Euro Heart Survey Research Articles

Value of admission glucose to predict impaired coronary microcirculation in acute ST-elevation myocardial infarction

Background: Acute hyperglycemia is frequently observed in non-diabetic ST-elevation myocardial infarction (STEMI) patients. It is thought to be associated with the release of stress-mediators like noradrenalin and cortisol, which antagonize insulin and promote glycogenolysis and hyperglycemia, or with the high incidence of impaired glucose tolerance among STEMI patients. Hyperglycemia recently was shown to be associated with the no-reflow phenomenon, which is mainly a manifestation of microvascular dysfunction. We recently showed that no-reflow (or not achieving TIMI 3 flow) with primary PCI for STEMI had independent prognostic value with regard tot 30-day, as well as 1-year mortality, next to admission glucose. Although no reflow in this study was an indirect measure of microvascular dysfunction, the significant association between no-reflow and increasing admission glucose and the attenuation of the effect of no-reflow by glucose concentration in multivariate analysis indicate the role of acute hyperglycemia in the pathophysiology of microvascular dysfunction. Methods: In 76 patients with a first anterior wall STEMI, baseline and minimal microvascular resistance in IRAs and non-IRAs immediately after reperfusion and at 1-week and 6-month follow-up were calculated as the ratio of mean transvascular pressure gradient to mean baseline and to adenosine-induced hyperemic blood flow velocity, respectively. Patients were divided in two groups, glucose below 11.0 mmol/L (group A) and glucose equal or higher than 11 mmol/L (group B), according to a cut-off level of the American Diabetes Association and the Euro Heart Survey. Results: Minimum microvascular resistance, defined as the ratio of mean distal pressure to average peak blood flow velocity during maximum hyperemia, showed a large variability (overall range, 0.75 to 4.89 mm Hg cm-1 s-1) and was significantly higher in group B than in group A immediately after reperfusion and at 1-week. Conclusion: In conclusion, minimal microvascular resistance is higher in anterior STEMI patients with hyperglycemia equal or above 11.0 mmol/L compared to patients with glucose leven lower than 11.0 mmol/L. Hyperglycemia in STEMI patients could prove to be an important predictor of microvacular dysfunction and obstruction.

Non-achievement of TIMI-3-flow results in significant increase in hospital mortality of primary PCI for STEMI and PCI for NSTE-ACS - findings of the Euro Heart survey PCI-registry

Non-achievement of TIMI-3-flow results in significant increase in hospital mortality of primary PCI for STEMI and PCI for NSTE-ACS - findings of the Euro Heart survey PCI-registry

Renal failure but not diabetes determines hospital mortality in patients with NSTE-ACS - results of the Euro heart survey ACS-registry

Background: Patients with NSTE-ACS often have diabetes (Diab) and/or renal failure (RF). It is unclear if RF and Diab are independent predictors of hospital mortality in NSTE-ACS. Methods: In 2006 to 2008, consecutive patients with ACS were enrolled into the EHS-ACS-Registry to document treatment and hospital outcome. We examined the impact of Diab and RF (GFR <60 ml/kg/min) on hospital outcome in patients with NSTE-ACS. Results: Of all ACS, 12,833 presented with NSTE-ACS. Patients with RF were older and more often had concomitant diseases as well as prior myocardial infarctions and coronary interventions independent of the presence of Diab. Patients with RF were less likely to undergo early reperfusion therapy (PCI <48h of symptom onset) as compared to patients without RF. In multivariate analysis, RF but not Diab predicted hospital mortality (p<0.05). View this table: Table 1 ![Figure][1] Figure 1 Conclusion: In patients with NSTE-ACS, RF outplayed Diab in the prediction of hospital mortality in NSTE-ACS and might be more important in risk stratification than Diab. [1]: pending:yes

Independent impact of diabetes and renal failure on hospital outcome of STEMI - results of the Euro Heart Survey ACS registry

Independent impact of diabetes and renal failure on hospital outcome of STEMI - results of the Euro Heart Survey ACS registry

Atrial fibrillation is an independent predictor of hospital mortality in STEMI but not in NSTE-ACS in clinical practice - results of the Euro heart survey ACS-registry

Atrial fibrillation is an independent predictor of hospital mortality in STEMI but not in NSTE-ACS in clinical practice - results of the Euro heart survey ACS-registry

Importance of gender differences in the diagnosis and management of patients with Acute Coronary Syndromes: The GRACE study in an Argentine Population

Coronary heart disease is the leading cause of mortality and morbidity in industrialized countries, in men as well as in women. Whereas the cardiovascular death rates are declining in men, they remain constant in women. Women with acute coronary syndrome (ACS) usually present later at hospitals for professional help and show more frequently with atypical symptoms, such as abnormal pain locations, nausea, vomiting, fatigue, and dyspnea. So far there are only speculations to explain these differences, but they could be related to different pain perception, older age, or other comorbidities (1). The misperception that females are somehow protected against cardiovascular disease may be one factor at the moment to evaluate the risk of heart disease women that is often underestimated. Recent data from the National Health and Nutrition Examination Surveys (NHANES) have shown that over the past two decades the prevalence of myocardial infarctions has increased in midlife (35 to 54 years) women, while declining in similarly aged men (1) . This view has also been challenged by Wiviott et al on the basis of an analysis from the TACTICS (Treat angina with Aggrastat and determine Costs of Therapy with Invasive or Conservative Strategies)–TIMI 18 study population (2). The under-recognition of heart disease and differences in clinical presentation in women lead to less aggressive treatment strategies. According to studies such as GUSTO IIb (Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes) (3), TIMI IIIB (Thrombolysis In Myocardial Infarction) (4), and the Euro Heart Survey (5), women present more frequently with unstable angina and non–ST-elevation myocardial infarction (NSTEMI), whereas men have ACS with ST elevation (STEMI). The outcome in NSTEMI appears equal, but in STEMI, mortality is higher in women. Cardiac-specific biochemical markers, like troponins, seemed a good tool independent of gender in identifying patients at risk. In patients with non–ST-elevation ACS,

A pioneering Argentinean study to better understand the regional gender differences on patients with Acute Coronary Syndromes.

Cardiovascular disease is well recognized as the leading cause of death in women. It is estimated that the lifetime risk for developing coronary artery disease (CAD) in women after 40 years of age is 32% (1) Acute coronary syndromes (ACS), including unstable angina (UA), non– ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI), represent a large portion of the clinical presentation of CAD. ACS it presents in different aspects, and gender is linked to many aspects of these presentations. The reason for gender differences in ACS presentation is likely multifactorial. These differences include, clinical presentation, delay to diagnosis and treatment, accuracy of diagnostic tests, differences in biomarkers, angiographic features, administration of antiplatelet therapies, drug side effects, and higher procedural complications. Previous studies have shown gender differences at each step along the treatment path for ACS patients, especially, women who had an acute myocardial infarction were less likely than men to be admitted to hospitals with revascularization capability (2). They have also demonstrated that in this high-risk population, women were offered cardiac catheterization and percutaneous coronary intervention (PCI) less frequently than men (3,4). The results from the Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO) IIb study (5) showed that women present significantly more often than men with UA/ NSTEMI and often with atypical features. These differences may be accounted for by differences in anatomy, pathophysiology of CAD, for the underutilization of acute antiplatelet therapy on hospital admission, and clinical characteristics in women vs men. In addition, there are conflicting data from randomized trials about the benefit of early invasive treatment in women (6-8). The data of 3100 female patients enrolled in the Euro Heart Survey ACS showed that female gender in the “real world” was not independently associated with worse in-hospital mortality, irrespective of the type

Incidence and Clinical Impact of Stroke Complicating Percutaneous Coronary Intervention

Stroke is a rare but serious complication of percutaneous coronary interventions (PCIs). So far, scant information is available about the incidence and outcome of patients developing stroke after PCI for stable angina or acute coronary syndrome (ACS) in daily clinical practice in Europe today. Between 2005 and 2008, 46888 patients undergoing PCI were enrolled into the PCI Registry of the Euro Heart Survey Programme (176 centers in 33 European countries) to document patient's characteristics, PCI details, and hospital complications in different PCI indications. Stroke was observed in 0.4% of the procedures in the total population, in 0.3% of PCIs in elective patients, and in 0.6% in PCIs performed for ACS. The overall in-hospital mortality was 19.2% for patients who developed stroke (elective PCIs, 10.0%; PCI for ACS, 23.2%) compared with 1.3% for those without stroke (elective PCIs, 0.2%; PCI for ACS, 2.3%). In multivariate analysis hemodynamic instability, age ≥ 75 years, history of stroke, and congestive heart failure were found to be independent predictors for periprocedural stroke in ACS, whereas only PCI of a bypass graft and renal failure could be identified as independent predictors for stroke in elective patients. Stroke as complication of PCI occurs rarely (0.4%) in clinical practice in Europe today. However, peri-interventional stroke is still associated with an exceedingly high in-hospital mortality rate. Most predictors for periprocedural stroke are not modifiable and cannot be diminished before PCI. Therefore, treatment of patients with stroke after PCI needs further research.

Characteristics, management and prognosis of elderly patients in the Euro Heart Survey on atrial fibrillation.

Atrial fibrillation (AF) is the most frequent sustained arrhythmia of elderly patients, in whom it determines an increase in morbidity and mortality. Aim of this study was to assess age-related differences in the characteristics, management and prognosis of patients with AF in European cardiology practices. The Euro Heart Survey on AF was an observational study sponsored by the European Society of Cardiology. Patients were enrolled between 2003 and 2004 in 182 hospitals of 35 countries. For the purposes of this study, they were categorized into three age-groups: <65 (n=2124), 65-80 (n=2534) and >80 years (n=671). Follow-up was closed in 2005. Compared with general population estimates, patients >80 years were underrepresented in the Euro Heart Survey. The oldest patients were less likely to be enrolled by university or specialized centers, to receive extensive diagnostic testing, and to receive oral anticoagulation despite a worse stroke risk profile. Furthermore, the oldest patients less often received rhythm control therapy, even when presenting with palpitations and non-permanent AF. During 1 year follow-up, elderly patients more often suffered a myocardial infarction, new onset heart failure and major bleedings. They had higher all-cause and cardiovascular mortality. Elderly patients with AF are less often referred to the cardiologist and, based on current guidelines, are inadequately studied and treated, compared to younger counterparts. Education on evidence- based management and the design of randomized controlled trials specifically targeting the elderly, should improve the management and prognosis of this frail segment of the AF population.

Interventional vs. surgical mitral valve therapy

Mitral regurgitation (MR) is the most frequent valvular heart disease in developed countries. Surgical repair represents the optimal treatment for severe degenerative MR; however, surgical correction of functional MR is controversial. The Euro Heart Survey showed that up to 50 % of patients with severe MR are today denied surgical treatment. Therefore, new transcatheter techniques have been developed to treat MR with less invasive approaches. Currently, the device with the widest clinical use is the MitraClip System. In this scenario, a multidisciplinary team approach is key in providing optimal individually tailored treatment for patients with MR.

Assessing operative risk and benefit in elderly patients with heart valve disease

The prevalence of heart valve disease increases with age, with the predominance of degenerative aetiology, as shown by the Euro Heart Survey on valvular heart disease.1 Advanced age is one of the pre-eminent risk factors of mortality and major morbidity after cardiac surgery. Nevertheless, several reports (including randomized studies) showed that consistent benefits can be achieved from cardiac surgery and percutaneous valve therapies in elderly patients,2–5 in terms of quality-of-life improvement, alleviation of symptoms, prevention of major adverse events, and increased survival. The clinical decision-making and individual risk profile evaluation in this context have been so far particularly challenging, leading to the clinical question of utility vs. futility. Concomitantly, the economic burden in high-risk elderly patients could have crucial implications and should be considered before proceeding, due to reduced expectancy of life. Moreover, ethical implications should be taken into account. The therapeutic decision in this context should be reached through a shared decision-making process, not only by a multidisciplinary ‘heart team’ discussion, but also by informing the patient thoroughly, and finally by deciding with the patient and family which treatment option is optimal, taking into account the patient perspective.6 Heart valve diseases in the elderly are often associated with a consistent number of extracardiac comorbidities, mainly related to atherosclerosis.1 In the clinical routine, the two surgical risk scores mostly used are the Logistic EuroScore (http://www.euroscore.org/calcold.html) and the STS score (http://riskcalc.sts.org/STSWebRiskCalc273/). Although both of them are quite accurate in predicting mortality in low-risk surgical candidates, they present several limits in the subset of the high-risk elderly patients. These scores provide relatively good discrimination (a gross estimation of risk category), but cannot be used to estimate an accurate operative mortality in an individual patient, because of unsatisfactory calibration (comparison between predicted and observed mortality). The value …

Gender inequality in the clinical outcomes of equally treated acute coronary syndrome patients in Saudi Arabia

BACKGROUND AND OBJECTIVESGender associations with acute coronary syndrome (ACS), remain inconsistent. Gender-specific data in the Saudi Project for Assessment of Coronary Events registry, launched in December 2005 and currently with 17 participating hospitals, were explored.DESIGN AND SETTINGSA prospective multicenter study of patient with ACS in secondary and tertiary care centers in Saudi Arabia were included in this analysis.PATIENTS AND METHODSPatients enrolled from December 2005 until December 2007 included those presented to participating hospitals or transferred from non-registry hospitals. Summarized data were analyzed.RESULTSOf 5061 patients, 1142 (23%) were women. Women were more frequently diagnosed with non ST-segment elevation myocardial infarction (NSTEMI [43%]) than unstable angina (UA [29%]) or ST-segment elevation myocardial infarction (STEMI [29%]). More men had STEMI (42%) than NSTEMI (37%) or UA (22%). Men were younger than women (57 vs 63 years) who had more diabetes, hypertension, and hyperlipidemia. More men had a history of coronary artery disease. More women received angiotensin receptor blockers (ARB) and fewer had percutaneous coronary intervention (PCI). Gender differences in the subset of STEMI patients were similar to those in the entire cohort. However, gender differences in the subset of STEMI showed fewer women given β-blockers, and an insignificant PCI difference between genders. Thrombolysis rates between genders were similar. Overall, in-hospital mortality was significantly worse for women and, by ACS type, was significantly greater in women for STEMI and NSTEMI. However, after age adjustment there was no difference in mortality between men and women in patients with NSTEMI. The multivariate-adjusted (age, risk factors, treatments, door-to-needle time) STEMI gender mortality difference was not significant (OR=2.0, CI: 0.7–5.5; P=.14).CONCLUSIONThese data are similar to other reported data. However, differences exist, and their explanation should be pursued to provide a valuable insight into understanding ACS and improving its management.

Management of Acute Coronary Syndromes

Management of Acute Coronary Syndromes

Are Elderly Patients with Acute Coronary Syndromes Undertreated? Data from Euro Heart Survey on ACS III Registry

Aim of the study was to assess the use and in-hospital outcome of invasive treatment in elderly patients with acute coronary syndromes (ACS) enrolled in the Euro Heart Survey ACS III Registry (2006-2009).

Mismatch between heart failure patients in clinical trials and the real world

Evidence-based medicine urges physicians to translate results from clinical trials to their patients. This, however, can only work, if real world patients are represented in clinical trials. We searched the literature on chronic heart failure (1950-2/2011) for studies designed to detect effects on mortality (mortality studies, MS) and exercise training studies (ETS) as the leading non-pharmaceutical/non-surgical treatment option in order to compare their characteristics with European (Euro Heart Survey on Heart Failure, EHSHF) and North American (Framingham Heart Study, FHS) epidemiological studies. After an extensive literature search, we identified 207 ETS and 59 MS. Subjects enrolled in ETS were younger (ETS: 62.5 ± 6.6; MS: 63.9 ± 4.6; EHSHF: 71.0 ± 3.5; FHS: 78.0 years), more often male (ETS: 80.9%; MS: 77.3%; EHSHF: 53.0%; FHS: 49.6%; p<0.001), and had substantially less comorbidities such as diabetes mellitus (ETS: 13.6%; MS: 22.5%; EHSHF: 27.0%; FHS: 25.3%; p<0.001), or hypertension (ETS: 26.3%; MS: 39.1%; EHSHF: 53.0%; FHS: 46.9%; p<0.001). Angiotensin converting enzyme-inhibitors, beta-blockers, and angiotensin-receptor-blockers were more commonly used in ETS than in EHSHF (all p<0.001). Only 16 (10.6%) ETS and 20 (62.5%) MS reported ethnic background. Heart failure patients in exercise training studies and mortality studies do not represent real world patients. In order to extrapolate data to the general population future exercise training studies as well as mortality studies need to include representative patients. Otherwise, knowledge gained can only be translated to a minority of our patients.

ESC Working Group on Valvular Heart Disease Position Paper--heart valve clinics: organization, structure, and experiences

With an increasing prevalence of patients with valvular heart disease (VHD), a dedicated management approach is needed. The challenges encountered are manifold and include appropriate diagnosis and quantification of valve lesion, organization of adequate follow-up, and making the right management decisions, in particular with regard to the timing and choice of interventions. Data from the Euro Heart Survey have shown a substantial discrepancy between guidelines and clinical practice in the field of VHD and many patients are denied surgery despite having clear indications. The concept of heart valve clinics (HVCs) is increasingly recognized as the way to proceed. At the same time, very few centres have developed such expertise, indicating that specific recommendations for the initial development and subsequent operating requirements of an HVC are needed. The aim of this position paper is to provide insights into the rationale, organization, structure, and expertise needed to establish and operate an HVC. Although the main goal is to improve the clinical management of patients with VHD, the impact of HVCs on education is of particular importance: larger patient volumes foster the required expertise among more senior physicians but are also fundamental for training new cardiologists, medical students, and nurses. Additional benefits arise from research opportunities resulting from such an organized structure and the delivery of standardized care protocols. The growing volume of patients with VHD, their changing characteristics, and the growing technological opportunities of refined diagnosis and treatment in addition to the potential dismal prognosis if overlooked mandate specialized evaluation and care by dedicated physicians working in a specialized environment that is called the HVC.

Complex questions command complex analyses: comparative effectiveness of drug treatment strategies in atrial fibrillation

Among the randomized clinical trials (RCTs) comparing rhythm- with ratecontrol trials conducted in the past 10 years [3–7], the AFFIRM trial is regarded as the most important, owing to its large sample size (4060 participants) and long follow-up (up to 6 years) [7]. Overall, the AFFIRM study showed that the strategy of restoring and maintaining sinus rhythm had no clear advantage in reducing overall mortality over the strategy of controlling the ventricular rate and allowing the AF to persist [7]. This conclusion held after combining the results of AFFIRM [7], and four other smaller trials [3–6], in a single meta-ana lysis estimate (OR: 0.87; 95% CI: 0.74–1.02 vs 1.12; 95% CI: 0.64–1.94 in the pooled ana lysis that included/excluded the AFFIRM trial) [8]. However, many clinicians feel uncomfortable with the rate-control strategy as the main therapeutic approach for AF. For some, the trial results do not mean that the rhythm control is not beneficial, but merely highlight the limitations of the current treatments to achieve and maintain sinus rhythm [9], while others believe the trial results are not generalizable to the full population of AF patients [8]. Such a conundrum demands more evidence through comparative effectiveness studies. To our knowledge, our group has published the first observational comparative effectiveness study of rhythm- versus rate-control drug strategies, published in July 2012 [10]. In this study, we used population-based administrative databases from Quebec (Canada) from 1999 to 2007 to select patients aged ≥66 years, hospitalized with an AF diagnosis who did not have AF-related drug prescriptions in the year before the admission, but received a prescription within 7 days of discharge. The study included 30,664 hospitalized AF patients who were followed-up for up to 8 years and, similar to the trials [7,8], found no difference in mortality between the rhythm- and rate-control drug treatment strategies in the first 3 - years post-treatment initiation. However, our long-term results differed from those of the clinical trials [7,8]; while the AFFIRM trial found no mortality difference at 5 years between the rhythm- and rate-control strategies [7], we found a significant 12% mortality reduction in the rhythm-control group found after 5 years of follow-up and a significant 23% reduc tion after 8 years. In the face of contradictory results between observational studies and RCTs trials, the observational design is oftentimes dismissed as being flawed due to poor control of confounding. We argue here, as others have done before us [11,12], that RCTs and observational studies are complementary designs and that much can be learned by examining results from different study designs and analyses [13,14]. Bias, due to unobserved confounding, is the Achilles’ heel of observational studies of drug effects [15–20], with lack of randomization being a particular concern in studies

Potential net clinical benefit of population-wide implementation of apixaban and dabigatran among European patients with atrial fibrillation

Vitamin K antagonists (e.g. warfarin) are commonly underutilised, due to limitations such as the need for monitoring, in high-risk atrial fibrillation (AF) patients. We therefore aimed to model the potential impact on clinical outcomes in patients with AF with the use of the novel oral anticoagulant (OAC) drugs, apixaban and dabigatran. We identified all high-risk (CHA₂DS₂-VASc score ≥2 ) patients with non-valvular AF and known one-year follow-up from the EuroHeart Survey on AF (EHS-AF). We modelled the expected numbers of clinical events on the novel OACs using published hazard ratios from their respective phase 3 clinical trials and calculated the numbers needed to treat and the mathematical net clinical benefit. Our analysis included 3,400 patients [39% females; mean (SD) age 67 (12) years; CHA₂DS₂-VASc score 3.0 (1.8)] of which 330 were excluded from the modelling analysis due to concomitant use of OAC and antiplatelet drugs. During one-year follow-up, 108 (3.2%) patients experienced thromboembolism, 51 (1.5%) major bleeds and 146 (4.3%) died. Compared to current treatments (i.e. warfarin, aspirin or nothing) the use of apixaban in high-risk patients would have potentially prevented an additional 17 deaths, 27 strokes and eight major bleeds within this cohort. With use of dabigatran 150 mg BID, 34 strokes could have been prevented and for dabigatran 110 mg BID, 16 strokes and six major bleeds would be avoided. Extrapolation of the data from the EHS-AF to the whole of Europe would translate into the prevention of an additional 64,573 major cardiovascular events and deaths each year among patients with a CHA₂DS₂-VASc ≥2 , by the use of apixaban, 43,235 with the use of dabigatran 150 mg bid and 27,272 with the use of dabigatran 110 mg bid. In conclusion, based on this modelling exercise, the utilisation of apixaban and dabigatran for thromboprophylaxis could provide a profound annual mathematical net clinical benefit on stroke and major bleeds, in European AF patients.

The EASE trial: surgery for infective endocarditis, have we found the right timing?

Despite recent advances in diagnosis and treatment, infective endocarditis (IE) is still a hazardous condition with high in-hospital mortality, reaching 12.6% (1) in the Euro Heart Survey programme. Surgical treatment is a potentially lifesaving treatment and is required in nearly 50% of patients (2). Indications for surgery are well defined in guidelines (3,4) but there is a lack of recommendations about the time when it must be done and, in general terms, prognosis is better if surgery is undertaken in the acute or active phase of IE, before cardiac tissue destruction takes place.

Characteristics, management and prognosis of elderly patients in the Euro Heart Survey on atrial fibrillation

Characteristics, management and prognosis of elderly patients in the Euro Heart Survey on atrial fibrillation