Acute Coronary Syndrome Discharge Research Articles

Prognosis and antithrombotic practice patterns in patients with recurrent and transient atrial fibrillation following acute coronary syndrome: A nationwide study

BackgroundFirst-time detected atrial fibrillation (AF) is associated with aggravated prognosis in patients admitted with acute coronary syndrome (ACS). Yet, among patients surviving beyond one year after ACS, it remains unclear how the recurrence of AF within the initial year after ACS affects the risk of stroke. MethodsWith Danish nationwide data from 2000 to 2021, we identified all patients with first-time ACS who were alive one year after discharge (index date). Patients were categorized into: i) no AF; ii) first-time detected AF during ACS admission without a recurrent hospital contact with AF (transient AF); and iii) first-time detected AF during ACS admission with a subsequent recurrent hospital contact with AF (recurrent AF). From index date, two-year rates of ischemic stroke were compared using multivariable adjusted Cox regression analysis. Treatment with antithrombotic therapy was assessed as filled prescriptions between 12 and 15 months following ACS discharge. ResultsWe included 139,137 patients surviving one year post ACS discharge: 132,944 (95.6%) without AF, 3920 (2.8%) with transient AF, and 2273 (1.6%) with recurrent AF. Compared to those without AF, the adjusted two-year hazard ratios of ischemic stroke were 1.45 (95% CI, 1.22–1.71) for patients with transient AF and 1.47 (95% CI: 1.17–1.85) for patients with recurrent AF. Prescription rates of oral anticoagulation increased over calendar time, reaching 68.3% and 78.7% for transient and recurrent AF, respectively, from 2019 to 2021. ConclusionIn patients surviving one year after ACS with first-time detected AF, recurrent and transient AF were associated with a similarly increased long-term rate of ischemic stroke.

Prognosis and antithrombotic practice patterns in recurrent and transient atrial fibrillation following acute coronary syndrome: a nationwide study

Abstract Background First-time detected atrial fibrillation (AF) during acute coronary syndrome (ACS) aggravates the prognosis and increases the risk of ischemic stroke. In this setting, AF may present as brief and transient or with recurrent episodes after discharge. However, data on the association between transient or recurrent AF and ischemic stroke in patients with ACS are sparse. Further, despite being associated with ischemic stroke, first-time detected AF patients have been reported with low oral anticoagulation (OAC) rates. Purpose To examine the associated rate of ischemic stroke and mortality in ACS survivors with transient or recurrent AF and to assess the antithrombotic practice patterns one year after ACS. Methods Using data from Danish nationwide registries, we identified all patients with first-time ACS, without known AF prior to ACS, from 2000–2017 who were alive one year after ACS discharge (index date). According to a grace period between ACS discharge and one year after ACS discharge, patients were categorized into: i) no AF; ii) first-time detected AF during ACS admission without AF recurrence (transient AF); and iii) first-time detected AF during ACS admission with a subsequent recurrent AF episode (recurrent AF). Patients who developed AF during the grace period were excluded. Patients were followed from one year post ACS discharge, and two-year rates of ischemic stroke and mortality were compared using multivariable adjusted Cox proportional hazards analysis. Further, we assessed the prescribed OAC rates in a three-month period following the index date. Results We included 116,793 patients surviving one year post ACS discharge: 111,708 (95.6%) without AF (64.9% male, median age 64 years), 2,671 (2.3%) with transient AF (58.0% male, median age 74 years), and 2,414 (2.1%) with recurrent AF (55.2% male, median age 76 years). The cumulative two-year incidence of ischemic stroke was 0.9%, 1.5%, and 2.3% for patients without AF, transient AF, and recurrent AF, respectively (Figure 1). The cumulative two-year incidence of mortality was 7.4%, 12.1%, and 20.3% for patients without AF, transient AF, and recurrent AF, respectively (Figure 1). Compared to those without AF, the adjusted two-year rates of outcomes were as follows: ischemic stroke: HR 1.15 (95% CI: 0.81–1.61) for patients with transient AF and HR 1.50 (95% CI: 1.14–1.98) for patients with recurrent AF; mortality: HR 0.98 (95% CI: 0.87–1.10) for patients with transient AF and HR 1.35 (95% CI: 1.23–1.49) for patients with recurrent AF (Figure). We identified that 20.9% for transient AF and 42.2% for recurrent AF were prescribed OAC therapy in the three-month period after one year. Conclusion In patients surviving one year after ACS with first-time detected AF, a recurrent AF episode was associated with an increased long-term rate of ischemic stroke and mortality, while transient AF yielded no statistically difference as compared with patients without AF. Funding Acknowledgement Type of funding sources: None.

Prognostic impact of severe anemia (hemoglobin <10g/dL) during treatment with dual antiplatelet therapy after hospital discharge for acute coronary syndrome

Abstract Introduction In recent years, the use of invasive strategies has become the generalized approach in the management of patients with acute coronary syndrome (ACS), justified by the associated prognostic benefit due to reduced mortality and the evolution of percutaneous coronary intervention (PCI). However, the benefits of an invasive approach in ACS are unclear in the population with significant anemia, as anemia is strongly associated with increased risk of morbidity and mortality in these patients. Aim To determine the ischaemic vs. bleeding risks from patients with severe anemia (hemoglobin <10 g/dL) during treatment with Dual Antiplatelet Therapy (DAPT) after an ACS undergoing PCI. Methods From a national multicentre registry, we analyzed 17 370 ACS pts. Pts were divided into two groups: group 1 - pts with severe anemia (hemoglobin <10g/dL) (n=557, 3.2%); group 2 - pts without severe anemia (hemoglobin 10g/dL) (n=16813, 96.8%). Primary endpoint was the occurrence of a composite of death and adverse cardiovascular events (stroke, reinfarction, and rehospitalization of cardiovascular etiology) at 1 year. Results The sample consisted in 73.4% men and 26.6% women, with mean age of 66±14 years. The incidence of severe anemia was 3.2%. Group 1 pts were older (75±12 vs 66±14, p<0.001), had a higher proportion of women (47.6% vs 25.9%, p<0.001), diabetes (55% vs 30.6%, p<0.001), hypertension (81.8% vs 68.2%, p<0.001) and chronic kidney disease (29.2% vs 5.2%, p<0.001). During hospitalization, group 1 had more heart failure (35.3% vs 15.1%, p<0.001), worst LVEF (27.3% vs 17.3%, p<0,001), bleeding (7.6%% vs 1.3%, p<0.001) and transfusion (23.4% vs 1%, p<0.001). During hospitalization, group 2 pts were more likely to undergo revascularization (82.9% vs 89.4%, p<0.001) and double antiaggregation (82.5% vs 95%, p<0.001). A multivariate analysis identified age [OR 1.48, 95% CI 1.32 to 1.89; p<0.001] and feminine sex [OR 2.21, 95% CI 1.89 to 3.61; p<0.001] as independent predictors of severe anemia during hospitalization. Patients with severe anemia had longer hospital stay (9 days vs 6 days; p<0.001), and higher 6-month mortality (8.7% vs. 2.9%; p<0.001). In multivariate analysis and after adjusting for different baseline characteristics, pts with severe anemia had higher occurrence of a composite of death and adverse cardiovascular events at 1-year compared to those without severe anemia [OR 3.04, 95% CI 1.21 to 5.04; p=0.029]. Conclusion We objected a low prevalence of ACS patients with severe anemia undergoing PCI (52.2%) but the incidence of ICP in these complex patients has increased in recent years, mainly due to the evolution of PCI over the last 40 years. Severe anemia was strongly associated with increased risk of morbidity and mortality in ACS pts. Funding Acknowledgement Type of funding source: None

Effectiveness of discharge education strategies versus usual care on clinical outcomes in acute coronary syndrome patients: a systematic review.

The objective of this review was to systematically review studies that evaluated the clinical effectiveness of hospital discharge education strategies provided to patients with acute coronary syndrome (ACS). In an era of shortening lengths of stay for patients with ACS, bedside education opportunities are diminishing; however, the importance of discharge education on medication management, emergency procedures and safe recovery remains vital to prevent rehospitalization. The following studies were considered for inclusion: English-language randomized controlled trials (RCTs) measuring educational strategies provided to adults with ACS as the only intervention prior to discharge or post-discharge from acute care, compared to usual care. An electronic search was performed by an experienced research librarian. MEDLINE, CINAHL, PsycINFO, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, Australian New Zealand Clinical Trials Registry, ClinicalTrials.gov and WHO International Clinical Trial Registry Platform were searched for studies published between 2000 and 2017. All citations were collated and uploaded into EndNote where duplicates were removed. Titles and abstracts were screened by two independent reviewers. The reference lists of all included studies were screened for additional references. Risk of bias was assessed using the JBI critical appraisal instrument for all included studies. In the case of missing or incomplete data, corresponding authors were contacted. The primary outcomes of interest were knowledge relating to ACS diagnosis, treatment and procedures. Secondary outcomes included lifestyle modifications, medication adherence/knowledge, general practitioner follow-up, attendance to cardiac rehabilitation (CR), readmission and mortality (up to 12 months). As data were collected using different instruments in each study, meta-analysis was not performed. The electronic search identified 3445 records. Following deduplication, 2093 citations were screened with 47 papers selected for assessment of eligibility. Three RCTs involving 175 participants were identified for inclusion. The certainty of this evidence (Grading of Recommendations, Assessment, Development and Evaluation) was rated as low to moderate. The risk of bias for all included studies was moderate. In all studies, the impact of inpatient educational interventions was assessed in relation to attendance to a CR program, exercise rates and medication adherence. Interventions included targeted educational sessions (15-40 minutes) where participants prioritized their learning needs and were provided tailored cardioprotective risk factor and lifestyle modification advice and invited to attend a CR program. One study presented the education in animation. In one study, intervention groups reported increased attendance to CR compared to control (47.3%; n = 9, versus 21.1%; n = 4) and another demonstrated significantly increased exercise rates from baseline to follow-up. No significant difference was reported between the intervention and control for medication adherence, and none of the studies reported readmission or mortality rates. The current review found little to no evidence for the effectiveness of current discharge practices on clinical outcomes. There has been limited research on modes of delivery or what the essential components for ACS discharge education should be. This review has highlighted the need for comprehensive effectiveness studies to provide a strong evidence-base to support ACS discharge practices. PROSPERO CRD42018094781.

Bleeding After Hospital Discharge Following Acute Coronary Syndrome: Incidence, Types, Timing, and Predictors.

BackgroundThe incidence and predictors of bleeding after acute coronary syndrome are unclear within the real‐world setting. Our objective was to determine the incidence, types, timing, and predictors of bleeding complications following hospital discharge after acute coronary syndrome.Methods and ResultsWe used the Clinical Practice Research Datalink, with linkage to Hospital Episode Statistics, to determine the incidence, timing, and types of bleeding events within 12 months after hospital discharge for acute coronary syndrome. We assessed independent associations between postdischarge bleeding and baseline patient characteristics using a competing risk regression model, accounting for death as a competing event. Among 27 660 patients surviving to hospital discharge, 3620 (13%) experienced bleeding complications at a median time of 123 days (interquartile range, 45–223 days) after discharge. The incidence of bleeding was 162/1000 person‐years (95% CI, 157–167/1000 person‐years) within the first 12 months after hospital discharge. Bruising (949 bleeds [26%]) was the most common type of first bleeding event, followed by gastrointestinal bleed (705 bleeds [20%]), whereas intracranial bleed was relatively rare (81 bleeds [2%]). Significant predictors of postdischarge bleeding included history of bleeding complication, oral anticoagulant prescription, history of peripheral vascular disease, chronic obstructive pulmonary disease, and advanced age (>80 years). Predictors for postdischarge bleeding varied, depending on the anatomic site of the bleeding event.ConclusionsBleeding complications after hospital discharge for acute coronary syndrome are common. Patients who experience these bleeding events have distinct baseline characteristics, which vary by anatomic site of the bleed. These characteristics can inform risk‐benefit considerations in deciding on favorable combination and duration of secondary antithrombotic therapy.

462Impact of severe anemia (hemoglobin <10 g/dl) in the ischemic-bleeding profile during treatment with dual antiplatelet therapy after hospital discharge for acute coronary syndrome

Abstract Introduction Anemia is strongly associated with increased risk of morbidity and mortality in patients after acute coronary syndromes (ACS). The aim of our study was to determine, after matching the baseline characteristics, the bleeding-ischemic risk profile during treatment with Dual Antiplatelet Therapy (DAPT) of patients with severe anemia (hemoglobin <10 g/dL) after an ACS undergoing Percutaneous Coronary Intervention (PCI). Methods The data analyzed in this study were obtained from the fusion of 3 clinical registries of ACS patients: BleeMACS (2004–2013), CardioCHUVI/ARRITXACA (2010–2016) and RENAMI (2013–2016). All 3 registries include consecutive patients discharged after an ACS with DAPT and undergoing PCI. The merged data set contain 26,076 patients. A propensity-matched analysis was performed to match the baseline characteristics of patients according to presence or not of severe anemia (hemoglobin <10 g/dL). The impact of severe anemia in the ischemic and bleeding risk was assessed by a competitive risk analysis, using a Fine and Gray regression model, with death being the competitive event. For ischemic risk we have considered a new acute myocardial infarction, whereas for bleeding risk we have considered major bleeding defined as bleeding requiring hospital admission. Follow-up time was censored by DAPT suspension/withdrawal. Results From the 26,076 ACS patients, 630 had severe anemia (2.4%). During a mean follow-up of 12.2±4.8 months, 964 patients died (3.7%), 640 had myocardial infarction (2.5%) and 685 had major bleeding (2.6%). After propensity-score matching, we obtained two matched groups (with hemoglobin < and ≥10 g/dL) of 621 patients. In comparison with patients without severe anemia, patients with hemoglobin <10 g/dL had similar risk of myocardial infarction (sHR 1.37, 95% CI 0.82–2.31, p=0.231) with higher risk of major bleeding (sHR 1.89, 95% CI 1.18–2.72, p=0.006). After propensity score matching, the cumulative incidence of myocardial infarction was 6 and 5 per 100 patients/year in patients with and without severe anemia, respectively, during DAPT. And the cumulative incidence of major bleeding was 12 and 6 per 100 patients/year in patients with and without severe anemia, respectively. The difference between myocardial infarction rate and major bleeding rate was −6 in patients with severe anemia (more bleeding than ischemic event rates; p<0.05) and −1 in patients with hemoglobin ≥10 g/dL (similar bleeding and ischemic event rates; p>0.05), per 100 patient-years (Figure). Conclusions After an ACS underwent PCI, during DAPT, the ischemic-bleeding balance of patients with severe anemia (hemoglobin <10 g/dL) is not favorable. In those patients, a short-term DAPT (<6 months) should be recommended.

P2539Impact of sex (female vs male) in the ischemic-bleeding profile after hospital discharge for acute coronary syndrome during treatment with dual antiplatelet therapy

Abstract Introduction Sex-specific differences exist in the presentation, pathophysiological mechanisms, and outcomes in patients with acute myocardial infarction. These differences could condition the treatment and prognosis of women compared to men with Acute Coronary Syndrome (ACS). The aim of our study was to determine, after matching the baseline characteristics of patients according to gender, the prognosis of women versus men during treatment with Dual Antiplatelet Therapy (DAPT), after an ACS undergoing Percutaneous Coronary Intervention (PCI). Methods The data analyzed in this study were obtained from the fusion of 3 clinical registries of ACS patients: BleeMACS (2004–2013), CardioCHUVI/ARRITXACA (2010–2016) and RENAMI (2013–2016). All 3 registries include consecutive patients discharged after an ACS with DAPT and undergoing PCI. The merged data set contain 26,076 patients. A propensity-matched analysis was performed to match the baseline characteristics of patients according to gender (female vs male). The impact of gender in the ischemic and bleeding risk was assessed by a competitive risk analysis, using a Fine and Gray regression model, with death being the competitive event. For ischemic risk we have considered a new acute myocardial infarction, whereas for bleeding risk we have considered major bleeding defined as bleeding requiring hospital admission. Follow-up time was censored by DAPT suspension/withdrawal. Results From the 26,076 ACS patients, 6,091 were women PAD (23.4%). During a mean follow-up of 12.2±4.8 months, 964 patients died (3.7%), 640 had myocardial infarction (2.5%) and 685 had major bleeding (2.6%). After propensity-score matching, we obtained two matched groups (according gender) of 5,341 patients. In comparison with male, female had similar risk of myocardial infarction (sHR 1.14, 95% CI 0.91–1.44, p=0.001) with lower risk of major bleeding (sHR 0.75, 95% CI 0.61–0.92, p=0.006). The cumulative incidence of myocardial infarction was 26 and 30 per 1,000 patients/year in men and women, respectively, during DAPT. And the cumulative incidence of major bleeding was 43 and 32 per 1,000 patients/year in men and women, respectively. The difference between myocardial infarction rate and major bleeding rate was −17 in male (more bleeding than ischemic event rates; p<0.05) and +3 in women (similar bleeding and ischemic event rates; p>0.05), per 1,000 patient-years (Figure). Figure 1 Conclusions After an ACS underwent PCI, during DAPT, the ischemic-bleeding balance is different between women and men. In women, the annual incidence of ischemic events was similar to the incidence of bleeding events. However, in men, the incidence of bleeding events is higher than the incidence of ischemic events,

P4623Impact of left ventricular ejection fraction in ischemic and bleeding risk after an acute coronary syndrome

Abstract Introduction Even though left ventricular ejection fraction (LVEF) is a well-documented strong predictor of mortality after an acute coronary syndrome (ACS), its differential impact on the ischemic and bleeding risk of hemorrhage and ischemia is not well established. The aim of this study was to assess the impact of LVEF, measured by echocardiography, on the risk of acute myocardial infarction (AMI) and major bleeding (MB) after hospital discharge for ACS, during treatment with dual antiplatelet therapy (DAPT). Methods The data analyzed in this study were obtained from the fusion of 3 clinical registries of ACS patients: BleeMACS (2004–2013), CardioCHUVI/ARRITXACA (2010–2016) and RENAMI (2013–2016). All 3 registries include consecutive patients discharged after an ACS with DAPT and undergoing PCI. From the initial merged data set, that contained 26,076 patients, we have excluded those without data about LVEF. So the final cohort was composed by 20,518 patients. The impact of LVEF in the ischemic and bleeding risk was assessed by a multivariable competitive risk analysis, using a Fine and Gray regression model, with death being the competitive event. All those variables with statistical (p<0.05) or clinical significance for the association with AMI and MB were included in the analysis. Follow-up time was censored by DAPT suspension/withdrawal. Results During a mean follow-up of 12.2±5.2 months, 789 patients died (3.8%), 431 had an AMI (2.1%) and 537 had a MB (2.6%). The mean of LVEF was 53.2% ± 10.7%. Only 15.5% of patients had LVEF <40% (n=3,179). As the LVEF decreased, the risk of AMI increased, whereas the behavior of the risk of MB was more heterogeneous (Figure). After a multivariable adjustment, LVEF (as continuous variable) was significantly associated with AMI (sHR 0.98, 95% CI 0.98–0.99; p=0.010), but not with MB (sHR 1.00, 95% CI 0.99–1.01; p=0.270). After stratifying by LVEF groups (≥ vs <40%), we found an association between LVEF and AMI (sHR 1.40, 95% CI 1.10–1.76; p=0.005), but not between LVEF and bleeding (HR 0.85, 95% CI 0.67–1.08; p=0.185). Conclusions After an ACS, as the LVEF decreases, there is an increase in ischemic risk, but not in bleeding risk. A LVEF <40% was independently associated with higher risk of AMI, but not with higher risk of MB.

461Modulation of ischemic and bleeding risk by peripheral artery disease after an acute coronary syndrome

Abstract Introduction Peripheral artery disease (PAD) is associated with heightened ischemic and bleeding risk in patients with acute coronary syndrome (ACS). With this study from real-life patients, we try to analyze the balance between ischemic and bleeding risk during treatment with dual antiplatelet therapy (DAPT) after an ACS according to the presence or not of PAD. Methods The data analyzed in this study were obtained from the fusion of 3 clinical registries of ACS patients: BleeMACS (2004–2013), CardioCHUVI/ARRITXACA (2010–2016) and RENAMI (2013–2016). All 3 registries include consecutive patients discharged after an ACS with DAPT and undergoing PCI. The merged data set contain 26,076 patients. A propensity-matched analysis was performed to match the baseline characteristics of patients with and without PAD. The impact of prior PAD in the ischemic and bleeding risk was assessed by a competitive risk analysis, using a Fine and Gray regression model, with death being the competitive event. For ischemic risk we have considered a new acute myocardial infarction (AMI), whereas for bleeding risk we have considered major bleeding (MB) defined as bleeding requiring hospital admission. Follow-up time was censored by DAPT suspension/withdrawal. Results From the 26,076 ACS patients, 1,600 have PAD (6.1%). Patients with PAD were older, and with more cardiovascular risk factors. DAPT with prasugrel/ticagrelor was less frequently prescribed in patients with PAD in comparison with the rest of the population (8.2% vs 22.8%, p<0.001). During a mean follow-up of 12.2±4.8 months, 964 patients died (3.7%), and 640 AMI (2.5%) and 685 MB (2.6%) were reported. After propensity-score matching, we obtained two matched groups of 1,591 patients. Patients with PAD showed a significant higher risk of both AMI (sHR 2.17, 95% CI 1.51–3.10, p<0.001) and MB (sHR 1.51, 95% CI 1.07–2.12, p=0.018), in comparison with those without PAD. The cumulative incidence of AMI was 63.9 and 29.8 per 1,000 patients/year in patients with and without PAD, respectively. The cumulative incidence of MB was 55.9 and 37.6 per 1,000 patients/year in patients with and without PAD, respectively. The rate difference per 1,000 patient-years for AMI between patients with and without PAD was +34.1 (95% CI 30.1–38.1), and for MB +18.3 (16.1–20.4). The net balance between ischemic and bleeding events comparing patients with and without PAD was positive (+15.8 per 1,000 patients/year, 95% CI 9.7–22.0). Conclusions PAD was associated with higher ischemic and bleeding risk after hospital discharge for ACS treated with DAPT. However, the balance between ischemic and bleeding risk was positive for patients with PAD in comparison with patients without PAD. As summary, ACS patients with PAD had an ischemic risk greater than the bleeding risk.

Treatment practices and lipid profile of patients with acute coronary syndrome: results from a tertiary care hospital

Background: Considering the increasing burden of cardiovascular risk factors and recent advances on the management of acute coronary syndromes (ACS), we studied the epidemiological characteristics and treatment strategies of patients presenting with ACS. We also evaluated the lipid profile and attainment of lipid goals in a ‘real world’ clinical setting.Methods: This was a substudy of IDEAL-LDL (Motivational interviewing to support low-density lipoprotein cholesterol (LDL-C) therapeutic goals and lipid-lowering therapy compliance in patients with acute coronary syndromes), a single-centre, prospective, randomised controlled trial. Baseline data from a total of 357 ACS patients were gathered using standardised methods.Results: Median age of patients was 60 years and 81.2% were males. Arterial hypertension and smoking were the most prevalent risk factors for coronary artery disease (CAD). Patients with ST-elevation myocardial infarction (STEMI) were heavier smokers, but were younger and exercised more compared to those with non-ST-elevation acute coronary syndrome (NSTE-ACS). Conversely, more NSTE-ACS patients had arterial hypertension, dyslipidaemia and diabetes mellitus. One-fifth of ACS patients was treated conservatively without a percutaneous coronary intervention (PCI). A combination of statin, dual antiplatelet therapy and beta-blockers were prescribed to 79.6% of patients upon discharge. A renin-angiotensin-aldosterone system inhibitor and a beta-blocker were prescribed to 67.3 and 91.8% of patients with LVEF ≤40%, respectively. Of patients with prior history of CAD, 63.1%, 71.4% and 58.3% received regularly statins, antiplatelets and beta-blocker treatment, respectively. Only 22.3% of these CAD patients had an optimal LDL-C of <70 mg/dl at admission.Conclusions: In hospitalised patients with ACS, management practices differed by ACS type and discharge medication was, mostly, in line with the latest guidelines. However, medication adherence and lipid lowering goals of secondary CAD prevention were largely unachieved.

Incidence, predictors and prognosis of new-onset cancer after hospital discharge for acute coronary syndrome

Introduction and objectivesThe concurrence of cancer and ischemic heart disease is a controversial issue, given the confluence of risk factors for both diseases. The aim of this study is to analyze the incidence, predictors, and prognosis of new-onset cancer after an acute coronary syndrome (ACS). MethodsRetrospective multicenter registry that includes 3867 consecutive patients discharged for ACS without a known history of cancer, from 2011 to 2015. The association between clinical variables and cancer occurrence was assessed by Fine-Gray proportional hazards regression analysis, and its prognostic impact was evaluated using Cox and Fine-Gray regression models. ResultsThe cumulative incidence of cancer was 2.47 per 100 patient/years. Four independent predictors of follow-up cancer were identified: age, male sex, smoking, and human immunodeficiency virus infection. We have constructed a simple risk score, based on the coefficients of these variables in the final multivariable model. Using this score, we stratified our population according to the risk of developing cancer: low (1.03% per year), moderate (2.35% per year), and high-risk (10.51% per year) groups. Post-discharge cancer was independently associated with an increased risk of non-cardiovascular death (HR, 17.65; 95%CI, 10.47–29.76) and bleeding (sHR, 2.54; 95%CI, 1.21–5.34), but not with reinfarction (sHR, 0.50; 95%CI, 0.16–1.56). ConclusionsCancer occurrence after hospital discharge for ACS is relatively low, but it could be predicted by the combination of 4 easily available clinical risk factors: age, male sex, smoking, and human immunodeficiency virus infection. Post-discharge cancer is associated with a higher risk of subsequent death and bleeding events.

Predictors of all-cause mortality and ischemic events within and beyond 1 year after an acute coronary syndrome: Results from the EPICOR registry.

Patients discharged after an acute coronary syndrome (ACS) have substantial risk of recurrent ischemic events or dying. A difference may exist in risk predictors for all-cause mortality and ischemic events between year 1 and 2 of follow-up post-ACS. EPICOR (NCT01171404) was a prospective, international, real-world cohort study of consecutive patients hospitalized for ACS within 24 hours of symptom onset and surviving to discharge. Total of 10 568 patients were enrolled (555 hospitals; 20 countries) and followed-up for 2 years. From these, 4943 were admitted with ST-elevation myocardial infarction (STEMI) and 5625 with non-ST-elevation ACS (NSTE-ACS). Potential baseline predictors of major adverse cardiac and cerebrovascular events (MACCE; death, non-fatal myocardial infarction [MI], non-fatal stroke) were evaluated in year 1 and 2 post-discharge. MACCE incidence per 100 person-years at risk within and after 1 year was 5.3 vs 3.6, primarily death (4.1 vs 2.3), with no significant differences for MI or stroke. Older age, lack of coronary revascularization, raised creatinine, low hemoglobin, previous cardiac disease, previous chronic obstructive pulmonary disease, raised glucose, male sex, and geographic region were risk factors for MACCE in both year 1 and 2. By contrast, low ejection fraction, poorer quality of life, low body mass index (BMI) <20 kg/m2 , in-hospital cardiac complications, and Killip class lost predictive power after 1 year. We observed continuous MACCE risk during 2 years of follow-up after discharge for ACS, with greater mortality within the first year. Specific predictors at discharge for events after 1 year could not be identified.

Factors associated with objectively measured exercise participation after hospitalization for acute coronary syndrome

BackgroundGuidelines recommend exercise for secondary prevention of acute coronary syndrome (ACS), however adherence to guidelines is low. A paucity of data examining factors associated with objectively-measured exercise post-discharge in ACS survivors exists. The purpose of this study was to identify factors associated with exercise during the 5 weeks after ACS discharge. MethodsA sample of 151 ACS patients treated at a university hospital were enrolled into an observational cohort study and wore an accelerometer for 35 days post-discharge. Days on which participants accumulated ≥30 min of moderate-to-vigorous physical activity in bouts ≥10 min were considered exercise days. Participants were categorized as non-exercisers (0 exercise days) or exercisers (≥1 exercise day). A multi-variable logistic regression model was used to examine the association between exercise and socio-demographics, depression, SF-12 physical and mental health scores, disease severity, length of hospitalization, and percutaneous coronary intervention. Results39.7% of participants were non-exercisers. Factors associated with non-exercise were age (OR: 1.11; 95% CI: 1.06–1.17, p < 0.001), female sex (OR: 2.76; 95% CI: 1.10–6.95, p = 0.031), and lower SF-12 physical health score (OR: 0.94; 95% CI: 0.90–0.98, p = 0.005). ConclusionIn ACS patients in whom exercise participation was objectively measured for 5 weeks post-discharge, demographic and poor physical health factors were associated with non-exercise. These findings identify populations (e.g. older adults, women) at especially high risk for being physically inactive in whom more intense intervention may be warranted.

Development and external validation of a post-discharge bleeding risk score in patients with acute coronary syndrome: The BleeMACS score

BackgroundAccurate 1-year bleeding risk estimation after hospital discharge for acute coronary syndrome (ACS) may help clinicians guide the type and duration of antithrombotic therapy. Currently there are no predictive models for this purpose. The aim of this study was to derive and validate a simple clinical tool for bedside risk estimation of 1-year post-discharge serious bleeding in ACS patients. MethodsThe risk score was derived and internally validated in the BleeMACS (Bleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coronary Syndrome) registry, an observational international registry involving 15,401 patients surviving admission for ACS and undergoing percutaneous coronary intervention (PCI) from 2003 to 2014, engaging 15 hospitals from 10 countries located in America, Europe and Asia. External validation was conducted in the SWEDEHEART population, with 96,239 ACS patients underwent PCI and 93,150 without PCI. ResultsSeven independent predictors of bleeding were identified and included in the BleeMACS score: age, hypertension, vascular disease, history of bleeding, malignancy, creatinine and hemoglobin. The BleeMACS risk score exhibited a C-statistic value of 0.71 (95% CI 0.68–0.74) in the derivation cohort and 0.72 (95% CI 0.67–0.76) in the internal validation sample. In the SWEDEHEART external validation cohort, the C-statistic was 0.65 (95% CI 0.64–0.66) for PCI patients and 0.63 (95% CI 0.62–0.64) for non-PCI patients. The calibration was excellent in the derivation and validation cohorts. ConclusionsThe BleeMACS bleeding risk score is a simple tool useful for identifying those ACS patients at higher risk of serious 1-year post-discharge bleeding.ClinicalTrials.govIdentifier: NCT02466854

Acute stress disorder symptoms after evaluation for acute coronary syndrome predict 30-day readmission

BackgroundThirty-day readmissions are a major concern for hospitals. Even though numerous readmission risk prediction models have been developed, their performance has been modest, and few predictors are modifiable. Stress is a modifiable factor that may increase risk of adverse post-hospitalization outcomes. We examined whether posttraumatic stress days after evaluation for acute coronary syndrome (ACS)—termed acute stress disorder (ASD) symptoms—was associated with 30-day all-cause emergency department (ED) and hospital readmission. MethodsParticipants were enrolled in the REactions to Acute Care and Hospitalization (REACH) study during ED evaluation for ACS. During inpatient stay or by phone after discharge, participants reported ASD symptoms in response to the event that brought them to the ED. ED or hospital readmissions within 30days of discharge were determined by research nurse record review. Logistic regression was used to assess the association between ASD symptoms and 30-day ED/hospital readmission. ResultsIn the analytic sample of 974 individuals, there were 123 ED/hospital readmissions within 30days of discharge. A 10-point ASD symptom increase was significantly associated with increased 30-day readmission risk in an unadjusted model [odds ratio (OR)=1.32, p=0.001] and a model adjusted for demographics, clinical characteristics, and ACS discharge diagnosis (OR=1.24, p=0.03). ConclusionsPosttraumatic stress shortly after acute coronary syndrome evaluation may help to understand vulnerability for readmission.

Secondary Prevention Beyond Hospital Discharge for Acute Coronary Syndrome: Evidence-Based Recommendations

In the past 3 decades, a better understanding of the pathophysiology of cardiovascular disease has resulted in innovations in the treatment and prevention of its clinical manifestations such as death, myocardial infarction, or stroke. After an acute coronary syndrome there are short- and long-term risks of subsequent cardiovascular events. This leads to opportunities to initiate strategies to reduce complications resulting from myocardial injury (cardiac protection) and to prevent recurrent acute coronary events (vascular protection). The results from clinical trials inform best practice and guidelines for patient management. Despite clear and consistent guidelines, an important number of patients are not receiving these treatments. Moreover, many others do not receive treatment that follows the strategy proven in the clinical trial and this is associated with a significant loss of opportunities to improve outcomes. The Canadian Heart Research Centre has therefore assembled a panel of experts to provide a review of available data and distill it to specific evidence-based recommendations that can be used by specialists and primary care physicians as a platform for secondary prevention. The therapeutic recommendations are conveniently divided into vascular protection (dual antiplatelet therapy, lipid-lowering, and renin angiotensin system inhibition) which should be considered in all patients; cardiac protection (addition of β-blocker therapy) in patients with left ventricular dysfunction including consideration for management of heart failure; and continuing management of risk factors and comorbid conditions on the basis of the specific patient profile. These recommendations are intended as a decision support tool and a quick reference for Canadian physicians.

Abstract 18325: Changes in Cognition and Lipid-lowering Therapy After the Acute Coronary Syndrome: Results From TRACE-CORE

Introduction: Lipid-lowering therapies (LLT) are a key component of treatment in acute coronary syndrome (ACS). Some studies have found an adverse effect of LLTs on cognition yet evidence is inconsistent. We describe 12-month trajectories of cognition among ACS survivors in relation to post-discharge LLT use. Methods: Adult patients (n=2187) hospitalized for ACS in Georgia and Massachusetts enrolled in Transitions, Risks, and Actions in Coronary Events: Center for Outcomes Research and Education (TRACE-CORE) and underwent serial cognitive assessments from index hospitalization through 12 months via the Telephone Interview for Cognitive Status (TICS; range: 0-41; higher scores indicate better cognitive function). The primary outcome was change in TICS and unadjusted between-group comparisons were conducted using the two-sample T-test at 1, 3, 6, and 12 months. A multivariable linear model was constructed to examine the between-group comparison adjusted for baseline demographics, cardiovascular and in-hospital risk factors, and other comorbidities. Results: Participants were 67% male, 80% non-Hispanic white, and aged 61.4±11.3 years. Ninety-two percent were discharged on LLT. At 1 month follow-up (n=1527), patients improved on subsequent cognitive testing regardless of treatment with LLTs; mean TICS improvement was 1.0 for patients on LLT vs. 1.6 for those untreated (p=0.11). In adjusted models, change in TICS did not differ by LLT use (β= -0.41; 95% CI:-1.15, 0.33). Interval changes at 3, 6, and 12 months did not differ by LLT use, with complete follow-up cognitive testing available for 1345 patients (see figure). Conclusions: The prescription of LLT is not associated with the trajectory of cognitive function after hospital discharge for ACS. Despite concerns about the potential cognitive impact of lipid-lowering drugs raised by previous studies, our findings do not support an adverse impact on cognition among ACS patients treated with LLT.

Clinical outcomes and medication adherence in acute coronary syndrome patients with and without type 2 diabetes mellitus: a longitudinal analysis 2006-2011.

The presence of type 2 diabetes mellitus magnifies the risks associated with acute coronary syndrome (ACS), increasing the risk of recurrent cardiovascular events (CVEs) and doubling the risk of death. Managing cardiovascular risk factors has little effect on lowering the mortality risk in patients with type 2 diabetes. To evaluate the relationship between type 2 diabetes mellitus and subsequent CVEs and medication adherence following ACS hospitalization. Patients with ACS were identified using ICD-9-CM codes for acute myocardial infarction or unstable angina. The risk of subsequent CVEs was assessed at 1 and 3 years after the index ACS event based on type 2 diabetes status, adjusting for baseline demographic characteristics, comorbidities, medication use, and index ACS characteristics. Of 140,903 patients with ACS (mean age 66.8 years, 58.6% male), 27.4% had type 2 diabetes. During follow-up, 22.0% had subsequent CVEs (26.2% type 2 diabetes, 19.0% nondiabetes). After adjusting for other covariates, type 2 diabetes was associated with increased risk of subsequent CVEs by 9.7% at 1 year and 10.2% at 3 years (both P < 0.001). Most patients were not revascularized at first recurrence after index ACS discharge (79.2% type 2 diabetes, 77.5% nondiabetes). Patients with type 2 diabetes had statistically significant higher adherence rates for antiplatelet agents at 1 year and antihypertensives at 1 and 3 years versus nondiabetes patients. Persistence was higher in the type 2 diabetes group for antihypertensives and in the nondiabetes group for antiplatelet agents and statins. This analysis demonstrates that patients with type 2 diabetes have a higher risk of subsequent CVEs following an initial event versus those without diabetes, despite evidence of higher treatment persistence for certain medications. Adherence rates remained suboptimal, suggesting a continuing need for patient education.

Is 6-month GRACE risk score a useful tool to predict stroke after an acute coronary syndrome?

ObjectivesThe risk of stroke after an acute coronary syndrome (ACS) has increased. The aim of this study was to do a comparative validation of the 6-month GRACE (Global Registry of...

Evaluation of proper prescribing of cardiac medications at hospital discharge for patients with acute coronary syndromes (ACS) in two Lebanese hospitals.

BackgroundCoronary artery disease (CAD) is the major leading cause of death worldwide. The national practice guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA) promote the use of several medical therapies for secondary prevention for patients with CAD. The purpose of this study was to evaluate whether ACS patients, admitted into two tertiary referral medical centers in Beirut, Lebanon, are discharged on optimal medical therapy based on the current AHA/ACC guidelines.MethodsWe reviewed the medical records of all patients with ACS who were admitted to the coronary care units (CCU) of two hospitals in Beirut, Lebanon between May and August 2012. Discharge prescriptions were reviewed and rating for the appropriateness of discharge cardiac medications was based on the AHA/ACC guidelines. We assessed whether patients were discharged on antiplatelet therapy, β-blockers, angiotensin converting enzymes inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), statins, and nitrates, unless contraindicated or not tolerated. In addition, we assessed whether patients and/or their caregivers were counseled about their disease(s) and discharge medications.Results186 patients with a mean age of 63 ± 11.78 years, 70.4% of which were males, were admitted with ACS and were included in the study. Fifty three (28.5%) patients had ST elevation MI (STEMI), 64 (34.4%) had non-ST-elevation myocardial infarction (NSTEMI) and 69 (37.1%) had unstable angina (USA). Sixty two patients (33.3%) were treated with medical therapy and 124 patients (66.7%) underwent percutaneous coronary intervention (PCI).Among eligible patients, 98.9% were discharged on aspirin, 89.1% on dual antiplatelet therapy (aspirin + thienopyridine or ticagrelor), 90.5% on a β-blocker, 81.9% on an ACEI or ARB, 89.8% on a statin, and 19.4% on nitroglycerin. Overall, 62.9% of the patients received the optimal cardiovascular drug therapy (the combination of dual antiplatelet therapy, a β-blocker, an ACEIs or an ARB, and a statin), 55.1% were counseled on their disease state(s) and drug therapy, and 92.2% and 55.9% were counseled on smoking cessation and life style changes, respectively.ConclusionIn patients admitted with ACS, discharge cardiac medications are prescribed at suboptimal rates. Education of healthcare providers and implementation of ACS discharge protocols may help improve compliance with ACC/AHA guidelines. In addition, clinicians should be encouraged to provide adequate patient counseling.