non-ST-elevation Acute Coronary Syndrome Patients Research Articles

The Prognostic Value of Biomarkers in Non-ST-Elevation Acute Coronary Syndrome Patients that are Treated by an Early Invasive Strategy: Insights from the OPTIMA-2 Trial.

Patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) consists of a heterogenic population and improvement in identification of a specific risk profile is needed. In this study we aimed to obtain better insight in the role of different biomarkers for patients undergoing a routine invasive diagnostic strategy within 24 hours after admission. An Immediate or Early Invasive Strategy in Non-ST-Elevation Acute Coronary Syndrome (OPTIMA-2) study was a randomized controlled prospective open-label multicentre trial, randomizing NSTE-ACS patients. An invasive strategy was either immediate ( 3 hours) or early (12-24 hours). Peak high-sensitive TroponinT (hsTropT) value was determined within the first 48 hours of admission. N-terminal proB-type natriuretic peptide (NTpro-BNP) and high-sensitivity C-reactive protein (hsCRP) values were determined at admission and at discharge. These biomarkers were then divided into tertiles and related to clinical outcomes up to one year. The relation between these biomarkers and myocardial function recovery established by echocardiography was analyzed as a secondary endpoint. The OPTIMA-2 study included 249 patients. Overall, there was no significant increase in the risk of developing an adverse cardiovascular event in the first year if biomarker tertiles at admission were compared. However, mean NT-proBNP levels at admission were higher for patients that experienced all-cause death withing the first year (1.93 0.49 vs 1.42 0.58, p = 0.05). Also, peak hs-cTnT (232.0 2846.0 vs 71.5 1152.0, p = 0.06) values at baseline were higher in patients experiencing a myocardial infarction within 1-year. NT-proBNP levels at admission and at discharge correlated with recovery of the left ventricular (LV) function at 30 days (coefficient 0.021 (95% CI = 0.009-0.033) and coefficient 0.016 (95% CI = 0.005-0.027)). In NSTE-ACS patients treated by an early invasive strategy and administration of modern anticoagulant and antiplatelet therapy, multiple biomarker measurements during admission could not predict the occurrence of recurrent cardiovascular events within the first year of follow-up.

Timing of invasive coronary angiography in non-ST-elevation acute coronary syndrome-an updated individual patient data meta-analysis.

The optimal timing of invasive coronary angiography in non-ST-elevation acute coronary syndrome (NSTE-ACS) was subject of several randomized controlled trials (RCTs) since more than 20 years. American and European guidelines recommend an early invasive strategy <24 h for high-risk NSTE-ACS patients with a global registry of acute coronary events (GRACE) risk score >140 but without evidence for ongoing ischaemia or haemodynamic instability.1,2 However, scientific evidence supporting this recommendation is sparse. Butt et al.3 analysed the effect of the GRACE risk score on all-cause mortality in a post-hoc analysis of the very early versus deferred invasive evaluation using computerized tomography (VERDICT) trial. We combined the published VERDICT data with an existing database of our previous meta-analysis (Supplementary material online for further details, Table S1, Table S2, and Figure S1r).4 Consecutively, we updated our previous GRACE risk score subgroup analysis to synthetize up-to-date scientific evidence from the currently available data. The methodology is described in the Supplementary material online in detail. In short, we performed one-stage as well as two-stage meta-analyses. Both approaches led to the same result that an early invasive strategy does reduce the risk of all-cause mortality in patients with a GRACE risk score >140 but not in patients with a GRACE risk score ≤140 or the unselected population of NSTE-ACS patients (Figure 1). While some heterogeneity is present in the total population (I2 = 30%), it is absent in each subgroup stratum (I2 = 0%; Supplementary material online, Figure S2). The reported finding is driven by the addition of data from the VERDICT trial. Exclusion of this trial leads to a similar finding as reported in our previous meta-analysis (see Supplementary material online, Table S3 and Supplementary material online, Figure S3).4

The clinical application of longitudinal layer specific strain as a diagnostic and prognostic instrument in ischemic heart diseases: A systematic review and meta-analysis.

2-dimensional Speckle-Tracking Echocardiography, to obtain longitudinal layer specific strain (LSS), has recently emerged as a novel and accurate non-invasive imaging technique for diagnosis as well as for prediction of adverse cardiac events. This systematic review and meta-analysis aimed to give an overview of the possible clinical implication and significance of longitudinal LSS. We conducted a systematic review and meta-analysis with all the studies involving layer specific strain in patients with ischemic heart disease (IHD). Of 40 eligible studies, 9 met our inclusion criteria. Studies that were included either investigated the prognostic value (n = 3) or the diagnostic value (n = 6) of longitudinal LSS. The pooled meta-analysis showed that longitudinal LSS is a significant diagnostic marker for coronary artery disease (CAD) in patients with IHD. Endocardial LSS was found to be a good diagnostic marker for CAD in IHD patients (OR: 1.28, CI95% [1.11-1.48], p < 0.001, per 1% decrease). Epicardial (OR: 1.34, CI95% [1.14-1.56], p < 0.001, per 1% decrease), Mid-Myocardial (OR: 1.24, CI95% [1.12-1.38], p < 0.001, per 1% decrease) and endocardial (OR: 1.21, CI95% [1.09-1.35], p < 0.001, per 1% decrease) LSS all entailed diagnostic information regarding CAD, with epicardial LSS emerging as the superior diagnostic marker for CAD in patients with SAP. Endocardial LSS proved to be the better diagnostic marker of CAD in patients with non-ST elevation acute coronary syndrome (NSTE-ACS). LSS was shown to be a good prognostic maker of adverse cardiac events in IHD patients. Two studies found endocardial circumferential strain to be the good predictor of outcome in CAD patients and when added to baseline characteristics. Epicardial LSS emerged as best predictor in acute coronary syndrome (ACS) patients. In patients with SAP, epicardial LSS was the stronger diagnostic marker while in NSTE-ACS patients, endocardial LSS was the stronger diagnostic marker. In addition, endocardial circumferential strain is the better predictor of adverse outcome in CAD patients whilst in ACS patients, epicardial LSS was found to be a better predictor of outcome.

Reduced-dose prasugrel monotherapy without aspirin after PCI with the SYNERGY stent in East Asian patients presenting with chronic coronary syndromes or non-ST-elevation acute coronary syndromes: rationale and design of the ASET Japan pilot study

The Acetyl Salicylic Elimination Trial (ASET) Japan pilot study is a multicentre, single-arm, open-label, proof-of-concept study with a stopping rule based on the occurrence of definite stent thrombosis. This study aims to demonstrate the feasibility and safety of low-dose prasugrel monotherapy following percutaneous coronary intervention (PCI) in Japanese patients presenting with chronic coronary syndromes (CCS) or non-ST-elevation acute coronary syndromes (NSTE-ACS). Four hundred patients with a SYNTAX score <23 requiring PCI due to CCS or NSTE-ACS will be screened and considered eligible for the study. The enrolment is planned in two phases: 1) 200 patients presenting with CCS, followed by 2) 200 patients presenting with NSTE-ACS. After optimal PCI with implantation of a SYNERGY (Boston Scientific) stent, patients will be enrolled and loaded with prasugrel 20 mg, followed by a maintenance dose of prasugrel 3.75 mg once daily without aspirin continued for 3 months in Phase 1 (CCS patients), and for 12 months in Phase 2 (NSTE-ACS patients). After these follow-up periods, prasugrel will be replaced by standard antiplatelet therapy according to local practice. The primary endpoint is a composite of cardiac death, target vessel myocardial infarction, or definite stent thrombosis after the index procedure. The primary bleeding endpoint is any Bleeding Academic Research Consortium type 3 or 5 bleeding occurring within 3 months of the index PCI for CCS patients, or 12 months for NSTE-ACS patients. The ASET Japan study is designed to demonstrate the feasibility and safety of reduced-dose prasugrel monotherapy after PCI in East Asian patients with acute and chronic coronary syndromes.

Angiographic and Procedural Characteristics in Frail Older Patients with Non-ST Elevation Acute Coronary Syndrome.

Angiographic and procedural characteristics stratified by frailty status are not known in older patients with non-ST elevation acute coronary syndrome (NSTEACS). We evaluated angiographic and procedural characteristics in older adults with NSTEACS by frailty category, as well as associations of baseline and residual SYNTAX scores with long-term outcomes. In this study, 271 NSTEACS patients aged ≥75 years underwent coronary angiography. Frailty was assessed using the Fried criteria. Angiographic analysis was performed using QAngio® XA Medis in a core laboratory. Major adverse cardiovascular events (MACE) consisted of all-cause mortality, MI, stroke or transient ischaemic attack, repeat unplanned revascularisation and significant bleeding. Mean (±SD) patient age was 80.5 ± 4.9 years. Compared with robust patients, patients with frailty had more severe culprit lesion calcification (OR 5.40; 95% CI [1.75-16.8]; p=0.03). In addition, patients with frailty had a smaller mean improvement in culprit lesion stenosis after percutaneous coronary intervention (50.6%; 95% CI [45.7-55.6]) than robust patients (58.6%; 95% CI [53.5-63.7]; p=0.042). There was no association between frailty phenotype and completeness of revascularisation (OR 0.83; 95% CI [0.36-1.93]; p=0.67). A high baseline SYNTAX score (≥33) was associated with adjusted (age and sex) 5-year MACE (HR 1.40; 95% CI [1.08-1.81]; p=0.01), as was a high residual SYNTAX score (≥8; adjusted HR 1.22; 95% CI [1.00-1.49]; p=0.047). Frail adults presenting with NSTEACS have more severe culprit lesion calcification. Frail adults were just as likely as robust patients to receive complete revascularisation. Baseline and residual SYNTAX score were associated with MACE at 5 years.

Prediction of 5-year Mortality in Invasively Managed NSTE-ACS Patients: Role of the Age, Creatinine, And Ejection Fraction (ACEF) Score

Long-term risk stratification in non-ST-elevation acute coronary syndrome (NSTE-ACS) by the ACEF score has not yet been assessed. The ACEF score (age/left ventricular ejection fraction +1 [if creatinine > 20 mg/l]) has been established in patients evaluated for coronary artery bypass surgery.

Management and Outcomes in the Elderly with Non-ST-Elevation Acute Coronary Syndromes Admitted to Spoke Hospitals with No Catheterization Laboratory Facility.

Background: Contemporary guidelines advocate for early invasive strategy with coronary angiography in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). Still, the impact of an invasive strategy in older patients remains controversial and may be challenging in spoke hospitals with no catheterization laboratory (cath-lab) facility. Purpose: The purpose of this study was to analyse the characteristics and outcomes of patients ≥80 years old with NSTE-ACS admitted to spoke hospitals. Methods: Observational–retrospective study of all consecutive NSTE-ACS patients admitted to two spoke hospitals of our cardiology network, where a service strategy (same-day transfer between a spoke hospital and a hub centre with a cath-lab facility in order to perform coronary angiography) was available. Patients were followed up for 1 year after the admission date. Results: From 2013 to 2017, 639 patients were admitted for NSTE-ACS; of these, 181 (28%) were ≥80 years old (median 84, IQR 82–89) and represented the study cohort. When the invasive strategy was chosen (in 105 patients, or 58%), 98 patients (93%) were initially managed with a service strategy, whereas the remainder of the patients were transferred from the spoke hospital to the hub centre where they completed their hospital stay. Of the patients managed with the service strategy, a shift of strategy after the invasive procedure was necessary for 10 (10%). These patients remained in the hub centre, while the rest of the patients were sent back to the spoke hospitals, with no adverse events observed during the back transfer. The median time to access the cath-lab was 50 h (IQR 25–87), with 73 patients (70%) reaching the invasive procedure <72 h from hospital admission. A conservative strategy was associated with: older age, known CAD, clinical presentation with symptoms of LV dysfunction, lower EF, renal failure, higher GRACE score, presence of PAD and atrial fibrillation (all p < 0.03). At the 1-year follow-up, the overall survival was significantly higher in patients treated with an invasive strategy compared to patients managed conservatively (94% ± 2 vs. 54% ± 6, p < 0.001; HR: 10.4 [4.7–27.5] p < 0.001), even after adjustment for age, serum creatinine, known previous CAD and EF (adjusted HR: 2.0 [1.0–4.0]; p < 0.001). Conclusions: An invasive strategy may confer a survival benefit in the elderly with NSTE-ACS. The same-day transfer between a spoke hospital and a hub centre with a cath-lab facility (service strategy) is safe and may grant access to the cath-lab in a timely fashion, even for the elderly.

Safety of intravenous cangrelor infusion during percutaneous coronary intervention in a real-world cohort of non-pretreated NSTEACS patients

Abstract Background and purpose Since publication of latest ESC guidelines in 2020, pretreatment with an oral P2Y12 receptor inhibitor (P2Y12i) is no longer systematically recommended in patients with non-ST elevation acute coronary syndrome (NSTEACS) [1]. Therefore, from now on, NSTEACS patients will arrive to the cathlab to a larger extent without having a loading dose of an oral P2Y12i administered. Cangrelor, a potent intravenous P2Y12i, is an emerging option that provides a rapid onset of platelet inhibition, but it has not been widely used yet [2]. We aimed to evaluate safety of cangrelor real-world use in NSTEACS patients who had not received an oral P2Y12i before percutaneous coronary intervention (PCI). Methods Development of periprocedural thrombotic complications, ischaemic and bleeding events at 30 days was retrospectively evaluated in a cohort of non-pretreated NSTEACS patients referred to PCI. Comparison among those who underwent intravenous infusion of cangrelor and those who received a loading dose of an oral P2Y12i (ticagrelor, prasugrel or clopidogrel) at the moment of PCI was performed. Results Between January and December of 2020, 155 non-pretreated NSTEACS patients were referred to our cathlab; of whom, 89 underwent PCI and were included in the analysis (18.0% with unstable angina, 82.0% with NSTEMI). Mean age was 66.0±14.3 years, 21 (23.6%) were female and the mean GRACE risk score was 112±34. PCI was performed ad-hoc (immediately after diagnostic catheterization) in 81 patients (91.0%), whereas 15 patients (16.9%) required PCI to be done in more than two times. Procedure was performed exclusively by radial or cubital artery access in 78 patients (87.6%). Regarding antiplatelet drug administration, cangrelor was used in 14 patients (15.7%), prasugrel in 35 (39.3%), ticagrelor in 29 (32.6%) and clopidogrel in 11 (12.4%). No significant differences were found among patients in terms of development of ischaemic events at 30 days (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke or stent thrombosis) or periprocedural thrombotic events (no-reflow, bailout use of anti-IIb/IIIb or intraprocedural stent thrombosis). The use of cangrelor did not raise the incidence of bleeding events at 30 days (7.1% vs. 15.1%, p=0.682) [Table 1]. Cangrelor tended to be more frequently used in high-risk NSTEMI patients (20.8% vs. 12.9%, p=0.357) and in case of complex PCI (26.3% vs. 7.8%, p=0.018) [Figure 1]. After controlling by both variables, cangrelor did not significantly increase the risk of bleeding or ischaemic events at 30 days either. Conclusions Intravenous infusion of cangrelor during PCI in non-pretreated NSTEACS patients shows no differences in terms of thrombotic or bleeding events in comparison to the administration of a loading dose of an oral P2Y12i. Our results also suggest that cangrelor could be a safe option in patients with high thrombus burden who require complex PCI. Funding Acknowledgement Type of funding sources: None.

Multimodality coronary imaging to predict non-culprit territory unrecognized myocardial infarction assessed by cardiac magnetic resonance in non-ST-elevation acute coronary syndrome

Abstract Objectives This study sought to assess the predictors of coherence tomography (OCT) and coronary computed tomography angiographic (CCTA) findings for non-infarct-related (non-IR) territory unrecognized myocardial infarction (UMI) in patients with first non-ST-elevation acute coronary syndrome (NSTE-ACS) presentation. Background UMI detected by cardiac magnetic resonance (CMR) is associated with adverse outcomes in patients with both acute coronary syndrome and chronic coronary syndrome. However, the association between the presence of UMI and findings of multimodality coronary imaging remains unknown. Methods We investigated 69 patients with a first clinical episode of NSTE-ACS, who underwent pre-PCI 320-slice CCTA, uncomplicated urgent percutaneous coronary intervention (PCI) with OCT assessment within 48 hours of admission, and post-PCI CMR. UMI was assessed on late gadolinium enhancement (LGE-CMR) by identifying regions of hyperenhancement with an ischemic distribution pattern in non-IR territories (non-IR UMI). Results Non-IR UMI was detected in 11 patients (15.9%). ROC analysis revealed the optimal cut-off value of PCATA in culprit vessel for predicting the presence of non-IR UMI were −71.3. Lower ejection fraction, higher Gensini score, high pericoronary inflammation (&amp;gt;−71.3), OCT-defined culprit lesion plaque rupture (OCT-PR), and OCT-defined culprit lesion cholesterol crystal (OCT-CC) were significantly associated with the presence of non-IR UMI (Figure 1A). OCT findings are shown in Figure 1B. Patients with non-IR UMI had a higher prevalence of OCT-PR and OCT-CC than those without. Compared with patients without non-IR UMI, the prevalence of high pericoronary inflammation was higher in patients with non-IR UMI (Figure 1C). When the total cohort was divided into four groups according to the numbers of aforementioned OCT-derived risk factors and PCATA, patients with all of these UMI risk factors showed 46.2% (6/13) prevalence of non-IR UMI, whereas none of 15 patients without these factors showed non-IR UMI (Figure 1D). Conclusions When culprit lesion showed OCT-PR, OCT-CC, and high PCATA, about half of these patients are likely to have non-IR UMI. The integrated CCTA and OCT assessment may help identify the presence of non-IR UMI, potentially providing prognostic information in first NSTE-ACS patients. Funding Acknowledgement Type of funding sources: None.

Correlation between NSTE-ACS risk scores with Syntax: can we predict coronary lesion complexity before angiography?

Abstract Background and aim Standard single antiplatelet regimen (SAPT) is currently recommended before invasive risk stratification in non-ST elevation acute coronary syndromes (NSTE-ACS). However, there are subsets in whom dual antiplatelet therapy (DAPT) may be more protective according to the coronary anatomy and revascularization strategy. We aimed to identify pre-procedural predictors of coronary artery complexity that may be helpful in selecting an individualized antiplatelet regimen. Methodology Retrospective single-center study including patients with NSTE-ACS performing coronary angiography between January 2020 and July 2021. Clinical variables and classical NSTE-ACS risk scores (TIMI, GRACE and HEART) were captured and SYNTAX 1 score was calculated. Patients were divided into low (0–22), moderate (23–32) and high (≥33) SYNTAX score. Multivariate logistic regression analysis was performed to determine predictors of anatomical complexity (defined as significant left main disease [stenosis ≥50%] or SYNTAX ≥33). Results A total of 448 patients were included (mean age 67±13 years; 74% males; 85% with NSTE-myocardial infarction). Overall, 350 (78%), 63 (14%) and 35 (8%) patients had a low, moderate or high-SYNTAX score, respectively. Thirty-one (7%) patients had significant left main disease. At multivariate analysis (adjusted for age, diabetes, renal function, GRACE and TIMI scores), the HEART score (hazard ratio 2.3, 95% confidence interval 1.5–3.3, p&amp;lt;0.001) predicted a high anatomical complexity. When performing ROC curve analysis, the HEART score had a high discriminative ability in identifying those with complex coronary anatomy (area under the curve 0.79, 95% CI 0.72–0.86, p&amp;lt;0.001) (Figure 1) – a score &amp;gt;7 showed a sensitivity of 76% and specificity of 75% in identifying such patients. Conclusion In this cohort of NSTE-ACS patients, the HEART score was an independent predictors of complex coronary anatomies. These results suggest that those with high (&amp;gt;7) HEART score may merit from SAPT as opposed to DAPT, given the high probability of complex lesions amenable to CABG. Funding Acknowledgement Type of funding sources: None.

The value of coronary computed tomography and very early invasive coronary angiography compared to standard intervention in older patients after non-ST segment elevation acute coronary syndromes

Abstract Background The optimal management of patients with non-ST elevation acute coronary syndromes (NSTEACS) remains a challenge. The merits of both computed tomography angiography (CTA) as a rule-out test for significant coronary artery disease and early invasive coronary angiography (ICA) are debated. Furthermore, there are limited data in older NSTEACS patients, who likely have more coronary artery calcification and are at higher risk of ACS-related complications. Methods This is a post hoc analysis of patients ≥75 years included in the Very Early Versus Standard Care Invasive Examination and Treatment of Patients with Non-ST-Segment Elevation Acute Coronary Syndrome Trial (VERDICT). The diagnostic accuracy of CTA was investigated in patients without previous coronary artery bypass grafting, renal dysfunction, or atrial fibrillation; the presence of a coronary artery stenosis ≥50% determined by ICA was used as reference. Patients were randomised to very early ICA within 12 hours of diagnosis or standard care (ICA within 48–72 hours of diagnosis) and followed for up to five years. The primary endpoint was the composite of all-cause mortality, nonfatal recurrent MI, hospital admission for refractory myocardial ischaemia or hospital admission for heart failure. Results From November 2010 to June 2016, 2147 patients were included in the VERDICT trial. Of these, 452 (21%) patients were ≥75 years of age. Most older patients had a GRACE score &amp;gt;140 (n=388, 88.8%). At the time of admission, older patients had lower levels of haemoglobin, estimated glomerular filtration rate, and left ventricular ejection fraction, and more often displayed elevated troponins and electrocardiogram changes indicating new ischaemia, than those &amp;lt;75 years. Of patients ≥75 years of age, 161 (35.6%) underwent CTA before ICA. Older patients had significantly higher calcium scores than younger patients (1187±1445 vs. 499±858 Agatston units, p&amp;lt;0.001). 19% of CTAs excluded significant coronary artery disease. The negative predictive value of the CTAs was 94 (95% CI 79–99)% and the sensitivity was 98 (95% CI 94–100)%, figure 1. The primary endpoint was observed more frequently in patients ≥75 years as compared to younger patients (n=222, 49% vs. n=390, 23%, p&amp;lt;0.001), even after adjustment for allocated treatment (adjusted HR 2.65, 95% CI 2.25–3.13, p&amp;lt;0.001). Among older patients randomised to very early ICA, there were no differences in the cumulated number of primary endpoints compared to older patients randomised to standard ICA (log-rank p=0.36), figure 2. Conclusion Among patients ≥75 years old with NSTEACS, CTA showed a high diagnostic accuracy. A very early ICA within 12 hours of diagnosis did not improve long-term composite outcome in these older patients with NSTEACS. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Rigshospitalets Research Foundation

Timing of coronary angiography in patients with non-ST-elevation acute coronary syndrome: long-term clinical outcomes from the nationwide SWEDEHEART registry.

Current guidelines stress the importance of early invasive assessment of patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), in particular those at high risk. However, supporting scientific evidence is limited. We aimed to investigate the prognostic impact of the timing of coronary angiography in a large cohort of NSTE-ACS patients. We performed a retrospective analysis including 34,666 NSTE-ACS patients registered from 2013 to 2018 in the SWEDEHEART registry. The prognostic implications of the timing of coronary angiography on a continuous scale and within <24 vs 24-72 hours were assessed using Cox regression analyses. The median time interval from admission to invasive assessment was 32.8 (25th, 75th percentiles 20.4-63.8) hours. There was no apparent time window within 96 hours from admission that provided prognostic benefit. Coronary angiography within 24-72 hours (vs <24 hours) was not associated with worse outcome overall (all-cause mortality: hazard ratio 1.01, 95% confidence interval [CI] 0.92-1.11; major adverse events: hazard ratio 1.04, 95% CI: 0.98-1.12). Interaction analyses indicated a greater relative benefit of coronary angiography <24 hours in some lower-risk groups (women, non-diabetics, patients with minor troponin elevation) but neutral effects in higher-risk groups (defined by age or the GRACE 2.0 score). These Swedish data do not provide support for an early invasive strategy in NSTE-ACS, especially in high-risk patients. Our results suggest that the timing of invasive assessment should rather be based on individualised decisions integrating symptoms and risk panorama than on strictly defined time intervals.

FREQUENCY OF ACUTE HEART FAILURE IN NON ST ELEVATION ACUTE CORONARY SYNDROME; CAN WE PREDICT THE HEART FAILURE ON CLINICAL AND ELECTROCARDIOGRAPHY (ECG) BASIS?

Objectives: Non-ST elevation acute coronary syndrome (NSTE-ACS) comprises NSTE myocardial infarction (NSTEMI) and unstable angina. A common complexity of NSTE-ACS is heart failure (HF). The objective of this study was to assess the incidence of in-hospital HF in NSTE-ACS patients and to link clinical and electrocardiographic (ECG) abnormalities to HF. Methodology: This study was performed at National Institute of Cardiovascular Diseases (NICVD) Karachi, from January 1, 2018 to June 30, 2018. The study included all adult patients who were hospitalized with a diagnosis of non-ST elevation ACS. Their socio demographic profile, clinical findings, ECG findings, and occurrence of heart failure during hospital stay was recorded. Data was entered and analyzed using SPSS v.23. Results: In this study 265 patients with NSTE-ACS were included. Mean age of 55.39±10.40 years was observed. There were 195 (73.6%) male patients. T-wave inversion was observed in 73 (27.5%) patients, ST-segment depression in 77 (29.1%), and both T-wave inversion and ST-segment depression in 71 (26.8%) patients. During their stay in the hospital, 28 patients (10.6 percent) developed HF. Diabetes, hypertension, smoking, a genetic susceptibility of ischemic heart disease, and combination of T-wave inversion and ST-segment depression on ECG was significantly correlated with HF (P≤0.05). Conclusion: The determinants of HF were diabetes, hypertension, smoking, family history of ischemic heart disease, and combination of T-wave inversion and ST depression on ECG.

Cost-effectiveness of clopidogrel vs. ticagrelor in patients of 70 years or older with non-ST-elevation acute coronary syndrome.

The POPular AGE trial showed that clopidogrel significantly reduced bleeding risk compared with ticagrelor without any signs of an increase in thrombotic events. The aim of this analysis was to estimate the long-term cost-effectiveness of clopidogrel compared with ticagrelor in these patients aged 70 years or older with non-ST-elevation acute coronary syndrome (NSTE-ACS). A 1-year decision tree based on the POPular AGE trial in combination with a lifelong Markov model was developed to compare clopidogrel with ticagrelor in terms of clinical outcomes, costs, and quality-adjusted life years (QALYs) in elderly patients (above 70 year) with NSTE-ACS. Cost-effectiveness was assessed from a Dutch healthcare system perspective. Events rates and utility data observed in the POPular AGE trial were combined with lifetime projections to evaluate costs and effects for a fictional cohort of 1000 patients. Treatment with clopidogrel instead of ticagrelor led to a cost saving of €1484575 (€1485 per patient) and a decrease of 10.96 QALYs (0.011 QALY per patient) in the fictional cohort. In an alternative base case with equal distribution over health states in the first year, treatment with clopidogrel led to an increase in QALYs. In all scenario analyses, treatment with clopidogrel was cost-saving. Clopidogrel is a cost-saving alternative to ticagrelor in elderly patients after NSTE-ACS, though regarding overall cost-effectiveness clopidogrel was not superior to ticagrelor, as it resulted in a small negative effect on QALYs. However, based on the results of the alternative base case and clinical outcomes of the POPular AGE trial, clopidogrel could be a reasonable alternative to ticagrelor for elderly NSTE-ACS patients with a higher bleeding risk.

Deceleration Capacity Improves Prognostic Accuracy of Relative Increase and Final Coronary Physiology in Patients With Non-ST-Elevation Acute Coronary Syndrome.

BackgroundBoth coronary physiology and deceleration capacity (DC) showed prognostic efficacy for patients with acute coronary syndrome (ACS). This retrospective cohort study was performed to evaluate the prognostic implication of DC combined with the relative increase and final coronary physiology as detected by quantitative flow ratio (QFR) for patients with non-ST-elevation ACS (NSTE-ACS) who underwent complete and successful percutaneous coronary intervention (PCI).MethodsPatients with NSTE-ACS who underwent PCI with pre- and post-procedural QFR in our department between January 2018 and November 2019 were included. The 24-hour deceleration capacity (DC 24h) was obtained via Holter monitoring. The incidence of major adverse cardiac and cerebrovascular events (MACCEs) during follow up was defined as the primary outcome. The optimal cutoffs of the relative increase, final QFR, and DC 24h for prediction of MACCEs were determined via receiver operating characteristic (ROC) analysis and the predictive efficacies were evaluated with multivariate Cox regression analysis.ResultsOverall, 240 patients were included. During a mean follow up of 21.3 months, 31 patients had MACCEs. Results of multivariate Cox regression analyses showed that a higher post-PCI QFR [adjusted hazard ratio (HR): 0.318; 95% confidence interval (CI): 0.129–0.780], a higher relative QFR increase (HR: 0.161; 95% CI: 0.066–0.391], and a higher DC (HR: 0.306; 95% CI: 0.134–0.701) were all independent predictors of lower risk of MACCEs. Subsequently, incorporating low DC (≤2.42) into the risk predicting model with clinical variables, the predictive efficacies of low relative QRS increase (≤23%) and low post-PCI QFR (≤0.88) for MACCEs were both significantly improved.ConclusionsThe DC combined with relative increase and final coronary physiology may improve the predictive efficacy of existing models based on clinical variables for MACCEs in NSTE-ACS patients who underwent complete and successful PCI.

Elevated TyG Index Predicts Incidence of Contrast-Induced Nephropathy: A Retrospective Cohort Study in NSTE-ACS Patients Implanted With DESs.

BackgroundTriglyceride-glucose (TyG) index is a reliable and specific biomarker for insulin resistance and is associated with renal dysfunction. The present study sought to explore the relationship between TyG index and the incidence of contrast-induced nephropathy (CIN) in non-ST elevation acute coronary syndrome (NSTE-ACS) patients implanted with drug-eluting stents (DESs).MethodsA total of 1108 participants were recruited to the study and assigned to two groups based on occurrence of CIN. TyG index was calculated as ln [fasting triglycerides (mg/dL) × fasting blood glucose (mg/dL)/2]. Baseline characteristics and incidence of CIN were compared between the two groups. Logistic regression analysis was performed to evaluate the relationship between TyG index and CIN.ResultsThe results showed that 167 participants (15.1%) developed CIN. Subjects in the CIN group had a significantly higher TyG index compared with subjects in the non-CIN group (8.9 ± 0.7 vs. 9.3 ± 0.7, P<0.001). TyG index was significantly correlated with increased risk of CIN after adjusting for confounding factors irrespective of diabetes mellitus status and exhibited a J-shaped non-linear association. Subgroup analysis showed a significant gender difference in the relationship between TyG index and CIN. Receiver operating characteristic (ROC) curve analysis indicated that the risk assessment performance of TyG index was superior compared with other single metabolic indexes. Addition of TyG index to the baseline model increased the area under the curve from 0.713 (0.672-0.754) to 0.742 (0.702-0.782) and caused a reclassification improvement of 0.120 (0.092-0.149).ConclusionThe findings from the present study show that a high TyG index is significantly and independently associated with incidence of CIN in NSTE-ACS patients firstly implanted with DESs. Routine preoperative assessment of TyG index can alleviate CIN and TyG index provides a potential target for intervention in prevention of CIN.

Non-ST-elevation acute coronary syndrome in chronic kidney disease: prognostic implication of an early invasive strategy.

The optimal timing of PCI for NSTE-ACS with CKD is unclear. The aim of our study was to assess whether early percutaneous coronary intervention (PCI) (within 24 hours from admission) is associated with improved in-hospital (mortality or acute kidney injury) and long-term events (composite of mortality, myocardial infarction, stroke and bleeding events) in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) with chronic kidney disease (CKD). We retrospectively studied NSTE-ACS patients who underwent PCI in large tertiary centers. CKD was defined as estimated glomerular filtration rate (eGFR)<60 mL/min/1.73 m2. A propensity score for the likelihood of an early invasive strategy was calculated. Relative risks (RR) and adjusted hazard ratios (HR) were estimated for in-hospital and follow-up events. We included 821 patients, mean age was 69±12 years; 492 (60%) received an early PCI, and 273 (33%) had an eGFR <60. Median follow-up was 391 days. At univariate analysis, early treatment was associated with significantly lower in-hospital and follow-up events. However, after adjustment for major prognostic factors, there was no significant association with both in-hospital (RR=1.06; 95% CI 0.83-1.36) and follow-up events (RR=1.07; 95% CI 0.83-1.37). When the association was assessed in strata of CKD, lack of statistically significant association was confirmed, even if a trend emerged in patients with preserved renal function both on primary outcome (RR=0.47, 95% 0.18-1.22) and time to secondary outcome (HR=0.62, 95% CI 0.36-1.08). In conclusion in a cohort of NSTE-ACS patients, an early invasive strategy does not independently affect prognosis.

Prognostic implication of serum glycated albumin for patients with non-ST-segment elevation acute coronary syndrome undergoing percutaneous coronary intervention

BackgroundIt has been demonstrated that glycated albumin (GA) is significantly associated with diabetes complications and mortality. However, among patients diagnosed with non-ST-elevation acute coronary syndrome (NSTE-ACS) administered percutaneous coronary intervention (PCI), the predictive value of GA for poor prognosis is unclear.MethodsThis study eventually included 2247 NSTE-ACS patients in Beijing Anzhen Hospital, Capital Medical University in January-December 2015 who received PCI. All patients were followed up until death or for 48 months post-discharge. The primary endpoint was major adverse cardio-cerebral events (MACCEs), including all-cause death, non-fatal myocardial infarction, ischemia-induced revascularization and non-fatal ischemic stroke.ResultsIn total, 547 (24.3%) MACCEs were recorded during the follow-up period. Upon adjusting for potential confounders, GA remained an important risk predictor of MACCEs (As nominal variate: hazard ratio [HR] 1.527, 95% confidence interval [CI] 1.236–1.886, P < 0.001; As continuous variate: HR 1.053, 95% CI 1.027–1.079, P < 0.001). GA addition significantly enhanced the predictive ability of the traditional risk model (Harrell’s C-index, GA vs. Baseline model, 0.694 vs. 0.684, comparison P = 0.002; continuous net reclassification improvement (continuous-NRI) 0.085, P = 0.053; integrated discrimination improvement (IDI) 0.007, P = 0.020).ConclusionGA is highly correlated with poor prognosis in NSTE-ACS patients undergoing PCI, suggesting that it may be a major predictive factor of adverse events among these individuals.

Development and Validation of a Risk Nomogram Model for Predicting Contrast-Induced Acute Kidney Injury in Patients with Non-ST-Elevation Acute Coronary Syndrome Undergoing Primary Percutaneous Coronary Intervention.

ObjectiveTo establish a nomogram model to predict the risk of contrast-induced acute kidney injury (CI-AKI) by analyzing the risk factors of CI-AKI and to evaluate its effectiveness.MethodsRetrospectively analyze the clinical data of non-ST-elevation acute coronary syndrome (NSTE-ACS) patients who underwent percutaneous coronary intervention (PCI) in our cardiology department from September 2018 to June 2021. Of these, patients who underwent PCI in an earlier period formed the training cohort (70%; n = 809) for nomogram development, and those who underwent PCI thereafter formed the validation cohort (30%; n = 347) to confirm the model’s performance. The independent risk factors of CI-AKI were determined by LASSO regression and multivariable logistic regression analysis. By using R software from which nomogram models were subsequently generated. The nomogram was developed and evaluated based on discrimination, calibration, and clinical efficacy using the concordance statistic (C-statistic), calibration plot, and decision curve analysis (DCA), respectively.ResultsThe nomogram consisted of six variables: age >75, left ventricular ejection fraction, diabetes mellitus, fibrinogen-to-albumin ratio, high-sensitive C-reactive protein, and lymphocyte count. The C-index of the nomogram is 0.835 (95% CI: 0.800–0.871) in the training cohort and 0.767 (95% CI: 0.711–0.824) in the validation cohort, respectively. The calibration plots exhibited that the nomogram was in good agreement between prediction and observation in the training and validation cohorts. Decision curve analysis and clinical impact curve suggested that the predictive nomogram had clinical utility.ConclusionThe nomogram model established has a good degree of differentiation and accuracy, which is intuitively and individually to screen high-risk groups and has a certain predictive value for the occurrence of CI-AKI in NSTE-ACS patients after PCI.

Early angiography in elderly patients with non-ST-segment elevation acute coronary syndrome: The cardio CHUS-HUSJ registry

In elderly patients with non-ST elevation acute coronary syndrome (NSTEACS), while routine invasive management is established in high-risk NSTEACS patients, there is still uncertainty regarding the optimal timing of the procedure. This study analyzes the association of early coronary angiography with all-cause mortality, cardiovascular mortality, heart failure (HF) hospitalization, and major adverse cardiovascular events (MACE) in patients older than 75years old with NSTEACS. This retrospective observational study included 7811 consecutive NSTEACS patients who were examined between the years 2003 and 2017 at two Spanish university hospitals. There were 2290 patients older than 75years old. We compared their baseline characteristics according to the early invasive strategy used (coronarography ≤24h vs. coronarography >24h) after the diagnosis of NSTEACS. Among the study participants, 1566 patients (68.38%) underwent early invasive coronary intervention. The mean follow-up period was 46months (interquartile range 18-71months). This association was also maintained after propensity score matching: early invasive strategy was significantly related to lower all-cause mortality [HR 0.61 (95% CI 0.51-0.71)], cardiovascular mortality [HR 0.52 (95% CI 0.43-0.63)], and MACE [HR 0.62 (CI 95% 0.54-0.71)]. In a contemporary real-world registry of elderly NSTEACS patients, early invasive management significantly reduced all-cause mortality, cardiovascular mortality, and MACE during long-term follow-up. In this real-world retrospective observational study that included 2451 patients older than 75years old, 1566 patients (68.38%) underwent early invasive coronary intervention. After performing a propensity score matching, the early invasive strategy was still associated with lower all-cause mortality [HR (hazard ratio) 0.61, 95% CI (95% confidence interval) (0.51-0.71)], cardiovascular mortality [HR 0.52 (95%CI 0.43-0.63)], and MACE [HR 0.62 (95%CI 0.54-0.71)] during long-term follow-up.