High-risk Acute Coronary Syndrome Research Articles

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.

PS-C05-5: CLINICAL IMPACT OF CREDO-KYOTO RISK SCORE ON IN-HOSPITAL BLEEDING IN PATIENTS WITH ACUTE CORONARY SYNDROME

Background: CREDO-Kyoto bleeding risk score was developed to predict the post-discharge bleeding events in patients with percutaneous coronary intervention. However, there were limited reports of the effectiveness of this score to predict the in-hospital bleeding events in patients with acute coronary syndrome (ACS). Methods: We evaluated 562 consecutive ACS patients in Saga university hospital between 2014 and 2019. Primary outcome was major bleeding during hospitalization. Major bleeding was defined as the GUSTO moderate/severe bleeding. Patients were classified into three groups according to the CREDO-Kyoto bleeding risk score (low, intermediate and high). Results: Major bleeding events occurred in 12.1% of all patients during hospitalization. Patients in the high risk group (n = 22) had significantly higher incidence of major bleeding than those in the intermediate (n = 113) and the low risk groups (n = 427) (22.7%, 18.6%, versus 9.8%, respectively, p = 0.02). Multivariate analysis showed that intermediate and high risk groups were independent predictors for the in-hospital major bleeding. Conclusions: CREDO-Kyoto risk score successfully identified high risk ACS patients for the major bleeding during hospitalization.

Evaluation of risk stratification program based on trajectories of functional capacity in patients with acute coronary syndrome: The REACP study.

As a validated assessment tool for functional disability (activities of daily living), the Barthel index (BI) assessed initially at admission has the potential to stratify patients with high-risk acute coronary syndrome (ACS). Dynamic trajectory evaluation of functional capacity in hospitals may provide more prognostic information. We aimed to establish a novel dynamic BI-based risk stratification program (DBRP) during hospitalization to predict outcomes among ACS patients. A total of 2,837 ACS patients were included from the Retrospective Multicenter Study for Early Evaluation of Acute Chest Pain. The DBRP rating (low, medium, and high-risk categories) was calculated from dynamic BI at admission and discharge. The primary outcome was all-cause mortality, and the secondary outcome was cardiac mortality. Of all the included patients, 312 (11%) died during a median follow-up period of 18.0 months. Kaplan-Meier analysis revealed that the cumulative mortality was significantly higher in patients in the higher risk category according to the DBRP. Multivariable Cox regression analysis indicated that, compared to the low-risk category, the higher risk category in the DBRP was an independent strong predictor of all-cause mortality after adjusting for confounding factors (medium-risk category: hazard ratio [HR]: 1.756, 95% confidence interval [95% CI]: 1.214-2.540; P = 0.003; high-risk category: HR: 5.052, 95% CI: 3.744-6.817; P < 0.001), and the same result was found for cardiac mortality. The DBRP was a useful risk stratification tool for the early dynamic assessment of patients with ACS. [http://www.chictr.org.cn], identifier [ChiCTR1900024657].

Periodontal disease as a non-traditional risk factor for acute coronary syndrome: a systematic review and meta-analysis.

Previous observational studies have suggested an association between periodontal disease (PD) and cardiovascular and cerebrovascular diseases. Nonetheless, evidence linking PD with coronary heart disease (CHD) and acute coronary syndrome (ACS) is still contradictory. We aim to systematically review the role of PD as a risk factor for ACS (myocardial infarction and unstable angina). The protocol was registered in PROSPERO (CRD42021286278) and we followed the recommendations of the PRISMA and AMSTAR 2 guidelines. We systematically searched for 7 databases and electronic thesis repositories from inception to February 2022. We included articles without language restriction following the PECO strategy (population: "adult participants"; exposure: "periodontal disease"; comparator: "no periodontal disease"; outcome: "acute coronary syndrome" OR "acute myocardial infarction" OR "unstable angina"). Odds ratios (OR) with 95% confidence intervals (95% CI) were pooled using random effects and heterogeneity was quantified by Cochran's Q and Higgins' I2 statistics. Subgroup analyses were carried out according to the participants' sex, type of diagnosis of PD, type of study, and continent of origin of studies. We included 46 papers (17 cohort, 25 case-control, and 4 cross-sectional studies) that met the inclusion criteria. This meta-analysis includes a total of 6,806,286 participants and at least 68,932 ACS events, mainly myocardial infarction (MI). In accordance with our results, PD is associated with a higher risk of ACS (OR 1.35; 95% CI 1.25-1.45). However, clinical and methodological heterogeneity was significant (I2=86%, p<0.05). In the sensitivity analysis, the exclusion of some studies with "extreme" results (outliers) did not significantly affect the overall estimate or heterogeneity. In subgroup analysis, we found no statistically significant differences between men and women according to subgroup difference tests (I2=0%, p=0.67). Conversely, there were differences according to the type of diagnosis of PD (clinical or self-reported diagnosis), type of study (cohort, case-control, or cross-sectional study), and the continent of origin (North America, South America, Asia, or Europe) of the studies (I2=79%-96%, p<0.10). Of the 46 studies, only 4 had a high risk of bias. Additionally, the funnel plot suggested publication bias. PD may be an important non-traditional risk factor for ACS. Although, this meta-analysis brings together more studies, and therefore more evidence, than any other previous similar study, its results should be interpreted with caution due to the great heterogeneity and the potential presence of bias.

Abstract 9440: Acs in a Patient With Amegakaryocytic Thrombocytopenia: A Management Dilemma

Introduction: The management of Acute Coronary Syndrome (ACS) in thrombocytopenia is challenging. This abstract highlights the management dilemma of a patient who presented with high-risk ACS and was found to have Amegakaryocytic thrombocytopenia (AMT). Case Presentation: A fifty-five-year-old man with no cardiovascular risk factors was admitted with high-risk ACS with recurrent ischemic ECG changes and high troponin-T. He was found to have a low platelet count of 9 x10^3/uL. The initial impression was ACS and ITP. Course: No antiplatelet or anticoagulation was commenced. CT coronary angiography showed ostial left main (LM) severe stenosis. The patient received steroids and IVIG. A week later, cyclosporin and eltrombopag were added as the thrombocytopenia was refractory. Bone marrow biopsy showed AMT. His chest pain was persistent with ECG ischemic changes. A multidisciplinary team (MDT) decided that revascularization is urgently required, but the surgical option would have an extremely high bleeding risk. Alternatively, the Percutaneous option using radial access would have significantly less bleeding risk. However, he will need DAPT for at least the first week, which if interrupted, he will be at risk for stent thrombosis. The final decision was for platelet transfusion, then to proceed with the PCI once the platelet count is 50,000 or more, and to maintain the count &gt; 15,000 by transfusion whenever required. Management: After the targeted transfusion, the patient was started on aspirin and clopidogrel, then successful IVUS guided PCI to ostial LM with new generation DES was done via radial access and low therapeutic ACT range. Post PCI, the patient remained asymptomatic; he was observed as an inpatient for 14 days, during which he required platelet transfusion once when his platelet count dropped &lt; 15.000. DAPT was given for a week and then he was maintained on clopidogrel. In 3 months of follow-up, the patient had no cardiac complaints, no bleeding, and platelets were maintained between 15 to 30 on clopidogrel. Conclusion: ACS with severe thrombocytopenia is a management dilemma. Platelets transfusion, radial access, targeting low ACT, and using new generation stents for shorter DAPT duration might decrease the bleeding risk and thrombotic events.

Effect of the Early Application of Evolocumab on Blood Lipid Profile and Cardiovascular Prognosis in Patients with Extremely High-Risk Acute Coronary Syndrome.

Proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors significantly reduce low-density lipoprotein cholesterol (LDL-C) and improve the prognosis of patients with acute coronary syndrome (ACS). However, the feasibility and safety of early application of PCSK9 inhibitors on the basis of statins combined with ezetimibe to strengthen lipid lowering in extremely high-risk coronary heart disease populations are still unknown.This study was a prospective, randomized controlled study. A total of 136 patients with extremely high-risk ACS with LDL-C ≥ 3.0 mmol/L after percutaneous coronary intervention (PCI) treatment were randomly assigned 1:1 to the control group (atorvastatin 40 mg/day and ezetimibe 10 mg/day) or the evolocumab group (evolocumab 140 mg every 2 weeks combined with atorvastatin 40 mg/day and ezetimibe 10 mg/day). We compared the blood lipid profiles, major adverse cardiovascular events (MACEs), and adverse reactions. MACEs included cardiogenic death, nonfatal myocardial infarction, nonfatal stroke, and readmission due to angina. Adverse reactions included allergies, myalgia, poor blood glucose control, and liver damage.Within 1 month, the average level of LDL-C in the evolocumab group decreased from 3.54 to 0.57 mmol/L and that in the control group decreased from 3.52 to 1.26 mmol/L. The LDL-C compliance (< 1.0 mmol/L) rate was significantly increased in the evolocumab group compared with the control group (82.35% versus 22.06%, P < 0.01). The average level of lipoprotein (a) (Lp (a) ) in the control group increased by 9.94 ± 51.93% from baseline after treatment, but evolocumab reduced the Lp (a) level (-38.84 ± 32.40%). Additionally, evolocumab further reduced the levels of apolipoprotein B/A1 (-70.56 ± 22.38% versus -51.29 ± 18.14%), cholesterol (-54.76 ± 18.10% versus -41.16 ± 18.14%), and apolipoprotein B (-66.47 ± 26.89% versus -46.78 ± 24.12%) compared with those in the control group, all P < 0.01. The blood lipid levels of both control and evolocumab groups stabilized after 1 month. During the 3-month follow-up, the incidence of MACEs after PCI was lower in the evolocumab group than in the control group (8.82% versus 24.59%, P = 0.015), and evolocumab combined with statins and ezetimibe did not increase the occurrence of adverse reactions (13.24% versus 11.48%, P = 0.762).In patients with extremely high-risk ACS with high levels of LDL-C, adding evolocumab to their treatment regimen as early as possible may enhance lipid lowering, increase the patient's LDL-C compliance rate in the short term, and improve cardiovascular prognosis but will not increase adverse reactions.

Systemic Immune-Inflammatory Index as a Determinant of Atherosclerotic Burden and High-Risk Patients with Acute Coronary Syndromes.

ResumoFundamento O índice imunoinflamatório sistêmico (IIS), derivado das contagens de neutrófilos, plaquetas e linfócitos, representa o equilíbrio homeostático entre os estados inflamatório, imune e trombótico. O IIS é superior a índices como a relação neutrófilos-linfócitos no prognóstico de várias malignidades, além de ser um melhor preditor de futuros eventos cardíacos que os fatores de risco tradicionais após a intervenção coronariana.Objetivos Este estudo objetivou avaliar a relação do IIS com a carga aterosclerótica e complicações hospitalares em pacientes com síndrome coronariana aguda.Métodos Desfechos clínicos, como extensão do dano miocárdico, carga aterosclerótica, sangramento, insuficiência renal aguda, duração da internação e mortalidade hospitalar, foram avaliados em uma coorte retrospectiva de 309 pacientes consecutivos com síndrome coronariana aguda. O IIS foi calculado como (plaqueta x neutrófilos)/contagem de linfócitos na admissão. A população estudada foi categorizada em tercis de IIS. Valores de p<0,05 foram considerados estatisticamente significativos.Resultados Os maiores valores de IIS foram encontrados em pacientes com infarto do miocárdio com supradesnivelamento do segmento ST (641,4 com angina pectoris instável, 843,0 com infarto do miocárdio sem supradesnivelamento do segmento ST e 996,0 com infarto do miocárdio com supradesnivelamento do segmento ST; p=0,004). Concentração máxima de troponina (0,94 versus 1,26 versus 3; p<0,001), número de vasos doentes (1 versus 2 versus 2; p<0,001), escore SYNTAX ( The SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery — sinergia entre intervenção coronária percutânea com taxus e cirurgia cardíaca) (9 versus 14 versus 17,5; p<0,001) e duração da internação (2 versus 2 versus 3; p<0,001) também aumentaram de acordo com o tercil de IIS (tercil 1 versus tercil 2 versus tercil 3). O IIS foi um preditor independente de escore SYNTAX (ß: 0,232 [0,001 a 0,003]; p<0,001), extensão do dano miocárdico (ß: 0,152 [0 a 0,001]; p=0,005) e duração da internação (ß: 0,168 [0,0 a 0,001]; p=0,003).Conclusões Este estudo demonstrou que o IIS, um índice hematológico simples, é um marcador melhor de carga aterosclerótica e internação mais longa do que fatores de risco bem conhecidos em pacientes com síndrome coronariana aguda de alto risco.

Prognostic value of a novel dNLR-PNI score in patients with acute coronary syndrome undergoing percutaneous coronary intervention.

There is currently limited information on the prognostic value of the dNLR-PNI (the combination of the derived neutrophil-to-lymphocyte ratio [dNLR] and prognostic nutritional index [PNI]) score for patients with acute coronary syndrome (ACS). We aimed to explore the predictive value of a dNLR-PNI score on the long-term prognosis of patients with ACS undergoing percutaneous coronary intervention (PCI). A total of 1773 patients with ACS who underwent PCI were consecutively enrolled from January 2016 to December 2018. The cutoff values of dNLR and PNI to predict major adverse cardiovascular events (MACE) were calculated using receiver operating characteristic curves. The patients were divided into three groups based on the dNLR-PNI score, and Kaplan-Meier curves and Cox regression models were used for survival analysis. The endpoints were MACE, including all-cause mortality and rehospitalisation for severe heart failure during follow-up. A total of 1542 patients with ACS who underwent PCI were included. Kaplan-Meier curves showed that a higher level of dNLR, PNI, or dNLR-PNI score was associated with a higher risk of MACE (all p < .001). In multivariate Cox regression models, the dNLR-PNI two score (hazard ratio 3.049, 95% confidence interval 1.503-6.184, p = .002) was found to be an independent predictor of all-cause mortality and rehospitalization for severe heart failure. A high dNLR-PNI score was independently associated with a higher risk of developing MACE in patients with ACS undergoing PCI. The dNLR-PNI score may be a useful prognostic parameter for identifying high-risk ACS patients after PCI.