Management Of Myocardial Infarction Research Articles

Prehospital management of acute coronary syndrome in patients on long-term direct oral anticoagulant treatment

Despite an increasing incidence of patients suffering from acute coronary syndrome (ACS) under simultaneous treatment with direct oral anticoagulants (DOAC), neither sufficient scientific data nor uniform guidelines for the anticoagulation treatment of these patients are currently available. The aim of this study was to determine the current practice of preclinical treatment of ACS in patients under DOAC treatment. An internet and paper-based survey of emergency physicians, specialists of internal medicine, anesthesiologists, emergency and intensive care physicians was performed concerning the prehospital treatment of ACS in patients under long-term DOAC treatment. Overall, 284 questionnaires were answered. Substantial differences in the current treatment of ACS under long-term DOAC therapy were identified. While 39% of the respondents stated that they administer a combination treatment of heparin and acetylsalicylic acid (ASA), 36% renounced the administration of heparin. If a dose reduction was performed, 71% answered that they reduce the heparin dosage. Also, in cases of ST-segment elevation myocardial infarction 48% of the physicians renounced the administration of heparin. In Germany there is currently aheterogeneous practice of emergency treatment of ACS patients under DOAC therapy with respect to the administration of heparin and ASA. Therefore, guidelines of the specialist medical societies should address the prehospital emergency anticoagulation management of ACS in patients under therapy with DOAC, which correspond to the needs of patients and emergency physicians.

Adherence / Compliance to the Standard Guidelines for Management of Acute Coronary Syndrome – Tertiary Care Centre Study

Adherence / Compliance to the Standard Guidelines for Management of Acute Coronary Syndrome – Tertiary Care Centre Study

P.275 Early life exposome pressure on later life immune fitness: a layman's perspective

The management of chronic cardiovascular diseases has evolved greatly in the last decades. Over the last thirty years, the management of acute coronary syndrome has improved, leading to an important lowering of the mortality in the acute phase of the event. Consequently, the optimal management of the secondary prevention of acute coronary syndrome has greatly evolved. Moreover, the increased number of pharmacological alternatives for patients affected by chronic heart failure and by non-valvular atrial fibrillation reserves a number of challenges for their correct management. Moreover, these diseases are without any reasonable doubt the largest contributor to global mortality in the present and will continue to be it in the future.The aim of this study was to provide the most updated information of the real-life drug use and their effectiveness. This review was performed to assess the potential knowledge gaps in the treatments of these diseases and to indicate potential perspective of pharmaco-epidemiological research in this area.

Challenges in Managing Acute Cardiovascular Diseases and Follow Up Care in Rural Areas: A Narrative Review.

This narrative review explores relevant literature that is related to the challenges in implementing evidence-based management for clinicians in rural and remote areas, while primarily focussing on management of acute coronary syndrome (ACS) and follow up care. A targeted literature search around rural/urban differences in the management of ACS, cardiovascular disease, and cardiac rehabilitation identified multiple issues that are related to access, including the ability to pay, transport and geographic distances, delays in patients seeking care, access to diagnostic testing, and timely treatment in an appropriate facility. Workforce shortages or lack of ready access to relevant expertise, cultural differences, and complexity that arises from comorbidities and from geographical isolation amplified diagnostic challenges. Given the urgency in management of ACS, rural clinicians must act quickly to achieve optimal patient outcomes. New technologies and quality improvement approaches enable better access to rapid diagnosis, as well as specialist input and care. Achieving an uptake of cardiac rehabilitation in rural and remote settings poses challenges that may reduce with the use of alternative models to centre-based rehabilitation and use of modern technologies. Expediting improvement in cardiovascular outcomes and reducing rural disparities requires system changes and that clinicians embrace attention to prevention, emergency management, and follow up care in rural contexts.

Trends of Use and Outcomes Associated With Glycoprotein-IIb/IIIa Inhibitors in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention.

Background: Glycoprotein IIb/IIIa inhibitors (GPIs) are a treatment option in the management of acute coronary syndromes (ACSs). Evidence supporting the use of GPIs predates trials establishing the benefits of P2Y12 inhibitors, routine early invasive therapy, and thrombectomy devices in patients with ACS. Objective: The aim of this study was to determine trends in GPI use and their associated outcomes in contemporary practice. Methods: We assessed GPI use in patients with ACS undergoing percutaneous coronary intervention (PCI) from the Melbourne Interventional Group registry (2005-2013). The primary endpoint was the 30-day incidence of major adverse cardiovascular events (MACE). The safety endpoint was in-hospital major bleeding. Results: GPIs were used in 40.5% of 12 357 patients with ACS undergoing PCI. GPI use decreased over the study period (P for trend <0.0001). Patients were more likely to receive GPIs if they were younger, presented with a ST-elevation myocardial infarction (STEMI), had more complex (B2/C-type) lesions, and when thrombectomy devices were used (all P < 0.0001). MACE were higher in patients receiving GPI (4.9% vs 4.1%, P = 0.03). Propensity score matching revealed no difference in 30-day mortality and 30-day MACE (odds ratio [OR] = 1.00; 95% CI = 0.99-1.004 and OR = 1.01; 95% CI = 0.99-1.02, respectively). GPI use was associated with more bleeding complications (3.6% vs 1.8%, P < 0.0001). Conclusion and Relevance: GPI use in ACS patients undergoing PCI has declined, and use appears to be dictated by ACS type and lesion complexity, as opposed to high-risk comorbidities. GPI use was associated with a doubling in bleeding complications.

Risk stratification in acute coronary syndrome: Evaluation of the GRACE and CRUSADE scores in the setting of a tertiary care centre.

ObjectiveRisk assessment plays a decisive role in the management of acute coronary syndrome (ACS). The GRACE and the CRUSADE scores are among the most frequently used risk assessment tools. We aimed to compare the performance of the GRACE and CRUSADE risk scores to predict in‐hospital mortality and major bleeding in a contemporary ACS population at a high‐volume academic hospital.MethodsAll patients treated for ACS from January 1, 2006 to December 31, 2015 at a tertiary care centre were prospectively enrolled. We calculated GRACE and CRUSADE risk scores. We compared the discrimination capacity of both scores for in‐hospital mortality and major bleeding.ResultsIn total 4087 patients (1151 [28.2%] female; age 62 ± 14 years) were included. Among these 2218 (54.3%) were diagnosed with ST‐elevation myocardial infarction, 113 (2.8%) died in hospital and major bleeding occurred in 65 (1.6%). Discrimination capacity for in‐hospital mortality of the GRACE score was superior to the CRUSADE score (receiver operator characteristic area under the curve (AUC) 0.91 (95% CI 0.89‐0.93) vs 0.83 (95% CI 0.80‐0.86); P < .01). Performance for major bleeding differed but was poor for both scores (AUC 0.71 [0.65‐0.76] for GRACE vs 0.61 [0.55‐0.68] for CRUSADE; P < .01).ConclusionThe GRACE score appears to be superior over CRUSADE to predict in‐hospital mortality. Major bleeding is rare in the era of primary PCI and performance of both scores for this outcome was poor.

A systematic review of randomized trials comparing double versus triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention.

Prior randomized controlled trials (RCT) evaluating the optimal antithrombotic therapies for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) have not been powered to evaluate ischemic outcomes. We compared double therapy with oral anticoagulation (OAC) and a P2Y12 inhibitor to triple therapy with an OAC + dual antiplatelet therapy in patients with AF requiring PCI. Using PRISMA guidelines, we searched for RCTs including patients with AF as an indication for OAC and undergoing PCI or medical management of acute coronary syndrome. The results were pooled using fixed-effects and random-effects models to estimate the overall effect of double therapy versus triple therapy on ischemic and bleeding outcomes. We identified four RCTs, comprising 10,238 patients (5,498 double therapy, 4,740 triple therapy). Trial-reported major adverse cardiovascular events were similar between double therapy and triple therapy (fixed effect model OR 1.09, 95% CI 0.94-1.26). However, stent thrombosis (61/5,496 double therapy vs. 33/4738 triple therapy; fixed effect model OR 1.57, 95% CI 1.02-2.40; number needed to treat with triple therapy = 242) favored triple therapy. Bleeding outcomes were less frequent with double therapy (746/5470 vs. 950/4710; fixed effect model OR 0.59, 95% CI 0.53-0.65; number needed to harm with triple therapy = 16), but with significant heterogeneity (Q = 8.33, p = .04; I2 = 64%), as were intracranial hemorrhages (19/5470 vs. 30/4710; fixed effect model OR 0.54, 95% CI 0.31-0.96). Double therapy in patients with AF requiring OAC following PCI or Acute coronary syndrome has a significantly better safety profile than triple therapy but may be associated with a modest increased risk of stent thrombosis.

MANAGEMENT OF ACUTE CORONARY SYNDROMES BEYOND THE FIRST YEAR: A CANADIAN CLINICAL PRACTICE SURVEY

The literature pertaining to the long-term antithrombotic management of acute coronary syndrome (ACS) patients has evolved significantly. However, given lingering uncertainty as to when an ACS patient might be considered a stable coronary disease patient, there is the possibility of diverging practices in the long-term care of ACS. Our goal was therefore to assess self-reported physician practice pertaining to the antithrombotic management of ACS patients without a formal indication for therapeutic anticoagulation.

Out-of-hospital management of acute coronary syndromes

In Europe, the biological and healthcare costs of acute coronary syndrome (ACS) are extremely high. For this reason, the Emergency Medical Service of the Lombardy Region (AREU Lombardy) has defined a "mission" that can partly resolve this issue, through an accurately balanced clinical/organizational plan of territorial medical rescue. The territorial and housing complexity of the Region has conditioned the recent strategic choices, that have foreseen the alignment to Europe with the introduction of the 1st level Public Safety Answering Point (NUE 1.1.2.), for the exact localization of the event, and its subsequent management by the Operations Centers of the Emergency Medical System with the dispatch of the most suitable rescue vehicles, all of which are capable of carrying out a 12-lead ECG for cardiology diagnostics. Furthermore, in order to meet the European quality requirements, all the rescuers are specifically trained to treat ACS, the healthcare professionals employed in the rescue are all "specialists", and a standard pharmacological treatment is administered prior to arrival at the hospital. As a result of this rescue organization, 78 425 12-lead ECGs were performed in Lombardy in 2018, subsequent to emergency calls; of the 52 528 cases of chest pain, the potential ACSs detected in the area were 41 220, of which 4980 confirmed in the emergency departments through the subsequent refined instrumental and laboratory diagnostics. The diagnoses of ST-elevation myocardial infarction at the territorial point of care were 1833, and all the events were pharmacologically pretreated in the territorial setting, according to the AREU procedure. In Lombardy, the out-of-hospital management of ACS is strictly aligned with the standards of the Ministerial Decree no. 70 of 2015 and follows a well-defined track, aimed at meeting the current quality goals and the performance indicators of this pathology. This track surely needs to be improved through the concerted effort by all the healthcare stakeholders in order to univocally define the outcome indicators, which at present are not yet perfectly defined.

P2678Performance of the European society cardiology 0/1-hour algorithm in the diagnosis of myocardial infarction with high-sensitivity cardiac troponin T: meta-analysis

Abstract Introduction A rapid rule-out or rule-in protocol based on the 0-hour/1-hour algorithm using high-sensitivity cardiac troponin T (hs-cTnT) is recommended by the European Society of Cardiology (ESC), and recently multiple studies have validated it in their settings. We conducted a systematic review and meta-analysis with the aim of assess the diagnostic accuracy of the 2015 ESC guidelines for management of acute coronary syndrome (ACS) in patients without ST-segment elevation's 0-/1-hour algorithm using hs-cTnT for the early rule-out and rule-in of acute myocardial infarction (AMI) on presentation. For the secondary analysis we evaluate cumulative mortality at 30 days. Methods We carried out a systematic review and meta-analysis of prospective studies involving adults presenting to the emergency department with possible ACS in which hs-cTnT measurements were obtained according to the ESC algorithm and AMI outcomes were adjudicated during the initial hospitalization. We searched MEDLINE, EMBASE, Cochrane database and LILACS, and unpublished abstracts presented in international congresses from 2015 to November 2018.To obtain estimates of sensitivity and specificity, with corresponding 95% confidence intervals (CI), we used a bivariable random-effects model. Summary receiver operating characteristic curves were drawn, plotting individual studies as well as the summary estimate. Results Seven studies involving 9251 patients were identified. The summary sensitivity of these tests in diagnosing acute MI at presentation to the emergency department was estimated to be 99.1% (95% CI 97.2–99.7%) and the summary specificity was 92.5% (95% CI 86.6–95.9%). With a false positive rate of 0.075 (95% CI 0.041–0.134), diagnostic odds ratio (DOR) of 1293.1 (95% CI −52.48 to 2638.5), and Likelihood Ratio (LR) +13.193 (95% CI 5.3–21, and LR −0.010 (95% CI −0.001 to 0.021). Cumulative mortality at 30 days in the rule-out group was 0,08% (4 studies; n=3715). Conclusion The European Society Cardiology 0-Hour/1-Hour Algorithm using High-Sensitivity Cardiac Troponin T has high diagnostic accuracy, it allows safe rule-out as well as accurate rule-in of acute myocardial infarction. With low cumulative 30-day mortality in patients assigned the rule-out zone.

P1731High-sensitivity troponin with sex-specific thresholds in suspected acute coronary syndrome

Abstract Background/Introduction Major disparities between women and men in the diagnosis, management and outcome of acute coronary syndrome are well recognised. Whether sex-specific diagnostic thresholds for myocardial infarction will address these differences is uncertain. Purpose To evaluate the impact of implementing a high-sensitivity cardiac troponin I (hs-cTnI) assay with sex-specific diagnostic thresholds for myocardial infarction in women and men with suspected acute coronary syndrome. Methods In a stepped-wedge, cluster-randomized controlled trial across ten hospitals we evaluated the implementation of a hs-cTnI assay in 48,282 (47% women) consecutive patients with suspected acute coronary syndrome. During a validation phase the hs-cTnI assay results were suppressed and a contemporary cTnI assay with a single threshold was used to guide care. Myocardial injury was defined as any hs-cTnI concentration &gt;99th centile of 16 ng/L in women and 34 ng/L in men. The primary outcome was myocardial infarction after the initial presentation or cardiovascular death at 1 year. In this prespecified analysis, we evaluated outcomes in men and women before and after implementation of the hs-cTnI assay. Results Use of the hs-cTnI assay with sex-specific thresholds increased myocardial injury in women by 42% (from 3,521 (16%) to 4,991 (22%)) and by 6% in men (from 5,068 (20%) to 5,369 (21%)). Whilst treatment increased in both sexes, women with myocardial injury remained less likely than men to undergo coronary revascularisation (15% versus34%), or to receive dual anti-platelet (26% versus43%), statin (16% versus26%) or other preventative therapies (P&lt;0.001 for all). The primary outcome occurred in 18% (369/2,072) and 17% (488/2,919) of women with myocardial injury during the validation and implementation phase respectively (adjusted hazard ratio 1.11, 95% confidence interval 0.92 to 1.33), compared to 18% (370/2,044) and 15% (513/3,325) of men (adjusted hazard ratio 0.85, 95% confidence interval 0.71 to 1.01). Patient management Conclusion Use of sex-specific thresholds identified five-times more additional women than men with myocardial injury, such that the proportion of women and men with myocardial injury is now similar. Despite this increase, women received approximately half the number of treatments for coronary artery disease as men and their outcomes were not improved. Acknowledgement/Funding The British Heart Foundation

Sex-Specific Thresholds of High-Sensitivity Troponin in Patients With Suspected Acute Coronary Syndrome

BackgroundMajor disparities between women and men in the diagnosis, management, and outcomes of acute coronary syndrome are well recognized. ObjectivesThe aim of this study was to evaluate the impact of implementing a high-sensitivity cardiac troponin I assay with sex-specific diagnostic thresholds for myocardial infarction in women and men with suspected acute coronary syndrome. MethodsConsecutive patients with suspected acute coronary syndrome were enrolled in a stepped-wedge, cluster-randomized controlled trial across 10 hospitals. Myocardial injury was defined as high-sensitivity cardiac troponin I concentration >99th centile of 16 ng/l in women and 34 ng/l in men. The primary outcome was recurrent myocardial infarction or cardiovascular death at 1 year. ResultsA total of 48,282 patients (47% women) were included. Use of the high-sensitivity cardiac troponin I assay with sex-specific thresholds increased myocardial injury in women by 42% and in men by 6%. Following implementation, women with myocardial injury remained less likely than men to undergo coronary revascularization (15% vs. 34%) and to receive dual antiplatelet (26% vs. 43%), statin (16% vs. 26%), or other preventive therapies (p < 0.001 for all). The primary outcome occurred in 18% (369 of 2,072) and 17% (488 of 2,919) of women with myocardial injury before and after implementation, respectively (adjusted hazard ratio: 1.11; 95% confidence interval: 0.92 to 1.33), compared with 18% (370 of 2,044) and 15% (513 of 3,325) of men (adjusted hazard ratio: 0.85; 95% confidence interval: 0.71 to 1.01). ConclusionsUse of sex-specific thresholds identified 5 times more additional women than men with myocardial injury. Despite this increase, women received approximately one-half the number of treatments for coronary artery disease as men, and outcomes were not improved. (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome [High-STEACS]; NCT01852123).

Inflammation as a universal pathogenetic link between injury, repair and regeneration, in acute coronary syndrome. From experiment to clinic

Theory of atherogenesis and its complications underwent numerous changes. Today we observe that inflammation is a universal pathogenetic link between various processes such as atherosclerosis, rupture of atherosclerotic plaques and following myocardial infarction, post-infarction cardiac repair and heart failure. This review discusses examples, difficulties, and prospects of implementation of anti-inflammatory therapies in management of acute coronary syndrome and its complications.

Use of Glycoprotein IIb/IIIa Inhibitors in the Modern Era of Acute Coronary Syndrome Management: A Survey of Cardiovascular Clinical Pharmacists

Evidence for the use of glycoprotein IIb/IIIa inhibitors (GPIs) in the management of acute coronary syndrome (ACS) is from the era of either limited utilization of P2Y12 inhibitors or prior the introduction of more potent P2Y12 inhibitors. This leads to divergent opinions regarding the role of these agents in contemporary practice. This study sought the opinion of cardiovascular clinical pharmacists regarding the role of GPIs in the modern of ACS management. A 13-question survey was created and distributed from June 2018 to July 2018 via the American College of Clinical Pharmacy’s Cardiology Practice and Research Network e-mail listserv. The survey consisted of questions regarding the ideal use of GPIs in ACS management, preferred agent selection, and rational for selection. All results were analyzed with descriptive statistics. There were a total 69 responses of 1175 (response rate 5.9%). The majority felt there was still a role for GPI in accordance to the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for ST-segment elevation myocardial infarction (65.2%), with eptifibatide being preferred (55.1%). For non-ST-segment myocardial infraction (NSTEMI), only 49.3% felt role of GPI was in line with the ACC/AHA guidelines, but a notable number of respondents felt GPIs were only indicated in NSTEMI patients for bailout or thrombotic complications (18.8%). A majority (56.5%) felt GPIs could be used as an alternative for cangrelor when bridging. The decision to use one agent over another were efficacy data, cost, and pharmacokinetic profile.

Cardiovascular Disease in Antiphospholipid Syndrome.

Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by venous, arterial or microvascular thrombosis or obstetric events in the presence of persistently positive antiphospholipid antibodies and constitutes a major cause of cardiovascular events in young people. Τhis review highlights the pathophysiology of cardiovascular complications in patients with APS and possible treatment options. Patients with APS have endothelial dysfunction, accelerated endothelial proliferation and intimal hyperplasia, atherogenesis, platelet activation, inflammatory products secretion and coagulation-fibrinolytic dysregulation. Cardiovascular complications include accelerated atherosclerosis, acute coronary syndrome, Libman-Sacks endocarditis, cardiomyopathy and venous, arterial or intracardiac thrombi. Moreover, pulmonary hypertension and peripheral microvascular dysfunction are common findings. Management of these patients is not well documented. The role of primary thrombosis prevention remains controversial in individuals with positive antiphospholipid antibodies. Treatment of traditional cardiovascular risk factors according to current guidelines for the prevention of cardiovascular disease in the general population is recommended for primary prevention of APS. Anticoagulation therapy with unfractionated or low-molecular-weight heparin overlapped with a vitamin K antagonist remains the mainstay of the treatment for APS patients with venous thrombosis, whereas direct oral anticoagulants are not yet recommended. Data are scarce regarding the secondary arterial thrombosis prevention and it is not clear whether dual or triple antithrombotic therapy is necessary. To date, it is recommended to follow current guidelines for the management of acute coronary syndrome in the general population. New treatment targets are promising options for patients with catastrophic APS.

Association of Thrombolysis in Myocardial Infarction (TIMI) Risk Score with Angiographic Severity of Coronary Artery Disease In Patients with Non-ST Elevation Acute Coronary Syndrome

Background: Clinical guidelines recommend that optimal management of acute coronary syndrome (ACS) should include patient risk stratification. Predicting the anatomical extension of coronary artery disease (CAD) is also potentially useful for clinical decision.&#x0D; Objective: The objective of our study was to determine whether the TIMI risk score correlates with the angiographic extent and severity of CAD in patients with NSTE- ACS.&#x0D; Materials and Methods: This was a cross-sectional observational study carried out in the Department of Cardiology, Chattogram Medical College Hospital (CMCH) from September 2017 to May 2018. A total of 200 patients diagnosed with NSTE- Acute Coronary Syndrome were included as sample by purposive sampling method. TIMI risk score for each patient was calculated and the patients were stratified into 3 groups according to the TIMI risk score: low risk (0-2); intermediate risk (3-4); high risk (5-7). The severity of the CAD was assessed by Vessel score and Gensini score.&#x0D; Result: The mean ± SD of the age of study population was 53.7 ±10.8 years (range 37–77) and 142 (71%) were male. Regarding cardiovascular risk factors, 137 (68.5%) patients had diabetes mellitus, 83 (41.5%) had dyslipidaemia, 155 (77.5%) had hypertension, 136 (68%) were current smoker and 70 (35%) had a family history of CAD. The Gensini score was higher in patients at high risk TIMI group (p&lt;0.001). Moreover, there was a signiûcant positive correlation between the TIMI and Gensini score (r=0.446,p&lt;0.001). TIMI score can predict significant CAD moderately well (area under the curve 0.661, p=0.001). Patients with TIMI score &gt; 4 were more likely to have significant three vessel CAD (65.9%) versus those with TIMI risk score 3-4 (17.9%) and TIMI risk score &lt; 3 (2%) (p&lt; 0.001).&#x0D; Conclusion: Study showed the TIMI score is significantly correlated with the extent of CAD as assessed by the Gensini score. It is accurate for predicting severe CAD among NSTE-ACS patients.&#x0D; University Heart Journal Vol. 15, No. 2, Jul 2019; 68-73

Intracoronary imaging for the diagnosis of the underlying substrate and clinical management of acute coronary syndromes: from evidence to expert consensus … and back!

Intracoronary imaging for the diagnosis of the underlying substrate and clinical management of acute coronary syndromes: from evidence to expert consensus … and back!

Predictors of 90-Days Readmissions for New Onset Heart Failure after Acute Coronary Syndrome

Background Coronary heart disease is one of the leading risk factors for the development of heart failure (HF). Despite major improvements in the management of acute coronary syndromes (ACS), HF remains the most common cause of readmission after ACS, followed by myocardial re-infarction. We sought to evaluate the risks and predictors for HF admission after ACS. Methods Using the national readmission database (NRD), we examined discharge data from 2010 until 2015 and identified all patients age 18 years and older with ACS recorded as the primary discharge diagnosis; we then excluded all patients with a prior diagnosis of HF. Chi-square test and Wilcoxon rank-sum test were used to compare proportions and continuous variables, respectively. We used logistic regression modeling to estimate the unadjusted odds of readmission for the covariates of interest. Results We identified 1,322,335 patients discharged after an ACS (36.2% STEMI). Of these, 56,345 (4.2%) were readmitted within 90-days with a new primary diagnosis of HF. The most common individual risk factors associated with HF admission were the presence of atrial fibrillation (OR 1.71), diabetes (OR 1.62) and lung disease (OR 1.49). The most common predictors for HF admission were STEMI (OR 1.28), development of acute kidney injury (AKI) (OR 1.49), length of stay > 5 days (OR 1.77) and discharge against medical advice (OR 1.88). Revascularization during index admission for ACS was a strong predictor against HF admission (OR of 0.61 and 0.49 for PCI and CABG respectively). Self-pay or private insurance were also associated with lower rates of HF admissions (OR 0.68 and 0.57, respectively). Conclusions Readmission for new-onset HF occurs in close to 5% of patients after ACS. The presence of atrial fibrillation, diabetes, development of AKI or prolonged hospitalization identifies a higher risk cohort at the time of discharge.

Endothelial Cells Strengthening: Improving Functions in Management of Acute Coronary Syndrome (A Double Blind Randomized Interventional Control Trial)

Objective: Endothelial dysfunction/injury is the main reason for Acute Coronary Syndrome (ACS). Current therapy includes antiplatelet, lipid lowering and thrombus removal by drugs/ intervention. Endothelial strengthening in management of ACS is less narrated in literature. This study describes endothelial strengthening and clinical outcome in ACS with Triphala powder, a mixture of Amla (Phyllanthus emblica), Harad (Terminalia chebula), and Behda (Terminalia bellirica). Methods: This is a double blind randomized interventional control trial. 80 cases coming to the emergency department were selected for study, divided into two groups. Group 1 (n=40, control), group 2 (n=40, study). Further subdivided into subgroup 1A and 2A ST-Elevation Myocardial Infarction (STEMI) and subgroup 1B and 2B Unstable Angina (UA). All subgroups were given clopidogrel, aspirin and atorvastatin and subjected to thrombolysis or Coronary Angiography (CAG) according to requirement. In addition study group was given Triphala powder 10 grams in a cup of water. Outcome was observed for relief in chest pain, ECG, Echocardiography changes at 50 minutes; (SSR) Sympathetic Skin Response was done initially. Statistical analysis was done by SPSS 20 software. Results: In intervention subgroups 2A and 2B there was significant relief in chest pain, settling down of ECG changes, and improvement in regional wall motion in echocardiography (p&lt;0.001). There was increased sympathetic activity in all subgroups (spike response in SSR). Conclusion: Sudden mismatch in ATP (Adenosine Triphosphate) supply results in endothelial dysfunction. It occurs primarily due to increase in sympathetic discharge. Endothelial dysfunction results in UA/STEMI. Triphala increases ATP synthesis by increasing mitochondrial capacity to maximum; strengthens endothelium which behaves like normal endothelium and resolves symptoms and signs of ACS.

Effects of obstructive sleep apnea on inflammatory markers in patients with acute coronary syndrome

Objective To examine the prevalence of obstructive sleep apnea (OSA) in patients with acute coronary syndrome (ACS), and to evaluate the relationship of OSA with inflammatory biomarkers in ACS patients. Methods Patients with ACS treated at Beijing Anzhen Hopital from June 2015 to May 2017 were enrolled. Subjects were evaluated for OSA by sleep study, and were divided into a normal-mild OSA group (Apnea Hypopnea Index, AHI < 15 times/h) and a moderate-severe OSA group (AHI≥15 times/h). Laboratory examination and sleep study were monitored to analyze the effects of OSA on biomarkers by LSD-t test, Mann-whitney U test, or Chi-square test. Correlation analysis was performed to analyze the association of OSA with high sensitivity C-reactive protein (hs-CRP) by Spearman correlation anaylsis. Results A cohort of 836 patients with ACS were enrolled including 408 patients in the normal-mild OSA group and 428 patients in the moderate-severe OSA group. The levels of leukocyte(×109L) [7.78 (6.33, 9.86) vs 7.29 (6.01, 9.16), P=0.006], neutrophils(×109L) [5.05 (3.84, 7.23) vs 4.80 (3.74, 6.66), P=0.044], monocytes(×109L) [0.42 (0.33, 0.54) vs 0.39 (0.31, 0.51), P=0.033], hs-CRP(mg/L) [3.18 (1.10, 11.52) vs 1.78 (0.65, 6.46), P<0.01], fibrinogen(g/L) [3.17 (2.87, 3.74) vs 2.97 (2.59, 3.50), P=0.002], and uric acid(μmol/L) [360 (302, 422) vs 341(283, 407), P=0.006] in the moderate-severe OSA group were significant higher than those in the normal-mild OSA group. AHI (correlation coefficient=0.171, R2=0.020, P<0.01), ODI (correlation coefficient = 0.201, R2=0.027, P<0.01), and TSaO2 < 90% (correlation coefficient = 0.105, R2=0.005, P<0.01) were positively correlated with hs-CRP; minimal SaO2 (correlation coefficient=-0.100, R2=0.001, P=0.008) and mean SaO2 (correlation coefficient = -0.127, R2= 0.006, P<0.01) were negatively correlated with hs-CRP. Conclusions For patients with ACS, the level of inflammatory markers in the moderate-severe OSA group is significantly higher than that in the normal-mild OSA group. Hs-CRP is significantly associated with the severity of OSA. Diagnosis and monitoring of OSA should be considered in ACS management in the future. Key words: Acute coronary syndrome; Obstructive sleep apnea; Inflammatory marker; C-reactive protein