ST-segment Elevation Acute Coronary Syndrome Research Articles

Acute rule-out of non–ST-segment elevation acute coronary syndrome in the (pre)hospital setting by HEART score assessment and a single point-of-care troponin: rationale and design of the ARTICA randomised trial

IntroductionBecause of the lack of prehospital protocols to rule out a non-ST-segment elevation acute coronary syndrome (NSTE-ACS), patients with chest pain are often transferred to the emergency department (ED) for...

Isolated Negative Vessel Remodeling–Induced Myocardial Ischemia

A 66-year-old man was referred to our hospital due to effort angina. His electrocardiogram (ECG) showed broad ST-segment depression, and high-sensitivity cardiac troponin I level was significantly increased, indicating non–ST-segment elevation acute coronary syndrome (ACS). Emergent coronary

ST-Segment Elevation ACS: Impact of Time to Diagnosis on Door-To- Balloon Time in the Real World. Data from the ARGEN-IAM-ST Registry

Background: Time elapsed from the onset of symptoms to diagnosis (TTD) can influence in achieving a door-to-balloon time<90 min (DBT <90 min). Methods: A retrospective analysis was performed on 1,518 patients prospectively and consecutively included in the ARGENAMI-ST registry. In 37.8% of cases. patients were treated with DBT <90 min and a median TTD of 120 min (IQR 60-266).The population was divided according to TTD above or below 120 min. A DBT <90 min was achieved more frequently inthose with TTD <120 min: 44% vs. 32.2% (p <0.001) respectively. Results: In patients with in situ percutaneous coronary intervention (PCI) and TTD 120 min (p 120 min (p: 0.003), as well as in patients admitted during non-working hours:41.9% vs. 30.4% (p <0.001). The independent predictors of achieving a DBT <90 min in the multivariate analysis were age<75 years: OR 1.57 (1.1-2.25; p: 0.01), PCI during working hours: OR 1.32 (1.04-1.67; p: 0.002), PCI in situ: OR 2.4 (1.9-3.0;p <0.001), having a pre-hospital ECG: OR 2.22 (1.73-2.86; p <0.001) and a TTD <120 min: OR 1.53 (1.23-1.9; p <0.001). Conclusions: In patients with TTD <120 minutes, a DBT <90 minutes is more frequently achieved, especially in those treated insitu and during working hours. In referred patients, only 1 in 3 achieves a DBT<90 min and there is no relationship with TTD.

Гендерные особенности клинического течения и исходов острого коронарного синдрома с подъемом сегмента ST

The aim of the research is to study clinical, hemodynamic, affective disorders in ST-segment elevation acute coronary syndrome (STEACS); to identify gender risk factors affecting the outcomes. Material and methods. The study included 90 males and 90 females with ST-segment elevation acute coronary syndrome. All patients underwent echocardiography, coronary angiography (CAG), and a set of laboratory examinations. Spielberger test, CES-D scales, Morisky-Green test, and Montreal Cognitive Function Scale were uses to study psycho-emotional status of 75 males and females. The treatment was carried out in accordance with current clinical protocols, clinical guidelines and standards. The prognosis was assessed in a year. The results were processed using nonparametric statistics methods. Results. It was revealed that the females, included in the study, were older than males; they more often suffered from coronary artery disease, hypertension, type 2 diabetes, constitutive obesity (before the index event); they more regularly underwent antihypertensive therapy; they more often reached target BP values. There were no differences in features of coronary anatomy, frequency of invasive treatment, but females were significantly more likely to undergo thrombolytic therapy. Males smoked more often; asked for medical help earlier from the onset of anginal syndrome; they were more susceptible to dilatation of the left ventricular cavity. Females more often than males had high and medium level of personal anxiety, as well as high level of situational anxiety. Predictors of worsening prognosis in females are 4-vascular lesion of coronary bed, cardiogenic shock upon admission, decreased hemoglobin, dilatation of the left atrium, decreased cognitive functions, smoking. In males the predictors are: 3-vascular damage, cardiogenic shock, renal failure. Conclusion. It was found that in STEACS there are differences between males and females in several clinical, anatomical and functional characteristics. Risk factors for an unfavorable prognosis are gender specific. The revealed facts can be useful in individualized treatment, rehabilitation and secondary prevention programs.

Morphine and Cardiovascular Outcomes Among Patients With Non-ST-Segment Elevation Acute Coronary Syndromes Undergoing Coronary Angiography

BackgroundMechanistic studies have shown that morphine blunts the antiplatelet effects of oral adenosine diphosphate receptor blockers. However, the clinical relevance of this interaction is controversial. ObjectivesThis study sought to explore the association between morphine and ischemic events in 5,438 patients treated with concomitant clopidogrel presenting with non-ST-segment elevation acute coronary syndromes (NSTEACS) in the EARLY ACS (Early Glycoprotein IIb/IIIa Inhibition in Patients With Non–ST-Segment Elevation Acute Coronary Syndrome) trial. Patients not treated with clopidogrel (n = 3,462) were used as negative controls. MethodsEndpoints were the composite of death, myocardial infarction (MI), recurrent ischemia, or thrombotic bailout at 96 h (4-way endpoint) and the composite of death or MI at 30 days. ResultsIn patients treated with clopidogrel, morphine use was associated with higher rates of the 4-way endpoint at 96 h (adjusted odds ratio [OR]: 1.40; 95% confidence interval [CI]: 1.04 to 1.87; p = 0.026). There was a trend for higher rates of death or MI at 30 days (adjusted OR: 1.29; 95% CI: 0.98 to 1.70; p = 0.072), driven by events in the first 48 h (adjusted hazard ratio: 1.54; 95% CI: 1.07 to 2.23; p = 0.021). In patients not treated with clopidogrel, morphine was not associated with either the 4-way endpoint at 96 h (adjusted OR: 1.05; 95% CI: 0.74 to 1.49; p = 0.79; pinteraction = 0.36 ) or death or MI at 30 days (adjusted OR: 1.07; 95% CI: 0.77 to 1.48; p = 0.70; pinteraction = 0.46). ConclusionsWhen used concomitantly with clopidogrel pre-treatment, morphine was associated with higher rates of ischemic events in patients with NSTEACS. (EARLY ACS: Early Glycoprotein IIb/IIIa Inhibition in Patients With Non–ST-Segment Elevation Acute Coronary Syndrome; NCT00089895)

Clinical and Angiographic Profile of Young Patients Presenting with Spontaneous Electrocardiogram Resolution of ST-Segment Elevation (Spontaneous Aborted) Myocardial Infarction: A Substudy of the Premature Coronary Artery Disease Registry (Registered Under [CTRI/2018/03/012544

Background: There are very few data regarding clinically defined spontaneous resolution (SR) in ST-segment elevation (STE) acute coronary syndrome (ACS) patients. Most recent European and American practice guidelines fail to give specific recommendations for these patients. Specifically, the timing of intervention in patients with SR remains unclear. Aim and Study: The aim of the study was to study the clinical, social, biochemical, and angiographic profile of Indian youth presenting with spontaneous resolution (SR) of ST-segment elevation (STE). Subjects and Methods: The premature coronary artery disease (PCAD) registry is a prospective, descriptive, observational study of Indians aged below 40 years with coronary artery disease (CAD) conducted between April 2017 and April 2020. Of 3450 patients registered in PCAD registry, a total of 41 (1.2%) out of these 3450 patients presented with STE myocardial infarction (MI), which resolved spontaneously, and hence these patients satisfied entry criteria. Entire clinical and angiographic profile of these patients was documented. Conventional lipids were estimated using commercially available kits. The data were analyzed by statistical software R version 3.5.0 (R Core Team (2018). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria). Results: The mean age of all patients under PCAD registry was 30.49 years. A majority of 38 (92.68%) of the patients were males, 30 (73.17%) were smokers. Of total, four patients (9.75%) were diabetic. Twenty-five out of 41 patients (60.97%) were coming under the below poverty line category. Five patients (12.19%) were Muslims by religion, whereas the remaining were Hindus. The majority (38 patients, 92.68%) were nonvegetarians. The most common index presentation of the transient STE was with anterior wall MI (27 patients, 65.85%). The mean total cholesterol of the entire study population was 172.947 ± 47.11. Thirty-nine out of 41 patients (95.12%) underwent diagnostic coronary angiogram. Ultimately, 32 out of 41 patients (78.05%) were discharged and continued on optimal medical therapy and follow-up and nine patients (21.95%) underwent percutaneous coronary revascularization. Conclusions: Patients with ACS and SR of ST-elevation on electrocardiogram (ECG) exhibit a characteristic profile that differentiates them from the rest of patients with STEMI: younger age, a greater prevalence of males and smokers, and a lesser elevation of the necrosis markers, a greater ejection fraction, and a higher prevalence of single-vessel disease. Contrary to popular belief, coronary angiogram showed a significant proportion of them to be having underlying organic CAD. Our study highlights the need for early intervention in such patients.

Outcomes of Women Compared With Men After Non–ST-Segment Elevation Acute Coronary Syndromes

BackgroundIt remains disputed whether women are at excess risk of adverse outcomes versus men after non–ST-segment elevation acute coronary syndromes (NSTEACS) or whether differences are explained by discordant risk factors. ObjectivesA sex-specific analysis of cardiovascular outcomes after NSTEACS across trials conducted by the Thrombolysis In Myocardial Infarction (TIMI) Study Group was performed to determine the impact of sex on cardiovascular outcomes in this dataset. MethodsTen TIMI trials were identified that enrolled >2,500 patients with NSTEACS within 30 days of hospitalization. Cox proportional hazards models were used to examine the association of sex with major adverse cardiovascular events (MACE) (cardiovascular death, myocardial infarction, or stroke) after adjusting for relevant risk factors in individual trials; point estimates were then combined by using random effects models. Individual components of the composite outcome and all-cause mortality were also analyzed. ResultsAmong 68,730 patients with NSTEACS, 19,827 (29%) were women. Women were older and more frequently had hypertension, diabetes, prior heart failure, and renal impairment than men. Before considering relevant confounders, women were at similar risk of MACE compared with men (hazard ratio [HR]: 1.04; 95% confidence interval [CI]: 0.99 to 1.09; p = 0.16) but at higher risk of all-cause death (HR: 1.12; 95% CI: 1.01 to 1.24; p = 0.03). After adjustment for baseline differences, risks of MACE (HR: 0.93; 95% CI: 0.88 to 0.98; p < 0.01) and all-cause death (HR: 0.84; 95% CI: 0.78 to 0.90; p < 0.0001) were lower among women compared with men. ConclusionsAfter accounting for cardiovascular risk factors, women enrolled in clinical trials were at lower risk of MACE than men after NSTEACS. Women, however, remain undertreated with many evidence-based therapies.

Place of Prasugrel, P2Y12 receptor antagonist, in an early invasive treatment of patients with acute coronary syndrome (according to the results of multicenter randomized controlled trial ISAR-REACT 5)

The conclusion of the Expert Council reports an agreement on the place of the P2Y 12 receptor blocker prasugrel in the early invasive treatment of patients with acute coronary syndrome ACS, according to the results of the multicenter randomized controlled study ISAR-REACT 5. Prasugrel should be considered the preferred P2Y 12 receptor blocker in the planned primary percutaneous coronary intervention and early invasive management of patients with ST segment elevation ACS. Herewith, prasugrel intake in patients with non-ST segment elevation ACS is preferable after coronary angiography and decision for coronary stenting.

P5368The prevalence and management of familial hypercholesterolemia in patients with acute coronary syndrome in Poland: results of the TERCET registry

Abstract Background Prevalence of familial hypercholesterolemia (FH) is high among patients with coronary artery disease (CAD). However, data on FH among patients with acute coronary syndrome (ACS) are still scarce. Purpose Therefore, we aimed to assess the prevalence, lipid-lowering therapy and short- and long-term outcomes in patients with FH among patients with ACS. Methods We finally included 19,582 consecutive patients from the Hyperlipidaemia Therapy in the tERtiary Cardiological cEnTer (TERCET) Registry for years 2006–2018. Among them, there were 7,319 patients admitted with ACS: 3,085 due to ST-segment elevation acute coronary syndrome (STEMI), 2,256 due to NSTEMI, and 1,978 due to unstable angina (UA). Stable CAD [sCAD] group n=12,462 that was treated as a reference one. Based on the personal and familial history of premature cardiovascular disease and low-density lipoprotein cholesterol (LDL-C) concentration, the Dutch Lipid Clinic Network (DLCN) algorithm was used for FH diagnosis. Results At the time of hospitalization, the overall occurrence of probable/definite FH and possible FH were 1.2% and 13.5% respectively. In patients with ACS, 1.6% had probable/definite FH and 17.0% possible FH. The highest occurrence of FH was observed in STEMI subgroup, where 20.6% of the patients had ≥3 points according to the DLCN criteria. There were significant differences in hypolipemic treatment between the FH subpopulations. In patients with definite/probable FH 92.3% and 91.5% were administered statins at discharge, respectively (including 52.9% prescribed intensive statin therapy). Patients with definite and probable FH had higher 30-day mortality than patients without FH (8.2% and 3.8% vs 2.0%, respectively; p=0.0052). However, no significant differences were observed between the FH groups in the 12-, 36- and 60-month follow-up (Figure). Propensity-score matching analysis showed that definite/probable FH patients had significantly higher all-cause mortality at the 36- and 60-month follow-up in comparison to non-FH subjects (11.4% vs 4.8% and 19.2% vs 7.2%, respectively; p≤0.021 for both). Outcomes depending on DCLN FH diagnosis. Conclusions The prevalence of FH according to the DLCN criteria in the Polish very high-risk population is even 14.7% and is significantly higher in patients with ACS than in patients with sCAD. Among patients included in the Registry, the occurrence of FH rises to 20.6% in the STEMI subgroup, and to 17.2% in the NSTEMI subgroup. Propensity-score matching analysis confirmed that FH itself is a cause of increased all-cause mortality in the long-term follow-up. Acknowledgement/Funding None

TCT-162 Impact of Thrombocytopenia on Subsequent 1-Year Major Adverse Cardiovascular Event (MACE) in Non–ST-Segment Elevation Acute Coronary Syndrome (NSTE-ACS)

The relationship of thrombocytopenia to subsequent major adverse cardiovascular events (MACE) in non–ST-segment elevation acute coronary syndrome (NSTE-ACS) is unclear. A total of 1,510 consecutive patients with NSTE-ACS presenting to a teaching hospital in Hong Kong in 2014 to 2018 were analyzed

TCT-639 Early Invasive Versus Initial Conservative Management Among Older Patients With Non-ST-Segment Elevation Acute Coronary Syndrome

Older patients with non–ST-segment elevation acute coronary syndromes (NSTE-ACS) are frequently encountered in routine clinical practice. However, real-world data on the use, influencing factors, clinical outcomes, and economic burden of early invasive strategy versus initial conservative

TCT-645 The Importance of Coronary Revascularization and Guideline-Directed Medical Therapy (GDMT) in Elderly With Non–ST Elevation Acute Coronary Syndrome (NSTE-ACS)

The importance of guideline-directed medical therapy (GDMT) and coronary revascularization in non–ST-segment elevation acute coronary syndrome (NSTE-ACS) cannot be overstressed. Yet treatment is often conservative in elderly patients. We examine the survival benefit of GDMT and revascularization

1-Year Outcomes of Delayed Versus Immediate Intervention in Patients With Transient ST-Segment Elevation Myocardial Infarction

ObjectivesThe aim of the present study was to determine the effect of a delayed versus an immediate invasive approach on final infarct size and clinical outcome up to 1 year. BackgroundUp to 24% of patients with acute coronary syndromes present with ST-segment elevation myocardial infarction (STEMI) but show complete resolution of ST-segment elevation and symptoms before revascularization. Current guidelines do not clearly state whether these patients with transient STEMI should be treated with a STEMI-like or non–ST-segment elevation acute coronary syndrome–like intervention strategy. MethodsIn this multicenter trial, 142 patients with transient STEMI were randomized 1:1 to either delayed or immediate coronary intervention. Cardiac magnetic resonance imaging was performed at 4 days and at 4-month follow-up to assess infarct size and myocardial function. Clinical follow-up was performed at 4 and 12 months. ResultsIn the delayed (22.7 h) and the immediate (0.4 h) invasive groups, final infarct size as a percentage of the left ventricle was very small (0.4% [interquartile range: 0.0% to 2.5%] vs. 0.4% [interquartile range: 0.0% to 3.5%]; p = 0.79), and left ventricular function was good (mean ejection fraction 59.3 ± 6.5% vs. 59.9 ± 5.4%; p = 0.63). In addition, the overall occurrence of major adverse cardiac events, consisting of death, recurrent infarction, and target lesion revascularization, up to 1 year was low and not different between both groups (5.7% vs. 4.4%, respectively; p = 1.00). ConclusionsAt follow-up, patients with transient STEMI have limited infarction and well-preserved myocardial function in general, and delayed or immediate revascularization has no effect on functional outcome and clinical events up to 1 year.

In-Hospital Coronary Revascularization Rates and Post-Discharge Mortality Risk in Non–ST-Segment Elevation Acute Coronary Syndrome

BackgroundThe relationship between in-hospital coronary revascularization rate (CRR) and post-discharge mortality rates in survivors of non–ST-segment elevation acute coronary syndrome (NSTE-ACS) at a system level is unclear. ObjectivesThe purpose of this study was to evaluate CRR and 2-year post-discharge mortality rate (2YMR) in NSTE-ACS. MethodsCRR and 2YMR were analyzed by hospital rate of CRR (in deciles), by country, and by world region in 11,931 patients with NSTE-ACS who survived to discharge and were enrolled in the EPICOR (long-tErm follow uP of antithrombotic management patterns In acute CORonary syndrome patients) and EPICOR Asia: twin multinational, observational, prospective cohort studies. ResultsSignificant differences in patient baseline characteristics, medical therapies, CRR, and 2YMR were found. Mean CRR ranged from 0.0% to 96.8% in the first and tenth decile, respectively (p < 0.001); from 12.3% in Romania to 92.4% in Slovenia (p < 0.001); and from 53.9% in South East Asia (SEAsia) to 90.4% in South Korea–Singapore–Hong Kong. 2YMR varied significantly between hospital deciles of CRR (3.6% in tenth decile vs. 9.2% in first decile; p < 0.001), countries (lowest 1.5% in Slovenia, highest 19.4% in Malaysia; p < 0.001), and regions (lowest 3.8% in South Korea–Singapore–Hong Kong, highest 11.7% in SEAsia; p < 0.001). Poisson regression models, adjusted for 15 mortality predictors, showed a significant inverse association between CRR and 2YMR for hospitals (r = −0.90; p < 0.001), countries (r = −0.65; p < 0.001), and regions (r = −0.87; p = 0.005). ConclusionsHigher CRRs at the hospital, country, and world region levels are strongly associated with higher post-discharge survival, suggesting CRR as a marker of higher system quality.

Coronariografía precoz y mortalidad a largo plazo en infarto agudo de miocardio de alto riesgo. Registro CARDIOCHUS-HUSJ

Introduction and objectivesThis study sought to analyze the association of early coronary angiography with all-cause mortality and cardiovascular mortality in patients with non–ST-segment elevation acute coronary syndrome (NSTEACS) using a large contemporary cohort of patients with NSTEACS from 2 Spanish tertiary hospitals. MethodsThis retrospective observational study included 5673 consecutive NSTEACS patients from 2 Spanish hospitals between 2005 and 2016. We performed propensity score matching to obtain a well-balanced subset of patients with the same probability of undergoing an early strategy, resulting in 3780 patients. Survival analyses were performed by Cox regression models once proportional risk test were verified. ResultsAmong the study participants, only 2087 patients (40.9%) underwent early invasive coronary angiography. The median follow-up was 59.0 months [interquartile range, 25.0-80.0 months]. All-cause mortality was 19.0%, cardiovascular mortality was 12.8%, and 51.1% patients experienced at least 1 major cardiovascular adverse event in the follow-up. After propensity score matching, the early strategy was associated with significantly lower mortality (hazard ratio: 0.79; 95% confidence interval 0.62-0.98) in high-risk NSTEACS patients. The early strategy showed a nonsignificant inverse tendency in patients with GRACE score <140. ConclusionsIn high-risk (GRACE score ≥ 140) NSTEACS patients in a contemporary real-world registry, early coronary angiography (first 24 hours after hospital admission) may be associated with reduced all- cause mortality and cardiovascular mortality at long-term follow-up.

Persistence with dual antiplatelet therapy after percutaneous coronary intervention for ST-segment elevation acute coronary syndrome: a population-based cohort study in Catalonia (Spain)

ObjectivesGuidelines recommending 12-month dual antiplatelet therapy (DAPT) in patients with ST-elevation acute coronary syndrome (STEACS) undergoing percutaneous coronary intervention (PCI) were published in year 2012. We aimed to describe the...

Cardiac Arrest within the First 24 Hours after Hospital Admission in ST-segment Elevation Acute Coronary Syndromes. The ARGEN-IAM-ST Registry

hospital mortality.Objectives: The aim of this study was to describe the prevalence, clinical characteristics, and in-hospital outcome of patientsfrom the ARGEN-IAM-ST registry with CA within the first 24 hours after hospital admission.Results: The prevalence of CA within the first 24 hours was 7.8% (136/1,754 patients). These patients were older (median age63 vs. 61 years, p<0.001) and had higher prevalence of cardiogenic shock (42.6% vs., 3%, p<0.01) and of in-hospital mortality(66% vs. 4%, p<0.001). Overall mortality of the registry was 8.8% (154/1754) and 58% occurred in patients with CA withinthe first 24 hours after admission.Conclusions: Cardiac arrest within 24 hours in patients with ST- segment elevation acute coronary syndrome is a serious eventrepresenting 60% of in-hospital mortality.

Cardiac Arrest within the First 24 Hours after Hospital Admission in ST-segment Elevation Acute Coronary Syndromes. The ARGEN-IAM-ST Registry

Cardiac Arrest within the First 24 Hours after Hospital Admission in ST-segment Elevation Acute Coronary Syndromes. The ARGEN-IAM-ST Registry

FREQUENCY OF TRADITIONAL RISK FACTORS AND EVALUATION OF LIPID PROFILE IN PATENTS WITH ACUTE CORONARY SYNDROME

Objective: To determine the frequency of traditional risk factors with evaluation oflipid profile in patients with acute coronary syndrome. Methodology: This was a descriptive cross sectional study with non-randomizedconsecutive sampling. The study was conducted from 1st June to 30thNovember, 2018 in Coronary Care Unit, Department of Cardiology, HayatabadMedical Complex, Peshawar, Pakistan in which all patients with age >18 yearswith diagnosis of acute coronary syndrome were recruited. Detail history ofhypertension, diabetes mellitus, smoking, and family history for coronary arterydisease was taken. Dyslipidemia was evaluated by measuring blood lipid profile.SPSS version 20 was used for analysis. Significance was set at P≤0.05. Results: We analyzed 384 patients with acute coronary syndrome out of which60.7% were male. There was no significant difference in age of male (25-91years) and female (26-90 years) patients. ST segment elevation acute coronarysyndrome was 74.5% and non ST segment elevation acute coronary syndromewas 25.5%. Frequency of dyslipidemia, hypertension, diabetes mellitus,smoking, and family history of coronary artery disease was 86.7%, 52.3%,34.1%, 26% and 9.6%, respectively. The most frequent lipid abnormality was inHDL cholesterol, followed by triglycerides, total cholesterol and LDL cholesterol. Conclusion: Dyslipidemia was the most common risk factor followed byhypertension, diabetes mellitus and smoking. The most common abnormalitiesin lipid profile were low level of HDL cholesterol, followed by triglycerides, totalcholesterol and LDL cholesterol. Key Words: Acute Coronary Syndrome, Risk Factors, Dyslipidemia,Hypertension, Diabetes Mellitus, Smoking

Safety of a Very Early Discharge Strategy for ST-segment Elevation Acute Coronary Syndrome.

Safety of a Very Early Discharge Strategy for ST-segment Elevation Acute Coronary Syndrome.