Ischemic ST-segment Changes Research Articles

Proof for piroximone's inotropic influence: Can it safely be used in coronary artery disease? analysis of end-systolic pressure-volume relations (conductance technique)

Improved contractility after applying piroximone (PIR) a new phosphodiesterase III inhibitor drug, is difficult to prove clinically. However, augmented contractility could increase the risk of myocardial ischemia when used in coronary artery disease (CAD). Analysis of the end-systolic pressure-volume relationship (ESPVR) as a load-independent parameter of the contractile left ventricular (LV) function allows for differentiation of PIR's effects: contractility vs. unloading. We therefore analyzed ESPVR and LV function in 16 CAD patients before and after PIR, 0.75 mg/kg intravenously. Emax increased by 39% (9/16 patients) and loops of the ESPVR (16 patients) moved leftward, indicating improved contractility. The difference in percent change PIR versus control (16 patients) demonstrated augmentation of LV function via unloading: LV volumes decreased (ESV by 37%, EDV by 19%), LV-filling pressure by 34%, and systemic vascular resistance by 19%; dP/dtmax increased by 28%, LV efficiency by 24%, cardiac index by 21%, and ejection fraction by 13%. Pacing-induced anginal threshold increased by 47% after PIR while the ischemic postpacing LV-filling pressure and ST-segment changes tended to normalize under the drug's influence. Thus, PIR improved LV function both by unloading and by positive inotropy. Lack of PIR-induced angina and an increased anginal threshold indicate that the drug can be used safely in CAD patients as well. The analysis of ESPVR proved to be safe and reliable in identifying contractility during the diagnostic cardiac catheterization routine.

Do We Really Need Another Biomarker to Diagnose Myocardial Infarction After Coronary Artery Bypass Graft Surgery?

Do We Really Need Another Biomarker to Diagnose Myocardial Infarction After Coronary Artery Bypass Graft Surgery?

Comparison of the effects of long-acting nifedipine CR and diltiazem R in patients with vasospastic angina: Aomori coronary spastic angina study

We compared the efficacy of once-daily administration of nifedipine CR 40 mg (N) with that of twice-daily diltiazem R 100mg (D) in patients with vasospastic angina (VSA) registered in 8 cardiovascular institutes in Aomori Prefecture. VSA was diagnosed by the ischemic ST segment changes during chest pain attacks at rest and/or acetylcholine induction test done during coronary angiography. Thirty-seven patients were randomly allocated to either the N (n=20) or D group (n=17). The number of symptomatic attacks and amount of short-acting nitrate use were examined based on data in diaries written by the patients. There were no significant differences in the baseline characteristics between the two groups. The mean number (median number) of attacks per week was significantly decreased in the N group from 2.56 (2.0) at baseline to 0.41 (0.0) after 4 weeks of treatment, to 0.24 (0.0) after 8 weeks, and to 0.36 (0.0) after 12 weeks (all p<0.05 vs. baseline). It was also decreased in D group from 2.71 (2.0) at baseline to 0.55 (0.0) after 4 weeks, to 0.32 (0.0) after 8 weeks, and to 0.27 (0.0) after 12 weeks (all p<0.05 vs. baseline). The numbers of attacks before and after treatment were comparable between N and D groups. In one patient in each of the N and D groups, the allocated drug was crossed over to the other due to recurrence of the attacks. One patient in each group experienced adverse effects and the drug was changed to the other. Once-daily administration of nifedipine CR was as effective as twice-daily diltiazem R in the prevention of VSA attacks.

Clinical characteristics in patients showing ischemic electrocardiographic changes during adenosine triphosphate loading single-photon emission computed tomography

Although ischemic electrocardiographic (ECG) changes during dipyridamole or adenosine infusion have been reported as a marker for severe coronary artery disease (CAD), few studies have focused on ST-segment changes with adenosine triphosphate (ATP)-loading myocardial single-photon emission computed tomography (SPECT). Between January 2003 and August 2008, 4650 consecutive patients underwent ATP-loading SPECT. After 1412 patients with left bundle branch block, pacemaker rhythm, or previous coronary revascularization were excluded, 16 out of 3238 patients (0.5%) showed ischemic ST-segment depression during ATP-loading myocardial SPECT. They were aged 67+/-11 years; 10 were men and 6 women. Of these patients, 8 demonstrated perfusion abnormalities, whereas the remaining 8 showed normal myocardial perfusion imaging. In 6 of the 8 patients with abnormal SPECT, coronary angiography was performed, revealing left main trunk disease in 1 patient, 3-vessel disease in 4, 1-vessel disease with proximal left ascending artery occlusion in 1, and an insignificant lesion in 1. By contrast, no major cardiac event was observed in the 8 patients with normal SPECT during follow-up for an average of 2 years. The prevalence of ischemic ST-segment changes during ATP loading is very rare. However, this finding should be taken into account since almost half of the patients, particularly those with perfusion abnormalities, may have severe CAD which requires coronary revascularization.

Abstract 4844: Influence of Early Stage Chronic Kidney Disease on Coronary Spastic Angina

Background: Chronic kidney disease (CKD) is associated with the morbidity and mortality of cardiovascular disease through atherosclerotic processes. However, the relationship between CKD and coronary artery spasm has not been elucidated. The aim of this study was to investigate whether CKD is associated with coronary spastic angina (CSA). Methods: We evaluated 127 patients (mean age 60 ± 12 years) who underwent coronary angiography with intracoronary acetylcholine or ergonovine provocation test. CSA was defined as total or subtotal coronary vasoconstriction with chest pain and ischemic ST segment changes on electrocardiography after provocation that were resolved by an intracoronary injection of isosorbide dinitrate, and the absence of organic coronary stenosis. Kidney function was determined by the estimated glomerular filtration rate (eGFR). Patients with eGFR ≤ 29 mL/min/1.73 m 2 were excluded. Results: There were 53 and 74 patients with and without CSA, respectively. Age and proportion of smokers, hypertension, diabetes mellitus, and obesity were similar between the two groups. The proportion of male gender and dyslipidemia was higher among the patients with, than without CSA (72 vs. 46 %, P = 0.004, and 49 vs. 31 %, P = 0.040). As compared with patients without CSA, patients with CSA had significantly lower eGFR value (70.4 ± 14.8 vs. 79.2 ± 17.2 mL/min/1.73 m 2 , P = 0.003) and higher proportion of eGFR category ≤ 59 mL/min/1.73 m 2 (25 vs. 11 %, P = 0.040). Prevalence of CSA was 56 % in the lowest eGFR quartile (&lt; 63.9 mL/min/1.73 m 2 ) and 55% in second lower quartile (63.9 – 75.0 mL/min/1.73 m 2 ), which was significantly increased compared to 23 % in highest quartile (≥ 85.3 mL/min/1.73 m 2 ) (P = 0.006 and P = 0.009, respectively). No significant difference was observed between highest and second highest quartile (75.0 – 85.3 mL/min/1.73 m 2 ). Logistic regression analysis showed that independent factors associated with CSA were male gender (OR, 3.938; 95%CI, 1.725 to 8.988) and eGFR (OR, 0.658; 95%CI, 0.506 to 0.857). Conclusions: Mildly and moderately decreased eGFR is associated with a higher prevalence of CSA, suggesting that early stage CKD is related to a relatively initial stage of atherosclerosis. Management for CKD might lower the incidence of CSA.

Early Treatment for Non‐ST‐Segment Elevation Acute Coronary Syndrome Is Associated with Appropriate Discharge Care

Acute treatment is associated with improved in-hospital outcomes for patients with non-ST-segment elevation acute coronary syndrome (NSTE ACS). Patients who receive appropriate acute treatment are more likely to receive guideline-recommended therapy at hospital discharge. Use of aspirin (ASA), beta-blockers, and clopidogrel was evaluated in the first 24 hours and upon hospital discharge according to the 2002 American College of Cardiology/American Heart Association (ACC AHA) guidelines for NSTE ACS. We compared the relationship between 3 groups: (1) ASA therapy given in the emergency department (ED); (2) ASA therapy not given in the ED, but within the first 24 hours; and (3) no acute ASA treatment. The ASA data set includes 10,468 high risk patients with positive cardiac biomarkers or ischemic ST-segment changes on ECG from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) Quality Improvement Initiative. Beta-blocker therapy was evaluated in 11,838 and clopidogrel treatment in 17,513 patients presenting to over 345 US hospitals. Patients who received acute ASA in the ED, ASA in the first 24 hours but not in the ED, and patients who did not receive ASA therapy within 24 hours had discharge ASA treatment rates of 91.8%, 91.4%, and 55.6%, respectively (P < 0.0001). Patients eligible for beta-blocker and clopidogrel therapy had discharge beta-blocker treatment rates of 91.1%, 92.4%, and 46.6% (P < 0.0001), and discharge clopidogrel treatment rates of 86.6%, 92.4%, and 38.5% (P < 0.0001), respectively. Acute treatment for NSTE ACS in-hospital is associated with appropriate treatment on hospital discharge. This link between early treatment and discharge therapy may lead to new approaches ensuring the delivery of high-quality, guideline-based care for patients with NSTE ACS.

The Obesity Paradox in Non-ST Segment Elevation Acute Coronary Syndromes: Results from the Rapid Risk Stratification of Unstable Angina Patients Can Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines Quality Improvement Initiative: Diercks DB, Roe MT, Mulgund J, et al. Am Heart J 2006;152:140–8

This retrospective observational study used data from the CRUSADE Initiative to compare in-hospital treatment and clinical outcomes of 80,845 patients with non-ST segment elevation acute coronary syndrome (ACS) to determine whether there was an association with body mass index (BMI). ACS was determined by positive cardiac markers or ischemic ST-segment changes. Patient weights were classified using World Health Organization guidelines of underweight (BMI < 18.5), normal (BMI 18.5–24.9), overweight (BMI 35–39.9), and extremely obese (BMI > 40).

Usefulness of Paradoxical Systolic Blood Pressure Increase After Exercise as a Predictor of Cardiovascular Mortality

Exercise treadmill testing (ETT) is a well-accepted examination for patients with suspected coronary artery disease (CAD), and exercise induced ST-segment deviation is commonly used for CAD detection. However, recent evidence shows that systolic blood pressure (SBP) changes during and after exercise were associated with CAD severity, risk of acute myocardial infarction and stroke, new-onset hypertension, and even cardiovascular mortality. We retrospectively assessed 3,054 patients referred for ETT in 1996. Blood pressure and heart rate were recorded at rest, during peak exercise, and 1 and 3 min after exercise. SBP at 3 min of recovery equal to or higher than that at 1-min of recovery was defined as paradoxical SBP increase. These patients were categorized into 4 groups according to ETT ST-segment change and postexercise SBP change. After 10 years of follow-up, 346 patients (11%) died, with 129 (4%) dying from cardiovascular disease (CVD). Among the 4 groups, patients with ischemic ST-segment change and paradoxical SBP increase were associated with a higher risk for mortality, with odds ratios of 1.86 (95% confidence interval 1.31 to 2.65) for all-cause mortality and 3.18 (95% confidence interval 1.94 to 5.20) for CVD mortality, respectively. Patients with isolated paradoxical SBP increase still had a higher risk of CVD mortality (odds ratio 1.80, 95% confidence interval 1.70 to 3.04), even after controlling other cardiovascular risk factors. In subgroup analysis of 346 mortality subjects, patients with ischemic ST-segment change and paradoxical SBP increase would be more likely to die from CVD. In conclusion, compared with ischemic ST-segment change, paradoxical SBP increase after exercise is an important and significant predictor of CVD mortality.

Patterns of transfer for patients with non–ST-segment elevation acute coronary syndrome from community to tertiary care hospitals

Practice guidelines for non-ST-segment elevation acute coronary syndromes (NSTE ACS) recommend early invasive management (cardiac catheterization and revascularization within 48 hours of hospital presentation) for high-risk patients, but interhospital transfer is necessary to provide rapid access to revascularization procedures for patients who present to community hospitals without revascularization capabilities. We analyzed patterns and factors associated with interhospital transfer among 19,238 patients with NSTE ACS (positive cardiac markers and/or ischemic ST-segment changes) from 124 community hospitals without revascularization capabilities in the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines quality improvement initiative from January 2001 through June 2004. Less than half of the patients (46.3%) admitted to community hospitals were transferred to tertiary hospitals, and fewer (20%) were transferred early (within 48 hours of presentation). Early transfer rates increased by 16% over 10 quarters in patients with a predicted low or moderate risk of inhospital mortality, compared with 5% in high-risk patients. By the last quarter of the analysis, 41.4% of low-risk patients were transferred early versus 12.5% of high-risk patients. Factors significantly associated with early transfer included younger age, lack of prior heart failure, cardiology inpatient care, and ischemic ST-segment electrocardiographic changes. Among patients who were not transferred, 29% had no further risk stratification performed with stress testing, ejection fraction measurement, or diagnostic cardiac catheterization (at hospitals with catheterization laboratories). Most patients with NSTE ACS presenting to community hospitals without revascularization capabilities are not rapidly transferred to tertiary hospitals, and lower-risk patients appear to be preferentially transferred early. Further investigation is needed to determine if improved risk-based triage at community hospitals can optimize transfer decision making for high-risk patients with NSTE ACS.

Obstructive sleep apnea and coronary artery disease

In the recent years intensive research has revealed numerous negative consequences of obstructive sleep apnea (OSA) for the cardiovascular system. The pathophysiological interaction between OSA and coronary artery disease is complex and comprises neural, humoral, mechanical and haemodynamic components. One of the most important effects of OSA is an increase of sympathetic nerve traffic, which persists during the day and is thought to play a key role in the association of OSA and elevated systemic blood pressure. Nowadays, OSA is accepted as an independent risk factor for arterial hypertension. Several investigations support an association of OSA with ischemic ST-segment changes, ventricular arrhythmias, and sudden cardiac death. In line with this, a growing body of evidence strongly supports OSA having prognostic implications for cardiovascular morbidity and mortality. Continuous positive airway pressure (CPAP) has been shown to have several beneficial effects on the cardiovascular system. Uncontrolled studies indicate that it reduces cardiovascular risk in patients with severe OSA and increased risk or manifest coronary artery disease. However, ongoing studies still have to confirm this.

Influence of Inpatient Service Specialty on Care Processes and Outcomes for Patients With Non–ST-Segment Elevation Acute Coronary Syndromes

Since the broad dissemination of practice guidelines, the association of specialty care with the treatment of patients with acute coronary syndromes has not been studied. We evaluated 55 994 patients with non-ST-segment elevation acute coronary syndromes (ischemic ST-segment changes and/or positive cardiac markers) included in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) Quality Improvement Initiative from January 2001 through September 2003 at 301 tertiary US hospitals with full revascularization capabilities. We compared baseline characteristics, the use of American College of Cardiology/American Heart Association guidelines class I recommendations, and in-hospital outcomes by the specialty of the primary in-patient service (cardiology versus noncardiology). A total of 35 374 patients (63.2%) were primarily cared for by a cardiology service, and these patients had lower-risk clinical characteristics, but they more commonly received acute (</=24 hours) medications, invasive cardiac procedures, and discharge medications and lifestyle interventions. Acute care processes were improved when care was provided by a cardiology service regardless of the propensity to receive cardiology care. The adjusted risk of in-hospital mortality was lower with care provided by a cardiology service (adjusted odds ratio 0.80, 95% confidence interval 0.73 to 0.88), and adjustment for differences in the use of acute medications and invasive procedures partially attenuated this mortality difference (adjusted odds ratio 0.92, 95% confidence interval 0.83 to 1.02). Non-ST-segment elevation acute coronary syndrome patients primarily cared for by a cardiology inpatient service more commonly received evidence-based treatments and had a lower risk of mortality, but these patients had lower-risk clinical characteristics. Results from the present analysis highlight the difficulties with accurately determining how specialty care is associated with treatment patterns and clinical outcomes for patients with acute coronary syndromes. Novel methodologies for evaluating the influence of specialty care for these patients need to be developed and applied to future studies.

Patterns of Aspirin Dosing in Non–ST-Elevation Acute Coronary Syndromes in the CRUSADE Quality Improvement Initiative

Recent studies have suggested that low-dose aspirin has preserved benefit with less bleeding compared with standard-dose aspirin when given with or without clopidogrel in patients with high-risk non-ST-segment elevation acute coronary syndromes (NSTE ACSs). We evaluated 22,618 patients with NSTE ACSs and high-risk features (ischemic ST-segment changes and/or positive cardiac markers) from 369 hospitals included in the CRUSADE initiative from May 4, 2003 to September 30, 2004. We analyzed acute (<24 hours of admission) and discharge aspirin doses in relation to concomitant clopidogrel use and other clinical predictors. Dosing of aspirin in the first 24 hours was as follows: 17.3% of patients (n = 3,911) received 81 mg, 13.5% (n = 3,062) received 162 mg, 67.4% (n = 15,247) received 325 mg, and 1.8% (n = 398) received >325 mg. Use of lower dose aspirin increased at discharge: 40.2% (n = 7,524) received 81 mg, 3.1% (n = 579) received 162 mg, and 55.7% (n = 10,423) received 325 mg. In patients who received concomitant clopidogrel at discharge (n = 12,635), 37.6% received aspirin 81 mg and 58.5% received 325 mg. Compared with patients who did not receive concomitant discharge clopidogrel (n = 4,772), 44.0% received aspirin 81 mg and 51.2% received 325 mg. Use of aspirin 81 mg was significantly lower in patients undergoing percutaneous coronary intervention (31.5% vs 46.2%, p <0.0001). In conclusion, most patients with high-risk NSTE ACSs in the United States continue to be treated with aspirin 325 mg at discharge with and without concomitant clopidogrel, despite recent studies that have shown a better safety profile with low-dose aspirin.

A Comparison of Acute Coronary Syndrome Care at Academic and Nonacademic Hospitals

Purpose Although adherence to guidelines recommendations is assumed to be more difficult for nonacademic community hospitals, patterns of adherence have not been evaluated by hospital type. We sought to identify hospital characteristics associated with high levels of adherence in order to gain insight into successful processes of care. Methods From January 2001 through March 2004, we analyzed data from 86,042 patients in the CRUSADE Initiative with high-risk non–ST-segment elevation acute coronary syndromes (NSTE ACS) defined by positive cardiac markers or ischemic ST-segment changes. Academic sites were defined by Council of Teaching Hospital affiliation in the American Hospital Association database. Adherence was determined for each hospital based on guidelines recommendations for the use of 4 acute (<24 hrs) and 5 discharge therapies in patients without contraindications. Multivariable modeling was used to standardize hospital estimates for patient characteristics and control for clustering within centers. Results A total of 60,285 patients were admitted to nonacademic hospitals (n = 355), and 25,757 were admitted to academic hospitals (n = 125). Academic hospitals were larger (median 500 vs 268 beds, P <.001) and more often had bypass services (88% vs 60%, P <.001). Composite adherence to recommended therapies was slightly higher at academic vs. nonacademic hospitals (median 77.8% vs 73.7%, P <0.01), and variance in individual hospital performance was greater among nonacademic sites. Nonacademic hospitals accounted for 15 of the 20 highest performing sites and 19 of the 20 lowest performing sites. In-hospital clinical outcomes, including cardiogenic shock, stroke, and death were similar for patients admitted to both types of hospital. Conclusion Adherence to American College of Cardiology and American Heart Association (ACC/AHA) guidelines for NSTE ACS care at academic hospitals is slightly higher than at nonacademic hospitals; however there is significant room for improvement within both systems. The larger performance variation in care among nonacademic hospitals highlights the need for continued emphasis on consistent care processes.

Intrathoracic Far‐Field Electrocardiogram Allows Continuous Monitoring of Ischemia After Total Coronary Occlusion

Recording of intrathoracic far-field electrocardiograms (FF-ECG) via can and electrodes of implantable cardioverter-defibrillators (ICD) is a promising method for continuous monitoring of myocardial ischemia. We assessed the hypothesis that experimentally induced ischemia provokes segment changes in the FF-ECG that can be detected by the ICD. In seven pigs with an ICD implanted in the left pectoral region and electrodes placed in the right ventricle and the superior vena cava, we occluded all major coronary arteries in proximal and distal locations for 180 s each. Surface and FF-ECGs were compared for presence and time course of ischemic ST segment changes. Reliable detection of ischemia by ST segment analysis was possible in all (38/38) experiments. Maximum deviation from baseline was larger in FF-ECG (1.21 mV) than surface ECG leads (0.23 mV, P < 0.01) for all occlusion sites. Ischemia could be detected earlier (P < 0.05) in the FF-ECG, with a sensitivity of 100%, 93%, and 100% after occlusions in the left anterior descending, left circumflex, and right coronary arteries, respectively. Intrathoracic FF-ECG allows reliable and reproducible detection of experimentally induced ischemia originating from all major coronary arteries and therefore could be an interesting tool for clinicians in monitoring high risk patients.

Patterns of Guideline Adherence and Care Delivery for Patients with Unstable Angina and Non–ST-segment Elevation Myocardial Infarction (From the CRUSADE Quality Improvement Initiative)

The Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) initiative is a prospective, rapid-cycle quality-improvement initiative that focuses on improving both the diagnostic evaluation of patients with non-ST-segment elevation (NSTE) acute coronary syndromes (ACS; defined as ischemic ST-segment changes and/or positive cardiac markers) and the use of treatments recommended by the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for management of NSTE ACS. The ultimate goal of the CRUSADE initiative is to improve the quality of care among high-risk patients with NSTE ACS. At the same time, the CRUSADE initiative provides the unique opportunity to evaluate the pattern of NSTE ACS management in a large-scale, routine practice setting in the United States. Cumulatively, the CRUSADE initiative has collected data from >165,000 patients with NSTE ACS admitted at >400 US hospitals since 2001. This article reviews the major results from the CRUSADE initiative on risk stratification, gaps in guidelines adherence, paradoxical care, and the association of guideline adherence with outcomes.

Recent Trends in the Care of Patients With Non–ST-Segment Elevation Acute Coronary Syndromes

The extent to which national health quality improvement initiatives have altered reported treatment gaps among patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) is unknown. We sought to determine recent trends in adherence to guideline-based therapies for NSTE ACS. We evaluated the treatment of patients with high-risk (positive cardiac markers and/or ischemic ST-segment changes) NSTE ACS enrolled in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA (American College of Cardiology/American Heart Association) Guidelines (CRUSADE) Quality Improvement Initiative from 2002 through 2004 (a total of 113 595 patients over 11 calendar quarters). We analyzed adherence to guideline-recommended therapies, including medications used in the acute care period (<24 hours after presentation), invasive procedures, in-hospital outcomes, and discharge therapies and interventions. The use of each class I guideline recommendation, as well as overall adherence to the guidelines, improved significantly (P<.001) during the study period. In the acute care setting, the use of antiplatelet agents increased by 5% and beta-blockers by 12%; at hospital discharge, the use of antiplatelet agents increased by 3% and beta-blockers by 8%. Heparin use in the acute care period increased by 6%, largely owing to a 9% increase in the use of low-molecular-weight heparin. Use of glycoprotein IIb/IIIa inhibitors in the acute care period also increased by more than 13%. At discharge, clopidogrel use increased by 22%, lipid-lowering agents by 11%, and angiotensin-converting enzyme inhibitors by 5%. While adherence improved, many patients still failed to receive 100% indicated treatments at the end of the study period. During the 4 years since the initial release of the ACC/AHA guidelines for NSTE ACS, adherence to class I recommendations has significantly improved among hospitals participating in CRUSADE. Still, further improvements are needed for optimal implementation of the these guidelines.

The obesity paradox in non–ST-segment elevation acute coronary syndromes: Results from the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines Quality Improvement Initiative

Although obesity is a known risk factor for coronary artery disease, its impact on the presentation, treatment, and outcome of patients with acute coronary syndromes (ACS) has not been well studied. Using data from the CRUSADE Initiative, we compared inhospital treatments and clinical outcomes of 80845 patients with high-risk non-ST-segment elevation (NSTE) ACS (positive cardiac markers and/or ischemic ST-segment changes) to determine whether there was an association with body mass index (BMI [kg/m2]). Patient weights were categorized according to World Health Organization classifications: Underweight (BMI <18.5), Normal range (BMI 18.5-24.9), Overweight (BMI 25-29.9), Obese Class I (BMI 30-34.9), Obese Class II (BMI 35-39.9), and Extremely Obese (BMI =40). Most (70.5%) of the CRUSADE patients were classified as overweight or obese; these patients were younger and more likely to present with comorbid conditions, including diabetes mellitus, hypertension, and hyperlipidemia. Medications given during the first 24 hours and invasive cardiac procedures recommended by the American College of Cardiology/American Heart Association guidelines for NSTE ACS were more commonly used in these patients. The incidence of death and death and reinfarction, adjusted for covariates, were generally lower in overweight and obese patients, compared with normal-weight patients, but higher in underweight and extremely obese patients. Most patients with NSTE ACS are overweight or obese. These patients receive more aggressive treatment, and, except for the extremely obese, have less adverse outcomes compared with underweight and normal-weight patients. Although obesity appears to be a risk factor for developing ACS at a younger age, it also appears to be associated with more aggressive ACS management and, ultimately, improved outcomes.

Regional Outcomes After Admission for High-Risk Non-ST-Segment Elevation Acute Coronary Syndromes

Purpose An analysis of reginal variation across the United States in the treatment and outcomes of patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) has not been previously performed. Subjects and Methods We assessed contemporary practice and outcomes in 56,466 high-risk patients with NSTE ACS (positive cardiac markers and/or ischemic ST-segment changes) admitted to 310 hospitals across four defined regions in the United States from January 1, 2001, to September 30, 2003. Patient clinical characteristics, acute (<24 hours) and discharge medications, in-hospital procedures, and in-hospital case-fatality rates were evaluated. Results Statistically significant but clinically small differences in baseline characteristics including age, gender, rates of diabetes, hypertension, and smoking, as well as medical treatment, including a greater than 5% variation in acute use of beta-blockers, clopidogrel, and statins use, were noted across regions. Adjusted rates of revascularization were similar across regions. Overall in-hospital case-fatality rate was 4.1%, with the highest rates in the Midwest (4.6%) and the lowest in the Northeast (3.5%). Adjusted odds ratios (OR) (95% confidence interval [CI] for death were significantly higher in the Midwest (OR 1.42, CI 1.19-1.70), West (OR 1.40 CI 1.05-1.87), and South (OR 1.33, CI 1.08-1.62), compared with the Northeast. Conclusions Management of high-risk patients with NSTE ACS is relatively uniform across the United States. However, in-hospital case-fatality rates vary significantly by region, and the differences are not explained by adjustment for standard clinical variables.

The influence of risk status on guideline adherence for patients with non–ST-segment elevation acute coronary syndromes

Practice guidelines for patients with non-ST-segment elevation (NSTE) acute coronary syndromes (ACS) recommend targeting evidence-based therapies for the highest-risk patients. We characterized guideline adherence for NSTE ACS by risk status. We analyzed inhospital treatments and outcomes for 77760 patients with NSTE ACS (ischemic ST-segment changes and/or positive cardiac markers) included in the CRUSADE initiative from January 2001 to September 2003 at 457 US hospitals. Compliance with the American College of Cardiology/American Heart Association Class guideline recommendations for NSTE ACS was evaluated in subgroups of eligible patients without listed contraindications at increased risk for mortality and among risk categories designated by an adapted version of the PURSUIT risk model designed to predict inhospital mortality. Inhospital mortality was increased in patients with diabetes mellitus (5.8% vs 4.3%), renal insufficiency (10.0% vs 3.9%), signs of congestive heart failure on presentation (10.6% vs 3.1%), and age > or = 75 years (8.6% vs 2.7%), compared with patients without these features. Use of guideline-recommended acute medications, invasive cardiac procedures, and discharge medications and interventions was significantly lower in patients with these high-risk features. Patients designated as high-risk for inhospital mortality were less likely to be treated with guideline-recommended therapies compared with low-risk and moderate-risk patients. Patients with NSTE ACS with the highest risk of mortality are less likely to receive guideline-recommended therapies and interventions. These findings highlight the need to clarify guideline recommendations for high-risk patients and to develop novel quality improvement approaches that target undertreated subgroups of patients with NSTE ACS.

Low-molecular-weight heparin compared with unfractionated heparin for patients with non–ST-segment elevation acute coronary syndromes treated with glycoprotein IIb/IIIa inhibitors: Results from the CRUSADE initiative

Both heparin and glycoprotein (GP) IIb/IIIa inhibitor therapy and early invasive management strategies are recommended by the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for the treatment of patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS). However, controversy exists about which form of heparin-unfractionated (UF) or low-molecular-weight (LMW)-is preferable. We sought to compare the efficacy and safety of these treatment strategies in a large contemporary population of patients with NSTE ACS. Using data from the CRUSADE Initiative, we evaluated LMWH and UFH in high-risk NSTE ACS patients (positive cardiac markers and/or ischemic ST-segment changes) who had received early (< 24 hours) GP IIb/IIIa inhibitor therapy and underwent early invasive management. In-hospital outcomes were compared among treatment groups. From a total of 11,358 patients treated at 407 hospitals in the US from January 2002-June 2003, 6881 (60.6%) received UFH and 4477 (39.4%) received LMWH. Patients treated with UFH were more often admitted to a cardiology inpatient service (73.6% vs. 65.5%, P < 0.0001) and more frequently underwent diagnostic catheterization (91.8% vs. 85.9%, P < 0.0001) and percutaneous coronary intervention (PCI) (69.7% vs. 56.9%, P < 0.0001) than patients treated with LMWH. The point estimate of the adjusted risk of in-hospital death or reinfarction was slightly lower among patients treated with LMWH (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.67-0.99) and the risk of red blood cell transfusion was similar (OR 1.01, 95% CI 0.89-1.15). Among patients who underwent PCI within 48 hours, adjusted rates of death (OR 1.14, 95% CI 0.71-1.85), death or reinfarction (OR 0.93, 0.67-1.31), and transfusion (OR 1.16, 0.89-1.50) were similar. Patients who underwent PCI more than 48 hours into hospitalization had reduced rates of death (OR 0.64, 0.46-0.88), death or reinfarction (OR 0.57, 0.44-0.73), and transfusion (OR 0.66, 0.52-0.84). In routine clinical practice, patients treated with GP IIb/IIIa inhibitors have slightly improved outcomes and similar bleeding risks with LMWH than with UFH. These findings are consistent with current ACC/AHA guidelines but raise important questions about the safety and effectiveness of antithrombotic therapy in real-world clinical practice. Using data from the CRUSADE Initiative, we evaluated low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) in high-risk patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) who received early (<24 hours) glycoprotein (GP) IIb/IIIa inhibitors and early invasive management. In-hospital outcomes were compared among treatment groups. LMWH was associated with slightly improved clinical outcomes and similar rates of transfusion compared with UFH. Our results support the current ACC/AHA guidelines recommendations but raise concerns about the safety and efficacy of UFH in the setting of background use of upstream GP IIb/IIIa inhibitors for patients with NSTE ACS in routine clinical practice.