High-risk Acute Coronary Syndrome Research Articles

Acute Coronary Syndrome After Aneurysmal Subarachnoid Hemorrhage: Incidence, Risk Factors and Impact on the Outcome

Background and Objectives: Development of acute coronary syndrome (ACS) after aneurysmal subarachnoid hemorrhage (aSAH) strongly affects further neuro-intensive care management. We aimed to analyze the incidence, risk factors and clinical impact of ACS in aSAH patients. Materials and Methods: This retrospective analysis included 855 aSAH cases treated between 01/2003 and 06/2016. The occurrence of ACS during 3 weeks of aSAH was documented. Patients’ demographic, clinical, radiographic and laboratory characteristics at admission were collected as potential ACS predictors. The association between ACS and the aSAH outcome was analyzed as the occurrence of cerebral infarcts in the computed tomography scans and unfavorable outcome (modified Rankin scale > 3) at 6 months after aSAH. Univariable and multivariable analyses were performed. Results: ACS was documented in 28 cases (3.3%) in the final cohort (mean age: 54.9 years; 67.8% females). In the multivariable analysis, there was a significant association between ACS, an unfavorable outcome (adjusted odds ratio [aOR] = 3.43, p = 0.027) and a borderline significance with cerebral infarcts (aOR = 2.5, p = 0.066). The final prediction model for ACS occurrence included five independent predictors (age > 55 years [1 point], serum sodium < 142 mmol/L [3 points], blood sugar ≥ 170 mg/dL [2 points], serum creatine kinase ≥ 255 U/L [3 points] and gamma-glutamyl transferase ≥ 36 U/L [1 point]) and showed high diagnostic accuracy for ACS prediction (AUC = 0.879). Depending on the cumulative score value, the risk of ACS in the cohort varied between 0% (0 points) and 66.7% (10 points). Conclusions: ACS is a rare, but clinically very relevant, complication of aSAH. The development of ACS can reliably be predicted by the presented prediction model, which enables the early identification of aSAH individuals at high risk for ACS. External validation of the prediction model is mandatory.

Abstract 4148074: Radial Artery Pseudoaneurysm Following Transradial Cardiac Catheterization: A Systematic Review and Case Report

Introduction/Background: Transradial cardiac catheterization (TRC) is recommended for patients with acute coronary syndrome over femoral artery catheterization. Randomized controlled trials show TRC has significantly lower rates of bleeding, vascular complications, and mortality in high-risk acute coronary syndrome patients. However, vascular complications like radial artery spasm, occlusion, arteriovenous fistula, perforation, and pseudoaneurysm (PSA) can still occur. Despite TRC's widespread adoption, recent data summarizing radial artery pseudoaneurysm post-TRC is lacking. Research Question/Hypothesis This review aims to identify at-risk patients, present a case of catheterization-related radial artery pseudoaneurysm, and provide diagnostic and management insights. We hypothesize that older patients with hypertension are at higher risk and that early detection and management are associated with low complication rates. Methods/Approach: Systematic searches were conducted in PubMed, Web of Science, EMBASE, and CINAHL databases. Two researchers independently selected articles, extracted data, and evaluated study quality on RA PSA post-TRC (2003–2023). A third reviewer resolved conflicts. The Joanna Briggs Institute (JBI) tool was used to evaluate bias risk. Additionally, a case report is presented. Results: From 3,262 records, 43 studies were selected, involving 67 patients (58.8% female, median age 73.5 years). Hypertension (39.5%) and atrial fibrillation (27.9%) were the most common comorbidities. Percutaneous interventions like stenting and angioplasty caused 58.1% of cases; diagnostic catheterizations accounted for 37.2%. Ultrasonography diagnosed 83.7% of cases. Symptoms appeared a few hours to four months post-TRC, with pulsatile mass (21.4%) and swelling (14.3%) being the most common, and pain and ecchymosis at 2.4% each. More than half of the patients (51.2%) required surgical intervention, but 66.7% recovered without deficits. Severe complications were rare, affecting fewer than 5%. Conclusions: A literature review of 43 articles with 67 patients suggests older female patients with hypertension may be more prone to radial artery pseudoaneurysm post-TRC. It typically presents as a pulsatile, painful swelling detectable by ultrasound. This complication precludes the use of the radial artery as a conduit for coronary artery bypass grafting. The review highlights the importance of vigilant post-catheterization monitoring to enable early detection and treatment.

Right bundle branch block in suspected acute coronary syndromes: Diagnostic challenges, treatment and prognosis

BackgroundThere is still conflicting evidence regarding the prognostic implications of right bundle branch block (RBBB) in the general population but also in patients with heart diseases like acute coronary syndromes (ACS). In accordance with current guidelines, RBBB in ACS patients is considered as STEMI equivalent. However, recent studies indicate that further differentiation is necessary in this group, as we will outline below. Methods and resultsA literature search was conducted in PubMed and Google Scholar.In previous studies, RBBB in the general population were mostly considered benign changes of the electrical conduction system. However, recent studies indicate that both complete and incomplete RBBB are associated with increased cardiovascular morbidity and mortality. In addition, among unselected patients with suspected ACS presenting to the emergency department, the prevalence of RBBB was 3 % and it was associated with elevated mortality. The subsequent angiographic identification of a culprit coronary artery stenosis leading to stent implantation was similar at approximately 2 % regardless of the initial ECG presentation with narrow QRS complexes, left bundle branch block (LBBB), or RBBB.Finally, in a group of high-risk patients for ST-elevation myocardial infarction (STEMI), the prevalence of RBBB was 12 %. While RBBB was associated with poor outcome compared to non-BBB and LBBB patients, diagnostic accuracy of STEMI criteria was not affected by the presence of RBBB. However, RBBB patients without distinct STEMI signs in ECG often showed acute STEMI on angiography indicating a potential benefit from immediate transfer to the cardiac catheterization laboratory. ConclusionIn the general population, patients with RBBB and risk factors may need further evaluation. Regarding ACS patients, recent studies support current guidelines that recommend acute invasive evaluation for high-risk ACS patients with RBBB, regardless of ST-T deviations. However, in an unselected group of ACS patients, differential diagnoses should also be investigated through additional diagnostic procedures.

Assessing the need for coronary angiography in high-risk acute coronary syndrome patients using artificial intelligence and computed tomography

Abstract Background/Introduction The use of coronary computed tomography angiography (CCTA) in managing high-risk acute coronary syndrome (ACS) patients is increasingly common. Yet, its role remains unvalidated in this context, posing challenges to traditional clinical decision-making algorithms. Physicians, accustomed to a hierarchical and structured approach involving symptom assessment, electrocardiograms, and biomarkers for deciding on the necessity of invasive coronary angiography (ICA), now face dilemmas when CCTA results challenge established diagnostic pathways and contradict clinical decisions based on usual criteria. Meanwhile, the potential of artificial intelligence (AI) which processes information in a way fundamentally different from human clinical reasoning, has been shown to aid decision-making in cardiovascular medicine. Yet, it has not been tested in this acute setting. Purpose This study aimed to evaluate the efficacy of the Chat Generative Pre-trained Transformer (ChatGPT) in guiding the need for ICA in high-risk ACS patients based on both standard clinical data and CCTA findings. Methods This investigation is a sub-study of a larger research project where high-risk ACS patients (all having a theoretical guideline-based indication for ICA) underwent CCTA prior to ICA. ChatGPT analyzed clinical vignettes containing patient data, electrocardiograms, troponin levels, and CCTA results to determine the necessity of ICA. The AI's recommendations were then compared to actual ICA findings to assess its decision-making accuracy. Results Among 86 patients with a clear indication for ICA, ChatGPT recommended against it for 19 patients, 16 of whom indeed had no significant findings at ICA (Figure). For 67 patients, ChatGPT advised proceeding with ICA, and a significant lesion was confirmed in 58 of them. Consequently, ChatGPT's overall accuracy stood at 86%, with a sensitivity of 95% and a specificity of 64%. The model's negative predictive value was 84%, and its positive predictive value was 87%. Conclusion These preliminary data suggest that ChatGPT can effectively assist in guiding the need for ICA among high-risk ACS patients, potentially reducing unnecessary procedures but further clinical studies to refine AI's role in clinical decision-making are required.ChatGPT's decision as per ICA's results

The sooner the better? What is the optimal timing for coronary angiography in high-risk non-ST-elevation acute coronary syndrome

Abstract Introduction current guidelines recommend an early invasive coronary angiography (ICA), in the first 24 hours, for high-risk non-ST elevation acute coronary syndrome (NSTE-ACS) patients. However, several studies have failed to demonstrate a significant improvement in all-cause mortality, with controversial results regarding recurrent ischemia and myocardial infarction. Purpose to evaluate the optimal timing of ICA in high-risk NSTE-ACS. Methods this was a national multicentre retrospective study of patients hospitalized for NSTE-ACS between October 2010 and October 2023. Patients presenting in Killip class IV, mechanical complications, life-threatening arrhythmias or cardiac arrest were excluded. Participants were divided into three groups, according to the timing of ICA: in the first 24 hours (D0), between 24 and 48 hours (D1) and between 48 and 72 hours (D2). The incidence of in-hospital complications and mortality, as well as 1-year mortality rate and cardiovascular rehospitalization, was compared for the three groups. Results a total of 9949 patients was included, 98.2% with non-ST elevation myocardial infarction (NSTEMI) and 1.8% with unstable angina with high-risk criteria (GRACE risk score >140 or transient ST-segment elevation). Most patients were submitted to early ICA (46.7%), with 26.7% and 26.6% in D1 and D2, respectively. Interestingly, patients in higher Killip class (II or III) were referred for ICA latter than patients in Killip class I (9.0% in D0 vs. 11.3% in D1 vs. 13.5% in D2, p<0.001). Regarding in-hospital complications, early ICA was associated with a lower incidence of acute heart failure (8.5% vs. 11.1% vs. 11.5%, p<0.001) and shorter length of stay (7 vs. 6 vs. 10 days, p=0.01). However, it did not reduce in-hospital mortality (1.2% vs. 0.7% vs. 0.8%, p=0.07), recurrent myocardial infarction (0.9% vs. 1.5% vs. 1.3%, p=0.09), cardiogenic shock (7.9% vs. 5.7% vs. 5.4%, p=0.19), mechanical complications (0.1% vs. 0.2% vs. 0.1%, p=0.50) or sustained ventricular tachycardia (0.8% vs. 0.6% vs. 0.4%, p=0.12). Left ventricular ejection fraction was also similar between groups (54%±12, p=0.97). There were also no significant differences between groups regarding 1-year mortality or cardiovascular rehospitalization (15.1% vs. 15.9% vs. 15.7%, p=0.89). Conclusion in high-risk NSTE-ACS patients, early ICA resulted in lower incidence of acute heart failure and shorter length of stay. However, timing of ICA didn’t show a significant impact on in-hospital mortality or complications, nor in 1-year mortality rate or cardiovascular rehospitalization.

Development of an Initial Screening Scale to Detect Patients With Chest Pain From Acute Coronary Syndrome in the Emergency Department.

Identifying patients with chest pain potentially due to acute coronary syndrome (ACS) early is crucial for triage nurses. They need a reliable, validated screening tool. This study aims to develop an initial screening scale to detect ACS in patients presenting with chest pain in the emergency department. We analyzed electronic medical records of 3131 chest pain patients from 103,041 emergency department visits between January 2018 and December 2019. ACS diagnosis was confirmed by cardiologists through clinical symptoms, electrocardiograms, and cardiac enzyme levels. The study proceeded in four stages: (1) identifying potential ACS predictors through a literature review, (2) validating these predictors with experts, (3) comparing data between ACS and non-ACS patients and (4) developing a screening scale based on identified predictors. Statistical methods included univariate analysis and binary logistic regression. The scale's accuracy was assessed using ROC curve analysis and compared to existing tools. Eight significant ACS predictors were identified: male sex, age over 49 for males and over 65 for females, typical symptoms, initial pain scale score of 6 or higher, pain duration of at least 10 min, history of ACS, hypertension, and dyslipidemia. Each predictor was scored, with typical symptoms and severe pain receiving higher scores, totaling up to 10 points. A score of 6 or more indicated high ACS risk, demonstrating accuracy comparable to the HEART and TIMI score systems. This study developed a new ACS screening scale for use by triage nurses in emergency departments. This scale can facilitate early detection and intervention for patients at high risk of ACS.

TCT-180 Unraveling the Outcomes of AngelMed Guardian Device in High-Risk Acute Coronary Syndrome Patients: A Case Series

TCT-180 Unraveling the Outcomes of AngelMed Guardian Device in High-Risk Acute Coronary Syndrome Patients: A Case Series

Correlations Between Acute Coronary Syndrome and Novel Inflammatory Markers (Systemic Immune-Inflammation Index, Systemic Inflammation Response Index, and Aggregate Index of Systemic Inflammation) in Patients with and without Diabetes or Prediabetes.

Type 2 diabetes mellitus (DM) is a recognized independent risk factor for both chronic coronary syndrome (CCS) and its complication, acute coronary syndrome (ACS). Patients with DM and prediabetes (preDM) face an increased ACS risk. Inflammation plays a significant role in the pathogenesis of both CCS and ACS. This study delves into novel inflammatory markers, such as the systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and aggregate index of systemic inflammation (AISI, also known as SIIRI or PIV), to explore their relationship with ACS and CCS in patients that have been or have not been diagnosed with DM or preDM. This study included data of 493 patients with chest pain undergoing coronary angiography. They were categorized into four groups: 1) without DM/preDM and with CCS; 2) with both DM/preDM and CCS; 3) without DM/preDM and with ACS, 4) with both DM/preDM and ACS. Standard methods of statistical analysis were used to reveal possible differences between groups and to find the most influential ACS risk factors in groups with DM/preDM and without DM/preDM. The analysis showed no significant differences in SII, SIRI, or AISI between the respective patient groups. A logistic regression analysis generated a model incorporating SII, high-density lipoprotein, and low-density lipoprotein levels as the influential ACS risk factors for patients with DM/preDM. The model demonstrated 71.0% accuracy, 37.0% sensitivity, and 89.4% specificity. The findings suggest that the aforementioned inflammatory markers may have potential for distinguishing DM/preDM patients at higher risk of ACS at a low financial cost. However, further comprehensive and well-designed research is required to validate their clinical utility.

Abstract P514: Association Between Glycemic Disorder and Acute Coronary Syndrome Among Patients With Stable Coronary Artery Disease: A Propensity Score Matching Analysis

Background: Type 2 diabetes mellitus is known as a major risk factor of acute coronary syndrome (ACS) as previous studies reported. However, the association between prediabetes and ACS is not fully investigated among patients with stable coronary artery disease (CAD). Furthermore, no study has examined whether there’s effect modification by sex, age and BMI in the association between glycemic disorder and ACS. Our study aimed to evaluate the role of glycemic disorder in ACS occurrence among patients CAD. Methods: In this cross-sectional study based on electronic medical records (EMR), participants with CAD after elective coronary artery angiography (CAG) during 2016-2020 were enrolled. Diagnosis of prediabetes was based on patients’ HbA1c level ranging from 5.7% to 6.4% or fasting plasma glucose (FPG) level between 5.6 - 6.9 mmol/L. The diabetes diagnosis was defined as HbA1c ≥6.5% or fasting plasma glucose (FPG) ≥7.0 mmol/L. Multivariable logistic regression models were built to evaluate the association between prediabetes, diabetes and ACS, adjusting for age, body mass index (BMI), hypertension, low density lipoprotein, triglyceride level, statin and anti-platelet medication use. Subjects with prediabetes were matched 1:1 to healthy controls using propensity score matching to test the robustness of the result. In the subgroup analysis, we examined the heterogeneity of age, sex and BMI in the association between glycemic disorders and ACS. Results: Among 1525 participants, 1158 were male and 367 were female. Compared to participants with no diabetes, those with prediabetic were not significantly associated ACS, after adjusting for potential confounders. The result persisted after 1:1 propensity score matching. There was effect modification by sex in the association between glycemic disorders and ACS (P glycemic disorder*sex = 0.012). Female participants with diabetes, compared to those without diabetes, were positively associated with ACS (OR 2.00, 95% CI 1.00 - 3.98). The association between glycemic disorders and ACS remained stable among those with severe coronary stenosis. Conclusions: Our finding suggested that the association between prediabetes and ACS did not differ from those with normal glycemic status and CAD. The association remained consistent among those with severe coronary stenosis. Besides, sex modifies the association, and female participants with diabetes should be paid attention to their higher risk of ACS.

A 2024 scientific update on the clinical performance of drug-coated balloons.

Continuous advances in the field of interventional cardiology have led to the development of drug-coated balloons (DCB). These represent a promising device for overcoming the well-known limitations of traditional metallic stents, which are associated with a persistent yearly increased risk of adverse events. This technology has the ability to homogeneously transfer the drug into the vessel wall in the absence of a permanent prosthesis implanted in the coronary vessel. Robust data support the use of DCB for the treatment of in-stent restenosis, but there is also currently growing evidence from long-term follow-up of large randomised clinical trials regarding the use of these devices in other scenarios, such as de novo small and large vessel disease, complex bifurcations, and diffuse coronary disease. Other critical clinical settings such as diabetes mellitus, high bleeding risk patients and acute coronary syndromes could be approached in the upcoming future by using DCB, alone or as part of a blended strategy in combination with drug-eluting stents. There have been important scientific and technical advances in the DCB field in recent years. The purpose of this paper is to review the most current data regarding the use of DCB, including the mid- and long-term follow-up reports on the safety and efficacy of this novel strategy in different clinical and angiographic scenarios.

Albumin combined with neutrophil-to-lymphocyte ratio score and outcomes in patients with acute coronary syndrome treated with percutaneous coronary intervention.

Evidence about the association between albumin combined with neutrophil-to-lymphocyte ratio score (ANS) and survival outcomes in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) is rare. This study aimed to evaluate the prognostic value of ANS in patients with ACS undergoing PCI by propensity score matching (PSM) analysis. Patients with ACS undergoing PCI were consecutively enrolled in this prospective cohort study from January 2016 to December 2018. The albumin and neutrophil-to-lymphocyte ratio cutoff values for predicting major adverse cardiovascular events (MACEs) were calculated using receiver operating characteristic curves. Survival analysis was performed using Kaplan-Meier estimates, the Cox proportional hazard regression models and PSM. The study endpoint was the occurrence of a MACE, which included all-cause mortality and rehospitalization for severe heart failure during follow-up. Overall, 1549 patients with adequate specimens were identified and assigned into different groups for comparison. Before and after PSM, the Kaplan-Meier curves showed that a higher ANS value was associated with a higher risk of MACEs (all P < 0.001). The multivariate Cox proportional hazard regression model showed that the ANS (per 1 score increase) [hazard ratio (HR), 2.016; 95% confidence interval (CI), 1.329-3.057; P = 0.001 vs. HR, 2.166; 95% CI, 1.344-3.492; P = 0.002] was an independent predictor for MACEs. This study tentatively confirms that ANS may be a valuable clinical indicator to identify high-risk ACS patients after PCI. More high-quality prospective studies are needed in the future.

A novel case of yamaguchi syndrome in the Saudi population

Background: Apical hypertrophic cardiomyopathy (ApHCM) known as Yamaguchi syndrome, is an uncommon variant of hypertrophic cardiomyopathy, with higher incidence reported in the Asian populations. The clinical presentation of ApHCM is vague thus can mimic other conditions, which can lead to a delayed or a missed diagnosis. Only a few reports have described the incidence of Yamaguchi syndrome in other populations other than Asians. Case Presentation: A 46-year-old male, heavy smoker, with unremarkable past medical history was presented to the emergency department with severe central chest pain that radiates to the left side, exacerbated by excretion, and relived by rest not associated with shortness of breath or palpitation. Additionally, the patient reported two similar episodes that occurred the past 4 days. However, physical examination was unremarkable. Initially the patient was labeled as high-risk acute coronary syndrome (unstable angina vs non-ST segment myocardial infarction). Cardiac markers including troponin I and Creatine kinase-MB were within normal range. ECG revealed deep T wave inversion in the inferior limb leads and pericardial leads suggestive of right coronary and left anterior descending artery or left main coronary lesion. The patient underwent for urgent cardiac catheterization which revealed normal coronary arteries. Transthoracic echocardiograph (TTE) showed isolated apical hypertrophy with preserved LV function, suggestive of ApHCM. The patient was advised on smoking cessation and discharged on beta blocker. Conclusion: There is an imminent need to establish further research investigating the prevalence of Yamaguchi syndrome among the Saudi population.

Head-to-head comparison of two angiography-derived fractional flow reserve techniques in patients with high-risk acute coronary syndrome: A multicenter prospective study

BackgroundFFRangio and QFR are angiography-based technologies that have been validated in patients with stable coronary artery disease. No head-to-head comparison to invasive fractional flow reserve (FFR) has been reported to date in patients with acute coronary syndromes (ACS). MethodsThis study is a subset of a larger prospective multicenter, single-arm study that involved patients diagnosed with high-risk ACS in whom 30–70% stenosis was evaluated by FFR. FFRangio and QFR – both calculated offline by 2 different and blinded operators – were calculated and compared to FFR. The two co-primary endpoints were the comparison of the Pearson correlation coefficient between FFRangio and QFR with FFR and the comparison of their inter-observer variability. ResultsAmong 134 high-risk ACS screened patients, 59 patients with 84 vessels underwent FFR measurements and were included in this study. The mean FFR value was 0.82 ± 0.40 with 32 (38%) being ≤0.80. The mean FFRangio was 0.82 ± 0.20 and the mean QFR was 0.82 ± 0.30, with 27 (32%) and 25 (29%) being ≤0.80, respectively. The Pearson correlation coefficient was significantly better for FFRangio compared to QFR, with R values of 0.76 and 0.61, respectively (p = 0.01). The inter-observer agreement was also significantly better for FFRangio compared to QFR (0.86 vs 0.79, p < 0.05). FFRangio had 91% sensitivity, 100% specificity, and 96.8% accuracy, while QFR exhibited 86.4% sensitivity, 98.4% specificity, and 93.7% accuracy. ConclusionIn patients with high-risk ACS, FFRangio and QFR demonstrated excellent diagnostic performance. FFRangio seems to have better correlation to invasive FFR compared to QFR but further larger validation studies are required.

Hematological biomarkers of troponin, neutrophil-to-lymphocyte ratio, and monocyte-to-lymphocyte ratio serve as effective predictive indicators of high-risk mortality in acute coronary syndrome.

Assessing high-risk mortality in acute coronary syndrome (ACS) patients, encompassing ST-Elevation Myocardial Infarction (STEMI), Non-ST-Elevation Myocardial Infarction (NSTEMI), and Unstable Angina Pectoris (UAP), is crucial. However, the prognostic significance of hematological parameters in predicting high-risk mortality in ACS patients remains uncertain despite advancements in ACS research. The aim was to investigate prognostic significance of hematological parameters troponin, Creatine Kinase-MB (CKMB), Neutrophil-to-Lymphocyte Ratio (NLR), Platelet-to-Lymphocyte Ratio (PLR), Monocyte-to-Lymphocyte Ratio (MLR), Basophil-to-Lymphocyte Ratio (BLR), and Eosinophil-to-Lymphocyte Ratio (ELR) levels in predicting high-risk mortality in ACS patients. In this retrospective observational study, data from medical records of 115 patients with ACS, including 40 with STEMI, 38 with NSTEMI, and 37 with UAP, were analyzed. Patients were selected using stratified random sampling, whereby five patients were randomly chosen each month from January 2021 to December 2022 while maintaining a 1:1:1 ratio of selection. Troponin (r = 0.519) and NLR (r = 0.484) showed moderate positive correlations with high-risk STEMI mortality. Meanwhile, troponin (r = 0.387), NLR (r = 0.279), PLR (r = 0.276), MLR (r = 0.250), BLR (r = 0.237), and ELR (r = -0.344) were found to be significantly correlated with high-risk ACS mortality. Troponin, CKMB, NLR, and MLR were significant (AUC>0.7) for high-risk STEMI mortality, and Troponin, NLR, and MLR were significant for high-risk ACS mortality. The results of the multivariate regression analysis indicated that only Troponin (OR:2.049; 95%CI: 1.802-8.218; p = 0.014), NLR (OR:1.652; 95%CI: 1.306-7.753; p = 0.030), and MLR (OR:4.067; 95%CI: 1.182-13.987; p = 0.026) were capable of predicting high-risk ACS mortality. Sub-group analysis showed an increased risk of ACS mortality by GRACE score >140 in patients with elevated levels of Troponin (OR:2.787; 95%CI: 1.032-7.524; p < 0.05), NLR (OR:3.287; 95%CI: 1.340-8.059; p < 0.05), and MLR (OR:4.156; 95%CI: 1.634-10.569; p < 0.05) above the cut-off value. Troponin, NLR, and MLR levels above the cutoff independently predict high-risk mortality in ACS.

Time to coronary catheterization in patients with NST-ACS and high GRACE score

Abstract Introduction Current European guidelines recommend early (&amp;lt;24 hours) invasive coronary angiography (ICA) strategy in certain high-risk non-ST segment elevation acute coronary syndrome (NSTE-ACS) patients, including those with GRACE score over 140. The evidence for this recommendation is based on older trials using pre high-sensitive troponin (HsTn) biomarkers and non-contemporary therapy. Purpose To assess the association between GRACE score over 140, timing of ICA and their interaction on clinical outcomes in patients with ACS with no ST elevation, using (HsTn) as part of the calculated GRACE risk score. Methods and results Between February 1st 2016 and July 31th 2021, 1767 patients with a primary diagnosis of NSTE-ACS without indication for urgent ICA, underwent ICA during index hospitalization. 655 (37%) patients underwent early-invasive ICA (within 24 hours) and 1112 (63%) underwent late ICA (between 24 hours and 1 week). 107 patients had a GRACE risk score of 140 or above and 1660 had a GRACE risk score under 140. The primary composite outcome was all-cause mortality, stroke, and recurrent MI. The median time from admission to ICA was 13.3 hours (IQR 6.0,20.6) for the early group and 59.9 hours for the late group (IQR 23.5,96.3). The vast majority of patients had re-vascularization (75.1%) performed, mostly by PCI (69.4%). There was no difference between the early and late ICA groups in the primary composite outcome (late Catheterization &amp;gt;24h HR 1.196, 95% CI 0.969-1.475, P-value 0.096). Using a multivariable cox regression model for the composite outcome revealed no difference between the early and late ICA groups (late Catheterization &amp;gt;24h HR 1.0735, 95% CI 0.862-1.327, P-value 0.512) with no effect for performing early ICA in patients with GRACE score over 140 (HR 1.291 95% CI 0.910-1.831, p-0.151). Conclusion Early ICA strategy in patients with NSTE-ACS patients and GRACE risk score over 140, compared with late ICA, was not associated with improved composite outcome of death, myocardial infarction, and stroke at 1 year.

Almost 1 in 2 patients with acute coronary syndrome are extremely high-risk and potential candidates for in-hospital triple lipid-lowering therapy: data from the CALLINICUS-Hellas Registry

Abstract Introduction The great heterogeneity of acute coronary syndrome (ACS) patients in the risk for cardiovascular events recurrence, prompted a recent position paper endorsed by the International Lipid Expert Panel to propose criteria, i.e. coexistence of multivessel coronary artery disease (CAD), polyvascular disease, heterozygous familial hypercholesterolemia (heFH), diabetes mellitus (DM) with estimated glomerular filtration rate (eGFR) &amp;lt;60 ml/min/1.73 m2 and/or lipoprotein (a) [Lp(a)] &amp;gt;50 mg/dL etc., which define the extremely high-risk ACS patients for whom an low-density lipoprotein cholesterol (LDL-C) &amp;lt;40 mg/dL was proposed. Purpose To estimate the proportion of patients with ACS that fulfill the criteria of the extremely high-risk group and are potential candidates for "extremely" intensive early lipid-lowering therapy (LLT) aiming at an LDL-C &amp;lt;40 mg/dL. Methods We recruited 780 consecutive patients with ACS who were participants of the CALLINICUS-Hellas Registry which is a prospective multicenter observational study that explores the adherence to LLT, the achievement of LDL-C targets and the cardiovascular events at 6- and 24-months after hospital discharge of patients with ACS. Results The prevalence of high risk components was: heFH 13.5%, multivessel CAD 44%, polyvascular disease 3.2%,and DM with eGFR &amp;lt;60 ml/min/1.73 m2 and/or Lp(a) &amp;gt;50 mg/dL 8.1%. By excluding the overlapping between these conditions, 430 ACS patients (55.1%) had at least one of the characteristics which define the extremely high-risk patients (Figure). Presuming a 65% LDL-C reduction of the levels (the pretreatment if on LLT prior admission or the admission if not on prior LLT) of the extremely high-risk ACS patients by taking a maximum dual LLT (intense statin plus ezetimibe), 312 patients, i.e., 40% of all initially recruited patients would fail to achieve an LDL-C &amp;lt;40 mg/dL suggesting that they require additional LLT, namely, a proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i). Conclusions Almost 1 in 2 patients with ACS have extremely high-risk characteristics and are candidates for in-hospital triple LLT (statin plus ezetimibe plus PCSK9i) aiming at an LDL-C &amp;lt;40 mg/dL, a strategy shown to improve plaque stability and possibly to reduce the recurrence rate of early coronary events.Figure

Identification of Low- versus High-Risk Acute Coronary Syndrome for a Selective ECG Monitoring Strategy.

While admission of patients with acute coronary syndromes (ACS) in cardiology intensive care unit (CICU) is usual, in-hospital major outcomes in lower risk patients may be evaluated after early coronary angiography according to the European guidelines. Consecutive ACS patients were prospectively included after coronary angiography evaluation within 24 h and percutaneous coronary intervention (PCI), when required. Patients were classified as high- or low-risk according to hemodynamics, rhythmic state, ischemic and bleeding risks. Major in-hospital outcomes were assessed. From January to June 2021, 277 patients were enrolled (62.8% with ST-segment elevation myocardial infarction (STEMI) (n = 174); 37.2% with non-NSTEMI (NSTEMI) (n = 103). PCI was required for 260 patients (93.9%). Seventy-four patients (26.7%) were classified as low-risk (n = 47 NSTEMI; n= 27 STEMI) and 203 patients (73.3%) as high-risk of events. All patients were monitored in CICU. While 38 patients (18.7%) from the high-risk group reached the primary endpoint, mainly related to rhythmic or conduction disorder (n = 24, 11.8%) or unstable hemodynamics (n = 17; 8.4%), only 1 patient (1.3%) in the low-risk group had one major outcome (no fatal bleeding); p < 0.01. The negative predictive value of our patient stratification for the absence of major in-hospital outcome was 100% (CI95%: 100-100%) for STEMI and 97.9% [CI95%: 93.2-100%] for NSTEMI patients. Stratification of ACS patients after early coronary angiography and most of the time PCI, identify a population with very low risk of in-hospital events (1/4 of all ACS and 1/2 of NSTEMI) who may probably not require ECG monitoring and/or CICU admission. (NCT04378504).

The incidence and outcomes of high-risk acute coronary syndromes in Western Cape Province, South Africa: A prospective cohort study.

Tygerberg Hospital (TBH) is a tertiary-level hospital in Western Cape Province, South Africa, that provides healthcare to a large low- to middle-income population with services including centralised advanced cardiac care. Acute coronary syndrome (ACS) remains an important cause of death in the region despite a high burden of communicable diseases, including HIV. To describe the incidence of ST-elevation myocardial infarction (STEMI) and high-risk non-ST-elevation ACS (HR-NSTEACS) in the TBH referral network, describe the in-hospital and 30-day mortality of these patients, and identify important high-risk population characteristics. The Tygerberg Acute Coronary Syndrome Registry database is an ongoing prospective study that enrols all STEMI and HR-NSTEACS patients in the TBH referral network. All patients aged >18 years presenting with STEMI or HR-NSTEACS were treated in accordance with current European Society of Cardiology guidelines and were included prospectively over a 9-month surveillance period. A waiver of consent was granted to include patients who died before giving informed consent. Data collected included a demographic profile, risk factors for cardiovascular disease, in-hospital therapy and 30-day mortality. A total of 586 patients were enrolled, with a male predominance (64.5%) and incidence rates of STEMI and HR-NSTEACS of 14.7 per 100 000 and 15.6 per 100 000, respectively. The mean patient age was 58 years, and STEMI patients tended to be younger than HR-NSTEACS patients (56 v. 58 years; p=0.01). Cardiovascular risk factors were prevalent overall, but hypertension (79.8% v. 68.3%; p<0.01) and pre-existing IHD (29.1% v. 7.0%; p=0.03) were more prevalent in the HR-NSTEACS group. HIV was present in 12.6% of patients tested, similar to the background population rate. The overall 30-day all-cause mortality rate was 6.1%, with an in-hospital mortality rate of 3.9%. The 30-day mortality rates were similar for STEMI (1.8%) and HR-NSTEACS (2.6%) (p=0.75). HIV did not affect mortality rates. Use of a guideline-based approach to treating ACS in a low- to middle-income country setting yields mortality rates comparable to those in high-income countries. However, the lower-than-expected incidence rates of both STEMI and HR-NSTEACS in a relatively young population with a high prevalence of traditional cardiovascular risk factors, and a relatively high proportion of STEMI, suggest potential under-recording of ischaemic heart disease in the region. The rate and outcomes of coronary artery disease (CAD) in people living with HIV were similar to those in people without HIV, suggesting that traditional risk factors still drive CAD outcomes in the region.

Characteristics of Wellens' Syndrome in the Current PCI Era: A Single-Center Retrospective Study.

The goal of this retrospective study was to reveal the prevalence, angiographic characteristics, clinical presentation, and long-term outcomes of non-ST-segment elevation myocardial infarction (NSTEMI) patients with Wellens' syndrome. Procedural results for percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS) have improved in recent years. However, there is still a paucity of available clinical trial data for Wellens' syndrome even though it is a well-known high-risk ACS. Among a total of 3528 patients with ACS who underwent angioplasty from 2017 to 2019 at the Cardiovascular Center of Beijing Friendship Hospital, 476 NSTEMI patients with culprit left anterior descending (LAD) vessels were enrolled in this study. According to electrocardiographic criteria of Wellens' syndrome, the patients were divided into a Wellens group (n = 138) and a non-Wellens group (n = 338). The primary endpoint was cardiac death; the secondary endpoints were main adverse cardiovascular and cerebrovascular events (MACCEs), a composite of all-cause death, cardiac death, heart failure, target lesion revascularization, recurrent myocardial infarction, and stroke. All of the medical and follow-up data were obtained from our institutional database. The incidence of Wellens' syndrome in all ACS patients was 5.7% (200 of 3528). Among the 200 patients with Wellens' syndrome, 138 had NSTEMI, for a proportion of 69%. There was a significant decrease in the percentage of preexisting coronary heart disease (CHD), prior myocardial infarction, and previous PCI (P < 0.05) in the Wellens group compared with the non-Wellens group. On coronary angiography, single-vessel lesions were more common in the Wellens group (11.6% vs. 5.3%, P=0.016), and almost all (97.1%) of these patients received drug-eluting stents. Notably, the Wellens group had a higher proportion of early PCI than the non-Wellens group (71% vs. 61.2%, P=0.044). At 24 months, there was no statistically significant difference in cardiac death (P=0.111) between the two groups, but the MACCEs were comparable (Wellens: 5.1% vs. non-Wellens: 13.3%, P=0.009). Age ≥65 years was the largest independent risk factor for adverse prognosis. With early recognition and aggressive intervention, Wellens' syndrome is no longer a risk factor for adverse prognosis in patients with NSTEMI in the current PCI era.

Derivation and validation of pragmatic clinical models to predict hospital length of stay after cardiac surgery in Ontario, Canada: a population-based cohort study.

Cardiac surgery is resource intensive and often requires multidisciplinary involvement to facilitate discharge. To facilitate evidence-based resource planning, we derived and validated clinical models to predict postoperative hospital length of stay (LOS). We used linked, population-level databases with information on all Ontario residents and included patients aged 18 years or older who underwent coronary artery bypass grafting, valvular or thoracic aorta surgeries between October 2008 and September 2019. The primary outcome was hospital LOS. The models were derived by using patients who had surgery before Sept. 30, 2016, and validated after that date. To address the rightward skew in LOS data and to identify top-tier resource users, we used logistic regression to derive a model to predict the likelihood of LOS being more than the 98th percentile (> 30 d), and γ regression in the remainder to predict continuous LOS in days. We used backward stepwise variable selection for both models. Among 105 193 patients, 2422 (2.3%) had an LOS of more than 30 days. Factors predicting prolonged LOS included age, female sex, procedure type and urgency, comorbidities including frailty, high-risk acute coronary syndrome, heart failure, reduced left ventricular ejection fraction and psychiatric and pulmonary circulatory disease. The C statistic was 0.92 for the prolonged LOS model and the mean absolute error was 2.4 days for the continuous LOS model. We derived and validated clinical models to identify top-tier resource users and predict continuous LOS with excellent accuracy. Our models could be used to benchmark clinical performance based on expected LOS, rationally allocate resources and support patient-centred operative decision-making.