Therapy In Acute Coronary Syndromes Research Articles

Prior Antiplatelet Therapy and Clinical Outcomes in Acute Coronary Syndrome

Background: Antiplatelet agents remain the mainstay of therapy in acute coronary syndrome (ACS). There is limited information on outcomes of prior antiplatelet (PAP) use in ACS patients.

Lipid-Lowering Efficacy of Ezetimibe in Patients with Atherosclerotic Cardiovascular Disease: A Systematic Review and Meta-Analyses.

IntroductionPatients with atherosclerotic cardiovascular disease (ASCVD), especially those with recent (< 1 year) acute coronary syndrome (ACS), are at high risk for recurrent cardiovascular events. This risk can be reduced by lowering low-density lipoprotein cholesterol (LDL-C) levels. A comprehensive meta-analysis on the LDL-C-lowering efficacy of ezetimibe is lacking. This study attempts to address this gap.MethodsA systematic literature review of randomized controlled trials evaluating the LDL-C-lowering efficacy of ezetimibe in the ASCVD population was conducted. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for publications from database inception to August 2018 and for conference abstracts from 2015 to August 2018. Meta-analyses were conducted to evaluate the LDL-C-lowering efficacy of ezetimibe in the ASCVD population and the recent ACS subgroup.ResultsIn total, 12 studies were eligible for the meta-analyses. Treatment with combination ezetimibe plus statin therapy showed greater absolute LDL-C reduction than statin monotherapy (mean difference − 21.86 mg/dL; 95% confidence interval [CI] − 26.56 to − 17.17; p < 0.0001) after 6 months of treatment (or at a timepoint closest to 6 months). Similarly, in patients with recent ACS, combination ezetimibe plus statin therapy was favorable compared with statin monotherapy (mean treatment difference − 19.19 mg/dL; 95% CI − 25.22 to − 13.16; p < 0.0001).ConclusionsEzetimibe, when added to statin therapy, provided a modest additional reduction in LDL-C compared with statin monotherapy. However, this may not be sufficient for some patients with ASCVD who have especially high LDL-C levels despite optimal statin therapy.Electronic supplementary materialThe online version of this article (10.1007/s40256-019-00379-9) contains supplementary material, which is available to authorized users.

P5535Gender differences with short-term vs 12 months dual antiplatelet therapy in patients with acute coronary syndrome treated with the COMBO dual therapy stent: a 1-year analysis of the REDUCE trial

Abstract Background Gender differences in the thrombotic and bleeding risk have been suggested to condition the benefits of antithrombotic therapies in Acute Coronary Syndrome (ACS) patients, and mainly among those undergoing percutaneous coronary interventions with drug eluting stents (DES). Therefore, the impact of gender on the optimal duration of dual antiplatelet therapy (DAPT) treated is still unclear and was therefore the aim of the present sub-study. Methods REDUCE is a prospective, multicenter, randomized, investigator-initiated study, designed to enroll 1500 ACS patients after treatment with the COMBO Dual Stent Therapy, based on a non-inferiority design. Patients were randomized in a 1:1 fashion to either 3 or 12 months of DAPT. Primary study endpoint was a composite of all-cause mortality, myocardial infarction, definite/probable stent thrombosis (ST), stroke, target-vessel revascularization (TVR) and bleeding (BARC II, III, V) at 12 months. Secondary endpoints were cardiovascular mortality and the individual components of the primary endpoint. Results From June 2014 to May 2016 300 women and 1196 men were randomized in the trial. Among them 43.7% of females and 51.9% of males were assigned to the 3 months DAPT treatment. Baseline characteristics were well matched between the two arms, but of a lower rate of TIMI flow &lt;3 (p&lt;0.001) and lower systolic blood pressure (p&lt;0.05) among women and a more advanced age (p=0.05) among men receiving a shorted DAPT. At 1 year follow-up, no difference in the primary endpoint was observed according to DAPT duration (females: 6.9% vs 5.9%, HR [95% CI]=1.19 [0.48–2.9], p=0.71; males: 8.2% vs 9%, HR [95% CI]=0.92 [0.63–1.35], p=0.67). Results were confirmed after correction for baseline differences (females: adjusted HR [95% CI]=1.12 [0.45–2.78], p=0.81; males: adjusted HR [95% CI]=0.90 [0.61–1.32], p=0.60). Comparable rates of survival, thrombotic (MI, stent thrombosis, TVR, stroke) and bleeding events were observed with the two DAPT strategies, with no impact of gender. Conclusions The present study shows that among ACS patients randomized in the REDUCE trial, a 3 months DAPT strategy offers comparable results as compared to a standard 12 months DAPT at 1-year follow-up in both male and female gender. Acknowledgement/Funding None

P6406Platelet reactivity in Hepatitis C virus infected patients on dual antiplatelet therapy for acute coronary syndrome

Abstract Background Coronary artery disease (CAD) has been recognized as a serious and potentially life-threatening complication of Hepatitis C Virus (HCV) infection. High on treatment platelet reactivity has been associated with high risk of ischemic events in patients with CAD, but data regarding the association with HCV infection are still lacking. Purpose We sought to assess platelet reactivity on dual anti-platelet therapy and long-term outcome of acute coronary syndrome (ACS) patients infected with HCV. Methods ACS patients infected with HCV were matched to ACS patients without HCV for age, sex, diabetes, hypertension and renal function. Primary and secondary study endpoints were the proportion of patients with high on treatment platelet reactivity (HTPR) and long-term outcomes, respectively. Results HCV-infected ACS patients had higher levels of platelet reactivity (ADP10-LTA: 56% ± 18% vs. 44% ± 22%; p=0.002; Arachidonic Acid-LTA: 25% ± 21% vs. 16% ± 15%; p=0.011) and higher rate of HTPR on clopidogrel and aspirin compared with non-HCV patients. Multivariable analysis demonstrated HCV-infection to be an independent predictor of HTPR. At follow-up, estimated major adverse clinical events (MACE: cardiac death, non fatal myocardial infarction and any revascularization) were 57% vs. 37%, p=0.006 in HCV-infected ACS and non-HCV, respectively. Also, TIMI major bleeding rates were higher in HCV-infected subjects (11% vs. 3%; p=0.043) as compared with non-infected patients. Platelet function according to HCV status Conclusions ACS patients with HCV infection have increased on treatment platelet reactivity, higher rate of HTPR, MACE and bleedings as compared with non-HCV patients.

P1752Impact of frailty addition in ischemic and bleeding risk scores in elderly patients with Atrial Fibrillation and Acute Coronary Syndrome: a subanalysis from LONGEVO-SCA registry

Abstract Background The prevalence of Atrial Fibrillation (AF) and Acute Coronary Syndrome (ACS) increases with age. Frail older adults are at high risk of multiple adverse events during admission and short term mortality. FRAIL score is an easy tool that evaluates: fatigue, resistance, ambulation, concomitant diseases and weight loss. Purpose The aim of this study was to validate FRAIL score in AF elderly patients with ACS related to adverse events and the impact of its addition in clinical scores. Methods The prospective multicenter LONGEVO-SCA enrolled unselected elderly patients hospitalized after non-STACS. We analyzed the predictive performance of FRAIL score in AF subgroup for adverse events (primary endpoint mortality or readmission) and the impact of frailty addition in ischaemic and bleeding scores. Results We analyzed 531 patients. 128 (24.1%) of them have AF (main age 84.6±3.7 years; 78 (61%) male) and 27.3% were frail (defined by FRAIL score ≥3). Frail AF patients had more prevalent comorbidities and received less evidence-based ACS therapies at discharge as oral anticoagulation (66% vs 60%; p&lt;0.001) or statins 96.3% vs 82.6%; p&lt;0.001). We analyzed the predictive performance of FRAIL score to adverse events and observed a modest predictive performance for mortality (c-statistic 0.648; 95% CI [0.605–0.690]; p&lt;0.001), readmissions (c-statistic 0.600; 95% CI [0.557–0.642]; p&lt;0.001) and for composite endpoint (c-statistic 0.620; 95% CI [0.577–0.663]; p&lt;0.001). We compared the addition of FRAIL score to the original risk scores and observed a significant improvement for the primary endpoint with the addition to CHA2DS2-Vasc score (p=0.009), GRACE (p&lt;0.001) and CRUSADE scores (p&lt;0.001). (Table) C-indexes for mortality or readmissions C-index 95% CI p p* Z* CHA2DS2-VASc score 0.619 0.576 to 0.662 &lt;0.001 0.009 2.586 CHA2DS2-VASc score + FRAIL 0.641 0.598 to 0.683 &lt;0.001 HAS-BLED score 0.649 0.606 to 0.691 &lt;0.001 0.445 0.764 HAS-BLED score + FRAIL 0.634 0.590 to 0.675 &lt;0.001 GRACE score 0.599 0.554 to 0.644 0.006 0.001 3.930 GRACE score + FRAIL 0.602 0.556 to 0.646 &lt;0.001 CRUSADE score 0.660 0.613 to 0.705 0.051 0.001 3.287 CRUSADE score + FRAIL 0.664 0.617 to 0.709 &lt;0.001 CI: Confidence interval. *For c-index comparison. p: P value. Conclusions This is the first validation of the FRAIL score in AF patients under ACS with a modest predictive performance to adverse events. The addition of frailty to clinical scores improved the predictive performance to adverse events in AF patients.

VWF, CXCL8 and IL6 might be potential druggable genes for acute coronary syndrome (ACS)

ObjectiveAcute coronary syndrome (ACS) is currently a leading cause of morbidity and mortality worldwide. This study aimed to screen critical genes and miRNAs involved in ACS. Materials and methodsMicroarray data (access number GSE19339) was downloaded from Gene Expression Omnibus (GEO) database. After data preprocessing, we screened the differentially expressed genes (DEGs) using limma package and subsequently performed enrichment analysis using DAVID tool. The protein-protein interaction (PPI) network and transcription factor (TF)-miRNA-target gene regulatory network were visualized using Cytoscape software. Finally, the drug-gene interactions were predicted using DGIdb database. ResultsA total of 425 DEGs were identified in ACS samples compared with healthy control samples. Functional enrichment analysis showed that DEGs were mainly involved in angiogenesis, inflammatory response and PI3K-Akt signaling pathway. IL6 and VEGFA were key nodes in PPI network. In addition, hsa-miR-29, hsa-miR-1, NFIC, NFKB1 and RELA were identified as key factors in TF-miRNA-target gene network. Finally, the prediction results revealed that VWF, CXCL8 and IL6 had higher degree than other genes. ConclusionIL6 and VEGFA might play major roles in ACS progression. Two miRNAs (hsa-miR-29 and hsa-miR-1) and three TFs (NFIC, NFKB1 and RELA) were critical genes involved in pathological process of ACS. VWF, CXCL8 and IL6 might be potential druggable genes for ACS therapy.

Antithrombotic therapy in acute coronary syndrome and stable coronary artery disease patients with atrial fibrillation: a 3-year retrospective cohort study.

Aim: Acute coronary syndrome (ACS) and stable coronary artery disease (SCAD) occur frequently in patients with atrial fibrillation (AF). However, the optimal antithrombotic therapy is still debated. Methods & results: We analyzed 976 coronary artery disease patients with AF from 2013 to 2014. ACS+AF patients tend to take dual antiplatelet therapy (p<0.001), whereas SCAD+AF patients prefer anticoagulation therapy (warfarin: p<0.001, dabigatran: p<0.05). Ventricular arrhythmia, congestive heart failure and ACS were the top three reasons for SCAD group patients' readmission, while reinfarction and congestive heart failure were two major factors in readmission of ACS group. Conclusion: ACS+AF group patients more likely choose dual antiplatelet therapy, whereas SCAD+AF group patients prefer anticoagulation therapy. Compared with ACS group, SCAD group had a higher rate of readmission.

Performance of acute coronary syndrome approaches in Brazil: a report from the BRACE (Brazilian Registry in Acute Coronary SyndromEs).

Diagnostic and therapeutic tools have a significant impact on morbidity and mortality associated with acute coronary syndromes (ACS). Data about ACS performance measures are scarce in Brazil, and improving its collection is an objective of the Brazilian Registry in Acute Coronary syndromEs (BRACE). The BRACE is a cross-sectional, observational epidemiological registry of ACS patients. Stratified 'cluster sampling' methodology was adopted to obtain a representative picture of ACS. A performance score (PS) varying from 0 to 100 was developed to compare studied parameters. Performance measures alone and the PS were compared between institutions, and the relationship between the PS and outcomes was evaluated. A total of 1150 patients, median age 63 years, 64% male, from 72 hospitals were included in the registry. The mean PS for the overall population was 65.9% ± 20.1%. Teaching institutions had a significantly higher PS (71.4% ± 16.9%) compared with non-teaching hospitals (63.4% ± 21%; P < 0.001). Overall in-hospital mortality was 5.2%, and the variables that correlated independently with in-hospital mortality included: PS-per point increase (OR = 0.97, 95% CI 0.95-0.98, P < 0.001), age-per year (OR = 1.06, 95% CI 1.03-1.09, P < 0.001), chronic kidney disease (OR = 3.12, 95% CI 1.08-9.00, P = 0.036), and prior angioplasty (OR = 0.25, 95% CI 0.07-0.84, P = 0.025). In BRACE, the adoption of evidence-based therapies for ACS, as measured by the performance score, was independently associated with lower in-hospital mortality. The use of diagnostic tools and therapeutic approaches for the management of ACS is less than ideal in Brazil, with high variability especially among different regions of the country.

Aortic dissection patients mimic acute coronary syndrome with preoperative antiplatelet therapy.

Acute Stanford type A aortic dissection (ATAAD) is often misdiagnosed as an acute coronary syndrome (ACS), and antiplatelet therapy (APT) for ACS will influence the timing and outcome of ATAAD. We reviewed the surgical outcome of these misdiagnosed ATAAD patients. From January 2011 to December 2015, 309 ATAAD patients received surgical therapy in our department, among whom 15 patients were misdiagnosed as ACS and took oral APT. We retrospectively reviewed the data of the perioperative and follow-up period. The average age of these 15 patients was 60.6±8.7 years old (9 males, 6 females). Five patients took aspirin orally, and 10 took aspirin and clopidogrel. Operations were performed 7, 3, and 1 day after stopping the agents in 2, 3, and 1 patient, respectively; the other 5 patients received emergency operation without stopping the agents. The cardiopulmonary bypass (CPB) time was 259.7±64.8 minutes, aortic cross-clamp time was 181.0±51.7 minutes, and selective cerebral perfusion and lower body arrest time were 34.9±8.1 minutes. There were two in-hospital deaths due to circulation failure (mortality 13.3%). The average drainage volume in the first 24 h after operation was 800.7±598.8 mL. During a mean follow-up period of 20.6±17.4 months, one patient had a sudden death. ATAAD misdiagnosed as ACS is not rare, and APT will increase the risk of bleeding in ATAAD patients. The decision of operation time relies on considering the balance between the rupture risk of aortic dissection and the hemorrhage risk of APT. The emergency operation for these patients will increase bleeding and transfusion.

Cardiovascular Sonothrombolysis.

This review will provide recent pre-clinical and initial clinical trials exploring the efficacy of sonothrombolysis as an adjunct to current emergent therapies in acute coronary syndromes. The initial clinical trials examining the efficacy of short pulse duration diagnostic ultrasound (DUS) high mechanical index impulses in patients with ST segment elevation myocardial infarction (STEMI) have demonstrated that there is improved patency of the infarct vessel, and improved microvascular flow following percutaneous coronary intervention. Subsequent randomized prospective trials have confirmed that in patients with acute STEMI receiving an intravenous microbubble infusion, diagnostic high mechanical index impulses applied in the apical windows pre- and post-percutaneous coronary intervention have reduced myocardial infarction size, as assessed by magnetic resonance imaging at 72h following presentation, and have been associated with better left ventricular systolic function at 6month follow-up. Sonothrombolysis has potential for improving early epicardial coronary artery patency and reduce left ventricular remodeling when added to current interventional strategies in STEMI.

The Use of Dual Antiplatelet Therapy in Acute Coronary Syndrome and Percutaneous Coronary Intervention

Currently, cardiovascular diseases play a leading role in the structure of morbidity. It is expected that by 2020 in developing countries cardiovascular diseases will take the leading position in the structure of mortality. Among the diseases of the cardiovascular system the leading position is occupied by coronary heart disease. One of the manifestations of coronary heart disease is acute coronary syndrome. In addition to endovascular treatment, dual antiplatelet therapy plays a key role in the treatment and prevention of acute coronary syndrome. Double antiplatelet therapy is a combination of acetylsalicylic acid and platelet P2Y 12 receptor inhibitors. One of the first drugs from the group of P2Y 12 receptor inhibitors is clopidogrel. It has been proven that the use of clopidogrel to date not always reduces the risk of development of thrombotic complications, of particular interest are the representatives of the new platelet P2Y 12 receptor inhibitors. Such platelet P2Y 12 -receptor inhibitors include ticagrelor and prasugrel. The article considers in detail the issue of efficiency and safety of prasugrel use. The results of the studies allow to distinguish this drug as an effective inhibitor of P2Y 12 platelet receptors in patients with acute coronary syndrome who have undergone percutaneous coronary intervention. Considering the pronounced antiplatelet effect of the drug, it should not be prescribed to patients with stroke and a history of transient ischemic attack. Prasugrel also should not be prescribed in a full dose to patients over 75 years old and patients weighing up to 60 kg. These studies showed that when the recommendations are followed, prasugrel demonstrates good results in reducing the frequency of cardiovascular events in patients with acute coronary syndrome and percutaneous coronary intervention. Separately, we can distinguish the effect of prasugrel on the development of stent thrombosis. So, in patients that underwent stenting, the use of prasugrel significantly reduced the frequency of confirmed stent thrombosis, which can also affect the development of undesirable cardiovascular events.

Medicines adherence to anti-platelet therapy in acute coronary syndrome: part 2

Ruth Paterson and Tasha Mahadi provide an overview of recently published articles that may be of interest to prescribers. Should you wish to look at any of the articles in more detail, a full reference is provided

Anticoagulation in Acute Coronary Syndrome: Review of Major Therapeutic Advances.

In patients with acute coronary syndrome (ACS), a persistent hypercoagulable state has been demonstrated and antithrombin therapy in addition to platelet inhibition has been proposed. Vitamin K antagonists (VKAs) were used as oral anticoagulant (OAC) therapy and produced mixed results whereas trials are still ongoing with non-vitamin K OACs (NOACs). A literature search regarding benefits and risks of different OAC therapies in ACS was conducted through MEDLINE and EMBASE (last 20 years until September 2018). Patients receiving dual antiplatelet therapy (DAPT) in combination with NOAC are to be considered at high bleeding risk. Rivaroxaban 2.5 mg BID in triple therapy with DAPT, rivaroxaban 15 mg, or dabigatran 110/150 mg BID in dual therapy with P2Y12 inhibitor (mainly clopidogrel) is safer in terms of bleeding risk than triple therapy with VKA plus DAPT. The reduction in ischemic events by NOACs was most promising when added to single antiplatelet therapy. Ongoing trials with apixaban and edoxaban could clarify whether dual therapy NOACs with P2Y12 inhibitor sufficiently protect against stent thrombosis or myocardial infarction and are safer in terms of bleeding risk than a dual therapy with a VKA and clopidogrel. In the absence of randomized trials, it is unknown whether dual therapy with NOAC and aspirin could be an alternative to NOAC and a P2Y12 inhibitor. Thus, the overall benefit of adding NOAC to antiplatelet treatment after ACS in patients without clear indication for long-term OAC is still unknown. Different OACs have been tested as antithrombotic therapy after ACS in combination with single or DAPT and led to a modest reduction in ischemic events. Further studies evaluating NOACs in combination with single antiplatelet therapy or shorter duration of triple antithrombotic therapy are warranted.

Very-low-dose twice-daily aspirin maintains platelet inhibition and improves haemostasis during dual-antiplatelet therapy for acute coronary syndrome

Higher aspirin doses may be inferior in ticagrelor-treated acute coronary syndrome (ACS) patients and reducing bleeding risk whilst maintaining antithrombotic benefits could improve outcomes. We characterized the pharmacodynamics of a novel dual-antiplatelet-therapy regimen consisting of very-low-dose twice-daily (BD) aspirin with standard-dose ticagrelor. A total of 20 ticagrelor-treated ACS patients entered a randomized crossover to take aspirin 20 mg BD (12-hourly) during one 14-day period and 75 mg once-daily (OD) in the other. After 14 days of treatment, serum thromboxane (TX)B2 and light-transmittance aggregometry were assessed pre- and 2 h post-morning-dose, bleeding time was measured post-dose, and TXA2 and prostacyclin stable metabolites were measured in urine collected 2 h post-morning-dose. Data are expressed as mean ± SD. After 14 days treatment, serum TXB2 levels were significantly greater 2 h post-dosing with aspirin 20 mg BD vs. 75 mg OD (3.0 ± 3.6 ng/mL vs. 0.8 ± 1.9 ng/mL; p = 0.018) whereas pre-dosing levels were not significantly different (3.5 ± 4.1 ng/mL vs. 2.5 ± 3.1 ng/mL, p = 0.23). 1-mmol/L arachidonic acid-induced platelet aggregation was similarly inhibited by both regimens pre-dose (8.5 ± 14.3% vs. 5.1 ± 3.6%, p = 0.24) and post-dose (8.7 ± 14.2% vs. 6.6 ± 5.3%; p = 0.41). Post-dose bleeding time was shorter with 20 mg BD (680 ± 306 s vs. 834 ± 386 s, p = 0.02). Urinary prostacyclin and TX metabolite excretion were not significantly different. In conclusion, compared to aspirin 75 mg OD, aspirin 20 mg BD provided consistent inhibition of platelet TXA2 release and aggregation, and improved post-dose hemostasis, in ticagrelor-treated ACS patients. Further studies are warranted to assess whether this regimen improves the balance of clinical efficacy and safety.

DOES THE CORRECTION OF THE ANXIETY-DEPRESSIVE DISORDERS INFLUENCE ON THE PROCESSES OF THE LEFT VENTRICULAR REMODELING IN PATIENTS WITH ACUTE CORONARY SYNDROME?

Aim:to study the dynamic of echocardiographic parameters in patients with acute coronary syndrome associated with anxiety and depressive disorders during the therapy by innovative Russian drug containing release-active antibodies to the brain-specific protein S-100 (Tenoten) in-hospital and during six months of treatment.Material and Methods. 54 patients with acute coronary syndrome associated with anxiety and depressive disorders were randomized into 2 groups: patients of group 1 were administered with anti-anxiety medicament Tenoten, 6 tablets per day in addition to the therapy for acute coronary syndrome; group 2 received placebo. All patients underwent echocardiography at inpatient and outpatient stages six months after randomization.Results. Clinically significant anxiety and subclinical depression were detected in patients of both study groups. The intake of anti-anxiety drug Tenoten for six months contributed to anxiety reduction, myocardial contractility improvement, and a decrease in the left ventricular volume indices. Negative changes were observed in comparison group: a decrease in the left ventricular ejection fraction, increase in volume indices, and decline in the left ventricular relaxation.Conclusion. Administration of Tenoten at a dose of six tablets per day to patients with acute coronary syndrome in combination with affective disorders resulted not only in improvement of a mental status, but it also contributed to suppression of the left ventricular remodeling processes.

Medicines adherence to anti-platelet therapy in acute coronary syndrome: part 1

Ruth Paterson and Tasha Mahadi provide an overview of recently published articles that may be of interest to prescribers. Should you wish to look at any of the articles in more detail, a full reference is provided

Antithrombotic therapy in elderly patients with acute coronary syndrome

Elderly adults constitute a rapidly increasing subgroup of patients presenting with acute coronary syndrome.Due to a higher risk of bleeding and more multiple complications in the elderly, the treatment of acute coronary syndrome is more conservative in these patients than in younger patients.The scarcity of evidence from randomized controlled trials makes antithrombotic therapy in elderly patients particularly challenging and controversial.This article reviews the current evidence on antithrombotic therapy for acute coronary syndrome in the elderly. Key words: Coronary; Thromboembolism

Reassessing the Mechanisms of Acute Coronary Syndromes.

The mechanisms that underlie superficial erosion, a cause of coronary thrombosis distinct from plaque rupture, have garnered recent interest. In an era of improved control of traditional risk factors, such as LDL (low-density lipoprotein), plaque erosion may assume greater clinical importance. Plaques complicated by erosion tend to be matrix-rich, lipid-poor, and usually lack prominent macrophage collections, unlike plaques that rupture, which characteristically have thin fibrous caps, large lipid pools, and abundant foam cells. Thrombi that complicate superficial erosion seem more platelet-rich than the fibrinous clots precipitated by plaque rupture. The pathogenesis of plaque rupture probably does not pertain to superficial erosion, a process heretofore little understood mechanistically. We review here data that support a substantial shift in the mechanisms of the thrombotic complications of atherosclerosis. We further consider pathophysiologic processes recently implicated in the mechanisms of erosion. Multiple processes likely predispose plaques to superficial erosion, including experiencing disturbed flow, basement membrane breakdown, endothelial cell death, and detachment potentiated by innate immune activation mediated through pattern-recognition receptors and endothelial-to-mesenchymal transition. Monocytes/macrophages predominate in the pathogenesis of plaque rupture and consequent thrombosis, but polymorphonuclear leukocytes likely promote endothelial damage during superficial erosion. The formation of neutrophil extracellular traps probably perpetuates and propagates intimal injury and potentiates thrombosis due to superficial erosion. These considerations have profound clinical implications. Acute coronary syndromes because of erosion may not require immediate invasive therapy. Understanding the biological bases of erosion points to novel therapies for acute coronary syndrome caused by erosion. Future research should probe further the mechanisms of superficial erosion, and develop point-of-care tests to distinguish acute coronary syndromes provoked by erosion versus rupture that may direct more precision management. Future clinical investigations should evaluate intervening on the targets that have emerged from experimental studies and the management strategies that they inform.

Secondary prevention therapies in acute coronary syndrome and relation to outcomes: observational study

ObjectiveTo ascertain the use of secondary prevention medications and cardiac rehabilitation after an acute coronary syndrome (ACS) and the impact on 2-year outcomes.MethodsCONCORDANCE (Cooperative National Registry of Acute Coronary care,...

The Impact of Anaemia in Patients with Acute Coronary Syndrome

Abstract Background: A significant number of patients with acute coronary syndrome (ACS) are reported to suffer from anaemia. However, data relating to anaemia and clinical outcomes in patients presenting with ACS, particularly in Africa, are scarce. This study thus aimed to assess the prevalence of anaemia and its association with clinical characteristics and in-hospital mortality in patients presenting with ACS to a large urban public hospital in South Africa. Methods: The study is a retrospective analysis of patients 18 years and above admitted with a diagnosis of ACS to the Charlotte Maxeke Johannesburg Hospital (CMJAH) over a two-and-a-half-year period between January 2010 and June 2012. Data on clinical characteristics, blood chemistry including haemoglobin (Hb) level, therapies received and in-hospital mortality was collected. Results: A total of 431 ACS patients fulfilled the diagnostic criteria for ACS during the review period. The majority were males (72.2%) with a mean age of 58 ± 12.4 years. Anaemia was found to be present in 18.8% of all patients. Patients with anaemia were found to be significantly older, more likely to be female, have hypertension or diabetes and were more likely to be in a higher Killip functional class as compared to those not having anaemia. Anaemic patients were also less likely to receive optimal medical therapy for ACS (60.5% vs. 72.7%, p &lt; 0.001). Killip class ≥3 (p &lt; 0.001), atrial fibrillation (p &lt; 0.045) and haemoglobin (Hb) &lt; 11.4 g/dl (p &lt; 0.0001) were significantly associated with mortality. However, only Hb of &lt;11.4 g/dl was found to be an independent predictor of mortality and had more than fourfold increased risk compared to those with normal Hb (CI – 1.393–13.041; RR – 4.262; p &lt; 0.011). Conclusion: Anaemia was present in almost one-fifth of patients presenting with ACS. Furthermore it was significantly associated with diabetes, hypertension, older age, female sex and Killip class ≥3. Anaemic patients were also less likely to receive optimal medical therapy. Importantly, a haemoglobin level &lt;11.4 g/dl was found to be an independent predictor of mortality. Simple serial measurement of Hb is recommended in patients presenting with ACS and should be incorporated into the risk stratification of patients with ACS.