non-ST Elevation Acute Coronary Syndrome Research Articles

Temporal analysis of non-ST segment elevation-acute coronary syndrome (NSTEACS) outcomes in ‘young’ patients under the age of fifty: A nationwide cohort study

BackgroundThe characteristics and risk factor profile of young patients presenting with non-ST segment elevation acute coronary syndrome (NSTEACS) and how they may have changed over time is not well reported. MethodsWe identified 26,708 NSTEACS patients aged under 50 presenting to United Kingdom (UK) hospitals between 2010 and 2017 from Myocardial Ischaemia National Audit Project (MINAP). We calculated incidence of NSTEACS per 100,000 UK population, using Office of National Statistics (ONS) population estimates, prevalence of comorbidities, ethnicity, and in-hospital mortality. We formed biennial groups to enable comparison, 2010–2011, 2012–2013, 2014–2015 and 2016–2017. ResultsThe incidence of NSTEACS per 100,000 population showed minimal change between 2010 and 2017 (2010: 5.4 per 100,000 and 2017; 4.9 per 100,000). Rates of smoking (2010–11; 58% and 2016–17; 53%), and family history of coronary artery disease (CAD) (2010–11; 51% and 2016–17; 44%) fell, but the proportion of patients from an ethnic minority background (2010–11; 12% and 2016–17; 20%), with diabetes mellitus (DM) (2010–11; 14%, and 2016–17; 18%) and female patients (2010–11; 22% and 2016–17; 24%) increased over the study period. Mortality from NSTEACS remained unchanged (2010–11; 1% and 2016–17; 1%). ConclusionsThe incidence of NSTEACS in patients aged under fifty has not reduced despite reduction in prevalence of risk factors such as smoking hypercholesterolaemia in those admitted to UK hospitals. Despite improved rates of early invasive coronary angiography and percutaneous coronary intervention in ‘young’ NSTEACS patients, in-hospital mortality remains unchanged.

Worldwide impact of COVID-19 on hospital admissions for non-ST-elevation acute coronary syndromes (NSTACS): a systematic review with meta-analysis of 553 038 cases.

How coronavirus disease 2019 (COVID-19) impacted non-ST-segment elevation acute coronary syndromes (NSTACS) is an object of controversial reports. To systematically review studies reporting NSTACS hospitalizations during the COVID-19 pandemic, and analyse whether differences in COVID-19 epidemiology, methodology of report, or public health-related factors could contribute to discrepant findings. Comprehensive search (Medline, Embase, Scopus, Web of Science, Cochrane Register), of studies reporting NSTACS hospitalizations during the COVID-19 pandemic compared with a reference period, following Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Data were independently extracted by multiple investigators and pooled using a random-effects model. Health-related metrics were from publicly available sources, and analysed through multiple meta-regression modelling. We retrieved 102 articles (553038 NSTACS cases, 40 countries). During peak COVID-19 pandemic, overall incidence rate ratio (IRR) of NSTACS hospitalizations over reference period decreased (0.70, 95% confidence interval (CI) 0.66-0.75; P<0.00001). Significant heterogeneity was detected among studies (I2=98%; P<0.00001). Importantly, wide variations were observed among, and within, countries. No significant differences were observed by study quality, whereas comparing different periods within 2020 resulted in greater decrease (IRR: 0.61; CI: 0.53-0.71) than comparing 2020vs. previous years (IRR: 0.74; CI 0.69-0.79). Among many variables, major predictors of heterogeneity were severe acute respiratory syndrome coronavirus 2 reproduction rate/country, number of hospitals queried, and reference period length; country stringency index and socio-economical indicators did not contribute significantly. During the COVID-19 pandemic, NSTACS hospitalizations decreased significantly worldwide. However, substantial heterogeneity emerged among countries, and within the same country. Factors linked to public health management, but also to methodologies to collect results may have contributed to this heterogeneity. The protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (ID: CRD42022308159).

Consequences of different cut-off values for high-sensitivity cardiac troponin for risk stratification of patients suspected for NSTE-ACS with a modified HEART score.

Aim: This study aims to enhance prehospital risk assessment for suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) patients using the HEART-score. By incorporating novel point-of-care high-sensitivity cardiac troponin devices, a modified HEART-score was developed and compared with the conventional approach. Patients & methods: Troponin points within the modified HEART-score are based on values below the limit of quantitation (LoQ), between the LoQ and 99th percentile and above the 99th percentile of the used device. A total HEART-score of three or lower is considered low-risk for major adverse cardiac events. Results & conclusion: The number of low-risk patients decreased based on the modified HEART-score. The sensitivity and negative predictive value increased which suggests increasing safety in ruling out patients with suspected NSTE-ACS.

Multimodality coronary imaging to predict non-culprit territory unrecognized myocardial infarction in Non-ST-Elevation acute coronary syndrome.

Unrecognized myocardial infarction (UMI) detected by cardiac magnetic resonance (CMR) imaging is associated with adverse outcomes in patients with acute and chronic coronary syndrome. This study aimed to assess the predictors of optical coherence tomography (OCT) and coronary computed tomography angiography (CCTA) findings for non-infarct-related (non-IR) territory UMI in patients presenting with non-ST-elevation acute coronary syndrome (NSTE-ACS). We investigated 69 patients with a first clinical episode of NSTE-ACS who underwent pre-percutaneous coronary intervention (PCI) 320-slice CCTA, uncomplicated urgent PCI with OCT assessment within 24h of admission, and post-PCI CMR. UMI was assessed using late gadolinium enhancement to identify regions of hyperenhancement with an ischemic distribution pattern in non-IR territories. Non-IR UMI was detected in 11 patients (15.9%). Lower ejection fraction, higher Gensini score, higher Agatston score, high pericoronary adipose tissue attenuation (PCATA), OCT-defined culprit lesion plaque rupture, and OCT-defined culprit lesion cholesterol crystal were significantly associated with the presence of non-IR UMI. On dividing the total cohort was divided into five groups according to the numbers of two OCT-derived risk factors and two CCTA-derived risk factors, the frequency of non-IR UMI frequency significantly increased according to the number of these relevant risk features (p < 0.001). Patients with all of the non-IR UMI risk factors showed 50% prevalence of non-IR UMI, compared with 2.2% of patients with low risk factors (≤ 2). Integrated CCTA and culprit lesion OCT assessment may help identify the presence of non-IR UMI, potentially providing prognostic information in patients with first NSTE-ACS episode.

The Role of Neutrophil to Lymphocyte Ratio and its Common Clinical Outcomes Among Patients with Non-ST Elevation Acute Coronary Syndrome.

To evaluate the admission neutrophil-to-lymphocyte ratio (NLR) for risk stratification for in-hospital outcomes and complications in non-ST-elevation acute coronary syndrome (non-ST-ACS) patients. We recruited consecutive patients with non-ST-ACS. The NLR was obtained and stratified as low, intermediate, and high-risk based on <3.0, 3.0-6.0, and >6.0, respectively. The new ST-T changes, arrhythmias, contrast-induced nephropathy (CIN), and mortality were recorded. Median NLR was 3 [2.1-5.3] for 346 patients with 19.9% and 30.6% in high- and intermediate-risk group. New ST-T changes were observed in 3.5% (12) out of which 8, 3, and 1 patient in low, intermediate, and high-risk group (p = 0.424), respectively. Arrhythmias were observed in 5.8% (20) with 7, 5, and 8 patients in low, intermediate, and high-risk group (p = 0.067), respectively. CIN was observed in 4.9% (17) with 5, 5, and 7 in low, intermediate, and high-risk group (p = 0.064), respectively. In-hospital mortality was recorded in 1.4% (5) with 2 and 3 patients in high and low-risk group (p = 0.260), respectively. A significant number of non-ST-ACS patients fall in the high-risk category of NLR. Although, the association between NLR and in-hospital mortality and adverse events was not statistically significant but relatively higher rates of events were observed in high risk group.

Thrombotic Risk in Patients with Acute Coronary Syndromes Discharged on Prasugrel or Clopidogrel: Results From the PROMETHEUS Study.

Based on recent clinical data, the 2020 ESC guidelines on non-ST elevation acute coronary syndrome (NSTE-ACS) suggest to tailor antithrombotic strategy on individual thrombotic risk. Nonetheless, prevalence and prognostic impact of the high thrombotic risk (HTR) criteria proposed are yet to be described. PROMETHEUS was a multicenter prospective study comparing prasugrel vs. clopidogrel in ACS patients undergoing PCI. In this analysis, we assessed prevalence and prognostic impact of HTR, defined according to the 2020 ESC NSTE-ACS guidelines, and if the benefits associated with prasugrel vs. clopidogrel vary with thrombotic risk. Patients were at HTR if presenting with one clinical plus one procedural risk feature. The primary endpoint was major adverse cardiac events (MACE), composite of death, myocardial infarction, stroke, or unplanned revascularization, at 1 year. Adjusted hazard ratio (adjHR) and 95% confidence intervals (CI) were calculated with propensity score stratification and multivariable Cox regression.Among 16065 patients, 4293 (26.7%) were at HTR and 11772 (73.3%) at low-to-moderate thrombotic risk. HTR conferred increased incidence of MACE (23.3 vs. 13.6%, HR 1.85, 95% CI 1.71 - 2.00, p < 0.001) and its single components. Prasugrel was prescribed in patients with less comorbidities and risk factors and was associated with reduced risk of MACE (HTR: adjHR 0.83, 95%CI 0.68-1.02; low-to-moderate risk: adjHR 0.75, 95%CI 0.64-0.88; pinteraction = 0.32). High thrombotic risk, as defined by the 2020 ESC NSTE-ACS guidelines, is highly prevalent among ACS patients undergoing PCI. The high thrombotic risk definition had a strong prognostic impact, as it successfully identified patients at increased 1-year risk of ischemic events.

Type of evidence supporting ACC/AHA and ESC clinical practice guidelines for acute coronary syndrome.

The aim of clinical practice guidelines for ST elevation myocardial infarction (STEMI) and non-ST elevation acute coronary syndrome (NSTE-ACS) is to assist healthcare professionals in clinical decision-making. We evaluated the type of studies supporting these guidelines and their recommendations. All references and recommendations in the 2013 and 2014 ACC/AHA and 2017 and 2020 (ESC clinical guidelines for STEMI and NSTE-ACS were reviewed. References were classified into meta-analyses, randomised, non-randomised, and other types (e.g., position papers, reviews). Recommendations were classified according to class and their level of evidence (LOE). We retrieved 2128 non-duplicated references: 8.4% were meta-analyses, 26.2% randomised studies, 44.7% non-randomised studies, and 20.7% 'other' papers. Meta-analyses were based on randomised data in 78% of cases and used individual-patient data in 20.2%. Compared to non-randomised studies, randomised studies were more frequently multicentre (85.5% vs. 65.5%) and international (58.2% vs. 28.5%). The type of studies supporting recommendations varied as per the LOE of the recommendation. For LOE-A recommendations, the breakdown of supporting recommendations was: 18.5% meta-analyses, 56.6% randomised studies, 16.6% non-randomised studies and 8.3% 'other' papers; for LOE-B this breakdown was 9%, 39.8%, 38.2%, and 12.9%; and for LOE-C; 4.6%, 19.3%, 30.3%, and 45.9%. The references supporting the ACC/AHA and ESC guidelines on STEMI and NSTE-ACS consisted of non-randomised studies in ~ 45% of cases, with less than a third of the references consisting of meta-analyses and randomised studies. The type of studies supporting guideline recommendations varied widely by the LOE of the recommendation.

Non-Obstructive Coronaries In Patients Presenting With The Non St-Elevation Acute Coronary Syndrome.

Worldwide, cardiovascular diseases are the major cause of mortality and morbidity with acute coronary syndrome as the most common clinical manifestation. In a typical clinical setup, around 30% of the patients presented with "ST-segment elevation myocardial infarction (STEMI)" caused by the complete occlusion of the coronary artery and the remaining 70% with intermittent or partial occlusion of the coronary termed as non-ST elevation The aim of this study was to assess the prevalence and characteristics of non-obstructive coronary arteries among patients presenting with non ST-elevation acute coronary syndrome (NSTE-ACS) at a tertiary care cardiac center of Karachi, Pakistan. This was a descriptive cross-sectional study, conducted at a tertiary care hospital in Karachi. Study inclusion criteria were patients of either gender admitted with NSTE-ACS and aged between 30-70 years. A routine coronary angiogram was performed in all the patients and the absence of ≥50% stenosis in any major epicardial vessel was taken in non-obstructive coronaries. A total of 174 patients (30-70 years) were included, of which 99 (56.9%) were male and the mean age was 59.43±11.24 years. In the distribution of socioeconomic status, 54 (31.0%) were lower class, middle class 81 (46.6%) while upper-class status were 39 (22.4%). Hypertension was observed in 76 (43.7%), chronic kidney disease in 20 (11.5%), and hyperlipidemia in 55 (31.6%). Non-obstructive coronary arteries were noted in 25 (14.4%) patients. It is to be concluded that non-obstructive coronary arteries are fairly prevalent in patients arriving in hospitals with NSTE-ACS in our population. Further research is needed to better understand the underlying pathophysiology and optimal management strategies for patients with NOCA in the setting of NSTEMI.

Strategy of dual antiplatelet therapy for patients with ST-elevation myocardial infarction and non-ST-elevation acute coronary syndromes: A systematic review and network meta-analysis

BackgroundVarious durations and de-escalation strategies of dual antiplatelet therapy (DAPT) after ST-elevation myocardial infarction (STEMI) or non-ST-elevation acute coronary syndromes (NSTE-ACS) have been tested in randomized controlled trials (RCT)s. However, evidence by specific ACS subtype is unknown. MethodsPubMed, EMBASE, and Cochrane CENTRAL were searched in February 2023. RCTs on DAPT strategies included STEMI or NSTE-ACS patients with standard DAPT (12 months) with clopidogrel or potent P2Y12 inhibitors, short-term DAPT (≤6 months) followed by potent P2Y12 inhibitors or aspirin, unguided de-escalation from potent P2Y12 inhibitors to low-dose potent P2Y12 inhibitors or clopidogrel at one month, and guided selection with genotype or platelet function tests were identified. The primary outcome was the net adverse clinical events (NACE) defined as a composite of major adverse cardiovascular events (MACE) and clinically relevant bleeding events. ResultsTwenty RCTs with a combined total population of 24,745 STEMI and 37,891 NSTE-ACS patients were included. In STEMI patients, unguided de-escalation strategy was associated with a lower rate of NACE compared with standard DAPT using potent P2Y12 inhibitors (HR:0.57; 95% CI:0.34–0.96) without increased risk of MACE. In NSTE-ACS patients, unguided de-escalation strategy was associated with a lower rate of NACE compared with the guided selection strategy (HR:0.65; 95% CI:0.47–0.90), standard DAPT using potent P2Y12 inhibitors (HR:0.62; 95% CI:0.50–0.78) and standard DAPT using clopidogrel (HR:0.73; 95% CI:0.55–0.98) without increased risk of MACE. ConclusionUnguided de-escalation strategy was associated with a reduced risk of NACE and may be the most effective DAPT strategy for STEMI and NSTE-ACS.

Association of mortality rates and availability of emergency and specialized, including high-tech, medical services for acute coronary syndrome in the Russian Federation

Aim. To study the impact of the availability of emergency and specialized, including high-tech, medical services for patients with acute coronary syndrome on mortality in Russia.Material and methods. We used the cointegration of time series characterizing mortality from acute coronary syndrome (ACS) and following parameters for the availability of emergency and specialized, including high-tech, care for ACS in Russia for the period from 2016 to 2021 according to the "Monitoring of interventions to reduce mortality from coronary artery disease": the proportion of ambulance visits for ACS with response time &lt;20 minutes; the proportion of patients with ST-elevation ACS (STE-ACS) hospitalized within 12 hours from symptom onset; proportion of patients with STE-ACS admitted to hospital within 2 hours of symptom onset; proportion of patients with ACS admitted to specialized departments; proportion of patients with STE-ACS with prehospital thrombolysis; proportion of patients with STE-ACS with thrombolysis; proportion of patients with STE-ACS who underwent percutaneous coronary intervention (PCI); proportion of patients with non-ST-elevation ACS (NSTE-ACS) who underwent PCI; the proportion of patients with STE-ACS admitted before 12 hours from the onset of symptoms who underwent PCI; proportion of patients with ACS who underwent coronary artery bypass grafting. To rank the availability indicators, the elasticity (E) coefficient was used, which characterizes the strength of the relationship between the factor and the result, which shows the change in the result value per 1% change in the factor.Results. According to contribution decrement to reducing mortality, the factors of health care availibility for patients with ACS-STE were arranged as follows (coefficient of elasticity and determination (R2) is indicated in brackets): "The proportion of patients with ACS-STE who underwent PCI" (E=1,5%; R2=0,60), "Proportion of patients with STE-ACS with prehospital thrombolysis" (E=1,1%; R2=0,91), "Proportion of patients with STE-ACS with thrombolysis" (E=1,0%; R2=0,96 ), "Proportion of patients with STE-ACS admitted before 12 h who underwent PCI" (E=0,9%; R2=0,94), "Proportion of patients with STE-ACS admitted to hospital before 12 h from the symptom onset" (E=0,5%; R2=0,97), "Proportion of patients with STE-ACS hospitalized &lt;2 hours from the symptom onset" (E=0,2%; R2=0,95). A significant resource in reducing mortality in ACS is the reduction in ambulance response time in ACS (E=2,3%; R2=0,87) and compliance with specialized hospitalization of patients with ACS (E=1,8%; R2=0,73), but in reducing mortality in NSTE-ACS, the proportion of patients with NSTE-ACS who underwent PCI (E=1,7%; R2=0,72).Conclusion. An analysis of the impact of the availability of emergency and specialized, including high-tech, medical services for patients with ACS in Russia showed that the greatest contribution to mortality reduction in STE-ACS is made by time reduction in PCI and an increase in the use of thrombolytic therapy, mainly at the prehospital stage, in NSTE-ACS — an increase in the number of PCIs, and in ACS in general, strict compliance with specialized hospitalization of patients and a reduction in ambulance response time in ACS.

Correlation of TIMI Risk Score and GRACE Risk Score with Lesion of Coronary Artery Disease in Patients with Non-ST Segment Elevation Acute Coronary Syndrome

Objective: To compare the correlation of “thrombolysis in myocardial infarction (TIMI)” and “Global Registry of Acute Coronary Events (GRACE)” risk score with lesion of coronary artery disease in patients with non-ST segment elevation acute coronary syndrome. Study Design: Cross-sectional study. Place and Duration: The Department of adult cardiology, “National Institute of Cardiovascular Diseases (NICVD)”, Karachi, Pakistan, from January 2021 to July 2021. Methodology: Demographics, weight, height, risk factors along with the required information needed for TIMI and GRACE score were obtained at the time of presentation in emergency department as per the scoring criteria. SYNTAX score was calculated after performing conventional angiography of the patients, using SYNTAX.com calculator. Results: In a total of 104 patients, the mean age was 57.21±12.22 years while 56 (53.8%) patients were male. Hypercholesterolemia was found in 33 (31.7%) patients. Mean score of TIMI was calculated as 4.680±2.064 while SYNTAX score was calculated as 26.45±12.94 and the correlation between TIMI risk score and SYNTAX score was noted as (r=0.109) and P value was found to be non-significant i.e. (P=0.270). Mean score of GRACE was noted as 135.38±90.88 while SYNTAX score was noted as 26.45±12.94 and the correlation between GRACE risk score and SYNTAX score was documented as (r=0.179) and P value was found to be non-significant i.e. (P=0.068). Practical Implications: Both TIMI and GRACE risk scoring systems showed weak correlations with SYNTAX scores. Conclusion: There is a weak correlation between TIMI risk score and SYNTAX score as well as GRACE risk score and SYNTAX score. Keywords: Acute coronary syndrome, coronary artery disease, GRACE score, myocardial infarction, thrombolysis.

Treatment adherence in patients without ST-elevation acute coronary syndrome.

Despite progress during the last decades, patients with coronary artery disease (CAD) remain with a high residual risk due to multiple reasons. Optimal medical treatment (OMT) provides a decrease of recurrent ischemic events after acute coronary syndrome (ACS). Therefore, treatment adherence results crucial to reduce further outcomes after the index event. No recent data are available in Argentinian population; the main objective of our study was to evaluate the adherence at 6 and 15 months in post non-ST elevation acute coronary syndrome (NST-ACS) consecutive patients. Secondary objective was to evaluate the relationship of adherence with 15-month events. A prespecified sub-analysis in the prospective registry Buenos Aires I was performed. The adherence was evaluated using the modified Morisky-Green Scale. A number of 872 patients had information about adherence profile. Of them 76.4% were classified as adherents at month 6 and 83.6% at 15 (P=0.06). We did not find any difference in baseline characteristic between the adherent and non-adherent patients at 6 months. The adjusted analysis showed that non-adherent patients had a rate of ischemic events at 15th month of 20% (27/135) vs. 11.5% (52/452) in adherent patients (P=0.001). The bleeding events defined were of 3.6% in the non-adherent group vs. 5% in the adherent group without a statistical difference (P=0.238). Adherence to treatment is still a major issue as almost 25% of patients should be considered as non-adherent to OMT. No clinical predictor of this phenomenon was identified but our criteria were not exhaustive. Good adherence to treatment was highly associated to a reduction of ischemic events, whereas no impact on bleeding events was found. These data support a better network and collaboration with shared decision between healthcare professionals with patients and family members to improve acceptance and adherence to optimal medical strategies.

Contemporary Evaluation of Therapeutic Anticoagulation for Non-ST Elevation Acute Coronary Syndrome in The Emergency Department

Contemporary Evaluation of Therapeutic Anticoagulation for Non-ST Elevation Acute Coronary Syndrome in The Emergency Department

Prognostic implications of non-infarct-related territory unrecognized myocardial infarction in patients with non-ST-segment-elevation acute coronary syndrome

BackgroundPrognostic value of non-infarct-related territory (non-IR) unrecognized myocardial infarction (UMI) in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) remains to be elucidated. We sought to evaluate the prognostic impact of non-IR UMI in patients with first NSTE-ACS presentation. MethodsThis retrospective single-center analysis was conducted in patients with NSTE-ACS without prior history of coronary artery disease, who underwent uncomplicated urgent percutaneous coronary intervention (PCI) within 48 h of admission between August 2014 and January 2018. All patients underwent postprocedural cardiac magnetic resonance imaging (CMR) within 30 days after PCI. Non-IR UMI was defined as the presence of non-IR delayed gadolinium enhancement with an ischemic distribution pattern. We investigated the association of non-IR UMI, other CMR findings and baseline clinical characteristics with major adverse cardiac events (MACE), defined as death, non-fatal myocardial infarction, stroke, late revascularization, and hospitalization for congestive heart failure. ResultsA total of 168 NSTE-ACS patients were included [124 men (73.8 %); 66 ± 11 years]. Non-IR UMI was detected in 28 patients (16.7 %). During a median follow-up of 32 (15–58) months, MACE occurred in 10 (35.7 %) patients with non-IR UMI, and 20 (14.3 %) patients without (p = 0.013). Cox's proportional hazards analysis showed that the presence of non-IR UMI was an independent predictor of MACE (hazard ratio [HR], 2.37, 95 % confidence interval [CI], 1.09–5.18, p = 0.030). In patients with NSTE-ACS undergoing urgent PCI, the prevalence of non-IR UMI was 16.7 %. ConclusionsNon-IR UMI provided prognostic information independent of conventional risk factors and the extent of myocardial injury caused by NSTE-ACS.

Early Effects of Ticagrelor Versus Clopidogrel on Peripheral Endothelial Function After Non-ST-Elevation Acute Coronary Syndrome and Assessment of Its Relationship With Coronary Microvascular Function

Peripheral endothelial dysfunction is an independent predictor of adverse long-term prognosis after acute coronary syndrome. Data are lacking on the effects of oral P2Y12-inhibitors on peripheral endothelial function in non-ST-elevation acute coronary syndrome (NSTEACS). Furthermore, the relation between peripheral endothelial function and invasive indexes of coronary microvascular function in NSTEACS is unclear. Between March 2018 and July 2020, hospitalized patients with NSTEACS were randomized (1:1) to ticagrelor or clopidogrel. Peripheral endothelial function was assessed with brachial artery flow-mediated vasodilation (FMD). Invasive indexes of coronary microvascular function were obtained using an intracoronary pressure-temperature sensor-tipped wire. In 70 patients included, mean age was 58.6years, 78.6% (n=55) were male and 20% (n=14) had diabetes mellitus. Compared with clopidogrel, ticagrelor significantly improved FMD (14.2±5.4% vs 8.9±5.3%, p<0.001) after a median treatment time of 41.2hours. The FMD was significantly correlated with the index of microcirculatory resistance (IMR) measured in the infarct-related artery (r=-0.38, p=0.001), with a stronger correlation found in those who did not have percutaneous coronary intervention (r=-0.52, p=0.03). Using receiver operating characteristic curve analysis, an FMD of 8.2% identified an IMR of >34 as the threshold, with 77.6% sensitivity and 52.4% specificity. In patients who did not have a percutaneous coronary intervention, an FMD of 11.49% identified an IMR of >34 with 84.6% sensitivity and 80% specificity. In conclusion, ticagrelor significantly improved peripheral endothelial function compared with clopidogrel in patients with NSTEACS. There was a significant correlation between brachial artery FMD and IMR of the infarct-related artery.

Effectiveness of GRACE risk score in patients admitted to hospital with non-ST elevation acute coronary syndrome (UKGRIS): parallel group cluster randomised controlled trial

ObjectiveTo determine the effectiveness of risk stratification using the Global Registry of Acute Coronary Events (GRACE) risk score (GRS) for patients presenting to hospital with suspected non-ST elevation acute coronary...

A systematic assessment of the characteristics of randomized controlled trials cited by acute coronary syndrome clinical practice guidelines.

The aim of this study was to describe the methodological features of the randomized controlled trials (RCTs) cited in American and European clinical practice guidelines (CPGs) for ST elevation myocardial infarction (STEMI) and non-ST elevation acute coronary syndrome (NSTE-ACS). Out of 2128 non-duplicated references cited in the 2013 and 2014 American College of Cardiology/American Heart Association and 2017 and 2020 European Society of Cardiology CPGs for STEMI and NSTE-ACS, we extracted data for 407 RCTs (19.1% of total references). The majority were multicenter studies (81.8%), evaluated pharmacological interventions (63.1%), had a 2-arm (82.6%), and superiority (90.4%) design. Most RCTs (60.2%) had an active comparator, and 46.2% were funded by industry. The median observed sample size was 1001 patients (84.2% of RCTs achieved≥80% of the intended sample size). Most RCTs had a single primary outcome (90.9%), which was a composite in just over half (51.9%). Among the RCTs testing for superiority, 44.0% reported a P-value of≥0.05 for the primary outcome and 61.9% observed a risk reduction of>15%. The observed treatment effect was lower-than-expected in 67.6% of RCTs, with 34.4% having at least a 20% lower-than-expected treatment effect. The calculated post hoc statistical power was≥80% for 33.9% of cited RCTs. This analysis demonstrates that RCTs cited by CPGs can still have significant methodological issues and limitations, highlighting that a better understanding of the methodological aspects of RCTs is crucial in order to formulate recommendations relevant to clinical practice.

Pre-hospital delay, clinical characteristics, angiographic findings, and in-hospital mortality in young and middle-aged adults with acute coronary syndrome: a single-centre registry analysis.

There are several differences between younger and older adults with acute coronary syndrome (ACS). However, few studies have evaluated these differences. We analysed the pre-hospital time interval [symptom onset to first medical contact (FMC)], clinical characteristics, angiographic findings, and in-hospital mortality in patients aged ≤50 (group A) and 51-65 (group B) years hospitalised for ACS. We retrospectively collected data from 2010 consecutive patients hospitalised with ACS between 1 October 2018 and 31 October 2021 from a single-centre ACS registry. Groups A and B included 182 and 498 patients, respectively. ST-segment elevation myocardial infarction (STEMI) was more common in group A than group B (62.6 and 45.6%, respectively; P < 0.001). The median time from symptom onset to FMC in STEMI patients did not significantly differ between groups A and B [74 (40-198) and 96 (40-249) min, respectively; P = 0.369]. There was no difference in the rate of sub-acute STEMI (symptom onset to FMC > 24 h) between groups A and B (10.4% and 9.0%, respectively; P = 0.579). Among patients with non-ST elevation acute coronary syndrome (NSTE-ACS), 41.8 and 50.2% of those in groups A and B, respectively, presented to the hospital within 24 h of symptom onset (P = 0.219). The prevalence of previous myocardial infarction was 19.2% in group A and 19.5% in group B (P = 1.00). Hypertension, diabetes, and peripheral arterial disease were more common in group B than group A. Active smoking was more common in group A than group B (67 and 54.2%, respectively; P = 0.021). Single-vessel disease was present in 52.2 and 37.1% of participants in groups A and B, respectively (P = 0.002). Proximal left anterior descending artery was more commonly the culprit lesion in group A compared with group B, irrespective of the ACS type (STEMI, 37.7 and 24.2%, respectively; P = 0.009; NSTE-ACS, 29.4 and 21%, respectively; P = 0.140). The hospital mortality rate for STEMI patients was 1.8 and 4.4% in groups A and B, respectively (P = 0.210), while for NSTE-ACS patients it was 2.9 and 2.6% in groups A and B, respectively (P = 0.873). No significant differences in pre-hospital delay were found between young (≤50 years) and middle-aged (51-65 years) patients with ACS. Although clinical characteristics and angiographic findings differ between young and middle-aged patients with ACS, the in-hospital mortality rate did not differ between the groups and was low for both of them.

European practice patterns for antiplatelet management in NSTE-ACS patients: Results from the REal-world ADoption survey focus on Acute antiPlatelet Treatment (READAPT) survey

BackgroundThe 2020 European Society of Cardiology (ESC) guidelines for the diagnosis and management of patients with non-ST elevation-acute coronary syndrome (NSTE-ACS) recommend early invasive coronary angiography in high-risk patients and no routine pre-treatment with oral P2Y12 receptor inhibitor in NSTE-ACS patients prior to defining coronary anatomy. ObjectiveTo assess the implementation of this recommendation in the real-life setting. MethodsA web-survey in 17 European countries collected physician profiles and their perceptions of the diagnosis, medical and invasive management of NSTE-ACS patients at their hospital. A sample size of at least 1100 responders permitted the estimation of proportions with a precision of at least ±3.0%. ResultsAmong the 3024 targeted participants, 1154 provided valid feedback defined as a 50% response rate of answers to the survey questions. Overall, >60% of the participants declared full implementation of the guidelines at their institution. The time delay from admission to coronary angiography and PCI was reported to be <24 h in over 75% of the hospitals while pre-treatment was intended in >50% of NSTE-ACS patients. Ad-hoc percutaneous coronary intervention (PCI) was performed in >70% of the cases while intravenous platelet inhibition was rarely used (<10%). Between countries differences in practice patterns for antiplatelet management for NSTE-ACS were observed, suggesting heterogeneous implementation of the guidelines. ConclusionsThis survey indicates that the implementation of 2020 NSTE-ACS guidelines on early invasive management and pre-treatment is heterogeneous, potentially due by local logistical constraints.

Occurrence of Severe Arrhythmias in Patients with Non-ST Elevation Acute Coronary Syndrome (NSTE-ACS): A Retrospective Study.

Non-ST elevation acute coronary syndrome (NSTE-ACS) is one of the most frequent manifestations of coronary artery disease. The occurrence of serious heart rhythm disorders (SHRDs) in NSTE-ACS is not well documented. However, continuous heart rhythm monitoring is recommended during the initial management of NSTE-ACS. The targeted monitoring of patients at greater risk for SHRDs could facilitate patients' care in emergency departments (EDs) where the flow of patients is continuously increasing. This retrospective single-center study included 480 patients from emergency and cardiology departments within the Strasbourg University Hospital between 1 January 2019 and 31 December 2020. The objective was to estimate the frequency of the occurrence of SHRDs among patients with NSTE-ACS. The secondary objective was to highlight the factors associated with a higher risk of SHRDs. The proportion of SHRDs during the first 48 h of hospital care was 2.3% (CI95%: 1.2-4.1%, n = 11). Two time periods were considered: before coronary angiography (1.0%), and during, or after coronary angiography (1.3%). In the first group, two patients required immediate treatment (0.4% of the patients) and no death occurred. In the univariate analysis, the variables significantly associated with SHRDs were age, anticoagulant medication, a decrease in glomerular filtration rate, plasmatic hemoglobin, and left ventricle ejection fraction (LVEF), and an increase in plasmatic troponin, BNP, and CRP levels. In the multivariable analysis, plasmatic hemoglobin > 12 g/dL seemed to be a protective factor for SHRDs. In this study, SHRDs were rare and, most often, spontaneously resolved. These data challenge the relevance of systematic rhythm monitoring during the initial management of patients with NSTE-ACS.