Objectives: To investigate the characteristics of the acute coronary syndromes underlying acute pulmonary oedema and their 30 day prognosis.
Patients: 185 consecutive patients with acute coronary syndromes and acute pulmonary oedema admitted to a tertiary care centre.
Main outcome and measures: Clinical, ECG, echocardiographic, enzymatic, and angiographic features were prospectively investigated.
Results: Non-ST segment elevation myocardial infarction (NSTEMI) was the most frequent cause of acute pulmonary oedema (61%) followed by unstable angina (UA; 21%) and ST segment elevation myocardial infarction (STEMI; 18%). In each group, mean age was ⩾ 70 years, but NSTEMI patients were the oldest and ⩾ 65% of patients had chronic hypertension. Moreover, patients with NSTEMI and UA were older and had a higher incidence of diabetes, previous myocardial infarction, and moderate to severe mitral regurgitation but a similarly reduced ejection fraction (NSTEMI, 41%; UA, 39%; and STEMI, 39%) and increased incidence of diastolic dysfunction and rate of multivessel disease (94%, 87%, and 86%, respectively). However, patients with STEMI had a higher creatine kinase MB peak concentration (158 v 76 μg/l in the NSTEMI group, p < 0.001) and 30 day mortality (26% v 9% in the NSTEMI group and 8% in the UA group, p < 0.024). Multivariate analysis identified ejection fraction < 40% and a peak creatine kinase MB concentration > 100 μg/l as the main prognostic markers (p < 0.03).
Conclusions: Acute pulmonary oedema is mostly a complication of elderly hypertensive patients with NSTEMI or UA (82%) and with multivessel disease often associated with mitral regurgitation. On the other hand, the larger infarct size and higher mortality in patients with STEMI with a similarly reduced ejection fraction suggest a more extensive acute systolic loss.
NSTEMI; prognosis; STEMI; unstable angina; acute pulmonary oedema
Younger, but not older, women have a higher mortality than men of similar age after a myocardial infarction (MI). We sought to determine whether this relationship is true for both ST elevation MI (STEMI) and non-ST elevation MI (NSTEMI).
Retrospective cohort study.
1057 USA hospitals participant in the National Registry of Myocardial Infarction between 2000 and 2006.
126 172 STEMI and 235 257 NSTEMI patients.
Main outcome measure
For both STEMI and NSTEMI, the younger the patient's age, the greater the excess mortality risk for women compared with men, while older women fared similarly (STEMI) or better (NSTEMI) than men (p<0.0001 for the age–sex interaction). In STEMI, the unadjusted women-to-men RR was 1.68 (95% CI 1.41 to 2.01), 1.78 (1.59 to 1.99), 1.45 (1.34 to 1.57), 1.08 (1.02 to 1.14) and 1.03 (0.98 to 1.07) for age <50 years, age 50–59, age 60–69, age 70–79 and age 80–89, respectively. For NSTEMI, corresponding unadjusted RRs were 1.56 (1.31 to 1.85), 1.42 (1.27 to 1.58), 1.17 (1.09 to 1.25), 0.92 (0.88 to 0.96) and 0.86 (0.83 to 0.89). After adjusting for risk status, the excess risk for younger women compared with men decreased to approximately 15–20%, while a better survival of older NSTEMI women compared with men persisted.
Sex-related differences in short-term mortality are age-dependent in both STEMI and NSTEMI patients.
The 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.
ACS 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.
The 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.
Objective. To investigate whether assessment of C-reactive protein (CRP) and apolipoproteins, besides the traditional lipid profile, enhances the assessment process for the risk of acute coronary syndrome (ACS). Methods. The study group consisted of 220 consecutive patients admitted to hospital within the first 6 hours from the onset of chest pain. Patients were diagnosed with unstable angina (n = 96), non-ST-elevation myocardial infarction (NSTEMI; n = 57), or ST-elevation myocardial infarction (STEMI; n = 67). ACS patients were compared with 116 healthy volunteers in a case-control study. The serum was assayed on admission for CRP, apolipoproteins ApoAI and ApoB100, and lipid parameters. Results. The highest concentrations of CRP were found in NSTEMI and STEMI, with a median value four-fold higher in ACS patients than in controls (P < 0.0001). Only CRP significantly increased the probability of ACS development (adjusted odds ratio for a 1 mg/L increase 1.90; 95% confidence interval [CI] 1.34–2.89) and explained 90% of the variation for ACS development. Similarly, we demonstrated the highest diagnostic accuracy for CRP among all investigated markers (area under the curve 0.80; 95% CI 0.75–0.85). Conclusions. Our study indicates that CRP superiorly to apolipoproteins and lipid profile facilitates the risk stratification for ACS occurrence.
Compared with ST elevation myocardial infarction (STEMI), long-term outcomes are known to be worse in patients with unstable angina/non-STEMI (UA/NSTEMI), which might be related to the worse health status of patients with UA/STEMI. In patients with UA/NSTEMI and STEMI underwent percutaneous coronary intervention (PCI), angina-specific and general health-related quality-of-life (HRQOL) was investigated at baseline and at 30 days after PCI. Patients with UA/NSTEMI were older and had higher frequencies in female, diabetes and hypertension. After PCI, both angina-specific and general HRQOL scores were improved, but improvement was much more frequent in angina-related HRQOL of patients with UA/NSTEMI than those with STEMI (44.2% vs 36.8%, P < 0.001). Improvement was less common in general HRQOL. At 30-days after PCI, angina-specific HRQOL of the patients with UA/NSTEMI was comparable to those with STEMI (56.1 ± 18.6 vs 56.6 ± 18.7, P = 0.521), but general HRQOL was significantly lower (0.86 ± 0.21 vs 0.89 ± 0.17, P = 0.001) after adjusting baseline characteristics (P < 0.001). In conclusion, the general health status of those with UA/NSTEMI was not good even after optimal PCI. In addition to angina-specific therapy, comprehensive supportive care would be needed to improve the general health status of acute coronary syndrome survivors.
Quality of Life; Acute Coronary Syndrome; Health Status; Myocardial Infarction; Angioplasty, Balloon, Coronary
The aim of this study was to determine the long-term safety of drug-eluting stent (DES) versus bare metal stent (BMS) implantation in a “real-world” setting.
Patients and methods
A total of 1809 patients who were treated with implantation of either BMS or DES were assessed. Kaplan-Meier and multivariate Cox regression analyses concerning primary endpoint of cardiac mortality were performed.
A total of 609 patients received DES. Mean age was 66.2 ± 11.3 years, 69.4% were male, and 1517 (83.8%) were treated for acute coronary syndrome (unstable angina 510 [28.2%], non-ST-elevation myocardial infarction [NSTEMI] 506 [28.0%], and ST-elevation myocardial infarction [STEMI] 501 [27.7%]). Mean follow-up was 34 ± 15 months. During follow-up, 268 patients died of cardiac causes (DES 42 [7.3%]; BMS 226 [19.6%]; P < 0.001). Univariate Kaplan-Meier analysis showed an advantage of DES over BMS concerning the primary end-point (P < 0.001). When adjusting for classic risk factors and additional factors that affect the progression of coronary heart disease (CHD), DES was not found to be superior to BMS (hazard ratio 0.996, 95% confidence interval 0.455–2.182, P = 0.993). Severely impaired renal function was an independent predictor for cardiac mortality after stent implantation.
Treatment with DES is safe in the long term, also in patients presenting with STEMI. However, in multivariate analyses it is not superior to BMS treatment.
coronary stent; outcome; renal insufficiency; myocardial infarction; STEMI
To identify differences among men and women with acute coronary syndrome in terms of in-hospital mortality, and to assess whether these differences are related to the use of percutaneous cardiovascular procedures.
Observational study based on the Minimum Basic Data Set. This encompassed all episodes of emergency hospital admissions (46,007 cases, including 16,391 women and 29,616 men) with a main diagnosis of either myocardial infarction or unstable angina at 32 hospitals within the Andalusian Public Health System over a four-year period (2000–2003). The relationship between gender and mortality was examined for the population as a whole and for stratified groups depending on the type of procedures used (diagnostic coronary catheterisation and/or percutaneous transluminal coronary angioplasty). These combinations were then adjusted for age group, main diagnosis and co-morbidityharlson score).
During hospitalisation, mortality was 9.6% (4,401 cases out of 46,007), with 11.8% for women and 8.3% for men. There were more deaths among older patients with acute myocardial infarction and greater co-morbidity. Lower mortality was shown in patients undergoing diagnostic catheterisation and/or PTCA. After adjusting for age, diagnosis and co-morbidity, mortality affected women more than men in the overall population (OR 1.14, 95% CI: 1.06–1.22) and in the subgroup of patients where no procedure was performed (OR 1.16, 95% CI: 1.07–1.24). Gender was not an explanatory variable in the subgroups of patients who underwent some kind of procedure.
Gender has not been associated to in-hospital mortality in patients who undergo some kind of percutaneous cardiovascular procedure. However, in the group of patients without either diagnostic catheterisation or angioplasty, mortality was higher in women than in men.
Unstable plaque is believed to be responsible for major adverse cardiac events (MACE).
To determine whether coronary computed tomography angiography (CCTA) could be used to predict future MACE.
Patients undergoing CCTA between January 2008 and February 2010 were consecutively enrolled in the study. The hospital database was screened for patients who later developed acute ST segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI) or cardiac death. Plaque scores were calculated and analyzed using one-way ANOVA to examine the relationship between plaque scores and MACE.
Of the 8557 patients who underwent CCTA, 1055 had hospital records available for follow-up. During follow-up, 25 patients experienced MACE including death (six patients), heart failure (two patients), STEMI (11 patients) and NSTEMI (six patients). The plaque scores were significantly increased in patients who later died, developed heart failure or experienced STEMI (P<0.05). Calcification, erosion and severe stenosis were responsible for the events (P<0.05). Mild and moderate lesions, positive remodelling, drug-eluting stent placement, occlusion and diffuse lesions were not predictive of MACE (P>0.05).
Severe calcification, erosion and severe stenosis predict death, heart failure and STEMI.
Coronary computed tomography angiography; Coronary plaque; Major adverse cardiac events; Risk factor
The term acute coronary syndrome (ACS) refers to any group of clinical symptoms compatible with acute myocardial ischemia and includes unstable angina (UA), non—ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). These high-risk manifestations of coronary atherosclerosis are important causes of the use of emergency medical care and hospitalization in the United States. A quick but thorough assessment of the patient's history and findings on physical examination, electrocardiography, radiologic studies, and cardiac biomarker tests permit accurate diagnosis and aid in early risk stratification, which is essential for guiding treatment. High-risk patients with UA/NSTEMI are often treated with an early invasive strategy involving cardiac catheterization and prompt revascularization of viable myocardium at risk. Clinical outcomes can be optimized by revascularization coupled with aggressive medical therapy that includes anti-ischemic, antiplatelet, anticoagulant, and lipid-lowering drugs. Evidence-based guidelines provide recommendations for the management of ACS; however, therapeutic approaches to the management of ACS continue to evolve at a rapid pace driven by a multitude of large-scale randomized controlled trials. Thus, clinicians are frequently faced with the problem of determining which drug or therapeutic strategy will achieve the best results. This article summarizes the evidence and provides the clinician with the latest information about the pathophysiology, clinical presentation, and risk stratification of ACS and the management of UA/NSTEMI.
Previous studies examining sex-related differences in the treatment of coronary artery disease have focused on patients in hospital. We sought to examine sex-related differences at an earlier point in care — presentation to the emergency department.
We collected data on ambulatory care and hospital admissions for 54 134 patients (44% women) who presented to an emergency department in Alberta between July 1998 and March 2001 because of acute myocardial infarction, unstable angina, stable angina or chest pain. We used logistic regression and Cox regression analyses to determine sex-specific associations between the likelihood of discharge from the emergency department or coronary revascularization within 1 year and 1-year mortality after adjusting for age, comorbidities and socioeconomic factors.
Following the emergency department visit, 91.3% of patients with acute myocardial infarction, 87.4% of those with unstable angina, 40.7% of those with stable angina and 19.8% of those with chest pain were admitted to hospital. Women were more likely than men to be discharged from the emergency department: adjusted odds ratio (and 95% confidence interval [CI]) 2.25 (1.75–2.90) for acute myocardial infarction, 1.71 (1.45–2.01) for unstable angina, 1.33 (1.15–1.53) for stable angina and 1.46 (1.36–1.57) for chest pain. Women were less likely than men to undergo coronary revascularization within 1 year: adjusted odds ratio (and 95% CI) 0.65 (0.57–0.73) for myocardial infarction, 0.39 (0.35–0.44) for unstable angina, 0.35 (0.29–0.42) for stable angina and 0.32 (0.27–0.37) for chest pain. Female sex had no impact on 1-year mortality among patients with acute myocardial infarction; it was associated with a decreased 1-year mortality among patients with unstable angina, stable angina and chest pain: adjusted hazard ratio (and 95% CI) 0.60 (0.46–0.78), 0.60 (0.46–0.78) and 0.74 (0.63–0.87) respectively.
Women presenting to the emergency department with coronary syndromes are less likely than men to be admitted to an acute care hospital and to receive coronary revascularization procedures. These differences do not translate into worse outcomes for women in terms of 1-year mortality.
To study gender differences in management and outcome in patients with non‐ST‐elevation acute coronary syndrome.
Design, setting and patients
Cohort study of 53 781 consecutive patients (37% women) from the Register of Information and Knowledge about Swedish Heart Intensive care Admissions (RIKS‐HIA), with a diagnosis of either unstable angina pectoris or non‐ST‐elevation myocardial infarction. All patients were admitted to intensive coronary care units in Sweden, between 1998 and 2002, and followed for 1 year.
Main outcome measures
Treatment intensity and in‐hospital, 30‐day and 1‐year mortality.
Women were older (73 vs 69 years, p<0.001) and more likely to have a history of hypertension and diabetes, but less likely to have a history of myocardial infarction or revascularisation. After adjustment, there were no major differences in acute pharmacological treatment or prophylactic medication at discharge.
Revascularisation was, however, even after adjustment, performed more often in men (OR 1.15; 95% CI, 1.09 to 1.21). After adjustment, there was no significant difference in in‐hospital (OR 1.03; 95% CI, 0.94 to 1.13) or 30‐days (OR 1.07; 95% CI, 0.99 to 1.15) mortality, but at 1 year being male was associated with higher mortality (OR 1.12; 95% CI, 1.06 to 1.19).
Although women are somewhat less intensively treated, especially regarding invasive procedures, after adjustment for differences in background characteristics, they have better long‐term outcomes than men.
Acute coronary syndrome (ACS) is characterized by increased inflammatory processes and endothelial activation. We investigated the association between ACS and inflammatory mediators and matrix-degrading enzymes.
We prospectively enrolled 55 consecutive patients with ACS: 25 with unstable angina (UA) and 30 with non-ST elevated myocardial infarction (NSTEMI). For comparison, 25 age- and sex-matched subjects with no significant coronary artery stenosis were included as the control group. Peripheral serum levels of interleukin (IL)-33, matrix metalloproteinase (MMP)-9, tissue inhibitor of MMP-1, and C-reactive protein (CRP) were measured on admission, and at 12, 24, 48, and 72 hours after the initial evaluation.
Compared to serum levels in the control group, serum levels of IL-33 decreased in the NSTEMI group (p < 0.05), and levels of MMP-9 and tissue inhibitor of matrix metalloproteinase (TIMP)-1 increased in the UA group (p < 0.01, p < 0.05, respectively) and NSTEMI group (p < 0.05, p < 0.05, respectively). IL-33 levels were significantly lower on admission than at 12 hours after the initial evaluation (p < 0.05). IL-33 levels were negatively correlated with MMP-9 levels (r = -0.461, p < 0.05) and CRP levels (r = -0.441, p < 0.05).
Elevated levels of MMP-9, TIMP-1, and decreased levels of IL-33 play a role in the development and progression of ACS.
Inflammation; Interleukin-33; Matrix metalloproteinase 9; Myocardial infarction
Matrix metalloproteinases (MMPs) and Tissue Inhibitor of Matrix Metalloproteinases (TIMPs) may be associated with atherogenesis and plaque rupture. We evaluated the relationship between MMP-1, MMP-9, TIMP-1 and IL-6 levels and risk factors, presentation, extent and severity of atherosclerotic coronary artery disease (CAD).
Consecutive patients who underwent coronary angiography were randomly included. The serum concentrations of MMP-1, MMP-9, TIMP-1 and IL-6 were analyzed with ELISA method in 134 patients. Participants were divided into 5 groups; stable angina pectoris (SAP; n= 34), unstable angina pectoris (USAP; n=29), non-ST elevation myocardial infarction (NSTEMI; n=16), acute ST elevation myocardial infarction (STEMI; n=25) and controls (n=30). Coronary angiographic Gensini score was calculated.
MMP-1 levels were higher in STEMI and NSTEMI groups compared with USAP, SAP and control groups (STEMI vs USAP p=0.005; STEMI vs SAP p=0.001; STEMI vs control p<0.001; NSTEMI vs USAP p=0.02; NSTEMI vs SAP p=0.027; NSTEMI vs control p<0.001). In STEMI group, MMP-9 levels were higher than USAP and control groups (p=0.002; p<0,001). TIMP-1 levels were not significantly different within all 5 groups. MMP-1 levels were found to be elevated in diabetic patients (p=0.020); whereas MMP-9 levels were higher in smokers (p=0.043). Higher MMP-1, MMP-9 and IL-6 levels were correlated with severe Left Anterior Descending artery (LAD) stenosis and higher angiographic Gensini Score (for severe LAD stenosis; r = 0.671, 0.363, 0.509 p<0.001; for Gensini score; r = 0.717, 0.371, 0.578 p<0.001).
Serum levels of MMP-1, MMP-9, and IL-6 are elevated in patients with CAD; more so in acute coronary syndromes. MMP-1, MMP-9 and IL-6 are associated with more extensive and severe CAD (as represented by Gensini score).
Matrix metalloproteinase; Interleukin-6; coronary artery disease; Gensini score.
To determine the epidemiology of acute coronary syndromes (ACS) in sub-Saharan Africa.
A prospective survey was carried out of all patients with a diagnosis of ACS who were admitted to the critical care unit of a tertiary teaching hospital over a 25-month period. Demographics, presentation, management and outcomes were subsequently recorded.
A total of 111 (5.1% of all hospitalisations) patients were recruited, with 56% presenting with ST-elevation myocardial infarction (STEMI) and the rest non-ST-elevation myocardial infarction (NSTEMI) or unstable angina (UA). Chest pain was the most common presenting symptom, and up to one-third of all STEMI patients did not receive any form of reperfusion therapy, primarily due to late presentation. As in the developed world, diabetes, hypertension and cigarette smoking still account for the most common predisposing risk-factor profile, and the mortality associated with ACS is about six to 10% in our unit.
ACS, contrary to common belief, is increasingly more prevalent in sub-Saharan Africa, with similar risk profiles to that in the developed world. Late presentation to hospital is common and accounts for the increased mortality associated with this condition.
acute coronary syndrome; clinical characteristics; sub-Saharan Africa
Data on mortality in young patients with ST-segment elevation myocardial infarction (STEMI) when compared to older people or regarding therapeutic strategies are contradictory. We investigate the prognosis of women under 40 after STEMI in a prospective nationwide acute coronary syndrome registry.
Material and methods
We analyzed all 527 consecutive men and women (12.3% females) aged from 20 to 40 years (mean 35.7 ±4.5) presenting with STEMI, of all 26035 STEMI patients enrolled.
Differences between genders in the major cardiovascular risk factors, clinical presentation, extent of the disease and time to reperfusion were insignificant. The majority of patients (67%) underwent coronary angiography followed by primary percutaneous coronary intervention (PCI) in 79.9% of them. A 92% reperfusion success rate measured by post-procedural TIMI 3 flow was achieved. There were no significant differences between genders in the administration of modern pharmacotherapy both on admission and after discharge from hospital. In-hospital mortality was very low in both genders, but 12-month mortality was significantly higher in women (10.8% vs. 3.0%; p = 0.003). Killip class 3 or 4 on admission (95% CI 19.6-288.4), age per 5-year increase (95% CI 1.01-3.73) and primary PCI (95% CI 0.1-0.93) affected mortality. In patients who underwent reperfusion there was moderately higher mortality in women than in men (7.1% vs. 1.9%; p = 0.046).
Despite little difference in the basic clinical characteristics and the management including a wide use of primary PCI, long-term mortality in women under forty after STEMI is significantly higher than in men.
gender-related difference; ST-segment elevation myocardial infarction; myocardial infarction; mortality; young
Background. Acute Coronary Syndrome (ACS) is a clinical condition encompassing ST Segment Elevation Myocardial Infarction (STEMI), Non-ST Segment Elevation Myocardial Infarction (NSTEMI), and Unstable Angina (UA) and is characterized by ruptured coronary plaque, ischemic stress, and/or myocardial injury. Emergency department (ED) physicians are on the front lines of ACS management. The role of new antiplatelet agents ticagrelor and prasugrel in acute ED management of ACS has not yet been defined. Objective. To critically review clinical trials using ticagrelor and prasugrel in the treatment of ACS and inform practitioners of their potential utility in treating ACS in the ED. Results. Trials on the efficacy of ticagrelor and prasugrel achieve statistical significance in decreasing composite endpoints in select patient populations. Conclusion. The use of ticagrelor and prasugrel as first line ED treatment of ACS is not well established. Current evidence supports the use of several agents with the final decision based on treatment protocols conjointly developed between cardiology and emergency medicine (EM). Further clinical trials involving head-to-head trials or comparisons of drug-based strategies are required to show superiority in reducing cardiac endpoints with regard to ED initiation of treatment.
To explore the relative association of admission blood glucose levels and antecedent diabetes on early and long-term survival in a contemporary UK population of patients with ST elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI).
Retrospective cohort study based on the Myocardial Ischaemia National Audit Project dataset.
Tertiary care centre.
4111 (20.3% known diabetes) consecutive patients admitted with acute myocardial infarction (58.3% STEMI) between October 2002 and September 2008.
Primary and secondary outcome measures
All-cause mortality at 30 days and 1 year. The relative association of admission blood glucose and of antecedent diabetes with mortality was assessed using multivariate Cox regression analysis. Furthermore, we compared these relationships in patients with STEMI to those with NSTEMI.
By 30 days and 1 year, 409 (9.9%) and 677 (16.5%) of patients died. After adjusting for covariates, diabetes did not show independent association with mortality at any time point, in the entire cohort (HR 30 days 0.93 (95% CI 0.63 to 1.38); 1 year 1.00 (0.77 to 1.30)) or in subgroups of STEMI (HR 30 days 1.03 (0.65 to 1.64); 1 year 1.08 (0.77 to 1.51)) and NSTEMI (HR 30 days 0.62 (0.26 to 1.50); 1 year 0.87 (0.56 to 1.36)). In contrast, after adjusting for covariates, admission glucose showed robust and independent association with mortality in the entire cohort (HR: 30 days 1.07 (1.04 to 1.10); 1 year 1.05 (1.03 to 1.08)), and in the subgroup of STEMI (30 days 1.07 (1.03 to 1.10); 1 year 1.07 (1.04 to 1.10)), and NSTEMI (HR 30 days 1.07 (1.00 to 1.14); 1 year 1.02 (0.97 to 1.06)).
Admission glucose is strongly associated with mortality in all presentations of acute myocardial infarction (AMI), irrespective of established diabetes diagnosis. The increased risk is maintained up to 1 year. Future studies are required to assess the impact of active management of elevated blood glucose in improving mortality in individuals admitted with AMI.
Objectives To determine whether coronary angiography for suspected stable angina pectoris is underused in older patients, women, south Asian patients, and those from socioeconomically deprived areas, and, if it is, whether this is associated with higher coronary event rates.
Design Multicentre cohort with five year follow-up.
Setting Six ambulatory care clinics in England.
Participants 1375 consecutive patients in whom coronary angiography was individually rated as appropriate with the Rand consensus method.
Main outcome measures Receipt of angiography (420 procedures); coronary mortality and acute coronary syndrome events.
Results In a multivariable analysis, angiography was less likely to be performed in patients aged over 64 compared with those aged under 50 (hazard ratio 0.60, 95% confidence interval 0.38 to 0.96), women compared with men (0.42, 0.35 to 0.50), south Asians compared with white people (0.48, 0.34 to 0.67), and patients in the most deprived fifth compared with the other four fifths (0.66, 0.40 to 1.08). Not undergoing angiography when it was deemed appropriate was associated with higher rates of coronary event.
Conclusions At an early stage after presentation with suspected angina, coronary angiography is underused in older people, women, south Asians, and people from deprived areas. Not receiving appropriate angiography was associated with a higher risk of coronary events in all groups. Interventions based on clinical guidance that supports individualised management decisions might improve access and outcomes.
It is well known that serum paraoxonase (PON1) plays an important role in the protection of LDL from oxidation. PON1 55 polymorphism is currently investigated for its possible involvement in cardiovascular diseases. The objective of our study is to verify if PON1 55 polymorphism is associated with risk of acute coronary syndrome (ACS) and with biochemical myocardial ischemia markers, such as troponin I, creatine kinase (CK)-MB, myoglobin, and C-reactive protein. We analysed PON1 55 polymorphism in a total of 440 elderly patients who underwent an ACS episode: 98 patients affected by unstable angina (UA), 207 AMI (acute myocardial infarction) patients affected by STEMI (ST elevation), and 135 AMI patients affected by NSTEMI (no ST elevation). We found that individuals carrying PON1 55 LL genotype are significantly more represented among AMI patients affected by NSTEMI; moreover, the patients carrying LL genotype showed significantly higher levels of myoglobin in comparison to LM + MM carriers patients. Our study suggests that PON1 55 polymorphism could play a role in the pathogenesis of cardiac ischemic damage. In particular, the significant association between PON1 55 LL genotype and the occurrence of a NSTEMI may contribute to improve the stratification of the cardiovascular risk within a population.
OBJECTIVE--To re-examine the prevailing hypothesis that women fare worse than men after acute myocardial infarction. DESIGN--10 year follow up of all patients with confirmed acute myocardial infarction registered in the database of the Danish verapamil infarction trial in 1979-81. SETTING--16 coronary care units, covering a fifth of the total Danish population. PATIENTS--3073 consecutive patients with acute myocardial infarction, 738 (24%) women and 2335 (76%) men. MAIN OUTCOME MEASURES--Early mortality (before day 15). For patients alive on day 15: mortality, cause of death, admission with recurrent infarction, and mortality after reinfarction. RESULTS--Early mortality increased significantly with age (P < 0.0001) but was not significantly related to sex, with a 15 day mortality of 17% in women and 16% in men. Adjustment for age and sex simultaneously revealed a significant interaction (P = 0.02) between these variables, with a greater increase with age in early mortality for men than for women (early mortality was equal for the two sexes at age 64 years). Ten year mortality in patients alive on day 15 was 58.8%. The overall age adjusted hazard ratio (95% confidence interval) for women versus men was 0.90 (0.80 to 1.01); 0.90 (0.78 to 1.04) for 10 year reinfarction (48.8%); and 0.98 (0.82 to 1.16) for 10 year mortality after reinfarction (82.3%). No difference in cause of death was found between the sexes. With a follow up of up to 10 years for patients alive on day 15 mortality, rate of reinfarction, and mortality after reinfarction increased with increasing age (P < 0.0001). CONCLUSION--Sex by itself is not a risk factor after acute myocardial infarction.
To review available evidence and examine issues surrounding the use of advanced antiplatelet therapy in an effort to provide a practical guide for emergency physicians caring for patients with acute coronary syndromes (ACS).
American College of Cardiology/American Heart Association (ACC/AHA) 2007 guidelines for the management of patients with unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI), AHA/ACC 2007 focused update for the management of patients with STEMI, selected clinical articles identified through the PubMed database (1965-February 2008), and manual searches for relevant articles identified from those retrieved.
English-language controlled studies and randomized clinical trials that assessed the efficacy and safety of antiplatelet therapy in treating patients with all ACS manifestations.
Data Extraction and Synthesis:
Clinical data, including treatment regimens and patient demographics and outcomes, were extracted and critically analyzed from the selected studies and clinical trials. Pertinent data from relevant patient registries were also evaluated to assess current clinical practice.
As platelet activation and aggregation are central to ACS pathology, antiplatelet agents are critical to early treatment. A widely accepted first-line treatment is aspirin, which acts to decrease platelet activation via inhibition of thromboxane A2 synthesis. Thienopyridines, which inhibit ADP-induced platelet activation, and glycoprotein (GP) receptor antagonists, which bind to platelet GP IIb/IIIa receptors and hinder their role in platelet aggregation and thrombus formation, provide complementary mechanisms of platelet inhibition and are often employed in combination with aspirin. While the higher levels of platelet inhibition that accompany combination therapy improve protection against ischemic and peri-procedural events, the risk of bleeding is also increased. Thus, the challenge in choosing appropriate therapy in the emergency department lies in balancing the need for potent platelet inhibition with the potential for increased risk of bleeding and future interventions the patient is likely to receive during the index hospitalization.
Objective: To investigate the association between environmental tobacco smoke (ETS) exposure (at least 30 minutes a day) and the risk of developing acute coronary syndromes (ACS).
Design and setting: The CARDIO2000 is a case–control study which was conducted in Greece from 2000 to 2001. Cases included 847 individuals with a first event of ACS and 1078 cardiovascular disease-free controls. Cases and controls were frequency matched on age (within three years of age), sex, and region.
Main outcome measures: ACS was defined as a diagnosis of first acute myocardial infarction or unstable angina.
Main independent variable: Exposure to ETS was measured by self report as follows: after the second day of hospitalisation for the cases, and at the entry for the controls, participants were asked whether they were currently exposed to tobacco smoke from other people (home and/or work) for more than 30 minutes a day. The responses were categorised into three levels: no exposure, occasional exposure (< 3 times per week), and regular exposure. In addition participants were asked how many years they had been exposed. Because these were self reported assessments and prone to bias, the results were compared to reports obtained from subjects' relatives or friends, using the Kendal's τ coefficient that showed high agreement.
Results: 731 (86%) of the patients and 605 (56%) of the controls reported current exposure of 30 minutes per day or more to ETS. Among current non-smokers, cases were 47% more likely to report regular exposure to ETS (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.26 to 1.80) compared to controls. Exposure to ETS at work was associated with a greater risk of ACS compared to home exposure (+97% v +33%). The risk of ACS was also raised in active smokers (OR 2.83, 95% CI 2.07 to 3.31) regularly exposed to ETS.
Conclusions: This study supports the hypothesis that exposure to ETS increases the risk of developing ACS. The consistency of these findings with the existing totality of evidence presented in the literature supports the role of ETS in the aetiology of ACS.
In Part 1 of this review, we discussed how plaque rupture is the most common underlying cause of most cases of unstable angina/non-ST-segment-elevation myocardial infarction (UA/NSTEMI) and how early risk stratification is vital for the timely diagnosis and treatment of acute coronary syndromes (ACS). Now, in Part 2, we focus on the medical therapies and treatment strategies (early conservative vs early invasive) used for UA/NSTEMI. We also discuss results from various large randomized controlled trials that have led to the contemporary standards of practice for, and reduced morbidity and death from, UA/NSTEMI.
In summary, ACS involving UA/NSTEMI is associated with high rates of adverse cardiovascular events, despite recent therapeutic advances. Plaque composition and inflammation are more important in the pathogenesis of ACS than is the actual degree of arterial stenosis. As results from new trials challenge our current practices and help us develop the optimal treatment strategy for UA/NSTEMI patients, the cornerstones of contemporary treatment remain early risk stratification and aggressive medical therapy, supplemented by coronary angiography in appropriately selected patients.
An early-invasive-treatment strategy is of most benefit to high-risk patients, whereas an early-conservative strategy is recommended for low-risk patients. Adjunctive medical therapy with acetylsalicylic acid, clopidogrel or another adenosine diphosphate antagonist, glycoprotein IIb/IIIa inhibitors, and either low-molecular-weight heparin or unfractionated heparin, in the appropriate setting, further reduces the risk of ischemic events secondary to thrombosis. Short- and long-term inhibition of platelet aggregation should be achieved by appropriately evaluating the risk of bleeding complications in these patients.
Abciximab; acute coronary syndrome/therapy; angina, unstable/drug therapy/therapy; angina pectoris; angioplasty, transluminal, percutaneous coronary; angiotensin-converting enzyme inhibitors; aspirin/administration & dosage; calcium channel blockers; clinical trial as topic; clopidogrel; dalteparin; drug therapy, combination; enoxaparin; eptifibatide; evidence-based medicine; fondaparinux; heparin; immunoglobulin Fab fragments; meta-analysis as topic; multicenter study as topic; multivariate analysis; myocardial infarction; myocardial revascularization; nitroglycerin/therapeutic use; platelet aggregation inhibitors; platelet glycoprotein GPIIb-IIIa complex; prodrugs/therapeutic use; proton pumps; randomized controlled trials as topic; review; risk assessment; stents; thrombolytic therapy; ticlopidine; treatment outcome; vasodilator agents
Objectives: To quantify the impact of baseline renal function on in-hospital and long term mortality in patients with unstable angina/non-ST elevation acute myocardial infarction (UA/NSTEMI) treated with a very early invasive strategy.
Design: Prospective cohort study of 1400 consecutive patients with UA/NSTEMI undergoing coronary angiography and subsequent coronary stenting of the culprit lesion as the primary revascularisation strategy within 24 hours of admission. Patients were stratified according to calculated glomerular filtration rate (GFR) on admission.
Results: In-hospital mortality was 0% among patients with a GFR ⩾ 130 ml/min/1.73 m2, 0.4% with a GFR of 90–129 ml/min/1.73 m2, 2.6% with a GFR of 60–89 ml/min/1.73m2, and 5.1% with a GFR of < 60 ml/min/1.73 m2. Cumulative three year survival rates were 92.6%, 95.5%, 91.9%, and 76.8%, respectively. Patients with a GFR of < 60 ml/min/1.73 m2 were four times more likely to die in hospital (hazard ratio (HR) 4.0, 95% confidence interval (CI) 1.8 to 9.1; p = 0.001) and four times more likely to die during long term follow up (HR 4.0, 95% CI 2.5 to 6.4; p < 0.001). After adjusting for potential confounders, a GFR of < 60 ml/min/1.73 m2 remained a strong independent predictor of long term mortality (HR 2.6, 95% CI 1.5 to 4.5; p = 0.001).
Conclusions: Baseline renal function is a strong independent predictor of in-hospital and long term mortality after UA/NSTEMI treated with very early revascularisation.
myocardial infarction; unstable angina; renal function; revascularisation
This study investigated the relationship between psychotropic medication use and adverse cardiovascular (CV) events in women with symptoms of myocardial ischemia undergoing coronary angiography.
Women enrolled in the Women’s Ischemia Syndrome Evaluation (WISE), were classified into one of 4 groups according to their reported antidepressant and anxiolytic medication usage at study intake: (1) No medication (n=352); (2) Anxiolytics only (n=67); (3) Antidepressants only (n=58); and (4) Combined antidepressant and anxiolytics (n=39). Participants were followed prospectively for the development of adverse CV events (e.g., hospitalizations for nonfatal myocardial infarction, stroke, congestive heart failure, and unstable angina) or all cause mortality over a median of 5.9 years.
Use of antidepressant medication was associated with subsequent CV events (HR= 2.16, 95% CI 1.21 to 3.93) and death (HR= 2.15, 95% CI 1.16 to 3.98) but baseline anxiolytic use alone did not predict subsequent CV events and death. In a final regression model that included demographics, depression and anxiety symptoms, and risk factors for cardiovascular disease, women in the combined medication group (i.e. antidepressants and anxiolytics) had higher risk for CV events (HR= 3.98, CI 1.74-9.10, p = .001 and all-cause mortality (HR=4.70, CI 1.7-12.97, p = .003) compared to those using neither medication. Kaplan Meier survival curves indicated that there was a significant difference in mortality among the four medication groups (p = .001).
These data suggest that factors related to psychotropic medication such as depression refractory to treatment, or medication use itself, are associated with adverse CV events in women with suspected myocardial ischemia.
psychotropic medication; mortality; women; cardiovascular disease; antidepressants; depression; anxiety