Acute Coronary Syndrome Subtype Research Articles

Temporal trends in concordance between ICD-coded and cardiac biomarker-classified hospitalisation rates for acute coronary syndromes: a linked hospital and biomarker data study

BackgroundSince 2000, the definition of myocardial infarction (MI) has evolved with reliance on cardiac troponin (cTn) tests. The implications of this change on trends of acute coronary syndrome (ACS) subtypes...

Investigating soluble CD40 ligand as a prognostic factor among acute coronary syndromes patients: A multi-center prospective case-control study.

Soluble CD40 ligand (sCD40L) is a protein that plays a crucial role in the inflammatory response associated with the development and progression of acute coronary syndrome (ACS). Recent studies have suggested that sCD40L may be a useful prognostic factor for ACS, but the data are conflicting. This study aimed to investigate the potential of sCD40L as a prognostic marker among ACS patients and provide valuable insights for clinical practice. To our knowledge, this is the first study of its type in the Arabic World. A multi-center prospective case-control study was conducted in Damascus, Syria, involving 158 participants with different ACS subtypes (STEMI, NSTEMI, UA) and a control group of healthy individuals. Sociodemographic data, medical history, and sCD40L levels were collected. The predictive ability of sCD40L for ACS, STEMI, NSTEMI, and UA was assessed using receiver operating characteristic (ROC) curves. Statistical analysis was performed using IBM SPSS version 25. The study included 58 STEMI, 33 NSTEMI, 36 UA patients, and 30 healthy individuals. The mean age of participants was 55 years (SD 10.7 years). Analysis of sCD40L levels revealed significantly higher concentrations in ACS patients compared to the control group (P < .001). ROC curve analysis demonstrated that sCD40L had a significant predictive ability for ACS, STEMI, and NSTEMI (P < .05), while its predictive value for UA was not statistically significant. This study provides evidence supporting the potential of sCD40L as a prognostic factor in ACS. The elevated levels of sCD40L observed in these subtypes indicate its potential usefulness in risk stratification and predicting adverse cardiovascular events. Further investigations are warranted to establish standardized sCD40L cutoff values and evaluate its clinical implications in the management of ACS patients.

Revascularization Strategy in Myocardial Infarction with Multivessel Disease.

The proportion of patients with multivessel coronary artery disease in individuals experiencing acute coronary syndrome (ACS) varies based on age and ACS subtype. In patients with ST-segment elevation myocardial infarction (STEMI) without cardiogenic shock, the prognostic benefit of complete revascularization has been demonstrated by several randomized trials and meta-analyses, leading to a strong guideline recommendation. However, similar data are lacking for ACS without ST-segment elevation (NSTE-ACS). Non-randomized data suggesting a benefit from complete revascularization in non-ST-segment elevation myocardial infarction (NSTEMI) are prone to selection bias and should be interpreted with caution. A series of large randomized controlled trials have been initiated recently to address these open questions.

Temporal trends in admission for cardiac rehabilitation after an acute coronary syndrome in France from 2009 to 2021: Persistent sex, age and social disparities

BackgroundCardiac rehabilitation after an acute coronary syndrome is recommended to decrease patient morbidity and mortality and to improve quality of life. AimsTo describe time trends in the rates of patients undergoing cardiac rehabilitation after an acute coronary syndrome in France from 2009 to 2021, and to identify possible disparities. MethodsAll patients hospitalized for acute coronary syndrome in France between January 2009 and June 2021 were identified from the national health insurance database. Cardiac rehabilitation attendance was identified within 6 months of acute coronary syndrome hospital discharge. Age-standardized cardiac rehabilitation rates were computed and stratified for sex and acute coronary syndrome subtypes (ST-segment elevation and non-ST-segment elevation). Patient characteristics and outcomes were described and compared. Factors independently associated with cardiac rehabilitation attendance were identified. ResultsIn 2019, among 134,846 patients with an acute coronary syndrome, 22.3% underwent cardiac rehabilitation within 6 months of acute coronary syndrome hospital discharge. The mean age of patients receiving cardiac rehabilitation was 62 years. The median delay between acute coronary syndrome hospitalization and cardiac rehabilitation was 32 days, with about 60% receiving outpatient cardiac rehabilitation. Factors significantly associated with higher cardiac rehabilitation rates were male sex, younger age (35–64 years), least socially disadvantaged group, ST-segment elevation, percutaneous coronary intervention and coronary artery bypass graft. Between 2009 and 2019, cardiac rehabilitation rates increased by 40% from 15.9% to 22.3%. Despite greater upward trends in women, their cardiac rehabilitation rate was significantly lower than that for men (14.8% vs. 25.8%). In 2020, cardiac rehabilitation attendance dropped because of the coronavirus disease 2019 pandemic. ConclusionsDespite the health benefits of cardiac rehabilitation, current cardiac rehabilitation attendance after acute coronary syndrome remains insufficient in France, particularly among the elderly, women and socially disadvantaged people.

Aspirin-free strategy for percutaneous coronary intervention in acute coronary syndrome based on the subtypes of acute coronary syndrome and high bleeding risk: the STOPDAPT-3 trial.

High bleeding risk (HBR) and acute coronary syndrome (ACS) subtypes are critical in determining bleeding and cardiovascular event risk after percutaneous coronary intervention (PCI). In 4476 ACS patients enrolled in the STOPDAPT-3, where the no-aspirin and dual antiplatelet therapy (DAPT) strategies after PCI were randomly compared, the pre-specified subgroup analyses were conducted based on HBR/non-HBR and ST-segment elevation myocardial infarction (STEMI)/non-ST-segment elevation ACS (NSTE-ACS). The co-primary bleeding endpoint was Bleeding Academic Research Consortium (BARC) type 3 or 5, and the co-primary cardiovascular endpoint was a composite of cardiovascular death, myocardial infarction, definite stent thrombosis, or ischaemic stroke at 1 month. Irrespective of the subgroups, the effect of no-aspirin compared with DAPT was not significant for the bleeding endpoint (HBR [N=1803]: 7.27 and 7.91%, hazard ratio (HR) 0.91, 95% confidence interval (CI) 0.65-1.28; non-HBR [N=2673]: 3.40 and 3.65%, HR 0.93, 95% CI 0.62-1.39; Pinteraction=0.94; STEMI [N=2553]: 6.58 and 6.56%, HR 1.00, 95% CI 0.74-1.35; NSTE-ACS [N=1923]: 2.94 and 3.64%, HR 0.80, 95% CI 0.49-1.32; Pinteraction=0.45), and for the cardiovascular endpoint (HBR: 7.87 and 5.75%, HR 1.39, 95% CI 0.97-1.99; non-HBR: 2.56 and 2.67%, HR 0.96, 95% CI 0.60-1.53; Pinteraction=0.22; STEMI: 6.07 and 5.46%, HR 1.11, 95% CI 0.81-1.54; NSTE-ACS: 3.03 and 1.71%, HR 1.78, 95% CI 0.97-3.27; Pinteraction=0.18). In patients with ACS undergoing PCI, the no-aspirin strategy compared with the DAPT strategy failed to reduce major bleeding events irrespective of HBR and ACS subtypes. The numerical excess risk of the no-aspirin strategy relative to the DAPT strategy for cardiovascular events was observed in patients with HBR and in patients with NSTE-ACS.

Comparison of Acute Coronary Syndromes in the Earthquake Zone before and in the First Month after the Earthquake: A Single-center and Retrospective Analysis.

Earthquakes can significantly impact both the occurrence and the management of acute coronary syndromes (ACS). This study aimed to investigate the effects of an earthquake on patients with ACS by comparing their clinical and angiographic features before and after the event. We utilized a retrospective observational cohort design, involving 260 ACS patients who underwent coronary angiography. Data on patient characteristics, clinical variables, and procedural details were extracted from medical records. Statistical analyses were conducted to compare the ACS groups pre- and post-earthquake and to assess outcomes, which included in-hospital mortality and complications. After the earthquake, the ACS patients were older and predominantly male. The distribution of ACS subtypes remained similar between the groups. The use of anticoagulation before the procedure decreased after the earthquake, while the usage of other medications remained stable. The incidence of non-critical coronary arteries decreased post-earthquake, and there was a higher frequency of non-intervention in this group. Intervention in the left anterior descending coronary artery was more common after the earthquake. In-hospital mortality was associated with post-earthquake ACS, certain ACS subtypes, shock at admission, bifurcation stenting, and the no-reflow phenomenon. Complete revascularization was found to reduce mortality. The duration of intensive care unit stays was longer before the earthquake, while in-hospital mortality was higher after the earthquake. Gender differences were observed in coronary ectasia, with females being more affected post-earthquake. Earthquakes significantly influence the clinical and angiographic features of ACS cases, thereby affecting mortality rates and revascularization outcomes.

Immature Platelet Fraction and Acute Coronary Syndrome; a Systematic Review and Meta-Analysis.

Immature Platelet Fraction (IPF) is a measure of the proportion of reticulated platelets (RPs) to all platelets in circulation. IPF may have both prognostic and diagnostic values in patients with Acute Coronary Syndrome (ACS). This study aims to comprehensively summarize the diagnostic utility of IPF levels in patients with ACS, specifically focusing on its ability to differentiate between different subtypes of ACS. We conducted a systematic search in online databases including MEDLINE, Scopus, and Google Scholar up to March 4th 2024, to identify relevant studies. The random-effect model, employing inverse variance for mean differences (MD) and Mantel-Haenszel methods for odds ratios (OR) were utilized to combine the data. Joanna Briggs Institute (JBI) appraisal tool was employed to assess the quality of included studies. Our systematic review contains 15 articles with a total sample size of 2,030 ACS patients. Pooled analysis revealed significant differences in IPF levels of ACS patients compared to healthy controls (MD (95%CI): 2.85 (0.86, 4.85), P-value = 0.004) and stable angina patients (MD (95%CI): 0.58 (0.23, 0.92), P-value < 0.001). Subgroup comparisons within ACS patients demonstrated higher IPF levels in myocardial infarction (MI) vs. unstable angina (UA) (MD (95%CI): 1.81 (0.41, 3.22), P-value = 0.01), ST elevation MI (STEMI) vs. non-ST elevation (NSTEMI) ACS (MD (95%CI): 0.74 (0.31, 1.17), P-value < 0.001), and NSTEMI vs. UA (MD (95% CI): 1.07 (0.24, 1.90), P-value = 0.01). IPF levels could increase in patients with ACS, particularly during the acute phase of STEMI. This suggests that IPF may be a useful biomarker for early diagnosis of ACS. Additionally, IPF levels may help differentiate between ACS subtypes.

Trends in acute coronary syndrome subtypes in France : Results from the MONICA registries over the period 2009–2018

Trends in acute coronary syndrome subtypes in France : Results from the MONICA registries over the period 2009–2018

Real-world assessment of antiplatelet treatment therapies for acute coronary syndrome (ACS) patients in the United States in a nationwide Electronic Health Record in 2018-2020

Abstract Background Acute coronary syndrome (ACS) is one of the leading causes of cardiovascular related deaths for adults in US. The clinical presentation of ACS is broad, which includes ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation MI (NSTEMI), and unstable angina (UA). There are limited data around contemporary real-world treatment landscape, therefore it is critical to understand the treatment pattern of the US ACS patients in the real-world setting. Purpose This study evaluated antiplatelet therapy (APT) treatment patterns among US patients without atrial fibrillation or oral anticoagulants (OACs) who experienced their first hospitalized ACS event during observation period. Methods The Optum® de-identified Electronic Health Record dataset from January 2018 through December 2020 was used for this study. Adult patients with an inpatient primary diagnosis of ACS during the index period were identified by ICD10 codes. The date of admission for the first ACS hospitalization was the index date. Patients with atrial fibrillation diagnosis or a record for OAC use before index date and during hospitalization were excluded. ACS subgroups and percutaneous coronary intervention (PCI) status were assessed during index hospitalization; patient characteristics and in-hospital antiplatelet treatment type were also evaluated. Results Among 63,767 patients included in this study, the mean age was 64.1 and 40.5% were female; 89.2% were treated with APT. For those patients not treated with APT, majority were treated with parental anticoagulants. Among 89.2% APT treated patients, 52.7% were initiated on dual antiplatelet therapy (DAPT), 27.4% were initiated on single antiplatelet therapy (SAPT), and 9.1% switched between different DAPT regimens. The top three used DAPT were aspirin+clopidogrel (30.5%), aspirin+ticagrelor (18.9%) and aspirin+prasugrel (2.6%); the most used SAPT were aspirin (22.6%), clopidogrel (2.6%), and ticagrelor (2.0%). For ACS subtypes, 26.3% were diagnosed as STEMI, 62.9% were NSTEMI, and 10.8% were UA; of them, 45.0% had PCI procedure within 30-days before or after the index date. ACS patients with PCI procedure had the highest APT treatment rate (95.2%) and highest DAPT treatment rate (70.6%). Across ACS subtypes, patients hospitalized for STEMI had the highest usage of aspirin+ticagrelor (34.5%), whereas patients hospitalized for NSTEMI had the highest usage of aspirin+clopidogrel (34.7%). Conclusion We observed wide variability in APT treatment across STEMI vs. NSTEMI and +/-PCI. Only 38.1% of non-PCI treated ACS patients received DAPT despite current guidelines. Further analyses are planned to explore the varying APT (and/or anticoagulant) regimens.Figure 1Figure 2

Nationwide time trends in patients hospitalized for acute coronary syndrome: a worrying generational and social effect among women.

To estimate the time trends in the annual incidence of patients hospitalized for acute coronary syndrome (ACS) in France from 2009 to 2021 and to analyse the current sex and social differences in ACS, management, and prognosis. All patients hospitalized for ACS in France were selected from the comprehensive National Health Insurance database. Age-standardized rates were computed overall and according to age group (over or under 65 years), sex, proxy of socioeconomic status, and ACS subtype [ST-segment elevation (STSE) and non-ST-segment elevation]. Patient characteristics and outcomes were described for patients hospitalized in 2019. Differences in management (coronarography, revascularization), and prognosis were analysed by sex, adjusting for cofonders. In 2019, 143,670 patients were hospitalized for ACS, including 53,227 STSE-ACS (mean age = 68.8 years; 32% women). Higher standardized incidence rates among the most socially deprived people were observed. Women were less likely to receive coronarography and revascularization but had a higher excess in-hospital mortality. In 2019, the age-standardized rate for hospitalized ACS patients reached 210 per 100 000 person-year. Between 2009 and 2019, these rates decreased by 11.4% (men: -11.2%; women: -14.0%). Differences in trends of age-standardized incidence rate have been observed according to sex, age, and social status. Middle aged women (45-64 years) showing more unfavourable trends than in other age classes or in men. In addition, among women the temporal trends were more unfavourable as social deprivation increased. Despite encouraging overall trends in patients hospitalized for ACS rates, the increasing trends observed among middle-aged women, especially socially deprived women, is worrying. Targeted cardiovascular prevention and close surveillance of this population should be encouraged.

Relationship between Cardiovascular Risk Factors and Development of Acute Coronary Syndrome

Acute coronary syndrome (ACS) which known as subcategory of coronary heart disease is considered a major cause of death. In Saudi Arabia, the prevalence of ACS is 8.2%. Early recognition of risk factors (RFs) associated with ACS is essential to prevent its progression. Therefore, the goals of this study is to estimate the prevalence of cardiovascular RFs among ACS patients and to appraise its association with the development of ACS. This retrospective multi-center cross-sectional study involved 170 patients admitted to Prince Sultan cardiac center, King Saud Hospital, and Bukayriyah General Hospital in Al Qassim, KSA. The participants categorized into three groups UA, NSTEMI, and STEMI. Patients with stable angina or previous MI were excluded from the study. 73.5% were males and 26.5% were females with a mean age of 58.2 ± 11.9. The distribution of ACS subtypes was 51.2%, 27.6%, and 21.2% for STEMI, NSTEMI and UA, respectively. The most common RFs were diabetes mellitus (DM), hypertension (66% each), and dyslipidemia (58%). The prevalence of RFs among STEMI group was 65.6% active smokers, 54.5% dyslipidemia, and 52.2% ischemic heart disease (IHD). On the other hand, in NSTEMI group hypertension and DM were nearly the same (32% &amp; 30% respectively), however family history of IHD was 42.9%. UA revealed a strong association with IHD and family history of IHD (30.4%, 28.6%, respectively).To conclude, most of ACS patients presented with STEMI followed by NSTEMI and the least with UA. Among the cardiovascular risk factors, HTN, DM, and dyslipidemia, were presented in more than half of the patients which strongly suggests an association with developing ACS.

Temporal trends in acute coronary syndrome hospitalisation rates: a comparison of administrative diagnosis coding and cardiac biomarker testing

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Victor Chang Cardiac Research Institute. Background/aims Accurate monitoring of trends in acute coronary syndromes (ACS) provides important information on the impacts of primary and secondary prevention. Use of cardiac troponin (cTn) assays with increasing sensitivity and specificity during the past 20 years have likely increased the rates of diagnosis of myocardial infarction (MI), particularly NSTEMI. We aimed to determine the correlation of ICD-coded ACS hospitalisation rates with biomarker-classified ACS rates to inform population-level monitoring of ACS trends in Australia. Methods We used linked hospitalisation, emergency department, mortality, and pathology data from all tertiary hospitals in Western Australia (WA). We identified all patients aged &amp;gt;20years with a principal diagnosis of STEMI or NSTEMI (ICD-10-AM I21.0-I21.4) or unstable angina (UA) (ICD-10-AM I20.0) from 2001-2017. Creatine kinase (CK) and cTn test results including high-sensitivity (hs-Tn) assays were classified as elevated based on the ESC/AHA Universal Definition using the upper reference limit value for each assay. We calculated age-standardised rates (ASRs) for ICD-10 coded STEMI, NSTEMI and UA hospitalisations, and those which were cTn positive (cTn+), or any biomarker positive including CK (Bm+). We assessed annual ASR ratios over time (reference: ICD-coded rates) and estimated annual % changes in admissions using Poisson regression models adjusting for 5-year age-group and sex. Results The cohort comprised 143,231 ICD-coded ACS hospitalisations for 91,701 patients. 60.5% of the patients were male and 95.2% of the ACS hospitalisations had linked cardiac biomarker records. Despite slightly lower ASRs, Bm+ based rates were consistent with patterns in ICD-coded admissions in both MI sub-types (Figure) with no significant differences stratified by sex. Average annual decline in STEMI admissions was -3.7% (95% CI -4.1%,-3.4%) and -3.2% (95% CI -3.6%, -2.9%) in ICD-coded and Bm+ hospitalisations respectively. The annual rise in ICD-coded NSTEMI ASRs was 4.1% (95% CI 3.9%, 4.4%) which correlated with the 4.4% (95% CI 4.1%, 4.7%) annual rise in Bm+ ACS hospitalisations. The age-standardised rate ratios of ICD-coded to Bm+ were 1.27 and 1.28 for STEMI and NSTEMI respectively in 2001 and remained consistent at 1.29 and 1.30 for STEMI and NSTEMI respectively in 2017, although this was not the case for cTn+:ICD-coded rate ratios. There was an inverse trend between ASRs of ICD-coded NSTEMI and UA over the study period which correlated with use of increasingly sensitive cTn assays. The proportion of UA admissions with Bm+ was consistently low (21%) over the study period. Conclusions Despite shifts from CK to cTn and hs-Tn assays during our study period, the present study highlights the validity of using linked hospitalisation data to monitor long term trends in ACS based on cardiac biomarker positivity. Figure legend. Age-standardised hospitalisation rates by classification status in ACS subtypes.

Impact of Geriatric Events on Clinical Outcomes and Resource Utilization of Acute Coronary Syndrome Hospitalizations.

Background The effect of geriatric events (GEs) on outcomes of acute coronary syndrome (ACS) admissions is poorly understood.We evaluated the prevalence and impact of GEs on clinical outcomes and resource utilization of older patients admitted with ACS. Methods Using the 2018 National (Nationwide) Inpatient Sample, we analyzed all elective hospitalizations forACS in older adults (age ≥ 65 years) and a younger reference group (age 55-64). Nationally-weighted descriptive statistics were generated for GEs based on ACS subtypes. Multivariate logistic regression models controlling for comorbidities, frailty, patient procedure, and hospital-level variables were used to estimate the association of age with GEs and GEs with outcomes. Results Out of 403,760 admissions analyzed, 71.9% occurred in older adults (≥65 years). The overall rate of any GE in older adults with ACS was 3.4%. With advancing age, the number of GEs was found to significantly increase (p<0.001). After adjustments, having any GE was found to have a significant impact on mortality (adjusted OR (AOR): 1.32; 95%CI: 1.15-1.54; p < 0.001), post-myocardial infarction (MI) complications (AOR: 1.53; 95%CI: 1.36-1.71; p < 0.001), prolonged hospital stays (AOR: 2.97; 95%CI: 2.56-3.30; p < 0.001), and non-home (acute care and skilled nursing home) discharge (AOR: 1.68; 95%CI: 1.53-1.85; p < 0.001). The occurrence of GEs was also associated with a substantial increase in total hospitalization costs with a mean increase of $48,325.22 ± $5,539 (p < 0.001). A dose-response relationship was established between GEs and all outcomes. Limitations of the study included the use of retrospective data and an administrative database. Conclusion Geriatric events were found to significantly worsen outcomes for older adults with ACS. There is, therefore, a need for increased awareness and effective management of GEs in older adults to improve their health outcomes and reduce the burden on the healthcare system.

Incidence of stroke and mortality due to stroke after acute coronary syndrome

ObjectivesStroke is a known complication after myocardial infarction (MI) and it is associated with increased mortality. We aimed to establish the true cumulative incidence of stroke and its subtypes and the associated mortality in a contemporary setting among patients treated for acute coronary syndrome (ACS). Materials and methodsA retrospective registry study based on the data of 8,049 consecutive patients treated for ACS in a sole provider of specialized cardiac and neurologic care for a catchment area of over 0.5 million residents between 2007 and 2018. Incident strokes and their subtypes were identified by in-depth review of written hospital records, hospital discharge registry data and causes of death registry data maintained by Statistics Finland up until December 31st 2020. ResultsDuring a median follow-up of 5.8 years (IQR 3.2-9.0) 570 ACS patients suffered a stroke. The cumulative incidences of stroke for first week, first month, first year and at thirteen years were: 0.8 %, 1.1 %, 2.2 % and 10.3 %. In long-term, patients with different ACS subtypes had similar cumulative incidence of strokes, although the incidence of in-hospital strokes was highest among myocardial infarction patients. Stroke mortality rate was 32.5 % (n=185/570). The majority (88.8 %) of strokes were ischemic with the proportion being most substantial for in-hospital strokes (95.6 %). ConclusionsThe risk of stroke among patients treated for ACS and the related mortality are still notable in a contemporary setting. A distinctive majority of strokes following ACS were ischemic especially early on after ACS.

Long-term follow-up of incident acute coronary syndrome: results from the French MONICA registries over the 2009-2017 period

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Santé Publique France, U1167 - RID-AGE - Facteurs de risque et déterminants moléculaires des maladies liées au vieillissement, Lille, France. Background The prognosis of an acute coronary syndrome (ACS) is strongly affected by the clinical, biological, and angiographic features of the event. However, few studies have characterized long-term recurrences of ACS after an incident (first) event. Aim The goals of this study were (i) to estimate the long-term (9 years) risk of ACS recurrence, including fatal ACS recurrence, among survivors of a first-ever ACS, according to its diagnosis subtype (STEMI / NSTEMI / Unstable angina (UA)) and (ii) to identify factors associated with these risks. Methods We assessed all men and women (aged 35-74) hospitalized between January 2009 and December 2016 for an incident (first-ever) ACS, in the 3 distinct geographical areas covered by the MONICA registries in the north, east and south-west of France, and still alive at discharge (Index event). ACSs were classified as STEMI, NSTEMI and UA. Patients were followed-up until December 2017. Recurrent events were defined as the first non-fatal or fatal ACS occurring after hospital discharge from the index event. Multivariate Cox regression models were used to assess the relationships between recurrent ACS and variables of interest. Results A total of 15,739 incident ACSs were included. The study comprised a total of 63,777 patients-years and a median duration of follow-up of 3.8 [1.6-6.0] years. There were 1,963 (12,4%) recurrent ACSs of which almost half (1,046; 53%) occurred during the first year. The 1-, 5- and 9- year cumulative probabilities of recurrent ACS were 6.7% [6.3-7.1%], 13.4% [12.8-14.0%] and 18.4% [17.4-19.5%], respectively, and those of fatal recurrent ACS were 1.4% [1.2-1.5%], 2.7% [2.3-3.0%] and 4.3% [3.6-4.9%], respectively. Annual 1-year recurrence rates decreased between 2009 and 2016, from 7.4% to 4.0% (p Cochran-Armitage test &amp;lt;0.001). After an index STEMI and NSTEMI, the most frequent form of recurrent event was a NSTEMI, whereas UA was more likely event after an index UA. The age at the time of the event, the geographical region (North to South gradient), the presence of a major event (i.e. resuscitated cardiac arrest, acute pulmonary oedema or cardiogenic shock), and an impaired left ventricular ejection fraction (LVEF) were significantly associated with the risk of recurrence and fatal recurrence. ACS subtype was not associated with recurrent risk after adjustment for confounders. Conclusions In conclusion, after an incident ACS the recurrence rate remained elevated, with one in five patients experiencing a recurrent ACS during a 9-years follow-up. Half of recurrent events occurred within the first year after the index event and NSTEMI was the most frequent form of recurrent event. Age at the time of the event, region, major event and impaired LVEF are factors associated with a higher risk of recurrence, the most important one being an LVEF &amp;lt;35%.

Temporal Changes in Pollen Concentration Predict Short-Term Clinical Outcomes in Acute Coronary Syndromes.

BackgroundAtmospheric changes in pollen concentration may affect human health by triggering various allergic processes. We sought to assess if changes in pollen concentrations were associated with different acute coronary syndrome (ACS) subtype presentations and short‐term clinical outcomes.Methods and ResultsWe analyzed data in consecutive patients presenting with ACS (unstable angina, non–ST‐segment–elevation myocardial infarction, and ST‐segment–elevation myocardial infarction) treated with percutaneous coronary intervention between January 2014 and December 2017 and enrolled in the VCOR (Victorian Cardiac Outcomes Registry). Baseline characteristics were compared among patients exposed to different grass and total pollen concentrations. The primary outcome was occurrence of ACS subtypes and 30‐day major adverse cardiac and cerebrovascular events (composite of mortality, myocardial infarction, stent thrombosis, target vessel revascularization, or stroke). Of 15 379 patients, 7122 (46.3%) presented with ST‐segment–elevation myocardial infarction, 6781 (44.1%) with non–ST‐segment–elevation myocardial infarction, and 1476 (9.6%) with unstable angina. The mean age was 62.5 years, with men comprising 76% of patients. No association was observed between daily or seasonal grass and total pollen concentrations with the frequency of ACS subtype presentation. However, grass and total pollen concentrations in the preceding days (2‐day average for grass pollen and 7‐day average for total pollen) correlated with in‐hospital mortality (odds ratio [OR], 2.17 [95% CI, 1.12–4.21]; P=0.021 and OR, 2.78 [95% CI, 1.00–7.74]; P=0.05), respectively, with a trend of 2‐day grass pollen for 30‐day major adverse cardiac and cerebrovascular events (OR, 1.50 [95% CI, 0.97–2.32]; P=0.066).ConclusionsIncreased pollen concentrations were not associated with differential ACS subtype presentation but were significantly related to in‐hospital mortality following percutaneous coronary intervention, underscoring a potential biologic link between pollen exposure and clinical outcomes.

The Improvement of Cardiac and Endothelial Functions of Xue-Fu-Zhu-Yu Decoction for Patients with Acute Coronary Syndrome: A Meta-Analysis of Randomized Controlled Trials.

Background Xue-Fu-Zhu-Yu decoction (XFZYD) is a traditional Chinese prescription that has been used to treat patients with blood stasis in China for many years. The present study aimed to evaluate the improvement of cardiac and endothelial functions of XFZYD for patients with acute coronary syndrome (ACS) through a systematic review and meta-analysis. Methods Six databases were searched to collect RCTs related to the treatment of XFZYD for ACS. The primary outcomes were cardiac and endothelial functions, including the levels of left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), and left ventricular end-systolic diameter (LVESD) in echocardiography, as well as the changes in the levels of nitric oxide (NO), endothelin-1 (ET-1), intercellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule-1 (VCAM-1) in the serum. The secondary outcomes were the blood levels of oxidative damage markers (including superoxide dismutase (SOD) and malondialdehyde (MDA)), C-reactive protein (CRP), brain natriuretic peptide (BNP), creatine kinase-MB (CK-MB), and cardiac troponin I (cTnI) as well as the incidence of adverse drug reactions (ADRs). Weighted mean difference (WMD) was estimated for all the outcomes with the random effects model. This type of analysis was conducted in the subgroups of the ACS subtypes, and the methodological quality was assessed using the handbook of Cochrane Collaboration. Results A total of 1,658 records were identified, and 16 randomized controlled trials (1,171 patients) were included. The primary outcomes suggested that XFZYD combined with routine treatment improved LVEF, reduced LVEDD and LVESD, and also improved the serum levels of NO, and reduced the levels of ET-1 and ICAM-1. XFZYD combination therapy significantly ameliorated the blood levels of SOD, MDA, BNP, CK-MB, and cTnI. However, the results indicated no significant difference between XFZYD plus routine treatment and routine treatment for the levels of VCAM-1 and CRP. Moreover, all the ADRs reported in the included studies were slight and the patients recovered soon. Conclusions The present study suggested that XFZYD may improve the cardiac and endothelial functions of ACS patients without serious ADRs. However, based on the mediocre methodological quality, the aforementioned conclusion should be confirmed in a multicenter, large-scale, and accurately designed clinical trial.

Effect of Genotype-Guided Oral P2Y12 Inhibitor Selection After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

BackgroundClopidogrel is the most frequently used P2Y12 inhibitor as a component of the dual antiplatelet regimen in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Prior studies have shown the variable efficacy of clopidogrel due to genotypic differences in the CYP2C19 enzyme function, which converts clopidogrel to its active metabolite. The aim of this meta-analysis is to evaluate the effectiveness of genotype testing-guided P2Y12 inhibitor prescription therapy to patients after PCI for ACS compared to non-genotype guided conventional treatment. MethodsA comprehensive literature search was performed in PubMed, Embase, and Cochrane to identify relevant trials. Summary effects were calculated using a DerSimonian and Laird random-effects model as odds ratio with 95% confidence intervals for all the clinical endpoints. ResultsSeven studies with 9617 patients were included. Genotype-guided strategy arm included prasugrel or ticagrelor prescription to patients with loss of function (LOF) of CYP219 alleles (most commonly alleles being *2 and *3) and clopidogrel prescription to those without the LOF allele. The conventional arm included patients treated with clopidogrel without genotype testing. Comparison of genotype arm with conventional arm showed decreased major adverse cardiovascular events (MACE), improved cardiovascular (CV) mortality, and reduced incidence of myocardial infarction (MI) in the genotype arm, and a similar stroke incidence in the two arms. Regarding adverse events, the incidence of stent thrombosis was lower in the genotype arm than the conventional arm. ConclusionOur analysis illustrates the possible advantages of genotype-guided P2Y12 inhibitor prescription strategy compared to non-genotype-guided strategy with reductions in MACE, CV mortality, MI, and stent thrombosis. This analysis can be used as a stepping stone to conducting further trials determining the efficacy of this treatment strategy in various ACS subtypes.

Abstract 11621: Effect of Genotype Guided Oral P2y12 Inhibitor Selection After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Introduction: Clopidogrel is the most frequently used P2Y12 inhibitor as a component of the dual antiplatelet regimen in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Prior studies have shown the variable efficacy of clopidogrel due to genotypic differences in the CYP2C19 enzyme function, which converts clopidogrel to its active metabolite. Hypothesis: The aim of this meta-analysis is to evaluate the effectiveness of genotype testing-guided P2Y12 inhibitor prescription therapy to patients after PCI for ACS compared to non-genotype guided conventional treatment. Methods: A comprehensive literature search was performed in PubMed, Embase, and Cochrane to identify relevant trials. Summary effects were calculated using a DerSimonian and Laird random-effects model as odds ratio with 95% confidence intervals for all the clinical endpoints. Results: Seven studies with 9617 patients were included. Genotype-guided strategy arm included prasugrel or ticagrelor prescription to patients with loss of function (LOF) of CYP219 alleles (most commonly alleles being *2 and *3) and clopidogrel prescription to those without the LOF allele. The conventional arm included patients treated with clopidogrel without genotype testing. Comparison of genotype arm with conventional arm showed decreased major adverse cardiovascular events (MACE) (RR 0.72, 95% CI 0.55-0.95; p=0.02, I 2 =23), improved cardiovascular (CV) mortality (RR 0.62, 95% CI 0.43-0.90; p=0.01, I 2 =0) and reduced incidence of myocardial infarction (MI) (RR 0.57, 95% CI 0.41-0.97; p&lt; 0.01), and a similar stroke incidence (RR 0.65, 95% CI 0.35-1.21; p= 0.18). Regarding adverse events, the incidence of stent thrombosis was lower in the genotype arm than the conventional arm (RR 0.52, 95% CI 0.28-0.96; p=0.04). Conclusions: Our analysis illustrates the possible advantages of genotype-guided P2Y12 inhibitor prescription strategy compared to non-genotype-guided strategy with reductions in MACE, CV mortality, MI, and stent thrombosis. This analysis can be used as a stepping stone to conducting further trials determining the efficacy of this treatment strategy in various ACS subtypes.

Abstract 11763: The impact of the Australian Warning Signs Campaign on Emergency Medical Service Use for Acute Coronary Syndrome and Unspecified Chest Pain

Background: Between 2009 and 2013, the National Heart Foundation of Australia ran mass media campaigns to improve Australian’s awareness of Acute Coronary Syndrome (ACS) symptoms and the need to call emergency medical services (EMS). This study examined the impact of this campaign on emergency department (ED) presentations and EMS use in Victoria, Australia. Methods: The Victorian Department of Health and Human Services provided data for adult Victorian patients presenting to public hospitals with an ED diagnosis of ACS or unspecified chest pain (U-CP). We modelled changes in the incidence of ED presentations, and the association between the campaign period and 1) EMS arrival and 2) referred to ED by a general practitioner (GP). Models were adjusted for increasing population size, ACS subtype and demographics. Results: Between 2003 and 2015, there were 124,632 eligible ED presentations with ACS and 536,148 with U-CP. In ACS patients, the campaign period was associated with an increase in ED presentations (Incidence Rate Ratio: 1.11; 95% CI: 1.07-1.15), a decrease in presentations via a GP (Adjusted Odds Ratio [AOR]: 0.77; 95% CI: 0.70-0.86), and an increase in EMS use (AOR: 1.10; 95%CI: 1.05-1.17). Similar, but smaller associations were seen in U-CP. Conclusions: The Warning Signs Campaign was associated with improvements in treatment seeking in ACS patients -including increased EMS use. The increase in ACS ED presentations corresponds with a decrease in out-of-hospital cardiac arrest over this time. Future education need to focus on improving EMS use in ACS patient groups where use remains low.