Hospital Admission For Acute Coronary Syndrome Research Articles

Insufficient long-term LDL-cholesterol management in patients with familial hypercholesterolemia 5 years after an acute coronary syndrome

Abstract Background Long-term control of cardiovascular risk factors after an acute coronary syndrome (ACS) is a cornerstone in preventing cardiovascular event recurrence. In patients with familial hypercholesterolemia (FH) and ACS, long-term management of LDL-cholesterol has been poorly studied. Purpose To investigate the extent of LDL-c and other cardiovascular risk factor management 5 years after ACS in patients with and without FH. Methods We collected data from 3,201 patients with an ACS from a Swiss multicenter cohort study and with 5-years follow-up data. At hospital admission for ACS, clinical FH was defined based on personal and familial history of premature cardiovascular disease as well as LDL-c levels, using the Dutch Lipid Clinic and the Simon Broome definitions. At the 5-years follow-up visit after ACS, we assessed LDL-c levels, lipid-lowering drugs, and control of cardiovascular risk factors comparing patients with FH and without FH. Results At the time of ACS, mean age of the 3,201 patients was 61.6 years old (SD 12.2), 643 (20.1%) were female, and 740 (23.1%) were diagnosed with clinical FH. At 5-years follow-up post-ACS, mean age was 56.6 years for FH patients and 69.6 years for patients without FH. 5 years after ACS, 15.4% and 33.5% patients with FH had an LDL-cholesterol ≤ 1.4 mmol/l, respectively ≤ 1.8 mmol/l, compared with 21.0% and 44.3% of those without FH (p=0.01, respectively <0.001) (see Figure and Table). Use of statins was similar between groups, but patients with FH were more frequently using high-dose statins compared to patients without FH (51.0% vs 42.9%, p<0.001). Use of lipid-lowering therapy in general such as statins, ezetimibe, fibrates, or niacin was more frequent in patients with FH than in those without FH (91.0% vs 87.0%, p=0.01). Beside LDL-c management, 5-year control of other cardiovascular risk factors tended to be superior in FH patients as compared to patients without FH: 78.5% vs 69.0% p<0.001 for systolic blood pressure (BP) < 140 mmHg; 46.2% vs 38.9% p=0.4 for reaching HbA1c < 7% in patients with diabetes; 46.9% vs 42.7% p=0.27 for smoking cessation, and 28.2% vs 21.0% p=0.1 for reduction of alcohol consumption <14 units/week . Conclusion Five years after an ACS, patients with FH had less optimal control of LDL-c levels despite being younger and more frequently using high dose statins compared to patients without FH. Combination of lipid-lowering therapy needs to be studied for optimal long-term management of patients with ACS and FH.Figure:CVRF 5 years post-ACS FH/non-FHTable:CVRF 5 years post-ACS FH/non-FH

Decline of Admission for Acute Coronary Syndromes and Acute Cardiovascular Conditions during COVID-19 Pandemic in Veneto Region.

Background: The present study aimed to examine longitudinal trends in hospitalizations for acute coronary syndrome (ACS) before and during the COVID-19 pandemic, by reviewing the data from 13 hospitals of the Veneto Region, in the north-east of Italy. Methods: We performed a multicenter, retrospective analysis including all the consecutive patients presenting with ACS and other acute cardiovascular (CV) conditions (defined as heart failure, arrhythmias, cardiac arrest and venous thromboembolism) hospitalized in 13 different hospitals of the Veneto Region covering a population of 2,554,818 inhabitants, during the first (between 15 March 2020 and 30 April 2020) and second (between 15 November 2020 and 30 December 2020) COVID-19 pandemic waves (the 2020 cohort). Data were compared with those obtained at the same time-windows of years 2018 and 2019 (the historical cohorts). Results: Compared to the historical cohorts, a significant decrease in the number of ACS cases was observed in 2020 (−27.3%, p = 0.01 and −32%, p < 0.001, comparing 2018 versus 2020 and 2019 and 2020, respectively). The proportion of patients hospitalized for acute CV conditions decreased during the first and second wave COVID-19 pandemic when compared to the historical cohorts (−36.5%, p < 0.001 and −40.6%, p < 0.001, comparing 2018 versus 2020 and 2019 and 2020, respectively). Pearson’s correlation evidenced a significant inverse relationship between the number of COVID-19 cases and both ACS hospital admissions (r = −0.881, p = 0.005) and hospitalizations for acute CV conditions (r = −0.738, p = 0.01), respectively. Conclusions: The decrease in hospitalizations for ACS and other acute CV conditions will strongly affect future patients’ management since undiagnosed nonfatal CV events represent a source of increased (and unknown) CV morbidity and mortality.

Stent-Save a Life international survey on the practice of primary percutaneous coronary intervention during the COVID-19 pandemic

AimTo assess the impact of the COVID-19 pandemic on admissions of patients with acute coronary syndromes (ACS) and primary percutaneous coronary intervention (PPCI) in countries participating in the Stent-Save a Life (SSL) global initiative. Methods and ResultsWe conducted a multicenter observational survey to collect data on patient admissions for ACS, ST-elevation myocardial infarction (STEMI) and PPCI in participating SSL member countries through a period during the COVID-19 outbreak (March and April 2020) compared with the equivalent period in 2019. Of the 32 member countries of the SSL global initiative, 17 agreed to participate in the survey (three in Africa, five in Asia, six in Europe and three in Latin America). Overall reductions of 27.5% and 20.0% were observed in admissions for ACS and STEMI, respectively. The decrease in PPCI was 26.7%. This trend was observed in all except two countries. In these two, the pandemic peaked later than in the other countries. ConclusionsThis survey shows that the COVID-19 outbreak was associated with a significant reduction in hospital admissions for ACS and STEMI as well as a reduction in PPCI, which can be explained by both patient- and system-related factors.

The burden of ischaemic heart disease in Brazil from 1990 to 2019 and the association between temporal changes and socioeconomic level

Abstract Introduction The burden of ischaemic heart disease (IHD) has declined in several countries, although IHD remains the leading cause of death globally. Brazil is a large country with high inequality in income distribution across different regions. Purpose This study sought to evaluate the burden of IHD in Brazil from 1990 to 2019, as well as the relationship between temporal changes and socioeconomic level of the Federative Units. Methods Estimates of prevalence, mortality, and disability-adjusted life-years (DALYs) due to IHD were retrieved from the Global Burden of Disease Study 2019. We used databases from the Ministry of Health of Brazil to obtain the number of hospitalisations from acute coronary syndrome (ACS) and acute myocardial infarction (AMI) in the context of the public service. The Socio-demographic Index (SDI), a composite indicator of income per capita, average educational attainment, and fertility rate in females younger than 25 years, was used as a measure of socioeconomic status. Rates with 95% uncertainty intervals are reported. Results In 2019, the age-standardised prevalence rate of IHD was 1,709 (1,466–1,994) per 100,000 inhabitants. This rate remained stable from 1990 to 2019 (percent change: −1.1 [−2.6–0.5]). The estimate of deaths from IHD in 2019 was 171,246 (156,180–180,511), corresponding to 12% (11%-13%) of total deaths in the country (the leading cause) and 43% of all cardiovascular deaths. In 2019, the age-standardised mortality rate due to IHD was 75 (68–79) per 100,000. The unadjusted mortality rate due to IHD mildly increased from 2005 to 2019, while the age-standardised rate continuously decreased from 1990 to 2019 (cumulative percent change: −53 (−55 to −50, Figure 1). A negative correlation was observed between the change in age-standardised mortality rate from IHD in the period and the 2019 SDI (Figure 2). In 2019, the age-standardised DALY rate due to IHD was 1,563 (1,472–1,636) per 100,000. This DALY rate was equivalent to 5.7% (5.1%-6.3%) of total DALYs, meaning that IHD was the second most common cause of DALYs in Brazil in females and males. From 1990 to 2019, the crude DALY rate per 100,000 remained fairly stable, and the age- standardised DALY rate per 100,000 gradually declined (−50% [−52% to −48%]). There was a negative correlation between the change in age-standardised DALY rate from IHD in the period and the SDI (r2 0.59, p-value &amp;lt;0.01). The number of hospital admissions for ACS remained stable from 2008 to 2019 (33 per 100,000 in 2019). The number of hospitalisations due to AMI increased from 25 per 100,000 in 2008 to 39 per 100,000 in 2019 (percent change: 52%). Conclusions While age-standardised mortality, DALY rates continuously decreased from 1990 to 2019, the burden of IHD in Brazil remains high, probably due to ageing and population growth. Reductions in age-standardised mortality, DALY rates over time tend to be more pronounced in more developed regions. Funding Acknowledgement Type of funding sources: None. Mortality rate (per 100,000)Change in mortality rate and SDI

Global effect of COVID-19 pandemic on the rate of acute coronary syndrome admissions: a comprehensive review of published literature

BackgroundThe COVID-19 pandemic has disrupted healthcare systems across the world. The rate of acute coronary syndrome (ACS) admissions during the pandemic has varied significantly.ObjectivesThe purpose of this study is to...

Greater decline of acute stroke admissions compared with acute coronary syndromes during COVID‐19 outbreak in Greece: Cerebro/cardiovascular implications amidst a second wave surge

A remarkable decline in admissions for acute stroke and acute coronary syndrome (ACS) has been reported in countries severely hit by the COVID-19 pandemic. However, limited data are available from countries with less COVID-19 burden focusing on concurrent stroke and ACS hospitalisation rates from the same population. The study was conducted in three geographically and demographically representative COVID-19 referral university hospitals in Greece. We recorded the rate of stroke and ACS hospital admissions during a 6-week period of the COVID-19 outbreak in 2020 and compared them with the rates of the corresponding period in 2019. We found a greater relative reduction of stroke admissions (51% [35 vs. 71]; incidence rate ratio [IRR]: 0.49, p=0.001) compared with ACS admissions (27% [123 vs. 168]; IRR: 0.73, p=0.009) during the COVID-19 outbreak (p=0.097). Fewer older (>65years) patients (stroke: 34.3% vs. 45.1%, odds ratio [OR]: 0.64, p=0.291; ACS: 39.8% vs. 54.2%, OR: 0.56, p=0.016) were admitted during the COVID-19 compared with the control period. Hospitalisation rates both for stroke and ACS were reduced during the COVID-19 outbreak in a country with strict social distancing measures, low COVID-19 incidence and low population mortality. Lack of triggers for stroke and ACS during social distancing/quarantining may explain these observations. However, medical care avoidance attitudes among cerebro/cardiovascular patients should be dissipated amidst the rising second COVID-19 wave.

The effect of the COVID-19 pandemic on acute coronary syndrome hospitalizations and out-of-hospital cardiac arrest in Greece

ObjectivesAfter coronavirus disease 2019 (COVID-19) outbreak, striking decreases in the number of hospital admissions for acute coronary syndromes (ACSs) and rises in rates of out-of-hospital cardiac arrest (OHCA) have been noted. Study designThis is an analysis of prospectively collected data from a cardiology department in a single, large volume hospital of the National Health System of the Metropolitan area of Athens. MethodsWe investigated the numbers of OHCA and hospital admissions for ACS during a 1-year period and made comparisons between the pre-COVID-19 and the COVID-19 outbreak periods. ResultsOne hundred and eighty five patients were admitted during the total period of observation with the diagnosis of ACS. The mean monthly number of admissions for ACS for the pre-COVID-19 era was significantly higher than that for the post-COVID-19 era (20.1 ± 7.8 vs 8.8 ± 6.5 admissions, Ρ = 0.024). The cases of OHCA which were transferred to our emergency room department by emergency medical services during the same period were nominally lower in the prepandemic compared with the postpandemic era (1.9 ± 1.7 vs 4.0 ± 4.6, P = 0.28). ConclusionsThe present study provides hints on the potential unintended consequences of the pandemic in countries characterized by fewer COVID-19 cases and fatalities but prompt measures of social contact restrictions and lockdown.

Acute Coronary Syndrome Admissions and Mortality Rate During COVID-19 Pandemic in Gaza

Background: What is the nature and duration of changes to admissions for different types of acute coronary syndrome (ACS), among patients during coronavirus disease 2019 (COVID-19) pandemic in Gaza? Methods: The investigators analyzed data on hospital admissions in Gaza for types of ACS from August 25-2020, to October 1, 2020, that were recorded in the Alshifa Hospital Cardiology Department Service Admitted Patient Care database. Admissions were classified as ST-elevation myocardial infarction (STEMI) and non-STEACS and we calculate the diagnostic and percutaneous coronary intervention (PCI) rate. Results: Hospital admissions for ACS declined from rate of 99 admissions to 40 admission in 2020in this time, a reduction of 60%. During the period of declining admissions, there were reductions in the number of admissions for all types of ACS, including both STEMI and NON-STEACS, but relative and absolute reductions were larger for NSTEMI, (from 73 patients in 2019 to 26 patients in 2020) with a percent reduction of 64% In parallel, reductions were recorded in the STEMI ( from 26 patients in 2019 to 14 patients in 2020) percent reduction 46 %, the mortality rate for STEMI patient was 4% in 2019 and 21% in 2020, for non-STEMI patient was 0% in 2019 and 4% in 2020. The diagnostic coronary angiography decrease from 130 to 31 cases (76%) and PCI decrease from 35 to 18 cases (49%) during this period Conclusions: We found that significant reduction in the number of patients with ACS who were admitted to the hospital during the pandemic, but increase in mortality rate by 17% in STEMI and 4% in NON-STEACS in Gaza strip

Will the hidden specter of acute coronary syndrome (ACS) and ST-segment elevation myocardial infarction (STEMI) emerge from the avalanche of COVID-19?

There has been a huge impact of the COVID-19 pandemic on global healthcare systems. Advisories across the world have appealed to people to stay at home and observe social distancing to slow down the pandemic. However it is important to realize as to how this is affecting acute cardiovascular care. Recent studies from Europe and USA have reported > 50% reduction in hospital admissions for ACS and declining rates of coronary interventions. The possible reasons for this noticeable reduction in patients with ACS/STEMI during the COVID-19 pandemic are multi-factorial. On one hand, it is due to change in thresholds for referring patients of ACS/STEMI for cardiac catheterization, with fibrinolysis being acceptable for many stable STEMI patients and conservative management being preferred for NSTEMI patients. Theories abound on how “staying at home” strategy may have led to an reduction in acute coronary events due to healthier lifestyle, better compliance and reduced stress. Realistically however, a more disquieting reason would be a “pseudo-reduction” ie. the incidence of ACS/STEMI is actually the same, but these patients are staying away from hospitals due to fear of contracting the infection. Lockdown restrictions have also limited transport options for patients seeking to reach hospitals in time. Healthcare systems need to be prepared for an anticipated downstream deluge of such untreated patients who may present with sequelae like heart failure, reinfarction, arrhythmias, mechanical complications etc. Scientific societies should have proactive campaigns to alleviate patient concerns, and encourage them to seek timely medical attention despite the COVID-19 pandemic.

Secondary prevention of acute coronary events with antiplatelet agents (SPACE-AA): One-year real-world effectiveness and safety cohort study in the French nationwide claims database

Background and aimsWe aimed to compare the effectiveness of ticagrelor vs. clopidogrel or prasugrel on recurrence of acute coronary syndromes (ACS) in real-life conditions, as requested by regulatory authorities at the time of marketing. MethodsWe performed a cohort study in SNDS, the French national healthcare database. All patients with a hospital admission for ACS in 2013 were followed one year. Patients on ticagrelor, clopidogrel or prasugrel were matched 1:1 using age, gender, index ACS type, and high-dimensional propensity scores (hdPS). Outcomes were ACS, stroke, all-cause death, and major bleeding, compared within matched groups using Cox proportional hazards models analysis during treatment. Results54,048 ACS were hospitalized in 2013. At discharge, 19,796 were dispensed clopidogrel, 8242 prasugrel, and 13,916 ticagrelor. Per group, 9224 ticagrelor vs. clopidogrel, 6752 ticagrelor vs. prasugrel, and 4676 prasugrel vs. clopidogrel patients were matched. Compared to clopidogrel, ticagrelor was associated with a lower hazard ratio of death 0.73 [0.59–0.90] and composite criterion (0.88, 95% CI [0.79–0.99] but not ACS 0.92 [0.80–1.06], stroke (0.96 [017-5.53]) or major bleeding (1.02 [0.82–1.26]). Prasugrel was not different from ticagrelor or clopidogrel for any outcome, in matched patients. ConclusionsTicagrelor in real-life conditions in matched populations was associated with a lower risk of all-cause death than clopidogrel, and a lower risk of composite outcome, as in the main pivotal clinical trial. Ticagrelor and prasugrel were not different, nor were prasugrel and clopidogrel.

Coronary Events After Dispensing of Ibuprofen: A Propensity Score-Matched Cohort Study Versus Paracetamol in the French Nationwide Claims Database Sample.

Non-steroidal anti-inflammatory drugs are associated with a dose and duration-dependent coronary risk. There is little information concerning analgesic-dose ibuprofen, among the most widely used drugs worldwide. Our objective was to measure the risks of acute coronary syndrome (ACS) after dispensing of ibuprofen, versus paracetamol. Propensity score 1:2-matched cohorts of ibuprofen or paracetamol treatment episodes (TEs) in Echantillon Généraliste de Bénéficiaires (EGB), the 1/97 sample of Système National des Données de Santé (SNDS), the French nationwide claims database, from 2009 to 2014, were compared. Outcomes were hospital admissions for ACS during the 3months after the dispensing of ibuprofen or paracetamol. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated overall and stratified on low-dose aspirin dispensing. A total of 315,269 ibuprofen TEs in 168,400 persons were matched to 630,457 paracetamol TEs in 395,952 patients. Event rates were 50-100 times higher in low-dose aspirin users (27 vs 0.28 per 1000 patient years). Overall there was no difference in risk of ACS at 3months (HR 0.94, 95% CI 0.74-1.20) despite a transient increase in the first 2weeks in ibuprofen users (HR 1.70, 95% CI 1.11-2.59). In the stratified analysis, this short-term risk was only found in aspirin users (5% of population, HR 1.84, 95% CI 1.24-3.24), but not in non-aspirin users (HR 1.09, 95% CI 0.40-2.94). There was no evidence for an increased risk of ACS in patients dispensed ibuprofen compared to paracetamol.

Predictors of long-term adherence to continuous positive airway pressure in patients with obstructive sleep apnoea and acute coronary syndrome.

Continuous positive airway pressure (CPAP) is an effective treatment for obstructive sleep apnoea (OSA), but an evaluation of CPAP adherence is rarely carried out among patients with acute coronary syndrome (ACS). The goals of the study are to analyse long-term adherence and identify the predictors of non-compliance with CPAP treatment for patients with non-sleepy OSA and ACS. This is an ancillary study of the ISAACC study, which is a multicentre, prospective, open-label, parallel, randomized, and controlled trial (NCT01335087) in patients with hospital admission for ACS. For the purpose of this study, only non-sleepy patients with moderate or severe OSA and randomized to receive CPAP treatment were analysed (n=357). Non-compliance was defined as CPAP dropout or average cumulative CPAP use of <4 hours/night. Multivariable logistic regression analysis was performed to identify predictors of CPAP adherence. Adherence to treatment was 35.3% at 12 months. According to the unadjusted analysis, higher apnoea-hypopnea index (AHI) (P<0.001) and oxygen desaturation index (ODI) (P=0.001) were associated with a lower risk of non-compliance. Multivariable logistic regression analysis showed that high AHI (P=0.0051), high amounts of smoking pack-year (P=0.0170), and long intensive care unit (ICU) stays (P=0.0263) were associated with lower odds of non-compliance. It also showed a significant interaction between ACS history and age (P=0.0131), such that young patients with their first ACS showed significantly lower odds of CPAP non-compliance than patients with recurrent ACS and significantly lower odds of CPAP non-compliance were associated with ageing only in patients with recurrent ACS. Protective factors against non-compliance with CPAP treatment in non-sleepy patients with ACS were illness severity (high values of AHI or ICU stay length) or smoking amount. Patients with no previous history of ACS showed lower odds of CPAP non-compliance than patients with a recurrent ACS with younger age.

The use of revascularization strategies in patients with acute coronary syndromes admitted to hospitals without catheterization facilities: Results from the ALERT-CZ registry

AimPercutaneous coronary intervention (PCI) became the standard of care for patients (pts) with acute coronary syndromes (ACS). Czech Republic is among European countries with well developed networks of PCI and non-PCI hospitals. Ample data about PCI-treated pts is available from many registries. Much less is known about treatments and outcomes of ACS pts admitted to hospitals without cath-lab. ALERT-CZ registry was designed specifically to analyze these pts presenting to local non-PCI hospitals. The aim was to see, whether the ESC guidelines are implemented in these local, small hospitals. Methods and resultsA total of 6265 pts with first hospital admission for ACS has been enrolled in 32 Czech community hospitals without cath-lab during a 3-year period (7/2008–6/2011). The mean age was 69.7±12.3 years, 39.5% were females, 35.4% had known diabetes mellitus, 76.0% hypertension, 28.3% previous myocardial infarction and 12.0% previous stroke. Twenty-five percent pts had signs of acute heart failure (Killip II in 19.0%, Killip III in 4.8% and Killip IV in 1.1%). The discharge diagnosis was ST-elevation myocardial infarction (STEMI) in 26.1%, non-STEMI in 53.1% and unstable angina pectoris (UAP) in 20.9%.Emergent interhospital transport to coronary angiography (CAG) and PCI within <12h from symptom onset was indicated in 73.4% of STEMI pts, elective CAG was indicated in 15.9% of STEMI, CAG was not indicated in 9.9% of STEMI and 0.9% STEMI pts refused CAG. Among non-STE ACS pts CAG was performed within <24h in 16.2%, between 24–72h in 18.2%, later in 38.1%, not indicated in 22.7%, refused by pts in 4.8%. The median stay in the PCI center was 2.0 days and only 37% pts returned after CAG (±PCI) to the referring community hospital, the rest was discharged from PCI center directly to home.Among STEMI pts the median time intervals were: pain—first medical contact (FMC) 120min, FMC—community hospital door 30min, door-in–door-out for emergency transfer 23min. Thrombolysis was used in 0.4% of STEMI—in rare situations when immediate transfer was logistically not possible.PCI was performed in 41.6% pts overall (65.9% STEMI, 35.8% non-STEMI and 26.4% UAP). CABG was performed in 2.9% pts overall (2.1%, 3.1% and 3.6% per diagnosis). Detailed pharmacotherapy data as well as indirect comparison with a separate PCI centers registry is beyond the space frame of this abstract and will be presented.The overall in-hospital mortality was 7.2%. Mortality per final diagnosis was 9.5% (STEMI), 8.7% (non-STEMI) and 0.5% (UAP). Mortality per age group was 16.2% (>80 years), 8.0% (70–80 years) and 2.4% (<70 years). ConclusionPatients presenting to non-PCI hospitals undergo revascularization procedures less frequently than those directly admitted to PCI centers. This may be related to baseline differences. The outcomes are influenced by these facts.

Impact of a National Smoking Ban on Hospital Admission for Acute Coronary Syndromes: A Longitudinal Study

A ban on smoking in the workplace was introduced in Ireland on March 29, 2004. As exposure to secondhand smoke has been implicated in the development of coronary disease, this might impact the incidence of acute coronary syndromes (ACS). The smoking ban was associated with a decreased rate of hospital admissions for ACS. We analyzed data collected in a registry of all patients admitted to hospital with ACS in the southwest of Ireland, catchment population 620 525, from March 2003 until March 2007. In the year following implementation of the ban, there was a significant 12% reduction in ACS admissions (177.9 vs 205.9/100,000; 95% confidence interval [CI]: 164.0-185.1, P = 0.002). This reduction was due to fewer events occurring among men (281.5 vs 233.5, P = 0.0011) and current smokers (408 vs 302 admissions, P < 0.0001). There was no change in the rate of admissions for ACS in the following year (174.3/100,000; 95% CI: 164.0-185.1, P > 0.1). However, a further 13% reduction was observed between March 2006 and March 2007 (149.2; 95% CI: 139.7-159.2). Variation in admissions with time as a continuous variable also demonstrated a reduction on implementation of the smoking ban. A national ban on smoking in public places was associated with an early significant decrease in hospital admissions for ACS, suggesting a rapid effect of banning smoking in public places on ACS. A further reduction of similar magnitude 2 years after implementation of the ban is consistent with a longer-term effect that should be further examined in long-term studies.

Gender Differences in Self-Reported Symptoms of Depression among Patients with Acute Coronary Syndrome

This study examined the prevalence of self-reported depressive symptoms and the self reported somatic depressive symptoms as measured by the Beck Depression Inventory-II (BDI-II) among patients hospitalized for acute coronary syndrome (ACS), and explored the impact of gender on both. A convenience sample of 789 adults (248 women and 541 men) was recruited for the study during hospital admission for ACS and participants were screened for self-reported depressive symptoms. BDI-II scores of ≥14 indicate a moderate level of depressive symptoms and this cut-off score was used to categorize patients into depressed and non-depressed groups. Pearson chi-square tests for independence (categorical variables) and t tests for independent samples (continuous variables) were used for gender comparisons. Results showed that depressive symptoms during ACS episodes were different between women and men. Women reported greater overall depressive symptoms (BDI-II mean = 11.89, S.D. = 9.68) than men (BDI-II mean = 9.00, S.D. = 7.93) (P < 0.000). Significantly more women (7.66%) were identified positive for somatic depressive symptoms (sleep and appetite disturbances and fatigue) than men (2.22%) (P = 0.0003). Findings support that there are gender differences in depressive symptoms experienced by patients hospitalized for ACS. Somatic symptoms of depression may be important indicators of depression especially among female ACS patients.

Randomised, Double-Blind, Placebo-Controlled Trial of Ivabradine in Patients with Acute Coronary Syndrome: Effects of the I f Current Inhibitor Ivabradine on Reduction of Inflammation Markers in Patients with Acute Coronary Syndrome—RIVIERA Trial Study Design and Rationale

Elevated levels of serum inflammatory markers such as high-sensitivity C-reactive protein (hs-CRP) represent independent risk factors for further cardiovascular events. In an atherosclerosis model, selective heart rate (HR) reduction with ivabradine has been shown to decrease markers of vascular oxidative stress, to improve endothelial function, and to reduce atherosclerotic plaque formation. We hypothesized that the addition of ivabradine to standard medical therapy has a beneficial effect on markers of inflammatory stress in acute coronary syndromes (ACS) patients. RIVIERA is a unicenter, randomized, double-blind, placebo-controlled trial involving 1,270 patients of either gender admitted to hospital with non ST elevation ACS. The primary study aim is to evaluate the effects of ivabradine therapy, initiated at the time of hospital admission, on hs-CRP levels. There is also a combined secondary endpoint i.e. to assess the effects of ivabradine on the occurrence of death, nonfatal myocardial infarction, recurrent symptomatic ischemia, urgent revascularization, and cardiac arrest at 30-days and 1-year follow up. We hypothesize that ivabradine therapy, when started immediately after hospital admission for ACS, will result in the reduction of hs-CRP levels and the improvement of cardiovascular outcome.

C‐reactive protein, interleukin‐6, secretory phospholipase A2 group IIA and intercellular adhesion molecule‐1 in the prediction of late outcome events after acute coronary syndromes

We investigated whether levels of C-reactive protein (CRP), interleukin-6 (IL-6), secretory phospholipase A(2) group IIA (sPLA(2)-IIA) and intercellular adhesion molecule-1 (ICAM-I) predict late outcomes in patients with acute coronary syndromes (ACS). Prospective longitudinal study. CRP (mg L(-1)), IL-6 (pg mL(-1)), sPLA(2)-IIA (ng mL(-1)) and ICAM-1 (ng mL(-1)) were measured at days 1 (n = 757) and 4 (n = 533) after hospital admission for ACS. Their relations to mortality and rehospitalization for myocardial infarction (MI) and congestive heart failure (CHF) were determined. Coronary Care Unit at Sahlgrenska University Hospital, Gothenburg, Sweden. Patients with ACS alive at day 30; median follow-up 75 months. Survival was related to day 1 levels of all markers. After adjustment for confounders, CRP, IL-6 and ICAM-1, but not sPLA(2)-IIA, independently predicted mortality and rehospitalization for CHF. For CRP, the hazard ratio (HR) was 1.3 for mortality (95% confidence interval (CI): 1.1-1.5, P = 0.003) and 1.4 for CHF (95% CI: 1.1-1.9, P = 0.006). For IL-6, HR was 1.3 for mortality (95% CI: 1.1-1.6, P < 0.001) and 1.4 for CHF (95% CI: 1.1-1.8, P = 0.02). For ICAM-1, HR was 1.2 for mortality (95% CI: 1.0-1.4, P = 0.04) and 1.3 for CHF (95% CI: 1.0-1.7, P = 0.03). No marker predicted MI. Marker levels on day 4 provided no additional predictive value. In patients with ACS, CRP, IL-6, sPLA(2)-IIA and ICAM-1 are associated with long-term mortality and CHF, but not reinfarction. CRP, IL-6 and ICAM-1 provide prognostic information beyond that obtained by clinical variables.

Fluvastatin in the therapy of acute coronary syndrome: Rationale and design of a multicenter, randomized, double-blind, placebo-controlled trial (The FACS Trial)[ISRCTN81331696

BackgroundActivation of inflammatory pathways plays an important contributory role in coronary plaque instability and subsequent rupture, which can lead to the development of acute coronary syndrome (ACS). Elevated levels of serum inflammatory markers such as C-reactive protein (CRP) represent independent risk factors for further cardiovascular events. Recent evidence indicates that in addition to lowering cholesterol levels, statins also decrease levels of inflammatory markers. Previous controlled clinical trials reporting the positive effects of statins in participants with ACS were designed for very early secondary prevention. To our knowledge, no controlled trials have evaluated the potential benefits of statin therapy, beginning immediately at the time of hospital admission. A previous pilot study performed by our group focused on early initiation of cerivastatin therapy. We demonstrated a highly significant reduction in levels of inflammatory markers (CRP and interleukin-6). Based on these preliminary findings, we are conducting a clinical trial to evaluate the efficacy of another statin, fluvastatin, as an early intervention in patients with ACS.MethodsThe FACS-trial (Fluvastatin in the therapy of Acute Coronary Syndrome) is a multicenter, randomized, double-blind, placebo-controlled study evaluating the effects of fluvastatin therapy initiated at the time of hospital admission. The study will enroll 1,000 participants admitted to hospital for ACS (both with and without ST elevation). The primary endpoint for the study is the influence of fluvastatin therapy on levels of inflammatory markers (CRP and interleukin-6) and on pregnancy associated plasma protein A (PAPP-A). A combined secondary endpoint is 30-day and one-year occurrence of death, nonfatal myocardial infarction, recurrent symptomatic ischemia, urgent revascularization, and cardiac arrest.ConclusionThe primary objective of the FACS trial is to demonstrate that statin therapy, when started immediately after hospital admission for ACS, results in reduction of inflammation and improvement of prognosis. This study may contribute to new knowledge regarding therapeutic strategies for patients suffering from ACS and may offer additional clinical indications for the use of statins.

Assessing response bias from missing quality of life data: The Heckman method

BackgroundThe objective of this study was to demonstrate the use of the Heckman two-step method to assess and correct for bias due to missing health related quality of life (HRQL) surveys in a clinical study of acute coronary syndrome (ACS) patients.MethodsWe analyzed data from 2,733 veterans with a confirmed diagnosis of acute coronary syndromes (ACS), including either acute myocardial infarction or unstable angina. HRQL outcomes were assessed by the Short-Form 36 (SF-36) health status survey which was mailed to all patients who were alive 7 months following ACS discharge. We created multivariable models of 7-month post-ACS physical and mental health status using data only from the 1,660 survey respondents. Then, using the Heckman method, we modeled survey non-response and incorporated this into our initial models to assess and correct for potential bias. We used logistic and ordinary least squares regression to estimate the multivariable selection models.ResultsWe found that our model of 7-month mental health status was biased due to survey non-response, while the model for physical health status was not. A history of alcohol or substance abuse was no longer significantly associated with mental health status after controlling for bias due to non-response. Furthermore, the magnitude of the parameter estimates for several of the other predictor variables in the MCS model changed after accounting for bias due to survey non-response.ConclusionRecognition and correction of bias due to survey non-response changed the factors that we concluded were associated with HRQL seven months following hospital admission for ACS as well as the magnitude of some associations. We conclude that the Heckman two-step method may be a valuable tool in the assessment and correction of selection bias in clinical studies of HRQL.

Early use of statins in acute coronary syndromes.

This review examines the use of statin medications early in the clinical course of acute coronary syndrome (ACS). Available data demonstrate that there are clear clinical benefits to this practice. Numerous previous studies have documented the primary and secondary benefits of statins in the prevention of coronary events. Recent trials show that when statins are used during hospital admissions for ACS, patients experience decreased recurrent myocardial infarction, lower death rates, and fewer repeat hospitalizations for ischemia or revascularization. Several studies suggest that the positive effects of statins on plaque stabilization, inflammation, thrombosis, and endothelial function may be independent of lipid levels. There is also an emerging view that beneficial lipid-lowering with statins in high-risk patients has no lower limit. This information suggests that all patients admitted for ACS should be treated with statins, regardless of cholesterol levels.