Management Of Myocardial Infarction Research Articles

Whats new in 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST segment elevation?

The article sumarizes the 2020 ESC Guidelines for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation. The diagnostics of ACS consists in assessment of chest pain, EKG and cardiac troponin. Troponin should be evaluated by high sensitivity assay. 0h/1h algorithms should be used to rule-in or rule-out ACS. Patients with a positive troponin have higher risk of cardivascular events and mortality and the early invasive treatment should be applied in these patients. In the guidelines several antithrombotic stretegies for different clinical conditions are mentioned, where the cornerstone for the length and intensity of antithrombotic treatment is the evaluation of bleeding risk. Further on the revascularization aspects and strategies are debated in the guidelines. Finally there are mentioned two specific conditions of ACS - Myocardioal infarction with non-obstructive coronary arteries and Spontaneous coronary artery dissection.

Utility of the strain in the management of acute coronary syndrome: Report of clinical case of a spontaneous hematoma of coronary artery: [[es]]Utilidad del strain en el manejo del síndrome coronario agudo: a propósito de un caso de hematoma espontáneo de arteria coronaria

Utility of the strain in the management of acute coronary syndrome: Report of clinical case of a spontaneous hematoma of coronary artery: [[es]]Utilidad del strain en el manejo del síndrome coronario agudo: a propósito de un caso de hematoma espontáneo de arteria coronaria

Saudi Heart Association Position Statement on the Use of Biomarkers for the Management of Heart Failure and Acute Coronary Syndrome.

BackgroundThe burden of acute coronary syndrome (ACS) and heart failure (HF) remains high in Saudi Arabia. Biomarkers can greatly improve the management and outcomes of these conditions, but no official guidance is available on their use in Saudi Arabia.Consensus panelAn expert panel of cardiologists, interventional cardiologists and cardiac surgeon reviewed available evidence and formulated recommendations relevant to clinical practice in Saudi Arabia.Consensus findingshigh-sensitivity cardiac troponins play a major role in the diagnosis of ACS and the exclusion of myocardial infarction in patients with HF. Natriuretic Peptides are recommended to determine the likelihood of a diagnosis of HF in a chronic setting and rapidly exclude HF in an acute setting. High-sensitivity cardiac troponins and NT-proBNP have good prognostic ability in ACS and HF. These biomarkers could also facilitate discharge planning and reduce unnecessary hospital admissions and resource wastage. The use of biomarkers should not be excessive and should abide by appropriateness criteria. High-sensitivity assays and NT-proBNP measurements are preferred.ConclusionBy outlining expert recommendations on the best practices in the use of biomarkers, the panel hopes to contribute towards a recognized updated guidance for all healthcare providers in Saudi Arabia on the evidence-based management of HF and ACS.

Development and Use of a Cardiac Clinical Guideline Mobile App in Australia: Acceptability and Multi-Methods Study.

BackgroundImplementation of clinical guidelines into routine practice remains highly variable. Strategies to increase guideline uptake include developing digital tools and mobile apps for use in clinical practice. The National Heart Foundation of Australia in collaboration with the Cardiac Society of Australia and New Zealand published 3 key cardiac clinical guidelines, including the Australian clinical guidelines for the (1) prevention and detection of atrial fibrillation, (2) detection and management of heart failure, and (3) management of acute coronary syndromes. To improve access and uptake for health care providers, we developed the Smart Heart Guideline App.ObjectiveThis study aims to evaluate the acceptability, implementation, and usability of an Australian-specific cardiac guidelines mobile app.MethodsWe used an iterative multiple methods development and implementation approach. First, we conducted a cross-sectional web-based survey with end users (n=504 health professionals) in 2017 to determine the acceptability of an Australian-specific cardiac clinical guidelines mobile app. Second, the Smart Heart Guidelines app was created using a design, user testing, and revision process. The app includes interactive algorithms and flowcharts to inform diagnosis and management at the point of care. The freely available app was launched in October 2019 on iOS and Android operating systems and promoted and implemented using multiple methods. Third, data from 2 annual national cross-sectional general practitioner (GP) surveys in 2019 and 2020 were evaluated to understand the awareness and use of the clinical guidelines and the app. Fourth, data from the app stores were analyzed between October 1, 2019, and June 30, 2021, to evaluate usage.ResultsMost health professionals surveyed (447/504, 89%) reported accessing resources electronically, and most (318/504, 63%) reported that they would use an Australian-specific cardiac guidelines app. GPs surveyed in 2019 were aware of the heart failure (159/312, 51%) and atrial fibrillation (140/312, 45%) guidelines, and in 2020, a total of 34 of 189 (18%) reported that they were aware of the app. The app was downloaded 11,313 times (7483, 66% from the Apple App Store; 3830, 34% from Google Play) during the first 20-month period. Most downloads (6300/7483, 84%) were a result of searching for the app in the stores. Monthly download rates varied. App Store data showed that people used the app twice (on average 2.06 times) during the 20 months. Many (3256/3830, 85%) Android users deleted the app.ConclusionsHealth professionals supported the development of the Smart Heart Guidelines app. Although initial downloads were promising, the frequency of using the app was low and deletion rates were high. Further evaluation of users’ experience of the most and least useful components of the app is needed.

Incidence, morbidity and mortality, and management of acute coronary syndrome during the time of COVID-19 lockdown

Incidence, morbidity and mortality, and management of acute coronary syndrome during the time of COVID-19 lockdown

Ideal P2Y12 Inhibitor in Acute Coronary Syndrome: A Review and Current Status.

Dual antiplatelet therapy (DAPT) has remained the cornerstone for management of acute coronary syndrome (ACS) over the years. Clopidogrel has been the quintessential P2Y12 receptor (platelet receptor for Adenosine 5′ diphosphate) inhibitor for the past two decades. With the demonstration of unequivocal superior efficacy of prasugrel/ticagrelor over clopidogrel, guidelines now recommend these agents in priority over clopidogrel in current management of ACS. Cangrelor has revived the interest in injectable antiplatelet therapy too. Albeit the increased efficacy of these newer agents comes at the cost of increased bleeding and this becomes more of a concern when combined with aspirin. Which P2Y12i is superior over another has been intensely debated over last few years after the ISAR-REACT 5 study with inconclusive data. Three novel antiplatelet agents are already in the pipeline for ACS with all of them succeeding in phase II studies. The search for an ideal antiplatelet remains a need of the hour for optimal reduction of ischemic events in ACS.

Profile and management of acute coronary syndromes at primary- and secondary-level healthcare facilities in Cape Town.

Little is known about the clinical profile and management of patients with acute coronary syndromes (ACS) in the South African public sector. We conducted a retrospective study of patients presenting with ACS to a secondary-level healthcare facility in Cape Town during a one-year period to study the clinical profile and management of these patients. Among the 214 patients in this cohort, 48 (27.5%) had ST-segment elevation myocardial infarction (STEMI), 43 (24.7%) had non-ST-segment elevation myocardial infarction and 83 (47.7%) unstable angina pectoris. We identified high rates of >12-hour delays in first medical contact after symptom onset (46%) and inaccurate ECG diagnosis of STEMI (29.2%), which were associated with low rates of thrombolysis (39.6%). High rates of non-adherence and ACS recurrence were also observed. To address the local challenges in ACS management highlighted in this study, we propose the development of a regional referral network prioritising access to expedited care and primary reperfusion interventions in ACS.

Clinical Significance of Elevated Levels of Cardiac Troponin T in Patients with Chronic Kidney Disease at Lagos University Teaching Hospital, Lagos

Background: This is an observational study of pre-dialysis patients with Chronic Kidney Disease (CKD) attending nephrology clinic at Lagos University Teaching Hospital to determine the clinical significance of elevated levels of Cardiac Troponin T (CTT) and possible associated factors.
 Methods: One hundred and forty-three (143) patients with CKD and no prior history of myocardial infarction were recruited and their serum levels of CTT were determined within 3 months of sample collection and storage at -80° C. ECG findings and clinical variables were compared. The 99 percentile cut-off value was derived using healthy individuals that met the inclusion criteria.
 Results: Mean blood CTT level was significantly higher in CKD patients compared to the general population. The 99th percentile value derived in the reference sample population was 48.02pg/ml. Statistical analysis showed significant association of CTT elevation with left ventricular hypertrophy, decreased renal function and age.
 Conclusion: CTT is generally elevated in pre-dialysis patients with CKD and a single elevated blood level of CTT above the 99th percentile may suggest asymptomatic Acute Coronary Syndrome. Serial rising levels of CTT and other clinical features will be of diagnostic significance in the diagnosis and management of asymptomatic acute coronary syndrome in patients with CKD.
 
 Authors
 O I Ajie , E C Azinge, B T Bello , T A Oshodi , O O Soriyan, I C Udenze 

Room for improvement: diagnosing and managing acute coronary syndromes in persons with reduced eGFR

Cardiovascular events are the leading cause of death in chronic kidney disease. A recent analysis from the High-Sensitivity Troponin in the Evaluation of Patients With Suspected Acute Coronary Syndrome trial focused on results in those with reduced estimated glomerular filtration rate. This commentary discusses aspects of acute coronary syndrome diagnosis in this group and the differential approach to acute coronary syndrome management that was observed between those with normal and reduced kidney function.

Acute Coronary Syndromes and SARS-CoV-2 Infection: Results From an Observational Multicenter Registry During the Second Pandemic Spread in Lombardy.

BackgroundCOVID-19 had an adverse impact on the management and outcome of acute coronary syndromes (ACS), but most available data refer to March-April 2020.AimThis study aims to investigate the clinical characteristics, time of treatment, and clinical outcome of patients at hospitals serving as macro-hubs during the second pandemic wave of SARS-CoV-2 (November 2020-January 2021).Methods and ResultsNine out of thirteen “macro-hubs” agreed to participate in the registry with a total of 941 patients included. The median age was 67 years (IQR 58-77) and ST-elevation myocardial infarction (STEMI) was the clinical presentation in 54% of cases. Almost all patients (97%) underwent coronary angiography, with more than 60% of patients transported to a macro-hub by the Emergency Medical Service (EMS). In the whole population of STEMI patients, the median time from symptom onset to First Medical Contact (FMC) was 64 min (IQR 30-180). The median time from FMC to CathLab was 69 min (IQR 39-105). A total of 59 patients (6.3%) presented a concomitant confirmed SARS-CoV-2 infection, and pneumonia was present in 42.4% of these cases. No significant differences were found between STEMI patients with and without SARS-CoV-2 infection in treatment time intervals. Patients with concomitant SARS-CoV-2 infection had a significantly higher in-hospital mortality compared to those without (16.9% vs. 3.6%, P < 0.0001). However, post-discharge mortality was similar to 6-month mortality (4.2% vs. 4.1%, P = 0.98). In the multivariate analysis, SARS-CoV-2 infection did not show an independent association with in-hospital mortality, whereas pneumonia had higher mortality (OR 5.65, P = 0.05).ConclusionDuring the second wave of SARS-CoV-2 infection, almost all patients with ACS received coronary angiography for STEMI with an acceptable time delay. Patients with concomitant infection presented a lower in-hospital survival with no difference in post-discharge mortality; infection by itself was not an independent predictor of mortality but pneumonia was.

A Clinical Profile of Acute Coronary Syndrome Patients in Kupang

Background: Cardiovascular diseases (CVDs) have been the leading cause of global deaths over the years. In Indonesia, coronary heart disease (CHD) is the most common CVDs, responsible for 29% of all deaths in 2017. East Nusa Tenggara is one of the provinces in Indonesia with the highest prevalence of CHD, which corresponded with growing cases of acute coronary syndromes (ACS). Therefore, we develop a registry to obtain patients' profiles as a basis for strategy development in ACS management.&#x0D; Methods: A retrospectively observational study was conducted on all patients who presented with ACS between January 2019 and September 2020 at a general hospital in Kupang, East Nusa Tenggara. Data collected include demography, patient awareness and transfer history, risk factors, physical findings, diagnosis, workup, treatment, and mortality.&#x0D; Results: A total of 282 patients with ACS (STEMI, 41,2%; NSTEACS, 58,8%) were included in this study. Most patients were male with a mean age of 58,2 ± 12,2 years and normal BMI (32.6%). Nearly 50% of all ACS patients have one or more comorbidities, followed by relatively low adherence to therapy. Half of the patients were referred, but only 16,9% of patients arrived at the first medical facility less than 1 hour after onset. Patients with NTSEACS had more risk factors than patients with STEMI. The median LOS was five days (range, 1-17 days) with 2,8% in-hospital death. The presence of patient and system delay might contribute to the low number of STEMI patients who received reperfusion therapy.&#x0D; Conclusions: This research serves as the primary data for the improvement of acute coronary syndrome management in Kupang and East Nusa Tenggara.

Management of Acute Coronary Syndromes in Patients in Rural Australia

Treatment of ST-segment elevation myocardial infarction (STEMI) in rural settings involves thrombolysis followed by transfer to a percutaneous coronary intervention-capable hospital. The first step is accurate diagnosis via electrocardiography (ECG), but one-third of all STEMI incidents go unrecognized and hence untreated. To reduce missed diagnoses of STEMI. This cluster randomized clinical trial included 29 hospital emergency departments (EDs) in rural Australia with no emergency medicine specialists, which were randomized to usual care vs automatically triggered diagnostic support from the tertiary referral hospital (management of rural acute coronary syndromes [MORACS] intervention). Patients presenting with symptoms compatible with acute coronary syndromes (ACS) were eligible for inclusion. The study was conducted from December 2018 to April 2020. Data were analyzed in August 2021. Triage of a patient with symptoms compatible with ACS triggered an automated notification to the tertiary hospital coronary care unit. The ECG and point-of-care troponin results were reviewed remotely and a phone call was made to the treating physician in the rural hospital to assist with diagnosis and initiation of treatment. The proportion of patients with missed STEMI diagnoses. A total of 6249 patients were included in the study (mean [SD] age, 63.6 [12.2] years; 48% female). Of 7474 ED presentations with suspected ACS, STEMI accounted for 77 (2.0%) in usual care hospitals and 46 (1.3%) in MORACS hospitals. Missed diagnosis of STEMI occurred in 27 of 77 presentations (35%) in usual care hospitals and 0 of 46 (0%) in MORACS hospitals (P < .001). Of eligible patients, 48 of 75 (64%) in the usual care group and 36 of 36 (100%) in the MORACS group received primary reperfusion (P < .001). In the usual care group, 12-month mortality was 10.3% (n = 8) vs 6.5% (n = 3) in the MORACS group (relative risk, 0.64; 95% CI, 0.18-2.23). Patients with missed STEMI diagnoses had a mortality of 25.9% (n = 7) compared with 2.0% (n = 1) for those with accurately diagnosed STEMI (relative risk, 13.2; 95% CI, 1.71-102.00; P = .001). Overall, there were 6 patients who did not have STEMI as a final diagnosis; 5 had takotsubo cardiomyopathy and 1 had pericarditis. There was no difference between groups in the rate of alternative final diagnosis. The findings indicate that MORACS diagnostic support service reduced the proportion of missed STEMI and improved the rates of primary reperfusion therapy. Accurate diagnosis of STEMI was associated with lower mortality. anzctr.org.au Identifier: ACTRN12619000533190.

Age Considerations in the Invasive Management of Acute Coronary Syndromes

The elderly constitute a major proportion of patients admitted with acute coronary syndrome (ACS) in the US. Due to pre-existing comorbidities, frailty, and increased risk of complications from medical and invasive therapies, management of ACS in the elderly population poses challenges. In patients with ST-elevation MI, urgent revascularization with primary percutaneous coronary intervention remains the standard of care irrespective of age. However, an early invasive approach in elderly patients with non-ST-elevation MI is based on individual evaluation of risks versus benefits. In this review, the authors discuss the unique characteristics of elderly patients presenting with ACS, specific geriatric conditions that need to be considered while making treatment decisions in these situations, and available evidence, current guidelines, and future directions for invasive management of elderly patients with ACS.

Cancer patients with acute coronary syndrome have non-superior bleeding risk compared to patients with similar characteristics – a propensity score analysis from the ProACS registry

IntroductionThe management of acute coronary syndrome (ACS) in malignancy is challenging due to higher bleeding risk. MethodsWe analyzed patients with cancer (active or in the previous five years) prospectively included in the ProACS registry between 2010 and 2019. Our aim was to assess safety (major bleeding, primary endpoint) and secondary efficacy endpoints (in-hospital mortality and combined in-hospital mortality, reinfarction and ischemic stroke) of ACS treatment. Propensity score matching analysis (1:1) was further performed to better understand predictors of outcomes. ResultsWe found 934 (5%) cancer patients out of a total of 18 845 patients with ACS. Cancer patients had more events: major bleeding (2.9% vs. 1.5%), in-hospital mortality (5.8% vs. 3.4%) and the combined endpoint (7.4% vs. 4.9%). The primary endpoint was related to cancer diagnosis (OR 1.97), previous bleeding (OR 7.09), hemoglobin level (OR 4.94), atrial fibrillation (OR 3.50), oral anticoagulation (OR 3.67) and renal dysfunction. Mortality and the combined secondary endpoint were associated with lower use of invasive coronary angiography and antiplatelet and neurohormonal blocker therapy. After propensity score matching (350 patients), there were no statistically significant differences in endpoints between the populations. ConclusionBleeding risk was not significant higher in the cancer population compared to patients with similar characteristics, nor were mortality or ischemic risk. The presence of cancer should not preclude simultaneous ACS treatment.

P60 COVID–19 (YEAR 2021) AND ACUTE MYOCARDIAL INFARCTION‘ TIME–DEPENDENT NETWORK: HUB–HEMODYNAMIC UNIT‘S EXPERIENCES

ObjectivesThe sudden SARS–CoV–2 emergency, has so far led to over 283 million infections and more than 5 million deaths globally, has put a strain on countries around the world. The result was a difficulty in accessing care both on an outpatient basis which resulted, in regione Campania, in a reduction in hospitalizations for ACS in the period Mar–Jun 2020 (1183) compared to the same period in 2019 (1862) (Agenas data ). The trend was inevitably reversed in the year 2021, with the new availability of access to treatment, due to both the reduction of restrictions and the vaccination coverage of the population, with a marked increase in hospitalizations for ACS as well as in the Hospital “ San Luca ”of Vallo della Lucania (Sa).MethodsCardiovascular diseases in 2021 are the leading cause of death in the world with 18.5 million lives lost a year and the leading cause also in Italy for both men (31.7%) and women (37.7%) ) with 230 thousand deaths certified by Istat, after 18 months of pandemic denounce a real war bulletin … The provincial cardiology network plays a fundamental role in the timeliness of the transfer to Hub centers such as the PO San Luca in the management of acute coronary syndromes.Results704 coronary angiography procedures and 118 emergency revascularizations (STEMI–NSTEMI at high risk Grace risk score> 140). Periprocedural complications were recorded around 0.5% (35) in line with the literature‘s data, all manageable and related to the femoral or radial puncture access.ConclusionsIn the year 2021, due to the reduction of restrictions and the marked increase in vaccination coverage, there was an increase in the number of hospitalizations for ACS and consequently in the mechanical myocardial revascularizations performed in Emergency (Stemi and Nstemi at high risk with Grace Risk Score> 140) probably linked to the lack of clinical–instrumental follow–up on an outpatient basis and day–hospital admissions in the year 2020 due to Covid–19 restrictions. At the Hemodynamics of the “San Luca” hospital (medium–volume center about 700 procedures / year), 118 emergency revascularisations were performed at 30.12.2021, compared to 82 in the same period of the year 2020.

Sex differences in time trends in acute coronary syndrome management and in 12-month lethality: Data from the French MONICA registries

BackgroundSex differences in clinical presentation, patient care and fatal outcomes after an acute coronary syndrome (ACS) have been reported. However, recent improvements in the care and treatment of ACSs have not been assessed with regard to possible sex differences. AimTo assess sex differences in trends between 2006 and 2016 in the characteristics of ACSs, their management, and the associated mortality. MethodsWe assessed all men and women (aged 35–74) covered by the MONICA registries in north, east and south-west France and having been hospitalized for an incident (first) ACS during a 12-month period in 2006 or a 6-month period in 2016. We analyzed the patients' clinical, biochemical, electrocardiographic and care-related data, and their vital status 28 days and 12 months after the ACS. ResultsIn 2006, women were older (<0.0001) and had more atypical symptoms than men (p < 0.01). These differences were no longer statistically significant in 2016. Medical care improved in both men and women. However, revascularization treatment, prescriptions of platelet aggregation inhibitors, statins, and functional rehabilitation were still more frequently provided to men than to women (p < 0.01) in 2016, independently of confounders. The 28-day or 12-month case fatality was not different between men and women in both 2006 and 2016. ConclusionsThe results of the present study evidenced an improvement over time in the management of ACS. However, although there were no longer sex differences in the patients' age and clinical presentation, women with ACS were still less likely than men to receive revascularization and pharmacological treatments in 2016.

Acute coronary syndrome in patients with hemophilia: a delicate balancing act.

Therapeutic advances have resulted in increased life expectancy in patients with hemophilia. Consequently, the prevalence of coronary artery disease in this population is increasing. Little is known about the optimal management of acute coronary syndrome in these patients. Current guidelines for the management of this condition are based mainly on expert opinion and generally recommend administration of the clotting factor prior to the anticoagulant, antiplatelet, and interventional therapies. We report a case that illustrates the potential harm that may come from this approach: evolution of non-ST-segment elevation acute coronary syndrome into ST-elevation acute coronary syndrome during the administration of recombinant clotting factor. We review available literature and describe the refined informatics-based guidelines for managing acute coronary syndrome in patients with hemophilia we developed in response to the presented clinical case. We propose adopting this novel informatics-based approach, which aids in the identification and early treatment of these patients, operationalizes timely involvement of hematology experts, and gathers data for further study.

Sex differences in acute coronary syndrome management and in 12-month case-fatality trends: data from the French MONICA registries

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Santé publique France, U1167 - RID-AGE - Facteurs de risque et déterminants moléculaires des maladies liées au vieillissement, Lille, France. Background Earlier studies, have reported sex differences in clinical presentation, management and outcomes of acute coronary syndrome (ACS) which have prompted the medical community to take actions to erase these differences. To our knowledge, there has been no recent analysis of sex difference trends in ACS management, to assess whether these differences have been attenuated over time. Aim To assess recent sex differences trends in ACS characteristics, management and associated mortality. Methods We assessed all men and women (aged 35-74) hospitalized for an incident (first) ACS, in the 3 distinct geographical areas covered by the MONICA registries in the north, east and south-west of France, during a 12-month period in 2006 and a 6-month period in 2016. We analyzed the patients’ clinical, biochemical, electrocardiographic and care-related data, and their vital status 12 months after the ACS. Results We analyzed 2023 incident ACSs in 2006 and 1173 in 2016. The proportion of men was three times higher than that of women in both periods. In 2016, women were younger (62.0 y in 2006 and 60.4 y in 2016; p=0.06) and men were older (57.6 y in 2006 and 59.0 y in 2016; p&amp;lt;0.01). Women had no longer more atypical symptoms than men in 2016. In both men and women, the proportion of patients with NSTEMI increased from 26% in 2006 to 39% in 2016 (p&amp;lt;0.0001), whereas the proportion of patients with unstable angina decreased from 14% in 2006 to 7% in 2016 (p&amp;lt;0.0001). Between 2006 and 2016, the proportion of thrombolysis fell from 10% to 1% (p&amp;lt;0.0001); conversely, the proportion of patients receiving angioplasty increased from 67% to 75% (p&amp;lt;0.001). However, men were still more likely than women to receive revascularization therapy (+19% in 2006 and +18% in 2016). Between 2006 and 2016, prescriptions of angiotensin-converting enzyme inhibitors at discharge decreased from 68% to 64% (p&amp;lt; 0.01), and prescriptions of statins increased from 89% to 91% (p=0.02), as did prescription of functional rehabilitation from 34% to 40% (p&amp;lt;0.0001). Despite these trends, platelet aggregation inhibitors, statins and functional rehabilitation were still less prescribed in women than men in 2016 (p&amp;lt;0.01), independently of confounders. Finally, the 12-month case fatality rate was 11% in 2006 and 10% in 2016 (p=0.15), without sex differences. Conclusions The results of the present study evidenced an improvement over time in the management of ACS. However, although there were no longer sex differences in the patients’ age and clinical presentation, women with ACS were still less likely than men to receive revascularization and pharmacological treatments in 2016.

Impact of Atrial Fibrillation and/or Flutter on in-Hospital Management and Outcomes in Non-ST Elevation Acute Coronary Syndromes

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation is the most common arrhythmia in patients with acute coronary syndromes, and it is increasing in prevalence considering the aging of populations and the overlap of risk factors. It was reported by earlier studies that atrial fibrillation and/or flutter portend worse prognosis in patients with acute coronary syndromes. Yet there is no data from Iraq regarding impact of these arrhythmias on prognosis of patients with NSTE-ACS. Purpose This study aimed to evaluate the impact of pre-existing or new onset atrial fibrillation and/or flutter on in-hospital management and outcomes in an Iraqi cohort of patients with NSTE-ACS. Methods Patients with NSTE-ACS were prospectively included. GRACE risk score was calculated by the investigator with subsequent classification into low, intermediate and high GRACE risk class. Then the patients were classified into those who had pre-existing or new onset atrial fibrillation and/or atrial flutter (Patients with AF) group versus those with no atrial fibrillation nor atrial flutter (non-AF group). Results N=200, among whom AF was evident in 8.5%. Patients with AF were older (64.47±10.02 vs 58.22±11.79 years, p=0.025), they were females in 35.3% vs 29% in non-AF counterparts, p=0.58. There were no statistical differences between the two groups regarding presence of hypertension, diabetes, prior history of ischemic heart disease (IHD) nor family history of IHD, however, AF group were smokers in 11.8% vs 36.6% in non-AF group, p=0.039. Patients with AF reported dyspnoea at presentation in 47.1% vs 27.9%. Patients with AF were at high GRACE risk class at presentation in 76.5% vs 28.4% in non-AF group, p&amp;lt;0.001. Patients with AF were referred less for catheterisation during index hospitalisation compared to non-AF counterparts (35.3% vs 72.1%, p=0.002). There were no statistical differences between the two groups regarding days to catheterisation nor days of hospitalisation. There were no statistical differences between the two groups regarding developing in-hospital acute heart failure, cardiogenic shock, persistent ischemic chest pain, nor in-hospital ventricular life-threatening arrhythmia (VT, VF or Complete heart block), however, patients with AF developed higher in-hospital stroke (5.9% vs 0.5%, p=0.034) and higher in-hospital death (11.8% vs 1.6%, p=0.011). Conclusion Patients with NSTE-ACS and concurrent AF presented at higher risk class at presentation and higher in-hospital stroke and in-hospital death compared to patients with no AF, yet those patients were catheterised less frequently during index hospitalisation. Larger studies are needed to assess the impact of AF on longer term prognosis in the setting of NSTE-ACS. More attention should be paid for this high-risk category of NSTE-ACS patients with more emphasis on following evidence-based guidelines regarding decision and timing of catheterisation in order to improve their outcomes.

The impact of the Fundamental Critical Course on knowledge acquisition in Rwanda.

Background Emerging critical care systems have gained little attention in low- and middle-income countries. In sub-Saharan Africa, only 4% of the healthcare workforce is trained in critical care, and mortality rates are unacceptably high in this patient population. Objectives We sought to retrospectively describe the knowledge acquisition and confidence improvement of practitioners who attend the Fundamental Critical Care Support (FCCS) course in Rwanda. Methods We conducted a retrospective study in which we assessed survey data and multiple-choice question data that were collected before and after course delivery. The purpose of these assessments at the time of delivery was to evaluate participants’ perception and acquisition of critical care knowledge.Results Thirty-six interprofessional clinicians completed the training. Performance on the multiple-choice questions improved overall after the course (mean score pre-course of 56.5% to mean score post-course of 65.8%, p-value <0.001) and improved in all content areas with the exception of diagnosis and management of acute coronary syndrome and acute respiratory failure/mechanical ventilation. Both physicians and nurses improved their scores significantly (68.9% to 75.6%, p-value = 0.031 and 52.0% to 63.5%, p-value <0.001, respectively). Self-reported confidence in level of knowledge also increased in all areas. Survey respondents indicated on open-answer questions that they would like the course offerings at least annually, and that further dissemination of the course in Rwanda was warranted. Conclusion Deploying the established FCCS course improved Rwandan healthcare provider knowledge and confidence across most critical care content areas. Therefore, this course represents a good first step in bridging the gaps noted in emerging critical care systems. Contributions of the study Critical care education in sub-Saharan Africa is limited and few staff have formal training. The aim of the study was to determine whether a focused course delivered in Rwanda on critical care management improved knowledge in key areas. Our retrospective study on results from a multiple choice question test and survey indicate that short courses may improve knowledge of critical care management.