non-ST Elevation Myocardial Infarction Patients Research Articles

FOXO1 and ANGPT2 relative gene expression in non-ST-segment elevation myocardial infarction among patients with or without type 2 diabetes.

IntroductionIt is well known that chronic hyperglycemia or chronic inflammation leads to both FOXO1 and Ang-2 gene (ANGPT2) expression induction in endothelial cells. ANGPT2 and FOXO1 relative gene expression in peripheral blood cells in diabetes and myocardial ischemia were not researched extensively.AimOur objective was to evaluate ANGPT2 and FOXO1 gene expression in peripheral blood cells in patients with non-ST elevation myocardial infarction (NSTEMI), both with and without type 2 diabetes mellitus (T2DM), and compare them to the results obtained from T2DM and control subjects.Material and methodsThis was a multi-center, prospective study of 138 NSTEMI patients with/without T2DM, T2DM and a control group. FOXO1, ANGPT2, TBP (TATA box binding protein – as a reference gene) gene expression levels in peripheral blood cells were measured in each patient. Electrocardiography and echocardiography with assessment of ejection fraction (EF) were performed. Patients with NSTEMI underwent urgent (< 24 h) coronarography and the SYNTAX score and GRACE 2.0 score were calculated.ResultsThe ANGPT2 gene relative expression in buffy coat in the analyzed samples was very low and detectable only in 11 patients from all groups (8.66% of all patients). The level of FOXO1 gene relative expression was significantly higher in patients with NSTEMI (median relative expression = 1.39) than in non-NSTEMI patients (median = 1.09) (W = 1578, p < 0.05) regardless of the presence of T2DM. The FOXO1 gene relative expression was not correlated with GRACE 2.0 score or SYNTAX score of NSTEMI patients. We did not observe any significant change in FOXO1 gene expression after successful angioplasty.ConclusionsOn the basis of our results we can conclude that analyzing the ANGPT2 gene relative expression in peripheral blood cells has no role in assessment of CAD complexity among patients with and without T2DM. FOXO1 gene relative expression in blood peripheral cells is elevated in patients with NSTEMI regardless of the presence of T2DM. FOXO1 expression does not decrease after successful percutaneous coronary intervention and is not correlated with the severity of CAD in patients with NSTEMI.

Long term prognostic benefit of complete revascularization in elderly presenting with NSTEMI: real world evidence.

The benefit of complete revascularization in elderly patients with non-ST elevation myocardial infarction (NSTEMI), and multivessel disease remains debated (MVD). The aim of our study was to determine the current long-term prognostic benefit of complete revascularization in this population. A retrospective cohort study of 1722 consecutive elderly NSTEMI patients was performed. Among the study participants 30.4% (n = 524) were completed revascularizated and in 69.6% (n = 1198) culprit vessel only revascularization was performed. A propensity score analysis was performed and we divided the study population into two groups: complete revascularization (n = 500) and culprit vessel only revascularization (n = 500). The median follow-up was 45.7 months, the all cause mortality (44.5% vs 30.5%, p < 0.001) (HR 0.74 (0.57-0.97); p = 0.035) and cardiovascular mortality (32.6% vs 17.4%, p < 0.001) (HR = 0.67 (0.47-0.94); p = 0.021) were significantly lower in patients with complete revascularization. In our study, we observed a long-term benefit of complete revascularization in elderly NSTEMI and MVD patients. Elderly patients should also be managed according to current guidelines to improve their long-term prognosis.

Immature Platelet Fraction as A Potential Marker To Differentiate Types of Acute Coronary Syndrome

Acute Coronary Syndrome (ACS) includes ST-Elevation Myocardial Infarction (STEMI), non-ST Elevation MyocardialInfarction (NSTEMI), and Unstable Angina (UA). Platelet plays an essential role in ACS pathogenesis. Immature PlateletFraction (IPF) and platelet indices can predict platelet activations. Platelet indices consist of platelet count, Mean PlateletVolume (MPV), Platelet Distribution Width (PDW), plateletcrit (Pct). This study aimed to analyze the differences of IPF andplatelet indices among ACS patients. This study was an observational analytical cross-sectional study conducted inDr. Soetomo Hospital during May-September 2019. The subjects consisted of 30-STEMI, 25-NSTEMI, and 24-UA patients.The EDTA-samples were measured for platelet indices and IPF using Sysmex XN-1000. The differences between IPF andplatelet indices among STEMI, NSTEMI, and UA patients were analyzed using Kruskal-Wallis and Mann-Whitney test. The IPFvalues were significantly higher in STEMI patients than NSTEMI and UA patients. The IPF values of NSTEMI patients werehigher than UA patients. The MPV, PDW, and P-LCR were significantly higher in STEMI and NSTEMI compared to UA. TheMPV, PDW, and P-LCR values of NSTEMI patients were significantly higher than UA patients. The significant differencesbetween STEMI and NSTEMI toward UA might be caused by the more severe thrombotic conditions in myocardial infarctionpatients than UA. The IPF values were significantly different among each type of ACS patients gave an opportunity using thisparameter to differentiate the ACS types. The MPV, PDW, and P-LCR were significantly higher in myocardial infarctionpatients than UA patients, which also allowed them to use those parameters to differentiate both conditions.

PCV50 Economic Burden of Major Cardiovascular Diseases and Ischemic Stroke in Saudi Arabia: A Cost of Illness Study

Cardiovascular diseases (CVD) are the leading cause of mortality in Saudi Arabia resulting to approximately 45.7% of all deaths cases. CVD represent a major economic burden to any healthcare system due to the high utilization of medical resources. This study aimed to estimate the economic burden and resource utilization of Acute Coronary Syndrome (ACS) and Ischemic Stroke (IS) patients in Saudi Arabia. This was a retrospective, single-center cost of illness study conducted from healthcare perspective. Patients medical records from Prince Sultan Cardiac Center (PSCC) in Riyadh were reviewed from January through December 2018. Patients who had a confirmed diagnosis of ACS or IS were included in this study. Prices and healthcare costing data were collected from the Ministry of Health, and PSCC business centre costing data. Descriptive statistics were performed. A total of 316 patients were eligible for this study. The average annual cost of each ST-elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI) patient was SAR 54,877 and SAR 50,215, respectively. The average annual cost of each unstable and stable angina patient was SAR 43,838 and SAR 41,640, respectively. The average annual cost per IS patient was SAR 89,739. The major drivers of costs among all study population were costs related to procedures which accounted for 39% of the total costs, followed hospitalization and medication costs (27% and 11%, respectively). ACS and IS comprise a heavy economic burden to Saudi healthcare system. The results of this study may inform efficient policy making by considering proper methods of recourses allocations especially for services that consume larger portions of the budgets dedicated to CVD and IS. Further studies are required to investigate the economic value of CVD and IS interventions, programs and services, a step that may help lowering the economics burden of CVD and IS in Saudi Arabia.

Increased Mean Platelet Volume (MPV) in Patients with ST Elevation Myocardial Infarction (STEMI) Compared to Non-ST Elevation Myocardial Infarction (NSTEMI) Patients

Platelets are known to have a role major in the pathogenesis of atherothrombosis. More giant and hyperreactive platelets accelerate the formation of an intracoronary thrombus. An increased MPV as an indicator of larger and more reactive platelets represents a risk factor for overall vascular mortality, including myocardial infarction. This study aimed to identify the increase of Mean Platelet Volume in Patients with Acute Coronary Syndromes, especially in ST-elevation myocardial infarction and Non-ST-elevation myocardial infarction. Thus this parameter can be used as consideration for diagnosis and treatment decisions. This research is an analytic observational with a cross-sectional method. The subjects were patients with STEMI and NSTEMI who were hospitalized in ICCU Dr.Sardjito Hospital Yogyakarta. Thirty-four subjects STEMI and NSTEMI patients at Dr. Sardjito Hospital, consisting of 28 males (82,35%) and six women (17,65%) with a mean age of 55,5 ± 10,3 years. The results showed that MPV in AMI was higher in patients with STEMI than NSTEMI, but this difference is not significant (p = 0,091). This study concludes that MPV to be higher in patients with STEMI compared to NSTEMI. MPV may be used as a marker of myocardial infarction in clinically appropriate situations.

Effectiveness and safety of antithrombotic strategies in elderly patients with acute myocardial infarction.

BACKGROUNDElderly patients represent a rapidly growing part of the population more susceptible to acute coronary syndromes and their complications. However, literature evidence is lacking in this clinical setting. AIMTo describe the clinical features, in-hospital management and outcomes of “elderly” patients with myocardial infarction treated with antiplatelet and/or anticoagulation therapy.METHODSThis study was a retrospective analysis of all consecutive patients older than 80 years admitted to the Division of Cardiology of St. Andrea Hospital of Vercelli from January 2018 to December 2018 due to ST-elevation myocardial infarction (STEMI) or non-ST elevation myocardial infarction (NSTEMI). Clinical and laboratory data were collected for each patient, as well as the prevalence of previous or in-hospital atrial fibrillation (AF). In-hospital management, consisting of an invasive or conservative strategy, and the anti-thrombotic therapy used are described. Outcomes evaluated at 1 year follow-up included an efficacy ischemic endpoint and a safety bleeding endpoint.RESULTSOf the 105 patients enrolled (mean age 83.9 ± 3.6 years, 52.3% males), 68 (64.8%) were admitted due to NSTEMI and 37 (35.2%) due to STEMI. Among the STEMI patients, 34 (91.9%) underwent coronary angiography and all of them were treated with percutaneous coronary intervention (PCI); among the NSTEMI patients, 42 (61.8%) were assigned to an invasive strategy and 16 (38.1%) of them underwent a PCI. No significant difference between the groups was found concerning the prevalence of previous or in-hospital de-novo AF. 10.5% of the whole population received triple antithrombotic therapy and 9.5% single antiplatelet therapy plus oral anticoagulation (OAC), with no significant difference between the subgroups, although a higher number of STEMI patients received dual antiplatelet therapy without OAC as compared with NSTEMI patients. A low rate of in-hospital death (5.7%) and 1-year cardiovascular death (3.3%) was registered. Seven (7.8%) patients experienced major adverse cardiovascular events, while the rate of minor and major bleeding at 1-year follow-up was 10% and 2.2%, respectively, with no difference between NSTEMI and STEMI patients.CONCLUSIONIn this real-world study, a tailored evaluation of an invasive strategy and antithrombotic therapy resulted in a low rate of adverse events in elderly patients hospitalized with acute myocardial infarction.

Revascularisation or medical therapy in elderly patients with acute anginal syndromes: the RINCAL randomised trial.

Historically the elderly have been under-represented in non-ST-elevation myocardial infarction (NSTEMI) management trials. The aim of this trial was to demonstrate that an intervention-guided strategy is superior to optimal medical therapy (OMT) alone for treating NSTEMI in elderly individuals. Patients (≥80 years, chest pain, ischaemic ECG, and elevated troponin) were randomised 1:1 to an intervention-guided strategy plus OMT versus OMT alone. The primary endpoint was a composite of all-cause mortality and non-fatal myocardial reinfarction at 1 year. Ethics approval was obtained by the institutional review board of every recruiting centre. From May 2014 to September 2018, 251 patients (n=125 invasive vs n=126 conservative) were enrolled. Almost 50% of participants were female. The trial was terminated prematurely due to slow recruitment. A Kaplan-Meier estimate of event-free survival revealed no difference in the primary endpoint at 1 year (invasive 18.5% [23/124] vs conservative 22.2% [28/126]; p=0.39). No significant difference persisted after Cox proportional hazards regression analysis (hazard ratio 0.79, 95% confidence interval 0.45-1.35; p=0.39). There was greater freedom from angina at 3 months (p<0.001) after early intervention but this was similar at 1 year. Both non-fatal reinfarction (invasive 9.7% [12/124] vs conservative 14.3% [18/126]; p=0.22) and unplanned revascularisation (invasive 1.6% [2/124] vs conservative 6.4% [8/126]; p=0.10) occurred more frequently in the OMT alone cohort. An intervention-guided strategy was not superior to OMT alone to treat very elderly NSTEMI patients. The trial was underpowered to demonstrate this definitively. Early intervention resulted in fewer cases of reinfarction and unplanned revascularisation but did not improve survival.

Cardiac Troponin Composition Characterization after Non ST-Elevation Myocardial Infarction: Relation with Culprit Artery, Ischemic Time Window, and Severity of Injury.

Troponin composition characterization has been implicated as a next step to differentiate among non-ST elevation myocardial infarction (NSTEMI) patients and improve distinction from other conditions with troponin release. We therefore studied coronary and peripheral troponin compositions in relation to clinical variables of NSTEMI patients. Samples were obtained from the great cardiac vein (GCV), coronary sinus (CS), and peripheral circulation of 45 patients with NSTEMI. We measured total cTnI concentrations, and assessed both complex cTnI (binary cTnIC + all ternary cTnTIC forms), and large-size cTnTIC (full-size and partially truncated cTnTIC). Troponin compositions were studied in relation to culprit vessel localization (left anterior descending artery [LAD] or non-LAD), ischemic time window, and peak CK-MB value. Sampling occurred at a median of 25 hours after symptom onset. Of total peripheral cTnI, a median of 87[78-100]% consisted of complex cTnI; and 9[6-15]% was large-size cTnTIC. All concentrations (total, complex cTnI, and large-size cTnTIC) were significantly higher in the CS than in peripheral samples (P < 0.001). For LAD culprit patients, GCV concentrations were all significantly higher; in non-LAD culprit patients, CS concentrations were higher. Proportionally, more large-size cTnTIC was present in the earliest sampled patients and in those with the highest CK-MB peaks. In coronary veins draining the infarct area, concentrations of both full-size and degraded troponin were higher than in the peripheral circulation. This finding, and the observed associations of troponin composition with the ischemic time window and the extent of sustained injury may contribute to future characterization of different disease states among NSTEMI patients.

Abstract 13907: Patients With NSTEMI Are at Higher Risk, Have Worse Outcomes, but Less Intense Cardiology Follow-up 1-3 Years Post-discharge: Findings From the TIGRIS Registry

Introduction: Non-ST-elevation myocardial infarction (NSTEMI) patients have more comorbidities and extensive CAD than STEMI patients. However, there is a need for comparative data on the long-term prognosis and resource utilization of stable patients after these MI subtypes. Methods: TIGRIS enrolled 9027 stable patients 1-3 years post-MI (369 centers, 25 countries) with ≥1 risk factor (age ≥65 years, diabetes, 2nd prior MI, multivessel CAD, CKD). The incidence of cardiovascular (CV) events and deaths, and self-reported EQ-D5 score were recorded over 2 years. Multivariable Poisson regression models were used to compare STEMI and NSTEMI patients for relative risks, adjusting for prognostically relevant patient factors. Results: MI subtype was known in 8494 patients (STEMI: 56%; NSTEMI: 44%). At enrollment, NSTEMI patients were more likely to be older, have diabetes, hypertension, hyperlipidemia, and prior CAD compared with STEMI patients. NSTEMI patients had significantly poorer self-rated health and a lower use of dual antiplatelet therapy at discharge and 1-3 years later. NSTEMI patients had a higher incidence of the composite of MI, stroke and CV death over 2 years (5.6% vs 4.0%, p&lt;0.001) and higher all-cause mortality (4.1% vs 2.6%, p&lt;0.001) vs STEMI patients (Figure). These excess risks for the composite outcome attenuated after adjusting for baseline characteristics (adj RR 1.18, 95% CI 0.96-1.45, p=0.11), but remained significant for all-cause mortality (adj RR 1.31, 95% CI 1.02-1.68, p=0.03). Resource utilization over 2 years was higher in NSTEMI patients, although the mean number of cardiologist visits were higher for STEMI patients (4.2 vs 2.8, p&lt;0.001). Conclusions: NSTEMI patients had a less favorable risk profile and experienced more adverse CV events during long-term follow-up than STEMI patients, but had less intense cardiology follow-up. Continued efforts are needed to optimize secondary prevention and care of stable patients after NSTEMI.

Abstract 14255: Contemporary Characteristics and Management of Patients Aged ≥ 80 Years Presenting With Non-ST Elevation Myocardial Infarctions in the United States: A Nationwide Inpatient Sample Cohort Study

Introduction: Improvements in primary prevention, medical therapies and interventions have coincided with a rapidly aging population across the globe. The contemporary characteristics and in-hospital outcomes of non-ST-elevation myocardial infarction (NSTEMI) among patients ≥ 80 years old in the United States (US) are not well studied. Methods: Adults (≥ 18) with a primary discharge diagnosis of NSTEMI were identified from the 2016 National Inpatient Sample. The exposure of interest was age ≥80 years, with a comparison group of those aged between 18 and 79 years. Results: Of 93,875 patients who had NSTEMI, 22,210 (23.65%) were ≥ 80 years. Among patients ≥ 80 years, 52.5% were female, 73.6% were Caucasians, with a significant proportion being managed by conservative therapy (73.4%). Patients ≥ 80 years were less likely to receive percutaneous coronary intervention (PCI) (adjusted odds ratio [aOR]: 0.49; 95% confidence intervals [CI]: 0.47-0.51) or coronary artery bypass graft surgery (CABG) (aOR: 0.28; 95% CI: 0.25-0.30) when compared to the younger group. Regardless of management strategy, patients ≥ 80 years old had higher inpatient mortality compared to younger patients. Patients ≥ 80 years undergoing PCI experienced more complete heart block, but not other complications, such as cardiogenic shock, cardiac arrest, and stroke, compared to the younger group (Table). NSTEMI patients ≥ 80 years who were managed conservatively or by CABG had a higher Elixhauser comorbidity index than patients undergoing PCI. Conclusions: A significant number of NSTEMI patients in the US were aged ≥ 80 years. Despite overall similar in-hospital complications profiles across management strategies, NSTEMI in patients ≥ 80 years was most often managed conservatively.

Meta-inflammation in monocytes of patients with Acute Coronary Syndrome

Abstract Background Several studies suggest that an alteration of monocyte metabolism might be implicated in inflammatory diseases. Enhanced glycolysis might be a hallmark of pro-inflammatory monocyte subsets. Improved glycolysis enables the immune cells to generate sufficient ATP and biosynthetic intermediates to carry out its particular effector functions. For macrophages this includes phagocytosis and inflammatory cytokine production. Pyruvate Kinase isozyme M2 (PKM-2) catalyzes the final step of glycolysis producing pyruvate and ATP. Latest studies have shown that a member of Jumonji family (JMJD8) acts as a positive regulator in TNF-induced NF-kB signaling leading to pro-inflammatory pathways in macrophages and is involved in angiogenesis and cellular metabolism through interacting with PKM-2 in endothelial cells. Purpose The aims of the study are to assess the expression of the glycolytic key enzyme PKM-2 in CD14+ monocytes obtained from patients with non-ST-elevation myocardial infarction (NSTEMI) or with stable angina (SA). Furthermore, the expression of JMJD8 was evaluated. Methods 30 patients with NSTEMI and 30 patients with SA were enrolled. Peripheral blood mononuclear cells were obtained from whole blood samples. For cytoplasmatic protein identification, cells were fixed and permeabilized and then incubated with fluorochrome-conjugated mAbs anti-CD14, anti-PKM-2 and anti-JMJD8. For analysis we used Two-tailed Mann-Whitney non parametric Comparison test. Results CD14+ monocytes from NSTEMI patients showed reduced expression of the key glycolytic enzyme PKM-2 as compared to CD14+ monocytes from SA patients (p=0.02) (Figure 1). JMJD8 expression in NSTEMI patients is increased compared with SA patients (p=0.02) (Figure 2). Conclusion This study introduces a role for immune-metabolism in the immunity dysregulation described in ACS patients and provides novel insights into the mechanisms responsible for coronary instability. Taking their potential interaction into account, our data suggest that in acute setting glycolysis key enzyme PKM2 expression is downregulated. Besides, JMJD8 protein levels increase in NSTEMI patients acting as potential limiting factor of PKM2 function. Moreover, our data propose the potential roles of immune-metabolism to detect novel therapeutic targets, associated with an accurate patient stratification based on immune-metabolic profiles, for prevention and treatment of atherosclerosis, in the perspective of a personalized medicine approach. Funding Acknowledgement Type of funding source: Private hospital(s). Main funding source(s): Fondazione Policlinico A. Gemelli

Mortality benefit of coronary angioplasty vs. conservative strategy in patients with prior coronary artery bypass surgery presenting with non-ST elevation myocardial infarction

Abstract Background Patients with prior coronary artery bypass graft (CABG) surgery have been excluded or under-represented in many of the trials of percutaneous coronary intervention (PCI) vs. conservative strategy in the management of patients presenting with non-ST elevation myocardial infarction (NSTEMI). Therefore, limited data supports the use of PCI in this context. Given the higher risk profile of these patients, clinicians may default to a conservative strategy given the lack of evidence of benefit of PCI. Our institution consists of one PCI and one non-PCI acute site and serves a population of 500 000 including a uniquely high proportion of the elderly with a high follow up rate and an ideal, interesting population to study with many patients offered a conservative strategy. Methodology Patients who presented over a 5 year period from Jan 2012 to Dec 2017 with NSTEMI and prior CABG were identified from Myocardial Ischaemia National Audit Project (MINAP) returns. Hospital records were reviewed to exclude patients with type 2 MI and ST elevation MI. We identified patients who were managed conservatively or with PCI and assessed outcomes at the end pf December 2019, giving a follow up range of 2–7 years. The primary outcome was all cause death or myocardial infarction. Secondary outcome measures included readmission at 30 days and 1 year, angina, need for revascularisation. Results 206 patients were identified (mean age 77.7y, 26% female) of whom 107 were managed medically and 99 underwent angiography. 74 (36%) of patients were admitted to the non-interventional site, of which 27 patients underwent angiography. Overall, 48 (23%) went on to have PCI (only 7% of patients from the non-PCI site). 29 patients had PCI to the native coronaries, 16 to a bypass graft and the remainder to both. Age and clinical frailty score (CFS) was significantly higher in patients managed conservatively. The primary end point occurred in a high proportion of patients (124, 74.6%) consisting of 28 MI and 96 deaths during the follow up period. Age at presentation, clinical frailty score (CFS), presence of heart failure and absence of statin use were were significantly associated with the primary outcome. There was a significant difference in the primary outcome in patients managed conservatively (113/158; 72%) compared to those who had PCI (11/48; 23%), P&amp;lt;0.001. Conclusion PCI in NSTEMI patients with prior CABG is significantly associated with improved survival and less myocardial infarction compared to a conservative strategy in this retrospective audit of our patient population, but PCI patients are younger and less frail, which, in themselves, could suggest treatment bias and might confer a survival benefit. PCI rates varied significantly when patients were assessed in non-interventional acute site compared to a PCI site which has important implications for service provision. A large-scale randomised control trial is warranted to guide best practice. Funding Acknowledgement Type of funding source: None

Early diagnosis of myocardial infarction in patients presenting late after chest pain onset

Abstract Background The European Society of Cardiology (ESC) recommends the clinical use of the 0/1h-algorithms in patients with suspected acute coronary syndrome (ACS) to rule-out or rule-in non-ST elevation myocardial infarction (NSTEMI). However, the diagnostic performance of the ESC 0/1h-algorithms was only validated in patients presenting within 12 hours after chest pain onset (=early presenters) to the emergency department (ED). To this date, evidence regarding their performance in patients with chest pain onset &amp;gt;12h (=late presenters) is lacking. Purpose To evaluate the diagnostic performance of the ESC 0/1h-algorithms in late presenters. Methods We prospectively enrolled patients presenting to the ED with symptoms suggestive of ACS such as acute chest discomfort. Two independent cardiologists adjudicated the final diagnoses based on all available clinical information including serial hs-cTn concentrations, follow-up information and cardiac imaging. Hs-cTnT/I concentrations at 0h and 1h were measured in a blinded fashion. The primary diagnostic endpoint was the diagnostic performance of the hs-cTnT/I ESC 0/1h-algorithms in patients presenting late after chest pain onset compared to those presenting early. Diagnostic performance was quantified by safety of rule-out (sensitivity and negative predictive value), accuracy of rule-in (specificity and positive predictive value), and efficacy (proportion of patients) classified as rule-out or rule-in within 1 hour after presentation to the ED. The primary prognostic endpoint was all-cause mortality after 30-days and two-years in patients in whom NSTEMI was ruled-out by the ESC 0/1h-algorithms. Results Among 4733 patients, 308/4733 (7%) presented late to the ED. The ESC hs-cTnT 0/1h-algorithm ruled-out 185/308 (60%) of late presenters with a sensitivity of 100% (95% CI, 93.7–100) and a negative predictive value (NPV) of 100% (95% CI, 98.0–100). Sixty-one of 308 (20%) were ruled-in with a specificity of 95.2 (95% CI, 91.8–97.2) and a positive predictive value (PPV) of 80.3% (95% CI, 68.7–88.4). The remaining 62/308 (20%) were classified as observe with a NSTEMI prevalence of 13%. In comparison, 59% of early presenters were ruled-out (sensitivity 99.3% [95% CI, 98.4–99.7]; NPV 99.8 [99.5–99.9]), 17% were ruled-in (specificity 96.2 [95% CI, 95.5–96.8]; PPV 81.4 [95% CI, 78.4–84.0]), and 45% were classified as observe. Late presenters in whom NSTEMI was ruled-out had 30-day and two-year survival rates of 100% and 98.2%, respectively. Similar findings were made for the ESC hs-cTnI 0/1h-algorithm. Conclusion The ESC hs-cTnT/I algorithms also provide excellent diagnostic performance for early triage and specifically safe rule-out of NSTEMI in patients presenting late after chest pain onset to the ED. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Swiss Heart Foundation, Swiss National Science Foundation

Increase of renal resistive index and mineral metabolism disorder in patients with acute coronary syndrome with preserved renal function.

Coronary artery disease is one of the first causes of death in the Western world; for this reason, it is essential to identify new, systemic, non-invasive and low-cost cardiovascular risk markers. The acute coronary syndrome includes ST-Elevation Myocardial Infarction (STEMI) and Non-ST-Elevation Myocardial Infarction (NSTEMI), based on ECG findings. We aimed to evaluate Renal Resistive Index (RRI) as a marker of cardiovascular risk and assess the associations with other cardiovascular risk factors (metabolic indexes, mineral metabolism disorders and endothelial dysfunction and atherosclerosis markers) in STEMI and NSTEMI patients. Clinical, laboratory and instrumental examinations as metabolic and inflammation indexes, markers of atherosclerosis and endothelial dysfunction (renal function, mineral metabolism disorders, inflammation indexes, Intima Media Thickness (IMT), Ankle Brachial Pressure Index, Left Ventricular Mass Index, Relative Wall Thickness) were performed. Eighty-one patients with STEMI and NSTEMI were enrolled. We showed a significant positive correlation between RRI and age (p<0.01), intact parathyroid hormone (p<0.01) and IMT (p<0.01), as well as a significant negative correlation between RRI and body surface area (BSA) (p=0.02), estimated Glomerular Filtration Rate (eGFR) (p<0.01), serum calcium (p<0.01) and 25-hydroxy-vitamin D (p=0.03). Moreover, we found a significant correlation between RRI and male patients (p<0.01), coronary artery disease history (CAD) (p=0.049), hypertension (p=0.025) and left ventricular eccentric hypertrophy (LVEH) (p=0.047). Our study showed an association between RRI and the main traditional and non-traditional cardiovascular risk factors involved in atherosclerosis pathogenesis, such as age, BSA, hypertension, male sex, CAD history, mineral metabolism disorders and LVEH, in patients with preserved renal function. Moreover, we found a significant correlation between RRI and eGFR, suggesting that RRI could be useful in the evaluation of both renal function and progression of renal damage, even in an early stage with a conserved or only slightly reduced kidney function. We also showed a significant correlation with some markers of systemic atherosclerosis such as IMT and LVEH. For a more precise assessment of prognosis and cardiovascular risk in patients with high cardiovascular mortality, we suggest performing a systematic RRI evaluation, considering the non-invasive nature of the procedure, its reproducibility, easy execution, and low costs.

An invasive strategy is associated with improved short- and long-term outcomes in acute myocardial infarction independently of frailty status and GRACE score: a nationwide analysis of 12144 episodes

Abstract Introduction Frailty is common among patients presenting with acute myocardial infarction (MI), who have conflicting risks regarding benefits and harms of invasive procedures. Purpose To assess the clinical management and prognostic impact of invasive procedures in frail MI patients in a real-world scenario. Methods We analysed 5422 episodes of ST-elevation MI (STEMI) and 6692 of Non-ST-elevation MI (NSTEMI) recorded from 2010–2019 in a nationwide registry. A validated deficit-accumulation model was used to create a frailty index (FI), comprising 22 features [BMI &amp;gt;25kg/m2, myocardial infarction, angina, heart failure, percutaneous coronary intervention (PCI), coronary artery bypass graft surgery (CABG), valvular disease, bleeding, pacemaker/implantable cardioverter defibrillator, chronic kidney disease (creatinine &amp;gt;2.0mg/dL), dialysis/renal transplant, stroke/transient ischaemic attack, diabetes, hypertension, dyslipidaemia, smoking, peripheral vascular disease, dementia, chronic lung disease, malignancy, polymedication (&amp;gt;3 cardiovascular drugs), admission haemoglobin &amp;lt;10g/dL; not including age]. Episodes with missing data on any FI parameter were not included. Frailty was initially defined as FI&amp;gt;0.25 (i.e. ≥6 features). Results Overall, 511 (9.4%) STEMI and 1763 (26.4%) NSTEMI patients were considered frail. Angiography, PCI and CABG were less frequently performed in frail patients (p&amp;lt;0.001). Delayed angiography (&amp;gt;72h) was more common among NSTEMI frail patients (p&amp;lt;0.001), and radial access was less commonly used overall (p&amp;lt;0.001). Guideline-recommended in-hospital medical therapy, including aspirin (NSTEMI), dual-antiplatelet therapy (STEMI/NSTEMI), heparin/heparin-related agents (NSTEMI), beta-blockers (STEMI) and ACEIs/ARBs (STEMI), was less commonly used in frail patients; discharge medical therapy exhibited similar patterns. Frail patients had longer hospital stay and increased in-hospital all-cause and cardiovascular (CV) mortality, as well as 1-year all-cause and CV hospitalization and all-cause mortality (p&amp;lt;0.001). Using receiver-operator-characteristics curve analysis, FI cutoffs of 0.11 (STEMI) and 0.20 (NSTEMI) yielded the best accuracy to predict 1-year all-cause mortality (area under the curve: 0.629 and 0.702 respectively, p&amp;lt;0.001) – these cutoffs were subsequently used to define frailty. Although frailty attenuated in-hospital risk reductions from angiography (STEMI/NSTEMI) and PCI (NSTEMI only) (Wald test p&amp;lt;0.05), their 1-year prognostic benefit remained unaffected (Wald test p&amp;gt;0.05). Angiography and PCI were associated with improved in-hospital and 1-year outcomes, independently of frailty status or GRACE score (p&amp;lt;0.001). Conclusion Frail MI patients are less commonly offered standard therapy; however, angiography and PCI were associated with short- and long-term prognostic benefits regardless of frailty status or GRACE score. Increased adherence to current recommendations might improve post-MI outcomes in frail patients. Invasive strategy and 1-year outcomes Funding Acknowledgement Type of funding source: Other. Main funding source(s): Portuguese Society of Cardiology

Gender in non- ST elevation myocardial infarction and unstable angina: is there any equality?

Abstract Background Historically, women (W) with acute coronary syndrome (ACS) have worse outcomes compared with men (M). This fact may occur due to gender-specific differences in the presentation and management of patients (P), which were mainly observed in studies dealing with ST-segment elevation infarction (STEMI). There seems to be a gap of knowledge in gender-specific differences in non- ST elevation myocardial infarction (NSTEMI) and unstable angina (UA). Purpose Assess gender-specific differences in presentation, treatment and outcomes in NSTEMI and UA patients. Methods A retrospective cohort study from consecutive ACS patients enrolled in a multicentre national registry from October 2010 to December 2018 was conducted, identifying 11394 P admitted with NSTEMI or UA. Demographic, clinical and treatment variables were compared between male gender and female gender P. A Cox multivariate regression was performed to evaluate predictor factors of stablished endpoints: mortality at 1-year (1y) and cardiovascular (CV) hospitalization at 1-year. Results A total 11394 P were included, 8145 M (71.5%) and 3249 W (28.5%), mean age of 68±13. W, comparing with M, had higher age (72±12 vs 66±13, p=0.001), higher prevalence of hypertension (85% vs 72%, p=0.001) and diabetes (41% vs 34%, p=0.001) and longer time from symptoms to hospital admission (360 minutes vs 297 minutes, p=0.001). Chest pain was less frequent as first symptom in W (85.6% vs 91.3%, p=0.001). In medical treatment, W had higher chance of not having administration of a loading dose of P2Y12 inhibitor (22.1% vs 18.1, p=0.001) and of being medicated with clopidogrel (85.7% vs 82.1%, p=0.002). At discharge, W were less frequently medicated with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (82.6% vs 84.4, p=0.028). Coronary angiography was less frequently performed in W (77.3% vs 85.7%, p=0.001). Coronary artery disease was less frequently found in the female gender (12.4% vs 4.8%, p=0.001). In-hospital mortality was higher in W (2.9% vs 2.1%), but in the multivariate analysis the female gender was not an independent predictor of in-hospital mortality (OR 1.05 [0.67- 1.65], p=0.823). 1-year mortality was higher in W (9.2% vs 7.3%) and 1-year CV hospitalization was higher in M (16.8% vs 14.4%). After adjusting for covariates in Cox regression analysis, difference was still significant for mortality (HR= 1.274 [1.038 - 1.564], p=0.02) and hospitalization (HR = 0.852 [0.726- 0.998], p=0.047). Conclusion In this NSTEMI and UA cohort, there are important gender-specific differences in comorbidities, diagnosis, management and outcomes. Gender was an independent predictor of 1-year mortality and 1-year CV hospitalization, but not an independent predictor for in-hospital mortality. Funding Acknowledgement Type of funding source: None

Predictive Power of In-Hospital and Long-Term Mortality of the GRACE, TIMI, Revised CADILLAC and PAMI Score in NSTEMI Patients with Diabetes - Data from TSOC ACS-DM Registry.

Risk score is widely used in non-ST segment elevation myocardial infarction (NSTEMI) patients to predict the in-hospital outcome for immediate coronary angiography decision and care of unit selection. This study compared the performances of the thrombolysis in myocardial infarction (TIMI), Global Registry of Acute Coronary Events (GRACE), Primary Angioplasty in Myocardial Infarction (PAMI), and Revised Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (Revised CADILLAC) risk scores in predicting in-hospital and long-term outcomes in diabetic NSTEMI patients. A total of 750 diabetic NSTEMI patients from 27 hospitals were enrolled between January 2013 and December 2015 in the nationwide registry initiated by the Taiwan Society of Cardiology. Four score systems were calculated with receiver operator characteristic analysis used to compare outcome discrimination performance. No studied risk scores reached acceptable discrimination per area under curve (AUC) in the prediction of in-hospital outcome except for the revised CADILLAC score which reached acceptable discrimination in new-onset cardiogenic shock (AUC = 0.7191) and acute renal failure (AUC = 0.7283). In long-term outcomes, only the revised CADILLAC score reached acceptable discrimination of mortality prediction at 6, 12 and 24 months (AUC = 0.7261 at 6 months, 0.7319 at 12 months, and 0.7256 at 24 months). Subgroup analysis based on the revised CADILLAC score risk class showed a significant difference in adjusted mortality rate between low-risk group/intermediate-risk group and high-risk group. Only the revised CADILLAC score showed acceptable accuracy to predict the long-term mortality outcome among the scores studied.

The current treatment and predictors of outcome in elderly patients with non-ST-elevation myocardial infarction in an all comers population: the POPular Age registry

Abstract Background Elderly patients form a large and growing part of the patients presenting with non-ST-elevation myocardial infarction (NSTEMI). Choosing the optimal antithrombotic treatment in these elderly patients is more complicated because they frequently have characteristics indicating both a high ischaemic and high bleeding risk. Purpose We describe the treatment of elderly patients (&amp;gt;75 years) admitted with NSTEMI, present the outcomes (major adverse cardiovascular events (MACE) and bleeding) and aim to find predictors for adverse events. Methods The POPular AGE registry is an investigator initiated, prospective, observational, multicentre study of patients aged 75 years or older presenting with NSTEMI. Patients were recruited between August 1st, 2016 and May 7th, 2018 at 21 sites in the Netherlands. The primary composite endpoint of MACE included cardiovascular death, non-fatal myocardial infarction and non-fatal stroke at one-year follow-up. Results A total of 757 patients were enrolled. During hospital stay 76% underwent coronary angiography, 34% percutaneous coronary intervention and 12% coronary artery bypass grafting (CABG). At discharge 78.6% received aspirin (non-users mostly because of the combination of oral anticoagulant and clopidogrel), 49.7% were treated with clopidogrel, 34.2% with ticagrelor and 29.6% were prescribed oral anticoagulation. Eighty-three percent of patients received dual antiplatelet therapy (DAPT) or dual therapy consisting of oral anticoagulation and at least one antiplatelet agent for a duration of 12 months. At one year, the primary outcome of cardiovascular death, myocardial infarction or stroke occurred in 12.3% of patients and major bleeding (BARC 3 or 5) occurred in 4.8% of the patients. The risk of MACE and major bleeding was highest during the first month and stayed high over time for MACE while the risk for major bleeding levelled off. Independent predictors for MACE were age, renal function, medical history of CABG, stroke and diabetes. The only independent predictor for major bleeding was haemoglobin level on admission. Conclusion In this all-comers registry, most elderly patients (≥75 years) with NSTEMI are treated with DAPT and undergoing coronary angiography the same way as younger NSTEMI patients from the SWEDEHEART registry. Aspirin use was lower as was the use of the more potent P2Y12 inhibitors compared to the SWEDEHEART which is very likely due to the concomitant use of oral anticoagulation in 30% of patients. The fact that ischemic risk stays constant over 1 year of follow-up, while the bleeding risk levels off after one month may suggest the need of dual antiplatelet therapy until at least one year after NSTEMI. Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): AstraZeneca

Avoiding the emergence of contrast-induced acute kidney injury in acute coronary syndrome: routine hydration treatment.

Patients with acute coronary syndrome (ACS) have about a three-fold risk for developing contrast-induced acute kidney injury(CI-AKI). Investigating studies on routine hydration therapy have frequently included patients with stable coronary artery disease and high risk of CI-AKI [estimated glomerular filtration rate (eGFR) < 60 ml/min]. However, data on routine hydration treatment in non-ST segment elevation myocardial infarction (NSTEMI) patients with eGFR ≥60 ml/min are insufficient. We aimed to investigate the association between routine hydration therapy and CI-AKI development in NSTEMI patients at low risk for nephropathy. We randomly assigned a total of 401 NSTEMI patients to two groups: the routine hydration group (198 patients) and the nonhydration group (control group) (203 patients). Intravenous hydration with isotonic saline (1 ml/kg/h, 0.9% sodium chloride) was given for 3-12 h before and 24 h after contrast exposure to the hydration group. CI-AKI was defined as the increase in serum creatinine values 0.5 mg/dl or 25% between 48 and 72 h after the invasive procedures. In our study, the incidence of CI-AKI development in the routine hydration group (7.1%) was significantly lower than in the nonhydration group (14.1%) (P: 0.02). This study revealed that older age, amount of contrast media, and routine hydration were independent risk factors for developing CI-AKI (P < 0.01, P: 0.04, P < 0.01, respectively). We found that preprocedural and postprocedural intravenous hydration therapy reduces the development of CI-AKI in patients with NSTEMI at low risk for CI-AKI. We suggest administering routine hydration therapy in all ACS patients regardless of eGFR values.

Trends in the Detection, Management and 30-Day Outcomes of Spontaneous Coronary Artery Dissection: A Six-Year, New Zealand Centre Experience

Spontaneous coronary artery dissection (SCAD) is an important but under-recognised cause of acute coronary syndrome (ACS), particularly in younger women. We assessed trends in the detection, management and outcomes of all patients with SCAD over 6 consecutive years. All patients with first diagnosis of SCAD at Christchurch Public Hospital, New Zealand, between January 2014 and January 2020 were included. Patient management and outcomes were determined by retrospective review of medical records. SCAD presentations were compared to total ACS presentations, obtained from a national ACS (ANZACS-QI) database. We identified 113 patients with angiographic diagnosis of SCAD. Median age was 54 years (88% female). The detection of SCAD increased over the period, both as a total number (Kendall's τ 0.87, p=0.015) and as a proportion of all ACS (p value for trend <0.0001). In 2019, SCAD represented 2.4% of all ACS and 18% of ACS in females aged less than 60 years. The most common presentation was non-ST elevation myocardial infarction (NSTEMI) in 72%; and, there was an increase in NSTEMI compared with STEMI over the period (p=0.023). Initial strategy of percutaneous coronary intervention (PCI) was undertaken in 12% of patients, with a significant trend towards a more conservative approach over the study period (p=0.019). The rate of 30-day major adverse cardiovascular events (MACE) was 8.8% overall, and significantly reduced over the study period to 3% in 2019 (p value for trend, 0.006). The detection of SCAD has increased and is a particularly important cause of ACS in younger women. This increase has been largely driven by an increasing number of NSTEMI patients diagnosed with SCAD, associated with a significant improvement in 30-day MACE.