significant differences in demographic, anamnestic, clinical and laboratory data. Mortality was 7.8 and 2.7% in low and high adherence subgroup, respectively (p<0.0001). Among pts excluded from this analysis because of lack of a pair (n=480) compared with those included there were more pts ≥65 (54.2 vs. 38.7%; p<0.0001), with Killip class ≥II (23.9 vs. 12.6%; p<0.0001), high risk of death by GRACE score (41.3 vs. 31.5%; p=0.0001), CHF (46.0 vs. 36.8%; p=0.0005), AF (17.5 vs. 12.6%; p=0.01), previous stroke (15.8 vs. 6.8%; p<0.0001), low guideline adherence (74.6 vs 50.0%; p<0.0001). Mortality was significantly higher in this subgroup of excluded pts (9.0 vs. 5.3%; p=0.007, or vs. 7.0% in abovementioned low adherence group). Conclusions: In RECORD2 registry among all ACS pts low adherence to guidelines was independent predictor of in-hospital death. But advantages of adherence to guidelines could be demonstrated only for subgroups of pts with lower risk. Adherence to guidelines in high risk pts was low. Statement of necessity to follow guidelines in all pts is to be accepted without formal proof.

THE ORGANIZATION OF MEDICAL CARE FOR ACUTE CORONARY SYNDROME PATIENTS IN PCI CAPABLE AND PCI NON-CAPABLE HOSPITALS FROM 2009-2012

Aim of the study. To evaluate the organization of medical care for acute coronary syndrome (ACS) patients in PCI capable and PCI non-capable hospitals from 2009-2012. Materials. Russian Registry of Acute Coronary Syndromes (ACS Registry) with an internet tracking was created in 2008 year. We performed an observational study of 139 882 ACS patients (56% M, 44% F; av. age - 65 years (56;75) [25%;75%]); ACS with ST elevation pts (ACS STe) - 45 707, ACS non ST elevation pts -84 603. Pts. were hospitalized due to ACS, prospectively enrolled in 167 hospitals from January 2009 to January 2013 in the ongoing ACS Registry. The ACS registry is carried out in cooperation with the Russian Ministry of Health. Results. The majority pts. before ACS had cardiovascular diseases and bad control of arterial hypertension. Many ACS STe pts to correspond for high risk in-hospital and 6-months death (GRACE risk score) (45,4% и 36,7%, accordingly). In 2012 fibrinolysis was used in 30,3% (positive dynamic on 8,3% from 2009). Percutaneous coronary interventions (PCI) for ACS STe pts. were used in 28,2% (primary PCI more than 80% pts). Conclusion. Russian ACS Registry may provide with information concerting characteristics and treatments of ACS pts. in different hospitals from Russia.

Improving Interventional Management of Acute Coronary Syndrome (ACS) Patients in New Zealand (NZ): A Comparison of the 2002, 2007 and 2012 National ACS Audits

Background: Invasive assessment and revascularisation is essential for optimal ACS patient (pt) management. The NZ Cardiac Society ACS audit group has provided ‘momentum’ for improved service provision over a decade. We assessed pts receiving invasive management over the three National ACS pts audits in May 2002, 2007 and most recently from the 2012 ‘SNAPSHOT’ audit.

Abstract 357: Effect of an Early Nurse Practitioner Based Transitional Care Program on Atrial Fibrillation Readmissions

Background: BRIDGE is a nurse practitioner (NP) based transitional care program for cardiac patients(pts) discharged from a large tertiary care health system. Attendance at the BRIDGE clinic has been shown to reduce early readmission and ED visits for acute coronary syndrome (ACS) pts. Little is known about causes of readmission for atrial fibrillation (AF) pts and whether an NP based program affects overall readmissions. Methods: Retrospective data on 1188 pts was abstracted from 2008 to 2010 for pts referred to BRIDGE. Early (30 day) readmission of pts with discharge diagnosis of AF underwent qualitative chart audit by a trained MD abstractor. When examining if BRIDGE affected readmissions, we excluded pts with ED visits/readmits prior to BRIDGE. Results: Median time to BRIDGE was 16 days. Of 1010 with complete data, 148 (15%) had a discharge diagnosis of AF; 110/148 (74%) AF pts attended BRIDGE. Thirty day readmission (30DR) for AF was 23% (34/148); 17/34 (57%) were sent to the ED by a MD or nurse. Attending BRIDGE had no effect on outcomes at all time points (table 1); 17 patients were readmitted before BRIDGE. Readmission at 6 months for AF was 41% for those who attended BRIDGE, 29% for those who did not (p=0.190). Table 2 details reasons for all 30DR in AF pts. Chart review demonstrated that all 30DR were appropriate, 83% (25/30) of non-elective readmissions were unavoidable, and of 5 potentially avoidable readmissions, 2 were due to patient non-compliance. Conclusions: 30-day readmission rates are high for pts recently discharged with a diagnosis of AF and most are unavoidable. A NP based transitional care clinic successful in reducing 30 day readmissions for ACS pts did not prevent either early or late readmissions in AF pts.

Abstract 9668: Comprehensive Analysis of Intravascular Ultrasonic and Angiographic Morphology of Culprit Lesions Between ST-Segment Elevation Myocardial Infarction and Non-ST-Segment Elevation Acute Coronary Syndrome

Background: Rupture of vulnerable plaque is a major cause of acute coronary syndrome (ACS), with some clots being partially or totally occlusive. However, it is not clear why some plaque ruptures lead to ST-segment elevation myocardial infarction (STEMI), whereas others cause non-ST-segment elevation ACS (NSTEACS). Methods: A consecutive 158 ACS pts whose culprit lesions imaged by preintervention intravascular ultrasound (IVUS) were enrolled (STEMI=81; NSTEACS=77). IVUS and angiographic findings of culprit lesions, and clinical demographics were compared between the groups. Results: Pts’ characteristics were identical except lower rate of prior statin use in pts with STEMI (20% vs 44%, p=0.001). Angiographic complex Ambrose lesion and thrombus were more common in STEMI than in NSTEACS (83% vs 62%, p=0.002; 51% vs 5%, p&lt;0.0001, respectively). In contrast, SYNTAX score was lower in STEMI (9±5 vs 12±7, p=0.01). In pts with STEMI, culprit echogenicity on IVUS was more hypoechoic (63% vs 40%, p=0.01), and the incidence of plaque rupture, attenuation and “microcalcification (granular calcification with attenuation)” were higher (53% vs 18%, p&lt;0.0001; 86% vs 68%, p=0.01; 75% vs 61%, p=0.04, respectively). Further, the max area of ruptured cavity, echo lucent zone and arc of microcalcification were significantly greater in STEMI compared with NSTEACS (1.8±1.0mm 2 vs 1.1±0.9mm 2 , p=0.006; 1.5±0.7mm 2 vs 1.2±0.8mm 2 , p=0.004; 100±55° vs 77±51°, p=0.01, respectively). On quantitative and color-coded IVUS, vessel and plaque area were significantly larger at min lumen area (MLA) site in STEMI (16.6±5.4mm 2 vs 14.2±5.5mm 2 , p=0.003; 13.9±5.1mm 2 vs 11.6±5.2mm 2 , p=0.003, respectively) and at max vessel area site (20.2±5.4mm 2 vs 18.0±6.4mm 2 , p=0.007; 13.7±4.1mm 2 vs 12.2±5.6mm 2 , p=0.02, respectively), leading to larger necrotic (6.8±3.8mm 2 vs 4.8±3.9mm 2 , p=0.04) and lipidic (1.5±0.6mm 2 vs 1.1±0.6mm 2 , p=0.02) tissue area at MLA site in STEMI as well as fibrotic tissue (7.3±2.5mm 2 vs 5.7±2.2mm 2 , p=0.03). Conclusion: Morphological feature (outward vessel remodeling and IVUS vulnerability [e.g. greater ruptured cavity, larger necrotic and lipidic tissue, and microcalcification]) of culprit lesions might relate to clinical presentation of pts with ACS.

Abstract 9569: Incidence of Acute Coronary Syndrome in the General Medicare Population, 1992-2009: A Real-World Perspective

Introduction: Acute coronary syndrome (ACS) is a major cause of mortality and morbidity among elderly patients in the US. We examined temporal trends in the incidence of ACS in Medicare patients over nearly two decades employing administrative data. Methods: The 5% Medicare database (~ 1.8 million pts/cohort yr) was used to identify ACS pts (age 65+, no ESRD) between 1992-2009. Medicare claims were used to identify patients hospitalized with ACS using the following ICD-9-CM diagnostic codes: acute myocardial infarction (AMI, 410) and unstable angina (UA, 411). Results: The incidence of ACS in the elderly Medicare population remained 2.4-2.5% between 1999-2002 and subsequently decreased to 1.7% by 2009 ("A" in the Figure). The trend was similar for all age, gender and race groups ("B" in the Figure) with the exception of patients &gt; 84 years, for whom the incidence of ACS increased from 2.8% in 1992 to 3.4% in 2002, before declining to 2.6% in 2009. The decrease in incidence of ACS since 2001 was driven by a decrease in diagnosis of UA (1.6-1.7% in 1992-1997 to 0.6% in 2009) but not in the diagnosis of AMI (holding steady between 1.2-1.4%), perhaps reflecting the introduction of more sensitive cardiac biomarkers. Conclusion: Improved cardiovascular outcomes in the US have also impacted elderly patients with ACS. In the last decade, there has been a steady progressive decline in the incidence of ACS in Medicare patients.

TCT-723 Transferring from Clopidogrel Loading Dose to Prasugrel Loading Dose in Acute Coronary Syndrome Patients: High on-Treatment Platelet Reactivity Analysis of the TRIPLET Trial

High on-treatment platelet reactivity (HPR) has been identified as an independent risk factor for ischemic events in acute coronary syndrome (ACS) patients (pts). In TRIPLET, ACS pts undergoing percutaneous coronary intervention (PCI) were given a prasugrel (pras) loading dose (LD) with or without a

THE REMODELING PARADOX AND CLINICAL OUTCOMES: INSIGHTS FROM PROSPECT

Although positive remodeling is a known marker of plaque instability, whether remodeling in angiographically mild non-culprit lesions (NCLs) prospectively predicts MACE has not been examined. 697 acute coronary syndrome pts were enrolled in the prospective, multicenter PROSPECT study and underwent

Do Acute Coronary Syndrome Patients Categorised at High Risk by GRACE Receive more Frequent and Earlier Coronary Angiography?

Background: The ESC recommends that Acute Coronary Syndrome (ACS) identified as high risk using the GRACE score undergo coronary angiography within 24 h. Our aim was to study how coronary investigation and management relate to risk in three New Zealand hospitals where GRACE is not routinely used. Method: Consecutive cohorts admitted to Middlemore, Taranaki and Waikato Hospitals with suspected ACS between August 2007 and August 2010 were recorded using the Acute Predict database. Patients (pts) were categorised low (<3%), intermediate (3–8%), and high risk (>8%) based on the GRACE admission-to-six month mortality score. Results: Of 3666 pts, 34%, 38% and 28% were low, intermediate and high risk, respectively. Europeans were more likely to be high risk than Maori, Pacific or Indians (32% vs 16%, 20%, and 20%, respectively). High risk pts were older, more likely to be women and to present with heart failure, impaired LV systolic function and severe coronary artery disease. However, high risk pts were less likely than low risk to receive coronary angiography (58 vs 83%, p < .001) and revascularisation (43 vs 58%, p < .001). The median time to angiogram was three days for all three risk groups, with no difference according to risk category at any centre. Conclusion: ACS pts categorised at high risk by GRACE score were least likely to receive coronary angiography and revascularisation, and were not prioritised ahead of lower risk pts. Routine use of a risk score to guide timing of coronary angiography post-ACS should be considered.