ST Elevation Acute Coronary Syndrome Research Articles

Cardiac rehabilitation makes a difference: lipid control targets and prognosis

Abstract Funding Acknowledgements None. Introduction Cardiac rehabilitation (CR) has become a fundamental element in the recovery of patients with acute coronary syndrome, since it achieves greater therapeutic adherence and better control of cardiovascular risk factors (CVRF). Purpose We aim to describe the characteristics of patients with ST-elevation acute coronary syndrome (STEACS) included in a cardiac rehabilitation program, as well as the achievement of prevention objectives and the occurrence of mayor adverse cardiovascular events (MACE). Methods We present a prospective registry of 664 patients admitted to a Coronary Unit with a diagnosis of STEACS during the years 2017-2020. They were classified according to their participation in a CR program. We compared history, lipid-lowering treatment (prior, at discharge and titration), lipid levels at discharge and at 1-year follow-up, and degree of compliance with lipid targets. MACE were observed at 2-year follow-up. Results From 664 patients, 351 were excluded due to lack of follow-up or early mortality. From a total of 313 patients (mean age 59.9±11.2 and 81% male), 55.3% were included in the CR program, with this group presenting a lower mean age (55.46±8.7 vs 65.39±11.5 p<0.001), as well as a higher frequency of a history of early ischemic heart disease and smoking, and a lower frequency of arterial hypertension and diabetes (Table). Lipid-lowering treatment at discharge was similar in both groups. In patients undergoing CR there was a lower level of total cholesterol and low-density lipoprotein cholesterol (LDLc) at one year (126.2±27 vs 137.2±34, p=0.002; 57.8±23 vs 67.5±26, p<0.001) compared to the group without CR. A greater reduction in LDLc (41.4% vs 0.86%, p<0.001) was achieved even from higher initial LDLc values. Titration of lipid-lowering treatment was also greater, with the old target of LDLc < 70 being achieved in a greater number of cases (81.5% vs 59.3%, p<0.001). At 1-year follow-up, the new cholesterol reduction target (LDL <55 or 50% reduction) was achieved in only 26.8% of patients, with a greater reduction being obtained in the CR group (34.1% vs 17.9%; p=0.02). At 2-year follow up, in CR group we found low rates of re-infarction (3.2% vs 4.1%), new revascularization (5.8% vs 7.3%), not statistically significant, but we could observe differences in mortality from all causes (0% vs 4.8%, p<0.01). Conclusions Participation in a CR program is associated with better lipid control in patients admitted for STEACS. These programs represent a basic tool for achieving increasingly demanding LDLc targets. Longer follow-up is needed to detect clinically important adverse events.

Prevalence of Risk Factors of Acute Coronary Syndrome in Erbil Cardiac Center: comparing ST-elevation with non ST-elevation Acute Coronary Syndrome

Background and objectives: Acute coronary syndrome is the leading cause of death all over the world, there are many different risk factors as important etiology for this acute condition, this syndrome has been studied in different countries with a variety of results. The aim was to define different risk factors for the patients admitted to Erbil cardiac center and to find out the most common of these factors and the relationship between different clinical types of this syndrome (namely ST-elevation myocardial infarction, non-ST elevation myocardial infarction/unstable angina) with varying types of risk factors. Methods: This was a cross-sectional descriptive nonrandomized study that included 100 patients with acute coronary syndrome, mean age of 57.5, the age range of 27—90 years, the majority of patients were male (78%), all patients were interviewed and investigated properly, and according to coronary angiographic findings treated by percutaneous coronary intervention or surgery. Results: The prevalence of acute coronary syndrome was significantly higher in male gender, the commonest risk factor was overweight and obesity 77% , followed in reduced frequency by other risk factors, More than half of patients(58.6%)with ST-elevation myocardial infarction were≤55years age, while 66.7% of patients with non ST-elevation myocardial infarction were >55years age. The most common artery involved was the left anterior descending artery, significant number 26.2% of non ST- elevation myocardial infarction/UA patients had three vessel stenosis and higher number34.5% of ST- elevation myocardial infarction patients had right coronary artery stenosis. Conclusions: The most common risk factor was overweight and obesity, no significant relation between clinical types and risk factors, low number of unstable angina cases seen in the emergency unit.

Management of acute coronary syndrome : ESC guidelines 2023

The new guidelines of the European Society of Cardiology (ESC) on the management of acute coronary syndrome (ACS) in 2023 encompass updates for both the guidelines pertaining to ST elevation myocardial infarction (STEMI) and acute coronary syndrome without ST segment elevation (NSTE-ACS). The previously separated guidelines from 2017 and 2020 were therefore revised and summarized. These guidelines address various topics, including diagnostics, acute management, antithrombotic treatment, out-of-hospital cardiac arrest, cardiogenic shock, invasive strategies, and long-term treatment. The notable updates compared to earlier guidelines address the recommendation regarding the timing of invasive diagnostics in NSTE-ACS (Non-ST elevation acute coronary syndrome), the procedure of revascularization in multivessel coronary artery disease and alternative regimens for antithrombotic treatment in patients with a high risk of bleeding.

The Role of Neutrophil to Lymphocytes Ratio and It's Common Clinical Outcomes Amount the Patient with Non ST Elevation Acute Coronary Syndrome

Objectives: To evaluate the admission neutrophil-to-lymphocyte ratio (NLR) for risk stratification for in-hospital out-comes and complications in non-ST-elevation acute coronary syndrome (non-ST-ACS) patients.
 Methodology: Methods: We recruited consecutive patients with non-ST-ACS. The NLR was obtained and stratified as low, inter- mediate, and high-risk based on <3.0, 3.0e6.0, and >6.0, respectively. The new ST-T changes, arrhythmias, contrast-induced nephropathy (CIN), and mortality were recorded.
 Results: Results: Median NLR was 3 [2.1-5.3] for 346 patients with 19.9% and 30.6% in high- and intermediate-risk group. New ST-T changes were observed in 3.5% (12) out of which 8, 3, and 1 patient in low, intermediate, and high-risk group (p = 0.424), respectively. Arrhythmias were observed in 5.8% (20) with 7, 5, and 8 patients in low, intermediate, and high- risk group (p = 0.067), respectively. CIN was observed in 4.9% (17) with 5, 5, and 7 in low, intermediate, and high-risk group (p = 0.064), respectively. In-hospital mortality was recorded in 1.4% (5) with 2 and 3 patients in high and low-risk group (p = 0.260), respectively.
 Conclusion: A significant number of non-ST-ACS patients fall in the high-risk category of NLR. Although, the association between NLR and in-hospital mortality and adverse events was not statistically significant but relatively higher rates of events were observed in high risk group.

Prognostic value of preprocedural pericoronary adipose tissue CT-Attenuation in patients with non ST-elevation acute coronary syndrome

Abstract Background Pericoronary adipose tissue attenuation expressed by fat attenuation index (FAI) on coronary CT angiography (CCTA) reflects pericoronary inflammation. FAI has been reported to be associated with cardiac mortality in patients with suspected coronary artery disease. However, the prognostic value of FAI in patients with non ST-elevation acute coronary syndrome (NSTE-ACS) after percutaneous coronary intervention (PCI) remains elusive. Methods This retrospective single-center observational study included a total of 358 patients with NSTE-ACS who underwent preprocedural 320-slice CCTA and emergent PCI within 24 hours from admission. Perivascular fat attenuation mapping was done around the three major coronary arteries-the proximal (4cm) right coronary artery (RCA), the left anterior descending artery (LAD), and the left circumflex artery (LCx). We assessed the prognostic value of FAI for all-cause and cardiac mortality. Clinical outcomes were assessed by death and cardiac death. Results During a median follow-up period of 1715 days (1008-2538), death and cardiac death occurred in 36 (10.1%) patients and 18 (5.0%) patients, respectively. High FAI values around LAD and LCx (but not around RCA) were predictive of all-cause mortality. High FAI values around RCA, LAD, and LCx were predictive of cardiac mortality. FAI in culprit vessels and average FAI values in three vessels were predictive of all-cause and cardiac mortality. ROC analysis revealed that the best cut-off FAI value in three vessels for predicting cardiac death is -65.8 (AUC: 0.752, 0.637-0.867.) Kaplan-Meier analysis revealed that patients with average FAI values in three vessels >-65.8 were significantly associated with poor prognosis of cardiac mortality. (P<0.001). Conclusion High perivascular FAI values are an indicator of increased cardiac mortality and, therefore, could guide early targeted secondary prevention and intensive medical management in patients with NSTE-ACS after PCI.Kaplan Meier analysis for cardiac death

New criteria to identify patients at higher risk for cardiovascular complications after percutaneous coronary intervention

Abstract A universal definition to identify patients at higher risk of complications after percutaneous coronary intervention (PCI) is lacking. We aimed to validate a recently developed score to identify patients at increased risk of all-cause death after PCI. All consecutive patients from a large PCI registry not presenting with ST-elevation myocardial infarction or cardiogenic shock were included. Each patient was assigned a score obtained by summing the points associated with the following variables: age >80 years (3 points), dialysis (6 points), left ventricular ejection fraction <30% (2 points), and multivessel PCI (2 points). Patients were stratified in 3 groups: low risk (score 0), intermediate risk (score 2 to 3), or high risk (score ≥4). The primary outcome was all-cause death, and the secondary outcomes were major adverse cardiovascular events and major bleeding. Events were assessed at 1 year after PCI. Between January 2014 and December 2019, 12,689 patients underwent PCI. Compared with the 9,884 patients at low risk, those at intermediate and high risk had a fourfold (hazard ratio 3.99, 95% confidence interval 2.95 to 5.38) and ninefold (hazard ratio 9.55, 95% confidence interval 6.89 to 13.2) higher hazard for all-cause death at 1 year, respectively. The score had a good predictive value for all-cause death at 1 year (area under the curve 0.70). The risk of major adverse cardiovascular events and major bleeding increased consistently from the low- to the high-risk group. In conclusion, in patients who underwent PCI for stable ischemic heart disease or non−ST-elevation acute coronary syndrome, a score based on 4 variables well predicted the risk of all-cause death at 1 year.Derivation of risk scoreAll-cause death rate at 1 year

Abstract 16613: Study of Modified HEART Score and HEART Pathway as Predictor of Major Adverse Cardiac Events (MACE) in Patients Presenting With Non ST Elevation- Acute Coronary Syndrome (NST-ACS)

Introduction: Among the various scores studied in literature, the modified HEART score and HEART pathway were found to have high discriminatory power of predicting major adverse cardiac events (MACE) in Non ST elevation acute coronary syndrome (NSTEACS) patients in various international studies. This warrants need for evaluation of these scores for better management of patients in hectic emergency departments of Indian healthcare system. Methods: This prospective observational study was conducted between January 2021 and May 2022 in a tertiary care hospital of New Delhi, India. Modified HEART score was calculated based on history, ECG, age, risk factors and highly sensitive troponin I (hsTrop I) values for 60 patients. Collected serum samples of hsTrop I at 0 and 3 hours were measured using ELISA kits. As per the score, patients in low risk group were discharged safely and intermediate and high risk groups were assessed with the help of stress testing and coronary angiography and managed accordingly. The occurrence of MACE was assessed at 30 days from presentation to healthcare facility. Results: The study showed that proportion of patients with MACE was significantly higher in high risk group (82.14%) as compared to low (0%) and intermediate risk group (20.83%) (p value <0.001). Modified HEART score was the best predictor of MACE at cut off point of >6 with 88.1% chances of correctly predicting MACE. Negative predictive value of HEART pathway was found to be 100% which enabled safe disposition of low risk group patients. Conclusions: Hence, when modified HEART score and HEART pathway were used together, it allowed efficient use of resources and prediction of MACE in NSTEACS. This was the first study done on Indian population where modified HEART score and HEART pathway were used simultaneously to predict the occurence of MACE.

Abstract 16906: Impact of ECPELLA Support on Mid-Term Survival and IABP-Shock II Score in Patients With Refractory Cardiogenic Shock Due to Acute Coronary Syndrome

Introduction: The prognosis remains extremely poor for acute coronary syndrome (ACS) with cardiogenic shock (CS) who required VA-ECMO. The IABP-SHOCK II score is a simple tool, and has demonstrated a high predictive ability for assessing the prognosis of patients with CS. Objective: To evaluate the impact of ECPELLA on intermediate-term survival compared to VA-ECMO with IABP support in patients with ACS and refractory CS and to assess the utility of the IABP-SHOCK II score in predicting outcomes for patients requiring VA-ECMO support. Methods: From January 2012 to December 2022, we enrolled 90 consecutive patients with ACS-CS who received VA-ECMO. Patents were divided into two groups; 44 patients received ECPELLA, and 46 patients received VA-ECMO with IABP. We assessed IABP-SHOCK II score and 180-day all-cause mortality. Results: There were no significant differences in age, rate of male sex, coronary risk factors, ST-elevated ACS, LMT lesion, extracorporeal cardiopulmonary resuscitation, and IABP-SHOCK II score between two groups. Kaplan-Meier analysis revealed that ECPELLA was associated with a significantly higher 180-day survival rate (p = 0.001). The patients were categorized into three groups based on the IABP-SHOCK II score: low (0-2), intermediate (3-4), and high (5-9). The IABP-SHOCK II risk score successfully stratified only the ECPELLA group into different risk categories for 30-day prognostic assessment. Conclusions: ECPELLA was associated with favorable mid-term survival compared to VA-ECMO with IABP support. Additionally, the IABP-SHOCK II score proved to be a useful tool for predicting mortality in patients treated with ECPELLA.

2023 Guidelines on Coronary Artery Disease: At a Glance

The guidelines have been released in the recent ESC congress held in Amsterdam, Netherlands. The summary is in two headings, new recommendations and change of recommendations compared to the previous guidelines. The wording to use classes of recommendations— is recommended – Class I, should be considered – Class IIa, may be considered – Class IIb, not recommended – Class III. In this guidelines of ACS, both ST segment elevation myocardial infarction and non ST segment elevation acute coronary syndrome diagnosis, management are addressed combinedly rather than separately as done in previous guidelines.Figures emphasizing the importance of evaluation of symptoms, diagnosis, and management are the highlights of the guidelines. Example: At initial assessment think ACS − Abnormal ECG, Clinical context, Stable patient?

Comparison of heart, grace and TIMI scores to predict major adverse cardiac events from chest pain in a Spanish health care region

Acute non-traumatic chest pain (ANTCP) is the second cause of consultation in the Emergency department (ED). About 70% of all Acute Myocardial Infarctions present as non persistent ST-elevation acute coronary syndrome (NSTE-ACS) in the electrocardiogram. Our aim was to compare whether the HEART risk score is more effective than the GRACE and TIMI scores for the diagnosis and prognosis of Major Adverse Cardiac Events (MACE) at six weeks in patients with ANTCP and NSTE-ACS. A prospective cohort study was conducted with patients with ANTCP that attended an ED and a Primary Care Emergency Center (PCEC) from April 2018 to December 2020. The primary outcome was MACE at six weeks. Diagnostic performance was calculated for each scale as the Area under the Receiver Operating Characteristic (ROC) curve (AUC), sensitivity (SE), specificity (SP), and predictive values (PV). Qualitative variables were compared using the Chi-square test, and continuous variables were compared using the nonparametric Kruskal–Wallis test. We adjusted a logistic regression for risk groups, age, and gender to determine the effect of the HEART, GRACE, and TIMI scores on MACE. The degree of agreement (kappa index) was calculated in the categorical classification of patients according to the three risk scales. Cox proportional hazards regressions were performed for each scale and were compared using partial likelihood ratio tests for non-nested models. From a sample of 317 patients with ANTCP, 14.82% had MACE at six weeks. The AUC was 0.743 (95% CI 0.67–0.81) for the HEART score, 0.717 (95% CI 0.64–0.79) for the TIMI score, and 0.649 (95% CI 0.561–0.738) for the GRACE score. The HEART scale identified low-risk patients with a higher SE and negative PV than the GRACE and TIMI scores. The HEART scale was better than the GRACE and TIMI scores at diagnosing and predicting MACE at six weeks in patients with ANTCP and probable NSTE-ACS. It was also a reliable tool for risk stratification in low-risk patients. Its application is feasible in EDs and PCECs, avoiding the need for complementary tests and their associated costs without compromising patient health.

The CineECG in ischemia localization in ST-elevation (equivalent) acute coronary syndromes

Aim of the studyIn this proof of concept study we aimed to visualize and quantify the injury vectors using the CineECG in representative examples of ST elevation acute myocardial infarction (STEMI) and STEMI-equivalent electrocardiograms (ECG's). For this purpose ECG's were selected with different ST deviation patterns in acute anterior wall, inferior or posterolateral wall infarctions. MethodsThe ST-amplitudes of the individual leads were measured between J-point and 60 ms after the J-point. These data were used to compute the direction and size (i.e. ST-amplitudes) of the injury vectors of the respective STEMI (equivalent)’s and displayed in the frontal, transverse and sagittal view. The relative contribution of the ST vector was computed for each axis (X,Y,Z) and per view using the length of the projected ST vector on the respective plane. ResultsThe injury vectors accurately pointed to the area at risk in either proximal, mid or distal occlusions of the respective coronary arteries. Moreover in LCX occlusions, where no or small ST abnormalities in the standard ECG were present, the CineECG was found to be capable in pointing towards the ischemic area. Especially the visualization of the ST-vector in the sagittal plane was found to be contributing. ConclusionsThese findings suggest that the CineECG could become a useful additional tool to support the clinician. Moreover our preliminary findings suggest that CineECG may be more capable in detecting ischemic changes in situations where the ECG is not supportive, such as in LCX occlusions. Further studies in patient cohorts are needed to confirm these observations.

КАРДИОЛОГИЧЕСКАЯ СЛУЖБА ИРКУТСКОЙ ОБЛАСТИ – ИТОГИ 2022 ГОДА И НАПРАВЛЕНИЯ РАЗВИТИЯ

КАРДИОЛОГИЧЕСКАЯ СЛУЖБА ИРКУТСКОЙ ОБЛАСТИ – ИТОГИ 2022 ГОДА И НАПРАВЛЕНИЯ РАЗВИТИЯ

Increasing Incidence of ST-Elevation Acute Coronary Syndrome in Young South Asian Population, a Challenge for the World? An Assessment of Clinical and Angiographic Patterns and Hospital Course of Premature Acute Myocardial Infarction

The incidence of premature ischemic heart disease (IHD) is increasing because of urbanization, a sedentary lifestyle, and various other unexplored factors, especially in South Asia. This study aimed to assess the distribution of premature ST-elevation acute coronary syndrome (STE-ACS) with its clinical and angiographic pattern along with hospital course in a contemporary cohort of patients who underwent primary percutaneous intervention at a tertiary care center in the South Asian region. We included consecutive patients of either gender diagnosed with STE-ACS and who underwent primary percutaneous intervention. Patients were stratified based on age as ≤40years (young) and >40years (old). Clinical characteristics, angiographic patterns, and hospital course were compared between the 2 groups. Of the total of 4,686 patients, 466 (9.9%) were young (≤40years). Young patients had a lower prevalence of hypertension (40.8% vs 54.5%, p<0.001), diabetes (26.6% vs 36.4%, p<0.001), metabolic syndrome (14.8% vs 24%, p<0.001), history of IHD (5.8% vs 9.3%, p=0.013) and a higher frequency of smoking (33% vs 24.7%, p<0.001), positive family history (8.2% vs 3.2%, p<0.001), and single-vessel involvement (60.1% vs 33.2%, p<0.001). The composite adverse clinical outcome occurrence was significantly lower in young patients (14.2% vs 19.5%, p=0.006). On multivariable analysis, history of IHD in young, whereas age, Killip class III/IV, intubated, arrhythmias on arrival, diabetes, history of IHD, pre-procedure left ventricular end-diastolic pressure, ejection fraction <40%, and slow flow/no-reflow during the procedure were found to be the independent predictors of adverse clinical outcome in old patients. In conclusion, we have a substantial burden of premature STE-ACS, mostly in male patients potentially driven by smoking and positive family history. Despite favorable pathophysiology, with mostly single-vessel hospital courses of STE-ACS in the young equally lethal in nature.

Type of evidence supporting ACC/AHA and ESC clinical practice guidelines for acute coronary syndrome.

The aim of clinical practice guidelines for ST elevation myocardial infarction (STEMI) and non-ST elevation acute coronary syndrome (NSTE-ACS) is to assist healthcare professionals in clinical decision-making. We evaluated the type of studies supporting these guidelines and their recommendations. All references and recommendations in the 2013 and 2014 ACC/AHA and 2017 and 2020 (ESC clinical guidelines for STEMI and NSTE-ACS were reviewed. References were classified into meta-analyses, randomised, non-randomised, and other types (e.g., position papers, reviews). Recommendations were classified according to class and their level of evidence (LOE). We retrieved 2128 non-duplicated references: 8.4% were meta-analyses, 26.2% randomised studies, 44.7% non-randomised studies, and 20.7% 'other' papers. Meta-analyses were based on randomised data in 78% of cases and used individual-patient data in 20.2%. Compared to non-randomised studies, randomised studies were more frequently multicentre (85.5% vs. 65.5%) and international (58.2% vs. 28.5%). The type of studies supporting recommendations varied as per the LOE of the recommendation. For LOE-A recommendations, the breakdown of supporting recommendations was: 18.5% meta-analyses, 56.6% randomised studies, 16.6% non-randomised studies and 8.3% 'other' papers; for LOE-B this breakdown was 9%, 39.8%, 38.2%, and 12.9%; and for LOE-C; 4.6%, 19.3%, 30.3%, and 45.9%. The references supporting the ACC/AHA and ESC guidelines on STEMI and NSTE-ACS consisted of non-randomised studies in ~ 45% of cases, with less than a third of the references consisting of meta-analyses and randomised studies. The type of studies supporting guideline recommendations varied widely by the LOE of the recommendation.

Clinical symptoms and ECG data in women with acute coronary syndrome

Background. There are many differences in chest pain symptoms between men and women in terms of location, nature, and additional symptoms. The issue of describing the differences in chest pain in men and women with acute coronary syndrome (ACS), as well as their correlation with changes in the electrocardiogram (ECG) and coronary angiography (CAG) remains relevant.Methods. The study included 588 patients of the cardiology department of the Novokuznetsk City Clinical Hospital No. 1 from 2013 to 2017 with a diagnosis of ACS. Depending on the gender, the subjects were divided into two groups: Group I – 330 men; Group II – 258 women.Results. ACS with ST elevation was more common in men (45.8 %) than in women (33.3 %; p = 0.002). There were no pathological ECG changes in women in 58.1 % of cases, in men – in 45.5 % (p &lt; 0.001). ECG type Q/ST elevation was detected more often in men (45.8 %) than in women (33.3 %; p = 0.002). The absence of coronary artery lesions was observed in 27.9 % of men and 44.2 % of women (p &lt; 0.001). Hemodynamically significant coronary artery stenosis was more common in men (57.6 %) than in women (38.7 %; p &lt; 0.001). In a typical angina clinic, hemodynamically significant coronary artery disease in patients with Q/without ST elevation ACS was detected in 40.2 % of men and in 58.5 % of women (p = 0.002). In the atypical angina clinic, hemodynamically significant lesions of coronary artery were more common in men (40.6 %) than in women (34.1 %; p = 0.02).Conclusion. In women atypical chest pains and intact coronary arteries were detected more often than in men, and hemodynamically significant coronary artery stenosis were found less often than in men. In men, a more pronounced pathology of the coronary arteries in ACS was revealed, in women – great difficulties in diagnosing ACS.

Non-Obstructive Coronaries In Patients Presenting With The Non St-Elevation Acute Coronary Syndrome.

Worldwide, cardiovascular diseases are the major cause of mortality and morbidity with acute coronary syndrome as the most common clinical manifestation. In a typical clinical setup, around 30% of the patients presented with "ST-segment elevation myocardial infarction (STEMI)" caused by the complete occlusion of the coronary artery and the remaining 70% with intermittent or partial occlusion of the coronary termed as non-ST elevation The aim of this study was to assess the prevalence and characteristics of non-obstructive coronary arteries among patients presenting with non ST-elevation acute coronary syndrome (NSTE-ACS) at a tertiary care cardiac center of Karachi, Pakistan. This was a descriptive cross-sectional study, conducted at a tertiary care hospital in Karachi. Study inclusion criteria were patients of either gender admitted with NSTE-ACS and aged between 30-70 years. A routine coronary angiogram was performed in all the patients and the absence of ≥50% stenosis in any major epicardial vessel was taken in non-obstructive coronaries. A total of 174 patients (30-70 years) were included, of which 99 (56.9%) were male and the mean age was 59.43±11.24 years. In the distribution of socioeconomic status, 54 (31.0%) were lower class, middle class 81 (46.6%) while upper-class status were 39 (22.4%). Hypertension was observed in 76 (43.7%), chronic kidney disease in 20 (11.5%), and hyperlipidemia in 55 (31.6%). Non-obstructive coronary arteries were noted in 25 (14.4%) patients. It is to be concluded that non-obstructive coronary arteries are fairly prevalent in patients arriving in hospitals with NSTE-ACS in our population. Further research is needed to better understand the underlying pathophysiology and optimal management strategies for patients with NOCA in the setting of NSTEMI.

Association of mortality rates and availability of emergency and specialized, including high-tech, medical services for acute coronary syndrome in the Russian Federation

Aim. To study the impact of the availability of emergency and specialized, including high-tech, medical services for patients with acute coronary syndrome on mortality in Russia.Material and methods. We used the cointegration of time series characterizing mortality from acute coronary syndrome (ACS) and following parameters for the availability of emergency and specialized, including high-tech, care for ACS in Russia for the period from 2016 to 2021 according to the "Monitoring of interventions to reduce mortality from coronary artery disease": the proportion of ambulance visits for ACS with response time &lt;20 minutes; the proportion of patients with ST-elevation ACS (STE-ACS) hospitalized within 12 hours from symptom onset; proportion of patients with STE-ACS admitted to hospital within 2 hours of symptom onset; proportion of patients with ACS admitted to specialized departments; proportion of patients with STE-ACS with prehospital thrombolysis; proportion of patients with STE-ACS with thrombolysis; proportion of patients with STE-ACS who underwent percutaneous coronary intervention (PCI); proportion of patients with non-ST-elevation ACS (NSTE-ACS) who underwent PCI; the proportion of patients with STE-ACS admitted before 12 hours from the onset of symptoms who underwent PCI; proportion of patients with ACS who underwent coronary artery bypass grafting. To rank the availability indicators, the elasticity (E) coefficient was used, which characterizes the strength of the relationship between the factor and the result, which shows the change in the result value per 1% change in the factor.Results. According to contribution decrement to reducing mortality, the factors of health care availibility for patients with ACS-STE were arranged as follows (coefficient of elasticity and determination (R2) is indicated in brackets): "The proportion of patients with ACS-STE who underwent PCI" (E=1,5%; R2=0,60), "Proportion of patients with STE-ACS with prehospital thrombolysis" (E=1,1%; R2=0,91), "Proportion of patients with STE-ACS with thrombolysis" (E=1,0%; R2=0,96 ), "Proportion of patients with STE-ACS admitted before 12 h who underwent PCI" (E=0,9%; R2=0,94), "Proportion of patients with STE-ACS admitted to hospital before 12 h from the symptom onset" (E=0,5%; R2=0,97), "Proportion of patients with STE-ACS hospitalized &lt;2 hours from the symptom onset" (E=0,2%; R2=0,95). A significant resource in reducing mortality in ACS is the reduction in ambulance response time in ACS (E=2,3%; R2=0,87) and compliance with specialized hospitalization of patients with ACS (E=1,8%; R2=0,73), but in reducing mortality in NSTE-ACS, the proportion of patients with NSTE-ACS who underwent PCI (E=1,7%; R2=0,72).Conclusion. An analysis of the impact of the availability of emergency and specialized, including high-tech, medical services for patients with ACS in Russia showed that the greatest contribution to mortality reduction in STE-ACS is made by time reduction in PCI and an increase in the use of thrombolytic therapy, mainly at the prehospital stage, in NSTE-ACS — an increase in the number of PCIs, and in ACS in general, strict compliance with specialized hospitalization of patients and a reduction in ambulance response time in ACS.

Treatment adherence in patients without ST-elevation acute coronary syndrome.

Despite progress during the last decades, patients with coronary artery disease (CAD) remain with a high residual risk due to multiple reasons. Optimal medical treatment (OMT) provides a decrease of recurrent ischemic events after acute coronary syndrome (ACS). Therefore, treatment adherence results crucial to reduce further outcomes after the index event. No recent data are available in Argentinian population; the main objective of our study was to evaluate the adherence at 6 and 15 months in post non-ST elevation acute coronary syndrome (NST-ACS) consecutive patients. Secondary objective was to evaluate the relationship of adherence with 15-month events. A prespecified sub-analysis in the prospective registry Buenos Aires I was performed. The adherence was evaluated using the modified Morisky-Green Scale. A number of 872 patients had information about adherence profile. Of them 76.4% were classified as adherents at month 6 and 83.6% at 15 (P=0.06). We did not find any difference in baseline characteristic between the adherent and non-adherent patients at 6 months. The adjusted analysis showed that non-adherent patients had a rate of ischemic events at 15th month of 20% (27/135) vs. 11.5% (52/452) in adherent patients (P=0.001). The bleeding events defined were of 3.6% in the non-adherent group vs. 5% in the adherent group without a statistical difference (P=0.238). Adherence to treatment is still a major issue as almost 25% of patients should be considered as non-adherent to OMT. No clinical predictor of this phenomenon was identified but our criteria were not exhaustive. Good adherence to treatment was highly associated to a reduction of ischemic events, whereas no impact on bleeding events was found. These data support a better network and collaboration with shared decision between healthcare professionals with patients and family members to improve acceptance and adherence to optimal medical strategies.

A systematic assessment of the characteristics of randomized controlled trials cited by acute coronary syndrome clinical practice guidelines.

The aim of this study was to describe the methodological features of the randomized controlled trials (RCTs) cited in American and European clinical practice guidelines (CPGs) for ST elevation myocardial infarction (STEMI) and non-ST elevation acute coronary syndrome (NSTE-ACS). Out of 2128 non-duplicated references cited in the 2013 and 2014 American College of Cardiology/American Heart Association and 2017 and 2020 European Society of Cardiology CPGs for STEMI and NSTE-ACS, we extracted data for 407 RCTs (19.1% of total references). The majority were multicenter studies (81.8%), evaluated pharmacological interventions (63.1%), had a 2-arm (82.6%), and superiority (90.4%) design. Most RCTs (60.2%) had an active comparator, and 46.2% were funded by industry. The median observed sample size was 1001 patients (84.2% of RCTs achieved≥80% of the intended sample size). Most RCTs had a single primary outcome (90.9%), which was a composite in just over half (51.9%). Among the RCTs testing for superiority, 44.0% reported a P-value of≥0.05 for the primary outcome and 61.9% observed a risk reduction of>15%. The observed treatment effect was lower-than-expected in 67.6% of RCTs, with 34.4% having at least a 20% lower-than-expected treatment effect. The calculated post hoc statistical power was≥80% for 33.9% of cited RCTs. This analysis demonstrates that RCTs cited by CPGs can still have significant methodological issues and limitations, highlighting that a better understanding of the methodological aspects of RCTs is crucial in order to formulate recommendations relevant to clinical practice.

Obesity paradox: a myth or reality, time to reveal the fact in a South Asian cohort presenting with STE-ACS undergoing primary percutaneous coronary intervention

ObjectivesObesity is a globally well-established risk factor for atherosclerotic cardiovascular diseases; however, some studies have witnessed survival benefits among obese patients and this phenomenon is termed ‘the obesity paradox’. Our...