Setting Of Acute Coronary Syndrome Research Articles

Diabetes and multivessel disease: coronary artery bypass grafting remains king.

Review the recently published scientific evidence to support the decision-making process of revascularization strategy in patients with diabetes mellitus (DM) and multivessel coronary artery disease (MVD). Recently published observational analyses have proven the superiority of coronary artery bypass grafting (CABG) in patients presenting with other comorbidities together with DM, such as renal disease or heart failure. Significant challenges and controversies surrounded the choice of the appropriate revascularization method in patients with DM and MVD over the last decades. FREEDOM trial was the first adequately powered randomized study to directly compare percutaneous coronary intervention (PCI) versus CABG in the DM population, showing the superiority of CABG in the long-term follow-up. Subsequently, other studies confirmed that CABG is also preferable over PCI in diabetic patients with particular comorbidities, such as renal failure and left ventricular dysfunction, and also in patients with type 1 DM and in the setting of an early acute coronary syndrome. Finally, in 2018, an individual level data meta-analysis reported an expressive reduction in all-cause mortality when comparing CABG versus PCI in patients with DM and MVD enrolled in the most recent clinical trials (hazard ratio 1.44, 95% confidence interval 1.20-1.74, P = 0.0001).

The Role of Direct Oral Anticoagulants in Patients With Coronary Artery Disease.

Despite contemporary management, patients with coronary artery disease (CAD) remain at high risk for thrombotic events. Several randomized controlled trials have evaluated the use of direct oral anticoagulants (DOACs) in patients with CAD, including in the setting of acute coronary syndrome (ACS) and stable CAD, and in patients with concomitant atrial fibrillation. Trials of apixaban and dabigatran in patients with ACS demonstrate no benefit with an increased risk of bleeding. Conversely, rivaroxaban at a reduced dose of 2.5 mg twice daily reduced thrombotic events and all-cause mortality when added to dual antiplatelet therapy in patients with ACS. Similarly, the addition of low-dose rivaroxaban to acetylsalicylic acid reduced the risk of thrombotic events in patients with stable CAD. However, the addition of a DOAC to antiplatelet therapy increased the risk of major bleeding. In patients with atrial fibrillation undergoing percutaneous coronary intervention, dual-pathway or low-dose triple therapy regimens including dabigatran or rivaroxaban reduced bleeding risk compared to traditional warfarin-based triple therapy, although it remains unclear whether these regimens preserve antithrombotic efficacy. DOAC-based antithrombotic regimens prove useful in patients with CAD in various settings; however, careful selection of patients and regimens per trial protocols are critical to achieving net benefit.

Clinical impact of mineralocorticoid receptor antagonists treatment after acute coronary syndrome in the real world: A propensity score matching analysis.

Recent studies suggest that the benefit of mineralocorticoid receptor antagonists in the acute coronary syndrome setting is controversial. The aim of this study was to examine the current long-term prognostic benefit of mineralocorticoid receptor antagonists in patients with acute coronary syndrome. We conducted a retrospective cohort study of 8318 consecutive acute coronary syndrome patients. Baseline patient characteristics were examined and a follow-up period was established for registry of death, major cardiovascular adverse events and heart failure re-hospitalization. We performed a propensity-matching analysis to draw up two groups of patients paired according to whether or not they had been treated with mineralocorticoid receptor antagonists. The prognostic value of mineralocorticoid receptor antagonists to predict events during follow-up was analysed using Cox regression. Among the study participants, only 524 patients (6.3%) were discharged on mineralocorticoid receptor antagonists. Patients on mineralocorticoid receptor antagonists had a different clinical and pharmacological profile. These differences disappeared after the propensity score analysis. The median follow-up was 40.7 months. After the propensity score analysis, the cardiovascular mortality and heart failure readmission rates were similar between patients who were discharged on mineralocorticoid receptor antagonists and those whose not. The use of mineralocorticoid receptor antagonists was only associated with a reduction in major cardiovascular adverse events (hazard ratio=0.83, 95% confidence interval 0.69-0.97, p=0.001). Our results do not corroborate the long-term benefit of mineralocorticoid receptor antagonists to improve survival after acute coronary syndrome in a large cohort of patients with heart failure or reduced left ventricular ejection fraction and diabetes. Their prescription was associated with a significantly lower incidence of major cardiovascular adverse events during the long-term follow-up without effect on heart failure development.

D-Dimer Levels and Effect of Rivaroxaban on Those Levels and Outcomes in Patients With Acute Coronary Syndrome (An ATLAS ACS-TIMI 46 Trial Substudy)

D-dimer has been used as both a diagnostic and prognostic biomarker in the assessment of patients with venous thromboembolism, but its prognostic value in the setting of arterial acute coronary syndromes (ACS) and the ability of pharmacotherapy to reduce D-dimer in ACS is less well characterized. It was hypothesized that elevated baseline D-dimer would be associated with poor clinical outcomes in ACS, and that Factor Xa inhibition with Rivaroxaban would reduce D-dimer acutely and chronically. The ATLAS ACS TIMI-46 trial assessed the safety and efficacy of rivaroxaban compared with placebo in ACS patients. A subset of subjects had a D-dimer measured at baseline (n = 1,834, 52.5%). A univariate and multivariable logistic regression assessed the relation between baseline D-dimer and a composite end point of cardiovascular death, myocardial infarction, or stroke through 6 months. The Wilcoxon rank sum test was used to compare change in D-dimer level between the treatment groups from baseline. Baseline D-dimer was associated with the composite efficacy outcome in a univariate logistic regression (odds ratio 1.15, 95% confidence interval 1.03 to 1.29, p = 0.015) and a multivariable logistic regression (odds ratio 1.13, 95% confidence interval 1.00 to 1.28, p = 0.048). Rivaroxaban administration lowered D-dimer levels compared wth placebo after administration of the first dose of study drug (p = 0.026), at day 30 (p < 0.001) and day 180 (p < 0.001). In conclusion, elevated baseline D-dimer was associated with an increased risk of the composite outcome within 6 months of the ACS event and administration of the Factor Xa inhibitor rivaroxaban was associated with lower D-dimer levels compared with placebo after the first dose, at day 30 and day 180.

P5673The different role of the advanced glycation end products axis in heart failure and in acute coronary syndrome settings

P5673The different role of the advanced glycation end products axis in heart failure and in acute coronary syndrome settings

Ticagrelor for the prevention of ischemic events in patients with prior myocardial infarction and peripheral artery disease

ABSTRACTIntroduction: Cardiovascular disease (CVD) is the main cause of death in the world. Coronary artery disease (CAD) is the most common form of CVD presentation, but the prevalence of peripheral artery disease (PAD) is increasing. Patients with polyvascular disease comprise a very high-risk population that has been infrequently studied.Areas covered: The authors review the current evidence of the efficacy and safety of ticagrelor in the setting of acute coronary syndrome and stable patients post-MI with and without PAD and summarize its pharmacokinetics, pharmacodynamics, and regulatory issues.Expert opinion: Randomized studies showed that ticagrelor is superior to clopidogrel in patients with acute coronary syndromes, and is superior to placebo in the chronic phase (>1 year) post-myocardial infarction. Sub-analyses of these studies suggest that patients with myocardial infarction and PAD, compared to patients without these characteristics, may have greater benefit with ticagrelor. Nonetheless, the global evidence about the role of ticagrelor in patients with myocardial infarction and PAD remains relatively sparse, and a prospective randomized trial testing this hypothesis would be necessary to provide more definite data regarding the efficacy and safety of ticagrelor in this very high-risk population.

Transient prominent anterior QRS forces in the setting ST segment elevation coronary syndrome: Left septal fascicular block

Numerous successive publications have shown that transient prominent anterior QRS forces (PAF) in the setting of acute coronary syndrome (ACS) is suggestive of critical proximal obstruction of left anterior descending coronary artery (LAD) before its first septal perforator branch (S1). Transient ischemia of the left septal fascicle resulting in left septal fascicular block has been proposed as the causative mechanism. We present a case of acute inferior ST-elevation myocardial infarction caused by acute proximal occlusion of the right coronary artery associated with proximal critical obstruction of the left anterior descending coronary artery.

IN-HOSPITAL BLOOD PRESSURE VARIABILITY AS A PREDICTOR OF CARDIO-RENAL OUTCOMES IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION

Objective: Data are scarce regarding the possible prognostic role of blood pressure variability (BPV) in the setting of acute coronary syndrome (ACS). The aim of this study is to determine the impact of in-hospital short-term BPV on cardiovascular outcomes and renal function in patients suffering an acute myocardial infarction (AMI). Design and method: A total population of 150 AMI patients (78.7% male; mean age: 63.57 years;68% hypertensives) underwent 24hr ambulatory BP measurement during their hospitalization. Systolic BPV was derived by coefficient of variability (CV). The study population was divided intoa STEMI group (n = 72) and a non-STEMI (n = 78) one. Cardiovascular outcomes included: new onset of ACS, pulmonary edema, hypertensive emergency, life threatening arrhythmias, whereas worsening of renal function (WRF) was defined as a reduction of GFR > or = 25% according to the RIFLE criteria.No deaths or strokes occurred during the study. Results: In the total study population a significant positive association was demonstrated between SBP CV andthe incidence of total cardiovascular outcomes [odds ratio, 1.240; CI, 1.023–1.503 (P = 0.028)]as well asWRF[odds ratio, 1.394; CI, 1.109–1.753 (P = 0.004)]. Results for the STEMI group were similar regarding both cardiovascular outcomes [odds ratio, 1.38; CI, 1.066–1.794 (P = 0.015)]and WRF [odds ratio, 1.666; CI, 1.126–2.465 (P = 0.011)]. However, the non-STEMI group failed to demonstrate any significant associations. Finally, we conducted a multinomial logistic regression model for the STEMI group, where SBP CV showed relative significance as a predictor of cardiovascular outcomes [odds ratio, 1.317; CI, 0.994–1.746 (P = 0.056)], independently of age, gender and history of hypertension, diabetes mellitus or coronary heart disease. Conclusions: In the setting of STEMI, assessment of systolic BPV using systolic BP CV could have a prognostic role of in-hospital cardio-renal outcomes suggesting a clinical need for further individualization of BP regulation in the integrative ACS management.

Giant cystic pheochromocytoma masquerading as acute coronary syndrome and transient left ventricular dysfunction: a case report

Objective of present study to present an atypical manifestation of pheochromocytoma and to illustrate the difficulty in managing an acute coronary syndrome and left ventricular dysfunction during a hypertensive crisis attributable to pheochromocytoma. We present the clinical history, physical findings, lab results and imaging studies of a 62year old man with acute coronary syndrome later found to have an adrenal mass. A 62-year-old man was suspected of having myocardial ischemia on the basis of symptoms of paroxysmal chest discomfort, diaphoresis, ST-segment elevation on an electrocardiogram, and elevated levels of cardiac enzymes. Coronary CT angiography was normal. Echocardiography revealed substantial ballooning of the apical, anterior, and inferior cardiac walls, consistent with catecholamine induced cardiomyopathy. He had a history of labile hypertension, headache, diaphoresis and palpitations of 4 years' duration. A right adrenal mass detected on Magnetic resonance imaging and increased plasma catecholamine levels were consistent with a pheochromocytoma. Treatment with prazosin and labetalol was initiated, and he underwent a right adrenalectomy, which confirmed thepheochromocytoma. Pheochromocytomas must be considered in the setting of acute coronary syndrome especially with presence of labile blood pressure. Inadvertent fibrinolysis can be avoided with proper clinical suspicion and timely coronary imaging.

β-Blocker treatment and prognosis in acute coronary syndrome associated with cocaine consumption: The RUTI-Cocaine Study

BackgroundThe use of β-blocker therapy in the setting of acute coronary syndrome (ACS) associated with cocaine consumption (ACS-ACC) is discouraged due to the risk of coronary vasoconstriction. We examined the prognostic value of β-blocker therapy in a contemporary ACS cohort. Methods and resultsProspective, single-center study conducted between January 2001 and December 2014 that examined cocaine use among young (≤50-year-old) consecutive patients admitted with an ACS. During the study period, 1002 patients were admitted; of these, 57 (5.7%) had a positive cocaine urine test We collected data on clinical characteristics and major adverse cardiovascular events (MACE) during follow-up. Among ACS-ACC patients, 33 (57.9%) received β-blocker therapy during hospital admission and after discharge. During a median follow-up of 4.0 (IQR: 2.4–6.5) years after the index event, 2 (6.1%) patients treated with β-blocker therapy died and 6 (18.2%) experienced hospital re-admission for myocardial infarction (MI); in contrast, there were 5 (20.8%) deaths and 5 (20.8%) readmissions due to MI in patients without β-blocker therapy. Lower rates of MACE were observed in patients treated with β-blocker therapy (30.3%) than those without β-blocker therapy (41.7%). The 90-day survival was higher in patients treated with β-blocker therapy (87.5% vs. 100%; Log rank test p = 0.035). ConclusionsIn patients with ACS-ACC, β-blocker treatment was associated with a significantly better clinical outcome, with lower rates of death and MI. Our findings support the evidence for long-term β-blocker administration in high-risk patients and highlight the need for large prospective multicenter studies of β-blocker treatment in ACS-ACC.

Longer Inflation Duration and Predilation–Sizing–Postdilation Improve Bioresorbable Scaffold Outcomes in a Long-term All-Comers Canadian Registry

BackgroundReal-world long-term safety and efficacy of the ABSORB (Abbott Vascular, Santa Clara, CA) bioresorbable vascular scaffold has not been well characterized in the literature, particularly in the setting of acute coronary syndromes (ACS). Herein, we report outcomes up to 4 years in such a high-risk cohort, with identification of parameters associated with better outcomes. MethodsReABSORB is a Canadian dual-centre, prospective, nonrandomized, all-comers registry consisting of 125 consecutively enrolled nontrial patients between October 2012 and December 2016. Angiographic and clinical follow-up is now available up to 4 years. ResultsAverage age was 59 ± 11 years and 69% were male. Most (70.4%) presented with ACS and the median available follow-up was 1330 days (interquartile range, 1035-1483). Treated lesions (n = 163) were type A in 23%, type B (1 or 2) in 64%, and type C in 13%. Procedural success and device success were 98.2% and 98.8%, respectively. Using Kaplan–Meier methods, major adverse cardiac event-free survival (EFS) up to 4 years of clinical follow-up was 90.7% overall. However, use of a predilation–sizing–postdilation (PSP) technique was associated with an EFS rate of 95.8% vs 74.0% without PSP (P = 0.001). No significant differences in major adverse cardiac EFS rates were found between patients with or without ACS (92.7% vs 86.0%, respectively, P = 0.239). Use of PSP as well as inflation time ≥ 60 seconds were independent predictors of EFS at 2 years. ConclusionsIn this prospective, real-world registry with mostly ACS patients, use of the recommended PSP implantation technique and longer inflations times were associated with significantly higher EFS.

Determinantes e impacto pronóstico de la insuficiencia cardiaca y la fracción de eyección del ventrículo izquierdo en el síndrome coronario agudo

Introduction and objectivesContemporary data on the incidence and prognosis of heart failure (HF) and the influence of left ventricular ejection fraction (LVEF) in the setting of acute coronary syndrome (ACS) are scant. The aim of this study was to examine the relationship between LVEF and HF with long-term prognosis in a cohort of patients with ACS. MethodsThis is a retrospective observational study of 6208 patients consecutively admitted for ACS to 2 different Spanish hospitals. Baseline characteristics were examined and a follow-up period was established for registration of death and HF rehospitalization as the primary endpoint. ResultsAmong the study participants, 5064 had ACS without HF during hospitalization: 290 (5.8%) had LVEF<40%, 540 (10.6%) LVEF 40% to 49%, and 4234 (83.6%) LVEF ≥ 50%. The remaining 1144 patients developed HF in the acute phase: 395 (34.6%) had LVEF<40%, 251 (21.9%) LVEF 40% to 49%, and 498 (43.5%) LVEF ≥ 50%. Patients with LVEF 40% to 49% had a demographic and clinical profile with intermediate features between the LVEF <40% and LVEF ≥ 50% groups. Kaplan-Meier curves showed that mortality and HF readmissions were statistically different depending on LVEF in the non-HF group but not in the HF group. Left ventricular ejection fraction ≥ 50% was an independent prognostic factor in the non-HF group only. ConclusionsIn ACS, long-term prognosis is considerably worse in patients who develop HF during hospitalization than in patients without HF, irrespective of LVEF. This parameter is a strong prognostic predictor only in patients without HF.Full English text available from: www.revespcardiol.org/en

ASSOCIATION BETWEEN THE LOW-DENSITY LIPOPROTEIN-CHOLESTEROL/HIGH-DENSITY LIPOPROTEIN-CHOLESTEROL RATIO AND CLINICAL OUTCOMES IN PATIENTS WITH ACUTE CORONARY SYNDROME AND DYSLIPIDEMIA: A SUBANALYSIS OF THE HIJ-PROPER STUDY

Well-controlled low-density lipoprotein-cholesterol (LDL-C) levels are important for secondary prevention of coronary artery disease, particularly in the setting of acute coronary syndrome (ACS). However, the association between other conventional lipid measures and major cardiovascular adverse

THE IMPACT OF DECREASED HIGH-DENSITY LIPOPROTEIN-CHOLESTEROL LEVEL AFTER LIPID-LOWERING THERAPY ON THE CLINICAL OUTCOMES IN PATIENTS WITH ACUTE CORONARY SYNDROME AND DYSLIPIDEMIA: A SUBANALYSIS OF THE HIJ-PROPER STUDY

Well-controlled low-density lipoprotein-cholesterol (LDL-C) levels are important for secondary prevention of coronary artery disease, particularly in the setting of acute coronary syndrome (ACS). However, the association between other conventional lipid measures and major cardiovascular adverse

NO REDUCTION IN BLEEDING ASSOCIATED WITH BIVALIRUDIN USE WHEN COMPARED TO UNFRACTIONATED HEPARIN AMONG PATIENTS WITH STABLE ISCHEMIC HEART DISEASE UNDERGOING PERCUTANEOUS CORONARY INTERVENTION

Bivalirudin has previously been shown to be associated with a reduction in the risk of bleeding associated with percutaneous coronary intervention (PCI) in the setting of acute coronary syndrome when compared with unfractionated heparin (UFH). More recent work has suggested this benefit to be

Impact of pre-procedural dual antiplatelet therapy on periprocedural myocardial infarction in patients undergoing percutaneous coronary interventions with adjunctive tirofiban

BackgroundRecent trials have failed to demonstrate any clinical benefit from pre-treatment with dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary interventions, (PCI), even in the setting of acute coronary syndrome. However, suboptimal platelet inhibition during (PCI) has been shown to enhance the risk of acute ischemic complications, such as stent thrombosis and periprocedural myocardial infarction (PMI), thus raising the attention on the potential advantages of adjunctive glycoprotein IIbIIIa inhibitors to obviate to the delayed onset of action of oral antiplatelet drugs. The aim of the present study was then to evaluate the impact of platelet reactivity and pre-procedural DAPT on PMI in patients undergoing PCI with adjunctive tirofiban. MethodsIn a consecutive cohort of patients undergoing PCI with tirofiban (intracoronary/intravenous ± prolonged infusion), periprocedural myonecrosis was defined as troponin I increase by 3 times the ULN or by 50% of an elevated baseline value, whereas PMI as CKMB increase by 3 times the ULN or 50% of baseline. Platelet function was assessed by impedance aggregometry. ResultsA total of 168 patients were included, 77 (45.8%) of whom were on DAPT at the time of PCI. Patients on DAPT had more often a history of previous PCI (p = 0.03), higher ACS at admission (p < 0.001) and creatinine levels (p = 0.03). Coronary calcifications and type C lesions were more frequent in patients without DAPT (p = 0.02 and p = 0.03, respectively), as much as TIMI flow < 3 (p = 0.03), while procedural characteristics were comparable. Baseline platelet reactivity was significantly reduced in DAPT treated patients (p < 0.001 for ASPI, COL and ADP tests). However the rate of periprocedural myonecrosis did not differ according to pre-procedural DAPT (68.4%vs 67%, p = 0.87; adjusted OR[95%CI] = 1.34[0.71–2.53], p = 0.36) and neither the occurrence of PMI (13.3% vs 12.6%, p = 0.99; adjusted OR[95%CI] = 1.24[0.51–3.1], p = 0.64). Furthermore, baseline platelet reactivity was similar in patients with and without PMI/myonecrosis with no relationship between platelet function and Troponin I peak. ConclusionIn patients undergoing PCI with adjunctive GP IIb-IIIa inhibitors, preprocedural DAPT and baseline platelet reactivity are not associated to the risk of periprocedural myocardial infarction or myonecrosis. These data further support the role of periprocedural Gp IIb-IIIa inhibitors in order to overcome any suboptimal inhibition of platelet aggregation at the time of the procedure due to drug-resistance or delayed (downstream) administration of ADP antagonists, especially in complex high-risk procedures.

CRT-100.90 Transradial Coronary Intervention (TCI) Using 5-Fr Versus 6-Fr Guiding Catheters in the Setting of Acute Coronary Syndrome (ACS)

As in any vascular access, the size of guiding catheter is an operator preference. Although 5-Fr versus 6-Fr guiding catheters for transradial coronary intervention (TCI) have similar vascular safety profiles and can be performed safely and successfully with either, the data comparing the 5-Fr vs. 6

A Novel Use of Computed Tomography Coronary Angiogram for Defining Critical Stenosis in a Patient with Anomalous Coronary Artery Origin in the Setting of Acute Coronary Syndrome: A Case Study

A Novel Use of Computed Tomography Coronary Angiogram for Defining Critical Stenosis in a Patient with Anomalous Coronary Artery Origin in the Setting of Acute Coronary Syndrome: A Case Study

Prognosis impact of frailty assessed by the Edmonton Frail Scale in the setting of acute coronary syndrome in the elderly

Elderly patients represent a large proportion of patients admitted for Acute Coronary Syndrome (ACS). Whether frailty, defined as a biological syndrome that reflects a state of decreased physiological reserve and vulnerability to stressors, may impact the clinical outcomes in this population remains unclear. To determine the prevalence of frailty and its impact on all-cause mortality in patients aged ≥ 80 years admitted for ACS. This prospective observational study was conducted among patients aged 80 or older admitted in a tertiary hospital for ACS. Frailty was assessed using the Edmonton Frail Scale (EFS), which provides a score ranging from 0 (not frail) to 17 (very frail). Population was divided into 3 classes: [0–3] EFS-score, [4–6] EFS-score, and [≥ 7] EFS-score. Two hundred and thirty-six patients were included with a mean follow-up duration of 470 days. The mean age was 85.9 years. Seventy-five patients died during follow-up period. Hundred and nineteen subjects (50.4%) had a [0–3] EFS-score, 68 patients (28.8%) had a [4–6] EFS-score and 49 patients (20.8%) had a [≥ 7] EFS-score. All-cause mortality rate was 17.7% in the [0–3] EFS-score group, 35.3% in the [4–6] EFS-score group and 61.2% in the [≥ 7] EFS-score group ( P < 0.001). After multivariate analysis, frailty status remained associated with all-cause mortality: HR was 1.59 (95% CI [0.78–3.26]) within the [4–6] EFS-score group, and HR was 4.03 (95% CI [2.02–8.04]) within the [≥ 7] EFS-score group ( Table 1 , Fig. 1 ). Frailty is a strong and independent prognosis factor of midterm all-cause mortality in elderly patients presenting with ACS.

Coronary Myeloperoxidase Provides Superior Characterisation of Coronary Inflammation in Patients Undergoing Percutaneous Coronary Interventions in the Setting of Non-ST Elevation Acute Coronary Syndrome

Coronary Myeloperoxidase Provides Superior Characterisation of Coronary Inflammation in Patients Undergoing Percutaneous Coronary Interventions in the Setting of Non-ST Elevation Acute Coronary Syndrome