non-ST Elevation Acute Coronary Syndrome Research Articles

The High-Grade Oxidative Profile (OXpr), Aortic Stiffness Parameters, and Hemogram-Derived Indices (HDI) as Predictors of Long-Term Major Adverse Cardiovascular Events (MACEs) Following Percutaneous Coronary Intervention (PCI) in Patients with Non-ST-Elevation Acute Coronary Syndrome (NSTE-ACS) and Chronic Coronary Syndrome (CCS)

The High-Grade Oxidative Profile (OXpr), Aortic Stiffness Parameters, and Hemogram-Derived Indices (HDI) as Predictors of Long-Term Major Adverse Cardiovascular Events (MACEs) Following Percutaneous Coronary Intervention (PCI) in Patients with Non-ST-Elevation Acute Coronary Syndrome (NSTE-ACS) and Chronic Coronary Syndrome (CCS)

Optical Coherence Tomography (OCT) evaluation of culprit lesions in patients with Non-ST Elevation Acute Coronary Syndromes (NSTE-ACS)

Abstract Funding Acknowledgements Type of funding sources: None. Background OCT is an excellent tool to determine plaque morphology in Acute Coronary Syndromes. While plaque rupture has been determined to be the dominant morphology in ST Elevation Myocardial Infarction, there is paucity of literature in NSTE-ACS, which includes Non–ST Segment Elevation Myocardial Infarction (NSTEMI) and Unstable angina (UA). Purpose To characterize culprit lesion morphology by OCT in NSTE-ACS and to evaluate the frequency of each type of lesion in patients presenting with NSTEMI and UA. Methods In this single-centre observational study, OCT imaging of culprit lesion was acquired during coronary angioplasty of culprit lesions of 50 patients presenting with NSTE-ACS between August 2020 to July 2021. A comparison of the frequency of each type of lesion between NSTEMI and UA was performed. Results OCT of culprit vessel in the entire cohort of NSTE-ACS showed plaque erosion in 32% (n=16), plaque rupture in 32% (n=16), tight stenosis in 26% (n=13) and calcific nodule in 10% (n= 5) patients. Lipid plaque was seen in a higher number of patients with plaque erosion and plaque rupture (93.8% and 87.5% respectively). Comparison of the frequency of these lesions in NSTEMI and UA, revealed that among NSTEMI patients (n=25), 48% had plaque erosion, 36% had plaque rupture, 12% had tight stenosis and 4% had calcific nodule whereas, among UA patients (n=25), 16% had plaque erosion, 28% had plaque rupture, 40% had tight stenosis and 16% had calcific nodule. There was a statistically significant increase in plaque erosion in NSTEMI compared to UA (p=0.015) while tight stenosis was significantly more common in UA (p=0.024). Similarly, red thrombus and spotty calcium (p=0.002 and 0.008 respectively) were higher in NSTEMI compared to UA. There was no significant difference in frequency of thin cap fibroatheroma, macrophages, cholesterol crystals, white thrombus, and neovascularization among the two groups. Conclusions OCT provides unique insights into the mechanisms of NSTE-ACS. In our study plaque erosion and plaque rupture were both equally seen in patients presenting with NSTE- ACS. However, NSTEMI patients had a higher frequency of plaque erosion, red thrombus, and spotty calcium when compared to UA. While UA patients had a higher incidence of tight stenosis.

What is changing in the treatment of acute coronary syndrome in the Russian Federation?

The work of the national network of vascular centers of the Russian Federation (RF), based on the Clinical recommendations of the Russian Society of Cardiology and the procedure for providing medical care to patients with cardiovascular diseases, has led to significant positive results in the treatment of patients with acute coronary syndrome (ACS) in the country, although a number of targets have not yet been reached. The purpose of the publication is to demonstrate the trend in therapeutic approaches to the management of patients with ACS in 2020-2022. in Russia and analysis of their effectiveness. Quantitative and qualitative indicators of the treatment of patients with ACS for the presented analysis were obtained on the basis of monitoring data from the Russian Ministry of Health for 2018-2021. presented: Monitoring of measures to reduce mortality from coronary heart disease, letters of the Ministry of Health of Russia dated March 13, 2015 No. 17-6 / 10 / 1-177 and dated July 24, 2015 No. 17-9 / 10 / 2-4128, within which data collection carried out monthly, on the portal of the Federal State Budgetary Institution "TsNIIOIZ" of the Ministry of Health of Russia - Automated system for monitoring medical statistics and the register REGION-IM (Russian Register of Acute Myocardial Infarction) - a multicenter prospective observational cohort study for 2020-2022, organized by the Federal State Budgetary Institution "National Medical Research Center of Cardiology named after Academician E.I. Chazov" of the Ministry of Health of Russia. In Russia with a diagnosis of ACS in 2020 and 2021 403,931 and 397,930 patients were hospitalized, respectively. The decrease in the number of patients diagnosed with ACS admitted to Russian hospitals by 22.32% was mainly due to a significant decrease in hospital admissions of patients diagnosed with non-ST elevation ACS (non-STE-ACS) (by 29.03%). At the same time, the admission of patients with ST elevation myocardial infarction (STEMI) decreased only by 6.02%. Compared to 2018-2019, in 2020-2022. increased mortality in primary percutaneous coronary intervention (PCI) (by 9.6%) and in the general STEMI group (by 12.3%); significantly increased mortality both in the general group of NSTE-ACS (by 48%) and during PCI for patients with non-STE-ACS (by 28.6%); there was an increase in the average annual number of primary PCI (by 12.6%); an absolute and relative increase in the number of PCI in non-STE-ACS was revealed (by 2.7 and 37.1%, respectively). In the country's hospitals, by the time of discharge, 95% of patients receive statins, beta-blockers – 87%, ACE inhibitors – 80%, acetylsalicylic acid – 82%, P2Y12 inhibitors – 98% of patients, regardless of the type of ACS. In Russia in 2020-2022 unfavorable tendencies in the provision of care to patients with ACS include: increased mortality in primary PCI and in the general STEMI group; increased mortality both in the general group of non-STE-ACS and during PCI for patients with non-STE-ACS. The positive results of the work of the national network of vascular centers include: absolute, relative and estimated increase in the number of primary PCI; absolute and relative increase in the number of PCI in non-STE-ACS; a high level of prescribing drugs with a proven positive effect on the prognosis.

Long-term predictors of major adverse cardiovascular events occurred in NSTE-ACS Algerian patients: Five-year follow-up

Risk assessment of patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) is the primordial step of management. Identification and analysis of predictive factors of long-term major cardiovascular events in non-ST-elevation acute coronary syndromes in an Algerian population. Prospective study including all patients admitted to our cardiology department for NSTE-acute coronary syndrome between November 01, 2015 and October 31, 2016 having benefited from a systematic invasive attitude with an average follow-up spanning more than 5 years, antecedents, risk factors, clinical, electrical, biological, echocardiographic and angiographic elements are collected individually and with the calculation of different risk scores (Grace, TIMI, PURSUIT, FRISC, HEART scores …) and angiographic scores (Syntax score, Jeopardy score, Duke coronary index, Gensini score …), MACCE at five-year, as well as global and cardiovascular mortality are correlated with the different elements and scores in an univariate, multivariate analysis, survival Kaplan–Meier curve, curve of occurrence of MACCE and ROC curve. Of the 296 patients included, we were able to ensure long-term follow-up in 274 patients (22 patients lost to follow-up/non-consenting, 7.4%) the rate of MACCE at 5 years is 35.0%, and the mortality rates of cardiovascular and global origin at 5 years were 15.7% and 18.6% respectively. The prognostic factors correlated with cardiovascular mortality at 5 years are age (per decade) OR at 1.56 (CI: 1.03–2.36, P < 0.036), renal function OR at 2.73 (CI: 1.24–6.0, P < 0.013), BNP > 300 pg/mL OR at 4.39 (CI: 1.93–9.98, P < 10−3), LVEF OR at 2.57 (CI: 1.38–4.80, P < 0.003) and carotid IMT OR at 4.72 (CI: 1.86–12.0, P < 0.001). The prognostic factors correlated with the occurrence of major cardiovascular events at 5 years are age (per decade) OR at 1.28 (CI: 1.01–1.63, P < 0.048), diabetes OR at 1.76 (CI: 1.02–3.04, P < 0.041), a Q wave of necrosis on the ECG (sequel) OR at 3.39 (CI: 1.61–7.12, P < 0.001), renal function OR at 2.57 (CI: 1.38–4.80, P < 0.013) and positive troponins OR at 1.91 (CI: 1.07–3.41, P < 0.029) (Fig. 1). This real-life study allowed us to identify relevant prognostic markers that allow us to guide therapeutic attitude: identified patients’ candidates for prolonged DAPT and made orientation for both primary and secondary prevention.

Effect of pretreatment with a P2Y12 inhibitor in patients with non-ST-elevation acute coronary syndrome: a systematic review and network meta-analysis.

This study aimed to systematically evaluate the effects of different types and doses of pretreatment with P2Y12 inhibitors in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) undergoing percutaneous coronary intervention (PCI). Electronic databases were searched for studies comparing pretreatment with different types and doses of P2Y12 inhibitors or comparison between P2Y12 inhibitor pretreatment and nonpretreatment. Electronic databases included the Cochrane Library, PubMed, EMBASE, and Web of Science. Literature was obtained from the establishment of each database until June 2022. The patients included in the study had pretreatment with P2Y12 inhibitors with long-term oral or loading doses, or conventional aspirin treatment (non-pretreatment). The primary endpoint was major adverse cardiac and cerebrovascular events (MACCEs) during follow-up within 30 days after PCI, which included determining the composite endpoints of cardiac death, myocardial infarction, ischemia-driven revascularization, and stroke. The safety endpoint was a major bleeding event. A total of 119,014 patients from 21 studies were enrolled, including 13 RCTs and eight observational studies. A total of six types of interventions were included-nonpretreatment (placebo), clopidogrel pretreatment, ticagrelor pretreatment, prasugrel pretreatment, double loading pretreatment (double loading dose of clopidogrel, ticagrelor, prasugrel) and P2Y12 inhibitors pretreatment (the included studies did not distinguish the types of P2Y12 inhibitors, including clopidogrel, ticagrelor, and prasugrel). The network meta-analysis results showed that compared to patients without pretreatment, patients receiving clopidogrel pretreatment (RR = 0.78, 95% CI:0.66, 0.91, P < 0.05) and double-loading pretreatment (RR = 0.62, 95% CI:0.41, 0.95, P < 0.05) had a lower incidence of MACCEs. There was no statistically significant difference in the incidence of major bleeding events among the six pretreatments (P > 0.05). In patients with NSTE-ACS, pretreatment with P2Y12 inhibitors before percutaneous intervention reduced the incidence of recurrent ischemic events without increasing the risk of major bleeding after PCI compared with nonpretreatment. Clopidogrel or double loading dose P2Y12 inhibitors can be considered for the selection of pretreatment drugs.

Improving Risk Stratification of Patients With Chest Pain in the Emergency Department.

The HEARTS3 score is used to predict acute coronary syndrome by evaluating the findings of chest pain patients at the end of the second hour. Additionally, the American College of Cardiology (ACC)/American Heart Association (AHA) 2014 non-ST elevation acute coronary syndrome (NSTE-ACS) management guideline suggests assessing cardiac troponin levels at the third and sixth hours as a class 1A recommendation. This study aimed to explore the value of the HEARTS3 score for the evaluation of patients withchest pain and its utility for determining whether a patient is eligible for early discharge from the emergency department. This study was prospectively conducted between March 1, 2016 to May 31, 2016 at the ED of the Research and Training Hospital in İstanbul. A total of 136 patients were evaluated, and HEARTS3 scores were calculated at the second, third, and sixth hours. Receiver operating characteristic (ROC) curves were used to calculate the specificity, sensitivity,negative predictive value (NPV) and positive predictive value (PPV) of these scores. The primary outcome was the occurrence of major adverse cardiac events (MACEs) within 30 days. In total, 29 patients with MACEs and 107 patients without MACEs were identified within 30 days. Based on the ROC curve, the cutoff value for early discharge was 6. The area under curve (AUC) values were 0.943, 0.963 and 0.976 at the second, third, and sixth hours, respectively. The sensitivity of the second-hour HEARTS3 score was 96.6%, and the NPV was 98.6%. Both the sensitivity and NPV reached 100% at the sixth hour. The HEARTS3 score was considered a feasible method for the prediction of MACEs. We concluded that a patient with a HEARTS3 score less than 6 may be discharged without serial troponin and ECG examination.

The Prognostic Value of serum ST2 in Patients with non-ST segment elevation acute coronary syndrome

The Prognostic Value of serum ST2 in Patients with non-ST segment elevation acute coronary syndrome

Single spot albumin to creatinine ratio as an independent predictor of 12 years follow-up mortality in acute coronary syndromes without ST-segment elevation.

Background: Up to date there is no evidence of the association between microalbuminuria, measured as single spot urine albumin to creatinine ratio (ACR), with very long-term mortality in patients with non-ST segment Elevation Acute Coronary Syndromes (NSTE-ACS). Aim: To evaluate the association between admission ACR and very long-term all-cause mortality in an unselected cohort of NSTE-ACS patients. Methods: A prospective cohort study was conducted, including patients with NSTE- ACS admitted in the Intensive Care Unit. The ACR was determined in spontaneous urine samples during the first 24 hours after admission and analyzed by immunoturbidimetry. The primary endpoint was all-cause mortality during the follow-up. Actuarial survival curves were compared by log rank test and a logistical Cox regression analysis was performed to identify variables independently associated with mortality in the follow-up. Statistics were calculated using the IBM Statistics program SPSS version 26. Results: 600 patients were analyzed. The overall average ACR value was 7 mg/gr (95% CI 4-26). 76% had normoalbuminuria (ACR 0-30 mg/gr), 22% had microalbuminuria (ACR 30-300 mg/gr), and 1.5% had macroalbuminuria (ACR &gt; 300 mg/gr). The median and interquartile range of follow-up was 12 years (95% IC 11-14). The average IAC among those who met the primary endpoint was 59.15 mg/gr (95% CI 52-66) and among the survivors, 27.66 mg/gr (95 % CI 63-77), p 0,003. ACR terciles were defined by 33th and 66th percentiles: tercile 1: patients with IAC of 0 to 4 mg/gr, tercile 2: IAC from 4 to 17 mg/g and tercile 3 values greater than 17mg/gr. Strong associations were observed between ACR with age, hypertension, stroke and history of COPD, previous use of angiotensin II converter/blocking enzyme inhibitors, systolic blood pressure at admission, ST segment deviation, left ventricle ejection fraction and elevation of serum Troponin T and CPK MB. All cause-mortality during the follow-up was 14% (CI 95% 11-17). Elevation of ACR was significantly associated with long term mortality risk: log rank test chi square: 133.936, p = 0.0001. By multivariate Cox regression analysis adjusted by age, gender, diabetes, hypertension, serum creatinine, troponin T elevation, ST segment deviation, previous AMI, prior use of aspirin, statins and percutaneous coronary intervention after hospitalization, the ACR was independently associated with a 12-year follow-up mortality: OR 13 (95% IC 5-35; p 0.0001). Conclusion: Single spot urine ACR at admission is a strong predictor of 12-year follow- up mortality in an unselected cohort of patients with NSTE-ACS.

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.

An international, stepped wedge, cluster-randomized trial investigating the 0/1-h algorithm in suspected acute coronary syndrome in Asia: the rational of the DROP-Asian ACS study

BackgroundMore than half of the world’s population lives in Asia. With current life expectancies in Asian countries, the burden of cardiovascular disease is increasing exponentially. Overcrowding in the emergency departments (ED) has become a public health problem. Since 2015, the European Society of Cardiology recommends the use of a 0/1-h algorithm based on high-sensitivity cardiac troponin (hs-cTn) for rapid triage of patients with suspected non-ST elevation acute coronary syndrome (NSTE-ACS). However, these algorithms are currently not recommended by Asian guidelines due to the lack of suitable data.MethodsThe DROP-Asian ACS is a prospective, stepped wedge, cluster-randomized trial enrolling 4260 participants presenting with chest pain to the ED of 12 acute care hospitals in five Asian countries (UMIN; 000042461). Consecutive patients presenting with suspected acute coronary syndrome between July 2021 and Apr 2024 were included. Initially, all clusters will apply “usual care” according to local standard operating procedures including hs-cTnT but not the 0/1-h algorithm. The primary outcome is the incidence of major adverse cardiac events (MACE), the composite of all-cause death, myocardial infarction, unstable angina, or unplanned revascularization within 30 days. The difference in MACE (with one-sided 95% CI) was estimated to evaluate non-inferiority. The non-inferiority margin was prespecified at 1.5%. Secondary efficacy outcomes include costs for healthcare resources and duration of stay in ED.ConclusionsThis study provides important evidence concerning the safety and efficacy of the 0/1-h algorithm in Asian countries and may help to reduce congestion of the ED as well as medical costs.

Pretreatment with a P2Y12 receptor inhibitor and delay to coronary artery bypass surgery in patients with non-ST segment elevation acute coronary syndrome.

2020 ESC guidelines for non-ST elevation acute coronary syndromes (NSTE-ACS) recommend against the pretreatment with P2Y12 receptor inhibitors (P2Y12i) in patients undergoing early invasive management (<24 h). The rationale is, in part, to prevent bleeding complications and the delay of coronary artery bypass graft surgery (CABG) in patients with suitable coronary anatomy. This study aimed to analyze the theoretical impact of pretreatment with a P2Y12i on delay to CABG surgery in a real-world population with NSTE-ACS. Single-center retrospective cohort of consecutive patients with NSTE-ACS undergoing invasive evaluation in 2019. Those with previous CABG or nonobstructive coronary disease were excluded. The total cohort included 262 patients (mean age 68±12 years, 69% male, 15% with unstable angina and mean GRACE score 134±35). Median time from FMC to angiography was 2 (1-4) days. Overall, 168 (64%) patients underwent percutaneous coronary intervention, 47 (18%) were proposed for CABG and the remainder received conservative management. All patients considered for CABG received pretreatment with P2Y12i (clopidogrel or ticagrelor). The median time from angiography to CABG was 12 (7-15) days. Six patients experienced recurrent angina (13%) and 2 (4%) died before surgery due to refractory ventricular fibrillation. Those who underwent CABG under P2Y12i effect were more likely to receive blood and platelets transfusions (64.7% vs. 28.6%, P=0.017 and 82.4% vs. 21.4%, P<0.001, respectively), although there were no differences regarding major bleeding. Pretreatment with P2Y12i was a potential but not the sole driver of CABG delay in our cohort. Adopting the new recommendations of withholding pretreatment might decrease this delay, but other factors must be considered.

Wellens Syndrome: Single Centre Study and Literature Review

Abstract Background Wellens syndrome is a clinical, biological, and electrocardiographic complex that identifies a subgroup of patients with unstable angina who have an impending risk of myocardial infarction and death, representing an equivalent of ST segment elevation myocardial infarction. Methods We conducted a prospective analysis of 64 consecutive patients, recruited over 2 years, with Wellens syndrome who underwent coronary angiography and we compared them with an age- and sex-matched group of patients with non-ST segment elevation acute coronary syndrome who underwent coronary angiography. The primary endpoints of our study were the rate of cardiovascular rehospitalizations, the rate of ischaemic reccurences, the rate of subsequent or recurrent revascularization, and the rate of mortality at six months from the index event. Results At 6 months, the patients in the control group had a higher rate of cardiovascular rehospitalizations (41.9% vs. 21.9%, p = 0.016). The rate of ischaemic recurrences and the rate of global mortality were similar across the two groups. Conclusion Physiopathologically and angiographically, Wellens syndrome is an abortive form of ST segment elevation myocardial infarction, but electrocardiographically and prognostically, it evolves similarly to a non-ST segment elevation acute coronary syndrome.

Coronary CT and timing of invasive coronary angiography in patients ≥75 years old with non-ST segment elevation acute coronary syndromes

BackgroundThe ability of coronary CT angiography (cCTA) to rule out significant coronary artery disease (CAD) in older patients with non-ST segment elevation acute coronary syndromes (NSTEACS) is unclear since valid...

Abstract 15498: Treatment Adherence in Patients With Non-st Elevation Acute Coronary Syndrome

Introduction: Optimal medical treatment demonstrated a reduction in cardiovascular outcomes after acute coronary syndrome. Treatment adherence results crucial to obtain that benefit, we do not have current data on the adherence in our population. Our objective was to evaluate the treatment adherence at 6 and 15 months in patients post non-ST elevation acute coronary syndrome (NST-ACS). Methods: It’s a prespecified sub-analysis in the prospective registry BUENOS AIRES 1 that include 1100 patients. The adherence was evaluated using the modified Morisky-Green scale. Results: The mean age was 65 ±11 years. At 6 month 76.4% were consider as adherents to pharmacological treatment. We didn’t find any predictors for adherence. Adherent patients had a rate of combined isquemic events (myocardial infarction, death or stroke) of 11.5% (52/452) versus 20% (27/135) in non-adherent patients at 15 months. Treatment adherence was an independent predictor of combined isquemic events (HR 0.517, IC95% 0.308-0.869, p=0.013). There weren’t any differences in the hemorrhagic events between the two groups. Conclusions: Our population had a high adherence treatment without any clinical predictor of this phenomenon. Adherence was related to a reduction in isquemic events without changing the hemorrhagic events. Nonetheless, one of four patients was considered as non-adherent after a hospitalization for NST-ACS, showing that we need intervention to reduce this number.

Optical Coherence Tomography (OCT) evaluation of culprit lesions in patients with Non-ST Elevation Acute Coronary Syndromes (NSTE-ACS)

Optical Coherence Tomography (OCT) evaluation of culprit lesions in patients with Non-ST Elevation Acute Coronary Syndromes (NSTE-ACS)

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.

Multivessel versus Culprit-Only Percutaneous Coronary Intervention in Patients with Non-ST-Elevation Acute Coronary Syndrome.

Background: There is uncertainty whether multivessel (MV-PCI) or culprit-only percutaneous coronary intervention (CO-PCI) should be the treatment of choice in patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) and multivessel disease (MVD). Aims: To evaluate clinical characteristics and outcomes in these patients undergoing MV-PCI or CO-PCI at the index procedure. Methods: Data were retrieved from the nationwide Netherlands Heart Registration. All NSTE-ACS patients with MVD undergoing PCI between 1 January 2017 and 1 October 2019 were grouped into a MV-PCI or CO-PCI group. The primary endpoint was all-cause mortality at long-term follow-up (median 756 days (593–996)). Secondary endpoints were reinterventions, urgent CABG, myocardial infarction (MI) < 30 days, target vessel revascularisation (TVR) and mortality at 1 year. Propensity score matching analyses were performed. Results: In total, 10,507 NSTE-ACS patients with MVD were included into the MV-PCI (N = 4235) and CO-PCI group (N = 6272). Analysing crude data, mortality rates at long-term follow-up (10.7% vs. 10.2%; p = 0.383), mortality at 1 year (6.0% vs. 5.6%; p = 0.412) and MI <30 days (0.8% vs. 0.9%; p = 0.513) were similar between both groups. Reinterventions (11.1% vs. 20.0%; p < 0.001), urgent CABG (0.1% vs. 0.4%; p = 0.001) and TVR (5.2% vs. 6.7%; p = 0.003) occurred less often in the MV-PCI group. Survival analysis after multiple imputation and propensity score matching showed similar mortality rates at long-term follow-up (log-rank p = 0.289), but a significant reduction for reinterventions in the MV-PCI group (log-rank p < 0.001). Conclusion: NSTE-ACS patients with MVD undergoing MV-PCI have similar mortality rates at long-term follow-up compared to CO-PCI. However, improved event-free survival in terms of fewer coronary reinterventions was observed.

Incorporation of Serial 12-Lead Electrocardiogram With Machine Learning to Augment the Out-of-Hospital Diagnosis of Non-ST Elevation Acute Coronary Syndrome

Ischemic electrocardiogram (ECG) changes are subtle and transient in patients with suspected non-ST-segment elevation (NSTE)-acute coronary syndrome. However, the out-of-hospital ECG is not routinely used during subsequent evaluation at the emergency department. Therefore, we sought to compare the diagnostic performance of out-of-hospital and ED ECG and evaluate the incremental gain of artificial intelligence-augmented ECG analysis. This prospective observational cohort study recruited patients with out-of-hospital chest pain. We retrieved out-of-hospital-ECG obtained by paramedics in the field and the first ED ECG obtained by nurses during inhospital evaluation. Two independent and blinded reviewers interpreted ECG dyads in mixed order per practice recommendations. Using 179 morphological ECG features, we trained, cross-validated, and tested a random forest classifier to augment non ST-elevation acute coronary syndrome (NSTE-ACS) diagnosis. Our sample included 2,122 patients (age 59 [16]; 53% women; 44% Black, 13.5% confirmed acute coronary syndrome). The rate of diagnostic ST elevation and ST depression were 5.9% and 16.2% on out-of-hospital-ECG and 6.1% and 12.4% on ED ECG, with ∼40% of changes seen on out-of-hospital-ECG persisting and ∼60% resolving. Using expert interpretation of out-of-hospital-ECG alone gave poor baseline performance with area under the receiver operating characteristic (AUC), sensitivity, and negative predictive values of 0.69, 0.50, and 0.92. Using expert interpretation of serial ECG changes enhanced this performance (AUC 0.80, sensitivity 0.61, and specificity 0.93). Interestingly, augmenting the out-of-hospital-ECG alone with artificial intelligence algorithms boosted its performance (AUC 0.83, sensitivity 0.75, and specificity 0.95), yielding a net reclassification improvement of 29.5% against expert ECG interpretation. In this study, 60% of diagnostic ST changes resolved prior to hospital arrival, making the ED ECG suboptimal for the inhospital evaluation of NSTE-ACS. Using serial ECG changes or incorporating artificial intelligence-augmented analyses would allow correctly reclassifying one in 4 patients with suspected NSTE-ACS.

The Prognostic Role of Corrected QT Interval with Quantitative Cardiac Troponin Levels in NTSEMI

Presence of different risk groups in non-ST-elevation acute coronary syndrome (NSTE-ACS), indicate the need for new tools to perform early diagnosis and prognostic stratification in order to indicate the appropriate startegy. In this sense, it has been shown that the corrected QT interval prolongation is an independent risk marker in NSTE-ACS with or without acute ischemic changes. However, there is scarce information about its relationship with other variables of known prognostic value, such as cardiac troponins.

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