Acute Coronary Syndrome Subtype Research Articles

Impact of a mass media campaign on presentations and ambulance use for acute coronary syndrome

ObjectiveBetween 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...

Management and 30-Day Mortality of Acute Coronary Syndrome in a Resource-Limited Setting: Insight From Ethiopia. A Prospective Cohort Study.

Background: Despite the fact that the burden, risk factors, and clinical characteristics of acute coronary syndrome (ACS) have been studied widely in developed countries, limited data are available from sub-Saharan Africa. Therefore, this study aimed at evaluating the clinical characteristics, treatment, and 30-day mortality of patients with ACS admitted to tertiary hospitals in Ethiopia.Methods: A total of 181 ACS patients admitted to tertiary care hospitals in Ethiopia were enrolled from March 15 to November 15, 2018. The clinical characteristics, management, and 30-day mortality were evaluated by ACS subtype. The Cox proportional hazards model was used to determine the predictors of 30-day all-cause mortality. A p-value < 0.05 was considered statistically significant.Results: The majority (61%) of ACS patients were admitted with ST-segment elevation myocardial infarction (STEMI). The mean age was 56 years, with male predominance (62.4%). More than two-thirds (67.4%) of patients presented to hospital after 12 h of symptom onset. Dyslipidemia (48%) and hypertension (44%) were the most common risk factors identified. In-hospital dual antiplatelet and statin use was high (>90%), followed by beta-blockers (81%) and angiotensin-converting enzyme inhibitors (ACEIs; 72%). Late reperfusion with percutaneous coronary intervention (PCI) was done for only 13 (7.2%), and none of the patients received early reperfusion therapy. The 30-day all-cause mortality rate was 25.4%. On multivariate Cox proportional hazards model analysis, older age [hazard ratio (HR) = 1.03, 95% CI = 1.003–1.057], systolic blood pressure (HR = 0.99, 95% CI = 0.975–1.000), serum creatinine (HR = 1.32, 95% CI = 1.056–1.643), Killip class > II (HR = 4.62, 95% CI = 2.502–8.523), ejection fraction <40% (HR = 2.75, 95% CI = 1.463–5.162), and STEMI (HR = 2.72, 95% CI = 1.006–4.261) were independent predictors of 30-day mortality.Conclusions: The 30-day all-cause mortality rate was unacceptably high, which implies an urgent need to establish a nationwide program to reduce pre-hospital delay, promoting the use of guideline-directed medications, and increasing access to reperfusion therapy.

Increases in early discharge following acute coronary syndrome hospitalisations and associated clinical outcomes in New Zealand between 2006 and 2015: ANZACS-QI-43 study.

International guidelines recommend early discharge for uncomplicated acute coronary syndrome (ACS) patients within 3 days; however, there is a paucity of contemporary literature regarding the safety of this strategy. To report the trends in the proportion of ACS hospitalisations discharged within 3 days and their outcomes in New Zealand. ACS hospitalisations 2006-2015 using national routinely collected data were categorised by length of stay (LOS) into ≤3, 4-5 and >5 days, excluding deaths during the index admission. Trend analysis of death, cardiovascular and bleeding events and their composites (net adverse clinical events) at 30-day and 1-year post-discharge were performed using generalised linear mixed regression models adjusting for covariates by LOS subgroups. Among 130 037 ACS hospitalisations, LOS ≤ 3 days increased from 32% in 2006 to 44% in 2016. This trend was observed for all demographics, ACS subtypes and management strategies. Event rates at 30 days and 1year were the lowest for the LOS ≤3 days subgroup (all-cause mortality 1.6% and 9.1% respectively). Thirty-day and 1-year all-cause mortality rates were unchanged over time for this subgroup (adjusted odds ratio (95% confidence interval) of 1.011 (0.985-1.038) and 0.991 (0.979-1.003)), while net adverse clinical event rates significantly decreased (0.962 (0.950-0.973) and 0.972 (0.964-0.980) respectively). There was a substantial increase in early discharge post-ACS over 10 years. These patients were associated with reduction in adverse clinical events up to 1year and no increase in all-cause mortality. These findings from a comprehensive national register suggest that guideline recommendations on early discharge after uncomplicated ACS are safe and appropriate.

The Multi-Ethnic New Zealand Study of Acute Coronary Syndromes (MENZACS): Design and Methodology

Background. Each year, approximately 5000 New Zealanders are admitted to hospital with first-time acute coronary syndrome (ACS). The Multi-Ethnic New Zealand Study of Acute Coronary Syndromes (MENZACS) is a prospective longitudinal cohort study embedded within the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) registry in six hospitals. The objective of MENZACS is to examine the relationship between clinical, genomic, and cardiometabolic markers in relation to presentation and outcomes post-ACS. Methods. Patients with first-time ACS are enrolled and study-specific research data is collected alongside the ANZACS-QI registry. The research blood samples are stored for future genetic/biomarker assays. Dietary information is collected with a food frequency questionnaire and information about physical activity, smoking, and stress is also collected via questionnaire. Detailed family history, ancestry, and ethnicity data are recorded on all participants. Results. During the period between 2015 and 2019, there were 2015 patients enrolled. The mean age was 61 years, with 60% of patients aged &lt;65 years and 21% were female. Ethnicity and cardiovascular (CV) risk factor distribution was similar to ANZACS-QI: 13% Māori, 5% Pacific, 5% Indian, and 74% NZ European. In terms of CV risk factors, 56% were ex-/current smokers, 42% had hypertension, and 19% had diabetes. ACS subtype was ST elevation myocardial infarction (STEMI) in 41%, non-ST elevation myocardial infarction (NSTEM) in 54%, and unstable angina in 5%. Ninety-nine percent of MENZACS participants underwent coronary angiography and 90% had revascularization; there were high rates of prescription of secondary prevention medications upon discharge from hospital. Conclusion. MENZACS represents a cohort with optimal contemporary management and will be a significant epidemiological bioresource for the study of environmental and genetic factors contributing to ACS in New Zealand’s multi-ethnic environment. The study will utilise clinical, nutritional, lifestyle, genomic, and biomarker analyses to explore factors influencing the progression of coronary disease and develop risk prediction models for health outcomes.

Analysis of risk factors for different subtypes of acute coronary syndrome.

AimsTo investigate the different risk factors among different subtypes of patients with acute coronary syndrome (ACS).MethodsA total of 296 patients who had ACS were retrospectively enrolled. Blood and echocardiographic indices were assessed within 24 hours after admission. Differences in risk factors and Gensini scores of coronary lesions among three groups were analyzed.ResultsUnivariate analysis of risk factors for ACS subtypes showed that age, and levels of fasting plasma glucose, amino-terminal pro-brain natriuretic peptide, and creatine kinase isoenzyme were significantly higher in patients with non-ST-segment elevation myocardial infarction (NSTEMI) than in those with unstable angina pectoris (UAP). Logistic multivariate regression analysis showed that amino-terminal pro-brain natriuretic peptide and the left ventricular ejection fraction (LVEF) were related to ACS subtypes. The left ventricular end-diastolic diameter was an independent risk factor for UAP and ST-segment elevation myocardial infarction (STEMI) subtypes. The severity of coronary stenosis was significantly higher in NSTEMI and STEMI than in UAP. Gensini scores in the STEMI group were positively correlated with D-dimer levels (r = 0.429) and negatively correlated with the LVEF (r = −0.602).ConclusionDifferent subtypes of ACS have different risk factors. Our findings may have important guiding significance for ACS subtype risk assessment and clinical treatment.

One-Year COMBO Stent Outcomes in Acute Coronary Syndrome: from the COMBO Collaboration.

The COMBO biodegradable polymer sirolimus-eluting stent includes endothelial progenitor cell capture (EPC) technology for rapid endothelialization, which may offer advantage in acute coronary syndromes (ACS). We sought to analyze the performance of the COMBO stent by ACS status and ACS subtype. The COMBO collaboration (n = 3614) is a patient-level pooled dataset from the MASCOT and REMEDEE registries. We evaluated outcomes by ACS status, and ACS subtype in patients with ST segment elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI) versus unstable angina (UA). The primary endpoint was 1-year target lesion failure (TLF), composite of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization. Secondary outcomes included stent thrombosis (ST). We compared 1965 (54%) ACS and 1649 (46.0%) non-ACS patients. ACS presentations included 40% (n = 789) STEMI, 31% (n = 600) NSTEMI, and 29% (n = 576) UA patients. Risk of 1-year TLF was greater in ACS patients (4.5% vs. 3.3%, HR 1.51 95% CI 1.01-2.25, p = 0.045) without significant differences in definite/probable ST (1.1% vs 0.5%, HR 2.40, 95% CI 0.91-6.31, p = 0.08). One-year TLF was similar in STEMI, NSTEMI, and UA (4.8% vs 4.8% vs. 3.7%, p = 0.60), but definite/probable ST was higher in STEMI patients (1.9% vs 0.5% vs 0.7%, p = 0.03). Adjusted outcomes were not different in MI versus UA patients. Despite the novel EPC capture technology, COMBO stent PCI was associated with somewhat greater risk of 1-year TLF in ACS than in non-ACS patients, without significant differences in stent thrombosis. No differences were observed in 1-year TLF among ACS subtypes.

Frequency and Reasons for Non-Administration and Suspension of Drugs During an Acute Coronary Syndrome Event. The ERICO Study.

ResumoFundamentos:Poucos estudos discutiram causas para o subtratamento medicamentoso na SCA.Objetivos:Avaliar a não-administração e suspensão de medicamentos durante o tratamento intra-hospitalar da SCA na Estratégia de Registro de Síndrome Coronariana Aguda (estudo ERICO).Métodos:Analisamos prontuários de 563 participantes ERICO para avaliar a frequência e motivos da não administração e/ou suspensão de medicamentos. Construímos modelos de regressão logística para avaliar se sexo, idade ≥65 anos, nível educacional ou subtipo de SCA estavam associados com (a) não administração de ≥1 medicamentos; e (b) não administração ou suspensão de ≥1 medicamentos. O nível de significância foi 5%.Resultados:A amostra é composta por 58,1% de homens e com idade mediana de 62 anos. Em 183 (32,5%) participantes ≥1 medicamentos não foram administrados e 288 (51,2%) apresentaram ≥1 medicamentos não administrados ou suspensos. As causas mais frequentes foram risco de sangramento (aspirina, clopidogrel e heparina), insuficiência cardíaca (betabloqueadores) e hipotensão (inibidores da enzima conversora da angiotensina e bloqueadores dos receptores da angiotensina). Indivíduos com idade ≥65 anos (razão de chances [RC]:1,51; intervalo de confiança de 95% [IC95%]:1,05-2,19) e com angina instável (RC:1,72; IC95%:1,07-2,75) tiveram maior chance de não-administração. Considerando apenas pacientes com infarto do miocárdio, idade ≥65 anos foi associada tanto à não administração quanto à não administração ou suspensão.Conclusões:A não administração ou suspensão de ≥1 medicamento não foi rara no estudo ERICO. Indivíduos com idade ≥65 anos ou com angina instável tiveram maior chance de não administração e podem ser subtratados nesse cenário.

Decline in acute coronary syndrome hospitalisation rates during COVID-19 lockdown in private hospitals in South Africa

We conducted a study of admission rates of acute coronary syndrome (ACS) in all Mediclinic hospitals in South Africa. The aim of the study was to quantify the extent of change in admission rates of ACS subtypes and to establish the degree of change in subtype proportions in the private sector assumed to be related to COVID-19 and/or lockdown implementation. Time intervals were demarcated by lockdown measures (March: pre-lockdown versus April: post-lockdown implementation), and comparisons were performed with equitable time periods (2019 versus 2020). For the comparison of proportions, data for April and May were summated.

A028 The Multi-Ethnic New Zealand Study of Acute Coronary Syndromes (MENZACS): Baseline Characteristics of Patients With First-time ACS

Each year, approximately 5000 New Zealanders are admitted to hospital with a first-time acute coronary syndrome (ACS). The aim of the Multi-Ethnic New Zealand Study of Acute Coronary Syndromes (MENZACS) is to examine the relationship of clinical, genomic and cardiometabolic markers in relation to presentation and outcomes post-ACS. MENZACS is a prospective, longitudinal cohort study embedded within the All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) programme in 6 hospitals. Patients with first-time ACS were enrolled and study-specific research data collected alongside the ANZACS-QI registry. Research blood samples were stored for future genetic/biomarker assays. We report here the baseline characteristics of the MENZACS cohort and compare to the ANZACS-QI registry (first-time ACS). Between 2015-2019, 2026 patients were enrolled, mean age 61yrs, 21% were female. Ethnicity and CV risk factor distribution was similar to ANZACS-QI: 13% Māori, 5% Pacific, 5% Indian and 74% NZ European. CV risk factors included 56% ex-/current smoker, 42% hypertension, 18% diabetes. 60% of the patients were aged < 65 years. ACS subtype for MENZACS vs ANZACS-QI: STEMI 40% vs 31%, NSTEMI 52% vs 59%. 99% had coronary angiography and 90% had revascularisation; there were high rates of secondary prevention medications (table).Tabled 1Discharge MedicationAspirin1927 (98%)Dual antiplatelet therapy1611 (82%)Statin1922 (97%)Beta-blocker1652 (84%)ACEi/ARB1550 (79%) Open table in a new tab MENZACS represents a cohort with optimal contemporary management and will be a significant epidemiological bioresource for the study of environmental and genetic factors contributing to ACS in New Zealand's multi-ethnic environment. The study will utilise clinical, nutritional, lifestyle, genomic and biomarker analyses to explore aetiological factors and develop risk prediction models for outcome.

Nationwide trends in acute coronary syndrome by subtype in New Zealand 2006–2016

ObjectivesRecent studies in acute coronary syndrome (ACS) have reported mixed results for trends in ACS subtypes. The All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) 31 study evaluated trends...

The prognostic value of nitrotyrosine levels in coronary heart disease: long-term evaluation in the Acute Coronary Syndrome Registry Strategy (ERICO study)

IntroductionWe aimed to analyze the association of nitrotyrosine (N-TYR) levels and long-term survival in an ongoing coronary heart disease (CHD) prospective cohort, the Acute Coronary Syndrome Registry Strategy (ERICO study). MethodsN-TYR levels collected during acute and subacute phase from onset of acute coronary syndrome (ACS) symptoms (myocardial infarction and unstable angina) were evaluated in 342 patients. We calculated case-fatality rates (180-days, 1 year, 2 years and 4 years) and survival analyses up to 4 years using Kaplan-Meier curves and Cox regression with respective cumulative hazard ratios (95% confidence interval; 95%CI), according to N-TYR tertiles up to 4 years of follow-up. Models are presented as crude, age and sex-adjusted and further adjusted for lipids and other confounders. ResultsOverall, median level of N-TYR was 208.33 nmol/l (range: 3.09 to 1500 nmol/l), regardless ACS subtype. During follow-up of 4 years, we observed 44 (12.9%) deaths. Overall survival rate was 298 (87.1%) (Survival days: 1353, 95%CI: 1320–1387 days). N-TYR levels did not associate with mortality / survival rates up to 4 years. ConclusionsNo relationship was found between N-TYR levels and mortality rates after ACS during 4-year follow-up in the ERICO study.

Trends of ST-Elevation Myocardial Infarction, Non-ST-Elevation Myocardial Infarction, and Unstable Angina in New Zealand 2006–2016: All New Zealand Acute Coronary Syndrome-Quality Improvement Acute Coronary Syndrome by Subtype Study

Background: Cardiovascular disease is a global leading cause of death. Varying trends have been reported in the management and outcomes of the three main categories of acute coronary syndrome (ACS): ST-elevation myocardial infarction (STEMI), non-ST-elevation MI (NSTEMI), and unstable angina (UA). This study evaluated recent trends in the incidence, invasive management, and case fatality of these ACS subtypes in New Zealand. Methods: Acute coronary syndrome hospitalisations in New Zealand between 1 January 2006 and 31 December 2016 were identified based on discharge coding, and categorised into STEMI, NSTEMI, and UA. Their annualised hospitalisation, coronary procedure, and 28-day and 1-year fatality rates were calculated. Results: Between 2006 and 2016 there were 188,264 ACS admissions, of which 16.0% were STEMI, 54.5% NSTEMI, 25.7% UA, and 3.8% MI unspecified. Incidence of all ACS subtypes fell, with the greatest declines in UA and least in STEMI. There was a significant rise in the percentage receiving angiography and total revascularisation, particularly percutaneous coronary intervention (PCI), but rates of coronary artery bypass grafting (CABG) increased for NSTEMI and UA. Case fatality at 28 days and 1 year was highest for STEMI and lowest for UA; case fatality only declined for NSTEMI while remaining stable for STEMI and UA over time. Conclusions: The observed declines in the incidence of all ACS subtypes is reassuring, as is the increase in revascularisation rates among these patients. Case fatality only declined in NSTEMI patients, not STEMI and UA patients, which needs to be further investigated.

Potassium levels and risk of in-hospital arrhythmias and mortality in patients admitted with suspected acute coronary syndrome

BackgroundIn acute coronary syndrome (ACS), potassium imbalance at admission has been associated with in-hospital arrhythmias, cardiac arrest, and mortality. However, several important presentation characteristics and subtype of ACS have not been considered. MethodsConsecutive patients (n = 32,955) admitted with suspected ACS between 2006 and 2011, registered in the Swedish Web-System for Enhancement and Development of Evidence-Based care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) and the Stockholm CREAtinine Measurements (SCREAM) project were included. Associations between admission plasma potassium categories (reference 3.5–<4.0 mmol/L) and in-hospital outcomes including mortality, cardiac arrest, new-onset atrial fibrillation, and second- or third-degree atrioventricular block were assessed with logistic regression models. Covariates included demographics, presentation characteristics, comorbidities, estimated glomerular filtration rate (eGFR), main diagnosis, and medication on admission. ResultsU-shaped associations between admission potassium, mortality and cardiac arrest were observed. However, in fully adjusted models, only hyperkalemia (5.0–<5.5 [OR 1.83; 95% CI, 1.34–2.49] and ≥5.5 mmol/L [OR 2.27; 95% CI, 1.57–3.27]) was associated with mortality, while only hypokalemia (3.0–<3.5 [OR 1.63; 95% CI, 1.21–2.19] and <3.0 mmol/L [OR 2.72; 95% CI, 1.56–4.74]) was associated with cardiac arrest. Potassium <3.0 mmol/L (OR 1.93; 95% CI, 1.00–3.76) was associated with new-onset atrial fibrillation. After multivariable adjustment, no association was observed between potassium and second- or third-degree atrioventricular block. Results were not modified by main diagnosis (ACS subtype or non-ACS diagnosis) or eGFR. ConclusionsHyperkalemia at admission is associated with in-hospital mortality and hypokalemia with cardiac arrest and new-onset atrial fibrillation in patients admitted with suspected ACS.

Presentation, management and outcomes of acute coronary syndrome: a registry study from Kenyatta National Hospital in Nairobi, Kenya.

SummaryBackgroundAcute coronary syndrome (ACS) is understudied in sub-Saharan Africa despite its increasing disease burden. We sought to create an ACS registry at Kenyatta National Hospital to evaluate the presentation, management and outcomes of ACS patients.MethodsFrom November 2016 to April 2017, we conducted a retrospective review of ACS cases managed at Kenyatta National Hospital between 2013 and 2016, with a primary discharge diagnosis of ACS, based on International Classification of Diseases (ICD) 10 coding (I20-I24). We compared the presentation, management and outcomes by ACS subtype using analysis of variance testing. We created multivariable logistic regression models using the Global Registry of Acute Coronary Events (GRACE) risk score to evaluate the association between clinical variables, including guideline-directed medical therapy and in-hospital outcomes.ResultsAmong 196 ACS admissions, the majority (65%) was male, and the median age was 58 years. Most (57%) ACS admissions were for ST-segment-elevation myocardial infarction (STEMI). In-hospital dual antiplatelet ( > 85%), beta-blockade (72%) and anticoagulant (72%) therapy was common. A minority (33%) of patients with STEMI was eligible for reperfusion therapy but only 5% received reperfusion. In-hospital mortality rate was 17%, and highest among individuals presenting with STEMI (21%). After multivariable adjustment, higher serum creatinine level was associated with higher odds of in-hospital death (OR = 1.84, 95% CI: 1.21– 2.78), and STEMI and Killip class > 1 were associated with in-hospital composite of death, re-infarction, stroke, major bleeding or cardiac arrest (STEMI: OR = 8.70, 95% CI: 2.52–29.93; Killip > 1: OR = 10.7, 95% CI: 3.34–34.6).ConclusionsWe describe the largest ACS registry at Kenyatta National Hospital to date and identify potential areas for improved ACS care related to diagnostics and management to optimise in-hospital outcomes.

Increase in white blood cell count is associated with the development of atrial fibrillation after an acute coronary syndrome

BackgroundEvidence linking an elevated white blood cell count (WBCC), a marker of inflammation, to the development of atrial fibrillation (AF) after an acute coronary syndrome (ACS) is limited. We examined the association between WBCC at hospital admission, and changes in WBCC during hospitalization, with the development of new-onset AF during hospitalization for an ACS. MethodsDevelopment of AF was based on typical ECG changes in a systematic review of hospital medical records. Increase in WBCC was calculated as the difference between maximal WBCC during hospitalization and WBCC at hospital admission. Multiple logistic regression analysis was used to adjust for several potentially confounding demographic and clinical variables in examining the association between WBCC, and changes over time therein, with the occurrence of AF. ResultsThe median age of study patients (n = 1325) was 60 years, 31.8% were women, and 80.1% were non-Hispanic whites. AF developed in 7.3% of patients with an ACS. Patients who developed AF, as compared with those who did not, had a similar WBCC at admission, but a greater increase in WBCC during hospitalization (6.0 × 109 cell/L vs. 2.7 × 109 cell/L, p < 0.001). After adjusting for several potentially confounding factors, an increase in WBCC was associated with the development of AF. This association was observed in patients with different ACS subtypes, types of treatment received, and according to time of acute symptom onset. ConclusionIncrease in the WBCC during hospitalization for an ACS should be further studied as a potentially simple predictor for new-onset AF in these patients.

Antibodies against MYC-Associated Zinc Finger Protein: An Independent Marker in Acute Coronary Syndrome?

Atherosclerosis is considered the pathophysiology underlying cardiovascular (CVD), cerebrovascular, and peripheral vascular diseases. Evidence supporting an autoimmune component is emerging, with imaging studies correlating MYC-associated zinc finger protein antibody (MAZ-Ab) optical density (OD) with plaque activity. This study compares MAZ-Ab OD on ELISA testing among patients presenting with acute coronary syndromes (ACSs) to healthy controls and investigates the association of MAZ-Ab to traditional CVD risk factors. Patients admitted with ACSs between August 2007 and July 2011 were included. Serum samples taken at presentation were retrospectively tested for MAZ-Ab and compared with serum from healthy volunteers with no CVD risk factors. Large-scale assessment of post-ACS prognostic relevance was performed using the established PLATO cohort. In total 174 ACS patients and 96 controls were included. Among ACS patients, median MAZ-Ab OD was higher compared with controls (0.46 vs. 0.27; p = 0.001). Although the majority of ACS patients (116/174; 67%) had suffered from a ST-elevation myocardial infarction, no significant differences in MAZ-Ab titers were evident between ACS subtypes (p = 0.682). No associations between MAZ-Ab OD and conventional CVD risk factors were identified. Large-scale testing revealed no prognostic stratification regarding reinfarction (OR 1.04 [95% CI: 0.94-1.16]; p = 0.436). MAZ-Ab OD was higher or all ACS phenotypes compared with controls. Given current understanding of MAZ-Ab function, these findings support an autoimmune component to CVD independent of conventional risk factors and indeed the extent of end-organ damage.

Migraine and risk of stroke and acute coronary syndrome in two case-control studies in the Danish population.

IntroductionMigraine has consistently been associated with increased risk of ischemic stroke, while the evidence for a relation with other types of stroke or coronary outcomes is limited. We examined the association between migraine and stroke and acute coronary syndrome (ACS) subtypes and the influence of potential confounding factors.MethodsAll first-time hospital contacts for stroke (n=155,216) or ACS (n=97,799) were identified in Danish National Patient Registers and matched with 2 control groups of the background population. A hospital diagnosis of migraine and use of migraine medication were the main exposures and associations (odds ratios [OR]) were estimated using multiple logistic regression. Confounding was also addressed by including use of general headache medication as a negative control exposure.ResultsThe diagnosis of migraine was associated with increased odds of both stroke (ORcrude, age <50 years: 4.80 [95% CI: 3.75–6.21]; ORcrude, age ≥50 years:1.91 [95% CI: 1.67–2.19]) and ACS (ORcrude:1.88 [95% CI: 1.53–2.32]), while the ORs for the associations between migraine medication and stroke and ACS were lower. Patients with a diagnosis of migraine or redeemed migraine medication had increased ORs of all stroke subtypes (ischemic, hemorrhagic stroke and transient ischemic attacks). The diagnosis of migraine was also associated with both angina and myocardial infarction (ST-elevation Myocardial Infarction [STEMI], non-STEMI and unspecified) with the highest OR for angina. These associations were not fully explained by adjustment for confounding co-variables or when compared with the negative control exposure that were assumed to be influenced by similar confounding factors, but no shared pathogenesis.ConclusionHospital-diagnosed migraine was associated with all stroke and ACS subtypes, with ischemic stroke and angina having the highest odds. Confounding did not explain the associations.

Impact of Pharmacist Intervention to Increase Compliance With Guideline-Directed Statin Therapy During an Acute Coronary Syndrome Hospitalization.

Despite evidence on poor adherence to guideline-directed statin therapy (GDST) following an acute coronary syndrome (ACS), little information has been published on pharmacist-led statin pilot programs for secondary prevention. We sought to evaluate the impact of a pharmacist intervention (PI) on GDST during an ACS hospitalization. A historical control (HC) group consisting of 125 ACS hospitalizations was retrospectively identified, with prospective data of 113 patients captured over 6 months in the PI group. The primary outcome of GDST was defined according to 2013 clinical guidelines and evaluated in all 238 qualifying patients. Secondary outcomes included number of interventions and use of logistic regression to investigate the relationship of ACS subtype with statin dose. On admission, GDST was ordered in 62.5% of the HC and 75.9% of the PI group. At discharge, the PI group had a higher rate of GDST relative to HC among all patients (86.7 % vs 77.4%, P = 0.06), and after exclusion of contraindications (84.8% vs 74.5%; P = 0.1), 10 patients required PI, accounting for an increase in GDST of 5.3%. Statin dose selection did not differ by ACS subtype (odds ratio = 0.79; 95% CI = 0.0.29-2.17; P = 0.18). PI did not significantly increase GDST. Increased compliance rates measured were primarily driven by higher baseline adherence and guideline incorporation over time.

Ischemic Stroke Risk After Acute Coronary Syndrome.

BackgroundPrior studies show an increased risk of ischemic stroke (IS) after myocardial infarction; however, there is limited evidence on long‐term risk and whether it is directly related to cardiac injury. We hypothesized that the risk of IS after acute coronary syndrome is significantly higher if there is evidence of cardiac injury, such as ST‐segment elevation myocardial infarction (STEMI) or non‐STEMI, than when there is no evidence of cardiac injury, such as in unstable angina.Methods and ResultsAdministrative claims data were obtained from all emergency department encounters and hospitalizations at California's nonfederal acute care hospitals between 2008 and 2011. Patients with STEMI, non‐STEMI, and unstable angina were identified using appropriate International Classification of Diseases, Ninth Revision, Clinical Modification codes. The primary outcome was IS during 2 years of follow‐up. Unadjusted and adjusted Cox proportional hazards models were used to determine the association between acute coronary syndrome subtype and IS risk. We identified 73 059 patients with a diagnosis of STEMI (n=26 427), non‐STEMI (n=39 833), or unstable angina (n=6819) during the study period. In the fully adjusted models that included potential confounders such as atrial fibrillation and congestive heart failure, the risk of IS was higher with STEMI (hazard ratio 4.17, 95% CI 3.00–5.83; P<0.001) and non‐STEMI (hazard ratio 3.73, 95% CI 2.68–5.19, P<0.001) compared with unstable angina.ConclusionsNon‐STEMI and STEMI confer an equally increased risk of IS. Studies exploring IS mechanisms in cardiac patients are needed to improve and tailor stroke prevention strategies.

Association of the C3435T Multi-Drug Resistance Gene-1 (MDR-1) Polymorphism with Clopidogrel Resistance among Moroccan Acute Coronary Syndromes (ACS) Patients

Background: Antiplatelet drugs are recommended as one of the main medications used in Acute Coronary Syndromes (ACS) patients. However, an inter-individual variability in platelet response to Clopidogrel has been found in a substantial group of them. Genetic is known be the dominant influencing factor for individual and interethnic variations in drug responses. Polymorphisms in the genes involved in Clopidogrel absorption, biotransformation to the active metabolite, or platelet response to adenosine diphosphate (ADP) have been associated to this impaired response. Interestingly, Multi-Drug Resistance gene-1 (MDR-1) polymorphism influences oral bioavailability of clopidogrel and prognosis of ACS patients. The objectives of our study are, first, to determine the frequency of the C3435T MDR1 polymorphism among Moroccan ACS patients compared to healthy subjects; and second, to assess its effect on Clopidogrel response in a sample of Moroccan ASC patients. Methods and results: 40 ACS patients were recruited and compared to 99 healthy controls. Extracted DNA samples were genotyped by PCR-RFLP method using MboI restriction enzyme. The VerifyNow assay was used to evaluate platelet function among ACS patients. Our results showed that HTA, Smoking, Creatinine and Sex were statistically associated to Clopidogrel resistance (P=0.05; P=0.05; P=0.05 and P=0.04 respectively). 63.64% of the ST (+) patients were carrying the mutant allele, 54.5% of them having the heterozygous genotype and 36.4% the homozygous mutant one, compared to 9.1% having the homozygous wild type genotype. 62.5% of the resistant group was carrying the mutant allele (50% of them had the TT mutant genotype, 25% CT and 25% CC profiles). Among cases, 42.5% were homozygous mutant TT, 35% CC and 22.5% CT, compared to 39.4% CC, 51.5% CT and 9.1% TT among healthy controls. This polymorphism was positively correlated to ACS risk of development in the CT genotype and the additive transmission model (OR [95% CI]=0.49 [0.16-0.99], P=0.002; OR [95% CI]=2.17 [0.94-2.72], P=0.02), increasing-thus- the association of this polymorphism with the risk of pathology occurrence. Conclusion: To the best of our knowledge, our study is the first in Morocco to assess the effect of the C3435T MDR1 polymorphism on Clopidogrel response in a sample of Moroccan ACS patients; we also tried to explore the frequency of this polymorphism among Moroccan ACS patients and compare them to healthy individuals. The distribution of the mutant allele in Clopidogrel resistance groups, among ACS sub-types, and also in cases compared to controls and there correlations, suggest a potential association of this variant with Clopidogrel resistance and ACS occurrence risk in our population. Understanding the functional and clinical consequences of this MDR1 variant and others may provide a basis for treating patients more effectively. If this variability in response could be assigned to a mutation in the MDR1 gene, patients could be screened and appropriate dose adjustments could be made on the basis of their MDR1 genotype.