ST-segment Elevation Acute Coronary Syndrome Research Articles

Contemporary Management and Prognostic Factors of Arrhythmia Recurrence in Patients with High-Energy Discharge of Cardiac Implantable Electronic Devices.

Background and Objectives: Understanding the underlying causes of implantable cardioverter-defibrillator (ICD) discharges is vital for effective management. This study aimed to evaluate the characteristics of patients admitted following ICD discharge, focusing on myocardial ischemia as a potential exacerbating factor and potential risk factors for VT recurrence. Materials and Methods: This retrospective, single-center study included 81 patients with high energy discharge from cardiac implantable electronic device admitted urgently to the cardiology department from 2015 to 2022. The exclusion criterion was ST-segment elevation acute coronary syndrome. Data were collected anonymously from electronic medical records. Patients were categorized based on coronary angiography, percutaneous angioplasty, presence of significant stenosis, recurrent ventricular tachycardia (VT), and catheter ablation. Clinical variables, including demographic data, echocardiographic parameters, and pharmacotherapy, were analyzed. The primary endpoint was the recurrence of VT during in-hospital stay. Results: Among 81 patients, predominantly male (86.4%), with a mean age of 63.6 years, 55 (67.9%) had coronary artery disease (CAD) as the primary etiology for ICD implantation. Coronary angiography was performed in 34 patients (42.0%) and showed significant stenosis (>50%) in 18 (41.8%) patients, while 8 (26.0%) individuals underwent percutaneous coronary intervention (PCI). Recurrent VT occurred in 21 subjects (26.3%), while ventricular catheter ablation was performed in 36 patients (44.0%). Referral for urgent coronary angiography was associated with presence of diabetes (p = 0.028) and hyperlipidemia (p = 0.022). Logistic regression analysis confirmed NYHA symptomatic class (OR 4.63, p = 0.04) and LVH (OR 10.59, p = 0.049) were independently associated with relapse of VT. CAD patients underwent catheter ablation more frequently (p = 0.001) than those with dilated cardiomyopathy. Conclusions: The study showed a low referral rate for coronary angiography among patients with ICD discharge. Presence of LVH and preexisting symptomatic class influence arrhythmia recurrence. Understanding these associations can guide personalized management strategies for ICD recipients.

TCT-6 Aspirin-Free Prasugrel Monotherapy After PCI in Patients With Non–ST-Segment Elevation Acute Coronary Syndrome

TCT-6 Aspirin-Free Prasugrel Monotherapy After PCI in Patients With Non–ST-Segment Elevation Acute Coronary Syndrome

Incidence and predictors of acute coronary syndrome after transcatheter mitral valve repair

ABSTRACT Background Acute coronary syndrome (ACS) post-transcatheter mitral valve repair (TMVR) carries high mortality. We aim to study the incidence and predictors of ACS in patients who underwent TMVR. Research design and methods We queried the U.S. National Readmission Database to identify all cases of TMVR from 2016 to 2019. We further evaluated the incidence of ACS and used multivariable logistic regression to determine independent predictors of ACS in this population. Results Among 3,742 patients who underwent TMVR, 264 (7.05%) developed ACS. Among ACS patients, 204 (77%) had non-ST-segment elevation ACS and 66 (25%) had ST-segment elevation ACS. Independent predictors of ACS were acute limb ischemia, cardiogenic shock, history of coronary artery disease (CAD), smoking, cardiac arrest, respiratory failure requiring mechanical ventilation, and acute kidney injury. In-hospital mortality among ACS was three times higher in ACS patients than without ACS (16.76% vs. 5.45%, p-value < 0.01). Conclusions ACS is not an uncommon complication after TMVR. The occurrence of ACS after TMVR is associated with high in-hospital mortality, longer length of stay, and higher hospital charges. The strongest predictors of ACS in these patients are the development of acute limb ischemia, cardiogenic shock, and a history of CAD.

Association of cell-free DNA with the length of ulcerated plaque in the infarct-related artery and the myocardial infarct size among patients with ST-segment elevation acute coronary syndrome undergoing percutaneous coronary intervention

Aim. To evaluate the changes of cell-free DNA (cfDNA) levels before and after percutaneous coronary intervention (PCI) in patients with ST-segment elevation acute coronary syndrome (STE-ACS). To identify associations of cfDNA concentration before and after PCI with complications and length of ulcerated plaque in patients with STE-ACS.Material and methods. This prospective single-center observational pilot study included 44 patients with STE-ACS admitted to the cardiac intensive care unit during the period of May-August 2023. In all patients, along with standard laboratory tests, cfDNA level was measured upon admission and 24 hours after PCI. Assessment of cfDNA associations before and after PCI was carried out in relation to following significant complications and conditions in STE-ACS patients: death, acute left ventricular failure (ALVF), acute heart failure (AHF), arrhythmia, number of stents implanted, number of segments with impaired local contractility, total stent length.Results. The mean age of the patients was 60,6±9,6 years, of which 74,6% were men. TIMI 0-1 flow was recorded in 93,2% of the subjects. The most common complications were cardiogenic shock (18,4%), arrhythmia (16,9%), AHF (13,6%), ALV (11,9%). Death was recorded in 8,5%. Implantation of 1 stent in PCI was performed in 75% of cases, while in the rest, 2 or more stents were implanted. The proportion of patients with impaired local contractility was 90%, the median stent length was 24,0 (20,0-50,0) mm. CfDNA level on admission did not differ from level after PCI 94,5 (78,3-155,5) ng/ml vs 115,0 (71,0-152,0), p=0,46. However, it signi­ficantly exceeded the cfDNA concentration from a group of healthy volunteers (78,0 (59,7-106,0), p=0,017). Characteristic curve showed significant relationships both for the concentration of cfDNA before (with implantation of 2 or more stents (AUC 0,71 with 95% confidence interval (CI) 0,56-0,86, p=0,039), stent length &gt;24 mm (AUC 0,73 with 95% CI 0,58-0,89, p=0,009)) and after PCI (with the number of impaired local contractility segments (AUC 0,73 with 95% CI 0,57-0,89, p=0,014)). If the cfDNA level before PCI was &gt;90 ng/ml, the risk of implantation of 2 or more stents per procedure increased by 5,4 times (odds ratio (OR) 5,4, 95% CI 1,11-28,93, p=0,044). The risk of a stent length &gt;24 mm with pre-PCI cfDNA &gt;107 ng/ml increased 9-fold (OR 9,0 with 95% CI 2,2-36,9, p=0,001), and the cfDNA level after PCI &gt;105 ng/ml increased the risk of impaired local left ventricular (LV) contractility in 2 or more segments by 5 times (OR 5,0, 95% CI 1,23-20,3).Conclusion. In the studied group of patients with STE-ACS subject to intervention, the cfDNA concentration before PCI was associated with the implantation of ≥2 stents and the stent length (&gt;24 mm). CfDNA level before PCI was associated with the number of segments of impaired local LV contractility (≥2).

Electrocardiographic criteria for occlusive and prognostically unfavorable coronary artery disease

Since patients with occlusive coronary artery thrombosis benefit more from emergency reperfusion, after the widespread introduction of thrombolytic therapy, the concept of Q-wave and non-Q-wave myocardial infarction was replaced by the concept of ST-segment elevation (STE) and non-STE (NSTE) acute coronary syndrome (ACS). But at present, due to the spread of mechanical reperfusion, this concept does not seem to be fully perfect. The electrocardiographic (ECG) diagnostic method allows, among patients with NSTE-ACS, to identify a group of patients with occlusive and/or prognostically unfavorable hemodynamically significant coronary lesions, as well as to provide them with timely percutaneous coronary intervention as early as possible and to improve outcomes. This article rationales changing approaches to the management of patients with NSTE-ACS and analyzes in detail the currently known ECG criteria for occlusive and/or prognostically unfavorable coronary lesions.

Prevalence and Predictors of Occlusive Myocardial Infarction in Patients Presenting With Non-ST-Elevation Acute Coronary Syndrome in Duhok, Iraq: A Cross-Sectional Study.

Background and aim Myocardial infarction is a major global health issue and the leading cause of death. Non-ST segment elevation acute coronary syndrome (NSTE-ACS) could behave like ST-segment elevation ACS in terms of causing total or near total occlusion of the coronary artery and leading to occlusive myocardial infarction (OMI). This study aims to assess OMI prevalence and associated factors in NSTE-ACS patients in Duhok, Iraq, to improve diagnosis and treatment outcomes. Materials and methods This prospective cross-sectional study, conducted at Azadi Heart Center and Zakho Teaching Hospital from March 2023 to March 2024, included 189 NSTE-ACS patients undergoing coronary angiography. Data collection encompassed demographics, clinical profiles, electrocardiographic (ECG) patterns, cardiac biomarkers, and angiographic outcomes. Patients were categorized into those with and without occlusive myocardial infarction (OMI). Results A total of 189 NSTE-ACS patients with a mean age of 58.65 (±10.38 SD) years were enrolled in the study. The overall OMI rate was 29.63%. OMI patients were older and had a higher prevalence of hypertension, dyslipidemia, and a family history of ischemic heart disease (IHD). Significant ECG changes associated with OMI included biphasic T-wave inversion and ST depression in specific leads. Marked elevation in troponin levels was also noted in OMI patients. The left anterior descending (LAD) artery was the most common culprit artery. Conclusions About one-quarter of our study cohort exhibited OMI. The condition was linked to clinical, ECG, and elevated troponin levels. The study underscores the importance of promptly recognizing occlusive myocardial infarction (OMI) in NSTE-ACS patients for better outcomes. Regular audits are imperative to augment awareness among healthcare professionals at cardiac centers regarding updated protocols and guidelines.

Development of a Clinical Pathway for Acute Coronary Syndrome at Philippine General Hospital

BACKGROUND: Acute coronary syndrome (ACS) is a leading cause of admission and mortality in a tertiary care hospital in the Philippines. The significant burden of the disease necessitates that evidence-based care set by international and local guidelines be met to improve service delivery and quality of care (QOC). Institution-specific QOC studies showed gaps between guideline recommendations and compliance. Development and utilization of a clinical pathway are among the identified strategies to improve compliance. It is also crucial for implementation of standard-of-care set specific to a hospital setting based on its needs and resources. METHODS: This is a descriptive research on the development of a clinical pathway for ACS appropriate for the emergency room setting of a tertiary care hospital from March 2021 to August 2022. Local QOC studies and evidence behind the latest international guideline recommendations on the management of ACS were reviewed to create the interim ACS Pathway. Two-level content validation of the interim pathway was done: internal validation with the consultants and fellows of the Division of Cardiovascular Medicine and external validation through focused group discussions with different hospital units and stakeholders to assess applicability and feasibility based on the resources of the setting, identify hindrances, and propose solutions in its implementation. RESULTS: An evidence-based clinical pathway for ACS that encompasses identification and management of ST-segment elevation myocardial infarction and non–ST-segment elevation acute coronary syndrome with judicious use of locally available and feasible resources applicable for local emergency room hospital setting was created. CONCLUSION: Review of local QOC studies and interdepartmental collaboration are necessary components in developing institution-specific clinical pathway for ACS. KEYWORDS: acute coronary syndrome, clinical pathway, quality of care

STUDY OF DIETARY REMODELING OF THE INTESTINAL MICROBIOTA BY GRAPE POLYPHENOLS AT THE LEVEL OF TRIMETHYLAMINE N-OXIDE (TMAO) IN PATIENTS WITH ACUTE CORONARY SYNDROME WITH ELEVATION OF THE SEGMENT ST

The main cause of mortality and disability in the adult population of our planet is cardiovascular diseases caused by atherosclerosis. The relevance of research into new methods of treating atherosclerosis is only increasing. In addition to dyslipedemia, infections and inflammation, new predictors of atherogenesis are being sought, and one of them is the level of trimethylamine N-oxide (TMAO). Many large studies have shown that circulating TMAO levels correlate with the development of atherosclerosis. In turn, the formation of TMAO depends on the state of the intestinal microbiome. That is, the stages of development of atherosclerosis can be influenced by changes in the intestinal microbiome. Purpose: Based on domestic and foreign scientific publications, to determine the effect of dietary remodeling of the gut microbiota by grape polyphenols on trimethylamine N-oxide (TMAO) levels in patients with STsegment elevation acute coronary syndrome. Results and conclusions: It was revealed that in patients with STEMI, the use of the prebiotic Kainar with grape polyphenols changes the concentration of TMAO in the blood. It was confirmed that there were statistically significant differences in TMAO values in the control group and the group taking Kaynar after 3 months and after 12 months.

Timing of Complete Multivessel Revascularization in Patients Presenting With Non-ST-Segment Elevation Acute Coronary Syndrome

BackgroundComplete revascularization of the culprit and all significant nonculprit lesions in patients with non–ST-segment elevation acute coronary syndrome (NSTE-ACS) and multivessel disease (MVD) reduces major adverse cardiac events, but optimal timing of revascularization remains unclear. ObjectivesThis study aims to compare immediate complete revascularization (ICR) and staged complete revascularization (SCR) in patients presenting with NSTE-ACS and MVD. MethodsThis prespecified substudy of the BIOVASC (Percutaneous Complete Revascularization Strategies Using Sirolimus Eluting Biodegradable Polymer Coated Stents in Patients Presenting With Acute Coronary Syndrome and Multivessel Disease) trial included patients with NSTE-ACS and MVD. Risk differences of the primary composite outcome of all-cause mortality, myocardial infarction (MI), unplanned ischemia-driven revascularization (UIDR), or cerebrovascular events and its individual components were compared between ICR and SCR at 1 year. ResultsThe BIOVASC trial enrolled 1,525 patients; 917 patients presented with NSTE-ACS, of whom 459 were allocated to ICR and 458 to SCR. Incidences of the primary composite outcome were similar in the 2 groups (7.9% vs 10.1%; risk difference 2.2%; 95% CI: −1.5 to 6.0; P = 0.15). ICR was associated with a significant reduction of MIs (2.0% vs 5.3%; risk difference 3.3%; 95% CI: 0.9 to 5.7; P = 0.006), which was maintained after exclusion of procedure-related MIs occurring during the index or staged procedure (2.0% vs 4.4%; risk difference 2.4%; 95% CI: 0.1 to 4.7; P = 0.032). UIDRs were also reduced in the ICR group (4.2% vs 7.8%; risk difference 3.5%; 95% CI: 0.4 to 6.6; P = 0.018). ConclusionsICR is safe in patients with NSTE-ACS and MVD and was associated with a reduction in MIs and UIDRs at 1 year.

Photon-counting computed tomography: 'one-stop shop' for coronary stenosis, inflammation, and myocardial assessment in ST-segment elevation acute coronary syndrome.

Photon-counting computed tomography: 'one-stop shop' for coronary stenosis, inflammation, and myocardial assessment in ST-segment elevation acute coronary syndrome.

Effectiveness of Primary Coronary Intervention for Patients With Delayed ST-Segment Elevation Myocardial Infarction: Insights from Moroccan Cardiology Intensive Care Units

The benefits of myocardial revascularization in ST-segment elevation acute coronary syndrome after 12 to 24 hours from symptom onset remain a topic of debate, especially in patients who are stable and asymptomatic. We analyzed the benefit of late revascularization by primary coronary intervention in patients admitted to Moroccan cardiac intensive care units (CICUs) with ST-segment elevation myocardial infarction after 12 hours of symptom onset. We included a total of 406 patients who met the inclusion criteria: 262 patients in the invasive strategy group and 144 patients in the conservative strategy group. A total of 74.6% were men, and 25.4% were women. For the primary outcome, 46 all-cause deaths were observed at 1 year, with 33 patients in the conservative strategy arm and 13 patients in the invasive strategy group, with a significant difference between the 2 groups (p <0.001). For secondary outcomes, there was no difference in readmission for acute coronary syndrome or acute heart failure between the 2 groups (p = 0.277, p = 0.205). For in-CICU cardiogenic shock and ejection fraction <35% at discharge, more events are observed in the conservative strategy, with a significant difference for both (p <0.001). In multivariable analysis, 1-year all-cause mortality was independently associated with revascularization between 12 and 48 hours (hazard ratio [HR] 0.372, 95% confidence interval [CI] 0.182 to 0.762, p = 0.007), ejection fraction <35% at discharge (HR 1.92, 95% CI 1.22 to 2.54, p = 0.04), and cardiogenic shock in-CICU (HR 2.69, 95% CI 1.82 to 3.78, p = 0.005).Although no evidence exists to date on the true benefit of late primary coronary intervention revascularization in patients with ST-segment elevation myocardial infarction, this practice remains common, as indicated by the results of most registries.

Antithrombotic therapy in patients with acute coronary syndrome: similarities and differences between a European expert consensus document and the 2023 European Society of Cardiology guidelines.

Antithrombotic therapy represents the cornerstone of the pharmacological treatment in patients with acute coronary syndrome (ACS). The optimal combination and duration of antithrombotic therapy is still matter of debate requiring a critical assessment of patient comorbidities, clinical presentation, revascularization modality, and/or optimization of medical treatment. The 2023 European Society of Cardiology (ESC) guidelines for the management of patients with ACS encompassing both patients with and without ST segment elevation ACS have been recently published. Shortly before, a European expert consensus task force produced guidance for clinicians on the management of antithrombotic therapy in patients with ACS as well as chronic coronary syndrome. The scope of this manuscript is to provide a critical appraisal of differences and similarities between the European consensus paper and the latest ESC recommendations on oral antithrombotic regimens in ACS patients.

Endovascular prevention of distal embolism in pathogenesis of no-reflow phenomenon in percutaneous coronary interventions in patients with ST-segment elevation acute coronary syndrome

Endovascular prevention of distal embolism in pathogenesis of no-reflow phenomenon in percutaneous coronary interventions in patients with ST-segment elevation acute coronary syndrome

Unveiling Cardiovascular Outcomes: A Comparative Analysis of CABG Recipients versus Non-CABG Patients in the Management of Acute Coronary Syndrome (ACS).

The history of bypass surgery for coronary arteries and subsequent coronary angioplasty is a crucial and vital issue for patients with acute coronary syndrome (ACS). This study aims to investigate and compare the occurrence of cardiovascular events in patients with a history of Coronary Artery Bypass Grafting (CABG) versus those without such a history, specifically focusing on individuals diagnosed with ACS. This cohort study was conducted at Madani Hospital in Tabriz, Iran. Patients diagnosed with ACS who were hospitalized and underwent Percutaneous Coronary Intervention (PCI) from the beginning of 2018 to the beginning of 2020 were included. The records for follow-up regarding mortality and cardiovascular events were documented for the next three years (2020 to 2023). Subsequently, patients were categorized into two groups: those with a history of CABG and those without a history of CABG. Patients of each study group were divided into two groups: ST-segment elevation acute coronary syndrome (STEA)CS/primary PCI and non-ST-segment elevation acute coronary syndrome (NSTEACS)/PCI, a total of approximately 473 cases were collected. The study groups were compared in terms of in-hospital and long-term cardiovascular events as well as other clinical outcomes. A comparison of hospital and long-term events between the CABG group and the control group demonstrated a significant difference only in cases of recurrent myocardial infarction (MI)/ACS in long-term events (P=0.001). Additionally, comparing hospital and long-term events in the CABG group and the STEACS/NSTEACS control group revealed a significant difference only in cases of recurrent MI/ACS in long-term events (P=0.05). Patients with a history of CABG may face a higher risk of cardiovascular events, especially in recurrent MI/ACS. A thorough examination and closer monitoring of this patient group are needed to ensure improvement and mitigate the risks associated with potential complications arising from previous CABG surgeries.

Long-Term Outcomes of Invasive vs Conservative Strategies for Older Patients With Non-ST-Segment Elevation Acute Coronary Syndromes.

Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is a frequent cause of hospital admission in older people, but clinical trials targeting this population are scarce. The After Eighty Study assessed the effect of an invasive vs a conservative treatment strategy in a very old population with NSTE-ACS. Between 2010 and 2014, the investigators randomized 457 patients with NSTE-ACS aged≥80 years (mean age 85 years) to an invasive strategy involving early coronary angiography with immediate evaluation for revascularization and optimal medical therapy or to a conservative strategy (ie, optimal medical therapy). The primary endpoint was a composite of myocardial infarction, need for urgent revascularization, stroke, and death. The long-term outcomes are presented. After a median follow up of 5.3 years, the invasive strategy was superior to the conservative strategy in the reduction of the primary endpoint (incidence rate ratio: 0.76; 95%CI: 0.63-0.93; P=0.0057). The invasive strategy demonstrated a significant gain in event-free survival of 276days (95%CI: 151-400days; P=0.0001) at 5 years and 337days (95%CI: 123-550days; P=0.0001) at 10 years. These results were consistent across subgroups of patients with respect to major cardiovascular prognostic factors. In patients aged≥80 years with NSTE-ACS, the invasive strategy was superior to the conservative strategy in the reduction of composite events and demonstrated a significant gain in event-free survival. (The After Eighty Study: a randomized controlled trial; NCT01255540).

Timing of coronary angiography and use of antiplatelet pretreatment in patients with NSTEACS in Spain

Introduction and objectivesThe optimal timing of coronary angiography in patients admitted with non–ST-segment elevation acute coronary syndrome (NSTEACS) as well as the need for pretreatment are controversial. The main objective of the IMPACT-TIMING-GO registry was to assess the proportion of patients undergoing an early invasive strategy (0-24hours) without dual antiplatelet therapy (no pretreatment strategy) in Spain. MethodsThis observational, prospective, and multicenter study included consecutive patients with NSTEACS who underwent coronary angiography that identified a culprit lesion. ResultsBetween April and May 2022, we included 1021 patients diagnosed with NSTEACS, with a mean age of 67±12 years (23.6% women). A total of 87% of the patients were deemed at high risk (elevated troponin; electrocardiogram changes; GRACE score>140) but only 37.8% underwent an early invasive strategy, and 30.3% did not receive pretreatment. Overall, 13.6% of the patients underwent an early invasive strategy without pretreatment, while the most frequent strategy was a deferred angiography under antiplatelet pretreatment (46%). During admission, 9 patients (0.9%) died, while major bleeding occurred in 34 (3.3%). ConclusionsIn Spain, only 13.6% of patients with NSTEACS undergoing coronary angiography received an early invasive strategy without pretreatment. The incidence of cardiovascular and severe bleeding events during admission was low.

TCT-139 Timing of Complete Multivessel Revascularization in Patients Presenting With Non–ST-Segment Elevation Acute Coronary Syndrome

TCT-139 Timing of Complete Multivessel Revascularization in Patients Presenting With Non–ST-Segment Elevation Acute Coronary Syndrome

TCT-165 Aspirin-Free Prasugrel Monotherapy: 30-Day Clinical Outcome After Percutaneous Coronary Intervention in Chronic Coronary Syndrome and Non–ST-Segment Elevation Acute Coronary Syndrome

TCT-165 Aspirin-Free Prasugrel Monotherapy: 30-Day Clinical Outcome After Percutaneous Coronary Intervention in Chronic Coronary Syndrome and Non–ST-Segment Elevation Acute Coronary Syndrome

TCT-368 Optimal Timing of Invasive Strategy in Patients With High-Risk Non–ST-Segment Elevation Acute Coronary Syndrome: A Meta-Analysis

TCT-368 Optimal Timing of Invasive Strategy in Patients With High-Risk Non–ST-Segment Elevation Acute Coronary Syndrome: A Meta-Analysis

Age and gender-based categorization of very premature, premature, and non-premature acute myocardial infarction: A comparison of clinical and angiographic profile and in-hospital outcomes

BackgroundIn this study, we aimed to assess and compare the distribution of demographic and clinical characteristics and composite adverse clinical outcomes after primary percutaneous coronary intervention (PCI) among “very premature”, “premature”, and “non-premature” patients with “ST-segment elevation acute coronary syndrome (STE-ACS)” presented at a tertiary care center. MethodsWe included consecutive patients diagnosed with STE-ACS undergoing primary PCI. The “very premature” was defined as ≤40 years for males and ≤ 45 years for females, “premature” as <55 years for males and < 65 years for females, and “non-premature” as ≥55 years for males and ≥ 65 years for females. Clinical characteristics, angiographic patterns, and hospital course were compared among the three groups. ResultsIn a sample of 4686 patients, 78.8%(3691) were male, and the average age was 55.6 ± 11 years. In total, 12%(561) were categorized as very premature, 38.3%(1797) as premature, and 49.7%(2328) as non-premature. The distribution of clinical characteristics in very premature, premature, and non-premature groups were as follows; hypertension in 44.6% vs. 53.5% vs. 54.9%; p < 0.001, diabetes in 30.3% vs. 36.8% vs. 35.5%; p = 0.018, smoking in 29.6% vs. 23.3% vs. 26.3%; p = 0.005, obesity in 19.4% vs. 18.4% vs. 15.3%; p = 0.008, single vessel diseases in 58.8% vs. 37.8% vs. 28.8%; p < 0.001, and composite adverse clinical outcomes in 14.1% vs. 16.7% vs. 21.8%; p < 0.001, respectively. ConclusionIn conclusion, we have a substantial burden of premature STE-ACS. Very premature STE-ACS was found to be associated with a better prognosis, but a substantial burden of composite adverse clinical outcomes was also observed.