Outcomes Of Acute Coronary Syndrome Research Articles

Complications and outcome of acute coronary syndrome in young adult patients at a tertiary health center

Complications and outcome of acute coronary syndrome in young adult patients at a tertiary health center

Coronary artery bypass grafting in myocardial infarction and unstable angina pectoris: in-hospital outcomes. Part 2

To assess in-hospital outcomes of coronary artery bypass grafting in patients with acute coronary syndrome, depending on the presence or absence of myocardial infarction. Over the period from 2017 to 2018 within the framework of a single-centre register, the study enrolled a total of 166 consecutive patients admitted with non-ST segment elevation acute coronary syndrome and subjected to coronary artery bypass grafting. Depending on the outcome of acute coronary syndrome, the patients were divided into 2 groups: Group One included 98 (59%) patients with unstable angina pectoris and Group Two comprised 68 (41%) patients with myocardial infarction, who underwent surgery at an average of 16 (11; 20) days after manifestation of the clinical signs of myocardial infarction. The endpoints of the study were major adverse cardiovascular events during the in-hospital period: death, myocardial infarction, acute cerebral circulation impairment/transitory ischaemic attack, repeat revascularization, septic complications, multiple organ failure syndrome, wound infectious complications, requirement for repeated surgical debridement, remediastinotomy due to haemorrhage, the frequency of extracorporeal membrane oxygenation and renal replacement therapy. The mortality rate in the compared groups was similar: 3% (n=3) and 3% (n=2), respectively. Perioperative myocardial infarction occurred in 1 (1%) patient of the first group, with no cases of this complication observed in the second group. The frequency of reoperations due to haemorrhage in the early postoperative period in the group of unstable angina pectoris amounted to 3% (n=3) and was associated with administration of dual antithrombotic therapy, with no cases of this complication in the group of myocardial infarction. Wound complication in the second group were observed in 7.6% (n=5) and in the first group in 4% (n=4) (p=0.33). The differences turned out to be statistically insignificant for such postoperative complications as multiple organ failure syndrome, requirement for repeated surgical debridement, renal replacement therapy, and extracorporeal membrane oxygenation. The residual SYNTAX Score in the group of myocardial infarction amounted to 2.3±2.8, whereas in the group of unstable angina pectoris to 2.3±3, thus suggesting complete revascularization in the total sample of patients with acute coronary syndrome. The average length of hospital stay (including the postoperative period) in the first group amounted to 26.3±6.6 days and in the second group to 27.4±7.2 days (p=0.53). The postoperative bed-day in the group with unstable angina pectoris was 12.6±3.2 and in the myocardial infarction group - 14.9±5.3 (p=0.06). The obtained in-hospital outcomes suggest that coronary artery bypass grafting may be an efficient and safe method of complete revascularization for patients with non-ST-elevation acute coronary syndrome, including that resulting in myocardial infarction, performed averagely on day 16 (11; 20) after the onset of clinical manifestations of myocardial infarction.

Sex Differences in Pre-hospital Analgesia and Outcomes in Patients Presenting with Acute Coronary Syndromes

Sex-differences persist in acute coronary syndrome (ACS) presentation, management, and outcomes. The impact of sex-differences on pre-hospital pain management of ACS with opioids is unknown. This study examined if sex-differences in pre-hospital pain scores, opioid administration and clinical outcomes exist in ACS patients.

Comparative analysis of safety of carotid endarterectomy performed in acutest and acute periods of ischaemic stroke

To comparatively analyse safety of eversion carotid endarterectomy performed in the acutest (0-72 hours) and acute (4-14 days) periods of minor ischaemic stroke. Between January 2015 and December 2019, specialists of the Department of Vascular Surgery of Municipal Clinical Hospital # 7 of Kazan performed a total of 80 eversion carotid reconstructions in the period of minor ischaemic stroke within 14 days. The patients were divided into 2 groups depending on the terms of performing carotid endarterectomy. The first group comprised 32 (40.0%) patients operated on in the acutest period of ischaemic stroke, i.e., within 72 hours from the onset of first symptoms of neurological deficit. The second group included 48 (60.0%) patients subjected to carotid endarterectomy within 4 to 14 days from the onset of first signs of neurological deficit. According to the obtained findings, haemorrhagic transformation in the early postoperative period occured in 2 Group Two patients, with one lethal outcome on POD 3. Cerebral ischaemia increased in one patient of each group without enlargement of the ischaemic zone according to brain computed tomography, with residual neurological deficit in Group I in remote period (Rankin scale score 1) and complete restoration in Group II (Rankin scale score 0). Recurrent minor ischaemic stroke on POD 1 developed in Group II with formation of a new lacunar region of ischaemia of the brain in the operated carotid basin and was verified by the findings of cerebral MRI with persisting neurological deficit for 6 months (Rankin scale score 2). The comparative assessment of severity of stroke on the day of operation and at discharge, as well as that of neurological symptomatology during the 1st and 6th months of follow up in both groups proved positive. No events of acute coronary syndrome, recurrent strokes or lethal outcomes were observed during the follow-up period. According to the findings of our study, patients with acute cerebral circulation impairment caused by embologenically dangerous lesions of internal carotid arteries should be operated on within the first 72 hours, if there are no accompanying changes requiring time for correction thereof.

The relationship between microvascular angina and De Ritis ratio in normal coronary artery patients with recurrent chest pain / De Ritis ratio and microvascular angina

Objective: De Ritis ratio (AST/ALT) is a strong predictor of outcomes in both heart failure and acute coronary syndromes. The usability of this parameter in patients with normal coronary arteries who had repeated application to health institutions due to chest pain has not been evaluated before. In this paper we aimed to investigate if De Ritis ratio may be used as a guiding in this group of patients.
 Methods: This retrospective study included 545 patients with normal coronary arteries according to the coronary angiographies performed in our clinic between January 2018 and June 2019. They were grouped into two according to hospital admittance with chest pain after angiography; group 1: no application, group 2: repeated application. At least 8 hours of fasting venous samples were collected for routine laboratory tests.
 Results: 545 patients with a mean age of 52.3 ± 11.2 (41.1%male) were included in the study. 16.5% of them had repeated applications with chest pain. Mean De Ritis ratio and CRP levels were different between the groups (p=0.028 and 0.045, respectively). In multivariate logistic regression analysis, De Ritis ratio was the only parameter that predicted repeated application with an Odds ratio (OR) = 3.062 ,95% CI= 1.267- 7.400 and p=0.013).
 Conclusion: Elevated De Ritis ratio and CRP conclude us that there may be microvascular coronary disease in this group of patients. The repeated application with chest pain, although normal coronary artery was obtained, should be taken into consideration and it should be kept in mind that additional tests may be required to rule out microvascular coronary disease.

Value of troponin T in assessment of the cardiopulmonary relationships in the patients with underlying chronic obstructive pulmonary disease hospitalized with acute coronary syndrome

The analysis of troponin T (TnT) blood levels in the patients with acute coronary syndrome (ACS) and the underlying chronic obstructive pulmonary disease (COPD) is relevant to assessment of the cardiovascular prognosis and the risk of respiratory complications. The aim of the study was to investigate TnT levels in the patients hospitalized with ACS and underlying COPD in order to analyze the cardiopulmonary relationships. Methods. 52 patients (29 men and 23 women) were divided into 2 groups depending on outcomes of ACS: the 1st group - 30 patients (57.7%) with acute myocardial infarction (AMI); the 2nd group - 22 patients (42.3%) without AMI. The acute exacerbation of COPD (AECOPD) was found in 33 patients (63.5%) upon admission to the hospital, and 19 patients (36.5%) did not have AECOPD. All patients underwent spirometry, the assessment of symptoms severity by COPD Assessment Test (CAT test) and the analyses for the level of TnT and oxygen saturation. Results. AECOPD was found upon admission in the 1st group more often than in the 2nd group: 76.7% vs 45.5% (p = 0.022). The patients with AECOPD had significantly higher levels of TnT than patients without AECOPD in both groups: 0.78 ± 0.17 and 0.59 ± 0.14 ng/mL respectively (p = 0.014) in the 1st group vs 0.19 ± 0.08 and 0.11 ± 0.04 ng/mL respectively (p = 0.002) in the 2nd group. In the 2nd group, 8 patients (80.0%) with AECOPD and 4 patients (33.3%) without AECOPD had levels of TnT in the range of «a myocardial necrosis» (p = 0.029) in the absence of AMI. The inverse correlation between levels of TnT and forced expiratory volume in 1 second (FEV1) was also found (R = 0.376; p = 0.009). Conclusion. Thus, the significantly increased levels of TnT in patients with ACS are associated with AECOPD upon admission, development of AMI and deterioration of the indexes of spirometry. It was shown that blood levels of TnT were significantly higher in the patients with AECOPD than in the patients with stable COPD in absence of AMI.

Effect of Obstructive Sleep Apnea and CPAP Treatment on Cardiovascular Outcomes in Acute Coronary Syndrome in the RICCADSA Trial.

We aimed to address the impact of OSA and its treatment with continuous positive airway pressure (CPAP) on major adverse cardiovascular and cerebrovascular events (MACCE) in patients with acute coronary syndrome (ACS). In this current analysis of the revascularized ACS subgroup (n = 353) of the Randomized Intervention with CPAP in Coronary Artery Disease and Obstructive Sleep Apnea (RICCADSA) trial (Trial Registry: ClinicalTrials.gov; No: NCT 00519597), participants with non-sleepy OSA (apnea-hypopnea-index [AHI] ≥ 15 events/h on a home sleep apnea testing, and Epworth Sleepiness Scale [ESS] score < 10; n = 171) were randomized to CPAP (n = 86) or no-CPAP (n = 85). The sleepy OSA patients (AHI ≥ 15 events/h and ESS ≥ 10) who were offered CPAP, and the ones with no-OSA (AHI < 5 events/h) were included in the observational arm. A post-hoc analysis was done to compare untreated OSA (no-CPAP; n = 78) and nonadherent sleepy/non-sleepy OSA (n = 96) with the reference group without OSA (n = 81). The primary endpoint (the first event of repeat revascularization, myocardial infarction, stroke or cardiovascular mortality) during a median 4.7-year follow-up was evaluated in time-dependent Cox proportional hazards models adjusted for confounding factors. The incidence of MACCE did not differ significantly in intention-to-treat population. On-treatment analysis showed a significant risk reduction in those who used CPAP for ≥4 vs. <4 h/day or did not receive treatment (adjusted hazard ratio [HR] 0.17; 95% confidence interval [CI] 0.03–0.81; p = 0.03). Compared with the reference group, nonadherent/untreated OSA was associated with an increased cardiovascular risk (adjusted HR 1.97, 95% CI 1.03–3.77; p = 0.04). We conclude that OSA is an independent risk factor for adverse cardiovascular outcomes in patients with ACS. CPAP treatment may reduce this risk, if the device is used at least 4 h/day.

Clinical profile, anatomical features and long-term outcome of acute coronary syndromes in human immunodeficiency virus-infected patients.

Long-term prognosis of acute coronary syndromes (ACS) in human immunodeficiency virus (HIV)-infected patients is unknown. To compare outcomes after ACS in HIV-infected and uninfected patients. Retrospective observational study. HIV cases were matched with two HIV-uninfected controls for age, sex and type of ACS. In 92 HIV patients (mean age 51.3 ± 9.0 years, 7.6% women), the prevalence of cardiovascular risk factors was high (smoking 71.7%; hypertension 41.3%; diabetes 14.1%); dyslipidaemia was more frequent (53 (57.6%) vs 79 (42.9%), P = 0.02) and obesity less common (8 (8.7%) vs 41 (22.3%), P = 0.002) than in controls. Eighty-seven (94.6%) HIV patients had undetectable viral load and 85 (92.4%) were under anti-retroviral therapy. Multivessel disease was more common in HIV patients than in controls (44 (47.8%) vs 71 (39.1%); P = 0.05) as was Killip class 3-4 on admission (9 (9.8%) vs 6 (3.3%); P = 0.04). The rate of in-hospital mortality was similar in both groups (2%), and there were no significant differences in 3-year mortality (10.2% vs 5.7%; P = 0.27). Non-cardiovascular readmissions at 3 years were more frequent in HIV patients than in controls (36.5% vs 7.4%; P < 0.001). Multivariate analysis identified previous coronary artery disease as the strongest predictor of mortality in HIV patients (hazard ratio 4.7, 95% confidence interval 1.4-15.7, P = 0.01), whereas HIV infection was not associated with prognosis. HIV patients with ACS had more frequent multivessel disease and heart failure than matched controls. However, in-hospital and long-term mortality was similar in both groups. Non-cardiovascular re-hospitalisations were more common in HIV patients.

The Rise of Transradial Artery Access for Percutaneous Coronary Intervention in Patients with Acute Coronary Syndromes in Australia.

Objectives The aim of this study was to evaluate the outcomes of acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) via transradial artery access (TRA) or transfemoral artery access (TFA). Background Over the last decade, evidence for the benefit of TRA for PCI has grown, leading to a steady uptake of TRA around the world. Despite this, the topic remains controversial with contrary evidence to suggest no significant benefit over TFA. Methods A retrospective study of consecutive ACS patients from 2011 to 2017 who underwent PCI via TRA or TFA. The primary outcome was Major Adverse Cardiovascular Events (MACE), a composite of death, myocardial infarction (MI), target lesion revascularisation (TLR), or coronary artery bypass graft surgery (CABG) at 12 months. Secondary outcomes included Bleeding Academic Research Consortium (BARC) bleeding events scored 2 or higher, haematoma formation, and stent thrombosis, in addition to all individual components of MACE. Results We treated 3624 patients (77% male), with PCI via TFA (n = 2391) or TRA (n = 1233). Transradial artery access was associated with a reduction in mortality (3% vs 6.3%; p < 0.0001), MI (1.8% vs 3.9%; p=0.0004), CABG (0.6% vs 1.5%; p=0.0205), TLR (1% vs 2.9%; p < 0.0001), large haematoma (0.4% vs 1.8%; p=0.0003), BARC 2 (0.2% vs 1.1%; p=0.0029), and BARC 3 events (0.4% vs 1.0%; p=0.0426). On multivariate Cox regression analysis, TFA, age ≥ 75, prior PCI, use of bare metal stents, cardiogenic shock, cardiac arrest, and multivessel coronary artery disease were associated with an increased risk of MACE. Conclusion Despite the limitations secondary to the observational nature of our study and multiple confounders, our results are in line with results of major trials and, as such, we feel that our results support the use of TRA as the preferred access site in patients undergoing PCI for ACS to improve patient outcomes.

Longitudinal management and outcomes of acute coronary syndrome in persons living with HIV infection.

Persons living with HIV (PLWH) have increased cardiovascular mortality, which may in part be due to differences in the management of acute coronary syndromes (ACS). The purpose of this study was to compare the in-hospital and post-discharge management and outcomes of ACS among persons with and without HIV. This was a retrospective cohort study using data from Symphony Health, a data warehouse. All patients admitted between 1 January 2014 and 31 December 2016 with ACS were identified by International Classification of Diseases billing codes. Multivariate logistic regression models were used to examine in-hospital, 30-day and 12-month event rates between groups. A total of 1 125 126 individuals were included, 6612 (0.59%) with HIV. Persons living with HIV were younger (57.4 ± 10.5 vs. 67.4 ± 12.9 years, P< 0.0001) and had more medical comorbidities. Acute coronary syndrome type did not differ significantly with HIV status. Persons living with HIV were less likely to undergo coronary angiography (35.2% vs. 37.2%, adjusted OR 0.87, 95% CI 0.83-0.92, P < 0.0001), and those with both HIV and STEMI underwent fewer drug-eluting stents (60.1% vs. 68.5%, adjusted OR 0.81, 95% CI 0.68-0.96, P = 0.016). Persons living with HIV had higher adjusted rates of inpatient mortality (OR 1.29, 95% CI 1.15-1.44; P < 0.0001), 30-day readmission (OR 1.18, 95% CI 1.09-1.27; P < 0.0001) and 12-month mortality (OR 1.32, 95% CI 1.22-1.44; P < 0.0001). Twelve months following discharge, PLWH filled cardiac medications at lower rates. In a contemporary cohort of persons hospitalized for ACS, PLWH received less guideline-supported interventional and medical therapies and had worse clinical outcomes. Strategies to optimize care are warranted in this unique population.

Abstract 13808: Implementation of Cardiopulmonary Exercise Testing and Its Impact on 2-year Outcomes in Acute Coronary Syndrome From Mie ACS Registry

Introduction: Cardiopulmonary exercise testing (CPET) determines intensity for exercise rehabilitation which may improve outcomes in patients with acute coronary syndrome (ACS). However, it is unclear how many patients are given exercise education based on CPET around hospital discharge. Purposes: To assess the implementation of CPET and to evaluate the impacts of clinical parameters including CPET variables on 2-year outcomes in ACS patients. Methods: We enrolled 3146 ACS patients without hemodialysis (age, 68±12 yrs; 78% male) 30 days after onset using data from Mie ACS registry, a prospective and multicenter registry, between 2013 and 2017. We compared clinical characteristics in patients with and without CPET at hospital discharge. Prognostic factors including CPET variables during the 2-year follow-up were determined. Results: Forty percent of the hospitals had CPET equipment. Out of 3146, 431 patients (12%) underwent CPET and were given CPET-based exercise education. Implementation of CPET was associated with younger age, male, ST-elevation myocardial infraction, and higher peak creatine phosphokinase (p≤0.03). While, hospitalization length &lt;7 days or &gt;21 days was inversely associated with CPET. During the 2-year follow-up, 198 all-cause deaths (6%) and 103 heart failure (HF) hospitalization were observed. Multivariate Cox regression analysis demonstrated that age, male, hospitalization length &gt;21 days, Killip ≥2, mechanical circulatory and/or ventilator support were positive predictors of all-cause death. While, CPET around hospital discharge (hazard ratio, 0.52; 95%CI, 0.27-0.99, p&lt;0.05) and hemoglobin level were independent negative predictors of all-cause death. Although patients with CPET tended to have greater myocardial damage, they did not have increased rate of HF hospitalization or major adverse cardiovascular events (MACE). When analyzed only in patients with CPET, peak oxygen uptake was the only independent predictor for all-cause death. Conslusions: The number of patients who underwent CPET at discharge was small in our registry. Although the rate of HF hospitalization and MACE were similar in patients with and without CPET, CPET and CPET-based exercise education did reduce all-cause mortality in ACS patients.

Abstract 13347: Effect of Severe Anemia (hemoglobin &lt; 10g/dl) on Short- and Long-term Outcome in Acute Coronary Syndrome: Insights of a Terciary Centre

Introduction: Although invasive strategies are the generalized approach in the management of ACS pts, their benefits in pts with significant anemia are unclear, as anemia is strongly associated with increased risk of morbidity and mortality. Aim: To determine the incidence and the impact of severe anemia (hemoglobin&lt;10g/dL) on short- and long-term outcome in pts hospitalized with ACS. Methods: We analyzed retrospectively 2905 ACSpts admitted for 6 years in our CCU. Pts were divided into two groups: group 1-pts with severe anemia(hemoglobin &lt; 10g/dL) (n=257,8.8%); group 2-pts without severe anemia (hemoglobin &gt;=10g/dL) (n=2648,91.2%). Primary endpoint was the occurrence of a composite of death and adverse cardiovascular events (stroke, reinfarction, and rehospitalization of cardiovascular etiology) at 6 months; FU was completed in 96%pts. Results: The sample consisted in 77.9% men and 22.1% women, with mean age of 64±13 years. The incidence of severe anemia was 8.8%. Group1 pts were older (p&lt;0.001), had a higher proportion of women (p&lt;0.001), diabetes (p&lt;0.001), CKD (p&lt;0.001) and AF (p&lt;0.001). During hospitalization, group 1 had more HF (p&lt;0.001), angor (p&lt;0.001), refarction (p=0.006), bleeding (p&lt;0.001) and transfusion (p&lt;0.001). Group 1 had a higher proportion of NSTEMI (p=0.009) as opposed to group2 which had more STEMI (p=0.031). During hospitalization, group 2 pts were more likely to undergo revascularization (p&lt;0.001). A multivariate analysis identified age [OR 1.06, 95%CI 1.04 to 1.07; p&lt;0.001] and feminine sex [OR 2.61, 95%CI 1.89 to 3.61; p&lt;0.001] as independent predictors of severe anemia during hospitalization. Pts with severe anemia had higher 6-month mortality (32.1%vs6.9%;p&lt;0.001). In multivariate analysis and after adjusting for different baseline characteristics, pts with severe anemia had higher occurrence of a composite of death and MACE at 6months [OR5.04,95%CI 1.21 to 21.04;p=0.026]. Conclusion: Severe anemia was strongly associated with increased risk of morbidity and mortality in ACS pts. However, pts with severe anemia who were double antiaggregated had no worse outcomes than those who had simple antiaggregation after 6months. Therefore, there was no significant difference regarding revascularization in these pts.

Abstract 16660: Gender Disparities in the Presentation, Management and Outcomes of Patients With Acute Coronary Syndrome: Insights From the Acute Coronary Syndrome Quality Improvement in Kerala (ACS QUIK) Trial

Introduction: Despite the increasing interest in sex differences in acute coronary syndrome (ACS) presentation, management, and outcomes in high-income countries, reports on such differences from low- and middle-income countries (LMICs) are limited. Limited resources in LMICs may worsen health disparities experienced by women and vulnerable populations. Methods: Using ACS QUIK trial database, we examined sex-differences in terms of baseline characteristics, management received, and relevant clinical outcomes of 21,374 patients presenting with ACS. The main outcomes were the rates of in-hospital and 30-day composite of death, reinfarction, stroke, and major bleeding. We fitted log Poisson multivariate random effects models to obtain the relative risks comparing females to males. We used random intercepts for different hospitals and centers as the clustering variable. Effect measure modification by baseline variables was examined by restricting the analysis to each category and comparing the effect estimates for females to males. Results: A total of 5,191 (24.3%) patients were women. Compared to men, women presenting with ACS were older (65±12 vs 58±12 years; p &lt; 0.001), more likely to have hypertension (61.2% vs 42.4%; p &lt; 0.001), and diabetes mellitus (53.5% vs 41.4%; p &lt; 0.001). After symptom onset, women tended to present later to the hospital (medians, 300 vs 238 mins; p &lt; 0.001) and had higher Killip class on presentation (17.8% vs 12.3%; p &lt; 0.001). Women presenting with STEMI were less likely to receive primary PCI (45.9% vs 49.8% of men, p &lt;0.001) and had longer median door-to-balloon times (medians, 90 vs 80 mins for men; p &lt;0.001). Compared to men, women were 53% more likely to experience in-hospital MACE (adjusted RR = 1.53; 95% CI, 1.32-1.77; p&lt;0.001), and 39% higher risk of 30-day MACE (adjusted RR = 1.39; 95% CI, 1.65-2.07, p &lt;0.001). Conclusion: In summary, our study confirms a higher CVD risk profile, delayed presentation, suboptimal medical care in women presenting with ACS in Kerala, India. Women were also found to have higher in-hospital and 30-day MACE, even after adjustment for potential confounders.

Body mass index and cardiovascular outcomes in patients with acute coronary syndrome by diabetes status: the obesity paradox in a Korean national cohort study

BackgroundThe “obesity paradox” has not been elucidated in the long-term outcomes of acute coronary syndrome (ACS). We investigated the association between obesity and cardiovascular (CV) outcomes in ACS patients with and without diabetes.MethodsWe identified 6978 patients with ACS aged 40–79 years from the Korean National Health Insurance Service-Health Screening Cohort between 2002 and 2015. Baseline body mass index (BMI) was categorized as underweight (< 18.5 kg/m2), normal weight (18.5–22.9 kg/m2), overweight (23.0–24.9 kg/m2), obese class I (25.0–29.9 kg/m2), and obese class II (≥ 30.0 kg/m2). The primary outcome was major adverse CV events (MACE)—CV death, myocardial infarction (MI), and stroke. The secondary outcomes were the individual components of MACE, hospitalization for heart failure (HHF), and all-cause death.ResultsAfter adjustment for confounding variables, compared to normal-weight patients without diabetes (reference group), obese class I patients with and without diabetes had a lower risk of MACE, but only significant in patients without diabetes (with diabetes: hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.78–1.14; without diabetes: HR 0.78, 95% CI 0.62–0.97). Obese class II patient with diabetes had a higher risk of MACE with no statistical significance (HR 1.14, 95% CI 0.82–1.59). Underweight patients with and without diabetes had a higher risk of MACE, but only significant in patients with diabetes (with diabetes: HR 1.79, 95% CI 1.24–2.58; without diabetes: HR 1.23, 95% CI 0.77–1.97).ConclusionIn ACS patients, obesity had a protective effect on CV outcomes, especially in patients without diabetes.

Acute Coronary Syndrome in Patients with Thrombotic Thrombocytopenic Purpura

Introduction: Thrombotic thrombocytopenic purpura (TTP) is a life-threatening clinical syndrome characterized by microangiopathy and a variable degree of end-organ ischemic damage. Cardiac involvement has been recognized as a major cause of mortality in these patients (Patschan et al, Nephrol Dial Transplant, 2006; Benhamou et al, J Thromb. Haemost, 2015). In this study, we aim to investigate clinical predictors and outcomes of acute coronary syndrome in the setting of TTP admissions. Methods: The National Inpatient Sample (NIS) was queried for all hospitalizations with a primary diagnosis of thrombotic microangiopathy (ICD- 9-CM code 4466 and ICD-10-CM code M3.11) from 2002 to 2017. Using ICD-9-CM procedure codes (9972), (9971), and (9979), as well as ICD-10-CM procedure codes (6A551Z3) and (6A550Z3) we identified patients who received plasma exchange (PLEX) during the same admission. Due to the wide spectrum of thrombotic microangiopathy diseases, we decided to include only those who received PLEX to get a more specific subpopulation who were presumed to have TTP. We stratified patients based on whether or not they had acute coronary syndrome (ACS) during the admission, defined as presence of any ICD code for either ST-segment elevation myocardial infarction (STEMI), Non-STEMI, or unstable angina. Baseline characteristics and inpatient outcomes were compared between groups. Statistical analysis was performed using SPSS v26 (IBM Corp, Armonk, NY, USA). The odds ratio (OR) and 95% confidence interval (CI) were calculated using the Cochran-Mantel-Haenszel test. A multivariate regression model was deployed to assess predictors of inpatient mortality. Complex weights were used throughout all calculations, enabling appropriate national projections. Results: A total of 15,640 patients with the diagnosis of thrombotic microangiopathy were identified during the studied period. Of those, 6,214 patients had received PLEX treatment during their admission (39.7%). The annual admission rate for TTP was ranging between 5-7/100,000 admissions. Patients had a mean age of 47.8 years; 67% were females, and 46.5% were Caucasian. Stratifying by geographic region, 24% were from the Northeast, 21% from the Midwest, 42% from the South, and 13% from the West. The most common primary payer was private insurance (42.7%). Overall inpatient mortality was 9.1%. The most common complications reported included acute kidney injury (42.5%), followed by acute respiratory failure (14.9%), incident dialysis (14.3%), acute encephalopathy (7.7%), acute heart failure (7.3%), acute cerebrovascular accident (7.2%), and acute coronary syndrome (6.3%). ACS was documented in 6.7% of patients. Compared with patients without ACS, those with ACS were relatively older and had a relatively higher prevalence of coronary artery disease, dyslipidemia, diabetes mellitus, essential hypertension, chronic kidney disease, and heart failure. Patients with ACS had a 3-fold higher in-hospital mortality and a longer mean hospital stay (19 days vs. 15 days, P&amp;lt;0.001). Using stepwise logistic regression, we identified age (aOR 1.03; 95% CI, 1.02 - 1.03; P &amp;lt;0.001), history of heart failure (aOR 2.02; 95% CI, 1.53-2.67; P &amp;lt;0.001), and history of coronary artery disease (aOR 2.69; 95% CI, 2.03 - 3.57; P &amp;lt;0.001) as independent predictors of ACS among patients hospitalized with TTP. On another regression analysis, certain complications were more prevalent in the ACS group including acute cerebrovascular accidents, acute heart failure, acute kidney injury, cardiogenic shock, and respiratory failure. Conclusion: Despite wider utilization of therapeutic plasmapheresis and improved supportive treatments for patients with TTP, associated morbidity and mortality remain significant. We demonstrate from this large retrospective cohort that ACS is an independent predictor of higher morbidity and mortality in TTP patients. We identified older age, history of heart failure, and history of coronary artery disease as independent predictors of ACS among patients admitted with TTP. Further studies are warranted to develop risk stratification models for patients with TTP. Figure Disclosures Anwer: Incyte, Seattle Genetics, Acetylon Pharmaceuticals, AbbVie Pharma, Astellas Pharma, Celegene, Millennium Pharmaceuticals.: Honoraria, Research Funding, Speakers Bureau.

Post-procedural high platelet reactivity with prasugrel loading predicts in-hospital adverse events in ACS patients

Abstract Background/Introduction High platelet reactivity (HPR) is associated with adverse cardiovascular events, primarily intrastent thrombosis, after a percutaneous coronary intervention (PCI). However, the relationship between hyperacute postprocedural HPR with prasugrel loading and clinical outcomes in acute coronary syndrome (ACS) remains unclear. Moreover, factors contributing to HPR in ACS with prasugrel loading are also unknown. Purpose To assess the effects of post-procedural HPR with prasugrel loading on clinical outcomes in ACS during hospitalization, and to define the appropriate cut-off values and identify factors contributing to HPR. Methods A single-center, retrospective observational study that enrolled 154 patients who underwent emergent PCI for ACS with prasugrel loading was performed. The P2Y12 reaction unit (PRU) value was measured immediately after PCI using the VerifyNowR system. The primary end-point was major adverse cardiac events (MACE, defined as the composite of death, myocardial infarction, stroke, heart failure, ventricular arrhythmia needing defibrillation). Results The mean patient age (standard deviation) was 70.7 (±12.5) years, 76.6% were men, and the average time from the prasugrel intake to PRU calculation was 103.2 (±48.5) min. During the mean hospital stay of 15.6 (±8.5) days, 24 in-hospital MACE (15.5%) and 8 deaths (5.2%) occurred. Thrombosis events, including myocardial infarction recurrence, did not occur (only one case of spontaneous coronary artery dissection was considered as myocardial infarction recurrence). PRU was significantly higher in the MACE group than that in Non-MACE group (287±55 and 232±64, respectively, p&amp;lt;0.001). The ROC curve analysis of PRU for discriminating the significant in-hospital MACE showed the cut-off value of 293 (sensitivity: 62.5%, specificity: 83.1% [AUC=0.756, p&amp;lt;0.0001]). A total of 37 patients (24%) were thus categorized as HPR (PRU&amp;gt;293) immediately after the emergent PCI. Kaplan-Meier curve showing MACE events occurred in the HPR group than that in the non-HPR group (40.5% vs 7.6%, p&amp;lt;0.001). Multiple cox analysis demonstrated that HPR was independent predictors of MACE in patients with ACS who underwent PCI (OR 11.01, 95% CI 2.39–20.2, p&amp;lt;0.0001). Multiple logistic regression model showed old age, female sex, low systolic blood pressure, short prasugrel intake to measure time, and large acute gain were independent predictors of HPR. Conclusion PRU was significantly higher in the MACE group, with an appropriate cut-off value of HPR of 293 in this study. HPR was an independent predictor of MACE during hospitalization; however, thrombosis events were not significant. HPR predictors were old age, female sex, low systolic blood pressure, short prasugrel intake to measure time, and large acute gain. This study shows the post-procedural HPR with prasugrel loading in patients with ACS can be a useful predictive marker of adverse events during hospitalization. Funding Acknowledgement Type of funding source: None

Heart-type fatty acid binding protein predicts cardiovascular events in patients with stable coronary artery disease: a prospective cohort study.

BackgroundHeart-type fatty acid binding protein (H-FABP) has been reported to be a prognostic predictor for cardiovascular outcome in acute coronary syndrome (ACS). However, its prognostic utility in patients with stable coronary artery disease (CAD) has not been well established. The aim of this study was to assess the association between H-FABP with the severity of coronary disease and cardiovascular events (CVEs) in patients with stable CAD.MethodsA total of 4,370 angiography-proven CAD patients were consecutively enrolled. The severity of CAD was assessed by Gensini Score (GS) and the numbers of diseased vessels. The CVEs included cardiovascular death, myocardial infarction, stroke and coronary revascularization. Cox regression analysis with adjusted hazard ratios (HRs) and Kaplan-Meier analysis were used to evaluate the relation of H-FABP to CVEs in this cohort.ResultsDuring a median follow-up of 51 months, 353 CVEs occurred. Overall, patients in the highest levels of H-FABP group had increased rate of multi-vessel stenosis and higher GS compared with those in the lowest group (P<0.05, respectively). Moreover, H-FABP levels were significantly higher in patients with events compared to those without (P<0.001). In Cox regression analysis, elevated H-FABP levels were found to be independently associated with a high risk of CVEs [adjusted HRs: 1.453; 95% confidence intervals (CIs): 1.040–2.029, P=0.028], especially with cardiovascular death (adjusted HRs: 2.865; 95% CI: 1.315–6.243, P=0.008).ConclusionsOur results demonstrated that H-FABP was also a useful predictor for CVEs in patients with stable CAD, which needed to be verified by further studies.

Trends and outcomes of acute coronary syndrome (ACS) in COVID-19 pandemic: Experience from a tertiary care centre introduction

Trends and outcomes of acute coronary syndrome (ACS) in COVID-19 pandemic: Experience from a tertiary care centre introduction

Risk factors and clinical outcomes of acute coronary syndrome in men: A retrospective study

Risk factors and clinical outcomes of acute coronary syndrome in men: A retrospective study

Global longitudinal strain and chronic kidney disease prognostic impact on acute coronary syndrome

Abstract Background Impaired left ventricular ejection fraction (LVEF) and chronic kidney disease (CKD) have been associated with poorer outcomes in acute coronary syndrome (ACS). Increasing evidence on global left ventricular longitudinal strain (GLS) suggests superiority over left ventricular ejection fraction (LVEF) in risk stratification. Methods This study was based on a retrospective analysis of consecutive patients admitted to a Coronary Care Unit between 2009 and 2016. Baseline characteristics and echocardiographic parameters, including LVEF, were assessed. For each patient, a two-dimensional speckle tracking of the left ventricle was assessed and average GLS was calculated using 2, 3 and 4-chamber views. Blood creatinine was measured during hospital stay and used to estimate glomerular filtration rate (GFR) with Modification of Diet in Renal Disease (MDRD) equation. A cox regression analysis was performed to determine mortality prediction value of average GLS, LVEF and GFR in this population. Receiver operating characteristic (ROC) curve analysis was conducted and area under the curve (AUC) was estimated. Results A total of 85 patients (66.7±12.7 years old; 78.8% males) were enrolled. LVEF mean was 49.4±9.8% and average GLS was −16.0±4.0%. GFR median was 80.0±48.9 ml/min/1.73m2. In cox regression analysis, worse average GLS was associated with greater mortality (HR 0.721; 95% CI 0.599–0.867; P=0.001). GFR was inversely related to death (HR 0.967; 95% CI 0.944–0.991, P=0.008). In cox regression analysis using average GLS and GFR as covariates, both proved to be independent predictors of mortality (for average GLS, HR 0.748; 95% CI 0.610–0.918, P=0.005; for GFR, HR 0.974; 95% CI 0.949–0.999; P=0.044). The AUC of average GLS to predict mortality was 0.78 (P&amp;lt;0.001, sensitivity 50.7% and specificity 100%) and for average GLS and GFR combined was 0.85 (P&amp;lt;0.001, sensitivity 84.0% and specificity 77.8%). Although LVEF proved to be a mortality predictor, the AUC obtained by ROC curve analysis was inferior to average GLS, with statistical significance (P=0.043). Conclusions GLS and CKD proved to be independent predictors of mortality in ACS patients. GLS showed superiority when compared to LVEF in risk stratification and in the future it might replace LVEF. The model combining GLS and GFR emphasized the increased risk of CKD patients and how they should be seen as high-risk patients. ROC curve analysis Funding Acknowledgement Type of funding source: None