Treatment Of Acute Coronary Syndromes Research Articles

Efficacy of single high-dose statin prior to percutaneous coronary intervention in acute coronary syndrome: a systematic review and meta-analysis

BackgroundThe impacts of single high-dose statin preloading in patients undergoing percutaneous coronary intervention (PCI) have not been fully examined. This study aims to evaluate post-procedure impacts of single high-dose statin pretreatment with acute coronary syndrome (ACS).MethodsThe meta-analysis reviewed Cochrane, PubMed, and Medline databases for studies comparing single high-dose atorvastatin or rosuvastatin to placebo in ACS patients undergoing PCI. The primary endpoints included major adverse cardiovascular events (MACE), myocardial infarction (MI), all-cause mortality, and target vessel revascularization (TVR) at three months. Secondary endpoints examined were the TIMI flow grade 3 and left ventricular ejection fraction (LVEF).ResultsComprehensive analysis was conducted on fifteen RCTs, encompassing a total of 6,207 patients (3090 vs 3117 patients). The pooled results demonstrated that a single high-dose of statin administered prior to PCI led to a significant decrease in the incidence of MACE at three months post-PCI compared to the control group (OR 0.50, 95%CI 0.35–0.71, p = 0.0001). The occurrence of MI (OR 0.57, 95%CI 0.42–0.77, p = 0.0002), all-cause mortality (OR 0.56, 95%CI 0.39–0.81, p = 0.0002), and TVR (OR 0.56, 95%CI 0.35–0.92, p = 0.02) was significantly lower in the statin single high-dose group compared to the control group. No significant effects on TIMI flow grade 3 (OR 1.20, 95%CI 0.94–1.53, p = 0.14) or left ventricular ejection fraction (OR 2.19, 95%CI − 0.97 to 5.34, p = 0.17) were observed. Subgroup analysis demonstrated reduced incidence of MACE with a single dose of 80 mg atorvastatin (OR 0.66, 95%CI 0.54–0.81, p < 0.0001) and 40 mg rosuvastatin (OR 0.19, 95%CI 0.07–0.54, p = 0.002).ConclusionsSingle high-dose statin before PCI in patients with ACS significantly reduces MACE, MI, all-cause mortality, and TVR three months post-PCI.

Intractable cough and hiccups after resuscitation and acute coronary syndrome treatment successfully treated using the Kampo medicine bukuyoingohangekobokuto: A case report

BackgroundEven in patients who survive resuscitation through multidisciplinary treatment, minor persistent symptoms can make hospital discharge difficult. Herein, we report a case of myocardial infarction with intractable symptoms following resuscitation, which were successfully treated using Kampo medicine. Case presentationA 71-year-old man experienced intractable cough and hiccups following resuscitation for acute myocardial infarction. Despite successful invasive treatment for his cardiac condition, the patient's persistent symptoms hindered his recovery and discharge from hospital. The patient was diagnosed with qi and blood deficiency, qi stagnation, and fluid retention, before being prescribed the Kampo medicine “bukuryoingohangekobokuto (BRIHK)”. Within days of treatment initiation, his symptoms notably improved, allowing him to be discharged. ConclusionThis case highlights the potential of Kampo medicine for addressing post-resuscitation symptoms that are refractory to conventional treatments, and emphasizes the importance of integrating Kampo medicine with Western medical practices to enhance patient care and quality of life.

Intravascular ultrasound-guided versus angiography-guided percutaneous coronary intervention in acute coronary syndromes (IVUS-ACS): a two-stage, multicentre, randomised trial

Intravascular ultrasound-guided percutaneous coronary intervention has been shown to result in superior clinical outcomes compared with angiography-guided percutaneous coronary intervention. However, insufficient data are available concerning the advantages of intravascular ultrasound guidance for patients with an acute coronary syndrome. This trial aimed to investigate whether the use of intravascular ultrasound guidance, as compared with angiography guidance, improves the outcomes of percutaneous coronary intervention with contemporary drug-eluting stents in patients presenting with an acute coronary syndrome. In this two-stage, multicentre, randomised trial, patients aged 18 years or older and presenting with an acute coronary syndrome at 58 centres in China, Italy, Pakistan, and the UK were randomly assigned to intravascular ultrasound-guided percutaneous coronary intervention or angiography-guided percutaneous coronary intervention. Patients, follow-up health-care providers, and assessors were masked to random assignment; however, staff in the catheterisation laboratory were not. The primary endpoint was target vessel failure, a composite of cardiac death, target vessel myocardial infarction, or clinically driven target vessel revascularisation at 1 year after randomisation. This trial is registered at ClinicalTrials.gov, NCT03971500, and is completed. Between Aug 20, 2019 and Oct 27, 2022, 3505 patients with an acute coronary syndrome were randomly assigned to intravascular ultrasound-guided percutaneous coronary intervention (n=1753) or angiography-guided percutaneous coronary intervention (n=1752). 1-year follow-up was completed in 3504 (>99·9%) patients. The primary endpoint occurred in 70 patients in the intravascular ultrasound group and 128 patients in the angiography group (Kaplan-Meier rate 4·0% vs 7·3%; hazard ratio 0·55 [95% CI 0·41-0·74]; p=0·0001), driven by reductions in target vessel myocardial infarction or target vessel revascularisation. There were no significant differences in all-cause death or stent thrombosis between groups. Safety endpoints were also similar in the two groups. In patients with an acute coronary syndrome, intravascular ultrasound-guided implantation of contemporary drug-eluting stents resulted in a lower 1-year rate of the composite outcome of cardiac death, target vessel myocardial infarction, or clinically driven revascularisation compared with angiography guidance alone. The Chinese Society of Cardiology, the National Natural Scientific Foundation of China, and Jiangsu Provincial & Nanjing Municipal Clinical Trial Project. For the Mandarin translation of the abstract see Supplementary Materials section.

Evaluation of the Safety and Efficacy of Coronary Intervention through the Brachial Artery Compared to the Radial Artery in Elderly Patients with Different Extubation Times

Introduction: Percutaneous coronary intervention (PCI) is an important treatment for acute coronary syndrome. The main puncture paths of PCI include radial artery, brachial artery, and femoral artery. The aim of this study was to investigate the safety and efficacy of transbrachial intervention in elderly patients. Methods: According to intraoperative and postoperative nursing records, a retrospective analysis was performed for 70 elderly patients who underwent coronary intervention were divided into brachial artery A group (33 cases) and brachial artery B group (37 cases) according to immediate postoperative extubation compression dressing and 6 hours postoperative extubation compression dressing, and matched elderly patients who had successful transradial artery puncture in the same period as radial artery group (35 cases). The success rate of puncture and catheterization, arterial puncture time, total operation time, length of hospital stay, patient comfort score, incidence of arterial spasm and occlusion, subcutaneous ecchymosis and hematoma, epidermal blister occurrence, vagal reflex, pseudoaneurysm development, arteriovenous fistula formation, nerve damage risk assessment and osteofascial compartment syndrome were compared. Results: Compared with the radial artery group, the brachial artery group (group A and group B) had a higher success rate of puncture and catheterization (97.0% vs. 97.3% vs. 80.0%, p = 0.013), shorter arterial puncture time (2.45 ± 0.38 vs. 2.40 ± 0.35 vs. 3.40 ± 0.37, p = 0.000), and lower incidence of arterial spasm (0.0% vs. 0.0% vs. 34.3%, p = 0.000), arterial occlusion (0.0% vs. 0.0% vs. 14.3%, p = 0.005) and puncture site bleeding (12.1% vs. 5.6% vs. 40.0%, p = 0.001). The incidence of epidermal blister was higher in brachial artery A group than in brachial artery B group (24.2% vs. 2.7%, p = 0.003) or radial artery group (24.2% vs. 0%, p = 0.001), and the incidence of epidermal blister in brachial artery B group and radial artery group was not much different. There was no difference between the three groups in total operation time, length of hospital stay, comfort score, subcutaneous ecchymosis and hematoma, vagal reflex, pseudoaneurysm, arteriovenous fistula, nerve damage and osteofascial compartment syndrome. Conclusion: In elderly patients, coronary intervention through brachial artery is not inferior to radial artery.

Current Strategies to Guide the Antiplatelet Therapy in Acute Coronary Syndromes.

The role of antiplatelet therapy in patients with acute coronary syndromes is a moving target with considerable novelty in the last few years. The pathophysiological basis of the treatment depends on platelet biology and physiology, and the interplay between these aspects and clinical practice must guide the physician in determining the best therapeutic options for patients with acute coronary syndromes. In the present narrative review, we discuss the latest novelties in the antiplatelet therapy of patients with acute coronary syndromes. We start with a description of platelet biology and the role of the main platelet signal pathways involved in platelet aggregation during an acute coronary syndrome. Then, we present the latest evidence on the evaluation of platelet function, focusing on the strengths and weaknesses of each platelet's function test. We continue our review by describing the role of aspirin and P2Y12 inhibitors in the treatment of acute coronary syndromes, critically appraising the available evidence from clinical trials, and providing current international guidelines and recommendations. Finally, we describe alternative therapeutic regimens to standard dual antiplatelet therapy, in particular for patients at high bleeding risk. The aim of our review is to give a comprehensive representation of current data on antiplatelet therapy in patients with acute coronary syndromes that could be useful both for clinicians and basic science researchers to be up-to-date on this complex topic.

Treatment of Acute Coronary Syndromes

Despite significant advances in the detection and rapid management of acute coronary syndromes (ACS), it continues to lead the cause of death statistics and they continuously represent the leading cause of death and living with disabilities, globally. Since ACS combine a spectrum of different diagnoses, a high degree of variability in possible clinical presentation and relevant gender differences, Individualised treatment is not always easy and is constantly changing due to novel evidence from research studies. Therefore, the aim of this article is therefore to explain relevant treatment options and to present the current state of science in the context of clinical patient treatment.

DIGITALIZATION OF THE ELECTROCARDIOGRAM IN THE OPTIMIZATION OF THE TREATMENT OF ACUTE AND CHRONIC CORONARY SYNDROMES WITH THE USE OF RANOLAZINE

Aim – to evaluate the effectiveness of ranolazine in optimizing the treatment of acute and chronic coronary syndromes, using the capabilities of a differentiated electrocardiogram.Material and methods. 135 patients were involved in the study: 45 patients with ST-segment elevation myocardial infarction (STEMI) and 90 patients with stable angina pectoris (SA), functional class II-III. Depending on the treatment received, patients with STEMI were divided into group I, with inclusion in basic therapy of ranolazine (Pn), which consisted of 30 people, and control group II, which included 15 patients who received only basic therapy (K). People with SA were divided into three groups depending on the drugs included in the complex therapy (antiplatelet agents, statins and nitrates): group A - 30 patients additionally took lercanidipine and enalapril as part of the "polypill" drug (LE), group B - 30 people who received lercanidipine and enalapril as part of the "polypill" drug and ranolazine (LE+Rn), group V - 30 participants who took ramipril and ranolazine (Pm+Pn). The duration of treatment was 30 days. All patients were interviewed according to the EQ-5D-5L questionnaire with the EQ-VAS visual analog scale, carried out echocardiography and electrocardiogram (ECG) with digitalization of its indicators using the "Smart-ECG" medical software.Results. In patients with STEMI in group I (Rn) we noted increasing in quality of life (40.00 (30.00; 50.00), Δ +100.00%, p&lt;0.001), left ventricular ejection fraction (LVEF) (50.50 (44.50; 55.00) %, Δ +6.93% (р&lt;0.001) and the ratio of maximal speed (MSR) in the ischemic zone (0.64 (0.55; 0.71), Δ +76.56%, p&lt;0.001). The frequency of increasing of MSR in the ischemic zone was significantly higher when ranolazine was included in the basic treatment (OR=7.000; 95% CI: 1.167; 42.001, p=0.020). An increase in the quality of life and a decrease in MSR in lead V2 (marker lead to assess LV hypertrophy) were observed in all groups of SA (in all cases p&lt;0.05). In group B (LE+Rn), the greatest increase in LVEF was recorded (57.00 (55.25; 60.75) %, Δ +8.77 %, p&lt;0.001). An increase of MSR in the ischemic zone was observed in group B (LE+Pn) (1.02 (0.62; 1.18), Δ +17.65%, p&lt;0.001) and in group V (Pm+Pn) (0.86 (0.57; 1.05), Δ +12.79%, p&lt;0.001). Conclusions. The addition of ranolazine in the treatment of STEMI and SA contributed to the improvement of the quality of life, the optimization of the contractile capacity of the myocardium due to the increase of LVEF, the increase of MSR indicator of the differentiated ECG in the ischemic zone, which confirmed the reduction of the electrical instability of the ischemic myocardium.

The Impact of Geriatric Conditions in Elderly Patients with Coronary Heart Disease: A State-of-the-Art Review.

The growing geriatric population presenting with coronary artery disease poses a primary challenge for healthcare services. This is a highly heterogeneous population, often underrepresented in studies and clinical trials, with distinctive characteristics that render them particularly vulnerable to standard management/approaches. In this review, we aim to summarize the available evidence on the treatment of acute coronary syndrome in the elderly. Additionally, we contextualize frailty, comorbidity, sarcopenia, and cognitive impairment, common in these patients, within the realm of coronary artery disease, proposing strategies for each case that may assist in therapeutic approaches.

An Unusual Presentation of Primary Anti-phospholipid Antibody Syndrome as Acute Coronary Syndrome in Young – A Case Report

A case report of a 32-year-old female patient without any traditional risk factors presented with angina to our hospital within 6 h. Her electrocardiogram (ECG) showed extensive anterior wall -ST elevation myocardial infarction (MI). She was treated with thrombolytic therapy in the form of tenecteplase and was given standard treatment for acute coronary syndrome (ACS). Her history revealed three recurrent pregnancy losses and a history of preeclampsia. Echocardiography showed regional wall motion abnormalities of the mid, distal, apex, and anterior wall with severe left ventricular systolic dysfunction. Routine blood investigations showed elevated total leukocyte count with neutrophilic predominance. With a history of recurrent pregnancy loss, she was investigated for anti-phospholipid anti-phospholipid antibody syndrome (APS) and was found to have positive lupus anticoagulant 1. She underwent coronary angiography (CAG) which showed a left main shaft 40% stenosis with an ulcerative lesion containing thrombus in the ostioproximal to mid-left anterior descending artery (LAD), other coronary arteries were normal. She was managed conservatively with glycoprotein IIb/IIIa inhibitor (Tirofiban) and switched to oral anticoagulation with Vitamin K antagonist (VKA-Acenocoumarin) along with dual-antiplatelet therapy.

Drug-Drug Interactions of FXI Inhibitors: Clinical Relevance.

Inhibitors of the factor FXI represent a new class of anticoagulant agents that are facing clinical approval for the treatment of acute coronary syndrome (ACS), venous thromboembolism (VTE), and stroke prevention of atrial fibrillation (AF). These new inhibitors include chemical small molecules (asundexian and milvexian), monoclonal antibodies (abelacimab, osocimab, and xisomab), and antisense oligonucleotides (IONIS-FXIRX and fesomersen), and thus, they have very peculiar and different pharmacokinetic and pharmacodynamic properties. Besides their clinical efficacy and safety, based on their pharmacological heterogeneity, the use of these drugs in patients with comorbidities may undergo drug-drug interactions (DDIs) with other concomitant therapies. Although only little clinical evidence is available, it is possible to predict clinically relevant DDI by taking into consideration their pharmacokinetic properties, such as the CYP450-dependent metabolism, the interaction with drug transporters, and/or the route of elimination. These characteristics may be useful to differentiate their use with the direct oral anticoagulant (DOAC) anti -FXa (rivaroxaban, apixaban, edoxaban) and thrombin (dabigatran), whose pharmacokinetics are strongly dependent from P-gp inhibitors/inducers. In the present review, we summarize the current clinical evidence on DDIs of new anti FXI with CYP450/P-gp inhibitors and inducers and indicate potential differences with DOAC anti FXa.

Abstract MP68: Strategic Placement of New Cathlab in the Largest Archipelago Country: Geospatial Analysis of Cathlab Coverage in Indonesia

Background: Acute coronary syndrome (ACS) is a special disease because treatment is significantly based on the time required to receive treatment. The standard gold treatment for ACS is Percutaneous Coronary Intervention (PCI), which would need Cathlab. The number of cathlabs increased significantly in Indonesia from 112 cathlabs in 2017 to 310 cathlabs in 2022. However, most cathlabs were built in areas that already had cathlabs. Despite the massive increase in the cathlab, it only slightly reduces the maldistribution (the GINI ratio decreases from 0.54 to 0.48). In response to the problem, the Ministry of Health (MoH) plans to build a cathlab in all 514 districts in Indonesia. Purpose: The idea of increasing the distribution of cathlab is extraordinary. But a new question arises: do we need to build cathlab in 514 District? Will the decision to make cathlabs in each district be effective and efficient? Methods: The cathlab location data was collected through a direct survey and site data mining. The total population and road network data are taken from an open-source geospatial system. Data were then analysed using GIS nearest-neighbor analysis to find the travel time to the nearest cathlab facility at the sub-district level. The results were then mapped on the Choropleth map. Location-Allocation Analysis was used to find the best location to build a new lab. The condition of each province was assessed using two indicators, time travel and volume. Time travel is the time a specific population needs to access the nearest cathlab. Faster time travel increases the likelihood of better outcomes. The population volume measures the number of required cathlabs by the population. The European Association of PCI recommends having one cathlab for a 500,000-650,000 people. Results: Our study found that Indonesia has a population of 330 Cathlab or 1.2 Cath per 1 million. Using geospatial analysis, these 330 categories can cover 47.5% (129 million) of the population below 1 hour and 68.1% (185 million) of the people below 2 hours. Using location-allocation analysis, we found 130 potential hospitals to get the cathlab located strategically, which will increase the coverage to 85% of the population below 2 hours of travel time. However, doubling the new cathlab to 265 cathlab only increases the range to 87%. Conclusions: Increasing the number of catheters without considering population coverage will only increase inefficiencies. The study results show that the efficient number of cathlab increases is obtained at 85% coverage with an increase of 130 cathlabs. This is due to the nature of the archipelagic country that is hindered by remote islands, high-altitude areas without roads, and some isolated areas between mountains. Different methods are needed to treat the remaining 15% of the population. Fibrinolytics have the advantage of having a low fixed cost and can still be performed in a hospital with limited facilities.

DYNAMICS OF THE LEVELS OF ASYMMETRIC DIMETHYLARGININE AND PLASMINOGEN ACTIVATOR INHIBITOR TYPE 1 IN PATIENTS WITH ACUTE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION AND TYPE 2 DIABETES MELLITUS DEPENDING ON THE REPERFUSION STRATEGY

Introduction. Despite the major successes achieved in the treatment of acute coronary syndromes (ACS), acute myocardial infarction (AMI) remains the main cause of death among the working-age population of Ukraine. The means of treatment of interventional cardiology can actually reduce the mortality of patients with ACS, improve the course of the acute period of the disease and ensure less reduction in the functional capabilities of the heart in the future. Among the many pathogenetic mechanisms of vascular inflammation in coronary heart disease and type 2 diabetes, endothelial dysfunction is the determining factor.&#x0D; The aim of the study. To evaluate the levels of plasminogen activator inhibitor type 1, asymmetric dimethylarginine and endothelial nitric oxide synthase on the 10-14th day in patients depending on the presence or absence of concomitant diabetes type 2 and the type of reperfusion therapy.&#x0D; Materials and methods. 130 patients with acute myocardial infarction were examined, who were divided into 2 groups: 1 group consisted of patients with acute myocardial infarction with accompanying type 2 diabetes (n=73), 2 group – patients with acute myocardial infarction without type 2 diabetes (n =57). The quantitative content of the plasminogen activator inhibitor type 1 (PAI-1) was determined by the immunoenzymatic method using a commercial test system manufactured by Technoclone PAI-1 ELISA Kit (Austria), endothelial nitric oxide synthase (NOS) – Enzyme-Linked Immunosorbent Assay (ELISA) Kit For Nitric Oxide Synthase Endothelial, asymmetric dimethylarginine (ADMA) – Immunodiagnostik ADMA ELISA Kit (Austria).&#x0D; Results. Percutaneous coronary intervention (PCI) contributes to a more significant decrease in the content of the marker of endothelial dysfunction – ADMA and an increase in NOS on the 10-14th day of acute myocardial infarction in comparison with standard therapy. During PCI, the level of PAI-1 did not reliably change during treatment due to post-inflammatory and post-traumatic activation of platelets in the vascular wall.&#x0D; Conclusions. In patients with acute myocardial infarction with type 2 diabetes mellitus, percutaneous coronary intervention contributes to a significant decrease in the content of asymmetric dimethylarginine and an increase in NOS on the 10-14th day of acute myocardial infarction, but was not accompanied by a significant decrease in the level of PAI-1, which in general indicates positive effect of performed myocardial revascularization.

Intracoronary Near-Infrared Spectroscopy to Predict No-Reflow Phenomenon During Percutaneous Coronary Intervention in Acute Coronary Syndrome

Near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS) can identify the lipid-rich lesions, described as high lipid-core burden index (LCBI). The aim of this study was to investigate the relationship between lipid core plaque (LCP) in the infarct-related lesion detected using NIRS-IVUS and no-reflow phenomenon during percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS). We investigated 371 ACS patients who underwent NIRS-IVUS in the infarct-related lesions before PCI. The extent of LCP in the infarct-related lesion was calculated as the maximum LCBI for each of the 4-mm longitudinal segments (maxLCBI4mm) measured by NIRS-IVUS. The patients were divided into 2 groups using a maxLCBI4mm cut-off value of 400. The overall incidence of no-reflow phenomenon was 53/371 (14.3%). No-reflow phenomenon was more frequently occurred in patients with maxLCBI4mm ≥400 compared to those with maxLCBI4mm <400 (17.5% vs. 2.5%, p<0.001). After propensity score matching, multivariable logistic regression analysis demonstrated that maxLCBI4mm (odds ratio: 1.008; 95% confidence interval: 1.005 - 1.012, p<0.001) was independently associated with no-reflow phenomenon. The maxLCBI4mm of 719 in the infarct-related lesion had the highest combined sensitivity (69.8%) and specificity (72.1%) for the identification of no-reflow phenomenon. In conclusion, in patients with ACS, maxLCBI4mm in the infarct-related lesion assessed by NIRS-IVUS was independently associated with no-reflow phenomenon during PCI.

Artificial intelligence based prediction model of in-hospital mortality among females with acute coronary syndrome: for the Jerusalem Platelets Thrombosis and Intervention in Cardiology (JUPITER-12) Study Group.

Despite ongoing efforts to minimize sex bias in diagnosis and treatment of acute coronary syndrome (ACS), data still shows outcomes differences between sexes including higher risk of all-cause mortality rate among females. Hence, the aim of the current study was to examine sex differences in ACS in-hospital mortality, and to implement artificial intelligence (AI) models for prediction of in-hospital mortality among females with ACS. All ACS patients admitted to a tertiary care center intensive cardiac care unit (ICCU) between July 2019 and July 2023 were prospectively enrolled. The primary outcome was in-hospital mortality. Three prediction algorithms, including gradient boosting classifier (GBC) random forest classifier (RFC), and logistic regression (LR) were used to develop and validate prediction models for in-hospital mortality among females with ACS, using only available features at presentation. A total of 2,346 ACS patients with a median age of 64 (IQR: 56-74) were included. Of them, 453 (19.3%) were female. Female patients had higher prevalence of NSTEMI (49.2% vs. 39.8%, p < 0.001), less urgent PCI (<2 h) rates (40.2% vs. 50.6%, p < 0.001), and more complications during admission (17.7% vs. 12.3%, p = 0.01). In-hospital mortality occurred in 58 (2.5%) patients [21/453 (5%) females vs. 37/1,893 (2%) males, HR = 2.28, 95% CI: 1.33-3.91, p = 0.003]. GBC algorithm outscored the RFC and LR models, with area under receiver operating characteristic curve (AUROC) of 0.91 with proposed working point of 83.3% sensitivity and 82.4% specificity, and area under precision recall curve (AUPRC) of 0.92. Analysis of feature importance indicated that older age, STEMI, and inflammatory markers were the most important contributing variables. Mortality and complications rates among females with ACS are significantly higher than in males. Machine learning algorithms for prediction of ACS outcomes among females can be used to help mitigate sex bias.

Clinical Interpretation of Serum Troponin in the Era of High-Sensitivity Testing.

Cardiac troponin (Tn) plays a central role in the evaluation of patients with angina presenting with acute coronary syndrome. The advent of high-sensitivity assays has improved the analytic sensitivity and precision of serum Tn measurement, but this advancement has come at the cost of poorer specificity. The role of clinical judgment is of heightened importance because, more so than ever, the interpretation of serum Tn elevation hinges on the careful integration of findings from electrocardiographic, echocardiographic, physical exam, interview, and other imaging and laboratory data to formulate a weighted differential diagnosis. A thorough understanding of the epidemiology, mechanisms, and prognostic implications of Tn elevations in each cardiac and non-cardiac etiology allows the clinician to better distinguish between presentations of myocardial ischemia and myocardial injury-an important discernment to make, as the treatment of acute coronary syndrome is vastly different from the workup and management of myocardial injury and should be directed at the underlying cause.

Simulation training for medical emergencies: Evaluation of dentists' long-term learning skills and confidence.

As the population ages and more patients experience medical emergencies during dental treatments, dentists must competently and confidently manage these situations. We developed a simulation training course for medical emergencies in the dental setting using an inexpensive vital sign simulation app for smartphones/tablets without the need for an expensive simulator. However, the duration for which this effect is maintained is unclear. This study was performed to evaluate the long-term educational effect at 3, 6, and 12 months after taking the course. Thirty-nine dental residents participated in this course. Scenarios included vasovagal syncope, anaphylaxis, hyperventilation syndrome, and acute coronary syndrome, each of which the participants had to diagnose and treat. The participants were evaluated using a checklist for anaphylaxis diagnosis and treatment skills immediately after and 3, 6, and 12 months after the course. The participants were also surveyed about their confidence in diagnosing and treating these conditions by questionnaire before, immediately after, and 3, 6, and 12 months after the course. The checklist scores for anaphylaxis were significantly lower at 3, 6, and 12 months after the course than immediately after the course. The percentage of participants who provided a correct diagnosis and appropriate treatment for vasovagal syncope, hyperventilation syndrome, and acute coronary syndrome was lower at all reassessments than immediately after the course. Because medical emergency management skills and confidence declined within 3 months, it would be useful to introduce a refresher course approximately 3 months after the initial course to maintain skills and confidence.

Outcomes of management strategies in patients with prior coronary artery bypass grafting presenting with an acute coronary syndrome

BackgroundPatients with prior coronary artery bypass grafting (CABG) presenting with an acute coronary syndrome (ACS) have poor outcomes and the optimal treatment strategy for this population is unknown. MethodsUsing linked administrative databases, we examined patients with an ACS between 2008 and 2019, identifying patients with prior CABG. Patients were categorized by ACS presentation type and treatment strategy. Our primary outcome was the composite of death and recurrent myocardial infarction at one year. ResultsOf 54,641 patients who presented with an ACS, 1670 (3.1%) had a history of prior CABG. Of those, 11.0% presented with an ST-elevation myocardial infarction (STEMI) of which, 15.3% were treated medically, 31.1% underwent angiography but were treated medically, 22.4% with fibrinolytic therapy and 31.1% with primary PCI. The primary outcome rate was the highest (36.8%) in patients who did not undergo angiography and was similar in the primary PCI (20.8%) and fibrinolytic group (21.9%). In patients presenting with a non-ST elevation acute coronary syndrome (NSTE-ACS) (89.0%), 33.2% were treated medically, 38.5% underwent angiography but were treated medically and 28.2% were treated with PCI. Compared to those who underwent PCI, patients treated conservatively demonstrated a higher risk of the composite outcome (14.8% vs 27.3%; adjusted hazard ratio 1.70, 95% confidence interval 1.22–2.37). ConclusionsPatients with prior CABG presenting with an ACS are often treated conservatively without PCI, which is associated with a higher risk of adverse events.

Pharmacist-Led Follow-Up Program for Rural Patients with Acute Coronary Syndrome: The PLURAL-ACS Pilot Program.

Patients living in rural settings have poorer access to care and more frequent readmissions after treatment for acute coronary syndrome (ACS) than patients in urban settings. It is unclear what types of medication-related issues are encountered by this cohort and whether pharmacist-led care could resolve them. To describe the issues related to cardiac medications encountered by rural patients after treatment for ACS and the impact of a pharmacist-led virtual follow-up pilot program in this population. A quality improvement initiative was developed whereby a cardiology pharmacist provided follow-up to post-ACS rural patients in Alberta, Canada, between March and May 2022. For each patient, the pharmacist identified and resolved cardiac medication-related issues through regular telephone visits over a 30-day period following hospital discharge. The primary outcome was the number of cardiac medication-related issues identified. Secondary outcomes included the types of medication-related issues identified and actions taken by the pharmacist to resolve them. During the 15-week program, 40 patients received care, and 139 virtual visits were completed. The median time spent per visit was 60 (interquartile range [IQR] 50-80) minutes. In total, 255 cardiac medication-related issues (6 per patient, IQR 3.75-8.25) were identified, of which 233 (91%) were resolved by the pharmacist. Prescription errors, adverse effects, and drug therapy optimization were the most common issues identified on days 1, 10, and 30, respectively. The pharmacist commonly undertook patient counselling (n = 126, 54%) and medication prescribing (n = 63, 27%) to address medication-related issues. A substantial number of cardiac medication-related issues were identified and resolved through a pharmacist-led virtual follow-up program in rural post-ACS patients. These findings could assist in the development of future follow-up programs to improve care for this high-risk population.

Aspirin-free strategy for percutaneous coronary intervention in acute coronary syndrome based on the subtypes of acute coronary syndrome and high bleeding risk: the STOPDAPT-3 trial.

High bleeding risk (HBR) and acute coronary syndrome (ACS) subtypes are critical in determining bleeding and cardiovascular event risk after percutaneous coronary intervention (PCI). In 4476 ACS patients enrolled in the STOPDAPT-3, where the no-aspirin and dual antiplatelet therapy (DAPT) strategies after PCI were randomly compared, the pre-specified subgroup analyses were conducted based on HBR/non-HBR and ST-segment elevation myocardial infarction (STEMI)/non-ST-segment elevation ACS (NSTE-ACS). The co-primary bleeding endpoint was Bleeding Academic Research Consortium (BARC) type 3 or 5, and the co-primary cardiovascular endpoint was a composite of cardiovascular death, myocardial infarction, definite stent thrombosis, or ischaemic stroke at 1 month. Irrespective of the subgroups, the effect of no-aspirin compared with DAPT was not significant for the bleeding endpoint (HBR [N=1803]: 7.27 and 7.91%, hazard ratio (HR) 0.91, 95% confidence interval (CI) 0.65-1.28; non-HBR [N=2673]: 3.40 and 3.65%, HR 0.93, 95% CI 0.62-1.39; Pinteraction=0.94; STEMI [N=2553]: 6.58 and 6.56%, HR 1.00, 95% CI 0.74-1.35; NSTE-ACS [N=1923]: 2.94 and 3.64%, HR 0.80, 95% CI 0.49-1.32; Pinteraction=0.45), and for the cardiovascular endpoint (HBR: 7.87 and 5.75%, HR 1.39, 95% CI 0.97-1.99; non-HBR: 2.56 and 2.67%, HR 0.96, 95% CI 0.60-1.53; Pinteraction=0.22; STEMI: 6.07 and 5.46%, HR 1.11, 95% CI 0.81-1.54; NSTE-ACS: 3.03 and 1.71%, HR 1.78, 95% CI 0.97-3.27; Pinteraction=0.18). In patients with ACS undergoing PCI, the no-aspirin strategy compared with the DAPT strategy failed to reduce major bleeding events irrespective of HBR and ACS subtypes. The numerical excess risk of the no-aspirin strategy relative to the DAPT strategy for cardiovascular events was observed in patients with HBR and in patients with NSTE-ACS.

The characteristic of acute coronary syndromes of patients with multivessel coronary artery disease in centers with and without cardiac surgery on-site.

Multivessel disease (MVD) is diagnosed in a fair number of patients with acute coronary syndrome (ACS). There are 36 cardiac-surgery (CS) centres and 157 catheterization laboratories dedicated to treat ACS in Poland. The aim of the study was to analyze MVD patient outcomes presented with ACS in centers with or without CS on-site. The present study is a retrospective analysis (2017-2020) of MVD ACS patients (n = 4618) outcomes between those treated in centers with CS on site (n = 595) and those without CS (n = 4023). Patients in CS centers had a higher prevalence of renal failure (13.3% vs. 8.8%, p ≤ 0.001) and a more frequent history of coronary angioplasty - percutaneous coronary intervention (18.9% vs. 14.4%, p = 0.005). During the coronary angiography a femoral artery access was more often used in CS center patients (47.1% vs. 15.2%, p < 0.001). Percutaneous coronary intervention of MVD was more often performed in CS centers (74.6% vs. 71.0%, p = 0.054). In-hospital death (7.6% vs. 4.6%, p = 0.002), reinfarction (1.1% vs. 0.1%, p < 0.001), hemorrhagic complications (6.4% vs. 1.6%, p < 0.001), recurrent target vessel revascularization (1.8% vs. 0.4%, p ≤ 0.001) and pulmonary edema (3.7% vs. 1.5%, p < 0.001) occurred more often in CS centers. The safety of ACS treatment in MVD patients in centers without CS on site is non-inferior to their treatment in centers with CS on site. Interestingly, there were more in-hospital adverse events observed in ACS MVD patients treated in centers with CS.