After Acute Coronary Syndrome Research Articles

Clinical Outcomes After Acute Coronary Syndromes or Revascularization Among People Living With HIV: A Systematic Review and Meta-Analysis.

Clinical outcomes after acute coronary syndromes (ACS) or percutaneous coronary interventions (PCIs) in people living with HIV have not been characterized in sufficient detail, and extant data have not been synthesized adequately. To better characterize clinical outcomes and postdischarge treatment of patients living with HIV after ACS or PCIs compared with patients in an HIV-negative control group. Ovid MEDLINE, Embase, and Web of Science were searched for all available longitudinal studies of patients living with HIV after ACS or PCIs from inception until August 2023. Included studies met the following criteria: patients living with HIV and HIV-negative comparator group included, patients presenting with ACS or undergoing PCI included, and longitudinal follow-up data collected after the initial event. Data extraction was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Clinical outcome data were pooled using a random-effects model meta-analysis. The following clinical outcomes were studied: all-cause mortality, major adverse cardiovascular events, cardiovascular death, recurrent ACS, stroke, new heart failure, total lesion revascularization, and total vessel revascularization. The maximally adjusted relative risk (RR) of clinical outcomes on follow-up comparing patients living with HIV with patients in control groups was taken as the main outcome measure. A total of 15 studies including 9499 patients living with HIV (pooled proportion [range], 76.4% [64.3%-100%] male; pooled mean [range] age, 56.2 [47.0-63.0] years) and 1 531 117 patients without HIV in a control group (pooled proportion [range], 61.7% [59.7%-100%] male; pooled mean [range] age, 67.7 [42.0-69.4] years) were included; both populations were predominantly male, but patients living with HIV were younger by approximately 11 years. Patients living with HIV were also significantly more likely to be current smokers (pooled proportion [range], 59.1% [24.0%-75.0%] smokers vs 42.8% [26.0%-64.1%] smokers) and engage in illicit drug use (pooled proportion [range], 31.2% [2.0%-33.7%] drug use vs 6.8% [0%-11.5%] drug use) and had higher triglyceride (pooled mean [range], 233 [167-268] vs 171 [148-220] mg/dL) and lower high-density lipoprotein-cholesterol (pooled mean [range], 40 [26-43] vs 46 [29-46] mg/dL) levels. Populations with and without HIV were followed up for a pooled mean (range) of 16.2 (3.0-60.8) months and 11.9 (3.0-60.8) months, respectively. On postdischarge follow-up, patients living with HIV had lower prevalence of statin (pooled proportion [range], 53.3% [45.8%-96.1%] vs 59.9% [58.4%-99.0%]) and β-blocker (pooled proportion [range], 54.0% [51.3%-90.0%] vs 60.6% [59.6%-93.6%]) prescriptions compared with those in the control group, but these differences were not statistically significant. There was a significantly increased risk among patients living with HIV vs those without HIV for all-cause mortality (RR, 1.64; 95% CI, 1.32-2.04), major adverse cardiovascular events (RR, 1.11; 95% CI, 1.01-1.22), recurrent ACS (RR, 1.83; 95% CI, 1.12-2.97), and admissions for new heart failure (RR, 3.39; 95% CI, 1.73-6.62). These findings suggest the need for attention toward secondary prevention strategies to address poor outcomes of cardiovascular disease among patients living with HIV.

Beyond the GRACE ACS Score: Do We Need a Different Model for Men and Women after STEMI?

Women, in comparison to men, experience worse outcomes after acute coronary syndrome (ACS). However, whether the female sex per se is an independent predictor of such adverse events remains unclear. This study aims to assess the association between the female sex and in-hospital mortality after ST-elevation myocardial infarction (STEMI). We conducted a retrospective cohort study by enrolling consecutive STEMI patients admitted to a tertiary hospital from January 2018 to February 2019. All patients were treated per current guideline recommendations. Multivariable logistic regression models were applied to evaluate in-hospital mortality using GRACE variables. Model accuracy was evaluated using c-index. A p-value < 0.05 was statistically significant. Out of the 1678 ACS patients, 709 presented with STEMI. The population consisted of 36% women, and the median age was 61 years. Women were older (63.13 years vs. 60.53 years, p = 0.011); more often presented with hypertension (75.1% vs. 62.4%, p = 0.001), diabetes (42.2% vs. 27.8%, p < 0.001), and hyperlipidemia (34.1% vs. 23.9%, p = 0.004); and were less likely to undergo percutaneous coronary intervention (PCI) via radial access (23.7% vs. 46.1%, p < 0.001). In-hospital mortality rate was significantly higher in women (13.2% vs. 5.6%, p = 0.001), and the female sex remained at higher risk for in-hospital mortality (OR 2.79, 95% CI 1.15-6.76, p = 0.023). A multivariate model including age, sex, systolic blood pressure, cardiac arrest, and Killip class was 94.1% accurate in predicting in-hospital mortality, and the c-index was 0.85 (95% CI 0.77-0.93). After adjusting for the risk factors in the GRACE prediction model, women remain at higher risk for in-hospital mortality.

Sex Differences in Low-Density Lipoprotein Cholesterol Treatment Among Young Israeli Patients Following Premature Acute Coronary Syndrome.

Introduction: Effective management of dyslipidemias is crucial for reducing morbidity and mortality among patients after acute coronary syndrome (ACS). Sex differences in dyslipidemia management after premature ACS in Israeli patients have not been extensively studied. This study aimed to investigate potential disparities between men and women in managing dyslipidemia, considering current guidelines. Methods: This retrospective cohort study examined patients who were 55 years old or younger and admitted to Meir Medical Center for ACS from January 2018 to February 2019. The study aimed to evaluate the use of lipid-lowering therapy (LLT), measure the achievement of target low-density lipoprotein cholesterol (LDL-C) levels, and analyze the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) in both male and female patients. Results: The study included a total of 687 participants, of which 23.3% were identified as females. Upon discharge, ∼80% of the patients were prescribed high-intensity statins. After 1 year, it was observed that females had higher levels of LDL-C and lower rates of achieving target LDL-C levels (<70 and 55 mg/dL) as compared with males (45% vs. 54.6% and 30% vs. 42.2%, respectively). The use of non-statin LLT at the 1-year mark was minimal in both groups. Finally, it was found that the occurrence of MACCE was similar between males and females. Conclusion: Sex disparities in dyslipidemia management after a premature ACS were apparent, with females having higher LDL-C levels and lower rates of target achievement. Intervention is necessary to address these disparities and encourage greater use of non-statin LLT.

Global longitudinal strain in long-term risk prediction after acute coronary syndrome: an investigation of added prognostic value to ejection fraction.

This study aimed to investigate the additional value of global longitudinal strain (GLS) on top of left ventricular ejection fraction (LVEF) in long-term risk prediction of combined death and heart failure (HF) re-hospitalization after acute coronary syndrome (ACS). This retrospective study included patients admitted with ACS between 2008 and 2014 from the three participating university hospitals. LVEF and GLS were assessed at a core lab from images acquired during the index hospital stay. Their prognostic value was studied with the Cox proportional hazards model (median follow-up 6.2years). A nested model comparison was performed with C-statistics. A total of 941 patients qualified for multivariable analysis after multiple imputation of missing baseline covariables. The combined outcome was reached in 17.7% of the cases. Both GLS and LVEF were independent predictors of the combined outcome, hazard ratio (HR) 1.068 (95% CI 1.017-1.121) and HR 0.980 (95% CI 0.962-0.998), respectively. The C-statistic increased from 0.742 (95% CI 0.702-0.783) to 0.749 (95% CI 0.709-0.789) (P = 0.693) when GLS entered the model with clinical data and LVEF. GLS emerged as an independent long-term risk predictor of all-cause death and HF re-hospitalization. However, there was no significant incremental predictive value of GLS when LVEF was already known.

Fixed combination of rivaroxaban and Aspirin: Tablet formulation and analytical method validation

Rivaroxaban and aspirin are commonly used antithrombotic agents in combination to prevent coronary artery disease (CAD) and atherothrombotic events in adult patients after acute coronary syndrome (ACS) with elevated cardiac biomarkers, or with coronary artery disease (CAD) or symptomatic peripheral artery disease (PAD) in high-risk patients. The recommended dosage is 2.5 mg rivaroxaban twice daily in combination with 75–100 mg aspirin once daily. This study aimed to develop a fixed-dose combination tablet of rivaroxaban (2.5 mg) and aspirin (50 mg) to enhance medication adherence and decrease pill burden.Compatibility studies were conducted on the active ingredients to develop the product formula. The formula and the manufacturing procedure were chosen based on the risk assessment for each active substance, wet granulation with both actives intragranular was found to have faster dissolution than direct mix formulae. Furthermore, a validated reverse-phase HPLC stability indicator method was developed to detect APIs and their possible degradants.

Safety and efficacy of combined dual antiplatelet therapy and factor VIII prophylaxis in patients with haemophilia A after acute coronary syndrome.

The increased life expectancy of patients with haemophilia A (HA) has led to a growing prevalence of cardiovascular risk factors and events. There is still scarce evidence on the safety and appropriate duration of dual antiplatelet therapy (DAPT) after acute coronary syndrome (ACS) in HA patients. We describe our experience on the clinical management of Italian HA patients after ACS. Nine patients with congenital HA treated with DAPT after a revascularization procedure performed for ACS have been enrolled and followed at the Angelo Bianchi Bonomi Haemophilia and Thrombosis Center in Milan between 2005 and September 2022. The safety and efficacy of DAPT with or without FVIII prophylaxis were assessed. Ten ACS events occurred in the nine HA patients (four mild and five severe). All events were treated with percutaneous transluminal coronary angioplasty with deployment of 1 to 3 drug-eluting stents followed by DAPT for 1-12 months. All patients except one were treated with FVIII prophylaxis during DAPT aimed at achieving FVIII trough levels ≥20-30IU/dL. DAPT was effective in all cases in preventing early ACS recurrence, with only a late recurrence. We observed two clinically relevant non-major bleeds (one in a patient without FVIII prophylaxis) and three minor bleeds. No venous thrombosis occurred. The long-term secondary antithrombotic prevention consisting of DAPT and FVIII prophylaxis achieving a trough level of 20-30IU/dL can be effective and safe in HA patients.

Effects of exercise training after acute coronary syndromes in octogenarians - prospective 12-month evaluation.

Aim: To demonstrate the impact of individual exercise training on the course of the disease, exercise tolerance and quality of life (QoL) in patients over 75 years after acute coronary syndrome (ACS). Materials and methods: Study included octogenarians after ACS randomly assigned into two groups: a training group (ExT) subjected to individualized physical training and a control group (CG) with standard recommendations for activity. Patients underwent exercise tolerance test (ETT), 6-minute walk test (6-MWT), NHP and QoL questionnaires evaluation, lab tests, ECG, echocardiographic examination at the beginning and after 2, 6 and 12 months. Results: Study included 51 patients, mean age 80 years, 50% men, all patients completed the study. Initial physical capacity was comparable in both groups. After 2-month training the average ETT exercise time increased by 12.5% (p=0.0004), the load increased by 13% (p=0.0005) and the 6-MWT results improved by 8.3% (p=0.0114). Among CG these changes were not significant. But 6 and 12 months after training cessation 6-MWT results returned to the initial values (p=0.069, p=0.062 respecitvely). Average ETT exercise time and average load decreased significantly after 12 months (p=0.0009, p=0.0006). Level of pain was significantly lower at the end of the training in ExT group (p=0.007), but it returned to initial 12 months later (p=0.48). QoL deteriorated significantly in the ExT group 12 months after training cessation (p=0.04). Conclusions: Cardiac rehabilitation in octogenarians after ACS was safe and improved physical performance in a short period of time. Cessation of training resulted in a loss of achieved effects and deterioration of the QoL.

Increasing Physical Tolerance during Cardiac Rehabilitation Helps to Restore Endothelial Function in Patients after Acute Coronary Syndrome

In recent years, many studies have been aimed at exploring the possibilities of cardiac rehabilitation as a tool to improve the prognosis in patients after acute coronary syndrome (ACS). Endothelial dysfunction is one of the initiating mechanisms of cardiovascular diseases, and myocardial infarction in particular, so it is important to assess the dynamics of changes in the number of endothelial progenitor cells (EPCs) in patients during cardiac rehabilitation with the increase in physical activity.&#x0D; The aim. To establish the relationship between the level of recovery of exercise tolerance and the recovery of endothelial function by determining the number of EPCs in patients undergoing cardiac rehabilitation after ACS.&#x0D; Materials and methods. The study included 44 patients with ST-elevation myocardial infarction who underwent urgent stenting of the infarct-related artery, with a mean age of 59 years (Q1-Q3; 51-64). All the study participants underwent laboratory tests (CD45+/CD34+ cell count before and after the exercise test) and instrumental tests (echocardiography, bicycle ergometry, coronary angiography). Statistical processing was carried out using SPSS Statistics 23 (trial version).&#x0D; Results. According to the results of the exercise test at the first examination, the patients were divided into 2 groups: group 1 with low exercise tolerance (≤50 W) and group 2 with high exercise tolerance (&gt;50 W). The data obtained indicate a link between better recovery of exercise tolerance after ACS and recovery of endothelial func-tion in patients with high exercise tolerance during follow-up compared to the patients whose exercise tolerance did not exceed 50 W, as evidenced by a statistically higher number of EPCs after exercise in patients with a favor-able course and high exercise tolerance (3633 vs. 2400 cells/ml) (p=0.006). Patients with low exercise tolerance were more likely to be diagnosed with lesions of left anterior descending coronary artery (96% vs. 70%, p=0.02). More severe coronary vascular lesions with stenosis of 75% of two or more arteries showed lower pre-exercise EPCs, but increased post-exercise EPCs (+228 cells/ml), whereas in the group with stenosis of more than 75% of one vessel, a decrease in post-exercise EPCs (–604 cells/ml) was observed (p=0.004). If patients have more than one stent, there is a 2.5-fold increased risk of decreased exercise tolerance to values of 25-50 W (relative risk = 1.8; 95% confidence interval: 1.3-2.4).&#x0D; Conclusions. The data obtained indicate that there is an association between a better recovery of exercise tolerance after ACS and recovery of endothelial function in patients with a favorable course at repeated examination, compared to patients whose level of exercise tolerance did not exceed 50 W (low exercise tolerance), as evidenced by a statistically greater number of EPCs after exercise test in patients with favorable course and high exercise tolerance compared with patients with unfavorable course and low exercise tolerance.

Leg strength and incidence of heart failure in patients with acute coronary syndrome.

The risk of developing heart failure (HF) after acute coronary syndrome (ACS) remains high. It is unclear whether skeletal muscle strength, in addition to existing risk factors, is a predictor for developing HF after ACS. We aimed to clarify the relationship between quadriceps isometric strength (QIS), a skeletal muscle strength indicator, and the risk of developing HF in patients with ACS. We included 1,053 patients with ACS without a prior HF or complications of HF during hospitalization. The median (IQR) age was 67 (57-74) years. The patients were classified into two groups-high and low QIS-using the sex-specific median QIS. The endpoint was HF admissions. During a mean follow-up period of 4.4±3.7 years, 75 (7.1%) HF admissions were observed. After multivariate adjustment, a high QIS was associated with a lower risk of HF (hazard ratio [HR]: 0.52, 95% confidence interval [CI]: 0.32-0.87). HR (95% CI) per 5% body weight increment increase of QIS for HF incidents was 0.87 (0.80-0.95). Even when competing risks of death were taken into account, the results did not change. The inclusion of QIS was associated with increases in net reclassification improvement (0.26; 95% CI, 0.002-0.52) and an integrated discrimination index (0.01; 95% CI, 0.004-0.02) for HF. The present study showed that a higher level of QIS was strongly associated with a lower risk of developing HF after ACS. These findings suggest that skeletal muscle strength could be one of the factors contributing to the risk of developing HF after ACS.

Long-term secondary prevention and outcome following acute coronary syndrome: real-world results from the Swedish Primary Care Cardiovascular Database.

Most studies of treatment adherence after acute coronary syndrome (ACS) are based on prescribed drugs and lack long-term follow-up or consecutive data on risk factor control. We studied the long-term treatment adherence, risk factor control, and its association to recurrent ACS and death. We retrospectively included 3765 patients (mean age 75 years, 40% women) with incident ACS from 1 January 2006 until 31 December 2010 from the Swedish Primary Care Cardiovascular Database of Skaraborg. All patients were followed until 31 December 2014 or death. We recorded blood pressure (BP), low-density lipoprotein cholesterol (LDL-C), recurrent ACS, and death. We used data on dispensed drugs to calculate the proportion of days covered for secondary prevention medications. Cox regressions were used to analyse the association of achieved BP and LDL-C to recurrent ACS and death. The median follow-up time was 4.8 years. The proportion of patients that reached BP of <140/90 mm Hg was 58% at Year 1 and 66% at Year 8. 65% of the patients reached LDL-C of <2.5 mmol/L at Year 1 and 56% at Year 8; however, adherence to statins varied from 43% to 60%. Only 62% of the patients had yearly measured BP, and only 28% yearly measured LDL-C. Systolic BP was not associated with a higher risk of recurrent ACS or death. Low-density lipoprotein cholesterol of 3.0 mmol/L was associated with a higher risk of recurrent ACS {hazard ratio [HR] 1.19 [95% confidence interval (CI) 1.00-1.40]} and death HR [1.26 (95% CI 1.08-1.47)] compared with an LDL-C of 1.8 mmol/L. This observational long-term real-world study demonstrates low drug adherence and potential for improvement of risk factors after ACS. Furthermore, the study confirms that uncontrolled LDL-C is associated with adverse outcome even in this older population.

Efficacy of eHealth Technologies on Medication Adherence in Patients With Acute Coronary Syndrome: Systematic Review and Meta-Analysis.

Suboptimal adherence to cardiac pharmacotherapy, recommended by the guidelines after acute coronary syndrome (ACS) has been recognized and is associated with adverse outcomes. Several randomized controlled trials (RCTs) have shown that eHealth technologies are useful in reducing cardiovascular risk factors. However, little is known about the effect of eHealth interventions on medication adherence in patients following ACS. The aim of this study is to examine the efficacy of the eHealth interventions on medication adherence to selected 5 cardioprotective medication classes in patients with ACS. A systematic literature search of PubMed, Embase, Scopus, and Web of Science was conducted between May and October 2022, with an update in October 2023 to identify RCTs that evaluated the effectiveness of eHealth technologies, including texting, smartphone apps, or web-based apps, to improve medication adherence in patients after ACS. The risk of bias was evaluated using the modified Cochrane risk-of-bias tool for RCTs. A pooled meta-analysis was performed using a fixed-effect Mantel-Haenszel model and assessed the medication adherence to the medications of statins, aspirin, P2Y12 inhibitors, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and β-blockers. We identified 5 RCTs, applicable to 4100 participants (2093 intervention vs 2007 control), for inclusion in the meta-analysis. In patients who recently had an ACS, compared to the control group, the use of eHealth intervention was not associated with improved adherence to statins at different time points (risk difference [RD] -0.01, 95% CI -0.03 to 0.03 at 6 months and RD -0.02, 95% CI -0.05 to 0.02 at 12 months), P2Y12 inhibitors (RD -0.01, 95% CI -0.04 to 0.02 and RD -0.01, 95% CI -0.03 to 0.02), aspirin (RD 0.00, 95% CI -0.06 to 0.07 and RD -0.00, 95% CI -0.07 to 0.06), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (RD -0.01, 95% CI -0.04 to 0.02 and RD 0.01, 95% CI -0.04 to 0.05), and β-blockers (RD 0.00, 95% CI -0.03 to 0.03 and RD -0.01, 95% CI -0.05 to 0.03). The intervention was also not associated with improved adherence irrespective of the adherence assessment method used (self-report or objective). This review identified limited evidence on the effectiveness of eHealth interventions on adherence to guideline-recommended medications after ACS. While the pooled analyses suggested a lack of effectiveness of such interventions on adherence improvement, further studies are warranted to better understand the role of different eHealth approaches in the post-ACS context.

Gender differences in the development of heart failure after acute coronary syndrome: Insight from the CORALYS registry

BackgroundImpact of gender on heart remodeling after acute coronary syndrome (ACS) and consequently on development of heart failure (HF) remains to be elucidated. MethodsCORALYS is a multicenter, retrospective, observational registry enrolling consecutive patients admitted for ACS and treated with percutaneous coronary intervention. HF hospitalization was the primary endpoint while all-cause mortality and the composite endpoint of incidence of first HF hospitalization and cardiovascular mortality were the secondary ones. ResultsAmong 14,699 patients enrolled in CORALYS registry, 4578 (31%) were women and 10,121 (69%) males. Women were older, had more frequently hypertension and diabetes and less frequently smoking habit. History of myocardial infarction (MI), STEMI at admission and multivessel disease were less common in women. After median follow up of 2.9 ± 1.8 years, women had higher incidence of primary and secondary endpoints and female sex was an independent predictor of HF hospitalization (HR 1.26;1.05–1.50; p = 0.011) and cardiovascular death/HF hospitalization (HR 1.18;1.02–1.37; p = 0.022). At multivariable analysis women and men share as predictors of HF diabetes, history of cancer, chronic kidney disease, atrial fibrillation, complete revascularization and left ventricular ejection fraction. Chronic obstructive pulmonary disease (HR 2.34;1.70–3.22, p < 0.001) and diuretics treatment (HR 1.61;1.27–2.04, p < 0.001) were predictor of HF in men, while history of previous MI (HR 1.46;1.08–1.97, p = 0.015) and treatment with inhibitors of renin-angiotensin system (HR 0.69;0,49–0.96 all 95% CI, p = 0.030) in women. ConclusionsWomen are at increased risk of HF after ACS and gender seems to be an outcome-modifier of the relationship between a variable and primary outcome.

Drinking patterns of alcohol and risk of major adverse cardiovascular events after an acute coronary syndrome.

To evaluate the risk of alcohol consumption after acute coronary syndromes (ACS). A total of 6557 patients hospitalized for ACS at 4 Swiss centres were followed over 12 months. Weekly alcohol consumption was collected at baseline and 12 months. Binge drinking was defined as consumption of ≥6 units of alcohol on one occasion. Major adverse cardiovascular events (MACE) were defined as a composite of cardiac death, myocardial infarction, stroke or clinically indicated target vessel coronary revascularization. Cox regression analysis was performed to assess the risk of MACE in patients with heavy (>14 standard units/week), moderate (7-14 standard units per week), light consumption (<1 standard unit/week) or abstinence, and with binge drinking episodes, adjusted for baseline differences. At baseline, 817 (13.4%) patients reported heavy weekly alcohol consumption. At one-year follow-up, 695/1667 (41.6%) patients reported having at least one or more episodes of binge drinking per month. The risk for MACE was not significantly higher in those with heavy weekly consumption compared to abstinence (8.6% vs. 10.2%, HR 0.97, 95%CI 0.69-1.36) or light consumption (8.6% vs. 8.5 %, HR 1.41, 95%CI 0.97-2.06). Compared to patients with no-binge drinking, the risk of MACE was dose-dependently higher in those with binge drinking with less than one episode per month (9.2% vs 7.8%, HR 1.61, 95%CI 1.23-2.11), or one or more episodes per month (13.6% vs 7.8%, HR 2.17, 95%CI 1.66-2.83). Binge drinking during the year following an ACS, even less than once per month, is associated with worse clinical outcomes.

Telerehabilitation after acute coronary syndrome warrants a similar improvement in physical performance as stationary rehabilitation regardless of the age profile of the compared groups

Abstract   During the COVID-19 pandemic, the availability of cardiac rehabilitation (CR) was limited. On the other hand, during the epidemic hazard period, patients after acute coronary syndromes (ACS) required careful control and ensuring their improvement after the coronary event. The aim of this study was to assess whether CR conducted during the epidemic threat in remote mode ensures similar improvement in physical performance as rehabilitation conducted in stationary mode before the pandemic COVID-19. Material and methods In this one-center study, the demographic and clinical profiles in the groups of patients after ACS who completed a stationary CR before COVID-19 era or telerehabilitation during the COVID-19 pandemic were compared. The workload on the initial and final exercise tests (ExT) obtained by patients was assessed, as well as the values of differences between the final and initial ExT were compared. 359 patients (pts) participating in stationary CR before October 2020 and 60 pts - in telerehabilitation after July 2021 were included. Both, stationary and tele- CR were performed according to the guidelines of Working Group for Cardiac Rehabilitation of the national cardiac society. Telemedic platform was used to control ECG, blood pressure and body mass of pts participating in telerehabilitation. Statistical analysis included U Mann-Whitney test, T Student test and chi square test. Results The improvment of physical performance did not differ significantly between both groups. The pts who completed telerehabilitation were significantly older than those who completed stationary CR. The values of other parameter, like percent of females, BMI, percent of pts with arterial hypertension and diabetes mellitus type 2 or ejection fraction of left ventricle did not differ significanty between compared groups. The results of statistical analysis are presented in the table below. Conclusions In our center, telerehabilitation after acute coronary syndrome guaranteed an equally good improvement in physical capacity, which was observed in stationary rehabilitation patients, regardless of the difference in the age profile of the compared groups. These results encourage popularization of the cardiac rehabilitation mode with the remote control of the ECG, blood pressure and body weight.Comparison of the study groups

GDF-15 adds to GRACE 2.0 for long-term risk prediction in ACS but echocardiographic parameters do not: A SWEDEHEART prognostication study

Abstract Background The risk stratification score GRACE 2.0 has lately been validated to predict all-cause death up to three years after acute coronary syndrome (ACS). GRACE 2.0 does not take important prognostic biomarkers and imaging measurements that may improve long-term risk prediction in to account. This study set out to evaluate the clinical value of such parameters analyzed on top of GRACE 2.0. Methods The study was performed in a subset of 773 patients from the TOTAL-AMI cohort with ACS subjects recruited from three Swedish hospitals between 2008 and 2014. Biomarkers were analyzed with a Proximity Extension Assay panel and the echocardiographic parameters, Left Ventricular Ejection Fraction (LVEF) and Global Longitudinal Strain (GLS), were assessed at a core lab. LVEF, GLS and two high yield biomarkers (NTproBNP and GDF-15) were analyzed with Cox proportional hazards regression by stepwise addition of each variable to a baseline model with GRACE 2.0. The C-index was assessed for each model. All models were adjusted for treatment with betablockers and/or RAAS-inhibitors. Outcome was all-cause death at three years. Results Forty-one patients had died at three years follow-up. The mean population age was 64 years and 77% were men. Median LVEF was 55 % (inter quartile range: 47-60). LVEF, GLS and GDF-15 all emerged as independent predictors of three-year death in the multivariable models with GRACE 2.0 and medical treatment. Only GDF-15 rendered substantial improvement in the C-index on top of GRACE 2.0 (0.755 to 0.810). The echocardiographic measurements did not improve prognostication on top of GRACE 2.0 and GDF-15. Conclusions GRACE 2.0 emerged as a strong long-term risk-predictor irrespective of the biomarkers and imaging measurements. Although LVEF, GLS and GDF-15 also emerged as independent predictors of three-year death only GDF-15 improved the C-index to an extent that may be considered clinically meaningful.

Abstract 13043: LDL-C, Lp(a) and Hs-CRP Each Predict Future Cardiovascular Events After ACS on High-Intensity Statin Therapy. An Analysis of the ODYSSEY OUTCOMES Trial

Background: Atherosclerotic cardiovascular disease (ASCVD) risk has been jointly associated with levels of LDL cholesterol (LDL-C), lipoprotein [Lp](a)] and the inflammatory marker high-sensitivity C reactive protein (hsCRP). It is unclear whether and to what extent each of these biomarkers predict ASCVD risk after acute coronary syndrome (ACS), particularly in the era of intensive LDL-C lowering. Recent analysis of 3 trials in stable ASCVD patients with hypertriglyceridemia suggested that hsCRP may be a stronger predictor for recurrent events than LDL-C; however, only 52% received high-intensity statin. Methods: The ODYSSEY OUTCOMES trial enrolled post-ACS patients not at goal for atherogenic lipoproteins a median of 2.6 months after ACS and on treatment with maximum tolerated (89% high-intensity) atorvastatin or rosuvastatin. Absolute risk of major adverse cardiovascular events (MACE, the primary composite outcome of coronary heart disease death, nonfatal myocardial infarction, fatal/nonfatal ischemic stroke or unstable angina hospitalization) and all-cause death were analyzed as a function of baseline LDL-C, hs-CRP, and Lp(a) values in patients randomized to the placebo arm via natural cubic splines from Poisson regression models, adjusted for age, sex, diabetes, BMI, current smoking, and the other 2 predictor variables. Results: Among 9149 evaluable patients, median (Q1-Q3) LDL-C, hsCRP, and Lp(a) were 81 (71-97) mg/dL, 1.7 (0.8-3.9) mg/L, and 21.4 (6.6-60.1) mg/dL, respectively. For each parameter, a higher baseline value was associated with a substantial increase in risk of MACE ( Figure , all spline p&lt;0.0001). LDL-C and hsCRP were associated with all-cause death (p&lt;0.0001), but not Lp(a) (p&gt;0.05). Conclusion: In ACS patients receiving intensive statin therapy and not at goal for atherogenic lipoproteins, LDL-C, hs-CRP, and Lp(a) were independent predictors of MACE. LDL-C and hsCRP were independent predictors of all-cause death.

Falta de adherencia a ticagrelor frente a clopidogrel y riesgo de eventos en pacientes con SCA. Resultados del registro CREA-ARIAM

Introduction and objectivesPrior studies have not determined whether the effect of dual antiplatelet therapy (DAPT) cessation on the subsequent risk of major adverse cardiac events (MACE) varies by the choice of P2Y12-inhibitor after acute coronary syndrome (ACS). MethodsWe performed a prespecified subanalysis of a multicenter, prospective registry of ACS patients discharged on ticagrelor or clopidogrel between 2015 and2019. Nonadherence to DAPT was categorized as physician-guided discontinuation and disruption due to adverse effects, nonadherence, or bleeding. The association between DAPT cessation and 1-year MACE was analyzed using multivariate time-updated Cox models with inverse probability of censoring weighted estimators. ResultsOut of 2180 patients, 174 (8.3%) prematurely discontinued DAPT (physician-guided, n=126; disruption, n=48). Nonadherent patients were older and had more comorbidities than those on DAPT. Compared with physician-guided discontinuation, disruption occurred earlier after discharge and was more frequent with ticagrelor than with clopidogrel. In time-varying analysis, DAPT cessation was associated with an increased risk of MACE (adjusted HR, 1.32, 95%CI, 1.10-1.76), largely driven by disruption (adjusted HR, 1.47, 95%CI, 1.22-1.73). There was an exponential increase in MACE risk after DAPT cessation within 90 days after ACS, especially after disruption of ticagrelor compared with clopidogrel (Pinteraction<.001). After adjustment for DAPT duration, this interaction was not statistically significant on the additive scale (relative excess risk due to interaction 0.12, 95%CI,−0.99-1.24). ConclusionsIn this all-comers registry, 1 in 12 patients prematurely discontinued DAPT within 1 year after ACS. Compared with physician-recommended discontinuation, disruption resulted in a significantly higher risk of MACE. After adjustment for DAPT duration, this association was not moderated by the choice of P2Y12-inhibitor.Clinical trial registered at ClinicalTrials.gov (Identifier: NCT02500290)

Effect of Antecedent Hypertension on Mortality After Acute Coronary Syndromes in the Coronary Intervention Era: A Meta-analysis.

The effect of antecedent hypertension on mortality after acute coronary syndromes (ACS) in the percutaneous coronary intervention era is unclear. Therefore, this meta-analysis aimed to assess the effect of antecedent hypertension on short-term and long-term mortality after ACS in the coronary intervention era. PubMed, Medline, EMBASE, and the Cochrane library were systematically searched up to July 2023. Ten studies with a total of 64,989 of patients met the inclusion criteria. The outcomes of interest were all-cause in-hospital mortality and long-term all-cause mortality. No significant difference was observed in in-hospital mortality between the antecedent hypertension and non-antecedent hypertension groups in the ACS patients (pooled OR 1.07; 95% CI 0.79-1.45; I2=82%), which was the same as the ST elevation myocardial infarction group (pooled OR 1.01; 95% CI 0.73-1.39; I2=66%). However, the result was statistically significant for non-ST elevation myocardial infarction patients (pooled OR 0.67; 95% CI 0.55-0.82; p=0.0001; I2=0%). Antecedent hypertension was related to increased long-term mortality in patients with ACS (pooled OR 1.28; 95% CI 1.16-1.40; p=0.0001; I2=0%), which was the same as the ST elevation myocardial infarction subgroup. In the percutaneous coronary intervention era, antecedent hypertension is associated with higher long-term mortality in ACS patients. This meta-analysis found no significant difference in in-hospital mortality between the hypertension and non-hypertension groups. However, antecedent hypertension may be a protective factor related to in-hospital mortality for non-ST elevation myocardial infarction patients.

β1-blockers in the reduction of bleeding risk in patients prescribed with potent dual antiplatelet therapy after acute coronary syndrome or percutaneous coronary intervention

Backgroundβ1-blockers could improve clinical outcomes in patients with coronary artery disease by lowering the heart rate, blood pressure, and myocardial contractility. Moreover, recent studies have suggested that β1-blockers may also have the potential to reduce bleeding risk. ObjectivesThis study aimed to evaluate the association between β1-blockers and bleeding risk in the patients prescribed with potent dual antiplatelet therapy (DAPT) after acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI). MethodsPatients with ACS or undergoing PCI treated by DAPT of ticagrelor and aspirin were consecutively recruited. Follow-up for all eligible patients was conducted for 1 year. Major bleeding outcomes were defined as events that were type ≥2 based on the Bleeding Academic Research Consortium (BARC) criteria. ResultsA total of 1,113 eligible ticagrelor-treated patients were recruited. During the 1-year follow-up interval, 142 (12.6%) patients experienced BARC ≥2 bleedings including 23 patients (2.1%) suffering BARC ≥3 bleedings, with the most common site of bleeding located in the gastrointestinal tract. β1-blockers treatment was associated with a lower risk of BARC ≥2 bleedings (11.2% vs. 23.3%, adjusted HR: 0.42, 95% CI: 0.28-0.62, P < 0.01). Moreover, metoprolol (11.1% vs. 23.3%, adjusted HR: 0.56, 95% CI: 0.37-0.83, P < 0.01) and bisoprolol (11.3% vs. 23.3%, adjusted HR: 0.56, 95% CI: 0.33-0.96, P = 0.04) had similar effects on the reduction of bleeding risk. Conclusionβ1-blockers might be beneficial for the reduction of bleeding risk in potent dual antiplatelet therapy patients with ACS or undergoing PCI.

The importance of GRACE risk score in the development of high-grade atrioventricular conduction blocks after non-st-segment elevation myocardial infarction.

The development of high-grade atrioventricular block (HG-AVB) after acute coronary syndrome (ACS) increases morbidity and mortality rates. A significant portion of HG-AVBs resolve spontaneously after revascularization. We aimed to evaluate the power of the GRACE scoring system in predicting the development of HG-AVB and its importance in determining the need for cardiac pacemakers. Patients who applied to our center between July 2020 and February 2023 were included in the study. 600 patients [340 (56.6%) male, mean age 65.4±13.6] without ST-segment elevation (NSTEMI) and who underwent revascularization were evaluated within the scope of the study. The heart rhythms of the patients were evaluated from the electrocardiograms (ECG) at admission. Patients with HG-AVB and other patients were divided into two groups. The heart rhythms of these patients were evaluated during their hospitalization. Then, HG-AVB patients were also divided into two groups (with and without PPM need). Demographic, laboratory, angiographic, and echocardiographic characteristics of these patients were evaluated. Morbidity and mortality were higher in the HG-AVB group. These patients had longer intensive care and hospital stays. The mean age, creatinine value, GRACE score (GS), total cholesterol (TC), and RCA lesion rates were higher in the HG-AVB group; hemoglobin level was found to be lower. As a result of regression analysis, RCA lesion, hemoglobin value, GRACE score, creatinine, and TC levels were predictors of HG-AVB development. In determining the need for PPM, these variables were found to be effective. ROC analysis was performed for GS, which predicted the development of HG-AVB, and the cut-off value was found to be 185.5. The development of HG-AVB after NSTEMI is an important health problem. By detecting these patients and those who may need PPM beforehand, various complications can be prevented, and the length of stay in the hospital can be shortened. Calculation of GS is an important parameter that can be used to predict the development and course of HG-AVB.