Spectrum Of Acute Coronary Syndromes Research Articles

Kounis Syndrome: A Comprehensive Review of Pathophysiology, Clinical Manifestations, Diagnostic Challenges, and Therapeutic Strategies

Kounis syndrome, also known as allergic angina or allergic myocardial infarction, is a rare but potentially life-threatening condition characterized by the acute onset of chest pain, myocardial infarction, or sudden cardiac death in the setting of allergic or hypersensitivity reactions. The syndrome encompasses a spectrum of acute coronary syndromes triggered by various allergic insults, including medications, insect stings, food allergens, and environmental exposures. The pathophysiology involves the activation of mast cells and platelets, leading to coronary artery spasm, atheromatous plaque erosion or rupture, and subsequent myocardial ischemia or infarction. Diagnosis can be challenging due to the diverse clinical presentations and the need for a high index of suspicion. Management includes the identification and avoidance of triggers, along with the use of standard therapies for acute coronary syndromes. This review aims to provide a comprehensive overview of Kounis syndrome, focusing on its pathophysiology, clinical manifestations, diagnostic considerations, and therapeutic strategies.

Biological profiling in the spectrum of acute coronary syndrome: characterizing patients from MINOCA to NSTEMI with different features of the culprit plaque

Abstract Background In the last two decades, the development of procedures and tools such as coronary angiography and optical coherence tomography (OCT) have made it possible to highlight several aspects of acute coronary syndromes (ACS), identifying multiple subgroups such as patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) and patients with Non-ST-Elevation Myocardial Infarction (NSTEMI) and ruptured fibrous cap (RFC) or intact fibrous cap (IFC) culprit lesions. The aim of the study is to better characterize the ACS spectrum by evaluating the biological profile of non-characterized NTSEMI, RFC-NSTEMI, IFC-NSTEMI, and MINOCA patients. Methods We enrolled 56 consecutive patients presenting with ACS, specifically 16 patients with non-characterized NSTEMI, 12 patients with RFC-NSTEMI, 8 patients with IFC-NSTEMI, and 20 patients with MINOCA. Biological samples were collected and stored. We performed gene expression analysis through qRT-PCR technique for 21 genes. Results Our data displayed several differences in gene expression levels involved in inflammation, cellular adhesion, extracellular matrix turnover, and oxidative stress between the groups under examination. We observed no significant difference between non-characterized NSTEMI and MINOCA for all the studied genes. Alongside, MINOCA displayed significantly lower levels of the following genes than RFC and IFC patients: CD44, GPX1, ICAM1, PLA2G7, SOD1, and VEGFA. Furthermore, when compared with IFC patients, MINOCA showed lower levels of EDN1, LGALS8, MMP1, and TNF, and non-characterized NSTEMI showed a lower gene expression of CD31, ICAM1, and PI16. Finally, CD44, EDN1, GPX1, LGALS8, NOS3, SOD1, TFRC, and VEGFA were more expressed in RFC and IFC compared to non-characterized NSTEMI patients. Conclusions Our preliminary data, besides exploring new pathways in MINOCA patients, reflects the need for characterization and patients’ stratifications in the clinical management of ACS, since no differences were observed between non-characterized NSTEMI and MINOCA. This result may indicate that a one size fits all approach is not the most suitable since a plaque could be an innocent bystander and should be treated accordingly. A precision medicine approach that recognizes the presence of obstructive plaque and defines the type of culprit plaque (i.e., RFC or IFC) could identify better treatment, for a tailored therapy, allowing better prognosis and quality of life.Figure

Correlation of platelet indices with the spectrum of acute coronary syndrome and extent of coronary artery disease

Platelets have a major role in acute coronary syndrome and their activation is a hallmark of this. Troponin I, Troponin T and Creatine Kinase enzymes are not enough sensitive at an early stage of acute coronary syndrome. Platelet indices can be detected earlier, inexpensive, widely available and easily recordable in most clinical laboratories, thus could be a better marker in these patients. The primary objective of this study is to determine the correlation between platelet indices and spectrums of acute coronary syndrome or the number of vessels involved. This is a prospective observation study conducted in a tertiary care teaching hospital of eastern India over a period of six months where 125 patients were non-randomly selected with a diagnosis of acute coronary syndrome who underwent coronary angiogram and reports correlated with platelet parameters. A total of 100 patients were finally evaluated. Only platelet large cell ratio and platelet-crit were significantly higher in ST elevated myocardial infarction group compared to the unstable angina group. Across all the spectrums of acute coronary syndrome or extent of coronary artery disease there was a strong positive correlation within platelet distribution width, mean platelet volume and platelet large cell ratio, which was also very significant. Similarly total platelet count had a strong positive and very significant correlation with platelet-crit in the above groups. Increase platelet large cell ratio and platelet-crit seems to be independent risk factors for development of ST elevated myocardial infarct than unstable angina. Thus they could serve as simple but important early biomarkers for predicting development of ST elevated myocardial infarction compared to unstable angina in acute coronary syndrome patients.

Evaluation of Effectiveness and Tolerability of Fondaparinux in the Management of Symptomatic Acute Coronary Syndrome: A Real-World Evidence-Based Study on an Indian Population

Introduction Fondaparinux is a low molecular weight heparin anticoagulant used to manage the full spectrum of acute coronary syndrome (ACS) patients and has proved its efficacy and safety in multiple clinical trials. However, there are limited data available showing whether the same results could be reproduced in real-world practice on an Indian population. Our objective was to determine the effectiveness and tolerability of fondaparinux in the management of symptomatic ACS in real-world clinical practice.MethodsThe EMR data of hospitalized ACS patients (n = 611), from January 2015 to January 2020, representing UA or NSTEMI or STEMI and were prescribed fondaparinux (2.5 mg once daily) to manage ACS were analyzed. The effectiveness was analyzed as recurrence of ACS and tolerability as total incidence of major bleeding during hospitalization, at 30 days and 180 days. Appropriate statistical analysis was used with a statistically significance of p value < 0.05.ResultsThe incidence of recurrent ACS was not seen during hospitalization and in the first 30 days, while in only 0.65% (n = 4) patients, ACS reoccurred within 180 days. In a mean duration of 172.75 ± 3.20 days, UA was reported in 0.49% (n = 3) patients, NSTEMI in 0.16% (n = 1) of patients, and STEMI was not documented. None of the major bleeding events occurred during the entire study period, whereas minor bleeding events were reported during hospitalization 0.98% (n = 6) and at 30 days 0.16% (n = 1). The bleeding events were statistically insignificant (p value > 0.05). No incidences of stent thrombosis were reported during the entire study period.ConclusionsIn the real world, fondaparinux was found to be effective and tolerable when used to manage symptomatic ACS patients regardless of revascularization procedure with no incidence of stent thrombosis, and minimal recurrent ACS and insignificant increase in bleeding events.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40119-022-00253-x.

Circulating Soluble Lectin-like Oxidized Low-Density Lipoprotein Receptor-1 (sLOX-1): A Diagnostic Indicator across the Spectrum of Acute Coronary Syndrome.

Background: Cardiac troponin is the best marker to diagnose acute coronary syndrome (ACS). However, early diagnosis using markers for plaque instability may be of significance. Soluble lectin-like oxidized low-density lipoprotein receptor-1 (sLOX-1) plays an important role in the pathogenesis of atherosclerosis plaque rupture and may be a potential biomarker of coronary artery disease (CAD), including ACS. The current study aims to evaluate sLOX-1 levels in the sera of patients with ACS as an independent marker of CAD with other established diagnostic markers and assess its level before and after percutaneous intervention (PCI) in predicting the risk of future recurrence of ACS. Methods: Peripheral blood was obtained from a total of 160 patients, including patients who underwent coronary angiography (n = 18, group I), patients of stable CAD who underwent percutaneous intervention (n = 50, group II), patients of the acute coronary syndrome (n = 64, group III), and healthy controls (n = 28, group IV). A serum sLOX-1 concentration was measured by the enzyme-linked immunosorbent assay (ELISA). Results: The results obtained showed a statistically significant raised level of sLOX-1 in pre/post PCI patients of stable CAD/ACS with male preponderance. The area under the curve for sLOX-1 was 0.925 for cases that are discriminated from controls with sensitivity and specificity of 87.88 and 100%, respectively. SLOX-1 showed 100% sensitivity and specificity in the discrimination of the stable CAD that underwent PCI vs. control with an AUC of 1.00. The recurrence of coronary artery disease was observed in 9 out of 132 (6.8%) cases. The post-interventional sLOX-1 level was significantly different and higher in recurrent cases (p = 0.027) of ACS/CAD. Conclusions: sLOX-1 was a useful biomarker of stable CAD/ACS and has a potential in the risk prediction of a future recurrence of coronary artery disease.

Abstract 9142: Predictors of New-Onset Atrial Fibrillation in the Setting of Acute Coronary Syndromes: A Nationwide Multi-Center Study

Introduction: New-onset atrial fibrillation (AF) following acute myocardial infarction (AMI) is associated with adverse outcomes, though studies exploring the interaction between AF and the full spectrum of acute coronary syndromes (ACS) are scarce. We aim to identify predictors of new-onset AF in the setting of ACS by analyzing data from the prospective CONCORDANCE multi-center registry. Methods: Patients admitted to 41 Australian hospitals from 2009-2018 with ACS and had an angiogram were included. New-onset AF was defined as AF detected on index ECG and/or in-hospital AF. Independent predictors of new-onset AF were identified using multivariable logistic regression models. Results: Of 9070 consecutive patients admitted with ACS, 648 (7.1%) patients developed new-onset AF. These patients had higher rates of major adverse in-hospital events and all-cause mortality compared to patients without new-onset AF. Age (adjusted odds ratio [aOR] 1.04, 95% confidence interval [CI] 1.03-1.05), male sex (aOR 1.62, 95%CI 1.29-2.04), higher admission heart rate (aOR 1.02, 95%CI 1.01-1.02), cardiac arrest on admission (aOR 1.98, 95%CI 1.23-3.20), Killip classes 2 (aOR 1.38, 95%CI 1.10-1.73) and 3/4 (aOR 1.72, 95%CI 1.24-2.40) versus 1 were independent predictors of new-onset AF, whereas hypertension (aOR 0.81, 95%CI 0.67-0.99), higher minimum hemoglobin (aOR 0.98, 95%CI 0.97-0.98), pre-admission statins (aOR 0.71, 95%CI 0.56-0.89) and undergoing PCI (aOR 0.64, 95%CI 0.53-0.77) were associated with decreased risk of new-onset AF. When angiographic disease burden was included, double and triple-vessel disease were independent predictors of new-onset AF. However, sequential addition of CABG to the model nullified this association; (CABG (aOR 3.94, 95%CI 2.83-5.49), disease burden non-significant). In the CABG subgroup, peripheral arterial disease (aOR 1.98, 95%CI 1.20-3.27) was an independent predictor of new-onset AF (all p&lt;0.05). Conclusions: This present study identified patients at risk of new-onset AF in the setting of ACS. Such patients could be targeted for increased surveillance for AF and related adverse outcomes during the post-infarct period. In addition, future studies should explore strategies to prevent new-onset AF after ACS.

Effects of Prolonged Dual Antiplatelet Therapy in ST-Segment Elevation vs. Non-ST-Segment Elevation Myocardial Infarction.

The benefits and risks of prolonged dual antiplatelet therapy (DAPT) have not been studied extensively across a broad spectrum of acute coronary syndromes. In this study we investigated whether treatment effects of prolonged DAPT were consistent in patients presenting with ST-segment elevation myocardial infarction (STEMI) vs. non-STEMI (NSTEMI).Methods and Results:As a post hoc analysis of the SMART-DATE trial, effects of ≥12 vs. 6 months DAPT were compared among 1,023 patients presenting with STEMI and 853 NSTEMI patients. The primary outcome was a composite of recurrent myocardial infarction (MI) or stent thrombosis at 18 months after the index procedure. Compared with the 6-month DAPT group, the rate of the composite endpoint was significantly lower in the ≥12-month DAPT group (1.2% vs. 3.8%; hazard ratio [HR] 0.31, 95% confidence interval [CI] 0.12-0.77; P=0.012). The treatment effect of ≥12- vs. 6-month DAPT on the composite endpoint was consistent among NSTEMI patients (0.2% vs. 1.2%, respectively; HR 0.20, 95% CI 0.02-1.70; P=0.140; Pinteraction=0.718). In addition, ≥12-month DAPT increased Bleeding Academic Research Consortium (BARC) Type 2-5 bleeding among both STEMI (4.4% vs. 2.0%; HR 2.18, 95% CI 1.03-4.60; P=0.041) and NSTEMI (5.1% vs. 2.2%; HR 2.37, 95% CI 1.08-5.17; P=0.031; Pinteraction=0.885) patients. Compared with 6-month DAPT, ≥12-month DAPT reduced recurrent MI or stent thrombosis regardless of the type of MI at presentation.

TCT-394 Differential Effects of Prolonged Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients Presenting With Versus Without Acute Myocardial Infarction

Despite the broad spectrum of acute coronary syndrome, the benefits and risks of prolonged dual antiplatelet therapy (DAPT) according to initial presentation with or without myocardial infarction (MI) have not been well studied. In the SMART-DATE trial, 12-month or longer DAPT, when compared with 6

Analysis of Genetic Variation in CD40 and CD40L: Relationship with mRNA Relative Expression and Soluble Proteins in Acute Coronary Syndrome.

Acute coronary syndrome (ACS) can be triggered by the presence of inflammatory factors which promote the activation of immune cells by costimulatory molecules such as CD40 and its ligand CD40L. Environmental and genetic factors are involved in the etiology of the ACS. The aim of this study was to explore the gene and protein expression associated with CD40 and CD40L genetic variants in ACS patients from the western Mexican population. A total of 620 individuals from western Mexico were recruited: 320 ACS patients and 300 individuals without a history of ischemic cardiopathy were evaluated. The genotype was determined using TaqMan SNP genotyping assays. CD40 and CD40L expressions at the mRNA level were quantified using TaqMan Gene Expression Assays. Soluble protein isoforms were measured by enzyme-linked immunosorbent assay. We did not find evidence of association between CD40 (rs1883832, rs4810485, and rs11086998) and CD40L (rs3092952 and rs3092920) genetic variants and susceptibility to ACS, although rs1883832 and rs4810485 were significantly associated with high sCD40 plasma levels. Plasma levels of sCD40L can be affected by gender and the clinical spectrum of acute coronary syndrome. Our results do not suggest a functional role of CD40 and CD40L genetic variants in ACS. However, they could reflect the inflammatory process and platelet activation in ACS patients, even when they are under pharmacological therapy. Due to the important roles of the CD40-CD40L system in the pathogenesis of ACS, longitudinal studies are required to determine if soluble levels of CD40 and CD40L could be clinically useful markers of a recurrent cardiovascular event after an ACS.

The expanding spectrum of acute coronary syndromes: from STEMI to coronary dissection and Takotsubo syndrome.

The expanding spectrum of acute coronary syndromes: from STEMI to coronary dissection and Takotsubo syndrome.

Radial versus femoral access and bivalirudin versus unfractionated heparin in invasively managed patients with acute coronary syndrome (MATRIX): final 1-year results of a multicentre, randomised controlled trial

The Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox (MATRIX) programme was designed to assess the comparative safety and effectiveness of radial versus femoral access and of bivalirudin versus unfractionated heparin with optional glycoprotein IIb/IIIa inhibitors in patients with the whole spectrum of acute coronary syndrome undergoing invasive management. Here we describe the prespecified final 1-year outcomes of the entire programme. MATRIX was a programme of three nested, randomised, multicentre, open-label, superiority trials in patients with acute coronary syndrome in 78 hospitals in Italy, the Netherlands, Spain, and Sweden. Patients with ST-elevation myocardial infarction were simultaneously randomly assigned (1:1) before coronary angiography to radial or femoral access and to bivalirudin, with or without post-percutaneous coronary intervention infusion or unfractionated heparin (one-step inclusion). Patients with non-ST-elevation acute coronary syndrome were randomly assigned (1:1) before coronary angiography to radial or femoral access and, only if deemed eligible to percutaneous coronary intervention after angiography (two-step inclusion), entered the antithrombin type and treatment duration programmes. Randomisation sequences were computer generated, blocked, and stratified by intended new or current use of P2Y12 inhibitor (clopidogrel vs ticagrelor or prasugrel), and acute coronary syndrome type (ST-elevation myocardial infarction, troponin-positive, or troponin-negative non-ST-elevation acute coronary syndrome). Bivalirudin was given as a bolus of 0·75 mg/kg, followed immediately by an infusion of 1·75 mg/kg per h until completion of percutaneous coronary intervention. Heparin was given at 70-100 units per kg in patients not receiving glycoprotein IIb/IIIa inhibitors, and at 50-70 units per kg in patients receiving glycoprotein IIb/IIIa inhibitors. Clinical follow-up was done at 30 days and 1 year. Co-primary outcomes for MATRIX access and MATRIX antithrombin type were major adverse cardiovascular events, defined as the composite of all-cause mortality, myocardial infarction, or stroke up to 30 days; and net adverse clinical events, defined as the composite of non-coronary artery bypass graft-related major bleeding, or major adverse cardiovascular events up to 30 days. The primary outcome for MATRIX treatment duration was the composite of urgent target vessel revascularisation, definite stent thrombosis, or net adverse clinical events up to 30 days. Analyses were done according to the intention-to-treat principle. This trial is registered with ClinicalTrials.gov, number NCT01433627. Between Oct 11, 2011, and Nov 7, 2014, we randomly assigned 8404 patients to receive radial (4197 patients) or femoral (4207 patients) access. Of these 8404 patients, 7213 were included in the MATRIX antithrombin type study and were randomly assigned to bivalirudin (3610 patients) or heparin (3603 patients). Patients assigned to bivalirudin were included in the MATRIX treatment duration study, and were randomly assigned to post-procedure infusion (1799 patients) or no post-procedure infusion (1811 patients). At 1 year, major adverse cardiovascular events did not differ between patients assigned to radial access compared with those assigned to femoral access (14·2% vs 15·7%; rate ratio 0·89, 95% CI 0·80-1·00; p=0·0526), but net adverse clinical events were fewer with radial than with femoral access (15·2% vs 17·2%; 0·87, 0·78-0·97; p=0·0128). Compared with heparin, bivalirudin was not associated with fewer major adverse cardiovascular (15·8% vs 16·8%; 0·94, 0·83-1·05; p=0·28) or net adverse clinical events (17·0% vs 18·4%; 0·91, 0·81-1·02; p=0·10). The composite of urgent target vessel revascularisation, stent thrombosis, or net adverse clinical events did not differ with or without post-procedure bivalirudin infusion (17·4% vs 17·4%; 0·99, 0·84-1·16; p=0·90). In patients with acute coronary syndrome, radial access was associated with lower rates of net adverse clinical events compared with femoral access, but not major adverse cardiovascular events at 1 year. Bivalirudin with or without post-procedure infusion was not associated with lower rates of major adverse cardiovascular events or net adverse clinical events. Radial access should become the default approach in acute coronary syndrome patients undergoing invasive management. Italian Society of Invasive Cardiology, The Medicines Company, Terumo, amd Canada Research Chairs Programme.

Intracoronary near-infrared spectroscopy: an overview of the technology, histologic validation, and clinical applications.

Intracoronary near-infrared spectroscopy (NIRS) imaging, which is now clinically available in a combined NIRS and intravascular ultrasound catheter, is a novel catheter-based imaging modality capable of identifying lipid core plaque within the coronary arteries of living patients. The present manuscript provides an overview of intracoronary NIRS imaging with a focus on several concepts essential to individuals seeking to better understand this novel imaging modality. One of the major assets of NIRS is that it has been rigorously validated against the gold standard of histopathology and has been shown to accurately identify histologically-proven fibroatheroma. Clinical studies of NIRS have demonstrated its ability to accurately identify large lipid core plaques at culprit lesions across the spectrum of acute coronary syndromes. NIRS has also been shown to detect lesions at increased risk of causing peri-procedural myocardial infarction during PCI. With regards to predicting future risk, NIRS is seemingly capable of identifying vulnerable patients at increased risk of experiencing subsequent patient-level cardiovascular events. In addition to these clinical applications of NIRS, there are several large prospective observational studies underway to determine if NIRS imaging will be able to identify vulnerable plaques at increased risk of triggering site-specific future coronary events. These studies, once completed, are anticipated to provide valuable data regarding the ability of NIRS imaging to identify plaque vulnerability.

Isolated Right Ventricular Myocardial Infarction: An Orphan in Acute Coronary Syndrome Imaging

Introduction: Isolated right ventricular myocardial infarction is an uncommon entity in the spectrum of acute coronary syndrome. It is often overlooked during the assessment of patients suspected to have acute coronary syndrome.

Spectrum of acute coronary syndrome in North Eastern India – A study from a major center

AimSpectrum of acute coronary syndrome (ACS) has not been reported from North Eastern India. The present study was undertaken to study the clinical spectrum of ACS. MethodsWe prospectively collected data of 704 ACS patients from February 2011 to August 2012 in Gauhati Medical College, a tertiary care center. We evaluated data on clinical characteristic, treatment, and outcome in ACS patients. ResultsOf the 704 ACS patients, 72.4% presented with STEMI and 27.6% presented with NSTEMI/UA. Mean age of presentation was 56.5 years. Mean time to presentation was 11.42h and was higher in NSTEMI/UA than STEMI (12.86h vs. 9.98h, p<0.001). Treatment for STEMI did not differ much from NSTEMI/UA with ≥90% of patients in both groups receiving antiplatelets, statin, and anticoagulants. 39% of STEMI received thrombolytic therapy and percutaneous coronary intervention (PCI) rates were higher in STEMI. The 30-day mortality was found to be 10.22%, with STEMI having higher mortality than NSTEM/UA (11.76% vs. 6.18%, p=0.03). ConclusionThese data represent the first reported study on spectrum of ACS in North Eastern India and has noted few key differences from the national registry CREATE, with greater percentage of STEMI patients, greater delay in seeking treatment, greater 30-day mortality, and lesser percentage of patients receiving reperfusion therapy.

Long-term prognostic role of cerebrovascular disease and peripheral arterial disease across the spectrum of acute coronary syndromes

BackgroundIn acute coronary syndromes (ACS), the influence of cerebro-vascular disease (CVD) and/or peripheral artery disease (PAD) on short-midterm outcome has been well established. Data on long-term outcome however, are limited. Our study aimed to explore the effect of CVD and PAD on long-term outcome in a cohort of unselected ACS patients, including ST-elevation (STE-ACS) and non-ST-elevation (NSTE-ACS). Methods and resultsThe population consisted of 2046 consecutive patients with a confirmed final diagnosis of ACS; 896 (44%) had STE-ACS and 1150 (66%) NSTE-ACS. CVD alone was present in 98 patients (5%), 282 (14%) had PAD alone, and 30 (1.5%) had both. All cause mortality at 5 years was lowest in patients without CVD/PAD (33%), intermediate in patients with either CVD or PAD (62% and 63%, respectively) reaching 80% in those with both CVD and PAD. These findings were confirmed in the STE-ACS and NSTE-ACS subgroups. CVD and PAD remained independent predictors of mortality after multivariable analysis, the combined presence of both carrying the highest risk within each ACS type (HR 4.15, 95% CI 1.83–9.44 for STE-ACS; HR 2.14, 1.29–3.54 for NSTE-ACS). Patients with CVD and/or PAD were less likely to be treated invasively and received less evidence-based treatment at discharge. ConclusionsAcross the spectrum of ACS, extracardiac vascular disease harbors a negative long-term prognosis that worsens progressively with the number of affected arterial beds.

Prognostic significance of low QRS voltage on the admission electrocardiogram in acute coronary syndromes

PurposeTo examine the prognostic significance of low QRS voltage in a large contemporary cohort of patients with a broad spectrum of acute coronary syndromes (ACS). Methods12409 patients with STEMI or NSTE-ACS from the Global Registry of Acute Coronary Events (GRACE) and Canadian ACS I registries were stratified based on the presence of low QRS voltage (<0.5mV in all limb leads and <1.0mV in all precordial leads) on the admission ECG. We performed multivariable logistic regression to assess the independent association between low voltage and in-hospital and 6-month mortality, and tested for its interaction with ST-segment deviation for these outcomes. ResultsPatients with low voltage (3.2%) had higher GRACE risk scores, rates of prior myocardial infarction, and pathological Q waves, with less prevalent ST-segment deviation and ST-segment depression. They had worse left ventricular function and higher unadjusted rates of in-hospital and 6-month mortality. After adjustment for established prognosticators in the GRACE risk models in multivariable analysis, low voltage was independently associated with higher in-hospital mortality (adjusted OR 1.77, 95% CI 1.13–2.78, P=0.013) and mortality/re-infarction (adjusted OR 1.42, 95% CI 1.05–1.93, P=0.023), but not 6-month mortality (adjusted OR 1.25, 95% CI 0.85–1.84, P=0.27). There was no significant interaction between low voltage and ST-segment deviation for any endpoint (interaction P>0.10 for all endpoints). ConclusionsLow QRS voltage was associated with previous myocardial infarction and adverse hemodynamic variables at presentation. After adjusting for other prognosticators, low voltage independently predicted higher in-hospital mortality. This increased risk was not modulated by concomitant ST-segment deviation.

The proxy of renal function that most accurately predicts short- and long-term outcome after acute coronary syndrome

The aim of this study is to determine the most accurate renal function formula that predicts short- and long-term mortality in a wide spectrum of acute coronary syndrome (ACS) patients. We analyzed 8,726 consecutive patients (46.3% ST-elevation myocardial infarction [STEMI] and 53.7% non-ST-elevation ACS [NSTE-ACS]) enrolled in the ACS survey in Israel. Renal function, assessed using 5 formulas as proxies of creatinine clearance or estimated glomerular filtration rate (Cockcroft-Gault, modification of diet in renal disease [MDRD], Chronic Kidney Disease Epidemiology Collaboration, Mayo quadratic, and inulin clearance based), varied in applying the different formulas. For both STEMI and NSTE-ACS patients, the Mayo formula yielded the highest mean value (88.9 ± 27.7 and 81.4 ± 29.2 mL/min per 1.73 m(2), respectively) and Chronic Kidney Disease Epidemiology Collaboration the lowest (73.0 ± 23.1 and 67.0 ± 24.1 mL/min per 1.73 m(2), respectively). Using multivariate analysis, worse renal function was independently associated with increased mortality risk by 30% to 40% for each decrement of 10 U of creatinine clearance or estimated glomerular filtration rate in STEMI patients and by 25% to 30% for NSTE-ACS patients, using all 5 formulas. The only formula that more accurately predicted 1-year mortality than the MDRD formula was the Mayo quadratic formula with a 1-year net reclassification index of 0.26 and 0.14 for STEMI and NSTE-ACS patients, respectively, after multivariable adjustment. Worse renal function was an independent predictor for short- and long-term mortality using all 5 formulas in a broad spectrum of ACS patients, but only the Mayo quadratic formula had better accuracy in predicting mortality relative to the MDRD, suggesting that it may be the preferred prognosticator among ACS patients.

Trends in epidemiology and the treatment of acute coronary syndromes in the Czech Republic: Comparison of the CZECH-1 and CZECH-2 registries

BackgroundThe clinical spectrum of acute coronary syndrome (ACS) has changed due to a progressively ageing population over the last two decades. AimWe analysed the changes in the epidemiological and treatment strategies between two large registries that were performed in 2005 and 2012 in well-defined populations of the Czech Republic. Methods and resultsThe CZECH-1 and CZECH-2 registries enrolled all consecutive hospitalized patients with an initial diagnosis of ACS during a 1 or 2-month period, respectively. Thirty-six and 32 hospitals participated in the CZECH-1 and CZECH-2 registries, respectively. A total of 1921 patients were enrolled in the CZECH-1 registry and 1221 patients participated in the CZECH-2 registry. Patients enrolled in the CZECH-2 registry were older than those in CZECH-1 (68±12 vs. 66±12 years; p<0.001). ACS was not confirmed during hospitalization in 30.5 and 30.1% (p>0.05) of the patients in the CZECH-1 and CZECH-2 registries, respectively. Urgent angiography in patients with ST segment elevation myocardial infarction (STEMI) was performed in 92 and 94% of the patients (p>0.05), respectively; of these, 87 and 89% subsequently underwent primary PCI. There were no signifiant differences in in-hospital (4.2 vs. 4.4%, p=0.805) or in the mortality of patients with a final diagnosis of Q-myocardial (10.3 vs. 10.7%; p=0.870) or non-Q-myocardial infarction (4.7 vs. 3.8%; p=0.497) between the two registries. The estimated incidence of confirmed ACS and STEMI in a representative population from both registries was 3248 and 661cases/millionindividuals/year in the CZECH-1 registry and 2149 and 652cases/millionindividuals/year in the CZECH-2 registry. The fall in ACS incidence was almost exclusively due to a significant decrease in the incidence of unstable angina as the final diagnosis. At discharge, the patients with confirmed ACS were administered the following medications: aspirin (95 vs. 94%; p>0.05), clopidogrel (60 vs. 76.4%; p<0.001), beta-blockers (78 vs. 78%; p>0.05), angiotensin-converting enzyme (ACE) inhibitors (50 vs. 78%; p=<0.001) and statins (75 vs. 90%; p<0.001) in the CZECH-1 and CZECH-2 registries, respectively. ConclusionIn the Czech Republic, the age of the patients hospitalized with ACS increased between 2005 and 2012. Invasive reperfusion strategy for patients with STEMI was very high in both registries. The overall outcome in patients with confirmed ACS did not change between 2005 and 2012. The estimated incidence of ACS decreased due to the fall in unstable angina pectoris.

Balancing the risks of stent thrombosis and major bleeding during primary percutaneous coronary intervention

This editorial refers to ‘Bivalirudin is superior to heparins alone with bailout GPIIb/IIIa Inhibitors in patients with ST-segment elevation myocardial infarction transported emergently for primary percutaneous coronary intervention: a pre-specified analysis from the EUROMAX trial’[†][1], by U. Zeymer et al ., on page 2460. Two feared peri-procedural complications of primary percutaneous coronary intervention (PCI) are stent thrombosis (ST) and major bleeding. Although rare, ST is associated with high rates of myocardial infarction and death.1 Potent antithrombotic therapy around the time of PCI markedly reduces the risk of ST, but increases bleeding hazard ( Figure 1 ). Historically, the anticoagulant of choice for PCI has been unfractionated heparin (UFH). Glycoprotein inhibitors (GPI) added to heparin significantly reduce peri-procedural ischaemic complications, but increase major bleeding and the need for transfusions. There has been a consistent association between major bleeding and increased mortality.2 In PCI for elective indications and across the spectrum of acute coronary syndrome (ACS), the direct thrombin inhibitor bivalirudin is non-inferior to heparin plus GPI with respect to overall ischaemic complications, but significantly decreases major bleeding. Figure 1 Balancing reductions in stent thrombosis with increases in major bleeding. PCI, percutaneous coronary intervention. In this issue of European Heart Journal , an important pre-specified analysis by Zeymer et al. uses the European Ambulance Acute Coronary Syndrome Angiography (EUROMAX) study population to compare patients receiving bivalirudin with patients receiving heparins [UFH or low-molecular weight heparin (LMWH)] with routine GPI use (defined as initiation before or during coronary angiography) and patients receiving heparins with only bailout GPI use (defined as initiation after the start of PCI). This study expands on the original EUROMAX findings by reporting a significant difference in the composite primary endpoint of death or major bleeding that favours bivalirudin over heparins with routine GPI use and heparins with bailout GPI use (5.1 vs. … [1]: #fn-1

Prognostic Implications of Prominent R Wave in Electrocardiographic Leads V1 or V2 in Patients With Acute Coronary Syndrome

Although the adverse prognosis of Q-waves on electrocardiogram (ECG) has been demonstrated, the prognostic significance of prominent R wave (PRW) in V1 or V2 across a broad spectrum of acute coronary syndrome (ACS) has not been specifically studied. In the Global Registry of Acute Coronary Events (GRACE) and the Canadian ACS Registry I ECG substudies, admission ECGs were analyzed in an independent core ECG laboratory. PRW was defined as R wave >40 to 50 ms in V1 or V2, R/S ≥1 in V1, or R/S ≥1.5 in V2. Among 11,895 patients with ACS, 495 (4.2%) had PRW; they were less likely to have a history of hypertension or heart failure and had lower GRACE risk scores, but a higher incidence of ST-segment depression (all p ≤0.001). Patients with PRW had similar rates of in-hospital death (2.8% vs 4.1%, respectively, p = 0.15) but lower rates of in-hospital heart failure (8.5% vs 15.2%, respectively, p = 0.02) and 6-month mortality (4.6% vs 8.4%, respectively, p = 0.004). In multivariable analyses, PRW was not a significant independent predictor of in-hospital mortality (adjusted odds ratio = 0.99, 95% confidence interval 0.55 to 1.8) or 6-month mortality (adjusted odds ratio = 0.70, 95% confidence interval 0.43 to 1.15). Among 4,418 patients who underwent coronary angiography, those with PRW had a higher prevalence of left circumflex artery disease (62.5% vs 49.5%, respectively, p = 0.01). In conclusion, across the broad spectrum of patients with ACS, PRW provides no significant additional prognostic utility beyond comprehensive risk assessment using the GRACE risk score. PRW is more frequently associated with left circumflex artery disease.