Risk Stratification In Acute Coronary Syndromes Research Articles

Exploring the Role of Non-HDL Cholesterol in Acute Coronary Syndrome: A Case-Control Study

Objectives: This case-control study aimed to investigate the association between non-high-density lipoprotein (non-HDL) cholesterol levels and acute coronary syndrome (ACS) among individuals not recently treated with statins. Methodology: A total of 100 participants with ACS, who had not received recent statin therapy, were selected from the Coronary Care Unit (CCU) at Al-Kadhimiyah Hospital in Baghdad, Iraq. Controls, matching the eligibility criteria of cases except for ACS symptoms, were randomly chosen from the same hospital. Both groups met criteria including age over 40, and a history of diabetes mellitus, hypertension, smoking, and obesity. Statistical significance was set at p < 0.05. Results: The study found a significant independent association between elevated non-HDL cholesterol levels and ACS, with an average non-HDL level of 154.2 mg/dl (normal: 130 mg/dl) among ACS cases (p < 0.001), compared to 120 mg/dl in controls. Elevated non-HDL levels were also correlated with increased BMI (p = 0.01, r = 0.3) and various lipid markers (p < 0.05), except HDL. Conclusion: Elevated non-HDL cholesterol levels upon admission may serve as a potential indicator of ACS risk. These findings underscore the importance of non-HDL cholesterol assessment in ACS risk stratification and management.

Hollow Crystallization COF Capsuled MOF Hybrids Depict Serum Metabolic Profiling for Precise Early Diagnosis and Risk Stratification of Acute Coronary Syndrome.

Acute coronary syndrome (ACS), comprising unstable angina (UA) and acute myocardial infarction (AMI), is the leading cause of death worldwide. Currently, lacking effective strategies for classifying ACS hinders the prognosis improvement of ACS patients. Disclosing the nature of metabolic disorders holds the potential to reflect disease progress and high-throughput mass spectrometry-based metabolic analysis is a promising tool for large-scale screening. Herein, a hollow crystallization COF capsuled MOF hybrids (UiO-66@HCOF) assisted serum metabolic analysis is developed for the early diagnosis and risk stratification of ACS. UiO-66@HCOF exhibits unrivaled chemical and structural stability as well as endowing satisfying desorption/ionization efficiency in the detection of metabolites. Paired with machine learning algorithms, early diagnosis of ACS is achieved with the area under the curve (AUC) value of 0.945 for validation sets. Besides, a comprehensive ACS risk stratification method is established, and the AUC value for the discrimination of ACS from healthy controls, and AMI from UA are 0.890, and 0.928. Moreover, the AUC value of the subtyping of AMI is 0.964. Finally, the potential biomarkers exhibit high sensitivity and specificity. This study makes metabolic molecular diagnosis a reality and provided new insight into the progress of ACS.

The prediction role of TIMI score in correlation with coronary angiogram to determine the coronary artery disease severity and extent in patients presenting with Non-ST Elevation Acute Coronary Syndrome

Background: Accurate risk stratification in patient clinically presented as a case of Non-ST Elevation acute coronary syndrome (NSTE-ACS) is important to assess the prognosis as well as to estimate the possible adverse event especially in those patient who are at high risk. Of these scoring risk; Thrombolysis In Myocardial Infarction (TIMI) risk score have been well corroborated to predict the possible prognosis for patients with NSTE-ACS. However, their value in estimation the severity of coronary artery disease (CAD) has been less studied. Objective: To determine the role of TIMI score in prediction the severity of CAD and its extent by correlate the TIMI score with coronary angiography in patients have NSTE-ACS. Patients and Methods: A cross section study, conducted on 264 successive patients admitted with Non-ST Elevation acute coronary syndrome at Ibn-Albitar cardiac center, Baghdad, Iraq, from the 1st of October 2017 to the 1st of October 2018. Patients were rearranging into three groups according to the seven standard variables of TIMI score. The extent of CAD was examined on coronary angiography; a lesion defined significant if stenosis ≥70% in any artery of three major coronary arteries or ≥50% of left main coronary artery. Results: The total number of was 246 patients, mean age was 62.5±2.3 years. There were 67 (27.2%) of them belong to group 1 (low risk group), 142 (57.7%) of them belong to group 2 (intermediate risk group), and 37 (15.1%) of them belong to group 3 (high risk group). 54.1% of patients in group 3 had significant three-vessels coronary artery disease on comparing with 17.6% of group 2 patients and only 7.5% of group 1 patients had these lesions on coronary angiography (P-value <0.01). On the other hand, one-vessel coronary artery disease occurs more commonly and significant statistically (P-value <0.01) in group 2 (31.7%) than in patients in group 1 (26.9%) and group 3 (10.8%). Conclusion: High TIMI risk score patients were more probably to have significant multi-vessels coronary lesions in comparison with those with TIMI risk score in intermediate or low range which lead to help in stratify the risk and possibility of early intervention. Keywords: Coronary Angiography, Non-ST Elevation Acute Coronary Syndrome, Acute Coronary Syndrome risk stratification, TIMI score.

Prevalence and prognostic importance of lung ultrasound findings in acute coronary syndrome: A systematic review.

Heart failure (HF) complicating acute coronary syndrome (ACS) is a herald of adverse outcomes. In this systematic review, we investigated the prevalence of lung ultrasound (LUS) findings and their prognostic utility among patients with ACS. We searched the online databases PubMed, EMBASE, and Web of Science for studies (full-text articles, published in English) that used LUS in adult patients with ACS [ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina]. Of 462 studies screened, five prospective, observational investigations published between 2010 and 2021 including 1087 patients met our inclusion criteria. Two studies employed 28-zone imaging protocols whereas three used eight-zone protocols. The proportion of patients with a prior HF diagnosis was ≤ 5% in all studies. The prevalence of B-lines was examined prior to or within 12hours after coronary angiogram and reporting varied between studies due to different imaging protocols or quantification methods. A higher number of B-lines on admission was associated with an increased risk for developing symptomatic HF during the baseline hospitalization and with a higher in-hospital mortality rate using either 8 or 28-zone protocols. A higher number of B-lines at baseline was also associated with an increased risk of subsequent HF hospitalization or all-cause death. Pulmonary congestion by LUS performed on admission appears to be a common finding among patients hospitalized for ACS and is associated with adverse in-hospital and long-term outcomes. Further investigations using standardized LUS protocols are warranted and have the potential to improve risk stratification in ACS.

Abstract 12915: Machine Learning Models Show That Age, Functional Status, and TNF-α Accurately Predicts Multimorbidity in Acute Coronary Syndrome

Introduction: Increasing prevalence of multimorbidity (>2 conditions) put individuals, especially older adults, at increased risk for acute coronary syndrome (ACS). Machine learning techniques provide an opportunity to identify clinical factors associated with multimorbidity that may aid in identifying subgroups of multimorbid patients that are at higher risk for ACS. Our primary objective was to use machine learning techniques to identify factors associated multimorbidity in individuals presenting to the emergency department (ED) for potential ACS. Hypothesis: Markers of chronologic and physiologic aging are associated with multimorbidity and vary by functional status and inflammatory profiles. Methods: This was a secondary analysis of data collected from a large multi-site study aimed at characterizing sex differences in symptoms suggestive of ACS in the ED. Variables of interests were measured with the Charlson Comorbidity Index, the Duke Activity Status Index, and serum cytokines (TNF-α, IL-6, and IL-18). A logistic regression model was applied to a sample of 414 patients utilizing a 70/30 test/train split to determine if biomarkers, functional status, sex, and age were associated with multimorbidity. Results: Patients were predominantly male (62.5%), white (73.0%), and had a mean age of 58.9 years. The accuracy of the model in predicting multimorbidity was 86.8% in the training set (n=290). In validation testing, accuracy was 73.0% (n=124). Functional status (OR .960, 95% CI .94-.206, p<0.000), age (OR 1.10, 95% CI 1.04-1.10, p<0.000), and TNF- α (OR 2.21, 95% CI 1.17-4.45, p<0.000), were associated with multimorbidity. The overall model was significant with a χ 2 (286, N=71.1) = 6, p>0.05. A responder operator curve was run on the individual variables and age, functional status, and TNF- α and showed significant discrimination levels (c-statistic 0.74, 0.73, and 0.65, respectively). Conclusions: Multimorbidity increases the risk for ACS. TNF-α, functional status, and age improved models of ACS risk stratification in a heterogeneous sample of multimorbid patients. Machine learning methodologies exhibit utility in identifying potential clinical markers of multimorbidity.

Association of Platelet Lymphocyte Ratio (PLR) and Neutrophil Lymphocyte Ratio (NLR) with Global Registry of Acute Coronary Events (GRACE) Score in Acute Coronary Syndrome

Introduction: Acute Coronary Syndrome (ACS) has morbidity and mortality significantly increase, it requires risk stratification for the assessment and selection of initial invasive strategies. The Global Registry of Acute Coronary Events (GRACE) scores recommended as risk stratification of ACS. Some of studies found that the combination of GRACE scores with other clinical and laboratory parameters can increase predictive value of ACS. Platelet Lymphocyte Ratio (PLR) and Neutrophil Lymphocyte Ratio (NLR) act as parameter of systemic inflammation in ACS. Aims of the study to determine the association between PLR and NLR with risk stratification GRACE score. Method: This study is analytical with a cross-sectional retrospective design. This study included 70 patients with a diagnosis of ACS based on medical record data. Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) 22.0. P-value <0.05 was considered statistically significant. Results: This study was found a positive correlation between PLR and NLR with the GRACE score of patients ACS (r=0.485, p<0.001; r=0.570, p<0.001). The PLR and NLR were both found the significantly higher in the high risk GRACE score respectively (188 ± 47, p < 0.001; 7.9± 2.7, p<0.001). The ROC curve analysis, cutt-off PLR of 123 and above (sensitivity of 72.7 %; specificity of 70.3), while cutt-off NLR of 4 and above (sensitivity of 78.8%; specificity of 70.3%) to detect high risk GRACE score. Conclusion: There is a significant association between PLR and NLR with GRACE score Keywords: Platelet Lymphocyte Ratio, Neutrophil Lymphocyte Ratio, GRACE score, Acute Coronary Syndrome.

Association of biomarkers of fibrinolysis and inflammation with mortality in acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Universidad de Buenos Aires. Introduction in acute coronary syndromes (ACS), plaque rupture elicits a prothrombotic response that is counter balanced by a fibrinolytic response. D-dimer (DD) serves as a marker of both processes, reflecting thrombin activity and through cross-linked fibrin degradation. Inflammatory mediators are also involved, evidenced with the rise of C-reactive protein (CPR) levels, enhancing the prothrombotic and proatherogenic endothelial vascular response. Current evidence with these biomarkers has shown conflicting results with no conclusive impact on cardiovascular outcomes, risk stratification nor potential treatments. Purpose our aim was to determine an association between DD and CRP with in-hospital and 1-year mortality in patients with ACS. Methods observational study of patients admitted to a coronary care unit with ACS and elevated troponin. Clinical characteristics, in-hospital and 1-year outcomes and serum levels at admission of DD and CRP were assessed. Results we included 127 patients with ACS. Mean age was 68.4 ± 12.8 years and 61% were male, 57.7% had hypertension, 17.1% had dyslipidemia, 25.2% had diabetes and 17.9% had previous myocardial infarction. Most patients received DAPT and 67.5% underwent PCI or CABG during the index hospitalization. In-hospital mortality was 5.7% and 1-year all-cause and cardiovascular mortality were 14.6% and 9.7% respectively. The median of admission DD for patients who died during hospital stay was higher than those who survived (4.59 [IQR 1.94-6.05 ug/ml FEU] vs 0.56 [IQR 0.31-1.12 ug/ml FEU], p = 0.001). At 1-year follow-up, the median of admission DD for patients who died was significantly higher than those who survived: 1.55 (IQR 0.91-5.08 ug/ml FEU) vs. 0.53 (IQR 0.29-0.90 ug/ml FEU), p < 0.001 (figure A). We analyzed positive DD vs. negative DD at admission, with 0.5 ug/ml FEU cut-off value, almost a quarter of the positive patients were dead at 1-year follow up (22.4% vs. 2.4% negative DD, p= 0.011). We found a positive significative correlation between DD and CRP levels (R = 0.56, p < 0.001) (figure B). Conclusion high levels of DD at admission were strongly associated with in-hospital and 1-year mortality. Significant correlations with CRP could explain the inflammatory nature that lead to poorer outcomes. DD could be useful in risk-stratification in ACS; however, a specific threshold should be defined for this type of patients. Abstract Figure A. Figure B.

Correlation of plasma N-acetyl-neuraminic acid level with TIMI risk stratification and clinical outcomes in patients with acute coronary syndrome

To explore the correlation of plasma N-acetyl-neuraminic acid level with Thrombolysis In Myocardial Infarction (TIMI) risk score and clinical outcomes of patients with acute coronary syndrome (ACS). We consecutively enrolled 708 consecutive patients (401 male and 307 female, mean age 63.6±10.6 years) undergoing coronary angiography in our hospital between October, 2018 and July, 2019, including 597 patients with ACS and 111 without ACS (control group). The patients with ACS group were divided into high (n=104), moderate (n=425) and low (n=68) risk groups according to their TIMI risk scores. All the participants were examined for plasma Neu5Ac level using liquid chromatography-tandem mass spectrometry and underwent coronary angiography with their Gensini scores calculated. The patients with ACS were followed up after discharge for a mean of 15 months for the occurrence of major adverse cardiac events (Mace). Binary logistic regression analysis was performed to identify the risk factors of Mace in these patients. Plasma Neu5Ac levels were significantly higher in ACS group than in the control group (P < 0.05). ROC curve analysis showed that plasma Neu5Ac level could assist in the diagnosis of ACS (0.648 [0.597-0.699]) with a sensitivity of 39.2% and a specificity of 86.5% at the cutoff value of 288.50 ng/mL. In the ACS patients, plasma Neu5Ac level was significantly higher in the high-risk group than in the moderate-risk and low-risk groups (P < 0.05) and could assist in the diagnosis of a high risk (0.645 [0.588-0.703]) with a sensitivity of 42.3% and a specificity of 80.1% at the cutoff value of 327.50 ng/ mL. Plasma Neu5Ac was positively correlated with age, serum uric acid, creatinine, lipoprotein a, Ddimer, C-reactive protein, MB isoform of creatine kinase and Gensini score and negatively correlated with high-density lipoprotein level. During the followup, 80 ACS patients experienced Mace, who had significantly higher plasma Neu5Ac level than those without Mace (n=517). Logistic regression analysis showed that plasma Neu5Ac level and a history of previous stroke were independent risk factors for the occurrence of Mace. Plasma Neu5Ac level can provide assistance in the diagnosis and risk stratification of ACS and is an independent risk factor for prognosis of ACS patients.

Association between the ratio of serum n-3 to n-6 polyunsaturated fatty acids and acute coronary syndrome in non-obese patients with coronary risk factor: a multicenter cross-sectional study

BackgroundPrevious studies have reported that being overweight, obese, or underweight is a risk factor for ischemic cardiovascular disease (CVD); however, CVD also occurs in subjects with ideal body mass index (BMI). Recently, the balance of n-3/n-6 polyunsaturated fatty acids (PUFAs) has received attention as a risk marker for CVD but, so far, no study has been conducted that investigates the association between BMI and the balance of n-3/n-6 PUFAs for CVD risk.MethodsWe evaluated the association between n-3/n-6 PUFA ratio and acute coronary syndrome (ACS) in three BMI-based groups (< 25: low BMI, 25–27.5: moderate BMI, and ≥ 27.5: high BMI) that included 1666 patients who visited the cardiovascular medicine departments of five hospitals located in urban areas in Japan.ResultsThe prevalence of ACS events was 9.2, 7.3, and 10.3% in the low, moderate, and high BMI groups, respectively. We analyzed the relationship between ACS events and several factors, including docosahexaenoic acid/arachidonic acid (DHA/AA) ratio by multivariate logistic analyses. In the low BMI group, a history of smoking (odds ratio [OR]: 2.47, 95% confidence interval [CI]: 1.40–4.35) and low DHA/AA ratio (OR: 0.30, 95% CI: 0.12–0.74) strongly predicted ACS. These associations were also present in the moderate BMI group but the magnitude of the association was much weaker (ORs are 1.47 [95% CI: 0.54–4.01] for smoking and 0.63 [95% CI: 0.13–3.10] for DHA/AA). In the high BMI group, the association of DHA/AA (OR: 1.98, 95% CI: 0.48–8.24) was reversed and only high HbA1c (OR: 1.46, 95% CI: 1.03–2.08) strongly predicted ACS. The interaction test for OR estimates (two degrees of freedom) showed moderate evidence for reverse DHA/AA ratio–ACS associations among the BMI groups (P = 0.091).ConclusionsDHA/AA ratio may be a useful marker for risk stratification of ACS, especially in non-obese patients.

Machine Intelligence in Cardiovascular Medicine.

The computer science technology trend called artificial intelligence (AI) is not new. Both machine learning and deep learning AI applications have recently begun to impact cardiovascular medicine. Scientists working in the AI domain have long recognized the importance of data quality and provenance to AI algorithm efficiency and accuracy. A diverse array of cardiovascular raw data sources of variable quality-electronic medical records, radiological picture archiving and communication systems, laboratory results, omics, etc.-are available to train AI algorithms for predictive modeling of clinical outcomes (in-hospital mortality, acute coronary syndrome risk stratification, etc.), accelerated image interpretation (edge detection, tissue characterization, etc.) and enhanced phenotyping of heterogeneous conditions (heart failure with preserved ejection fraction, hypertension, etc.). A number of software as medical device narrow AI products for cardiac arrhythmia characterization and advanced image deconvolution are now Food and Drug Administration approved, and many others are in the pipeline. Present and future health professionals using AI-infused analytics and wearable devices have 3 critical roles to play in their informed development and ethical application in practice: (1) medical domain experts providing clinical context to computer and data scientists, (2) data stewards assuring the quality, relevance and provenance of data inputs, and (3) real-time and post-hoc interpreters of AI black box solutions and recommendations to patients. The next wave of so-called contextual adaption AI technologies will more closely approximate human decision-making, potentially augmenting cardiologists' real-time performance in emergency rooms, catheterization laboratories, imaging suites, and clinics. However, before such higher order AI technologies are adopted in the clinical setting and by healthcare systems, regulatory agencies, and industry must jointly develop robust AI standards of practice and transparent technology insertion rule sets.

Left ventricular ejection fraction adds value over the GRACE score in prediction of 6-month mortality after ACS: the MADDEC study.

BackgroundReduced left ventricular ejection fraction (LVEF) is a risk marker for mortality after an acute coronary syndrome (ACS). Global Registry of Acute Coronary Events (GRACE) risk score, developed almost two decades ago, is the preferred scoring system for risk stratification in ACS. The aim of this study was to validate the GRACE score and evaluate whether LVEF has incremental predictive value over the GRACE in predicting 6-month mortality after ACS in a contemporary setting.MethodsA retrospective analysis of all 1576 consecutive patients who were admitted to Tays Heart Hospital and underwent coronary angiography for a first episode of ACS (2015–2016). Clinical risk factors were extensively recorded. Adjusted Cox regression analysis was used to analyse the associations between LVEF and the GRACE score with 6-month all-cause mortality. The incremental predictive value was assessed by the change in C-statistic by Delong’s method for paired samples and by index of discrimination improvement (IDI).ResultsIn univariable analysis, both LVEF and the GRACE were associated with 6-month mortality, and after applying both variables into the same model, the results remained significant (GRACE score: HR: 1.036, 95% CI 1.030 to 1.042; LVEF: HR: 0.965, 95% CI 0.948 to 0.982, both HRs corresponding to a one unit change in the exposure variable). The GRACE score demonstrated good discrimination for mortality (C-statistic: 0.833, 95% CI 0.795 to 0.871). Adding LVEF to the model with the GRACE score improved model performance significantly (C-statistic: 0.848, 95% CI 0.813 to 0.883, p=0.029 for the improvement and IDI 0.0171, 95% CI 0.0016 to 0.0327, p=0.031).ConclusionsAdding LVEF to the GRACE score significantly improves risk prediction of 6-month mortality after ACS.

The Mean Platelet Volume in the Prognosis of Coronary Artery Disease Severity and Risk Stratification of Acute Coronary Syndromes.

Introduction:Platelets play a crucial role in thrombotic episodes. Mean Platelet Volume (MPV) is the primary indicator of platelet’s activation; its measurement is easy and time-effective.Aim:We tested the hypothesis that MPV is correlated with SYNTAX score in patients that suffered from an Acute Coronary Syndrome (ACS).Material and Methods:One hundred and four (104) patients (79 male–25 female, mean age 64.2±11.1 years), who were hospitalized for an ACS and underwent coronary angiography, were included in the study. Syntax score, as an indicator of the severity of coronary artery disease (CAD), was calculated. We tried to investigate the correlation between the first measured MPV, CRP, Creatinine and high sensitivity Troponin with the Syntax score of the patient and the association of MPV and a possible Major Advanced Cardiac Event (MACE) during hospitalization.Results:The patients were divided into four groups according to the SYNTAX score: Group A (SYNTAX score: 0, n=12), group B: Mild CAD (SYNTAX score: 1–22, n=68), group C: Moderate CAD (SYNTAX score: 23–32, n=12), and group D: Severe CAD (SYNTAX score: ≥ 33, n=12). Four patients (3.8%) developed a MACE during their hospitalization. MPV was significantly correlated to Syntax score (r=0.658, p<0.001) and was found to be an independent predictor factor of MACE with HR=6.8 (95% Confidence Interval 1.46-33.36). The cut-off value of MPV was 7.5 with a sensitivity of 98% and a specificity of 30.8%.Conclusion:We determined a positive correlation between MPV and Syntax score, transforming this simple test in a possible factor of risk stratification in ACS.

Accuracy of the Global Registry of Acute Coronary Events (GRACE) Risk Score in Contemporary Treatment of Patients With Acute Coronary Syndrome

BackgroundGlobal Registry of Acute Coronary Events (GRACE) score has been routinely used for risk stratification in acute coronary syndromes (ACS). We aimed to investigate whether the GRACE score has remained relevant with contemporary treatment of patients with ACS. MethodsIncluded were patients with ACS in the Acute Coronary Syndrome Israeli Survey (ACSIS). Patients were divided into high (> 140) and low–intermediate (≤ 140) GRACE score. Outcomes were compared for each GRACE score group among patients enrolled in early (2000 to 2006), mid (2008 to 2010) and late (2013 to 2016) surveys. ResultsIncluded were 4931 patients. For patients with GRACE scores > 140, temporal improvements in therapy were associated with reduced 7-day all-cause mortality (5.7%, 4.1%, and 2.0% for patients in early, mid-, and late surveys, respectively, P = 0.01) and 1-year mortality rates (27.8%, 25.3%, and 21.8% for patients in early, mid-, and late surveys, respectively, P = 0.07). Among patients with GRACE scores ≤ 140, all-cause mortality rates at 1 year were lower among participants enrolled in recent surveys (5.3%, 3.5%, and 3.1% for patients in early, mid-, and late surveys, respectively, P = 0.01). No significant differences in the accuracy of the GRACE score in predicting 7-day mortality were observed, (area under the curve [AUC] = 0.83, 0.87, and 0.75 for early, mid-, and late surveys, respectively, P = NS). Similarly, for 1-year all-cause mortality, the accuracy of the GRACE score remained comparable (AUC = 0.79, 0.84, and 0.82 for early, mid-, and late surveys, respectively, P = NS). ConclusionsOur results validated the accuracy of the GRACE score for risk stratification in ACS. The discrimination of the score has not been influenced by the better outcome with latest treatment.

National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016.

The modern care of suspected and confirmed acute coronary syndrome (ACS) is informed by an extensive and evolving evidence base. This clinical practice guideline focuses on key components of management associated with improved clinical outcomes for patients with chest pain or ACS. These are presented as recommendations that have been graded on both the strength of evidence and the likely absolute benefit versus harm. Additional considerations influencing the delivery of specific therapies and management strategies are presented as practice points. This guideline provides advice on the standardised assessment and management of patients with suspected ACS, including the implementation of clinical assessment pathways and subsequent functional and anatomical testing. It provides guidance on the: diagnosis and risk stratification of ACS; provision of acute reperfusion therapy and immediate post-fibrinolysis care for patients with ST segment elevation myocardial infarction; risk stratification informing the use of routine versus selective invasive management for patients with non-ST segment elevation ACS; administration of antithrombotic therapies in the acute setting and considerations affecting their long term use; and implementation of an individualised secondary prevention plan that includes both pharmacotherapies and cardiac rehabilitation. Changes in management as a result of the guideline: This guideline has been designed to facilitate the systematic integration of the recommendations into a standardised approach to ACS care, while also allowing for contextual adaptation of the recommendations in response to the individual's needs and preferences. The provision of ACS care should be subject to continuous monitoring, feedback and improvement of quality and patient outcomes.

From Mars to Venus: Gender Differences in the Management and Outcomes of Acute Coronary Syndromes.

Ischemic heart disease remains a leading cause of morbidity and mortality in industrialized nations, and contributes substantially to healthcare expenditure worldwide. As the evidence base in acute coronary syndromes (ACS) has expanded dramatically over decades, longitudinal data demonstrate improvements in risk factor modification, organization of healthcare systems, and disease management that have substantially attenuated the adverse prognosis of both ST-segment elevation myocardial infarction (STEMI) and non-STsegment elevation ACS (NSTE-ACS). Nevertheless, discrepancies remain between genders, and women with ACS often sustain worse outcomes than men. In this review, we focus on the gender and sex-specific commonalities and differences in the pathophysiology, clinical presentations, diagnosis, and risk stratification of ACS. We highlight available data on the interactions between gender and efficacy of current pharmacological and interventional treatment for NSTE-ACS and STEMI. We also examine gender differences in the trends of clinical outcomes, and possible mechanisms that account for persistent care gaps where future efforts can be directed.

Hs-Troponin I Followed by CT Angiography Improves Acute Coronary Syndrome Risk Stratification Accuracy and Work-Up in Acute Chest Pain Patients: Results From ROMICAT II Trial

ObjectivesThis study compared diagnostic accuracy of conventional troponin/traditional coronary artery disease (CAD) assessment and highly sensitive troponin (hsTn) I/advanced CAD assessment for acute coronary syndrome (ACS) during the index hospitalization. BackgroundhsTnI and advanced assessment of CAD using coronary computed tomography angiography (CTA) are promising candidates to improve the accuracy of emergency department evaluation of patients with suspected ACS. MethodsWe performed an observational cohort study in patients with suspected ACS enrolled in the ROMICAT II (Rule Out Myocardial Infarction/Ischemia using Computer Assisted Tomography) trial and randomized to coronary CTA who also had hsTnI measurement at the time of the emergency department presentation. We assessed coronary CTA for traditional (no CAD, nonobstructive CAD, ≥50% stenosis) and advanced features of CAD (≥50% stenosis, high-risk plaque features: positive remodeling, low <30-Hounsfield units plaque, napkin-ring sign, spotty calcium). ResultsOf 160 patients (mean age: 53 ± 8 years, 40% women) 10.6% were diagnosed with ACS. The ACS rate in patients with hsTnI below the limit of detection (n = 9, 5.6%), intermediate (n = 139, 86.9%), and above the 99th percentile (n = 12, 7.5%) was 0%, 8.6%, and 58.3%, respectively. Absence of ≥50% stenosis and high-risk plaque ruled out ACS in patients with intermediate hsTnI (n = 87, 54.4%; ACS rate 0%), whereas patients with both ≥50% stenosis and high-risk plaque were at high risk (n = 13, 8.1%; ACS rate 69.2%) and patients with either ≥50% stenosis or high-risk plaque were at intermediate risk for ACS (n = 39, 24.4%; ACS rate 7.7%). hsTnI/advanced coronary CTA assessment significantly improved the diagnostic accuracy for ACS as compared to conventional troponin/traditional coronary CTA (area under the curve 0.84, 95% confidence interval [CI]: 0.80 to .88 vs. 0.74, 95% CI: 0.70 to 0.78; p < 0.001). ConclusionshsTnI at the time of presentation followed by early advanced coronary CTA assessment improves the risk stratification and diagnostic accuracy for ACS as compared to conventional troponin and traditional coronary CTA assessment. (Multicenter Study to Rule Out Myocardial Infarction/Ischemia by Cardiac Computed Tomography [ROMICAT-II]; NCT01084239)

Abstract 273: Myocardial Infarction with Non Obstructive Coronary Artery Disease: Prevalence, Clinical Features and Outcomes

Background: Myocardial infarction with non-obstructive coronary arteries (MINOCA) is an enigma that is being increasingly recognized with the frequent use of angiography following Acute Myocardial Infarction (AMI). The current study is a prospective, contemporary analysis of MINOCA vs. Myocardial Infarction with obstructive coronary artery disease (MI-CAD) in regards to prevalence, clinical features, and in-hospital outcomes. Methods: All consecutive patients undergoing coronary angiography for AMI (as per the Third Universal AMI Definition) in South Australian public hospitals from January 2012 - December 2013 were included. Data was captured by Coronary Angiogram Database of South Australia (CADOSA), a comprehensive registry compatible with the NCDR® CathPCI® Registry. The AMI patients were classified as MI-CAD or MINOCA on the basis of the presence or absence of a significant stenosis (≥50%) on angiography. Results: From 4,189 angiography procedures undertaken for AMI, 468 (11%) were classified as MINOCA. Patients with MINOCA were younger (59±15 vs. 64±13 years, p &lt;0.01) and more likely to be female (53% vs. 26%, p &lt;0.01), compared to those with MI-CAD. Age-adjusted analysis comparing patients with MINOCA to MI-CAD revealed differences in: (1) cardiovascular risk factors including hypertension (52% vs. 66%, p&lt;0.01), diabetes (19% vs. 32%, p&lt;0.01), dyslipidemia (46% vs. 62%, p&lt;0.01), and current smoker status (27% vs. 37% p&lt;0.01); (2) AMI type and size with fewer ST elevation myocardial infarcts (27% vs. 41%, p&lt;0.01) and lower peak troponin values (180 ng/L, IQR 353 vs. 264 ng/L, IQR 680, p&lt;0.01) amongst MINOCA patients. Furthermore, the GRACE Score for acute coronary syndrome risk stratification was lower for the MINOCA patients compared to MICAD (150±34 versus 160±35, p &lt;0.01). Despite fewer cardiovascular risk factors, the absence of obstructive coronary artery disease, smaller infarcts, and a lower GRACE score, the in-hospital mortality was similar for MINOCA and MI-CAD patients (2.2% vs. 3.0%, p=0.22). Moreover, MINOCA patients were less likely to receive secondary prevention therapies at discharge including antiplatelet therapy (60% vs. 92%, p&lt;0.01) beta-blockers (41% vs. 65%, p&lt;0.01), statin (55% vs. 88%, p&lt;0.01), ACE-inhibitor/angiotensin receptor blocker (59% versus 81%, p&lt;0.01), or referral to cardiac rehabilitation (15% versus 52%, p&lt;0.01). Conclusions: In contemporary cardiology practice, MINOCA may be more frequent than previously appreciated and has a guarded prognosis despite its apparent lower risk profile. Improving the use of secondary prevention therapies in these patients may improve their prognosis.

0243: Complete blood count in risk stratification of acute coronary syndromes: a routine blood test, many analytical parameters, which is the best?

Risk stratification is a key element to treatment optimization and prognostic assessment in acute coronary syndromes (ACS). The aim of the present study was to evaluate and compare the predictive power (PP) of 6 month mortality (6M) of different complete blood count parameters in patients (P) with ACS. Retrospective study including P with ACS consecutively admitted to a coronary care unit over 4 years and a minimal 6 month follow-up. In all P the following CBC parameters were evaluated in the first 24 hours: hemoglobin (Hg), hematocrit (Htc), red blood cell distribution width (RDW) and platelets (Pl). In a subgroup of 540 P admitted over a 1 year, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), leukocytes (L) and neutrophils (N) were also evaluated. We included 1906 P (mean age 64±13y; 49,9% with ST-elevation infarction). The in-hospital mortality was 3,9% and 6M was 8,9%. After calculation of 6M AUC, only Hg (0,712; p<0,001), Htc (0,703; p<0,001) and RDW (0,622; p=0,05) had PP of 6M. There were no statistically significant differences between the PP of Hg, Hct and RDW. From the cut-off values obtained, a multivariate logistic regression model was constructed. Only Hct and RDW persisted as independent predictors of 6M, with an OR of 3,6 (CI 95%; 2,18-40,43; p<0,001) and 2,8 (CI 95%; 1,04-7,67; p=0,04), respectively. In a subgroup of P, in addition to previous parameters, L (0,598; p=0,04) and N (0,619; p=0,014) also had PP of 6M. There were no statistically significant differences between the PP of Hg, Hct, RDW, L and N, with the exception of RDW that had a stronger PP than L (p=0.032). After multivariate analysis, L and N also persisted as independent predictors of 6M, with an OR of 5,1 (CI 95%; 1,42-18,18; p=0,012) and 3,0 (CI 95%; 1,04-8,74; p=0,04), respectively. CBC is a routine blood test, which includes parameters that without extra costs can be helpful in risk stratification of ACS. In the present study, Hg, Hct, RDW, L and N had PP for 6M in ACS. There were no significant differences regarding the PP of 6M between these variables, with the exception of RWD that had a stronger PP than L.

Abstract 18506: Relief of Myocardial Edema in Advanced Decompensated Heart Failure is Associated with Improved Left Ventricular Systolic and Diastolic Function

Introduction: Cardiac magnetic resonance (CMR) imaging with quantitative T2-mapping allows identi[[Unable to Display Character: &amp;#64257;]]cation of myocardial edema, improving risk-stratification in acute coronary syndromes and myocarditis. Hypothesis: Global myocardial edema contributes to left ventricular (LV) dysfunction in advanced decompensated heart failure (ADHF). Methods: CMR with quantitative T2-mapping was performed in consecutive ADHF patients (n=17) undergoing right heart catheterization for worsening dyspnea and volume overload. Patients received vasodilators and diuretics to achieve pulmonary capillary wedge pressure (PCWP) ≤18 mmHg and central venous pressure (CVP) ≤10 mmHg, while maintaining mean arterial pressure ≥65 mmHg. After reaching hemodynamic targets, the pulmonary arterial catheter was removed and CMR imaging repeated. Changes in LV T2-values, hemodynamics, and CMR volumetric measurements were compared. Results: Study patients (64±11 years, male 88%, LV ejection fraction 23±8%, ischemic cardiomyopathy 50%) received decongestive treatment during 5±2 days. PCWP and CVP decreased from 25±7 to 17±4 mmHg and 13±6 to 7±3 mmHg, respectively (p&lt;0.001 for both), while cardiac index increased from 2.14±0.60 to 2.58±0.49 L/min/m 2 (p=0.012). LV T2-values dropped consistently from 59.6±4.9 ms to 56.3±5.2 ms after decongestion (p=0.002; Figure). Decreasing LV T2-values correlated well to both decreasing PCWP (r=0.75; p=0.001) and increasing cardiac index (r=0.58; p=0.023). Although LV end-diastolic volume index (142±31 to 135±34 mL/m 2 ; p=0.033) and end-systolic volume index (110±29 to 99±33 mL/m 2 ; p=0.001) both decreased significantly, the extent of these changes were not correlated to changing T2-values (r=0 and 0.11, respectively; p=ns). Conclusions: Global LV myocardial edema is observed in ADHF and reversible with successful decongestive therapy. Relief of myocardial edema strongly correlates with improvements in systolic and diastolic function.

Significance of lead aVR in acute coronary syndrome.

The 12-lead electrocardiogram (ECG) is a crucial tool in the diagnosis and risk stratification of acute coronary syndrome (ACS). Unlike other 11 leads, lead aVR has been long neglected until recent years. However, recent investigations have shown that an analysis of ST-segment shift in lead aVR provides useful information on the coronary angiographic anatomy and risk stratification in ACS. ST-segment elevation in lead aVR can be caused by (1) transmural ischemia in the basal part of the interventricular septum caused by impaired coronary blood flow of the first major branch originating from the left anterior descending coronary artery; (2) transmural ischemia in the right ventricular outflow tract caused by impaired coronary blood flow of the large conal branch originating from the right coronary artery; and (3) reciprocal changes opposite to ischemic or non-ischemic ST-segment depression in the lateral limb and precordial leads. On the other hand, ST-segment depression in lead aVR can be caused by transmural ischemia in the inferolateral and apical regions. It has been recently shown that an analysis of T wave in lead aVR also provides useful prognostic information in the general population and patients with prior myocardial infarction. Cardiologists should pay more attention to the tracing of lead aVR when interpreting the 12-lead ECG in clinical practice.