Early Invasive Treatment Strategy Research Articles

Effects of Premature Ventricular Complex Burden on Left Ventricular Global Longitudinal Strain in Patients without Structural Heart Disease.

Background: Evaluation of left ventricular (LV) function in patients with idiopathic premature ventricular contraction (PVC) with preserved LV ejection fraction (LVEF), especially in the subclinical stage, may be of great importance in terms of directing early treatment. Methods: A total of 122 patients, retrospectively recruited, were divided into three groups according to PVC burden: Group 1; 5% ≤ PVC < 10%, Group 2; 10% ≤ PVC < 15%, and Group 3; 15% ≤ PVC. Transthoracic echocardiography (TTE) was performed to evaluate LV parameters. Results: LV-GLS (Global longitudinal strain) was found to be significantly lower in groups 2 and 3 with high PVC burden (18.9% ± 1.4, 17.5% ± 2.1, 16.3% ± 1.3; p < 0.001, respectively). Correlation analysis revealed a positive and significant correlation between PVC burden and deterioration in LV-GLS (r: 0.536; p < 0.001). In addition, PVC burden was found to be an independent predictor of LV-GLS deterioration in multiple linear regression analysis (β: 0.525, p < 0.001). The ROC curve analysis demonstrated that a PVC burden cut-off value of 8.4% was associated with a LV-GLS deterioration greater than -18, with a specificity of 75.4% and a sensitivity of 75.4% (AUC: 0.81 [0.73-0.88] 95% CI; p < 0.001). Conclusions: PVC burden was an independent predictor of deterioration in LV-GLS. The presence of LV-GLS deterioration due to PVC burden emphasizes the necessity for closer patient monitoring, observation of the response to pharmacological treatment, and evaluation of early invasive treatment strategies in selected patient groups.

The impact of COVID-19 on clinical outcomes among acute myocardial infarction patients undergoing early invasive treatment strategy.

BackgroundThe implications of coronavirus disease 2019 (COVID‐19) infection on outcomes after invasive therapeutic strategies among patients presenting with acute myocardial infarction (AMI) are not well studied.HypothesisTo assess the outcomes of COVID‐19 patients presenting with AMI undergoing an early invasive treatment strategy.MethodsThis study was a cross‐sectional, retrospective analysis of the National COVID Cohort Collaborative database including all patients presenting with a recorded diagnosis of AMI (ST‐elevation myocardial infarction (MI) and non‐ST elevation MI). COVID‐19 positive patients with AMI were stratified into one of four groups: (1a) patients who had a coronary angiogram with percutaneous coronary intervention (PCI) within 3 days of their AMI; (1b) PCI within 3 days of AMI with coronary artery bypass graft (CABG) within 30 days; (2a) coronary angiogram without PCI and without CABG within 30 days; and (2b) coronary angiogram with CABG within 30 days. The main outcomes were respiratory failure, cardiogenic shock, prolonged length of stay, rehospitalization, and death.ResultsThere were 10 506 COVID‐19 positive patients with a diagnosis of AMI. COVID‐19 positive patients with PCI had 8.2 times higher odds of respiratory failure than COVID‐19 negative patients (p = .001). The odds of prolonged length of stay were 1.7 times higher in COVID‐19 patients who underwent PCI (p = .024) and 1.9 times higher in patients who underwent coronary angiogram followed by CABG (p = .001).ConclusionThese data demonstrate that COVID‐19 positive patients with AMI undergoing early invasive coronary angiography had worse outcomes than COVID‐19 negative patients.

ANALYSIS OF THE OCCURRENCE OF VARIOUS CARDIOVASCULAR EVENTS IN PATIENTS WITH MYOCARDIAL INFARCTION WITHOUT ST SEGMENT ELEVATION DURING 6TH AND 12TH MONTHS

Myocardial infarction remains one of the leading causes in the structure of general and cardiovascular morbidity and mortality worldwide. Despite significant progress in the treatment of acute myocardial infarction in most developed countries, the emergence and prevention of early and late complications is of great interest. Existing unified methods of diagnosis and treatment of NSTEMI significantly avoid adverse events in the rehabilitation period of the disease, however, the long-term prognosis of this category of patients remains unfavorable due to the development of myocardial dysfunction after postinfarction remodeling and prognostic adverse arrhythmias. The search for opportunities to predict the development of complications, study of remodeling processes and their impact on the development of electrical instability of the myocardium, which is currently considered a promising area of non-invasive diagnosis of myocardial infarction. With regard to NSTEMI, the unfavorable long-term prognosis is primarily due to the development of myocardial dysfunction, electrical instability of the myocardium or the development of recurrent coronary events.&#x0D; Aim. To analyze the probability of occurrence of various cardiovascular events in patients with myocardial infarction without ST-segment elevation during 6 and 12 months of follow-up.&#x0D; Materials and methods. We conducted a comprehensive study of 200 patients with acute myocardial infarction without ST-segment elevation aged 38 to 80 (mean 62.0 ± 0.71, median 62 and interquartile range 55 and 70). A retrospective analysis of patients' condition during 6 and 12 months of follow-up was performed. Surveillance of patients was carried out in the mode of telephone contact with patients, assessment of the condition on scheduled visits (1st, 3rd, 6th and 12th month after hospitalization of patients with acute myocardial infarction) and recording of unscheduled and urgent requests of patients for medical help. We conducted a retrospective analysis of the condition of NSTEMI patients during 6 and 12 months of follow-up. Surveillance of patients was carried out in the mode of telephone contact with patients, assessment of the condition on scheduled visits (1st, 3rd, 6th and 12th month after hospitalization of patients with acute myocardial infarction) and recording of unscheduled and urgent requests of patients for medical help. During the observation of patients we recorded the cardiovascular events, such as cardiovascular death, myocardial infarction, stroke, heart decompensation, heart rhythm disorders.&#x0D; Results. Analysis of cardiovascular events observed during the year in the examined group of patients revealed that during the first year after an acute coronary event the most common complications were the development of acute decompensation of chronic heart failure, acute heart failure de novo and atrial fibrillation paroxysms de novo. To a lesser extent, events such as episodes of unstable angina, non-fatal myocardial infarction and strokes, and sudden cardiac death have been reported. Time dependence was demonstrated only for the first two, namely an increase in the frequency of complications at a later date – from the 6th to the 12th month compared to the first 6 months of follow-up.&#x0D; Conclusions. Manifestations of cardiac decompensation and arrhythmia in the delayed period of the disease are associated with manifestations of structural remodeling and electrical instability of the myocardium, while the reduction of fatal complications is a consequence of early invasive treatment strategy.

Abstract 15943: Health Status and Quality of Life With Early Invasive and Non-invasive Treatment Strategies for Patients With Claudication

Introduction: Improving health status; symptoms, function, and quality of life (QoL) are key treatment goals in patients with peripheral arterial disease (PAD) and claudication. Hypothesis: Compared with medical management only, early revascularization in patients with claudication is associated with greater improvements in disease-specific health status. Methods: Patients with new or worsening claudication, who underwent revascularization within 3 months of enrolment or were treated non-invasively (statin, aspirin, cilostazol, supervised exercise therapy, risk factor management) were identified from 16 vascular medicine clinics in the US, Netherlands and Australia participating in the PORTRAITregistry. Patients were propensity-matched on the likelihood of receiving invasive therapy. The Peripheral Artery Questionnaire (PAQ) was used to assess patients’ disease-specific health status at enrollment, and at 3, 6 and 12 months of follow-up using hierarchical Generalized Linear Models for repeated measures. Results: Among 1142 patients (mean age of 67.7 years, 63.0% male), 229 (20.1%) underwent early revascularization while 913 (79.9%) were managed non-invasively. At baseline, patients who underwent invasive vs. non-invasive management had lower PAQ summary (mean ± SD; 44.41 ± 19.98 vs 50.98 ± 21.79, P&lt;0.001) and quality of life scores (45.52 ± 23.95 vs 52.43 ± 26.19, P&lt;0.001). Compared with patients treated non-invasively, patients who underwent revascularization reported improved health status over time, through 1 year of follow up (P &lt;0.001 for all PAQ domains) ( Figure 1 ). Conclusion: Patients who underwent early revascularization had worse baseline health status but a greater improvement over 1 year of follow-up when compared with patients managed without revascularization. Summarizing real-world health status benefits following a PAD diagnosis can support preference-sensitive decisions for PAD management.

Abstract 24: Health Status Differences Between Early Invasive and Non Invasive Treatment Strategies in Patients With Peripheral Artery Disease: Insights From Portrait Registry

Background: In patients with symptomatic peripheral artery disease (PAD), a key treatment goal is to improve their health status; their symptoms, function, and quality of life (QoL). While medical therapy with lifestyle changes is recommended in all, revascularization can be a consideration to alleviate PAD symptoms. We sought to compare the real-world impact of either treatment strategy on patients’ health status improvement. Methods: Patients with new or worsening PAD symptoms (Rutherford category 1-3), from 10 U.S. specialty vascular clinics between 2011-2015, who either underwent early revascularization (using stent, angioplasty or surgery within 3 months of enrolment) or medical management alone (statin, aspirin, cilostazol, supervised exercise therapy, risk factor (diabetes, hypertension) management) were identified from the Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories (PORTRAIT) registry. The Peripheral Artery Questionnaire (PAQ) was used to assess patients’ disease-specific health status at enrollment and at 3, 6 and 12 months of follow up. The differences in PAQ overall summary scores, and each subdomain, were compared using an adjusted generalized linear model for repeated measures (Figure 1). Results: Among 797 patients (mean age of 68.6 years, 58.1% male), 226 underwent early revascularization and 571 were managed medically. At baseline, patients in the revascularization vs. medical management cohort had lower PAQ summary scores (mean ± SD; 42.6 ± 20.7 vs. 48.5 ± 22.3, P&lt;0.001) and QoL scores (43.4 ± 23.9 vs. 50.4 ± 26.4, P&lt;0.001). Over 1 year of follow-up, patients who underwent revascularization reported significantly higher health status over time than patients managed medically without revascularization (P &lt;0.001 for all PAQ sub-domains; Figure 1). Conclusion: Patients with PAD who received early revascularization had worse health status at baseline, but they reported a greater degree of improvement over 1 year of follow-up when compared to patients managed medically without revascularization. Summarizing real-world health status benefits following a PAD diagnosis is critical to help guide preference-sensitive decisions on PAD management.

Early invasive strategy in senior patients with non-ST-segment elevation myocardial infarction: is it cost-effective? - a decision-analytic model and value of information analysis

BackgroundNon-ST-elevation myocardial infarction (NSTEMI) is the most common type of heart attack in the UK and it is becoming increasingly prevalent among older people. An early invasive treatment strategy may...

100.10 Social Predictors of Percutaneous Coronary Intervention for NSTEMI in the Nationwide Inpatient Sample (NIS) Database

The treatment of choice for ST-elevation myocardial infarction (STEMI) is percutaneous coronary intervention (PCI). The choice of early invasive versus conservative treatment strategies is less clear-cut for unstable angina and non-ST-elevation myocardial infarction (NSTEMI) and is often based on

Early Versus Standard Care Invasive Examination and Treatment of Patients With Non-ST-Segment Elevation Acute Coronary Syndrome.

The optimal timing of invasive coronary angiography (ICA) and revascularization in patients with non-ST-segment elevation acute coronary syndrome is not well defined. We tested the hypothesis that a strategy of very early ICA and possible revascularization within 12 hours of diagnosis is superior to an invasive strategy performed within 48 to 72 hours in terms of clinical outcomes. Patients admitted with clinical suspicion of non-ST-segment elevation acute coronary syndrome in the Capital Region of Copenhagen, Denmark, were screened for inclusion in the VERDICT trial (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography) ( ClinicalTrials.gov NCT02061891). Patients with ECG changes indicating new ischemia or elevated troponin, in whom ICA was clinically indicated and deemed logistically feasible within 12 hours, were randomized 1:1 to ICA within 12 hours or standard invasive care within 48 to 72 hours. The primary end point was a combination of all-cause death, nonfatal recurrent myocardial infarction, hospital admission for refractory myocardial ischemia, or hospital admission for heart failure. A total of 2147 patients were randomized; 1075 patients allocated to very early invasive evaluation had ICA performed at a median of 4.7 hours after randomization, whereas 1072 patients assigned to standard invasive care had ICA performed 61.6 hours after randomization. Among patients with significant coronary artery disease identified by ICA, coronary revascularization was performed in 88.4% (very early ICA) and 83.1% (standard invasive care). Within a median follow-up time of 4.3 (interquartile range, 4.1-4.4) years, the primary end point occurred in 296 (27.5%) of participants in the very early ICA group and 316 (29.5%) in the standard care group (hazard ratio, 0.92; 95% CI, 0.78-1.08). Among patients with a GRACE risk score (Global Registry of Acute Coronary Events) >140, a very early invasive treatment strategy improved the primary outcome compared with the standard invasive treatment (hazard ratio, 0.81; 95% CI, 0.67-1.01; P value for interaction=0.023). A strategy of very early invasive coronary evaluation does not improve overall long-term clinical outcome compared with an invasive strategy conducted within 2 to 3 days in patients with non-ST-segment elevation acute coronary syndrome. However, in patients with the highest risk, very early invasive therapy improves long-term outcomes. URL: https://www.clinicaltrials.gov . Unique identifier: NCT02061891.

Long-term Follow-up of the Trial of Routine Angioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI)

BackgroundThe Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI) demonstrated superiority of routine early coronary angiography (and percutaneous coronary intervention [PCI]) compared with standard therapy in fibrinolytic-treated patients with ST-segment elevation myocardial infarction (STEMI) at 30 days. The aim of the current study was to evaluate the long-term (>7 year) effects of an early invasive strategy. MethodsWe linked the study cohort and administrative datasets to assess long-term follow-up status including repeat procedures, hospitalizations, and major adverse cardiovascular events (MACE). Kaplan-Meier and Cox regression analysis were used to evaluate the relationship between randomized treatment and long-term adverse outcomes. ResultsA total of 881 patients had long-term follow-up and were included in our study. After a mean follow-up of 7.8 years, there were no significant differences in death, myocardial infarction (MI), unstable angina, stroke, transient ischemic attack (TIA), or heart failure admissions (hazard ratio [HR] 0.91; 95% confidence interval [CI] 0.73–1.13]; P = 0.41) between those randomized to an early invasive vs standard treatment strategy. Following the index hospitalization, there were no significant difference in the rates of coronary revascularization between the early invasive and the standard therapy groups (81 [19.3%] vs 76 [17.9%]; P = 0.61). ConclusionsDespite the short-term benefit and safety of an early invasive strategy in patients with STEMI receiving fibrinolysis, no statistically significant differences in MACE were observed over 7.8 years.

Left bundle-branch block in patients with acute myocardial infarction: Presentation, treatment, and trends in outcome from 1997 to 2016 in routine clinical practice

Whether patients with acute myocardial infarction presenting with new or presumed new left bundle-branch block (LBBB) should be treated in the same way as those presenting with ST-elevation (STE) is still a matter of debate. Data from 28,358 patients enrolled in AMIS Plus from 1997 to 2016 were analyzed to evaluate differences in treatment and outcome of patients presenting with LBBB (n=2295) or STE (n=26,090) on their initial electrocardiogram using descriptive statistics and multivariate logistic regression. LBBB patients were older (75.0 vs 64.3 years, P<.001) with a greater burden of risk factors and comorbidities. They were admitted 80 minutes later and more frequently in Killip III/IV (20% vs 7%, P<.001). Even after adjustment for age and gender, LBBB patients were less likely to receive aspirin (odds ratio [OR] 0.40, 95% CI 0.34-0.47), P2Y12 inhibitors (OR 0.50, 95% CI 0.45-0.54), β-blockers (OR 0.81, 95% CI 0.76-0.89), and statins (OR 0.70, 95% CI 0.63-0.76) or undergo percutaneous coronary interventions (OR 0.38, 95% CI 0.35-0.42). Crude in-hospital mortality of patients with LBBB was 16.2% versus 6.5% for patients with STE, but adjusted OR was 1.07 (95% CI 0.93-1.24). Mortality of LBBB patients decreased from 22.6% in 1997-2001 to 11.9% in 2012-2016. Acute myocardial infarction patients with new or presumed new LBBB presence are at high risk of morbidity and mortality. They were treated less aggressively, and although mortality has halved during the last 20 years, there may be room for further improvement. Additional studies are needed to better identify those patients with LBBB who may maximally benefit from an early invasive treatment strategy.

Outcomes of early invasive treatment strategy in elderly patients with non-ST elevation acute coronary syndromes.

As benefits of revascularization in non-ST elevation acute coronary syndromes (NSTEACSs) in the elderly are still unproven, we sought to assess the association between invasive or conservative management of NSTEACS and short-, mid- and long-term mortality or composite outcome of all-cause mortality and myocardial infarction in a cohort of consecutive elderly patients. Consecutive NSTEACS patients older than 75 years discharged between 2006 and 2010 from a single intensive cardiac care unit, and managed with invasive or conservative strategy according to available guidelines were retrospectively surveyed. By multivariate regression and sensitivity analysis, crude and adjusted mortality and composite outcome were estimated at prespecified time points of short-term (in-hospital or 30 days mortality), mid-term (T1: 31 days to 6 months), and long-term (T2: 31 days to 12 months). A total of 453 patients (median age 80 years, 47% men) were evaluated; 301 (66.5%) underwent invasive treatment. Invasive was associated with significantly lower risk of short- [odds ratio (OR) 0.28, 95% confidence interval (CI) 0.12-0.67, P = 0.004], mid- (OR 0.33, 95% CI 0.16-0.67, P = 0.003) and long-term mortality (OR 0.34, 95% CI 0.20-0.58, P < .0001). Invasive strategy was also associated with nonsignificant lower short- (OR 0.55, 95% CI 0.28-1.07, P = 0.077), and highly significant lower mid- (OR 0.52, 95% CI 0.34-0.81, P = 0.003) and long-term adjusted cumulative composite outcome rate (OR 0.68, 95% CI 0.46-0.98, P = 0.004). In NSTEACS elderly patients, invasive strategy is independently associated with lower short-, mid- and long-term mortality and composite outcome.

Early invasive versus non-invasive treatment in patients with non-ST-elevation acute coronary syndrome (FRISC-II): 15 year follow-up of a prospective, randomised, multicentre study

The FRISC-II trial was the first randomised trial to show a reduction in death or myocardial infarction with an early invasive versus a non-invasive treatment strategy in patients with non-ST-elevation acute coronary syndrome. Here we provide a remaining lifetime perspective on the effects on all cardiovascular events during 15 years' follow-up. The FRISC-II prospective, randomised, multicentre trial was done at 58 Scandinavian centres in Sweden, Denmark, and Norway. Between June 17, 1996, and Aug 28, 1998, we randomly assigned (1:1) 2457 patients with non-ST-elevation acute coronary syndrome to an early invasive treatment strategy, aiming for revascularisation within 7 days, or a non-invasive strategy, with invasive procedures at recurrent symptoms or severe exercise-induced ischaemia. Plasma for biomarker analyses was obtained at randomisation. For long-term outcomes, we linked data with national health-care registers. The primary endpoint was a composite of death or myocardial infarction. Outcomes were compared as the average postponement of the next event, including recurrent events, calculated as the area between mean cumulative count-of-events curves. Analyses were done by intention to treat. At a minimum of 15 years' follow-up on Dec 31, 2014, data for survival status and death were available for 2421 (99%) of the initially recruited 2457 patients, and for other events after 2 years for 2182 (89%) patients. During follow-up, the invasive strategy postponed death or next myocardial infarction by a mean of 549 days (95% CI 204-888; p=0·0020) compared with the non-invasive strategy. This effect was larger in non-smokers (mean gain 809 days, 95% CI 402-1175; pinteraction=0·0182), patients with elevated troponin T (778 days, 357-1165; pinteraction=0·0241), and patients with high concentrations of growth differentiation factor-15 (1356 days, 507-1650; pinteraction=0·0210). The difference was mainly driven by postponement of new myocardial infarction, whereas the early difference in mortality alone was not sustained over time. The invasive strategy led to a mean of 1128 days (95% CI 830-1366) postponement of death or next readmission to hospital for ischaemic heart disease, which was consistent in all subgroups (p<0·0001). During 15 years of follow-up, an early invasive treatment strategy postponed the occurrence of death or next myocardial infarction by an average of 18 months, and the next readmission to hospital for ischaemic heart disease by 37 months, compared with a non-invasive strategy in patients with non-ST-elevation acute coronary syndrome. This remaining lifetime perspective supports that an early invasive treatment strategy should be the preferred option in most patients with non-ST-elevation acute coronary syndrome. Swedish Heart-Lung Foundation, Swedish Foundation for Strategic Research, and Uppsala Clinical Research Center.

Outcomes after planned invasive or conservative treatment strategy in patients with non-ST-elevation acute coronary syndrome and a normal value of high sensitivity troponin at randomisation: A Platelet Inhibition and Patient Outcomes (PLATO) trial biomarker substudy.

Current guidelines for patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) recommend early invasive treatment in intermediate-to-high risk patients based on medical history, electrocardiogram (ECG) and elevated troponin. Patients with normal levels of cardiac troponin measured with a high-sensitivity method (cTnT-hs) might not benefit from early invasive procedures. In this Prospective Randomized Platelet Inhibition and Patient Outcomes (PLATO) blood-core substudy, 1232 patients presented with NSTE-ACS had a high sensitivity cardiac troponin T (cTnT-hs) level <99th percentile (<14 ng/l) at randomisation. The outcomes in relation to a planned invasive ( n=473) vs planned conservative treatment ( n=759), were evaluated by adjusted Cox proportional hazard analyses. In patients with a normal cTnT-hs at randomisation, regardless of randomised treatment, a planned invasive vs conservative treatment was associated with a 2.3-fold higher risk (7.3% vs 3.4%, p=0.0028) for cardiovascular (CV) death or myocardial infarction (MI), driven by higher rates of procedure-related MI (3.4% vs 0.1%), while there were no differences in rates of CV death (1.3% vs 1.3%, p=0.72) or spontaneous MI (3.0% vs 2.1%, p=0.28). There were significantly more major bleeds (hazard ratio (HR) 2.98, p<0.0001), mainly due to coronary artery bypass graft (CABG)-related (HR 4.05, p<0.0001) and non-CABG procedural-related major bleeding events (HR 5.31, p=0.0175), however there were no differences in non-procedure-related major bleeding (1.5% vs 1.9%, p=0.45). Findings were consistent for patients with a normal cTnI-hs at randomisation. In patients with NSTE-ACS and normal cTnT-hs, a planned early invasive treatment strategy was associated with increased rates of procedure-related MI and bleeding but no differences in long-term spontaneous MI, non-procedure-related bleeding or mortality.

Effectiveness of an Early Versus a Conservative Invasive Treatment Strategy in Acute Coronary Syndromes

Randomized clinical trials have found that early invasive strategies reduce mortality, myocardial infarction (MI), and rehospitalization compared with a conservative invasive approach in acute coronary syndromes (ACSs), but the effectiveness of such strategies in real-world settings is unknown. To investigate adverse cardiovascular outcomes of an early versus a conservative invasive strategy in a national cohort of patients with ACSs. Retrospective cohort study. Administrative health care data on hospitalizations, procedures, and outcomes abstracted from the Danish national registries and covering all acute invasive procedures in patients presenting with an ACS. 19704 propensity score-matched patients hospitalized with a first ACS between 1 January 2005 and 31 December 2011. Risk for cardiac death or rehospitalization for MI within 60 days of hospitalization. Compared with a conservative approach, early invasive strategies were associated with a lower risk for cardiac death (cumulative incidence, 5.9% vs. 7.6%; adjusted hazard ratio [HR], 0.75 [95% CI, 0.66 to 0.84]; P< 0.001). Similar results were found for rehospitalization for MI (cumulative incidence, 3.4% vs. 5.0%; adjusted odds ratio, 0.67 [CI, 0.58 to 0.77]; P< 0.001) and all-cause death (cumulative incidence, 7.3% vs. 10.6%; adjusted HR, 0.65 [CI, 0.59 to 0.72]; P< 0.001). Potential residual confounding due to lack of core clinical variables. In this real-world cohort of patients with a first hospitalization for an ACS, the use of an early invasive treatment strategy was associated with a lower risk for cardiac death and rehospitalization for MI compared with a conservative invasive approach. Department of Cardiology, University Hospital Gentofte.

Risk of cardiovascular disease in patients on thrice-weekly versus twice-weekly hemodialysis

Society of Cardiology (ESC). Eur Heart J 2011;32:2999–3054. [3] Antman EM, CohenM, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA 2000;284:835–42. [4] Backus BE, Six AJ, Kelder JH, Gibler WB, Moll FL, Doevendans PA. Risk scores for patients with chest pain: evaluation in the emergency department. Curr Cardiol Rev 2011;7:2–8. [5] Fox KA, Dabbous OH, Goldberg RJ, et al. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ 2006;333:1091. [6] Granger CB, Goldberg RJ, Dabbous O, et al. Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med 2003;163:2345–53. [7] Lagerqvist B, Diderholm E, Lindahl B, et al. FRISC score for selection of patients for an early invasive treatment strategy in unstable coronary artery disease. Heart 2005;91:1047–52. [8] Palmerini T, GenereuxP, CaixetaA, et al. Anewscore for risk stratificationof patientswith acute coronary syndromes undergoing percutaneous coronary intervention: the ACUITY-PCI (Acute Catheterization and Urgent Intervention Triage Strategy-Percutaneous Coronary Intervention) risk score. JACC Cardiovasc Interv 2012;5:1108–16. [9] Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest 2010;137:263–72.

Early Invasive Versus Initial Conservative Treatment Strategies in Octogenarians with UA/NSTEMI

BackgroundPrevious studies have demonstrated improved outcomes with an early invasive strategy in patients with unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI). However, there are limited data for patients ≥80 years of age in these studies. MethodsWe used the 2003-2010 Nationwide Inpatient Sample databases to identify all patients ≥80 years of age (octogenarians) with UA/NSTEMI. Multivariable logistic regression was used to compare in-hospital outcomes in octogenarians with UA/NSTEMI undergoing early invasive (coronary angiography within 48 hours of admission, with or without revascularization) versus initial conservative treatment. ResultsAmong 968,542 octogenarians with UA/NSTEMI, 806,902 (83.3%) were managed using an initial conservative approach and 161,640 (16.7%) using an early invasive strategy. Patients in the early invasive group were more likely to be younger, men, white, and had a higher prevalence of smoking, dyslipidemia, obesity, hypertension, known coronary artery disease, carotid artery disease, and peripheral vascular disease. In-hospital mortality was significantly lower in octogenarians in the early invasive group (adjusted odds ratio [OR] 0.76; 95% confidence interval [CI], 0.74-0.78). Early invasive strategy was associated with lower rates of acute ischemic stroke (adjusted OR 0.63; 95% CI, 0.60-0.66), intracranial hemorrhage (adjusted OR 0.60; 95% CI, 0.510.70), gastrointestinal bleeding (adjusted OR 0.63; 95% CI, 0.60-0.65), and shorter average length of stay (5.3 vs 5.8 days, P <.001), but higher cardiogenic shock (adjusted OR 2.14; 95% CI, 2.06-2.23) and total hospital cost (23,584 vs 13,278 USD). ConclusionCompared with an initial conservative approach, an early invasive strategy in octogenarians with UA/NSTEMI was associated with lower in-hospital mortality, acute ischemic stroke, intracranial hemorrhage, gastrointestinal bleeding, and shorter length of stay, but higher cardiogenic shock and total hospital cost.

Risk Stratification and Timing of Revascularization: Which Patients Benefit from Early Versus Later Revascularization?

In acute coronary syndromes, risk stratification is essential, particularly in patients without ST elevation, and is based upon clinical, electrocardiogram (ECG), and biological markers. Among them, recent and repeated attacks of angina, ST-segment deviation from baseline on the admission ECG as well as elevated markers of myonecrosis (particularly increased troponin levels), myocardial dysfunction (B-type natriuretic peptide [BNP]; N-terminal prohormone of BNP[NT-proBNP]), and inflammation (high-sensitivity C-reactive protein) are predictors of an adverse outcome. These variables can be incorporated into broader risk predictive scores, among which the TIMI (Thrombolysis in Myocardial Infarction) and GRACE (Global Registry of Acute Coronary Events) scores are the most widely used. Two general therapeutic strategies (routine invasive vs conservative or selective invasive) are employed in the treatment of non-ST-segment elevation acute coronary syndrome (NSTEACS). Evidence-based analysis and the current American College of Cardiology/American Heart Association/Society for Cardiac Angiography and Interventions clinical practice guidelines recommend an early invasive treatment strategy (8-24h) for intermediate or high clinical risk patients with NSTEACS.

Treatment of acute coronary syndrome: Part 1: Non-ST-segment acute coronary syndrome

Acute coronary syndrome is a common cause of morbidity and mortality, both in the United States and worldwide. The goal of this review is to familiarize clinicians with recent information regarding the diagnosis and treatment of acute coronary syndrome. PubMed search and review of the relevant medical literature. Acute coronary syndrome encompasses three clinical diagnoses: unstable angina, non-ST-segment elevation myocardial infarction), and ST-segment elevation myocardial infarction. The definition, pathophysiology, clinical presentation, diagnosis, and treatment of unstable angina/non-ST-segment elevation myocardial infarction are reviewed here. Diagnosing unstable angina/non-ST-segment elevation myocardial infarction is a significant challenge in critically ill patients not initially suspected of having acute coronary syndrome (i.e., noncardiac intensive care unit patients), and diagnostic and treatment strategies for these patients have not been clearly established. Patients with acute coronary syndrome benefit from intensive medical therapy, including antianginal, antiplatelet, antithrombotic, and statin agents. Depending on their risk for future cardiovascular events as well as their risk of bleeding complications, patients may benefit from either an early invasive treatment strategy, in which routine coronary revascularization is performed, or a conservative strategy, in which revascularization is reserved for patients with recurrent or provocable cardiac ischemia.

Incidence and distribution of occluded culprit arteries and impact of coronary collaterals on outcome in patients with non-ST-segment elevation myocardial infarction and early invasive treatment strategy

It is assumed that patients with non-ST-elevation myocardial infarctions (NSTEMI) showing an infero- or posterolateral occluded culprit artery (OCA) during diagnostic angiography frequently elude standard 12-lead electrocardiogram diagnosis. In addition, coronary collaterals may have beneficial effects in patients with OCA. We examined 448 consecutive NSTEMI patients within 72 h of symptom onset. All patients underwent early invasive angiography plus optimal medical therapy. We compared clinical characteristics and 30-days/6-month major adverse cardiovascular events (MACE) between patients with OCA and non-OCA. The secondary objective was to investigate the effect of angiographically visible coronary collaterals on 6-month MACE in patients with OCA. The angiograms revealed OCA in 130 (29%) of 448 patients. Patients with OCA showed more often infero- or posterolateral lesions (75 vs. 53%, p < 0.001) and more collaterals (57 vs. 8%, p < 0.001) compared with those with non-OCA. Patients with OCA had larger infarcts (peak CK-MB 2.1 ± 2.3 vs. 1.2 ± 1.1 μmol/L/s, p < 0.001), lower left ventricular ejection fraction (42 ± 21 vs. 48 ± 20%, p = 0.01), were more often revascularized (89 vs. 78%, p = 0.005), and had higher risk-adjusted 6-month MACE largely driven by its association with non-fatal reinfarctions (HR 2.16, 95% CI 1.04-4.50, p = 0.04). Patients with OCA and angiographically absent collaterals had significantly higher risk-adjusted 6-month MACE than those with OCA and angiographically visible collaterals (HR 1.96, 95% CI 1.02-3.76, p = 0.04). Approximately one-fourth of patients with NSTEMI revealed OCA that was more frequently found in coronary arteries supplying the infero- or posterolateral myocardium. Patients with OCA had larger infarcts and more non-fatal reinfarctions than patients with non-OCA. Well-developed collaterals may limit the myocardial damage in these patients.

Predictive value of C-reactive protein on 30-day and 1-year mortality in acute coronary syndromes: an analysis from the ACUITY trial

We sought to evaluate the association between C-reactive protein (CRP) sampled on admission and short- and long-term mortality in patients with acute coronary syndromes (ACS) undergoing early invasive treatment. Baseline levels of CRP were determined in 2,974 patients with moderate and high-risk ACS undergoing an early invasive treatment strategy in the large-scale randomized ACUITY trial. The relationship of CRP to 30-day and 1-year clinical outcomes were assessed according to quartiles of CRP values. Patients with CRP levels in the fourth quartile compared to the first quartile had significantly higher 30-day mortality (2.3 vs. 0.3%, P = 0.0004) and 1-year mortality (5.5 vs. 2.8%, P = 0.0003). CRP level as a continuous variable was associated with 30-day mortality (OR [95% CI] for one unit increase in logarithmically transformed CRP level = 1.42 [1.08-1.89], P = 0.01) and 1-year mortality (OR [95% CI] = 1.24, [1.04-1.47], P = 0.02). By multivariable analysis, higher baseline CRP levels independently predicted 30-day and 1-year mortality, a relationship that was particularly strong for patients with the highest quartile of CRP (OR [95% CI] = 5.19 [1.14-23.68], P = 0.009). In troponin-positive patients, increasing quartiles of CRP were associated with a trend for 30-day mortality (P (trend) = 0.08) and a significant increase in 1-year mortality (P (trend) = 0.02); this relationship was not present in troponin-negative patients. Baseline CRP level is a powerful independent predictor of both early and late mortality in patients with ACS being treated with an early invasive strategy, especially in troponin positive patients.