Unstable angina/non-ST-elevation Myocardial Infarction Research Articles

Cost-effectiveness of intravascular ultrasound-guided percutaneous intervention in patients with acute coronary syndromes: A UK perspective.

Use of intravascular ultrasound (IVUS) during percutaneous coronary intervention (PCI) is associated with improved clinical outcomes over angiography alone. Despite this, the adoption of IVUS in clinical practice remains low. To examine the cost-effectiveness of IVUS-guided PCI compared to angiography alone in patients with acute coronary syndromes (ACS). A one-year decision tree and lifetime Markov model were constructed to compare the cost-effectiveness of IVUS-guided PCI to angiography alone for two hypothetical adult populations consisting of 1,000 individuals: ST-elevation myocardial infarction (STEMI) and unstable angina/ non-ST-elevation myocardial infarction (UA/NSTEMI) patients undergoing drug-eluting stent (DES) implantation. The UK healthcare system perspective was applied using 2019/20 costs. All-cause death, myocardial infarction (MI), repeat PCI, lifetime costs, life expectancy and quality-adjusted life-years (QALYs) were assessed. Over a lifetime horizon, IVUS-guided PCI was cost-effective compared to angiography alone in both populations, yielding an incremental cost-effectiveness ratio of £3,649 and £5,706 per-patient in STEMI and UA/NSTEMI patients, respectively. In the one-year time horizon, the model suggested that IVUS was associated with reductions in mortality, MI and repeat PCI by 51%, 33% and 52% in STEMI and by 50%, 29% and 57% in UA/NSTEMI patients, respectively. Sensitivity analyses demonstrated the robustness of the model with IVUS being 100% cost-effective at a willingness-to-pay (WTP) threshold of £20,000 per QALY-gained. From a UK healthcare perspective, an IVUS-guided PCI strategy was highly cost-effective over angiography alone amongst ACS patients undergoing DES implantation due to the medium- and long-term reduction in repeat PCI, death, and MI.

Comparison of multiple risk scores in assessing medium-to long-term clinical outcomes in unstable angina / non-ST-elevation myocardial infarction patients undergoing multi vessel percutaneous coronary intervention: An observational, registry-based study in India

ObjectivePost-revascularization mortality in multivessel coronary artery disease (MVCAD) has been explored via several risk scores. Here, we assessed and compared various risk scores in predicting medium to long-term clinical outcomes in unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) patients with MVCAD undergoing percutaneous coronary intervention (PCI). MethodsWe analyzed a cohort of a tertiary care center registry enrolling patients in South India, Kerala, with MVCAD (N = 200) who had undergone PCI between 2010 and 2018. The outcomes evaluated were all-cause mortality and major adverse cardiac events (MACE). The risk scores assessed included SYNTAX score (SS), residual SYNTAX score (rSS), SYNTAX revascularization index (SRI), age, creatinine, and ejection fraction (ACEF) score, clinical SYNTAX score (cSS), and SYNTAX score II (SSII). ResultsOf the analyzed risk scores, SSII had the best predictive capability with the area under the curve (AUC) of 0.79 in c-statistics, followed by ACEF score and cSS with AUCs of 0.74 and 0.65, respectively for all-cause mortality (p < 0.01). Kaplan–Meier survival curves and multivariate analysis by Cox regression showed SSII with cut-offs of >35.15 and > 29.55 to be the only score associated with higher mortality and MACE, respectively. ConclusionsIn UA/NSTEMI patients with relatively less complex MVCAD treated by PCI, the SSII, ACEF and cSS risk scores could predict the outcomes better. The SSII showed the best predictive performance for all-cause mortality and MACE. Scores based on baseline and residual atherosclerotic burden (SS, rSS, and SRI) performed poorly in predicting the mortality and MACE.

Revascularization vs. Conservative Management in Geriatric Population With Unstable Angina/Non-ST-Elevation Myocardial Infarction (UA/NSTEMI): A Systematic Review and Meta-Analysis

Revascularization vs. Conservative Management in Geriatric Population With Unstable Angina/Non-ST-Elevation Myocardial Infarction (UA/NSTEMI): A Systematic Review and Meta-Analysis

Single Center Trends in Acute Coronary Syndrome Volume and Outcomes During the COVID-19 Pandemic.

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has greatly affected healthcare delivery across the world. In this report, we aim to further characterize the changes in cardiac catheterization at our institution, specifically in the setting of acute coronary syndrome (ACS).MethodsWe performed a retrospective analysis of patients undergoing cardiac catheterization between December 23, 2019 and April 12, 2020 at our institution. All patients with cardiac catheterizations for ACS, ST-elevation myocardial infarction (STEMI) activation, and out-of-hospital cardiac arrest (OHCA) were analyzed. Cardiac catheterization volume, as well as clinical and procedural characteristics of patients undergoing cardiac catheterization, was compared before and during the COVID-19 pandemic.ResultsPatients presenting with ACS and OHCA were similar in terms of demographics and comorbidities during both time periods. The mean monthly volume for ACS cases dropped by 26% during the pandemic, which was consistent among both unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) and STEMI cases. OHCA volume decreased significantly as well (five cases per month before to zero cases during the pandemic, P = 0.01). Among patients with STEMI, initial markers of cardiac injury, door-to-balloon time, and all-cause mortality were similar in both time periods.ConclusionsWith the start of the COVID-19 pandemic, there was a reduction in cardiac catheterization volume across the spectrum of ACS at our institution, which was consistent with reports from other centers across the globe. Patients with STEMI during the initial phase of the COVID-19 pandemic did not seem to have delays in presentation or significant differences in all-cause mortality at our institution.

The Value of the GRACE Score for Predicting the SYNTAX Score in Patients with Unstable Angina/Non-ST Elevation Myocardial Infarction

BackgroundIn patients with unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI), Global Registry for Acute Coronary Events (GRACE) score is a valid tool for risk stratification. The Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score is an angiographic scoring system to guide the decision-making between coronary artery bypass grafting (CABG) surgery and percutaneous coronary intervention (PCI). The aim of the present study was to assess the accuracy of the GRACE score in predicting the severity and extent of coronary artery stenosis by SYNTAX score. MethodsA total of 330 patients with acute coronary syndrome (ACS) were enrolled in the study. For every patient, the GRACE score was calculated. All patients underwent coronary angiography within 2 days and the SYNTAX scoring system was used to evaluate the severity and extent of coronary stenotic lesions. Based on ROC curve analysis, the cut-off value of GRACE score that could predict SYNTAX score ≥ 23 was calculated. ResultsGRACE score was 107.12 ± 34.4 in patients with SYNTAX SCORE < 23 and 134.80 ± 48.3 in patients with SYNTAX score ≥ 23 (p value = 0.001). A positive correlation was observed between the GRACE score and angiographic SYNTAX score (r = 0.34 p < 0.001). We found that a GRACE score of 109 is the optimal cut-off to predict SYNTAX score ≥ 23 with a sensitivity of 73.5% and specificity of 60% (p < 0.001). Its negative predictive value was 94.0%. ConclusionGRACE score had significant but modest value to predict the severity and extent of coronary artery stenosis in patients with ACS.

Two-year Follow-up of Patients With Unstable Angina/Non-ST Segment Elevation Myocardial Infarction Undergoing Early Invasive Strategy: Predictors of Normal or Near-Normal Coronary Angiography and Mortality.

Predictors of normal or near-normal coronary angiography (NONCAG) in patients with unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) and their importance regarding the prognosis are not understood. Accordingly, we determined these predictors as well as mortality risk factors at 2-year follow-up of UA/NSTEMI patients managed by the early invasive strategy. We prospectively studied consecutive patients with UA/NSTEMI managed with the early invasive strategy at Tehran Heart Center, in 1-year period. Echocardiography was performed before coronary angiography (CAG) for all the patients. Baseline characteristics, laboratory parameters, echocardiographic findings, invasive treatment modalities, and survival status after 2 years of follow-up were collected. We identified the predictors of NONCAG in the first phase of the study and then the risk factors of mortality in the second phase. In the study period, 298 patients including 211 (71%) males, with the age of 59.31 ± 10.72 years were enrolled. The following factors were predictors of NONCAG: the female sex (P < 0.001); negative family history of CAD (P = 0.028); Thrombolysis in Myocardial Infarction (TIMI) risk score (P < 0.001); and early transmitral flow velocity/mean mitral annular velocity (E/E'mean) (P = 0.003). The following items were significant protective factors against mortality: percutaneous coronary intervention (PCI) (P = 0.012), age (P = 0.001), and E/E'mean (P = 0.020). Patients' baseline characteristics as well as echocardiographic data could help in predicting those with NONCAG and PCI can be considered as the treatment of strategy with the most protection against mortality.

Characteristics and long term outcomes of patients with acute coronary syndromes due to culprit left main coronary artery disease treated with percutaneous coronary intervention

BackgroundPatients with acute coronary syndrome (ACS) due to unprotected culprit left main coronary artery disease (LMCAD) treated with percutaneous coronary intervention (PCI) are rare, high-risk, and not represented in trials. Data regarding long term outcome after PCI are limited. MethodsBetween January 2000 and December 2014, there were 8,794 patients hospitalized with unstable angina/non-ST elevation myocardial infarction (UA/NSTEMI) or ST-elevation myocardial infarction (STEMI) treated with PCI at our institution; of these, 83 (0.94%) patients were identified as having culprit LMCAD ACS. ResultsOf the 83 patients with unprotected LMCAD ACS, 40 patients presented with STEMI and 43 patients presented with UA/NSTEMI. As compared to LM UA/NSTEMI, LM STEMI patients were younger and had less hypertension, with a trend towards greater frequency of cardiogenic shock. Distal LM involvement was common in both groups and did not differ by ACS type. In-hospital mortality was 33% in LM STEMI and 9% in LM UA/NSTEMI (P = .009). Over median follow up of 6.3 years, long term survival rates in both groups were similar (46% for STEMI vs 51% for UA/NSTEMI; P = .50 by log-rank). ConclusionsUnprotected culprit LMCAD ACS necessitating PCI is uncommon, occurring in <1% of cases, but is associated with reduced survival, with long term follow-up noting continued and similar risk of death regardless of index ACS type.

Management of diabetic patients hospitalized for acute coronary syndromes: a prospective multicenter registry.

Patients with diabetes mellitus and acute coronary syndrome (ACS) present an increased risk of adverse cardiovascular events. An Italian Consensus Document indicated 'three specific must' to obtain in this subgroup of patients: optimal oral antiplatelet therapy, early invasive approach and a tailored strategy of revascularization for unstable angina/non-ST-elevation-myocardial infarction (UA/NSTEMI); furthermore, glycemia at admission should be managed with dedicated protocols. To investigate if previous recommendations are followed, the present multicenter prospective observational registry was carried out in Lombardia during a 9-week period between March and May 2015. A total of 559 consecutive ACS patients (mean age 68.7 ± 11.3 years, 35% ≥75 years, 50% STEMI), with 'known DM' (56%) or 'hyperglycemia', this last defined as blood glucose value ≥ 126 mg/dl at admission, were included in the registry at 29 hospitals with an on-site 24/7 catheterization laboratory. Patients with known diabetes mellitus received clopidogrel in 51% of the cases, whereas most patients with hyperglycemia (72%) received a new P2Y12 inhibitor: according to clinical presentation in case STEMI prasugrel/ticagrelor were more prescribed than clopidogrel (70 vs. 30%, P < 0.001); on the contrary, no significant difference was found in case of UA/NSTEMI (48 vs. 52%, P = 0.57).Overall, 96% of the patients underwent coronary angiography and 85% received a myocardial revascularization (with percutaneous coronary intervention in 92% of cases) that was however performed in fewer patients with known diabetes mellitus compared with hyperglycemia (79 vs. 90%, P = 0.001).Among UA/NSTEMI, 85% of patients received an initial invasive approach, less than 72 h in 80% of the cases (51% <24 h); no difference was reported comparing known diabetes mellitus to hyperglycemia. Despite similar SYNTAX score, patients with known diabetes mellitus had a higher rate of Heart Team discussion (29 vs. 12%, P = 0.03) and received a surgical revascularization in numerically more cases.Most investigators (85%) followed a local protocol for glycemia management at admission, but insulin was used in fewer than half of the cases; diabetes consulting was performed in 25% of the patients and mainly in case of known diabetes mellitus. Based on data of the present real world prospective registry, patients with ACS and known diabetes mellitus are treated with an early invasive approach in case of UA/NSTEMI and with a tailored revascularization strategy, but with clopidogrel in more cases; glycemia management is taken into account at admission.

Relative Efficacy and Safety of Prasugrel and Clopidogrel in Medically Managed Patients of High Risk Unstable Angina/Non-St-Elevation Myocardial Infarction (UA/NSTEMI)

Relative Efficacy and Safety of Prasugrel and Clopidogrel in Medically Managed Patients of High Risk Unstable Angina/Non-St-Elevation Myocardial Infarction (UA/NSTEMI)

The Role of Some Inflammatory Markers (IL-6 and CRP) in the Pathogenesis of Acute Coronary Syndrome in Iraqi CCU for Heart Diseases

In this work an enzyme linked immunosorbent assay (ELISA) technique has been used for detection of some inflammatory markers in serum of acute coronary syndrome (ACS)-Patients Admitted to the cardiac care unit (CCU) of Iraqi Centre For Heart Diseases and Ibn AlNafees Teaching Hospital. The present method includes quantitative measurement of interleukine-6 (IL-6) and C-reactive protein (CRP), as their increase during symptoms may be responsible for identifying the mechanism of myocardial damag, in addition to their best performance than other quantitative tests perhaps due to their association with atherosclerotic process that belongs to the endothelial dysfunction. Aim of this study is to estimate the prevalence and correlation of IL-6 with CRP in ACS- patients presented with unstable angina/ non-ST elevation myocardial infarction (UA/NSTEMI) symptoms to be as new diagnostic parameters in Iraqi CCU. Seventy (70) ACS- patients with mean age (58.55 year ± 9.98), from Jun.2009 to Feb. 2010 with diagnosis of UA/NSTEMI were included in this study. Proper history, physical examination, electrocardiograph (ECG), and Echocardiography (ECHO) were performed for all patients in addition to the routine laboratory works including fasting blood glucose, lipid profile, assay of transaminases activity (Aspartate and Alanine transaminase),and biomarkers analysis as cardiac troponin I and T, creatine kinase (CK and CK-MB) and myoglobin. Blood sample was collected from all patients for quantitative assay of IL-6 and CRP. All patients underwent diagnostic coronary angiography, were 66 of them with abnormal coronary outcome and four patients have normal coronary arteries, study include 39- male and 31 female. Seventeen of 67 patients (25.4%) had elevated serum level of IL-6 and fifty four of 62 patients (87.1%) had elevated serum level of CRP. Statistically found strong and significant (SS) correlation between IL-6 and CRP (assessed by Spearman's rho correlation coefficient, P&lt;0.01). The significant proportion of UA/NSTEMI patients that had elevated serum levels of IL-6 and/or CRP, in addition to the strong correlation with coronary angiographic findings make these inflammatory markers to be considered as risk stratification factors and good predictors for coronary artery disease independent of other traditional risk factors for cardiovascular disease (CVD).&#x0D; Key words: ACS. IL-6. CRP.

Demographics of Acute Coronary Syndrome (ACS) Egyptian patients admitted to Assiut University Hospital: Validation of TIMI and GRACE scores

AimsThis prospective cross-sectional observational study aimed at reporting the demographics of ACS patients admitted to Assiut University Hospital, Egypt, and validating both TIMI (Thrombolysis in Myocardial Infarction) and GRACE (Global Registry of Acute Coronary Events) scores in the prediction of both in-hospital MACE and 30-day mortality and recurrent MI in both ST-elevation myocardial infarction (STEMI) and unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) patients. MethodsData were collected from all admitted patients over one year from April 1, 2011. ResultsThe study included 795 patients, 270 (34%) with STEMI and 525 (66%) with UA/NSTEMI with a comparable mean age (58±11 vs 57±12years, respectively). The STEMI patients had higher rates of male gender (75% vs 64%), smoking (51% vs 38%), and familial predisposition (16% vs 7%). The UA/NSTEMI patients had higher rates of a history of previous ischemia (70% vs 24%), hypertension (59% vs 33%), and diabetes (45% vs 34%). STEMI was associated with a higher in-hospital MACE (23.3% vs 13.7%) and a higher 30-day all-cause mortality rate (9% vs 2%) and recurrent non-fatal MI (35% vs 15%). ConclusionACS occurs at a relatively young age in our locality, in patients sharing common known coronary risk factors. STEMI patients, in our locality, represent approximately one-third of ACS patients and are associated with worse in-hospital as well as 30-day outcomes. Both TIMI and GRACE risk scores are valid for use in ACS patients in the Assiut governorate (c-statistics 0.72–0.97), with a better discriminative ability for the GRACE score, especially in UA/STEMI patients.

Early Invasive Versus Initial Conservative Treatment Strategies in Octogenarians with UA/NSTEMI

BackgroundPrevious studies have demonstrated improved outcomes with an early invasive strategy in patients with unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI). However, there are limited data for patients ≥80 years of age in these studies. MethodsWe used the 2003-2010 Nationwide Inpatient Sample databases to identify all patients ≥80 years of age (octogenarians) with UA/NSTEMI. Multivariable logistic regression was used to compare in-hospital outcomes in octogenarians with UA/NSTEMI undergoing early invasive (coronary angiography within 48 hours of admission, with or without revascularization) versus initial conservative treatment. ResultsAmong 968,542 octogenarians with UA/NSTEMI, 806,902 (83.3%) were managed using an initial conservative approach and 161,640 (16.7%) using an early invasive strategy. Patients in the early invasive group were more likely to be younger, men, white, and had a higher prevalence of smoking, dyslipidemia, obesity, hypertension, known coronary artery disease, carotid artery disease, and peripheral vascular disease. In-hospital mortality was significantly lower in octogenarians in the early invasive group (adjusted odds ratio [OR] 0.76; 95% confidence interval [CI], 0.74-0.78). Early invasive strategy was associated with lower rates of acute ischemic stroke (adjusted OR 0.63; 95% CI, 0.60-0.66), intracranial hemorrhage (adjusted OR 0.60; 95% CI, 0.510.70), gastrointestinal bleeding (adjusted OR 0.63; 95% CI, 0.60-0.65), and shorter average length of stay (5.3 vs 5.8 days, P <.001), but higher cardiogenic shock (adjusted OR 2.14; 95% CI, 2.06-2.23) and total hospital cost (23,584 vs 13,278 USD). ConclusionCompared with an initial conservative approach, an early invasive strategy in octogenarians with UA/NSTEMI was associated with lower in-hospital mortality, acute ischemic stroke, intracranial hemorrhage, gastrointestinal bleeding, and shorter length of stay, but higher cardiogenic shock and total hospital cost.

259: Relationships between chronic use of statins, presentation of acute coronary syndrome and one-year mortality after a first event in patients from the French MONICA registries

Statins have demonstrated their efficacy in many situations to prevent cardiovascular risk. In this work we investigated the link between chronic use of statins, type of subsequent acute coronary syndrome (ACS), namely ST-elevation myocardial infarction (STEMI) or unstable angina/non ST-elevation myocardial infarction (UA/NSTEMI), early complications and their impact on one-year mortality in real life conditions. Our study was based on 2006 data from the French MONICA population-based registry which collects all cases of ACS occurring in people aged 35-74 in 3 French areas. The sample consisted of 1951 hospitalized incident ACS (72 were excluded because of missing data). Relationship between chronic use of statins and type of ACS or early complications (resuscitated cardiac arrests and shocks) were analyzed through logistic regression. Impact on one-year mortality was evaluated through Cox models. Analyses were adjusted for patients’ characteristics (living area, age, gender and previous cardiovascular treatments). Before index event, the rate of statins treated patients was 18%. The percentage of UA/NSTEMI among all hospitalized ACS was 45%; 54.5% in patients with previous statins treatment and 42.9% in those without (p<0.0001). The adjusted odds ratio (OR) for UA/NSTEMI was 1.29 (p=0.049) for subjects with versus those without statins. There was a significant association between statins and early complications (adjusted OR 0.58; p=0.030). Statins treatment prior to event was associated with a significant decrease in one-year mortality with an adjusted HR equal to 0.62 (p=0.017). In our registry, people already treated with statins before an incident ACS had a lower rate of one-year mortality. This may result from a lower probability to develop STEMI, or early complications. However it remains difficult to assess from these observational data what is related to the treatment and what is related to potential confounding bias.

903 The Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes (TRILOGY ACS) Trial

The optimal antiplatelet strategy for high-risk patients with unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) who are managed medically without undergoing coronary revascularization remains unclear.

2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non–ST‐Elevation Myocardial Infarction (Updating the 2007 Guideline): Highlights for the Clinician

The 2011 Update to the Unstable Angina/Non-ST-Elevation Myocardial Infarction (UA/NSTEMI) Guideline is based in evolving data or expert opinion and incorporates information from late-breaking clinical trials presented at the 2008-2009 Scientific Sessions of the American College of Cardiology, the American Heart Association, and the European Society of Cardiology, among others, as well as selected data through April 2010. The 5 key issues highlighted in this summary are: (1) the timing of acute interventional therapy in non-ST-elevation myocardial infarction; (2) emphasis on the timing, duration, and application of dual and triple antiplatelet therapy; (3) specific recommendations for patients with diabetes mellitus; (4) the role and potential benefit of invasive therapy in patients with advanced renal dysfunction; and (5) issues of quality improvement for acute coronary syndromes.

2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/ Non–ST-Elevation Myocardial Infarction (Updating the 2007 Guideline)

Jeffrey L. Anderson, MD, FACC, FAHA, Chair; Cynthia D. Adams, RN, PhD, FAHA; Elliott M. Antman, MD, FACC, FAHA; Charles R. Bridges, MD, ScD, FACC, FAHA[‡][1]; Robert M. Califf, MD, MACC; Donald E. Casey, Jr, MD, MPH, MBA, FACP[§][2]; William E. Chavey II, MD, MS[#][3]; Francis M. Fesmire, MD,

The Clinical Significance of Aspirin Resistance in Patients With Chest Pain

There are conflicting data in the literature about the clinical significance of aspirin resistance. We aimed to prospectively evaluate the prevalence of biochemical aspirin resistance in patients on aspirin therapy who were admitted to the emergency clinic with chest pain. We also aimed to evaluate the relation between acute coronary syndromes (ACS) and aspirin resistance. A total of 338 patients were included in the study. Platelet reactivity was measured with the PFA-100 system (Dade Behring Inc, Deerfield, IL). Aspirin resistance determined by the PFA-100 was defined as a normal collagen and/or epinephrine closure time despite aspirin treatment (<165 s). Patients were divided into 4 groups: stable angina pectoris (SAP), unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI), ST-elevation myocardial infarction (STEMI), and rule out ACS. Aspirin resistance was found in 81 (24%) patients in all groups. Patients with ACS had significantly more aspirin resistance than patients with rule out ACS or patients with SAP (P < .001). In the SAP group, 31 (19.6%) patients; in the UA/NSTEMI group, 19 (35.8%) patients; in the STEMI group, 14 (50%) patients; and in the rule out ACS group, 17 (17.2%) patients had aspirin resistance (P < .001). In the multivariate analysis, cardiac biomarker elevation on admission to emergency department and platelet count appeared as independent factors predictive of aspirin resistance. We demonstrated that incidence of aspirin resistance was significantly higher in patients who were finally diagnosed as ACS, especially in aspirin-taking patients admitted to the emergency clinic with STEMI.

Practical Implications of ACC/AHA 2007 Guidelines for the Management of Unstable Angina/Non-ST Elevation Myocardial Infarction

Unstable angina/non-ST elevationmyocardial infarction (UA/NSTEMI) is one of the major life-threatening causes of hospitalization in the United States. The number of hospital discharges for acute coronary syndrome in 2005 was estimated at 1.4 million and approximately 0.4 million discharges per year were for STEMI while 1 million were for UA/NSTEMI. Evidenced-based medications and lifestyle modification interventions are probably used less frequently in patients with acute coronary syndrome. Quality improvement interventions to improve adherence to the guidelines may reduce the high mortality rates associated with ACS in contemporary practice. In this article we focused on practical implications of American College of Cardiology (ACC)/American Heart Association (AHA) 2007 guidelines for the management of UA/NSTEMI. It will aid to provide the supporting evidence for the acute as well as continued management of patients with these disorders.

Does Simplicity Compromise Accuracy in ACS Risk Prediction? A Retrospective Analysis of the TIMI and GRACE Risk Scores

BackgroundThe Thrombolysis in Myocardial Infarction (TIMI) risk scores for Unstable Angina/Non-ST–elevation myocardial infarction (UA/NSTEMI) and ST-elevation myocardial infarction (STEMI) and the Global Registry of Acute Coronary Events (GRACE) risk scores for in-hospital and 6-month mortality are established tools for assessing risk in Acute Coronary Syndrome (ACS) patients. The objective of our study was to compare the discriminative abilities of the TIMI and GRACE risk scores in a broad-spectrum, unselected ACS population and to assess the relative contributions of model simplicity and model composition to any observed differences between the two scoring systems.Methodology/Principal FindingsACS patients admitted to the University of Michigan between 1999 and 2005 were divided into UA/NSTEMI (n = 2753) and STEMI (n = 698) subpopulations. The predictive abilities of the TIMI and GRACE scores for in-hospital and 6-month mortality were assessed by calibration and discrimination. There were 137 in-hospital deaths (4%), and among the survivors, 234 (7.4%) died by 6 months post-discharge. In the UA/NSTEMI population, the GRACE risk scores demonstrated better discrimination than the TIMI UA/NSTEMI score for in-hospital (C = 0.85, 95% CI: 0.81–0.89, versus 0.54, 95% CI: 0.48–0.60; p<0.01) and 6-month (C = 0.79, 95% CI: 0.76–0.83, versus 0.56, 95% CI: 0.52–0.60; p<0.01) mortality. Among STEMI patients, the GRACE and TIMI STEMI scores demonstrated comparably excellent discrimination for in-hospital (C = 0.84, 95% CI: 0.78–0.90 versus 0.83, 95% CI: 0.78–0.89; p = 0.83) and 6-month (C = 0.72, 95% CI: 0.63–0.81, versus 0.71, 95% CI: 0.64–0.79; p = 0.79) mortality. An analysis of refitted multivariate models demonstrated a marked improvement in the discriminative power of the TIMI UA/NSTEMI model with the incorporation of heart failure and hemodynamic variables. Study limitations included unaccounted for confounders inherent to observational, single institution studies with moderate sample sizes.Conclusions/SignificanceThe GRACE scores provided superior discrimination as compared with the TIMI UA/NSTEMI score in predicting in-hospital and 6-month mortality in UA/NSTEMI patients, although the GRACE and TIMI STEMI scores performed equally well in STEMI patients. The observed discriminative deficit of the TIMI UA/NSTEMI score likely results from the omission of key risk factors rather than from the relative simplicity of the scoring system.

Gender differences among patients with acute coronary syndromes undergoing percutaneous coronary intervention in the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR)

Although prior studies have demonstrated disparities in the management and outcomes of women with acute coronary syndrome (ACS), there are limited large-scale contemporary data on gender differences in post-intervention outcomes in this population. We analyzed patients according to 2 ACS categories, unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) and ST-elevation myocardial infarction (STEMI) who had a percutaneous coronary intervention in the ACC-NCDR from January 1, 2004, to March 30, 2006. Of 199,690 patients, 55,691 women presented with UA/NSTEMI, and 12,335 women presented with STEMI. Clinical and angiographic characteristics, procedural and treatment patterns, and in-hospital outcomes were examined. Women presented more often with UA/NSTEMI than men (82% of women vs 77% of men, P < .0001). Despite having greater comorbidities, women in both ACS categories had fewer high risk angiographic features than men. Women were less likely to receive aspirin or glycoprotein IIb/IIIa inhibitors, and were less often discharged on aspirin or statin. For in-hospital mortality, the adjusted odds ratio for men compared to women was similar (odds ratio 0.97, P = .5). Women had higher rates of cardiogenic shock, congestive heart failure, any bleeding, and any vascular complications. Importantly, rates of subacute stent thrombosis were less in women compared to men (0.43% vs 0.57%, P = .0003). Although women had fewer high-risk angiographic features than men, they continue to have higher rates of in-hospital complications. This suggests the need for gender-tailored techniques to minimize post-intervention complications and maximize application of evidence-based antiplatelet therapies.