non-ST Elevation Coronary Syndrome Research Articles

Echocardiographically determined ejection fraction in the elderly admitted with non-ST-elevation acute coronary syndromes in a spoke hospital with no cath-lab facility and the treatment-risk paradox

Abstract Funding Acknowledgements Type of funding sources: None. Background The elderly with non-ST-elevation coronary syndromes (NSTE-ACS) represents an high risk group and may benefit from early invasive strategy, that may be difficult to achieve in spoke hospitals with no cath-lab facility. Although a strong predictor of mortality in NSTE-ACS, the role of echocardiographically determined left ventricular ejection fraction (EF) in this setting is poorly determined. Purpose we aimed to analyze characteristics and outcomes of patients ≥80 years with NSTE-ACS admitted to spoke hospitals according to EF. Methods Observational retrospective study of all consecutive NSTE-ACS patients admitted to a spoke hospital, where a same-day transfer between spoke hospital and hub center with a cath-lab facility to perform coronary angiography was available. Patients were divided in 3 groups according to EF: normal (EF≥55%), mild-moderate (EF 35-55%) and severe reduction (FE < 35%). Results from 2013-2017, 181 patients ≥80 years (median 84, IQR 82-89) were admitted for NSTE-ACS in a spoke hospital of our provincial cardiology network. Of these, 66 patients (36%) had normal EF, 79 (44%) had mild-moderate and 36 (20%) had severely EF reduction. GRACE risk score was high (>140) in the whole cohort, increasing with the lowering of EF (165 ± 27 in normal EF, 179 ± 28 in mildly-moderate and 193 ± 31 in severe reduction; p < 0.001). The three groups did not differ in term of age, gender, CV risk factors, known CAD, presence of severe COPD, PAD and atrial fibrillation (all p > 0.1). As expected, clinical signs of heart failure presented more frequently with worsening of EF (2% in normal EF, 8% in mildly-moderate and 56% in severe reduction; p < 0.001) and serum creatinine tended to be higher with worsening of EF (p = 0.05). Of note, the invasive strategy was chosen less often with worsening of EF (68% in normal EF, 58% in mildly-moderate and 39% in severe reduction (p = 0.1). When the invasive strategy was chosen, time from admission to cath lab consistently raised with worsening of EF (53 ± 35 hours in normal EF, 68 ± 46 in mildly-moderate and 104 ± 81 in severe reduction; p = 0.001), therefore the proportion of patients reaching the cath lab in <72 hours as recommended from guidelines decreased with worsening of EF (73% in normal EF, 67% in mildly-moderate and 39% in severe reduction; p = 0.03). Table. However, at 1-year follow-up, the overall survival did not differ across the EF groups (p = 0.26). Figure. Conclusion in the elderly admitted with NSTE-ACS in a spoke hospital with no cath lab facility EF may be part of the "treatment-risk paradox": the worse is the EF, the less patients are sent for invasive strategy and when invasive strategy is chosen the more time they have to wait for cath lab. However, in this setting, the impact of classical classification of EF in normal, mildly-moderate and severe reduction on 1-year mortality may not be significant and should not impede the access to invasive strategy in a timely fashion. Abstract Table Abstract Figure

When COVID-19 delays the management of an urgent heart condition: A rare case of a spontaneous dissection of two coronary arteries.

Some severe life‐threatening conditions could be misdiagnosed during the current COVID‐19 pandemic.

GRACE-recurrent low-risk chest pain: A user's guide.

GRACE-recurrent low-risk chest pain: A user's guide.

Improved efficiency and cost reduction in the emergency department by replacing contemporary sensitive with high-sensitivity cardiac troponin immunoassay.

The Authors planned this study to evaluate the impact of replacing a contemporary-sensitive with HS cTnI immunoassay on hospital and laboratory workload. The authors say that, 'Despite some evidence, the clinicians are still hesitant to replace the former so-called contemporary-sensitive methods with HS-cTn techniques, justifying this reluctance with concerns of overutilization, possible over diagnosis of cardiac injuries, overcrowding of emer-gency departments (EDs), and excess of cardiac invasive testing. Several factors have lead clinicians to use terms such as "troponin leak", "false-positive" troponin elevation, or "troponinemia". The results of this study show substantial organizational and economic benefits by replacing con-temporary-sensitive with HS cTnI immunoassays. This is very important question because there are some areas such as acute non-ST elevation coro-nary syndromes (NSTEMI) and in elderly patients, the specificity is very low for the simultaneous presence of factors that can alter the dosage of HS-cTnI values.

The epidemiology of acute coronary syndromes in French Guiana

BackgroundFrench Guiana is an overseas territory of France with marked specificities in terms of populations, socioeconomic factors, risk factors, and an access to care. In this context, the objective of the present study was to describe the epidemiology of acute coronary syndromes in French Guiana and to make comparisons with mainland France and neighbouring country. MethodsThe data were obtained from a retrospective descriptive hospital-based cohort conceived to describe the incidence of acute coronary syndromes and their epidemiologic and clinical characteristics. It included patients aged 18 or more hospitalised for a first coronary syndrome in the reference centre for coronary syndromes in Cayenne French Guiana between Jan 1st 2012 and Dec 31st 2014. Overall, 266 patients were analysed. ResultsThe mean age was 64 years (SD=12.54). A majority of patients were men (sex ratio=1.83). The proportion of patients born in an overseas French territory (44.36%) was similar to that of those born in a foreign country (43.98%), and 11.65% were born in mainland France. Only 59% of patients had regular health insurance. Moreover, 33.21% had universal medical insurance (CMU for those below a minimal income), 4.91% had state insurance (for illegal foreign patients) and 2.64% had no insurance at all. The main risk factors were high blood pressure (73.68%), diabetes (39.85%), hypercholesterolemia (40.23%), and smoking (37.97%). Overall, 82/266 patients developed an ST elevation coronary syndrome (STEMI) and 184/266 had a non-ST elevation coronary syndrome NSTEMI or unstable angina pectoris. Thrombolysis was only performed in 20.73% of patients with STEMI. Mortality at 1 month was 8/82 (9.76%) for STEMI and 2/184 (1.09%) for NSTEMI. ConclusionsThe epidemiologic profile of acute coronary syndromes in French Guiana is different from that of mainland France and Europe to the neighbouring country Brazil. Mortality of STEMI also seems higher than in mainland France, but similar to Brazil. In a context of frequent health inequalities, interventions targeting the major risk factors, notably high blood pressure, obesity and diabetes, have the potential to significantly impact cardiovascular morbidity and mortality.

Étude des complications per-transfert interhospitalier des patients présentant un syndrome coronarien aigu sans élévation du segment ST

Aim of the studyPatients with non ST-segment elevated acute coronary syndrome justify specific management in a hospital with an Intensive Cardiac Care Unit. In our area, these transfers are often provided by the Emergency Medical Service. Nevertheless we wonder whether a quasi-systematic medicalization of these patients is rational. Patients and methodWe tried to authenticate the need for medicalization of these patients through a prospective study including any patient with acute non-ST elevation Coronary Syndrome managed in one of the peripheral hospitals of the area and transferred to the major hospital center in La Roche-sur-Yon. We noted all the complications that occurred during the transfer and, if need be, when these complications required medical intervention. ResultsOut of 226 patients included, 19 had a complicated form of acute non-ST elevation Coronary Syndrome. Out of the remaining 207 patients, 16 (7.7 %) showed a complication during their transfer, 5 of which underwent a medical intervention, none of which was immediately vital. Nevertheless, the statistical analysis did not highlight any significant worsening factors. ConclusionThe low rate of complications occurring during the transfer of initially stable patients encourages us to limit our indications of medicalization in favour of only the unstable patients or having a complication of their non-ST elevation acute coronary syndrome.

What is the Role for Glycoprotein IIb/IIIa Inhibitor Use in the Catheterization Laboratory in the Current Era?

In the era of dual antiplatelet therapy of aspirin and clopidogrel and systematic stent implantation, Glycoprotein IIb/IIIa Inhibitors (GPI), including abciximab, eptifibatide and tirofiban, proved beneficial in improving early outcome of Percutaneous Coronary Intervention (PCI), especially in higher risk clinical and/or anatomical subsets. This was associated however, with an increased incidence of bleeding complications. To review whether the established results of GPI in PCI are maintained in the contemporary era of more effective antiplatelet agents (i.e., prasugrel, ticagrelor and cangrelor) and safer anticoagulants (i.e., bivalirudin) and interventional techniques (i.e., radial approach). The most relevant evidence on the use of GPI in stable coronary artery disease, non-STelevation coronary syndromes and ST-elevation myocardial infarction was reviewed. Overall the relative efficacy and safety of GPI in contemporary PCI is maintained, largely irrespective of the use of more effective antiplatelet agents and/or safer anticoagulants and interventional techniques. However, an increase in the absolute occurrence of major and/or minor bleeding and/or need for blood transfusions is generally observed. Because of the persistent benefit of GPI in limiting early ischemic complications, especially in higher risk clinical and/or anatomical subsets, and the associated risk of increased bleeding complications, also in contemporary PCI, these agents should currently be used on a selective rather than routine basis, including bail out administration for peri-procedural thrombotic complications.

54 Frail older patients have a greater improvement in physical quality of life than robust patients at one year following invasive treatment for non-st elevation acute coronary syndrome

IntroductionFrailty, a vulnerability to physiological stressors due to a decline in reserve with age, is common in older patients who present with non-ST elevation coronary syndrome (NSTEACS) and is associated...

Предикторы осложненного течения острого коронарного синдрома без подъема сегмента ST в госпитальном периоде

Предикторы осложненного течения острого коронарного синдрома без подъема сегмента ST в госпитальном периоде

Anticoagulation therapy and invasive management of acute non-ST elevation coronary syndromes: guidelines and everyday practice

Introduction and goal: The latest 2011 non-ST- segment elevation acute coronary syndromes (NSTE- ACS) management guidelines indicated that all patients should receive anticoagulation drugs irrespective of the treatment strategy. In this report, 2-year data on anticoagulation therapies for NSTE-ACS are presented, in relation to invasive management selection and treatment outcomes in a clinical setting without registered bivalirudin. Patients and Methods: Data for 374 patients with NSTEACS treated in the Coronary Care Unit in General Hospital Slavonski Brod, Croatia were analyzed from January 2012 to December 2013. Treatment strategies, outcomes and complications among patients treated with different anticoagulation agents (enoxaparine, fondaparinux or unfractionated heparin) were analyzed and compared. Results: In all, 72% of all NSTE-ACS patients were treated invasively, out of which 66% underwent angiography within 72 hours. Urgent and early angiography was performed in 44% of all invasively treated patients. Generally, 58% and 5% of patients received enoxaparine and unfractionated heparin (UFH), respectively, whereas fondaparinux was administered in 37% of patients. Median age of patients treated with enoxaparine was 66, compared to 76 in the fondaparinux group. There were significantly more patients treated with enoxaparine and UFH than with fondaparinux in the invasive strategy group. We observed that the number of patients treated with fondaparinux in the invasive group increased together with the period between symptom onset and angiography. The number of patients treated conservatively with either fondaparinux or enoxaparine was almost equal. There were no patients treated conservatively with UFH. In general, in-hospital mortality was low, 2.6% with no significant differences in bleeding events regarding the selection of anticoagulation therapy. Conclusions: Although the guidelines gave preference to fondaparinux, everyday practice in our hospital showed that enoxaparine was a preferred agent, particularly in younger patients selected for early invasive strategy, most probably because of the risk/benefit ratio and opportunity of avoiding the mixing of anticoagulation agents. Only 5% of patients were selected for urgent invasive approach with UFH, which should probably increase in the future. Considering a higher cost of bivalirudin, the introduction of this agent for non-ST segment elevation myocardial infarction management does not seem to be mandatory in our clinical setting, since this small group of patients was adequately managed with UFH.

B-type natriuretic peptide as an independent predictor of coronary disease extension in non-ST elevation coronary syndromes with preserved systolic function

B-type natriuretic peptide (BNP) has been employed as a risk marker in patients with coronary artery disease (CAD) with ST elevation and non-ST elevation. It is not yet established if early BNP measurements provide additional information to troponin and electrocardiographic analysis in patients without ventricular enlargement and systolic dysfunction. This study compared BNP levels in patients with stable angina (SA) and acute coronary syndromes with non-ST elevation in relation to angiographic lesions (NSTEMI-ACS). Moreover, the diagnostic utility of BNP was determined using the receiver operating characteristic curve. 280 patients with CAD without ST elevation and preserved systolic function were studied. BNP samples were measured in all recruited patients within 24 hours of hospitalization. BNP values increased progressively with the severity of diagnosis: SA (n = 85; 50.4 ± 50 pg/ml) NSTEMI-ACS (n = 195; 283 ± 269 pg/ml; p < 0.0001). The analysis of BNP in relation to the number of involved vessels demonstrated significantly increased levels in patients with multivessel disease compared to patients with 1- or 2-vessel disease (p < 0.001 and p < 0.003). Values of BNP >80 pg/ml were shown to be able to predict CAD severity and coronary vessel involvement (AUC = 0.80; p = 0.0001) with a sensitivity of 78% and a specificity of 72%. In multivariate analysis, BNP levels >80 pg/ml, CAD history, and ST deviation >2 mm were confirmed as independent predictors of CAD severity. Circulating BNP levels appear elevated in NSTEMI-ACS, without left ventricular systolic dysfunction. A BNP cut-off value of 80 pg/ml is a good predictor of CAD extension.

Anomalous origin of circumflex artery from right sinus of Valsalva: A rare cause of non-ST elevation syndrome

We present a case with anomalous origin of the left circumflex artery from the right coronary artery ostium, which caused a non-ST elevation coronary syndrome. A review of the literature indicates this to be an extremely rare case.

Right coronary ostium agenesis with absence of the right coronary artery: A rare case of non-ST elevation coronary syndrome

We present a case with right coronary ostium agenesis with anomalous origin of the right coronary artery from the left circumflex artery, which caused a non-ST elevation coronary syndrome. A review of the literature indicates this to be an extremely rare case.

Direct thrombin inhibitors for non-ST–segment elevation acute coronary syndromes: what, when, and where?

Background Unfractionated heparin has been the cornerstone of antithrombin therapy in the treatment of non-ST–segment elevation acute coronary syndromes for more than a decade. Several new anticoagulants have emerged in recent years and have been studied extensively in patients with unstable coronary syndromes and in the percutaneous coronary intervention setting. Methods Direct thrombin inhibitors comprise a family of agents with promising properties that offer several potential advantages over unfractionated heparin. Hirudin has been studied in patients with ST-elevation myocardial infarction, non-ST–elevation coronary syndromes, and coronary angioplasty. Bivalirudin has been studied in patients undergoing percutaneous coronary revascularization, with very promising efficacy and safety profile compared with unfractionated heparin. Results The clinical trials of direct thrombin inhibitors in non-ST–elevation acute coronary syndromes and coronary angioplasty are reviewed.

Elevated C-reactive protein levels are associated with myocardial ischemia early in the course of non-ST elevation coronary syndromes

Background High plasma levels of C-reactive protein (CRP) are associated with shortor long-term ischemic complications in patients with unstable coronary artery disease. However, a possible direct relationship of plasma CRP with spontaneous myocardial &hernia early I” the course of non ST elevation acute coronary syndromes (NSTACS) was not thoroughly investigated. MethodsTo evaluate this issue 172 consecutive patients with NSTACS with no elevated plasma cardiac troponin T levels upon admission (cTnT-zO.1 yojdl) who underwent a 24 hour continuous IBlead electrocardiographic (ECG) monitoring were studied. The associatlon of plasma CRP levels upon admission with either the incidence or duration of the recorded myocardial ischemla (ST-segment shifts) was evaluated. Patients divided into three groups according to the tertiles of CRP values upon admission. Results During 3,696 hours of contmuous 12.lead ECG monitoring, 169 ST-segment shifts were recorded in 48 patients with a mean number of 3.5k2.0 shifts per patient and a mean duration of 29.6i23.6 min per episode, corresponding to a total duration of 124.4k143.6 mm per patlent. There was a significant gradual increased risk for either the incidence (p<O.OOl) or the total duration of ST-segment shifts with increasing of CRP tertiles (p=O.Ol). MultivarIate analysis showed that CRP tertiles were independently and positively related to the occurrence of ST-segment shifts. Conclusions High plasma levels of CRP may be associated with a higher incidence of myocardial tschemia early III the tours.? of NSTACS, suggesting a direct relationship of inflammation in this process.