High-risk non-ST-elevation Acute Coronary Syndrome Research Articles

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.

Prognostic benefit from an early invasive strategy in patients with non ST elevation acute coronary syndrome (NSTEACS): evaluation of the new risk stratification in the NSTEACS European guidelines

Abstract Objectives The objective of our work is to evaluate the prognostic benefit of an early invasive strategy in patients with high-risk NSTACS according to the recommendations of the 2020 clinical practice guidelines during long-term follow-up. Methods This retrospective observational study included 6454 consecutive NSTEACS patients. We analyze the effects of early coronary angiography (&amp;lt;24 h) in patients with: (a) GRACE risk score &amp;gt;140 and (b) patients with “established NSTEMI” (non ST-segment elevation myocardial infarction defined by an increase in troponins) or dynamic ST-T-segment changes with a GRACE risk score &amp;lt;140. Results From 2003 to 2017, 6454 patients with “new high-risk NSTEACS” were admitted, and 6031 (93.45%) of these underwent coronary angiography. After inverse probability of treatment weighting, the long-term cumulative probability of being free of all-cause mortality, cardiovascular mortality and MACE differed significantly due to an early coronary interven- tion in patients with NSTEACS and GRACE &amp;gt;140 [HR 0.62 (IC 95% 0.57–0.67), HR 0.62 (IC 95% 0.56–0.68), HR 0.57 (IC 95% 0.53–0.61), respectively]. In patients with NSTEACS and GRACE &amp;lt;140 with established NSTEMI or ST/T-segment changes, the benefit of the early invasive strategy is only observed in the reduction of MACE [HR 0.62 (IC 95% 0.56–0.68)], but not for total mortality [HR 0.96 (IC 95% 0.78–1.2)] and cardiovascular mortality [HR 0.96 (IC 95% 0.75–1.24)]. Conclusions An early invasive management is associated with reduced all-cause mortality, cardiovascular mortality and MACE in NSTEACS with high GRACE risk score. However, this benefit is less evident in the subgroup of patients with a GRACE score &amp;lt;140 with established NSTEMI or ST/T-segment changes. Funding Acknowledgement Type of funding sources: None.

Prognostic benefit from an early invasive strategy in patients with non-ST elevation acute coronary syndrome (NSTEACS): evaluation of the new risk stratification in the NSTEACS European guidelines.

The objective of our work is to evaluate the prognostic benefit of an early invasive strategy in patients with high-risk NSTACS according to the recommendations of the 2020 clinical practice guidelines during long-term follow-up. This retrospective observational study included 6454 consecutive NSTEACS patients. We analyze the effects of early coronary angiography (< 24h) in patients with: (a) GRACE risk score > 140 and (b) patients with "established NSTEMI" (non ST-segment elevation myocardial infarction defined by an increase in troponins) or dynamic ST-T-segment changes with a GRACE risk score < 140. From 2003 to 2017, 6454 patients with "new high-risk NSTEACS" were admitted, and 6031 (93.45%) of these underwent coronary angiography. After inverse probability of treatment weighting, the long-term cumulative probability of being free of all-cause mortality, cardiovascular mortality and MACE differed significantly due to an early coronary intervention in patients with NSTEACS and GRACE > 140 [HR 0.62 (IC 95% 0.57-0.67), HR 0.62 (IC 95% 0.56-0.68), HR 0.57 (IC 95% 0.53-0.61), respectively]. In patients with NSTEACS and GRACE < 140 with established NSTEMI or ST/T-segment changes, the benefit of the early invasive strategy is only observed in the reduction of MACE [HR 0.62 (IC 95% 0.56-0.68)], but not for total mortality [HR 0.96 (IC 95% 0.78-1.2)] and cardiovascular mortality [HR 0.96 (IC 95% 0.75-1.24)]. An early invasive management is associated with reduced all-cause mortality, cardiovascular mortality and MACE in NSTEACS with high GRACE risk score. However, this benefit is less evident in the subgroup of patients with a GRACE score < 140 with established NSTEMI or ST/T-segment changes.

Pre-hospital risk stratification using a modified thrombolysis in myocardial infarction score: a retrospective medical record review

Introduction: Paramedics commonly convey patients with non-ST elevation acute coronary syndrome (NSTEACS) to emergency departments (EDs) where a risk stratification model (RSM) determines the risk of death or adverse cardiovascular events, and thus whether the patient should be transferred to a specialist heart attack centre (HAC) for an invasive procedure. If paramedics were to risk-stratify the patients in the pre-hospital environment using a modified thrombolysis in myocardial infarction (MTIMI) RSM, this could result in primary triage to an appropriate hospital. Methods: A retrospective medical record review was completed using patients from a metropolitan ambulance service, one ED and one HAC comparing the current method of identifying high risk NSTEACS with a new method; the MTIMI RSM. Positive predictive value, negative predictive value, logistic regression and receiver operating statistic area under the curve (c-statistic) were used to compare methods. Results: Notes of 108 patients were used in this study. Current practice produced a c-statistic (c) of 0.73 (95% CI 0.62 to 0.85) and the MTIMI RSM (c=0.72, CI 0.61 to 0.83). The best RSM overall was the abbreviated MTIMI RSM with only three variables identified through logistic regression (c=0.79, 0.68 to 0.89). Conclusions: Both methods of identifying high-risk NSTEACS were similar as they both used the ECG variable, which was approximately twelve times more prognostic than any other variable. The need to identify a pre-hospital RSM with a good prognostic power still exists; therefore, other RSMs should be explored in a prospective study.

Timing of intervention in high-risk non-ST-elevation acute coronary syndromes in PCI versus non-PCI centres : Sub-group analysis of the ELISA-3 trial.

AimsTo compare the effect of timing of intervention in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) in percutaneous coronary intervention (PCI) versus non-PCI centres.Methods and resultsA post-hoc sub-analysis was performed of the ELISA III trial, a randomised multicentre trial investigating outcome of early (< 12 h) versus late (> 48 h) angiography and revascularisation in 542 patients with high-risk NSTE-ACS. 90 patients were randomised in non-PCI centres and tended to benefit more from an early invasive strategy than patients included in the PCI centre (relative risk 0.23 vs. 0.85 [p for interaction = 0.089] for incidence of the combined primary endpoint of death, reinfarction and recurrent ischaemia after 30 days of follow-up). This was largely driven by reduction in recurrent ischaemia. In non-PCI centres, patients randomised to the late group had a 4 and 7 day longer period until PCI or coronary artery bypass grafting, respectively. This difference was less pronounced in the PCI centre.ConclusionsThis post-hoc analysis from the ELISA-3 trial suggests that NSTE-ACS patients initially hospitalised in non-PCI centres show the largest benefit from early angiography and revascularisation, associated with a shorter waiting time to revascularisation. Improved patient logistics and transfer between non-PCI and PCI centres might therefore result in better clinical outcome.

Cost-Effectiveness Analysis of Anticoagulation Strategies in Non-ST-Elevation Acute Coronary Syndromes

Contemporary studies document the outcomes of unfractionated heparin (UFH), enoxaparin, fondaparinux, and bivalirudin in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). It remains unclear which anticoagulant regimen is the most cost-effective. To perform a cost-effectiveness analysis comparing 4 anticoagulant regimens in NSTE-ACS. A decision analysis was conducted from a healthcare provider perspective. Data sources included the SYNERGY, OASIS-5, and ACUITY trials, including 2 subgroup analyses. A decision tree model was created incorporating the outcomes associated with 4 antithrombotic approaches: UFH with eptifibatide, enoxaparin with eptifibatide, bivalirudin alone, and fondaparinux with eptifibatide. The percentage of eptifibatide use in each arm was consistent with clinical trials. Probabilities of complications (eg, myocardial infarction, revascularization, major/minor bleeding at 30 days) were calculated. Costs were assigned to each outcome, incorporating the cost associated with diagnosis-related group and/or current procedural terminology codes, drug acquisition, and red blood cell infusions. Multiple sensitivity analyses were performed. The base case analysis showed bivalirudin monotherapy to be the least costly regimen ($1131 per average course), and it dominated enoxaparin plus eptifibatide ($1609) and UFH plus eptifibatide ($1739) in cost-effectiveness. The total average cost of fondaparinux with eptifibatide ($1184) was higher than bivalirudin alone, but the combination was more effective, resulting in an incremental cost of $2569 per each additional patient treated without complication. Sensitivity analyses showed the model's results to be sensitive to drug acquisition cost and complication probabilities. Probabilistic sensitivity analyses favored neither bivalirudin nor fondaparinux; however, when 2 or more vials of bivalirudin were necessary, bivalirudin was no longer a cost-effective alternative. Bivalirudin is the least costly agent in moderate- to high-risk NSTE-ACS patients managed with an early invasive approach, if its use is consistent with the ACUITY trial. Fondaparinux is the preferred agent in patients undergoing a conservative treatment strategy.