Type Of Acute Coronary Syndrome Research Articles

Thoughts, actions, and factors associated with prehospital delay in patients with acute coronary syndrome

The objective was to study patients' interpretations, thoughts, and actions after symptom onset in acute coronary syndrome (ACS) in total and in relation to gender, age, history of coronary artery disease, type of syndrome, and residential area and its influence on prehospital delay. We performed a national survey comprising intensive cardiac care units at 11 hospitals in Sweden. A total of 1,939 patients with diagnosed ACS and symptom onset outside hospital completed a questionnaire containing standardized questions within 3 days after admission. Three-quarters of the patients interpreted their symptoms as cardiac in origin, and the most common reason was that they knew someone who had had an acute myocardial infarction. The majority contacted a family member, whereas only 3% directly called for an ambulance. Interpreting the symptoms as cardiac in origin and severe pain were major reasons for deciding to seek medical care. Approaching someone after symptom onset and the belief that the symptoms were cardiac in origin were factors associated with a shorter prehospital delay, whereas taking medication to relieve pain resulted in the opposite. The reaction pattern was influenced by gender, age, a history of coronary artery disease, and the type of ACS, but to a lesser extent by residential area. Interpreting symptoms as cardiac in origin and approaching someone after symptom onset were major reasons for a shorter prehospital delay in ACS.

Abstract 1514: Effect of Prior Medication on Clinical Characteristics and Hospital Outcome of Acute Coronary Syndromes

Background: Patients (Pts) with acute coronary syndrome (ACS) are often on medication at time of admission, because of risk factors and/or prior history of cardiovascular disease. We assessed the influence of prior medication on mode of presentation and prognosis of ACS. Methods: We studied 18,400 Pts included in a nationwide prospective registry of ACS and determined the influence of prior medication with aspirin (ASA), beta-blockers (BB), angiotensin converting enzyme inhibitors (ACEI), and statins (Stat) on type of ACS and its effect on all-cause hospital mortality. Results: ACS presentation was more benign in Pts previously medicated with ASA, BB, ACEI or Stat (Table ). Pts on prior medication with these drugs were older, more often female, less often smokers, and more often presented BMI >=25, diabetes, hypertension, hypercholesterolemia, and prior history of cerebrovascular or peripheral arterial disease, MI or myocardial revascularization. Of the 3453 Pts with prior MI, 63.9% were on ASA, 42.0% BB, 47.6% ACEI, and 49.4% Stat. Of the 2946 diabetics, 29.6% were on ASA, 32.5% ACEI, and 25.7% Stat. Of the 1275 Pts with prior stroke/TIA, 36.3% were on ASA and 24.2% Stat. Of the 382 Pts with peripheral arterial disease, 38.8% were on ASA and 33.7% Stat. Overall, 344 (3.4%) of the 9980 non-ST-elevation ACS and 703 (8.3%) of the 8420 ST-elevation MI Pts died. Prior BB was an independent predictor of hospital mortality in non-ST-elevation ACS (adjusted OR = 1.58; 95% CI, 1.09–2.29; p=0.016), but not ST-elevation MI. Prior medication with ASA, an ACEI or a Stat did not influence outcome of either type of ACS. Conclusions: In the real world, Pts at high risk for atherothrombotic disease are insufficiently medicated with ASA, BB, ACEI and/or Stat. Prior medication with these drugs is associated with a more benign clinical presentation of ACS. Further studies are required to clarify the mechanisms conferring increased hospital mortality in Pts with non-ST-elevation ACS admitted on a BB.

Behandlung des akuten Koronarsyndroms in Deutschland: Erfahrungen eines deutschen Clusters des GRACE-Registers

The acute coronary syndrome (ACS) remains a major cause of mortality and morbidity in the western world. The Global Registry of Acute Coronary Events (GRACE) documents inpatients with all types of ACS and a follow-up at three months in Germany and worldwide. The data of the German Cluster Detmold were compared with data from the worldwide GRACE registry (31,070 patients). Data from 849 patients with ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI) and unstable angina (UA) were collected from October 2001 to September 2005 in eight participating hospitals in the GRACE2 Cluster Detmold. Compared with the worldwide GRACE data the patients in the Cluster Detmold had longer pre-hospital admission times (STEMI patients < 1 h: 13.9 % vs. 17.0 %; p < 0.05); more frequent interventions (PCI 60.1 % vs. 48.7%; p < 0.001) and less thrombolysis (17.9 vs. 42.5%; p < 0.001) in STEMI patients; more frequent use of platelet inhibitors (clopidogrel and ticlopidine, 93.4 % vs. 89.4%; p < 0.001) and unfractionated heparin (69.8 % vs. 36.5; p < 0.001), and less frequent use of low molecular weight heparin (31.1 % vs. 51.2%; p < 0.001); more frequent use of RAS blocking agents (80.2 vs. 66.6, p < 0.001) and beta blockers (87.4 vs. 78.8, p < 0.001) and less frequent use of lipid lowering agents (23.5 vs. 72.5%; p < 0.001). Current management of ACS in Germany closely follows the recommendations of the German society of Cardiology. Differences in practice may account for the observed substantially lower event rates in Germany during hospitalization, but there is still room for improvement in the pre-hospital phase und in the degree to which pharmacotherapy is used for secondary prevention.

Management of Hypertension in Relation to Acute Coronary Syndromes and Revascularisation

In patients with acute coronary syndromes (ACS), hypertension is common. The type of ACS and severity of hypertension would determine the treatment algorithm. In ST elevation myocardial infarction (MI), time to reperfusion is essential whereas in malignant hypertension the reduction of blood pressure to prevent end organ damage is the priority. Many therapeutic drugs available for ACS and hypertension are commonly used to treat both these conditions simultaneously. Once the ACS is treated medically, revascularization therapy is likely to be considered. Importantly, optimization of hypertension management may prevent subsequent complications. In this review, we discuss the frequency of hypertension and ACS as single clinical conditions, as well as combined presentations. The pathophysiology of myocardial perfusion in hypertensive patients and the effect of blood pressure (BP) normalization is discussed. This review focuses on treatment strategies from a non-interventional and interventional perspective. Finally, current medications used in treating hypertension in ACS will be compared with regards to their mode of action and prognostic value.

Impact of diagnosis and sex on long-term prognosis in acute coronary syndromes

There is limited information on long-term outcome in patients surviving the acute phase of an acute coronary syndrome (ACS). As yet, the effects of the type of syndrome and sex on mortality and morbidity in the long run have not been well described. We studied 1618 patients <80 years old with ACS and alive 30 days after hospitalization in a coronary care unit. The patients were followed for 5 years. They were divided into 4 groups according to the type of ACS (ST-segment elevation myocardial infarction [STEMI], non-STEMI, unstable angina pectoris high risk, and unstable angina pectoris low risk). There was no significant sex difference in unadjusted 5-year mortality (P = .20). After adjustment for age, the hazard ratio with the corresponding 95% CI for a higher late 5-year mortality in women in relation to men was 0.89 (0.70-1.13, P = .34). Women were hospitalized for heart failure significantly more frequently during follow-up, a significance that disappeared after adjustment for age. Non-STEMI was associated with a significantly higher long-term mortality than STEMI, before but not after adjustment for covariates (hazard ratio [95% CI] 1.02 [0.75-1.37], P = .92). Of these, age, ST depression on admission, and early revascularization with percutaneous coronary intervention appeared to be of particular importance. Non-STEMI had a significantly higher rate of acute/subacute revascularization during follow-up, even after adjustment for age. Before, but not after, adjustment for covariates, a diagnosis of non-STEMI was associated with a poorer prognosis than other types of ACS. Small sex differences in long-term outcome in survivors of ACS were found.

Connexin37 (GJA4) genotype predicts survival after an acute coronary syndrome

GJA4 1019 C > T, MMP3 -1171delA, and SERPINE1 -668delG genotypes have been associated with the risk of incident myocardial infarction. We tested the hypothesis that these genotypes would predict long-term mortality after an acute coronary syndrome (ACS). We assembled a prospective cohort study on 726 patients with ACS admitted between March 2000 and October 2001. Kaplan-Meier estimates and Cox proportional hazards models of 3-year mortality adjusted for age, race, ACS type, prior heart failure, diabetes, and revascularization were used to compare groups. The GJA4 1019 C > T genotype was significantly related to mortality over 3 years (8.3% vs 14%, for the C/C vs T allele carriers; P = .02), with an adjusted hazard ratio of 1.7 (95% confidence interval 1.05-2.8, P = .03). This finding was consistent in both men and women (hazard ratio = 1.9 and 1.7, respectively) with no significant sex interaction (P = .8). The MMP3 -1171delA and SERPINE1 -668delG genotypes were not significantly related to mortality in the overall population (all P > .4). GJA4 1019 C > T genotype predicted risk of death after an ACS, whereas the MMP3 and SERPINE1 genotypes did not. The GJA4 1019 C > T polymorphism may warrant integration into comprehensive risk stratification algorithms for patients with ACS.

Psychological and clinical predictors of return to work after acute coronary syndrome

Resumption of paid employment following acute coronary syndrome (ACS) is an important indicator of recovery, but has not been studied extensively in the modern era of acute patient care. A total of 126 patients who had worked before hospitalization for ACS were studied with measures of previous clinical history, ACS type and severity, clinical management, and sociodemographic characteristics. Depressed mood (Beck Depression Inventory) and type D personality were measured 7-10 days following admission. Among them, 101 (80.2%) had returned to work 12-13 months later. Failure to resume work was associated with cardiac factors on admission (heart failure, arrhythmia), cardiac complications during the intervening months, and depression scores during hospitalization. It was not related to age, gender, socioeconomic status, type of ACS, cardiac history, acute clinical management, or type D personality. In multivariate analysis, the likelihood of returning to work was negatively associated with depression, independently of clinical and demographic factors [adjusted odds ratio 0.90, CI 0.82-0.99, P=0.032]. Depressed mood measured soon after admission is a predictor of returning to work following ACS. The management of early depressed mood might promote the resumption of economic activity and enhance the quality of life of cardiac patients.

Implications of hyperglycaemia and ethnicity in patients with acute coronary syndromes in New Zealand

Admission blood glucose (ABG) is an independent predictor of death in patients with acute ST elevation myocardial infarction (STEMI). In New Zealand, mortality following myocardial infarction is disproportionally higher in Maori. Little information, however, exists concerning the predictive value of ABG in non-ST elevation acute coronary syndromes (NSTEACS) events or indeed if similar ethnic differences exist in outcome in this patient population. To assess the predictive value of ABG and ethnicity in individuals admitted with acute coronary syndromes (ACS) on mortality. A retrospective analysis of hospital discharge diagnosis of all ACS between 1 January 1999 and 31 December 2002 at Waikato hospital, Hamilton, New Zealand. The primary outcome was all-cause mortality. There were 4408 episodes of ACS with 1091 (25%) due to STEMI. There were 806 (18%) deaths. The presence of diabetes mellitus (DM) or an elevated ABG, in the absence of a history of DM, was associated with poor patient outcome. Early mortality is seen in individuals presenting with STEMI. People in the highest glucose category were older, more likely to be Maori, had a higher percentage of people with diabetes and remained in hospital longer, regardless of ACS type, than those in the lowest glucose category. Diabetes was more common in Maori (33%) than in Europeans (17.5%); p < 0.001. Significant risk factors for mortality were age, gender, diabetes, ethnicity, glucose and STEMI. For each mmol/l increase in glucose there is a 4.3% increase risk of dying. Adjusting for age and gender, Maori have a much higher mortality than Europeans (RR 2.12; p < 0.00001) regardless of ACS type (STEMI or NSTEACS). Our study confirms the higher mortality following ACS, of Maori compared to New Zealanders of European origin. A raised ABG is a marker of this increased risk in all patients with ACS.

Inflammatory Biomarkers in Acute Coronary Syndromes

Acute coronary syndromes (ACS) are multifactorial and occur in response to inflammation, plaque rupture and subsequent thrombosis, progressive mechanical obstruction, and dynamic obstruction.1 Patients with ACS span a large spectrum of risk that progresses from unstable angina (UA) to non–ST-elevation myocardial infarction (NSTEMI) to ST-elevation myocardial infarction (STEMI). ECG findings and markers of myocyte necrosis are used to define the type of ACS and guide reperfusion strategy in ST-elevation myocardial infarction. For patients with non–ST-elevation (NSTE) ACS, however, a large degree of uncertainty remains regarding long-term risk and optimal secondary prevention for the individual patient. Increasingly, biomarkers are being used as tools to identify subgroups of patients with ACS who are at increased risk for subsequent cardiovascular events. Among potential biomarkers, much interest has focused on biomarkers of inflammation. The process that leads to eventual plaque erosion or rupture involves a number of inflammatory mechanisms, including endothelial dysfunction, leukocyte migration, extracellular matrix degradation, and platelet activation (Figure).2 The optimal inflammatory biomarker would provide a method for quantitating cardiovascular-specific inflammation, thereby predicting the risk of recurrent atherothrombosis and its clinical sequelae. Because they address a separate aspect of ACS pathophysiology, biomarkers of inflammation may provide unique information to the clinician separate from that provided by biomarkers of myocyte necrosis and hemodynamic stress. Pathophysiological sequence of inflammatory biomarkers in ACS. In this schematic diagram showing the development of an atherosclerotic plaque and the local vascular events that surround an ACS, the inflammatory biomarkers are superimposed with a semiquantitative representation of their relative importance during the sequence of events shown. Cytokines and acute-phase reactants such as IL-6, MCP-1, TNF-α, IL-18, IL-10, CRP, and serum amyloid A (SAA) may establish or be surrogate markers for basal inflammation that leads to development of atherosclerotic plaque. Activation of endothelial adhesion molecules such as …

Temporal trends in the type of recurrent acute coronary syndrome

Different pathogenic mechanisms have been suggested for acute coronary syndrome (ACS) with ST segment elevation (STEMI) or without ST segment elevation (NSTEMI) and for unstable angina (UA). Our objective was to analyze the incidence of different types of ACS in relation to the temporal occurrence, as first or recurrent ACS.

Effect of the new diagnostic criteria for ST-elevation and non-ST-elevation acute myocardial infarction on 4-year hospitalization: an analysis of hospital discharge records in the Veneto Region

To assess the burden of hospitalization for acute coronary syndrome (ACS) and the impact of the new diagnostic criteria for acute myocardial infarction on epidemiology of ACSs. We analysed the hospital discharge record archives of the Veneto Region in the period 2000-2003, including admissions of regional residents outside the study area. We defined a list of ICD-9-CM codes for the identification of different types of ACS. We examined trends in standardized hospitalization rates as well as patient characteristics (age, sex) and pattern of care (setting, invasive revascularization, length of hospital stay, in-hospital mortality). The hospitalization rate for non-ST-elevation myocardial infarction increased by about 70%, with a parallel decrease in hospitalizations for unstable angina, whereas the hospitalization rate for ST-elevation myocardial infarction remained unchanged. These trends are likely influenced by the new diagnostic criteria for acute myocardial infarction. At the end of the study period, although the main patient characteristics did not vary substantially, the pattern of care turned out to be more aggressive. Despite some limitations, our results indicate that the new diagnostic criteria for acute myocardial infarction have a major impact on epidemiological evaluation. These data may be relevant when comparing epidemiological data of different periods and planning healthcare policies. Further studies are needed in order to evaluate the accuracy of ICD-9-CM codes in the diagnosis of ACSs.

The impact of time and day on the presentation of acute coronary syndromes

The frequency of acute myocardial infarction (AMI) peaks on Mondays and in the mornings. However, the distribution of the types of acute coronary syndromes (ACS), including unstable angina (UA), has not been systematically evaluated. The distribution of the types of ACS and clinical presentations varies by time and day of admission. A retrospective cohort study was conducted in 1,946 consecutive nontransfer ACS admissions (1999-2004) to a tertiary-care academic center to assess presenting clinical variables in patients admitted on days versus nights (6 P.M.-6 A.M.) and weekdays versus weekends (Friday 6 P.M.-Monday 6 A.M.). There were fewer ACS admissions than expected on nights and weekends (p < 0.001), but the proportion of patients with ACS presenting with ST-elevation myocardial infarction (STEMI) is 64% higher on weekends (p < 0.001) and 31% higher on nights (p = 0.022). This increased proportion with STEMI results in a greater proportion of ACS with AMI on weekends (up arrow 10%, p = 0.006) and nights (up arrow 7%, p = 0.033). Using multivariate modeling, the increase in patients with AMI on weekends was not explained by conventional risk predictors. Although fewer patients with ACS presented on nights and weekends, patients at those times were more likely to have an AMI, driven largely by an increased proportion with STEMI at those times. Consideration should be given to these findings when developing clinical care paradigms, health care staffing needs, and when comparing new treatment outcomes in patients with ACS.

Designing prehospital ECG systems for acute coronary syndromes. Lessons learned from clinical trials involving 12-lead ST-segment monitoring

Background Clinical trials in prehospital electrocardiography have focused primarily on ST elevation myocardial infarction (STEMI). The aims of this study were to determine, in patients presenting to the emergency department with acute coronary syndrome (ACS), the (1) relative frequency of various ACS types and (2) sensitivity of conventional ST-T criteria for diagnosing ischemia in non-STEMI or unstable angina. Methods A secondary analysis was conducted using data from prospective trials involving 12-lead ST monitoring. Results Of 968 patients with ACS, 120 (12%) were STEMI, 289 (30%) were non-STEMI, and 559 (58%) were unstable angina. Conventional electrocardiogram (ECG) criteria were insensitive (sensitivity, 20%) for detecting ischemia in patients with non-STEMI or unstable angina. There was no ischemia on the initial ECG in 85 patients who had subsequent events with ST monitoring. Conclusion Non-STEMI and unstable angina are the most prevalent types of ACS. The initial ECG is insensitive for detecting ischemia in this population. Transient myocardial ischemia detected with ST monitoring commonly occurs in patients without ischemia on the initial ECG. ST monitoring should be considered in designing prehospital ECG systems.

Perceived Work Performance of Patients who Experienced an Acute Coronary Syndrome Event

The objectives of this study were to describe the perceived work performance of patients previously diagnosed with acute coronary syndrome (ACS) and to determine the relationship between patient-specific variables and perceived work performance. This cross-sectional study utilized a mailed survey to all patients discharged from a university affiliated hospital with the diagnosis of ACS during a 3-year period. Perceived work performance was measured using the Work Performance Scale (WPS). Independent variables included health status (SF-8, PCS-8, MCS-8 and EQ-5D visual analog scale), cardiac functional status (Duke activity status index), symptom count, comorbidity index, patient-perceived cardiac disease severity, medication count and compliance, job satisfaction, current employment duration, patient demographics and ACS type. Step-wise multivariate linear regression models determined the independent variables with significant association (p < 0.05) to WPS. Of 1,217 patients surveyed, 490 (40%) responded, including 158 currently working (study sample). The regression model with the highest explanatory ability (r² = 0.29) included number of symptoms, age, perceived cardiac severity and PCS-8, with more symptoms, higher perceived severity, higher age and lower PCS-8 scores associated with lower WPS. Currently employed ACS patients report a high level of work performance. Symptom burden, perceived disease severity, age and physical function appear to be associated with perceived work performance.

Usefulness of the TIMI Risk Index in Predicting Short- and Long-Term Mortality in Patients With Acute Coronary Syndromes

In a cohort of 710 patients with acute coronary syndromes (ACSs), we demonstrated that the Thrombolysis In Myocardial Infarction Risk Index--a predictor of 30-day mortality in clinical trial patients with ST-elevation myocardial infarction (STEMI)--is a strong predictor of short- and long-term mortality with good discrimination ability (c statistics 0.77 to 0.79) among all subtypes of ACSs (STEMI, non-STEMI, and unstable angina pectoris). These results verify the utility of the Risk Index in unselected patients with STEMI, broaden its application to other types of ACSs, and extend its utility to stratification of long-term mortality risk.

Symptoms and type of symptom onset in acute coronary syndrome in relation to ST elevation, sex, age, and a history of diabetes

Various efforts to reduce patient delay in acute coronary syndrome (ACS) have had limited success. One reason might be a misinterpretation of the symptoms of ACS. The aim of this study was therefore to explore the characteristics and severity of symptoms among patients with an ACS in overall terms and in relation to the type of ACS, sex, age, and diabetes. A total of 1939 patients at 11 hospitals in Sweden answered a questionnaire containing questions relating to the localization and intensity of symptoms, the presence of associated symptoms, the characteristics and experience of pain/symptoms, and the type of symptom onset. Patients with ST elevation differed from those without by more frequently having associated symptoms. They had higher pain/discomfort intensity and more frequently had pain with abrupt onset reaching maximum intensity within minutes. However, this type of symptom onset was only seen in less than half the patients with ST elevation and only 1 in 5 fulfilled all the criteria usually associated with a severe heart attack. Women differed from men in a few respects. They more frequently reported pain/discomfort in the neck or jaw and back, vomiting, and scored their pain/discomfort slightly higher than men. Differences between age groups were minor and there was no difference between patients with and without diabetes. The most striking finding was the low proportion of patients with the type of symptoms that are commonly associated with ACS. This is important for the planning of educational campaigns/programs to reduce patient delay.

Spectrum of Acute Coronary Syndromes: History and Clinical Presentation in Relation to Sex and Age

Objectives: To study sex-based differences in the clinical presentation in relation to age and type of acute coronary syndrome (ACS) in patients under 80 years of age. Methods: The study includes 1,744 consecutive patients with the full spectrum of ACS (ST elevation myocardial infarction (MI), non-ST elevation MI, and unstable angina of high- and low-risk types) admitted to the coronary care unit in a university hospital. Results: The women were older than the men and were as likely to present with ST elevation MI. They had lower rates of prior MI and prior coronary artery bypass surgery than men but similar rates of percutaneous coronary interventions. Further, women were less likely to have a short delay before admission to hospital and they were attended to less rapidly in the emergency department. The prevalence of risk factors, prior cardiovascular disease and ongoing treatment with cardiovascular drugs were strongly associated with less severe type of ACS with no significant sex interaction. Presentation with non-ST elevation MI was significantly associated with older age while the opposite was true for unstable low-risk angina. ECG signs of acute ischemia were not associated with age. Significant interactions between age and sex were observed for the prevalence of treatment with diuretics as well as hypotension at presentation, both more prevalent among women than men below 65 years of age. Conclusions: Women are struck by ACS at a higher age than men, are less likely to present early for hospital care, and at younger age women are more likely to present with hypotension. There is a striking difference in risk factors and previous history depending on type of ACS in both sexes.

Symptoms in acute coronary syndromes: does sex make a difference?

Background Coronary heart disease is a major problem in both men and women, but several studies have shown sex differences in symptoms of acute coronary syndromes (ACS). Some findings, however, have been disparate and inadequate, and thus a comprehensive overview of this literature would be of value. Method Fifteen studies that identified symptoms of ACS for both women and men were examined through a review of the literature from 1989 to 2002. Terms used for the search included “myocardial infarction,” “symptoms,” “gender differences,” and “acute coronary syndromes.” Results Although chest pain was the most common symptom in both men and women, several differences were also noted. In all types of ACS, women had significantly more back and jaw pain, nausea and/or vomiting, dyspnea, indigestion, and palpitations. In a number of studies, which solely sampled patients with acute myocardial infarction, women demonstrated more back, jaw, and neck pain and nausea and/or vomiting, dyspnea, palpitations, indigestion, dizziness, fatigue, loss of appetite, and syncope. Men reported more chest pain and diaphoresis in the myocardial infarction sample. The designs and methodologies of the studies varied considerably. Conclusion In addition to the typical symptom of chest pain in ACS, women experience other atypical symptoms more frequently than men. Thus, there may be sex differences in the symptoms of ACS, differences that have a bearing not only on clinical practice, but also on the interpretation of available clinical studies and the design of future investigations.

Acute coronary syndromes complicated by symptomatic and asymptomatic heart failure: does current treatment comply with guidelines?

Patients with acute coronary syndromes (ACS) complicated by heart failure (HF) are at increased risk of death. Treatment with angiotensin-converting enzyme inhibitors (ACEI), beta-blockers, and early invasive risk stratification are recommended for these patients. The purpose of the current study was to assess adherence to treatment guidelines of patients with ACS complicated by HF in Europe and the Mediterranean region. Of the 10,484 patients who participated in Euro-Heart ACS survey, 9587 had known HF status and were without cardiogenic shock; 7058 (74%) did not have symptomatic HF and 2529 (26%) presented with or developed symptomatic HF during hospitalization. HF patients were older and had more cardiovascular risk factors. ACEI were more commonly used in HF patients (75% vs 56%, P < .01), whereas beta-blockers were less frequently used (75% vs 82%, P < .01). Coronary angiography and in hospital revascularization rates were lower among HF patients (42% vs 57% for coronary angiography, P < .01, and 32% vs 42% for revascularization, P < .01). Similar trends were noticed among patients with left ventricular dysfunction (symptomatic and asymptomatic).Adjusted in-hospital mortality risk was higher among patients with ACS complicated by symptomatic HF regardless of electrocardiographic type of ACS: (ST-elevation ACS, OR 2.5, 95% CI 1.6-3.9; non-ST-elevation ACS, OR 8.9,95% CI 4.5-17.7; undetermined-ECG ACS, OR 9.3, 95% CI 2.5-34). Patients with ACS complicated by HF were at increased risk of dying. A relatively high percentage of HF patients were treated with ACEI and beta-blockers in accordance with current recommendations. Rates of coronary angiography and revascularization were significantly lower in ACS patients with HF versus those without HF, which potentially contributed to their worse mortality [corrected]

Six-month outcomes in a multinational registry of patients hospitalized with an acute coronary syndrome (The Global Registry of Acute Coronary Events [GRACE

Relatively limited data are available, particularly from the perspective of a multinational registry, about the post-discharge outcomes and management practices of patients with an acute coronary syndrome (ACS). The objectives of this longitudinal study were to examine 6-month outcomes in a large multinational sample of patients hospitalized with an ACS. A total of 5,476 patients with ST-segment elevation acute myocardial infarction (STEAMI), 5,209 patients with non–ST-segment elevation acute myocardial infarction (NSTEAMI), and 6,149 patients with unstable angina pectoris discharged from 90 hospitals in 14 countries comprised the study population. The study sample was recruited from 18 cluster sites in 14 countries that are currently collaborating in the Global Registry of Acute Coronary Events (GRACE) study. The 6-month post-discharge death rates were 4.8% in patients with STEAMI, 6.2% in patients with NSTEAMI, and 3.6% in patients with unstable angina pectoris. Approximately 1 in 5 of each of our comparison groups were rehospitalized for heart disease during the 6-month follow-up, and approximately 15% of each of the respective study cohorts underwent coronary revascularization during follow-up. Demographic and clinical characteristics of post-discharge decedents were identified according to type of ACS. Our results suggest that a considerable proportion of patients who were discharged from the hospital after an ACS, with some differences noted according to type of ACS, remain at increased risk for adverse outcomes during the relatively brief post-discharge period. These data suggest the need for better long-term medical management and more intense follow-up of patients with an ACS to improve their long-term outlook.