UA Patients Research Articles

Comparing the ability of GRACE 2.0 scores for predicting mortality in patients with and without diabetes

Abstract Background The GRACE 2.0 (G2) was an improvement on GRACE. Neither contains DM in the model. In the GRACE, DM independently predicted in-hospital but not the 6-month post-discharge mortality. Similar analysis for GRACE 2.0 score is unavailable. Purpose Assess the ability of the GRACE 2.0 score in predicting mortality in patients with and without diabetes. Methods Retrospective cohort analysis of data on non-STEMI and UA patients admitted in two hospitals between 2010 and 2019 entered into the Myocardial Infarction National Audit Project database. All baseline characteristics of the population and G2 scores were recorded. Death at 1 year was recorded from hospital and general practice records. Follow up was censored at the last recorded contact of the patient with a medical professional. The discriminative power of the G2 score in patients with and without diabetes in predicting mortality was determined by comparing the area under the receiver operating characteristic curve (c-statistics). Accuracy of calibration was evaluated by plotting the mean predicted vs observed mortality in each decile of predicted risk. Results Of 2841 patients entered, complete data was available for 2768 patients (age 69±14yrs, 62.3% male, 877(31.7%) with diabetes). G2 risk was higher in DM (8.3, IQR 3.9 to 19.0 v 5.5, IQR 2.6 to 13.0; p<0.0001). 337 patients died, 156 with DM. Higher deaths occurred in DM group (17.8% vs 16.3; adjusted OR 1.81, 95% CI 1.41-2.33, p<0.0001) (fig 1D). G2 discriminated between events well in whole cohort (AUC 0.81, p<0.001) with no difference between DM and non-DM patients (AUC DM: 0.78, 95% CI 0.75 to 0.81; non-DM 0.81, 0.79 to 0.83; δAUC 0.0301, p=0.242) (fig1E). Calibration of predictions by G2 was excellent across all deciles of risk for the whole cohort (fig 1A). However, G2 underestimated mortality in DM versus non-DM (fig1B,C), especially in the higher deciles of risk (fig 1 F,G). Conclusion(s) Discrimination of the GRACE 2.0 model was excellent for mortality at 1-year with no difference between patient with and without diabetes in our cohort of NSTEMI and UA patients. However, calibration plots suggest GRACE 2.0 underestimates mortality in diabetic compare to non-diabetic patients. This may suggest that risk stratification with GRACE 2.0 in diabetic patients may have to be considered with caution.Figure 1.

Comparing the ability of GRACE 2.0 and GRACE 3 scores for predicting in-hospital mortality in patients with and without diabetes

Abstract Background Sex-specific refinement of GRACE 2.0 was published as GRACE 3.0 (G3). The relative ability of G3 in predicting in-hospital mortality in diabetic patients has not been explored. Purpose Explore the ability of G3 in determining in-hospital mortality in patients with and without diabetes. Methods Retrospective cohort analysis of data on NSTEMI and UA patients admitted in two hospitals between 2010 and 2019 entered into the Myocardial Infarction National Audit Project database. All baseline characteristics and G2, G3 scores were recorded. In hospital death was recorded from hospital records. The discriminative power of the G2 score was determined by comparing the area under the receiver operating characteristic curve (c-statistics). Accuracy of calibration was evaluated by plotting the mean predicted vs observed mortality in each decile of predicted risk, Hosmer-Lemeshow (HL) goodness-off it test and the Nagelkerke R2 (NR2). Results G3 was calculated in 2768 patients (age 69±14yrs, 62.3% male, 877(31.7%) with diabetes. Median risk for the cohort was 1.3%, (95% CI 1.2 to 1.4). G3 risk was higher in patients with diabetes (median 2.0 IQR 0.6 to 5.5 vs 1.0 IQR 0.3 to 3.7, p<0.0001). In-hospital mortality occurred in 68 (2.5%) patients with no difference between the diabetes groups (3.1% and 2.2% died in the DM and non-DM groups respectively). In the whole cohort, G3 reclassified 139(7.5%) patients in low-intermediate to high risk-category and 159(17.4%) patients in high to low-intermediate category. 10.1% and 6.5% were upgraded and 16.1% and 18.1% were downgraded in DM and non-DM groups. Overall discriminatory power of G3 (AUC 0.87, 95% CI 0.86 to 0.88, p<0.0001) was excellent but no different from G2 (AUC 0.86 95% CI 0.85 to 0.88, p<0.0001) (δAUC 0.009, p=0.461). In patients with diabetes, G3 yielded higher AUC (AUC 0.85, 95% CI 0.83 to 0.87, p<0.0001) than G2 (AUC 0.82, 95% CI 0.79 to 0.84, p<0.00101) but this was not statistically significant (δAUC 0.031, p=0.142). In patients without DM, the difference was smaller (δAUC 0.002, p=0.906). Neither G2 (δAUC 0.061, p=0.185) nor G3 (δAUC 0.028, p=0.473) was better in discrimination in DM compared to non-DM groups (Fig1A,B). In the diabetic group, calibration plot for the G3 score showed suboptimal calibration with consistent overestimation of the risk across all risk deciles (Figure1C), with the HL test showing significant differences between the observed and predicted values (p <0.0001) and the NR2 was low 0.09. The GRACE 2 score showed better calibration (Fig1D) (HL: p=0.09, NR2 0.11). In patients without diabetes, calibration plot for the G3 (HL: p= 0.17; NR2 0.33) (Fig1E) and G2 (HL: p=0.15, NR2 0.25) (Fig1F) shows similar pattern of overestimation of the risk less so for latter. Conclusion G3 and G2 shows excellent discrimination for in-hospital mortality in both diabetic and non-diabetic patients. G2 seems to show better calibration than G3 for diabetic patients.

MicroRNA Inhibiting Atheroprotective Proteins in Patients with Unstable Angina Comparing to Chronic Coronary Syndrome

Patients with unstable angina present clinical characteristics of atherosclerotic plaque vulnerability, contrary to chronic coronary syndrome patients. The process of athersclerotic plaque destabilization is also regulated by microRNA particles. In this study, the investigation on expression levels of microRNAs inhibiting the expression of proteins that protect from atherosclerotic plaque progression (miR-92a inhibiting KLF2, miR-10b inhibiting KLF4, miR-126 inhibiting MerTK, miR-98 inhibiting IL-10, miR-29b inhibiting TGFβ1) was undertaken. A number of 62 individuals were enrolled—unstable angina (UA, n = 14), chronic coronary syndrome (CCS, n = 38), and healthy volunteers (HV, n = 10). Plasma samples were taken, and microRNAs expression levels were assessed by qRT-PCR. As a result, the UA patients presented significantly increased miR-10b levels compared to CCS patients (0.097 vs. 0.058, p = 0.033). Moreover, in additional analysis when UA patients were grouped together with stable patients with significant plaque in left main or proximal left anterior descending (“UA and LM/proxLAD” group, n = 29 patients) and compared to CCS patients with atherosclerotic lesions in other regions of coronary circulation (“CCS other” group, n = 25 patients) the expression levels of both miR-10b (0.104 vs. 0.046; p = 0.0032) and miR-92a (92.64 vs. 54.74; p = 0.0129) were significantly elevated. In conclusion, the study revealed significantly increased expression levels of miR-10b and miR-92a, a regulator of endothelial protective KLF factors (KLF4 and KLF2, respectively) in patients with more vulnerable plaque phenotypes.

Investigating soluble CD40 ligand as a prognostic factor among acute coronary syndromes patients: A multi-center prospective case-control study.

Soluble CD40 ligand (sCD40L) is a protein that plays a crucial role in the inflammatory response associated with the development and progression of acute coronary syndrome (ACS). Recent studies have suggested that sCD40L may be a useful prognostic factor for ACS, but the data are conflicting. This study aimed to investigate the potential of sCD40L as a prognostic marker among ACS patients and provide valuable insights for clinical practice. To our knowledge, this is the first study of its type in the Arabic World. A multi-center prospective case-control study was conducted in Damascus, Syria, involving 158 participants with different ACS subtypes (STEMI, NSTEMI, UA) and a control group of healthy individuals. Sociodemographic data, medical history, and sCD40L levels were collected. The predictive ability of sCD40L for ACS, STEMI, NSTEMI, and UA was assessed using receiver operating characteristic (ROC) curves. Statistical analysis was performed using IBM SPSS version 25. The study included 58 STEMI, 33 NSTEMI, 36 UA patients, and 30 healthy individuals. The mean age of participants was 55 years (SD 10.7 years). Analysis of sCD40L levels revealed significantly higher concentrations in ACS patients compared to the control group (P < .001). ROC curve analysis demonstrated that sCD40L had a significant predictive ability for ACS, STEMI, and NSTEMI (P < .05), while its predictive value for UA was not statistically significant. This study provides evidence supporting the potential of sCD40L as a prognostic factor in ACS. The elevated levels of sCD40L observed in these subtypes indicate its potential usefulness in risk stratification and predicting adverse cardiovascular events. Further investigations are warranted to establish standardized sCD40L cutoff values and evaluate its clinical implications in the management of ACS patients.

Maxillofacial haemorrhagic symptoms in emergency department patients: impact of antithrombotics

PurposeTo investigate the effect of antithrombotics on the occurrence of maxillofacial haemorrhagic symptoms, and to determine if these haemorrhagic symptoms are predictors of maxillofacial fractures.MethodA prospective cohort study was conducted of consecutive patients with maxillofacial trauma who had been admitted to the emergency department of four hospitals in the Netherlands. This study compared five haemorrhagic symptoms (peri-orbital haematoma, raccoon eyes, epistaxis, subconjunctival ecchymosis, and intra-oral haematoma) between patients not-using (NUA) and using (UA) of antithrombotics, and whether these maxillofacial haemorrhagic symptoms served as predictors for maxillofacial fractures.ResultsOut of the 1005 patients, 812 (81%) belonged to the NUA group, and 193 (19%) to the UA group. UA patients exhibited higher frequencies of peri-orbital hematoma (54% vs. 39%, p < 0.001), raccoon eyes (10% vs. 5%, p = 0.01), and subconjunctival ecchymoses (16% vs. 7%, p < 0.001). In NUA, peri-orbital hematoma (OR = 2.5, p < 0.001), epistaxis (OR = 4.1, p < 0.001), subconjunctival ecchymosis (OR = 2.3, p = 0.02), and intra-oral hematoma (OR = 7.1, p < 0.001) were significant fracture predictors. Among UA, peri-orbital hematoma (OR = 2.2, p = 0.04), epistaxis (OR = 5.4, p < 0.001), subconjunctival ecchymosis (OR = 3.7, p = 0.008), and intra-oral hematoma (OR = 22.0, p < 0.001) were significant fracture predictors.ConclusionMaxillofacial haemorrhagic symptoms were observed more frequently in the UA group than in the NUA group. However, in both groups, maxillofacial haemorrhagic symptoms appear to be predictors of maxillofacial fractures. Caution is warranted in attributing these symptoms solely to antithrombotic use during emergency department assessments.

Unstable angina in the context of high-sensitive troponins: Still a marker of high risk? A comparison of outcomes with adjudicated type 1 myocardial infarction

BackgroundUnstable angina (UA), considered historically a marker of high risk, has rarely been studied in the high sensitive troponin era. We sought to characterise this population and determine short- and medium-term outcomes for UA and compared this to both patients with musculoskeletal chest pain and adjudicated type 1 MI (NSTEMI). MethodWe conducted a post-hoc analysis of 2 prospective cohort studies of suspected acute coronary syndrome in 2 hospitals in the northwest of England. (n = 3018) We used a dedicated symptom score to diagnose unstable angina. Type 1 MI (NSTEMI) was diagnosed by independent physician adjudication according to 3rd universal definition of MI. Follow-up was 100% complete for all patients to 1 year. Results185 (6.1%) and 249 (8.3%) were adjudicated as suffering from UA and NSTEMI respectively. We restricted our analysis of UA to 158 (5.2%) patients with UA with high sensitive troponin T (Roche Elecsys) ≤14 ng/L (≤99th percentile). Compared to the NSTEMI population, the UA cohort were younger (59 vs 74, p < 0.002), had a lower incidence of hypertension (56.3% vs 69.1%, p = 0.009), had significantly lower composite risk scores and had fewer ECG abnormalities (ST depression >1 mm, 5.1% vs 15.6%, p = 0.001, T wave flattened, biphasic or inverted 24.1% vs 47.8%, p < 0.0001).Subsequent Type 1 MI to 30 days and 1 year in the UA cohort was 1.9% and 1.9% respectively compared to 0.8% and 2.4% in the index type 1 MI (NSTEMI cohort) respectively. However, compared to patients presenting with musculoskeletal chest pain (n = 468) there was a significantly greater incidence of subsequent MI and coronary revascularisation in patients with unstable angina. All cause death at 30 days and 1 year was 0.0% and 0.6% (n = 1) for UA patients and 2.8% (n = 7) and 16.1% (n = 40) for the NSTEMI cohort respectively. ConclusionUA, defined objectively by a symptom score and absence of myocyte necrosis, is still prevalent as an entity, with a risk of subsequent MI and urgent or emergency coronary revascularisation. However, mortality is >10-fold lower when compared to NSTEMI, indicating a less severe pathology in terms of atherosclerosis or plaque burden, and implying the need for a different management strategy to that of NSTEMI.

Accuracy and tolerability of self-sampling of capillary blood for analysis of inflammation and autoantibodies in rheumatoid arthritis patients—results from a randomized controlled trial

BackgroundRheumatoid arthritis (RA) requires early diagnosis and tight surveillance of disease activity. Remote self-collection of blood for the analysis of inflammation markers and autoantibodies could improve the monitoring of RA and facilitate the identification of individuals at-risk for RA.ObjectiveRandomized, controlled trial to evaluate the accuracy, feasibility, and acceptability of an upper arm self-sampling device (UA) and finger prick-test (FP) to measure capillary blood from RA patients for C-reactive protein (CRP) levels and the presence of IgM rheumatoid factor (RF IgM) and anti-cyclic citrullinated protein antibodies (anti-CCP IgG).MethodsRA patients were randomly assigned in a 1:1 ratio to self-collection of capillary blood via UA or FP. Venous blood sampling (VBS) was performed as a gold standard in both groups to assess the concordance of CRP levels as well as RF IgM and CCP IgG. General acceptability and pain during sampling were measured and compared between UA, FP, and VBS. The number of attempts for successful sampling, requests for assistance, volume, and duration of sample collection were also assessed.ResultsFifty seropositive RA patients were included. 49/50 (98%) patients were able to successfully collect capillary blood. The overall agreement between capillary and venous analyses for CRP (0.992), CCP IgG (0.984), and RF IgM (0.994) were good. In both groups, 4/25 (16%) needed a second attempt and 8/25 (32%) in the UA and 7/25 (28%) in the FP group requested assistance. Mean pain scores for capillary self-sampling (1.7/10 ± 1.1 (UA) and 1.9/10 ± 1.9 (FP)) were significantly lower on a numeric rating scale compared to venous blood collection (UA: 2.8/10 ± 1.7; FP: 2.1 ± 2.0) (p=0.003). UA patients were more likely to promote the use of capillary blood sampling (net promoter score: +28% vs. −20% for FP) and were more willing to perform blood collection at home (60% vs. 32% for FP).ConclusionsThese data show that self-sampling is accurate and feasible within one attempt by the majority of patients without assistance, allowing tight monitoring of RA disease activity as well as identifying individuals at-risk for RA. RA patients seem to prefer upper arm-based self-sampling to traditional finger pricking.Trial registrationDRKS.de Identifier: DRKS00023526. Registered on November 6, 2020.

Evaluation of soluble lectin-like oxidized low-density lipoprotein receptor-1 (sLOX-1) and sLOX-1/oxidized LDL ratio as novel biomarkers of acute coronary syndrome.

The lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1) is involved in the pathophysiology of atherosclerosis and acute coronary syndromes (ACS). In patients with acute coronary syndrome, circulating soluble LOX-1 (sLOX-1) levels are dramatically elevated. This study aimed to assess sLOX-1 levels in acute coronary syndromes and determine the ratio of sLOX-1 and oxidative LDL in cases of myocardial infarction and unstable angina pectoris and the ROC curve for this ratio sLOX-1. A case-control study was conducted at the department of chemistry and biochemistry, college of medicine, Al- Nahrain University, Baghdad, Iraq, from September 2020 to January 2021. In a total of 90 subjects (30 patients with myocardial infarction within the first six hours of chest pains, 30 patients with unstable angina pectoris, and 30 healthy donors). The ELISA technique measured concentrations of sLOX-1 and oxidized LDL. In addition, Troponin and highly sensitive C reactive protein were measured by the same technique (Fluorescence immune assay), and lipid profile was measured using the Spectrophotometer technique. The median level of sLOX-1 in MI group was 476.17 pg/ml (90.88-675.4 pg/ml) which was significantly higher than that of UA patients (median=289.1 pg/ml [62.74-585.43 pg/ml]) and controls (median=144.52 pg/ml [79.17-283.83 pg/ml]) with highly significant differences and the median sLOX-1/OX-LDL ratio in patients with MI was 64.6 (range 15.17-100.15) which was significantly higher than either patients with UA (median=37.6 [7.06-88.65]) or controls (median=25.29 [12.7-43.04]). There were elevated levels of sLOX-1 in acute coronary syndromes. The sLOX-1/oxidized LDL ratio also strongly indicated the diagnosis and a discriminatory force on the ROC curve for myocardial infarction.

Danhong injection improves elective percutaneous coronary intervention in ua patients with blood stasis syndrome revealed by perioperative metabolomics

Objective: To observe the effect of Danhong injection (DHI) on perioperative metabolomics of unstable angina pectoris (UA) with blood stasis syndrome. Materials and Methods: A prospective, randomized, controlled, and single-blind clinical trial was conducted. Sixty-one UA patients with traditional Chinese medicine blood stasis syndrome undergoing elective percutaneous coronary intervention (PCI) were randomly divided into the Danhong and control groups, and 10 healthy volunteers were included as baseline. The Danhong group received western medicine + DHI treatment, while the control group received western medicine + saline. Nontargeted metabolomics was used to analyze the serum metabolites of healthy volunteers in the Danhong and control groups before and 5 days after PCI. Results: Before treatment, there was no significant difference in serum metabolites between the Danhong and control groups, but there was a significant difference between the two groups and the healthy group. Differential metabolites were clustered mainly in glycerophospholipid, sphingolipid, purine, and amino acid groups, which were generated in their metabolic pathways. After 5 days of PCI, the profiles of serum metabolites were significantly closer between the Danhong-or control-treated groups and that of the healthy group. Furthermore, DHI treatment converted the serum metabolite profile more to that of the healthy group than the control treatment. Conclusion: The beneficial effect of DHI on patients with unstable angina is reflected at the level of serum metabolic biomarkers.

Prevalence of Modifiable Risk Factors among Acute Coronary Syndrome Patients in a Tertiary Care Hospital

Background and Objectives: Acute Coronary Syndrome (ACS) is one of the major causes for mortality and morbidity among the cardiovascular diseases in India. In this study the modifiable risk factors leading to ACS are considered and its prevalence in a Tertiary care hospital is studied.&#x0D; Materials and Methods: This is a prospective type of study conducted in a tertiary care hospital. A total of 100 patients diagnosed with ACS were taken in this study. Their data was taken, and results were formulated in excel data sheet.&#x0D; Results: Among the UA patients, 65% were found to be dyslipidaemic, 60% as obese, 45% as diabetics, 47.5% as hypertensive and 40% as smokers. Among the NSTEMI patients, 66.67% were found to be dyslipidaemic, 52.78% as hypertensive, 44.44% as smokers, 30.56% as diabetics and 27.78% as obese. Among the STEMI patients, 37.50% were found to be dyslipidemic, 25% as both diabetic and obese, 20.83% as hypertensive,12.5% as smokers.&#x0D; Hypertension, dyslipidemia, smoking and obesity showed significance.&#x0D; Conclusion: The prevalence of modifiable risk factors is a major concern for developing ACS and when they are modified there will be a great reduction in the incidence of ACS.

Lacrimal gland enlargement and tear film changes in acromegaly patients: A controlled study

PurposeEvaluation of the lacrimal gland volume (LGV) and its correlation with tear film functions, serum growth hormone (GH) and insulin-like growth factor-1 (IGF-1) levels in acromegaly patients compared to a control group was aimed. MethodsThis prospective case-control study included the eyes of 38 patients with uncontrolled (UA) and 48 patients with controlled acromegaly (CA) and 44 patients with nonfunctioning pituitary adenoma. LGV of the patients was evaluated at the baseline, 3rd, and 6th-month visits with magnetic resonance imaging. Schirmer's test, tear breakup time (TBUT), and ocular surface disease index (OSDI) scores were evaluated at the same visits. Their correlation with serum IGF-1 and GH was investigated. Main outcome measure was the difference in mean LGV. ResultsThe mean LGV of the acromegaly patients at the baseline visit (116.0 ± 33.2 mm3) and the 3rd-month visit (119.5 ± 36.4 mm3) was higher than the control group (65.2 ± 22.3 mm3 and 63.2 ± 22.3 mm3, respectively; p < 0.001) without any significant difference between the UA and CA patients in the LGV in three consecutive visits (p > 0.05). Among all patients, IGF-1 and GH levels showed a positive correlation with the LGV (p < 0.001; r = 0.52; r = 0.6, respectively). However, Schirmer, TBUT, and OSDI scores did not show any difference among the three groups at each visit (p > 0.05). ConclusionAcromegaly patients may have larger lacrimal glands compared to the controls and this increase correlated with the increased IGF-1 and GH levels. Lacrimal gland volume may have no effect on its tear film related functions.

Poor long-term outcome in acute coronary syndrome in a real-life setting: Ten-year outcome of the TACOS study.

Long-term outcome of the three categories of acute coronary syndrome (ACS) in real-life patient cohorts is not well known. The objective of this study was to survey the 10-year outcome of an ACS patient cohort admitted to a university hospital and to explore factors affecting the outcome. A total of 1188 consecutive patients (median age 73 years) with ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI) or unstable angina pectoris (UA) in 2002-2003 were included and followed up for ≥ 10 years. Mortality for STEMI, NSTEMI and UA patients during the follow-up period was 52.5%, 69.9% and 41.0% (p < 0.001), respectively. In multivariable Cox regression analysis, only age and creatinine level at admission were independently associated with patient outcome in all the three ACS categories when analyzed separately. All the three ACS categories proved to have high mortality rates during long-term followup in a real-life patient cohort. NSTEMI patients had worse outcome than STEMI and UA patients during the whole follow-up period. Our study results indicate clear differences in the prognostic significance of various demographic and therapeutic parameters within the three ACS categories.

Abstract 13103: Nourin-dependent Mirna-106b : A Novel Early Inflammatory Diagnostic Biomarker for Cardiac Injury

Introduction: Nourin is an inflammatory mediator rapidly released by ischemic myocardium “before” necrosis, and by necrotic cells . It stimulates leukocyte “ chemotaxis ” and “ activates ” leukocytes and vascular endothelial cells to release several “ cytokine storm ” mediators. Using Nourin amino acid sequence, Bioinformatics analysis indicated that Nourin is likely regulated by miRNA-106b ; an inflammatory-signaling pathway linked to myocardial ischemia. Hypothesis: As an "initial" inflammatory marker, the Nourin-dependent miR-106b can early diagnose ischemia-induced injury in UA patients when Troponin levels are below the decision limit, and in STEMI patients. The underlying regulatory mechanism involves lncR-CTB89H12.4 and mRNA-ANAPC11; associated with ischemia. Methods: Gene expression of lncR-CTB89H12.4 / miR-106b and mRNA-ANAPC11 were measured in serum samples from UA (n=30 - confirmed by invasive coronary angiography and negative Troponin) and STEMI (n=16) patients at presentation, and healthy volunteers (n=16). Results: Gene expression of miR-106b was up-regulated by 150-fold in UA compared to healthy, and by 4.6-fold in STEMI compared to UA (Fig. 1). Receiving Operator Characteristics (ROC) analysis revealed a statistically significant difference in miR-106b that discriminated UA from healthy controls with a test sensitivity of 87% sensitivity &amp; specificity of 88%. Diagnostic sensitivity was 86% and specificity was 90% for discriminating UA from STEMI. Additionally, Spearman’s correlation analysis revealed a significant association of miR-106b with lncR-CTB89H12.4 and mRNA-ANAPC11. The down regulation of lncR-CTB89H12.4 after ischemia resulted in the up-regulation of miR-106b and activation of mRNA-ANAPC11 . Conclusions: The Nourin-dependent miR-106b is a promising early inflammatory biomarker indicating UA patients and discriminating between UA and STEMI. Regulations appears to be from lncR-CTB89H12.4 and mRNA-ANAPC11 .

Differences between rural and urban prostate cancer patients

BackgroundWe hypothesized that the residency status (rural area [RA] vs urban clusters [UC] vs urban areas [UA]) affects stage and cancer-specific mortality (CSM) in contemporary newly diagnosed prostate cancer (PCa) patients of all stages, regardless of treatment.MethodsNewly diagnosed PCa patients with available residency status were abstracted from the Surveillance, Epidemiology, and End Results database (2004–2016). Propensity-score (PS) matching, cumulative incidence plots, multivariate competing-risks regression (CRR) models were used.ResultsOf 531,468 PCa patients of all stages, 6653 (1.3%) resided in RA, 50,932 (9.6%) in UC and 473,883 (89.2%) in UA. No statistically significant or clinically meaningful differences in stage at presentation or CSM were recorded. Conversely, 10-year other cause-mortality (OCM) rates were 27.2% vs 23.7% vs 18.9% (p < 0.001) in RA vs UC vs UA patients, respectively. In CRR models, RA (subhazard ratio [SHR] 1.38; p < 0.001) and UC (SHR 1.18; p < 0.001) were independent predictors for higher OCM relative to UA. These differences remained statistically significant in fully PS-adjusted multivariate CRR models.ConclusionRA, and to a lesser extent UC, PCa patients are at higher risk of OCM than UA patients. Higher OCM may indicate shorter life expectancy and should be considered in treatment decision making.

Short-term prognosis of unstable angina in the era of high-sensitivity cardiac troponin: insights for early rule-out strategies.

It is unclear if strategies to rule-out myocardial infarction (MI) based on a single high-sensitivity troponin T (hsTnT) measurement at the emergency department (ED) presentation may also exclude unstable angina. We measured hsTnT ex-post on the admission frozen blood sample of 644 subjects with Braunwald IIIB CK-MB-negative unstable angina. This analysis included the 240 patients with hsTnT value ≤99th percentile reference limit (UA). We evaluated the clinical outcome of UA patients and the applicability of two rule-out strategies based on the combination of a non-ischemic ECG with (1) a single hsTnT value below the Limit-of-Detection (LoD), (2) a TIMI risk score ≤1. UA patients with hsTnT ≤99th percentile reference limit had a favorable 30-day outcome [0.8% MI, 0% cardiovascular death (CVD)], but the rate of CVD/MI at 180-day was 4.7%. Sensitivities for UA were 94.6% according to the 'TIMI ≤1-strategy' and 75.4% according to 'hsTnT-below-LoD-strategy', accounting for 5.4 and 24.6% missed diagnoses, respectively. A prognostic risk stratification to guide appropriate outpatient assessment in potential discharged unrecognized UA patients was developed: a risk score based on the combination of age >60 years and C-reactive protein >4.5 mg/L effectively stratified the 180-day CVD/MI occurrence: 0, 2.5 and 12.7% for score 0, 1 and 2 (log-rank = 0.001, C-statistic = 0.776). Single measurement hsTnT strategies, successfully tested to rule-out MI, may allow safe ED discharge of patients with a suspected acute coronary syndrome: even if UA may not be excluded, its short-term prognosis is favorable. UA patients with a C-reactive protein >4.5 mg/L and older than 60 years have a substantial medium-term cardiovascular risk and may benefit from a timely outpatient diagnostic assessment.

Geographic and demographic features of neuroendocrine tumors in the United States of America: A population-based study.

The incidence of neuroendocrine tumors (NETs) is rapidly rising. There are very few studies investigating the role of sociodemographic factors in NETs. This study was aimed at examining how geographic and sociodemographic characteristics shape outcomes in the NET population. A retrospective analysis using the Surveillance, Epidemiology, and End Results database was performed, and the NET patient population from 1973 to 2015 was studied. Univariate and multivariable analyses were performed to evaluate patients' disease-specific survival (DSS) and overall survival (OS). Geographic and sociodemographic factors, including the location of residence (urban area [UA] vs rural area [RA]), sex, race, insurance status, and marital status, were included in the analysis. A total of 53,034 patients (5517 in RAs and 47,517 in UAs) were included in the analysis. The incidence of NETs was found to be rising in both RAs and UAs but more rapidly in RAs (with the highest incidence in 2006-2015: 5.93 per 100,000 in RAs vs 4.10 per 100,000 in UAs). Patients from RAs presented at advanced stages in comparison with patients from UAs (regional, 18% vs 16%; distant, 15% vs 13%; P<.01). In the multivariable model, RA patients had a trend toward poorer OS (hazard ratio, 1.05; P=.053) in comparison with UA patients. The multivariable analysis showed significantly worse DSS and OS for uninsured, single, and male patients in comparison with insured, married, and female patients, respectively. This study has identified sociodemographic disparities in NET outcomes. Access to health care could be a potential contributing factor, although differences in environmental exposure, health behavior, and tumor biology could also be responsible.

P3621Epidemiology of acute coronary syndrome by subtype in New Zealand 2006–2016: an ANZACS-QI nationwide linkage study of hospitalisation, procedures and case fatality

Abstract Background Acute coronary syndrome (ACS) is a common manifestation of cardiovascular disease. Inconsistent trends have been reported in the management and outcomes of the three main categories of ACS (ST-elevation myocardial infarction [STEMI], non ST-elevation myocardial infarction [NSTEMI] and unstable angina [UA]). The aims of this study were to evaluate recent trends in the incidence, invasive management and case fatality of these ACS subtypes in New Zealand. Methods All ACS hospitalisations between 2006–2016 were identified from routinely collected national data, and categorised into STEMI, NSTEMI, UA, and unspecified myocardial infarction (MI). For each ACS subtype, annual hospitalisation and coronary procedure rates, 28-day and 1-year fatality rates were calculated and trends tested using Poisson regression adjusted for age and sex. Results There were 188,264 ACS admissions, of which 16.0% were STEMI, 54.5% NSTEMI, 25.7% UA and 3.8% MI unspecified. During this period, the incidence of all ACS subtypes fell, STEMI by 3.4%/y, NSTEMI by 5.9%/year and UA by 8.5%/year. There was also a rise in the proportion of ACS patients receiving angiography and revascularisation. Rates of percutaneous coronary intervention rose for STEMI, NSTEMI and UA, but rates of coronary artery bypass grafting increased only for NSTEMI and UA. Case fatality at 28 days and 1 year was higher for STEMI than NSTEMI, and lowest for UA. Over the period there was a relative 1.6%/y decline in one-year case fatality for NSTEMI (p&lt;0.001), but no significant change for STEMI and UA. Conclusions The observed declines in the incidence of all ACS subtypes is reassuring, as is the increase in the rate of revascularisation among these patients. The finding that case fatality declined in NSTEMI patients but not in STEMI and UA patients, despite an increase in invasive management in all groups, require further investigation.

The effect of clinical coronary disease severity on outcomes of carotid endarterectomy with and without combined coronary bypass

ObjectiveThe management of patients with carotid stenosis and symptomatic coronary artery disease (CAD) is challenging. This study assessed the impact of clinical coronary disease severity on carotid endarterectomy (CEA) with and without combined coronary artery bypass (CCAB). MethodsUsing the Vascular Quality Initiative, patients with symptomatic CAD who underwent CCAB or isolated CEA (ICEA) from 2003 to 2017 were identified. Patients were stratified by CAD severity: stable angina (SA) and recent myocardial infarction/unstable angina (UA). Primary outcomes, including perioperative stroke, myocardial infarction (MI), and stroke/death/MI (SDM), were assessed between procedures within each CAD cohort. ResultsThere were 9098 patients identified: 887 CCAB patients (215 [24%] SA, 672 [76%] UA) and 8211 ICEA patients (6385 [78%] SA, 1826 [22%] UA). Overall, CCAB patients had higher rates of stroke (2.6% vs 1.3%; P = .002) and SDM (7.3% vs 3.5%, P < .001) but similar rates of MI (0.9% vs 1.6%; P = .12) compared with ICEA patients. In SA patients, no difference was seen in stroke (ICEA 1.2% vs CCAB 1.9%; P = .36), MI (1.3% vs 1.4%; P = .95), or SDM (2.9% vs 4.7%; P = .13). In UA patients, no difference was seen in stroke (ICEA 1.6% vs CCAB 2.8%; P = .06), but ICEA patients had higher rates of MI (2.4% vs 0.7%; P = .01) and CCAB patients had higher rates of SDM (8.2% vs 5.5%; P = .01). After logistic regression in the UA cohort, predictors of MI included ICEA (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.1-7.0; P = .04) and carotid symptomatic status (OR, 2.1; 95% CI, 1.1-3.8; P = .01); carotid symptomatic status also predicted stroke (OR, 2.0; 95% CI, 1.1-3.6; P = .03), but CCAB did not. ConclusionsIn patients with symptomatic CAD, both clinical CAD severity and operative strategy affect outcomes. In SA patients, CCAB does not increase perioperative morbidity. However, CCAB in UA patients prevents MI while not appreciably increasing stroke risk. This suggests that coronary revascularization before or concomitant with CEA should be considered in UA patients but that prioritizing coronary intervention is less important in SA patients.

Studies MicroRNA 208 as a Novel Cardiac Marker in Acute Coronary Syndrome in Egyptian Patients

AbstractBackground: Acute coronary syndrome ACS patients presented to Emergency Department ED require rapid differ-ential diagnosis. Although troponin is the gold marker for ACS, there still undiagnosed patients. MicroRNAs circulate in human plasma and affected by varying cardiac pathologies. miRNA-208 was found to be elevated with ACS specially AMI.Aim of Study: The aim of this study was to investigate cTnI levels, correlated to miRNA-208 levels in ACS patients to evaluate rapid, accurate and final diagnosis in ED.Subjects and Methods: One hundred consecutive patients with ACS presenting to the Emergency Department of the National Heart Institute, Giza (Egypt) between March and June 2018, were recruited for the study, stratified into four groups according to the final diagnosis as AMI (including twenty five patients) and unstable angina UA (including twenty three patients), other cardiac patients (eighteen patients) and non cardiac (fourteen patients) twenty control subjects. Were included their cardiac markers and miRNA-208 levels were assayed and compared to the control healthy group on admis-sion.Results: Results revealed significant difference between cardiac levels on admission compared to that obtained for miRNA-208. Only miRNA-208 levels were diagnosed on admission compared to that of cTnI. MiRNA-208 was found to be increased up to 38.6 folds without differential cut off.Conclusion: Early measurement of both troponin I and miRNA-208 may revolutionize the diagnostic accuracy and therapeutic decision-making in patients with symptoms sug-gestive of ACS; differentiate between UA or AMI patients on admission. Cardiac troponin 1 cTnI alone require more time to be controlled as diagnostic while high sensitive cTn may lead to false positive results. MiRNA-208 can be used as a novel marker for early diagnosis of ACS although RT-PCR still time consuming, requires time improved techniques.

Identification of potential plasma biomarkers and metabolic dysfunction for unstable angina pectoris and its complication based on global metabolomics.

Unstable angina pectoris (UA) is one of the most dangerous clinical symptoms of acute coronary syndrome due to the risk of myocardial ischemia, which can lead to high morbidity and mortality worldwide. Though there are many advantages in understanding the pathophysiology of UA, the identification of biomarkers for the diagnosis, prognosis, and treatment of UA remains a challenge in the clinic. A global metabolomics research based on ultra-performance liquid chromatography (UPLC) combined with Q-TOF/MS was performed to discover the metabolic profile of health controls, UA patients, and UA patients with diabetes mellitus (DM), and screen for potential biomarkers. Twenty-seven potential biomarkers were determined using pattern recognition. These biomarkers, which include free fatty acids, amino acids, lysoPE and lysoPC species, and organic acids, can benefit the clinical diagnosis of UA. Pathway analysis indicated that arginine and proline metabolism, glycerophospholipid metabolism, and purine metabolism were affected in the UA patients, uniquely. Additionally, alterations in the metabolic signatures between UA and UA-complicated DM were also explored. As a result, six differential metabolites with an area under the curve (AUC) of more than 0.85 were identified as biomarkers for the diagnosis of UA and UA complicated with DM. Pathway analysis implied tryptophan metabolism was a key metabolic pathway in UA patients with DM, which provides new insights into the pathological study and drug discovery of UA.