Independent Predictor Of Acute Coronary Syndrome Research Articles

Artificial intelligence-based automated plaque quantification from CCTA to predict acute coronary syndrome on top of obstructive or ischemic coronary artery disease

Abstract Background Artificial intelligence (AI)-based quantitative computed tomography (AI-QCT) is a novel tool for automated plaque characterization and quantification from coronary computed tomography angiography (CCTA). The prognostic value of various AI-QCT plaque types on top of the presence of obstructive or ischemic coronary artery disease (CAD) is unknown. Purpose To investigate the added prognostic value for acute coronary syndrome (ACS) of AI-QCT total plaque burden (percent atheroma volume (PAV) %), and its subcomponents non-calcified plaque burden (NCPB), low-attenuation plaque burden (LAP), and calcified plaque burden (CPB) (%) on top of obstructive or ischemic CAD. Methods A cohort of 2007 symptomatic patients having undergone CCTA and selective downstream PET perfusion for suspected CAD was analyzed. Patients with prior or early elective revascularization within 6 months from CCTA were excluded. Obstructive CAD was defined as ≥1 vessel with >50% visual stenosis, and ischemic CAD as absolute hyperemic myocardial blood flow ≤2.3 ml/g/min in ≥2 adjacent segments on 15O-H2O PET. Multivariable Cox regressions adjusted for clinical confounders (age, sex hypertension, typical angina) including each plaque type separately (per 1.0%) on top of obstructive or ischemic CAD, respectively, were performed. The amount of LAP was <1% and therefore pooled together with NCPB. Results Throughout a median follow-up of 7 years, 72/2007 patients experienced ACS (50 myocardial infarction, 22 unstable angina). On top of obstructive CAD, all plaque types were independent predictors of ACS (Figure 1A), however according to the C-indexes (p-value vs. obstructive CAD), only PAV (C-index=0.814, p=0.010) and NCPB+LAP (C-index=0.818, p=0.014), but not CPB (C-index=0.800, p=0.066) significantly improved the prediction of ACS on top of obstructive CAD (C-index=0.790) (Figure 2A). On top of ischemic CAD (1967 patients, 66 events), all plaque types were also independent predictors of ACS (Figure 1B). But, similarly, according to the C-indexes (p-value vs. ischemic CAD), only PAV (C-index=0.818, p=0.003), and NCPB+LAP (C-index=0.818, p=0.005), but not CPB (C-index=0.798, p=0.054) significantly improved the prediction of ACS on top of ischemic CAD (C-index=0.776) (Figure 2B). NCPB+LAP alone performed similarly as PAV on top of obstructive (p=0.554) and ischemic CAD (p=0.991) (Figure 2). Conclusions Among patients with native coronary arteries treated medically, AI-based plaque quantification significantly improved the prediction of ACS on top of obstructive or ischemic CAD. The risk of ACS was largely related to NCPB+LAP, whereas CPB did not significantly improve risk stratification.Adjusted HR for ACS per plaque typeC-indexes for ACS

Association of Perceived Stress with Acute Coronary Syndrome: A Matched Case Control Study

Background Acute Coronary Syndrome (ACS), a leading cause of morbidity and mortality globally. While traditional risk factors for ACS are well studied, the role of perceived stress remains underexplored in our context. Hence, we aimed to find the association of perceived Stress with Acute Coronary Syndrome.MethodsA hospital based case control study, matched with age and gender was conducted at Birat medical College teaching Hospital from 1st July to 28th November2023. Consecutive sampling techniques was employed to enroll 50 cases and 50 controls from the hospital. Data on demographics and risk factors were collected, and the Perceived Stress Scale-10 (PSS-10) was used to measure stress in both groups. Multivariate logistic regression analysis was conducted to determine the independent association of PSS-10 with ACS.ResultsPerceived stress had no statistical significant association with ACS (P=0.069, OR= 0.918, CI 0.837-1.007) when adjusting for other risk factors. However, hypertension (P=0.004, OR=4.59, CI=1.61-13.09), smoking (P=0.004, OR=8.48, CI=2.09-34.38), and a family history of cardiovascular disease (P=0.028, OR=4.97, CI=1.19-20.75) showed statistically significant associations with ACS, while controlling for other factors.Conclusions The study found higher perceived stress in ACS patients, but it wasn't an independent predictor of ACS. Significant associations with hypertension, smoking, and family history emphasize the need for comprehensive risk factor management in preventing cardiovascular disease.

Assessing the Role of MAPH Score in Predicting Acute Coronary Syndrome: A Cross-sectional Study

Introduction: Incorporating the concepts of hyperviscosity, platelet hyperactivity, and age-related risk of Acute Coronary Syndrome (ACS), a new score has been put forward-the Mean platelet volume-Age-total Protein-Haematocrit (MAPH) score, which can determine the increased thrombotic tendency associated with ST-Segment Elevation Myocardial Infarction (STEMI). The MAPH score includes parameters such as Mean Platelet Volume (MPV), age, total protein, and haematocrit. Researchers have found that a high MAPH score is associated with a high thrombus burden in cases with STEMI and Non ST-Elevation Myocardial Infarction (NSTEMI). However, the association between MAPH score and ACS is undefined. Aim: To assess the role of MAPH score in predicting ACS. Materials and Methods: This cross-sectional study was conducted in the Department of Pathology, Srinivas Institute of Medical Sciences and Research Centre Mangalore, Karnataka, India for six months. The study included 100 clinically diagnosed cases of ACS and 100 healthy controls. The demographic data, MPV, total protein, and haematocrit values of all cases and controls were collected and tabulated, and statistical analysis was performed. Receiver Operating Characteristic (ROC) curve analysis was performed on each MAPH score parameter, and cutoff values for each parameter were obtained based on the Youden index. After calculating the MAPH score of cases and controls, multivariate logistic regression analysis was performed to evaluate the role of the MAPH score as an independent predictor of ACS. Results: A statistically significant increase in MPV (p-value =0.017) and total protein (p-value<0.001) was noted among the cases. The calculated cut-off values for MPV, age, total protein, and haematocrit were 8.4 fL, 54 years, 6.8 g/dL, and 49.1%, respectively. A statistically significant increase in the MAPH score was noted among the cases compared to the controls. Finally, multivariate logistic regression analysis identified the MAPH score as an independent predictor of ACS. Conclusion: This was the first study investigating the association between MAPH scores in patients with ACS. The MAPH score was identified as an independent predictor of ACS and can be used as a screening tool to predict and diagnose the condition in primary healthcare settings. This helps to ensure early coronary revascularisation and reduce Coronary Artery Disease (CAD)- related mortality and morbidity to a greater extent.

Elevated plasma pyruvate kinase M2 concentrations are associated with the clinical severity and prognosis of coronary artery disease.

Pyruvate kinase M2 (PKM2) was involved in the pathophysiology of atherosclerosis and coronary artery disease (CAD). We tested whether plasma PKM2 concentrations were correlated with clinical severity and major adverse cardiovascular events (MACEs) in CAD patients. A total of 2443 CAD patients and 238 controls were enrolled. The follow-up time was two years. Plasma PKM2 concentrations were detected by enzyme-linked immunosorbent assay (ELISA) kits (Cloud-Clone, Wuhan, China) using SpectraMax i3x Multi-Mode Microplate Reader (Molecular Devices, San Jose, USA). The predictors of acute coronary syndrome (ACS) were assessed by logistic regression analysis. The association between PKM2 concentration in different quartiles and MACEs was evaluated by Kaplan-Meier (KM) curves with log-rank test and Cox proportional hazard models. The predictive value of PKM2 and a cluster of conventional risk factors was determined by Receiver operating characteristic (ROC) curves. The net reclassification improvement (NRI) and the integrated discrimination improvement (IDI) were utilized to evaluate the enhancement in risk prediction when PKM2 was added to a predictive model containing a cluster of conventional risk factors. In CAD patients, PKM2 concentration was the independent predictor of ACS (P < 0.001). Kaplan-Meier cumulative survival curves and Cox proportional hazards analyses revealed that patients with a higher PKM2 concentration had higher incidence of MACEs compared to those with a lower PKM2 concentration (P < 0.001). The addition of PKM2 to a cluster of conventional risk factors significantly increased its prognostic value of MACEs. Baseline plasma PKM2 concentrations predict the clinical severity and prognosis of CAD.

Downregulation of TIGIT Expression in FOXP3+Regulatory T Cells in Acute Coronary Syndrome.

ObjectiveLittle is currently known on the role of T-cell immunoglobulin and ITIM domain (TIGIT) expression in Foxp3+ regulatory T cells (TIGIT+Tregs) in acute coronary syndrome (ACS) patients. The aim of this study was to investigate the role and alterations of TIGIT+Tregs in ACS patients.MethodsWe enrolled 117 subjects, including 61 ACS patients, 26 chronic coronary syndrome (CCS) patients, and 30 control subjects without coronary artery disease. The quantification of TIGIT+Tregs was determined by flow cytometry; serum interleukin-6 (IL-6) and transforming growth factor-β (TGF-β) were also measured.ResultsTIGIT+Tregs expression was significantly lower in ACS patients compared with CCS and control patients (P<0.05). The expression of TIGIT+Tregs was comparable in patients with and without traditional risk factors (P>0.05). Logistic regression analysis revealed that TIGIT+Tregs levels are independent predictors of ACS (P<0.01). Receiver-operating characteristic (ROC) curve analysis showed the expression levels of TIGIT+Tregs had a discriminative power for ACS (P<0.01). IL-6 levels were increased (P<0.01), while TGF-β was decreased in ACS patients compared with CCS and control patients (P<0.01). Meanwhile, an inverse correlation between IL-6 and TIGIT+Tregs was observed (P<0.01), while a positive correlation between TGF-β and TIGIT+Tregs was found (P<0.05).ConclusionTIGIT+Tregs levels are significantly reduced in ACS, accompanied by upregulated IL-6 and downregulated TGF-β expression. The downregulated TIGIT+Tregs are independent predictors of ACS. These findings suggest that TIGIT+Tregs may have an anti-inflammatory and protective effect on ACS, and its decreased expression may be associated with atherosclerotic plaque destabilization.

Acute Coronary Syndrome in Patients with Thrombotic Thrombocytopenic Purpura

Introduction: Thrombotic thrombocytopenic purpura (TTP) is a life-threatening clinical syndrome characterized by microangiopathy and a variable degree of end-organ ischemic damage. Cardiac involvement has been recognized as a major cause of mortality in these patients (Patschan et al, Nephrol Dial Transplant, 2006; Benhamou et al, J Thromb. Haemost, 2015). In this study, we aim to investigate clinical predictors and outcomes of acute coronary syndrome in the setting of TTP admissions. Methods: The National Inpatient Sample (NIS) was queried for all hospitalizations with a primary diagnosis of thrombotic microangiopathy (ICD- 9-CM code 4466 and ICD-10-CM code M3.11) from 2002 to 2017. Using ICD-9-CM procedure codes (9972), (9971), and (9979), as well as ICD-10-CM procedure codes (6A551Z3) and (6A550Z3) we identified patients who received plasma exchange (PLEX) during the same admission. Due to the wide spectrum of thrombotic microangiopathy diseases, we decided to include only those who received PLEX to get a more specific subpopulation who were presumed to have TTP. We stratified patients based on whether or not they had acute coronary syndrome (ACS) during the admission, defined as presence of any ICD code for either ST-segment elevation myocardial infarction (STEMI), Non-STEMI, or unstable angina. Baseline characteristics and inpatient outcomes were compared between groups. Statistical analysis was performed using SPSS v26 (IBM Corp, Armonk, NY, USA). The odds ratio (OR) and 95% confidence interval (CI) were calculated using the Cochran-Mantel-Haenszel test. A multivariate regression model was deployed to assess predictors of inpatient mortality. Complex weights were used throughout all calculations, enabling appropriate national projections. Results: A total of 15,640 patients with the diagnosis of thrombotic microangiopathy were identified during the studied period. Of those, 6,214 patients had received PLEX treatment during their admission (39.7%). The annual admission rate for TTP was ranging between 5-7/100,000 admissions. Patients had a mean age of 47.8 years; 67% were females, and 46.5% were Caucasian. Stratifying by geographic region, 24% were from the Northeast, 21% from the Midwest, 42% from the South, and 13% from the West. The most common primary payer was private insurance (42.7%). Overall inpatient mortality was 9.1%. The most common complications reported included acute kidney injury (42.5%), followed by acute respiratory failure (14.9%), incident dialysis (14.3%), acute encephalopathy (7.7%), acute heart failure (7.3%), acute cerebrovascular accident (7.2%), and acute coronary syndrome (6.3%). ACS was documented in 6.7% of patients. Compared with patients without ACS, those with ACS were relatively older and had a relatively higher prevalence of coronary artery disease, dyslipidemia, diabetes mellitus, essential hypertension, chronic kidney disease, and heart failure. Patients with ACS had a 3-fold higher in-hospital mortality and a longer mean hospital stay (19 days vs. 15 days, P&amp;lt;0.001). Using stepwise logistic regression, we identified age (aOR 1.03; 95% CI, 1.02 - 1.03; P &amp;lt;0.001), history of heart failure (aOR 2.02; 95% CI, 1.53-2.67; P &amp;lt;0.001), and history of coronary artery disease (aOR 2.69; 95% CI, 2.03 - 3.57; P &amp;lt;0.001) as independent predictors of ACS among patients hospitalized with TTP. On another regression analysis, certain complications were more prevalent in the ACS group including acute cerebrovascular accidents, acute heart failure, acute kidney injury, cardiogenic shock, and respiratory failure. Conclusion: Despite wider utilization of therapeutic plasmapheresis and improved supportive treatments for patients with TTP, associated morbidity and mortality remain significant. We demonstrate from this large retrospective cohort that ACS is an independent predictor of higher morbidity and mortality in TTP patients. We identified older age, history of heart failure, and history of coronary artery disease as independent predictors of ACS among patients admitted with TTP. Further studies are warranted to develop risk stratification models for patients with TTP. Figure Disclosures Anwer: Incyte, Seattle Genetics, Acetylon Pharmaceuticals, AbbVie Pharma, Astellas Pharma, Celegene, Millennium Pharmaceuticals.: Honoraria, Research Funding, Speakers Bureau.

External validation of a clinical decision rule to identify patients at low risk for acute coronary syndrome who do not need objective coronary artery disease testing

Abstract Background Rapid high-sensitivity cardiac troponin (hs-cTn) based algorithms have substantially improved the early rule-out of acute myocardial infarction (AMI) and thereby facilitated the selection of patients eligible for outpatient management. However, it remains unclear, which patients after rule-out of AMI should still undergo objective anatomic or functional cardiac testing for the detection of relevant coronary artery disease. A pilot study has derived a clinical decision rule for the selection of patients who do not need objective anatomic or functional cardiac testing for coronary artery disease (“No Objective Testing” (NOT) rule). Purpose To externally validate the performance of the NOT-rule in a multicentre study. Methods Patients presenting to the ED with symptoms suggestive of an acute coronary syndrome (ACS) were enrolled in a large prospective international multicentre study at 12 study sites in five European countries. Two independent cardiologists centrally adjudicated the final diagnosis using all clinical data including cardiac imaging and at least 90-day follow-up. The NOT-rule is applied in patients, in whom a 2h accelerated diagnostic protocol (using hs-cTnI concentrations at 0h/2h and ECG data) has ruled-out AMI and based on clinical variables. In brief, the first rule is a weighted score derived from independent predictors of ACS that classifies patients as low-risk if they score ≤4 points. The second rule was simplified and ruled patients out if they were younger than 50 years, had no history of an AMI or known CAD, and no prescribed nitrates. The third rule equals the second except nitrate use was omitted. Primary objective was the safety and efficacy of the NOT-rules for rule-out of major adverse cardiac events (MACE) including AMI, unstable angina pectoris, urgent or emergency revascularisation or cardiovascular death at 30-days of follow-up. Secondary objective was the safety and efficacy for rule-out of MACE at 2-years. Results Out of 3188 enrolled patients, 2162 (68%) had hs-cTnI concentrations at 0h and 2h below the 99th centile as well as a non-diagnostic ECG and were therefore eligible for the analysis. MACE at 30-days occurred in 302 (14%) patients. The second and third rule offered highest safety and efficacy for rule-out of MACE at 30-days. Both identified 492 (23%) patients at low-risk with a sensitivity of 99.7% (95% CI 98.2–99.9%) and a negative predictive value (NPV) of 99.8% (95% CI 98.6–99.9%). One MACE was missed within 30-days (revascularisation of a one-vessel CAD). Sensitivity 98.9% (95% CI 97.1–99.7%) and NPV 99.2% (95% CI 97.8–99.7) were also very high for 1-year MACE, as well as 2-year MACE 98.4% (95% CI 96.5–99.4%) and 98.4% (95% CI 96.5–99.3%), respectively. Conclusions The NOT rules proved to be a safe tool that identifies nearly one-fourth of patients at very low risk for MACE, who may not need objective anatomic or functional cardiac testing for coronary artery disease. Performance of NOT rules Funding Acknowledgement Type of funding source: Other. Main funding source(s): Swiss National Science Foundation, the Swiss Heart Foundation, the KTI, the European Union, the Stiftung für kardiovaskuläre Forschung Basel, the University of Basel, the University Hospital Basel

Exploring the complex interactions of baseline patient factors to improve nursing triage of acute coronary syndrome.

Emergency department (ED) nurses need to identify patients with potential acute coronary syndrome (ACS) rapidly because treatment delay could impact patient outcomes. Aims of this secondary analysis were to identify key patient factors that could be available at initial ED nurse triage that predict ACS. Consecutive patients with chest pain who called 9-1-1, received a 12-lead electrocardiogram in the prehospital setting, and were transported via emergency medical service were included in the study. A total of 750 patients were recruited. The sample had an average age of 59 years old, was 57% male, and 40% Black. One hundred and fifteen patients were diagnosed with ACS. Older age, non-Caucasian race, and faster respiratory rate were independent predictors of ACS. There was an interaction between heart rate by Type II diabetes receiving insulin in the context of ACS. Type II diabetics requiring insulin for better glycemic control manifested a faster heart rate. By identifying patient factors at ED nurse triage that could be predictive of ACS, accuracy rates of triage may improve, thus impacting patient outcomes.

Effect of combined testing of ceramides with high-sensitive troponin T on the detection of acute coronary syndrome in patients with chest pain in China: a prospective observational study

ObjectiveCeramides are associated with coronary plaque vulnerability. We aim to investigate the potential diagnostic value of ceramides for acute coronary syndrome (ACS) in Chinese patients with chest pain.DesignProspective observational survey.SettingShanghai,...

Incidence, Clinical Characteristics, and Impact of Acute Coronary Syndrome Following Transcatheter Aortic Valve Replacement

ObjectivesThe authors sought to assess the incidence, predictors, management, and prognosis of acute coronary syndrome (ACS) following TAVR. BackgroundAbout one-half of the patients undergoing transcatheter aortic valve replacement (TAVR) have concurrent coronary artery disease (CAD). However, the occurrence and clinical impact of coronary events following TAVR remain largely unknown. MethodsConsecutive patients undergoing TAVR in our institution between May 2007 and November 2017 were included. Patients were followed at 1, 6, and 12 months, and yearly thereafter. ACS was diagnosed and classified according to the Third Universal Definition of Myocardial Infarction. ResultsA total of 779 patients (mean age 79 ± 9 years, 52% male, mean STS: 6.8 ± 5.1%) were included, 68% of which had a history of CAD. At a median follow-up of 25 (interquartile range: 10 to 44) months, 78 patients (10%) presented at least 1 episode of ACS, with one-half of the events occurring within the year following TAVR. Clinical presentation was type 2 non–ST-segment elevation myocardial infarction (35.9%), unstable angina (34.6%), type 1 non–ST-segment elevation myocardial infarction (28.2%), and ST-segment elevation myocardial infarction (1.3%). Male sex (hazard ratio [HR]: 2.19; 95% confidence interval [CI]: 1.36 to 3.54; p = 0.001), prior CAD (HR: 2.78; 95% CI: 1.50 to 5.18; p = 0.001), and nontransfemoral approach (HR: 1.71; 95% CI: 1.04 to 2.75; p = 0.035) were independently associated with ACS. Coronary angiography was performed in 53 (67.9%) patients with ACS, and 30 of them (56.6%) underwent percutaneous coronary intervention. In-hospital death rate at the time of the ACS episode was 3.8%. At a median follow-up of 21 (interquartile range: 8 to 34) months post-ACS, all-cause and cardiovascular death rates were 37.3% and 25.3%, respectively. ConclusionsApproximately one-tenth of patients undergoing TAVR were readmitted for an ACS after a median follow-up of 25 months. Male sex, prior CAD, and nontransfemoral approach were independent predictors of ACS. ACS was associated with high midterm mortality.

DEMOGRAPHIC AND CLINICAL PREDICTORS OF ACUTE CORONARY SYNDROME IN PATIENTS WITH PREHOSPITAL CHEST PAIN AND BENIGN ECG FINDINGS

Early prehospital recognition of acute coronary syndrome (ACS) has been shown to improve patient outcomes. However, if the prehospital ECG is non-diagnostic for ischemia (i.e., no significant ST elevation or depression), emergency providers have no reliable tools for triaging chest pain. We sought to examine the demographic and clinical predictors of ACS in patients with benign ECG findings. This study prospectively enrolled consecutive, non-traumatic, chest pain patients transported by Emergency Medical Services to one of three UPMC-affiliated tertiary care hospitals in Pittsburgh between 2013 and 2014. We abstracted the following clinical data from patient charts: age; sex; chief complaint (i.e., angina-like pain, dyspnea, palpitation, syncope, gastrointestinal upset, cardiac arrest / pacemaker shock, substance abuse, generalized weakness); past medical history (i.e., hypertension, diabetes, coronary artery disease, prior infarction, and prior coronary revascularization); and presenting vital signs (heart rate, respiratory rate, blood pressure, and oxygen saturation). An independent reviewer examined in-hospital medical records to adjudicate the presence or absence of ACS, defined as the detection of cardiac biomarkers or the presence of ECG, clinical, echocardiographic, or nuclear evidence of acute myocardial injury. Patients with diagnostic ST changes on the prehospital ECG were excluded from the study. We used multivariate logistic regression to identify the predictors of the study outcome. After excluding those with diagnostic ECG (n=87), the final sample included 1,978 patients (age 56±17; 48% females). Overall, 68 patients (3.4%) had ACS with normal or benign ECG findings. In multivariate analysis, age (OR=1.03 [95% CI 1.02-1.05], per 1-year increase), angina-like pain (OR=3.3 [95% CI 1.1-9.7]), palpitation (OR=3.5 [95% CI 1.6-7.8]), and respiratory rate (OR=1.06 [95% CI 1.01-1.11], per 1-unit increase) were the only independent predictors of ACS in this population (all p values < 0.05). Sex, atypical chief complaints, and past medical history were not predictive of the primary outcome. In patients with prehospital chest pain and benign ECG findings, older age, the presence of angina-like pain with palpitation, and elevated respiratory rate are significant predictors of possible ACS. This finding can inform the future education and training of prehospital and emergency providers.

Clinical Characteristics of Patients Less than Forty Years Old with Coronary Artery Disease in Taiwan: A Cross-Sectional Study.

Coronary artery disease (CAD) rarely occurs in young adults. Our objective was to investigate the baseline characteristics and outcomes of young patients with CAD. We retrospectively enrolled patients aged < 40 years of age who underwent coronary angiography in a tertiary hospital in Taiwan between 2002 and 2015. The baseline characteristics and in-hospital outcomes of patients with acute coronary syndrome (ACS) and occlusive CAD (stenotic lesions > 50%) were compared with those of patients without ACS and non-occlusive CAD, respectively. We enrolled 245 young patients including 131 (53.5%) with ACS and 178 with occlusive CAD. The median age of the patients was 36.08 years and the mean follow-up period was 4.84 years. Of all study subjects, 220 (89.8%) were men and 140 (57.1%) were current smokers; there was an overall in-hospital mortality rate of 3.3%. Furthermore, age, body mass index, smoking, total leukocyte count, neutrophil-to-lymphocyte ratio, total cholesterol, and low-density lipoprotein were higher in patients with ACS and significant CAD than in those without ACS and nonstenotic CAD. Interestingly, triglyceride (TG) levels and the TG to high-density lipoprotein ratio were significantly higher in patients with ACS and occlusive CAD than in those without ACS and non-occlusive CAD. Logistic regression analysis revealed that smoking is an independent predictor of ACS and occlusive CAD. Our findings suggest that classical risk factors, obesity, and inflammation remain potent contributors to occlusive CAD and ACS in young adults in Taiwan. Efforts to prevent or minimize these risk factors, such as smoking cessation and aggressive lipid control, are necessary in young adults.

Study of markers of inflammation as predictors and prognosticators of acute coronary syndrome in patients with acute chest pain

Background: The role of inflammation in the pathogenesis of acute coronary syndrome (ACS) is established, however use of inflammatory markers as predictors for future short-term cardiovascular events in patients of acute coronary syndrome. Objective: To assess whether inflammatory markers C-reactive protein (hs-CRP), total leucocyte count (TLC) and serum albumin can correlate with the diagnosis of ACS in patients with acute chest pain and to see whether these markers can be used to predict short-term cardiovascular events in patients of ACS. Methods: All Patients presenting within 12 hours of the onset of central non traumatic chest pain were enrolled and investigated, the diagnosis of ACS was made as per JACC 2004 guidelines for ST-elevation myocardial infarction, unstable angina and non-ST elevation myocardial infarction. All patients received routine institutional care and treatment as per diagnosis blinded to CRP, albumin, and total leucocyte count (TLC). The independent predictors of ACS and predictors of adverse events in 30 days was evaluated using multivariate analysis. Results: one forty nine patients of ≥ 18 years (88 male, 61 female) which were included in the study, the diagnosis of non-ischemic chest pain (NICP)were in 30 (20%) and ACS in 119 (80%) patients. TLC and hs-CRP levels were higher (11576±3083, 14.04±6.17) in patients with ACS compared to NICP (5596±1370, 2.39±1.55) with significant P-value (&lt;0.001). Significantly high hs-CRP level (19.95±6.46), TLC (15630±3522) and low serum albumin (3.45±0.31) were there in patients in whom adverse cardiovascular events occurred. Conclusion: Leucocyte count and hs-CRP level are the independent predictors of ACS in patients presenting to the emergency department with chest pain suggestive of ACS. High hs-CRP, TLC, neutrophil count and low serum albumin, lymphocyte count are independent predictors of adverse short-term cardiovascular events.Health Renaissance 2014;12(2): pp: 99-105

Plaque Characterization by Coronary Computed Tomography Angiography and the Likelihood of Acute Coronary Events in Mid-Term Follow-Up

BackgroundCoronary computed tomography angiography (CTA)-verified positive remodeling and low attenuation plaques are considered morphological characteristics of high-risk plaque (HRP) and predict short-term risk of acute coronary syndrome (ACS). ObjectivesThis study evaluated whether plaque characteristics by CTA predict mid-term likelihood of ACS. MethodsThe presence of HRP and significant stenosis (SS) of ≥70% were evaluated in 3,158 patients undergoing CTA. Serial CTA was performed in 449 patients, and plaque progression (PP) was evaluated. Outcomes (fatal and nonfatal ACS) were recorded during follow-up (mean 3.9 ± 2.4 years). ResultsACS occurred in 88 (2.8%) patients: 48 (16.3%) of 294 HRP(+) and 40 (1.4%) of 2,864 HRP(−) patients. ACS was also significantly more frequent in SS(+) (36 of 659; 5.5%) than SS(−) patients (52 of 2,499; 2.1%). HRP(+)/SS(+) (19%) and HRP(+)/SS(−) (15%) had higher rates of ACS compared with no-plaque patients (0.6%). Although ACS incidence was relatively low in HRP(−) patients, the cumulative number of patients with ACS developing from HRP(−) lesions (n = 43) was similar to ACS patients with HRP(+) lesions (n = 45). In patients with serial CTA, PP also was an independent predictor of ACS, with HRP (27%; p < 0.0001) and without HRP (10%) compared with HRP(−)/PP(−) patients (0.3%). ConclusionsCTA-verified HRP was an independent predictor of ACS. However, the cumulative number of ACS patients with HRP(−) was similar to patients with HRP(+). Additionally, plaque progression detected by serial CTA was an independent predictor of ACS.

Abstract P063: Defects in Well-Being Psychological Factors Rather Than Ill-Being Factors Are Predictors of Acute Coronary Syndrome: A Comprehensive Lifestyle Analysis

Introduction: An increasing body of evidence suggests that development of coronary artery disease (CAD) is probably affected by a variety of lifestyle factors. However, most studies have not assessed comprehensive lifestyle factors including well-being psychological factors simultaneously, therefore relative contribution of each factors is obscure. Hypothesis: A variety of lifestyle factors including defect in well-being psychological factors may contribute to development of CAD through interacting muturally. Methods and Results: A case-control, cross-sectional study analyzing comprehensive lifestyle factors of patients with acute coronary syndrome (ACS) and healthy control was conducted. 92 patients with ACS (73 male; 53.2 yr; 30 acute MI, 62 unstable angina) and 69 healthy control (43 male; 48.7yr) were recruited. For dietary analysis, food frequency questionnaire (FFQ) and 2 days of 24 hour dietary recall were used. Anxiety, depression, stress, job stress, and hostility were analyzed to assess psychological ill-being factors. Primary and secondary control strategies, health-related quality of life (HRQoL), and satisfaction degree in 7 life domains such as marriage, leisure, standard of living, job, family, sex life, and self were analyzed to assess well-being factors. Univariate analysis showed that ACS group vs. control group had more current/ex-smoker and exercised less (all, p&lt;0.05). FFQ analysis showed that ACS group vs. control consumed more energy intake, fats, proteins, seafoods, and sweets (all, p&lt;0.05). Psychological analysis showed that the ACS group had more depressive score, less mean satisfaction score in all 7 life domains, and less physical domain of HRQoL especially in the fields of 1) general health perceptrion and 2) bodily pain (all p&lt;0.05). The ACS group vs. control tended to use more primary control strategy, although not reaching statistical signifcance. Logistic regression analysis, after adjustment of age and gender, identified that mean satisfaction score in 7 life domains (OR: 9.66), primary control strategy (OR: 1.92), greater intake of sea foods (OR 6.53) and sweets (OR: 7.40), exercise (OR: 0.26), and smoking (OR:7.53) were determined as significant independent predictors of ACS (all, p&lt;0.05). Conclusions: Defects in well-being psychological factors rather than ill-being factors are closely associated with ACS. A variety of lifestyle factors, especially, poor satisfaction in 7 life domains, use of primary control strategy, greater intake of sea foods and sweets, smoking, and poor exercise are independent predictors of ACS. Therefore preventive intervention trial of ACS should include modification of comprehensive lifestyle factors including defects in well-being factors.

Abstract 16133: High Density Lipoprotein Cholesterol is an Alternative Marker to Troponin for Acute Coronary Syndrome in High Risk Patients

Introduction: It is well known that high density lipoprotein cholesterol is inversely correlated with the risk of coronary artery disease. However, data is limited regarding the relationship of high density lipoprotein cholesterol in the acute setting of coronary artery disease and particularly how it compares to the most well-known biomarker, cardiac troponin I. Hypothesis: We assessed the hypothesis that high density lipoprotein cholesterol could be used as an alternative marker to troponin for acute coronary syndrome (ACS) in high risk patients. Methods: We analysed 740 patients of the BRAVEHEART cohort presenting for coronary angiography at our institution between October 2009 and March 2014. Of these, 153 patients presented with ACS, including 44 with ST elevation myocardial infarction and 109 with non-ST elevation myocardial infarction, and 587 patients presented without ACS. Binary logistic regression was used to compare high density lipoprotein cholesterol and cardiac troponin I levels as predictors of ACS, independent of age, sex, cardiac risk factors and statin use. Results: Patients presenting with ACS had higher median cardiac troponin I levels (0.34 vs. 0.02 μg/L; p&lt;0.001), higher median serum triglyceride levels (1.5 vs. 1.3 mmol/L, p&lt;0.001) and lower median high density lipoprotein cholesterol levels (0.97 vs. 1.09 mmol/L, p&lt;0.001) than patients without ACS. There was no difference in total cholesterol and low density lipoprotein cholesterol between the two groups. After adjusting for differences in patient variables, the strongest independent predictors of ACS were cardiac troponin I (odds ratio (OR), 1.50; 95% confidence interval (CI), 1.24-1.82; p&lt;0.001) and high density lipoprotein cholesterol (OR, 0.12; 95% CI, 0.04-0.36; p&lt;0.001). Conclusion: In conclusion, high density lipoprotein cholesterol was found to be an independent marker of ACS in high risk patients at our institution. Further studies on high density lipoprotein cholesterol could determine its clinical use in conjunction with troponin levels in patients presenting with ACS.

Screening coronary CT angiography: possibilities and pitfalls.

Coronary artery calcium scoring (CACS) is a standard imaging tool to predict future cardiac events in asymptomatic subjects with intermediate Framingham risk score (FRS) due to its high accuracy for detecting coronary artery disease (CAD) [1]. In fact, the recently published 2013 guidelines of the AHA/ACC suggest an additional role for CACS in certain asymptomatic patients who are being considered for statin therapy but who are not included in four major statin benefit groups [2]. Notwithstanding these statements, it is undeniable that coronary CTA provides clearer anatomic definition of CAD than CACS and thus may have a role in screening for individuals at risk for CAD. The greatest advantage of coronary CTA over CACS is in visualization of the extent and type of coronary plaque. It has been estimated that CACS identifies only 20 % of total plaque volume that is present histologically [3]. Not only does coronary CTA visualize more of the total plaque amount, but it can provide superior information as to its location, whether the plaque is calcified, non-calcified or mixed, obstructive or non-obstructive and the status of vessel remodeling. Coronary CTA may also provide an advantage over CACS in identifying potential precursor lesions of the acute coronary syndrome (ACS), so-called vulnerable plaque [4]. In a cohort of symptomatic patients, Motoyama et al. [4] reported that the CT features of vulnerable plaque include positive remodeling and low attenuation plaque (\30 HU). ACS events were reported in only 0.49 % of patients lacking these features. In contrast, patients with plaques showing positive remodeling and/or low attenuation plaque had a very high hazard ratio of 22.8 for developing ACS compared with those lacking such plaques [4]. A more recently reported coronary CTA finding associated with risk is the so-called ‘‘napkin-ring sign’’, defined as plaque with low-attenuation center surrounded by a rim of higher attenuation. In one study comprising symptomatic and asymptomatic patients, the napkin-ring sign was an independent predictor of ACS, although the sign had a limited sensitivity of 41 % [5]. However, whether any of these findings that are associated with symptomatic patients can be generalized to an asymptomatic screening population is an open question. In addition, coronary CTA has other intrinsic limitations. It cannot reliably discriminate thin-cap fibroatheroma, an important feature of vulnerable plaque from thick-cap fibroatheroma because of limitations of spatial resolution [6]. CT density of a non-calcified plaque may also be altered by different kV settings or the degree of intracoronary enhancement after the contrast injection [7]. Thus, it is difficult to reliably differentiate lipid core from fibrous plaque based on the CT density itself. Other practical limitations to the use of screening coronary CTA instead of CACS include potentially increased radiation exposure, intravenous contrast use, and the concern that it will lead to increased unnecessary downstream testing. However, the gap between coronary CTA and CACS in terms of radiation exposure has been closed due to substantial progress in applying radiation sparing techniques [8, 9]. Thus, radiation S. M. Yoo Department of Diagnostic Radiology, CHA University Bundang Medical Center, Sungnam, South Korea

Smoking and the risk of acute coronary syndrome in young women treated in an emergency department

The aim of this study is to compare the clinical characteristics of young women (<40 years) with older (≥40 years) admitted to the hospital emergency department with the diagnosis of acute coronary syndrome (ACS), and identify which cardiovascular risk factors are predictors to suffer an ACS in the group of young women. We included women consecutively admitted in a tertiary hospital with a diagnosis of ACS. A total of 118 women with a diagnosis of ACS were included. Young women were more likely to smok and had a higher proportion of coronary artery disease of one vessel. The multivariable logistic regression analysis showed that smoking was the only variable associated independently with the presence of ACS in young women (OR: 6.451, 95% CI: 1.479 to 28.571, p = 0.01). The findings of this study indicate that smoking is an independent predictor of ACS in women less than 40 years.

Abstract 9575: Incidence of Subsequent Acute Coronary Syndrome in Patients with Atrial Fibrillation

Background . Cardiovascular comorbidities associated with atrial fibrillation (AF) are also risk factors for acute coronary syndrome (ACS). We sought to determine the incidence of subsequent ACS in Medicare pts with newly diagnosed AF. Methods . The 5% Medicare database was used to identify pts (age 65+, no ESRD) with AF in 2006 without a prior diagnosis of ACS or AF. Medicare claims were used to identify patients hospitalized with ACS using ICD-9-CM codes for acute myocardial infarction (410) and unstable angina (411). The cumulative incidence of ACS and death was calculated during 3-year follow up using competing risk analysis and independent predictors of ACS were identified using a Cox proportional hazards model. Results . 18,445 Medicare pts were newly diagnosed with AF in 2006. The baseline characteristics of this population were: age 78 ± 7.8 yrs, hypertension (67%), CAD (33%), DM (26%), dyslipidemia (24%), CHF (21%), CVA/TIA (15%). 1392 (8%) patients from this cohort received an ACS diagnosis within 3 years (Figure). The rate of incident ACS was 11% in pts with prior CAD, CHF or DM. The rates of death at 3 years varied by age (49% for age ≥ 85, 26% for ages 75-84, 16% for ages 65-74). Independent risk factors for incident ACS included: female gender (HR 1.38, p==0.003), prior CAD (HR 1.78, p&lt;0.0001), DM (HR 1.48, p &lt;0.0001), CHF (HR 1.41, p &lt;0.0001). Conclusion . Pts with a new diagnosis of AF had an 8% incidence of ACS within 3 years of the diagnosis of AF; this risk was higher in the presence of comorbid conditions. These data have important implications in chronically anti-coagulated AF pts, as the subsequent diagnosis of ACS will entail additional antiplatelet therapy and increased hemorrhagic risk. In elderly pts with AF, however, mortality is much more frequent than subsequent ACS.

Plasma apolipoprotein O level increased in the patients with acute coronary syndrome

Apolipoprotein (apo) O is a novel apolipoprotein that is present predominantly in high density lipoprotein (HDL). However, overexpression of apoO does not impact on plasma HDL levels or functionality in human apoA-I transgenic mice. Thus, the physiological function of apoO is not yet known. In the present study, we investigated relationships between plasma apoO levels and high-sensitive C-reactive protein (hs-CRP) levels, as well as other lipid parameters in healthy subjects (n = 111) and patients with established acute coronary syndrome (ACS) (n = 50). ApoO was measured by the sandwich dot-blot technique with recombinant apoO as a protein standard. Mean apoO level in healthy subjects was 2.21 ± 0.83 µg/ml whereas it was 4.94 ± 1.59 µg/ml in ACS patients. There were significant differences in plasma level of apoO between two groups (P < 0.001). In univariate analysis, apoO correlated significantly with lg(hsCRP) (r = 0.48, P < 0.001) in ACS patients. Notably, no significant correlation between apoO and other lipid parameters was observed. Logistic regression analysis showed that plasma apoO level was an independent predictor of ACS (OR = 5.61, 95% CI 2.16–14.60, P < 0.001). In conclusion, apoO increased in ACS patients, and may be regarded as an independent inflammatory predictor of ACS patients.