non-ST-segment Acute Coronary Syndrome Research Articles

The diagnostic accuracy of two-dimensional strain imaging echocardiography to detect the severity of coronary artery disease in non-ST segment elevation acute coronary syndrome

ObjectiveStrain imaging by two-dimensional speckle tracking echocardiography can detect severe coronary artery disease (CAD). This study aims to assess the diagnostic accuracy of various strain parameters in patients with non-ST segment acute coronary syndrome to detect the angiographic severity of CAD and also to compare among them. MethodsThis hospital-based observational study was conducted on 178 patients with NSTEACS and preserved left ventricular ejection fraction who presented in emergency or outdoor from July 2021 to December 2022. We excluded patients with prior coronary revascularization, heart failure, arrhythmia, more than trivial valvular heart disease, or poor acoustic window. Global longitudinal strain (GLS), peak systolic strain (SS), post systolic index (PSI), and systolic strain rate (SR) were calculated by speckle tracking with automated function imaging. Coronary angiography was done in all patients, and the syntax score was calculated. ResultsThe strain parameters showed a significant correlation with the syntax score. There was a statistically significant difference in strain parameters between patients with left main (LM) or triple vessel disease (TVD) and others. Receiver operating characteristic (ROC) curve analysis showed that GLS had a better diagnostic accuracy for detecting LM or TVD than other strain parameters. GLS with a cut-off value of −11.2% had a sensitivity of 85.7% and specificity of 53.5% for detecting LM or TVD. ConclusionStrain imaging can be a helpful bedside adjunct to conventional investigations for detecting severe CAD in patients with NSTEACS.

Lactate as a Predictor for Determining Invasive Intervention Time in non-ST-Segment Acute Coronary Syndromes

Objective: The aim was to evaluate the correlation of lactate levels measured at admission with the urgency of intervention in patients diagnosed with non-ST-segment acute coronary syndromes (NST-ACS).Methods: This was a prospective observational study conducted in a research hospital between March 2020 and June 2021. Patients admitted to the emergency department with chest pain and diagnosed with NST-ACS were divided into four group according to the recommendations of the European Society of Cardiology (ESC) 2015 guidelines to determine the priority of invasive intervention. Lactate levels were measured from venous blood samples. Whether there was a difference in terms of lactate levels between patients who were recommended for early invasive intervention (within 24 hours) and patients who were recommended for late invasive intervention (within 72 hours) was investigated. The sample size was estimated with G*Power and statistical analysis was performed using SPSS 22.Results: The mean age of the group recommended for early intervention was 62±11.45 years and the mean age of the group recommended for late intervention was 61±11.89 years. The time interval between the beginning of symptoms and admission to the emergency department was similar between the groups and the median was 4 hours. GRACE scores were significantly higher in the early intervention recommended group. There was no difference in terms of lactate levels between the groups. Correlations between GRACE scores and lactate levels were statistically non-significant (p>0.05). Conclusion: Lactate alone was not a good predictor for risk analyses and determination of invasive intervention time in NST-ACS patients without urgent invasive intervention indications.

Effects of early myocardial reperfusion and perfusion on myocardial necrosis/dysfunction and inflammation in patients with ST-segment and non-ST-segment elevation acute coronary syndrome: results from the PLATelet inhibition and patients Outcomes (PLATO) trial.

AimsRestoration of myocardial blood flow and perfusion during percutaneous coronary intervention (PCI) measured using Thrombolysis in Myocardial Infarction (TIMI) flow grade (TFG) and perfusion grade (TMPG) is associated with improved outcomes in acute coronary syndrome (ACS). Associations between TFG/TMPG and changes in biomarkers reflecting myocardial damage/dysfunction and inflammation is unknown.Methods and resultsAmong 2606 patients included, TFG was evaluated in 2198 and TMPG in 1874 with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment ACS (NSTE-ACS). Biomarkers reflecting myocardial necrosis [troponin T (TnT)], myocardial dysfunction [N-terminal prohormone brain natriuretic peptide (NT-proBNP)], inflammation [interleukin-6 (IL-6) and C-reactive protein (CRP)], and oxidative stress/ageing/inflammation [growth differentiation factor-15 (GDF-15)] were measured at baseline, discharge, and 1- and 6-month post-randomization. Associations between TFG/TMPG and changes in biomarker levels were evaluated using the Mann–Whitney–Wilcoxon signed test. In total, 1423 (54.6%) patients had STEMI and 1183 (45.4%) NSTE-ACS. Complete reperfusion after PCI with TFG = 3 was achieved in 1110 (85.3%) with STEMI and in 793 (88.5%) with NSTE-ACS. Normal myocardial perfusion with TMPG = 3 was achieved in 475 (41.6%) with STEMI and in 396 (54.0%) with NSTE-ACS. Levels of TnT, NT-proBNP, IL-6, CRP, and GDF-15 were substantially lower at discharge in patients with complete vs. incomplete TFG and STEMI (P < 0.01). This pattern was not observed for patients with NSTE-ACS. Patients with normal vs. abnormal TMPG and NSTE-ACS had lower levels of NT-proBNP at discharge (P = 0.01).ConclusionsSuccessful restoration of epicardial blood flow in STEMI was associated with less myocardial necrosis/dysfunction and inflammation. Attainment of normal myocardial perfusion was associated with less myocardial dysfunction in NSTE-ACS.

The additive value of copeptin for early diagnosis and prognosis of acute coronary syndromes.

One promising biomarker that has received substantial interest for the evaluation of suspected acute coronary syndromes (ACS) is copeptin. Therefore, our goal was to assess the additive value of copeptin for early diagnosis and prognosis of Non-ST segment acute coronary syndromes (NSTE-ACS). The study included ninety patients with suspected ACS. Patients with typical ischemic chest pain within six hours of symptom onset and without ST-segment elevation on electrocardiograph (ECG) were included. In addition to cardiac troponin I (cTnI), copeptin was assayed from venous blood samples obtained on admission, followed by serial troponin measurements six and twelve hours later. One year follow-up was performed for any major adverse cardiac events (MACEs) including cardiac death, re-infarction, re- hospitalization for ischemic events, heart failure, stroke and target lesion revascularization (TLR). Of seventy nine patients included in the final analysis, Forty (50.6%) were diagnosed as unstable angina (UA), while thirty nine (49.4%) had a non-ST elevation myocardial infarction (NSTEMI). Copeptin level on admission was significantly higher among NSTEMI patients than those with UA. With regard to the correlation analyses, copeptin was positively correlated with each of, Global Registry of Acute Coronary Events (GRACE), Thrombolysis In Myocardial Infarction (TIMI) and synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) scores. The sensitivity and negative predictive value (NPV) of the combination of admission copeptin and cTn-I were 100% and 100%, respectively, versus 57% and 70%, respectively, with admission of cTn-I alone. The area under curve (AUC) of the combination of copeptin and cTn-I was (0.975, p<0.001) and was significantly higher than the AUC of cTn-I alone (0.888, p<0.001). Admission copeptin was an independent predictor for MACEs by multiple regression analysis (OR: 0.01, 95% CI: 0.0-0.8, P=0.04). High values of copeptin had the highest rate of MACEs and coronary revascularization during one year of follow up. The combination of copeptin and conventional troponin I aids in early rule out of NSTEMI virtually independent of chest pain onset (CPO) with high NPV in patients presenting within three hours from chest pain onset with excellent prognostic value for risk stratification and prediction of MACEs.

High-sensitivity cardiac troponin T as a predictor of acute Total occlusion in patients with non-ST-segment elevation acute coronary syndrome.

BackgroundA large percentage of patients with non‐ST‐segment acute coronary syndrome (NSTE‐ACS) present with acute total occlusion (TO) of some major epicardial vessel that does not generate electrocardiographic changes. Ongoing research into the methods of accurately predicting acute TO have not yielded great success.HypothesisHigh‐sensitivity cardiac troponin T (hs‐cTnT) has a good predictive value for the presence of acute TO of the culprit artery in patients with NSTE‐ACS.MethodsA single‐center retrospective study of 1011 patients diagnosed with NSTE‐ACS who underwent coronary angiography and hs‐cTnT measured on admission. The predictive value of hs‐cTnT in the presence of acute TO was assessed by the area under the ROC curve.ResultsThe mean age of the population was 67.12 ± 13.18 and 74.1% were male. 7.3% of the patients presented with acute TO. The AUC for hs‐cTnT to predict acute TO was 0.95. A hs‐cTnT value of 1006 ng/L (71.8 fold of the URL) best predicted the presence of acute TO, with a sensitivity of 86% and specificity of 95% positive predictive value (PPV): 86% and negative predictive value (NPV): 94%.ConclusionsHs‐cTnT was a good predictor of acute TO in patients with NSTE‐ACS. Hs‐cTnT values greater than 1006 ng/L were highly predictive of acute TO of a major coronary vessel.

Association between serum S100A1 level and Global Registry of Acute Coronary Events score in patients with non-ST-segment elevation acute coronary syndrome.

ObjectiveAcute coronary syndrome (ACS) is associated with several clinical syndromes, one of which is acute non-ST-segment ACS (NSTE-ACS). S100A1 is a calcium-dependent regulator of heart contraction and relaxation. We investigated the association between the serum S100A1 level and the Global Registry of Acute Coronary Events (GRACE) risk score in patients with NSTE-ACS and the potential of using the serum S100A1 level to predict the 30-day prognosis of NSTE-ACS.MethodsThe clinical characteristics of 162 patients with NSTE-ACS were analyzed to determine the GRACE score. The serum S100A1 concentration was determined using fasting antecubital venous blood. The patients were divided into different groups according to the serum S100A1 level, and the 30-day NSTE-ACS prognosis was evaluated using Kaplan–Meier analysis.ResultsThe serum S100A1 levels differed significantly among the groups. Correlation analysis showed that the serum S100A1 level was positively correlated with the GRACE score. Kaplan–Meier analysis revealed that the number of 30-day cardiac events was significantly higher in patients with an S100A1 level of >3.41 ng/mL.ConclusionsS100A1 is a potential biomarker that can predict the progression of NSTE-ACS and aid in its early risk stratification and prognosis.

Early and long-term outcomes of complete revascularization with percutaneous coronary intervention in patients with multivessel coronary artery disease presenting with non-ST-segment elevation acute coronary syndromes.

IntroductionThe clinical significance of complete revascularization with percutaneous coronary intervention (CR-PCI) in patients with non-ST-segment acute coronary syndrome (NSTE-ACS) remains uncertain.AimTo evaluate the impact of CR-PCI during index hospitalization on short and long-term incidence of death and composite endpoint among patients with multivessel coronary artery disease (CAD) presenting with NSTE-ACS.Material and methodsWe analyzed consecutive data of 1,592 patients with multivessel CAD from 2006 to 2014. Patients with prior coronary artery bypass grafting (CABG), cardiogenic shock, treated conservatively or with CABG and scheduled for planned CABG or PCI after discharge were excluded. The 30-day and 12-month composite endpoint was defined as all-cause death, nonfatal myocardial infarction (MI) or ACS-driven unplanned revascularization. Six hundred and ninety-five patients were divided into 2 groups: CR-PCI (n = 137) (CR-PCI during index hospitalization) and IR-PCI (n = 558) (incomplete revascularization).ResultsIncidence of composite endpoint (3.6% vs. 10.2%; HR = 0.31; 95% CI: 0.12–0.87; p = 0.025) and death (0.7% vs. 5.7%, HR = 0.11; 95% CI: 0.02–0.93; p = 0.043) at 30 days was lower in CR-PCI than in IR-PCI. At 12-month follow-up occurrence of composite endpoint was lower in CR-PCI (14.7%) than in IR-PCI (27.4%, p = 0.0037). Multivariate analysis confirmed that CR PCI was associated with a reduction in 12-month composite endpoint (HR = 0.56; 95% CI: 0.31–0.99; p = 0.046). The 12-month mortality was lower in CR-PCI (7.4% vs. 14.8%; p = 0.031), but it was not confirmed in the multivariate analysis.ConclusionsIn patients with multivessel CAD and NSTE-ACS, CR-PCI during index hospitalization was independently associated with improved early and long-term prognosis without significant differences in periprocedural outcomes in comparison to IR-PCI.

Sensitive Troponin I and Stress Testing in the Emergency Department for the Early Management of Chest Pain Using 2-Hour Protocol.

Despite improvements in identifying high-risk patients with non-ST segment ACS (acute coronary syndrome), low risk patients presenting with atypical chest pain and non-diagnostic Electrocardiogram (ECG) continued to undergo unnecessary admissions and testing. Since 1992, our chest pain protocol included using 4-hour serial biomarkers from ED admission in combination with stress testing to evaluate these patients. Our study aimed at determining whether a new accelerated diagnostic protocol using sensitive cardiac troponin I (cTnI) 2 hours after admission to the ED followed by stress testing is safe and effective in emergency settings, allowing for appropriate triage, earlier discharge and reducing costs. We conducted a single center randomized trial at Presence St. Francis Hospital Chest pain center in Evanston, Illinois enrolling sixty-four consecutive patients with atypical chest pain and non-diagnostic ECG, participants were randomized to accelerated 2 hrs protocol or our pre-existing 4-hrs protocol. Sixty patients completed the protocol and were randomized to either a 2-hour (29 patients) or 4-hour protocol using both I-STAT and PATHFAST cTnI (31 Patients). Troponin I was evaluated at 0 and at 2 hours from ED presentation with and additional draw for patients in the 4-hour rule out-group. Patients with normal serial biomarkers were then evaluated with stress testing and qualified for earlier discharge if the stress test was negative, while those with a positive biomarker at any time were admitted. Thirty-six patients had exercise treadmill stress test and 24 patients had either nuclear or Echo stress test. Fifty-three patients had a normal stress test and were discharged home. One patient in the 4-hour group with normal serial troponins developed ventricular tachycardia/fibrillation during the recovery period of a regular stress test. Six patients had a positive PATHFAST cTnI and a normal I-STAT cTnI at 2-hours. Two out of these six patients evaluated by coronary angiography. One patient had severe tortuous coronaries but no significant obstructive lesion and one had a severe CAD who needed Coronary artery bypass grafting (CABG). Three of the six patients had a normal stress test and one patient decided to leave without further testing. None of the patients with a normal stress test had a major cardiac event or adverse cardiac outcome at six-month follow up. This study demonstrates that the 2 hours accelerated protocol using high sensitivity Troponin assay at 0 and 2 hours with comprehensive clinical evaluation and ECG followed by stress testing might be successful in identifying low-risk patient population who may benefit from early discharge from ED reducing associated costs and length of stay.

Frequency of Left Main Artery/Three Vessel Disease Predicted through ECG Changes in Patients Presenting with Non-ST Segment Acute Coronary Syndrome

BACKGROUND: Electrocardiography (ECG) is simple, quick and economic investigation for diagnosis of acute coronary syndrome. Its applicability in prediction of left main coronary artery/ 3 vessel coronary disease can be of very useful in saving precious time in the critical care of coronary patients. OBJECTIVE: Electrocardiography changes as a predictor of left main coronary artery / 3 vessel coronary disease in patients presenting with Non-ST segment elevation acute coronary syndrome. METHODOLOGY: This cross sectional study was executed from July 2014 to June 2015 at Isra University hospital Hyderabad taking 114 consecutive patients of age >20, of either gender, presenting with symptoms of Non-ST segment elevation MI or that showed ECG changes in lead aVR. Informed written consent for the study was taken from the immediate family members of patients. Approval from ethics review committee of Isra University was taken. Data analysis was done through SPSS. Descriptive statistics (Mean ±standard deviation for continuous & frequencies and percentages for categorical variables) were expressed. RESULTS: Patients’ mean ±SD age was 56.65 ±15.44 years (Range: 20-89 years). Male to female ratio was 3.4:1. More than a half (52%) of these patients had Left main (LM) / 3 vessels disease. About a quarter other (25%) had 2 vessels while (22%) had single vessel disease (P value

Abstract 17437: Do Patients With Uncomplicated Non-ST Segment Acute Coronary Syndromes Require Admission to Critical Care Units?

Background: Clinical practice guidelines recommend admitting patients with stable non-ST segment elevation acute coronary syndrome (NSTE ACS) to telemetry units, yet up to two thirds of patients are admitted to critical care units (CCU). The outcomes of patients with stable NSTE ACS initially admitted to a CCU versus a cardiology ward with telemetry have not yet been described. Methods: We used a population-based dataset of 7,869 patients hospitalized with NSTE ACS admitted to hospitals in Alberta, Canada between April 1, 2007 and Mar 31, 2013 and excluded patients (n=589) who received CCU procedures or therapies on the day of admission. We compared outcomes among patients initially admitted to a CCU (n=5141) with those admitted to cardiology telemetry wards (n=2728). Results: Patients admitted to cardiology telemetry wards were older (median 69 vs 65 years, p&lt;0.001), and more likely to be female (37.2% vs 32.1%, p&lt;0.001) and have a history of prior myocardial infarction (14.3% vs 11.5%, p&lt;0.001). Patients admitted directly to cardiology telemetry wards had similar hospital stays (6.2 vs 5.7 days, p=0.29), fewer cardiac procedures (39.1% vs 45.8%, p&lt;0.001) and higher mean Charleston scores (1.3 vs 1.0, p&lt;0.001) compared with patients initially admitted to CCUs. There were no differences in the frequency of cardiac arrest (0.7% vs 0.9%, p=0.51), in-hospital mortality (1.3% vs 1.2%, adjusted odds ratio (aOR) 1.57; 95% CI, 0.98 to 2.52), 30-day all-cause mortality (1.6% vs 1.5%, aOR 1.50; 95% CI 0.82 to 2.75), or 30-day all-cause post-discharge readmission (10.6% vs 10.8%, aOR 1.07; 95% CI 0.90 to 1.28) between cardiology telemetry ward and CCU patients. Results were similar across low, intermediate, and high risk NSTE ACS Charleston subgroups and in patients with non-ST segment myocardial infarction or unstable angina. Conclusions: No differences in clinically important outcomes were observed between patients with NSTE ACS initially admitted to wards or CCUs. These findings suggest that stable NSTE ACS can be managed appropriately in telemetry wards and present an opportunity to reduce hospital costs and critical care capacity strain.

Impact of comorbidities and gender on the use of coronary interventions in patients with high-risk non-ST-segment elevation acute coronary syndrome

Objectives: To determine the impact of gender and comorbidity on use of coronary interventions in patients diagnosed with high-risk non-ST-segment acute coronary syndrome (NSTEACS). Background: Guidelines recommend the use of coronary angiography for all patients diagnosed with NSTEACS with high-risk features, except in the presence of severe comorbidities. However, little is understood about the relationship between gender, comorbidity, and the use of coronary interventions. Methods: Retrospective analyses of the Victorian Admitted Episodes Data Set (VAED) including all patients diagnosed with NSTEACS with high-risk features on their first admission for ACS between June 2007 and July 2009. Hierarchical logistic regression models and correspondence analyses were used to understand the relationship between gender, comorbidities, and the use of coronary interventions. Results: Out of 16,771 NSTEACS patients with high-risk features, 6,338 (38%) were female. Females were older than males (aged ≥75: 62% vs 39%, p < 0.001) and more likely to have multiple comorbidities (≥2: 66% vs 59%, p < 0.001). After adjusting for potential confounders, females were more likely to receive no coronary intervention than males with a similar number of comorbid conditions (no comorbidities: OR 1.62, 95% CI 1.28–2.05; 1 comorbidity: OR 1.67, 95% CI 1.44–1.93; 2 comorbidities: OR 1.93, 95% CI 1.66–2.23; ≥3 comorbidities: OR 1.42, 95% CI 1.27–1.60). Conclusions: Lower rates of coronary intervention in females persisted after adjusting for number of comorbidities which suggests that gender may bias decisions regarding referral for coronary intervention in high-risk NSTEACS independent of other factors. © 2015 Wiley Periodicals, Inc.

Single-vessel or multivessel PCI in patients with multivessel disease presenting with non-ST-elevation acute coronary syndromes

Coronary artery disease is often diffuse and patients with non-ST-segment acute coronary syndromes (NSTE-ACS) demonstrate multivessel coronary disease. The purpose of this study was to clarify whether interventions on stable chronic non-culprit lesions in patients with NSTE-ACS can prevent future adverse events. We performed a retrospective cohort study of 990 consecutive patients who underwent either single-vessel PCI (SVPCI: n=379) or multivessel PCI (MVPCI: n=611) in a setting of NSTE-ACS. Cox proportional hazards regression analysis was performed to compensate for differences in baseline characteristics between the groups. To minimise the impact of confounding factors, we performed propensity matching (SVPCI: n=230, MVPCI: n=230). Patients who had MVPCI had a lower rate of prior interventional treatment or myocardial infarction, and more complex lesions than patients with SVPCI. At three years, all-cause mortality was significantly lower in the MVPCI group than the SVPCI group (13.0% vs. 18.3%, p=0.02, adjusted HR 0.55, 95% CI: 0.38-0.80), while the rates of target vessel revascularisation and a composite of all-cause death or myocardial infarction were not different between the groups. In the propensity-matched cohort, all-cause death remained significantly lower in the MVPCI group (adjusted HR 0.41, 95% CI: 0.22-0.75) compared to the SVPCI group. In this retrospective study, multivessel PCI reduced all-cause mortality in a setting of NSTE-ACS compared to single-vessel PCI. Further investigations to confirm these results are warranted.

Predictors of complicated athero-thrombotic lesions in non-ST segment acute coronary syndrome

Non-ST segment elevation acute coronary syndrome (NSTE-ACS) is a heterogeneous syndrome in terms of patho-physiological mechanisms and prognosis. We sought to investigate the clinical features associated with complicated athero-thrombotic (CAT) coronary lesions and their prognostic relevance in NSTE-ACS. We enrolled 701 consecutive NSTE-ACS patients without previous coronary bypass undergoing coronary angiography. The study population was divided into two groups according to the presence/absence of angiographic signs of endoluminal thrombi and/or plaque rupture, defined as CAT lesions. Multivariable analyses were used to identify predictors of CAT lesions. Their relation to composite endpoint of death, re-myocardial infarction, and re-unstable angina was investigated with the use of multivariable logistic regression. Patients with CAT lesions (n = 279, 40%) had a higher incidence of the combined endpoint (11.5 vs. 4.3%; P < 0.001). On multivariable analysis male sex [odds ratio (OR) 1.64, 95% confidence interval (CI) 1.17-2.30, P = 0.004], previous percutaneous coronary intervention (PCI) (OR 0.48, 95% CI 0.32-0.72, P < 0.001), severe angina (OR 1.72, 95% CI 1.18-2.52, P = 0.005) and anterior (i.e. V1-V4) ST segment depression (STD) were independently associated with CAT lesions (OR 1.71, 95% CI 1.14-2.57, P = 0.01). After adjustment for the Global Registry of Acute Coronary Events (GRACE) score only the presence of anterior STD emerged as an independent predictor of the clinical endpoint (OR 2.68, 95% CI 1.38-5.20, P = 0.003). The incorporation of anterior STD into the GRACE risk score showed an important trend toward improving prediction of endpoint as assessed by c-statistic (0.72 vs. 0.67; P = 0.08). In patients with NSTE-ACS male sex, severe angina and anterior STD were associated with an increased risk of CAT lesions. Patients with anterior STD were also at increased risk of in-hospital clinical events.

Ex vivo signatures of myocardial edema by in vivo T2-CMR in a novel large animal model of NSTE-ACS

Background Non ST-segment acute coronary syndromes (NSTEACS) comprise 70% of all ACS. Difficulty in recognizing which patients have myocardium at risk contributes to heterogeneity in NSTE-ACS management, leading to poor outcomes compared to ST-elevation myocardial infarction (STEMI). To date, lack of suitable animal models has impeded progress in optimizing care. We developed a novel canine model to mimic NSTE-ACS, and evaluated ex vivo myocardial characteristics in the context of in vivo T2-CMR that may identify at-risk and salvageable regions.

PROGNOSTIC VALUE OF NT-PROBNP COMPLEMENTS THE GEACE SCORE IN PEOPLE WITH NON-ST-SEGMENT ELEVATION ACUTE CORONARY SYNDROME

ObjectivesThis study was designed to investigate whether admission N-terminal pro-brain natriuretic peptide (NT-proBNP) increase the prognostic accuracy of Global Registry of Acute Cornary Events (GRACE) risk score in the prediction...

Nurses’ role in the acute management of patients with non-ST-segment elevation acute coronary syndromes: an integrative review

People with non-ST-segment acute coronary syndrome (NSTACS) need to receive appropriate evidence-based therapies to optimise outcomes. Nurses could play an integral part in ensuring appropriate care. An integrative literature review was prepared to evaluate the role nurses undertake during the acute phase in identifying, risk stratifying and managing patients with NSTACS. It also aimed to assess what role they might play in guideline adherence for this patient group. Papers published between January 1990 and November 2011 were considered for inclusion. They were identified through four electronic databases. Articles were evaluated and data extracted by two reviewers. From 38 papers read in full, 10 were eligible for inclusion. One reported on a randomised controlled trial, four on qualitative projects and the rest on postal questionnaires or case-note data. Reviewed literature suggested that nurses in the acute setting perform five different roles in the care of people with NSTACS: educator, comforter, risk rater, data conduit and decision maker. Little research was found that addressed nurses' role in guideline adherence. Just as nurse-led or nurse-initiated thrombolysis improved care for ST-segment elevation, there is the potential for nurses to improve acute, evidence-based treatment for patients with NSTACS, especially those at higher risk. Nurses' roles in acute coronary syndrome (ACS) should include objective global risk assessment to guide early treatment decisions and incorporate the varied and rich activities identified in studies presented in the review.

Assessment of multiple cardiac biomarkers in non-ST-segment elevation acute coronary syndromes: observations from the MERLIN-TIMI 36 Trial

The aim of this study is to simultaneously evaluate the incremental prognostic value of multiple cardiac biomarkers reflecting different underlying pathophysiological processes in a well-characterized population of patients with non-ST-segment acute coronary syndrome (NSTE-ACS). We measured cardiac troponin I (cTnI), N-terminal pro B-type natriuretic peptide (NT-proBNP), C-reactive protein, and myeloperodixase (MPO) among 4352 patients with NSTE-ACS in the MERLIN-TIMI 36 (Metabolic Efficiency With Ranolazine for Less Ischaemia in Non-ST Elevation Acute Coronary-Thrombolysis In Myocardial Infarction 36) trial and followed them for a mean of 343 days. When added individually to a multivariable model adjusted for clinical characteristics, the risk of cardiovascular (CV) death rose in a stepwise fashion with increasing quartiles of each biomarker, and when using their pre-defined cut-points [HR(adj) 2.71 (P < 0.001) for cTnI ≥0.03 ng/mL; HR(adj) 3.01 (P < 0.001) for NT-proBNP ≥400 pg/mL; HR(adj) 1.45 (P = 0.019) for high-sensitivity (hs) C-reactive protein ≥15 mg/L; and HR(adj) 1.49 (P = 0.006) for MPO ≥670 pmol/L]. After including all biomarkers, only NT-proBNP and cTnI were independently associated with CV death, and only cTnI with myocardial infarction (MI). The addition of NT-proBNP to a model adjusted for TIMI risk score incorporating cTnI significantly improved both the discrimination and re-classification of the model for CV death and heart failure (HF) while there was no such improvement after the addition of either MPO or hs-C-reactive protein. In this study of over 4300 patients presenting with NSTEACS, we found that both cTnI and NT-proBNP offer prognostic information beyond that achieved with clinical risk variables for CV death, MI, and HF. Myeloperoxidase and hs-C-reactive protein, while independently associated with some adverse CV outcomes, did not provide substantial incremental prognostic information when evaluated together with cTnI and NT-proBNP.

Prognostic differences between routine invasive and conservative strategies for the management of high-risk, non-ST segment acute coronary syndromes: Experience from two consecutive periods in a single center

Background The optimal revascularization strategy for non-ST elevation acute coronary syndromes (NSTE-ACS) remains controversial, especially in a real world context. The objective of this work was to assess differences at 1 year in all-cause mortality and the composite endpoint of mortality or acute myocardial infarction (MI) between two management strategies for NSTE-ACS: a conservative strategy (CS) versus a routine invasive strategy (RIS). Methods Of 799 consecutive patients admitted to our institution, 369 were treated with CS (from January 2001 to October 2002); 430 patients admitted with the same diagnosis were treated with RIS (from November 2002 to November 2004). A propensity score (PS) matched sample was created and included 694 patients (87% of the original population). The event rate was compared between each paired member of the PS-matched sample, one receiving RIS and the other CS, and their differences were tested by Cox proportional analysis. Results No significant differences in baseline characteristics were noted between the two management cohorts. By design, the rate of in-hospital catheterization and revascularization procedures increased in RIS compared with CS. The mortality rate was lower, but not significant, in RIS (HR: 0.76, 95% CI = 0.51–1.11; p = 0.155). For the composite of death or MI, RIS showed a relative risk reduction of 29% (HR: 0.71, 95% CI = 0.53–0.94); p = 0.018) compared with CS, differences that become non-significant ( p = 0.680) if we adjust for differences in rate of revascularization procedures and changes in medication prescription. Conclusions RIS was associated with a 1-year lower risk of the combined endpoint of all-cause death and MI in patients with NSTE-ACS, attributable to changes in frequency of revascularization procedures and in medical treatment.