The outcome of coronary artery bypass grafting surgery among patients hospitalized with acute coronary syndrome: the Euro Heart Survey of acute coronary syndrome experience

AIM: To determine the frequency and outcomes of coronary artery bypass graft (CABG) surgery in patients with a wide spectrum of acute coronary syndromes (ACS). METHODS AND RESULTS: We prospectively enrolled 10,484 ACS patients from 103 hospitals in 25 countries across Europe and the Mediterranean basin. Of the 10,204 patients with complete data, 460 (4.5%) underwent CABG while in hospital; 3.4% had ST elevation ACS, 5.4% had non-ST elevation ACS, and 4.4% had undetermined ECG ACS (p=0.001 for non-ST elevation ACS vs. others). In general, patients who underwent CABG were more likely to be males, to have diabetes mellitus, hyperlipidemia, a positive family history of premature coronary disease, and prior angina pectoris, but had less often prior heart failure. While in hospital, all CABG patients underwent coronary angiography and 15.2% also underwent percutaneous revascularization, as compared with 51.3 and 33.1% in the remaining patients, respectively. The in-hospital mortality was 3.7% for ACS patients who underwent CABG and 4.8% for non-CABG ACS patients (p=nonsignificant) with an adjusted odds ratio of in-hospital death for CABG patients of 1.00 (95% CI 0.59-1.61). CONCLUSIONS: Approximately 4.5% of ACS patients underwent CABG during their initial hospitalization, with a greater likelihood among non-ST elevation ACS patients. Of the CABG patients, 15.2% also underwent percutaneous revascularization. The outcome of CABG patients was as good as non-CABG patients, indicating that CABG remains an effective and safe means to achieve revascularization among ACS patients in current clinical practice.     

The second Euro Heart Survey on acute coronary syndromes: Characteristics, treatment, and outcome of patients with ACS in Europe and the Mediterranean Basin in 2004.

AIMS: Our study aimed to examine the management of acute coronary syndromes (ACS) in Europe and the Mediterranean basin, and to compare adherence to guidelines with that reported in the first Euro Heart Survey on ACS (EHS-ACS-I), 4 years earlier. METHODS AND RESULTS: In a prospective survey conducted in 2004 (EHS-ACS-II), data describing the characteristics, treatment, and outcome of 6385 patients diagnosed with ACS in 190 medical centres in 32 countries were collected. ACS with ST-elevation was the initial diagnosis in 47% of patients, no ST-elevation in 48%, and undetermined electrocardiographic pattern in 5% of patients. Comparison of data collected in 2000 and 2004 showed similar baseline characteristics, but greater use of recommended medications and coronary interventions in EHS-ACS-II. Among patients with ST-elevation, the use of primary reperfusion increased slightly (from 56 to 64%), with a significant shift from fibrinolytic therapy to primary percutaneous coronary intervention (PPCI). The use of PPCI rose from 37 to 59% among those undergoing primary reperfusion therapy. Analysis of data in 34 centres that participated in both surveys showed even greater improvement with respect to the use of recommended medical therapy, interventions, and outcome. CONCLUSION: Data from EHS-ACS-II suggest an increase in adherence to guidelines for treatment of ACS in comparison with EHS-ACS-I.     

Acute coronary syndromes in patients with prior cerebrovascular events: lessons from the Euro-Heart Survey of Acute Coronary Syndromes

Background

The aim of this study was to determine the frequency of prior cerebrovascular events (CE) among patients with an acute coronary syndrome (ACS) and to compare the clinical characteristics, clinical course, treatment, and outcomes of patients with ACS with and without a prior CE.

Methods and results

We prospectively enrolled 10,484 patients with ACS in 103 hospitals in 25 countries across Europe and the Mediterranean basin. A prior CE was reported in 254 of 4338 patients (5.9%) with ST elevation, 420 of 5215 patients (8.1%) without ST elevation, and 92 of 663 patients (13.9%) with an undetermined electrocardiographic pattern. In general, patients with a prior CE were older, more likely to be females and nonsmokers, more commonly had prior myocardial infarction, heart failure, bypass surgery, and were more likely to have diabetes, hypertension, and renal failure. While in the hospital, they had more heart failure, and they were more likely to receive warfarin, digoxin, diuretics and calcium-channel blockers, and less likely to receive antiplatelet agents, β-blockers, and statins. The inhospital mortality rates were 9.1% (with a prior CE) versus 6.4% (without a prior CE) for patients with ACS with ST elevation; 5.0% versus 2.0% for patients with ACS with non-ST elevation; and 14.1% versus 10.7% for patients with ACS with undetermined electrocardiographic results. The adjusted risk (95% CI) of inhospital death for patients with a prior CE was 1.12 (0.70, 1.81), 1.79 (1.06, 3.00), and 0.92 (0.44, 1.94) for ST-elevation ACS, non-ST-elevation ACS, and ACS with undetermined electrocardiogram, respectively. The P value for interaction between prior CE and the type of ACS on outcome was .10.

Conclusions

Patients with a prior CE constitute 7.5% of patients with ACS and have high-risk features. A prior CE is associated with increased inhospital mortality, particularly in patients with with non-ST-elevation ACS.     

Impact of on-site cardiac interventional facilities on management and outcome of patients with acute coronary syndromes

OBJECTIVES: To investigate the impact of on-site cardiac interventional facilities on the management and outcome of patients with versus those without ST elevation acute coronary syndromes (ACS) in the Canadian-American Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) IIb population. METHODS: Data from 4605 patients were analyzed in relation to the admitting hospital's capability to perform coronary procedures (noninvasive, angiography-capable and interventional hospitals). Differences in medication use, revascularization rate and patient outcome were determined. RESULTS: Whereas medication use during hospitalization and at discharge differed between non-ST elevation ACS patients treated in the three groups, these were generally more comparable among ST elevation ACS patients. In both ST segment cohorts, patients treated in interventional hospitals underwent coronary procedures more often (angiography rate greater than 70% versus 40% for noninvasive hospitals) and sooner (median two to three days versus four days in noninvasive hospitals) than those treated in other hospitals. Recurrent ischemia was significantly less common in non-ST elevation ACS patients treated in interventional hospitals (32% versus 36% in angiography-capable and 40% in noninvasive hospitals, P<0.001) and tended to be less common among ST elevation ACS patients treated in interventional hospitals. Patients treated in interventional hospitals tended to have lower mortality in the non-ST elevation ACS cohort but significantly fewer died in the ST elevation ACS during hospitalization and at 30 days, six months and one year (8.8% versus 11% in angiography-capable and 15% in noninvasive hospitals, P=0.015). These differences in mortality persisted after adjustment for key baseline covariates. Separate analysis of Canadian and American patients revealed similar mortality patterns, as to the total population, in both ST segment cohorts. CONCLUSIONS: Presence of an on-site cardiac interventional facility favourably affected the management and outcome of ACS patients in both non-ST and ST elevation cohorts.     

Clinical association between renal insufficiency and positive troponin I in patients with acute coronary syndrome

BACKGROUND: Whether renal insufficiency (RI) influences troponin levels in patients with acute coronary syndromes (ACS) is controversial. We attempted to determine whether there is an association between RI and troponin I (TnI) elevation in patients presenting with ACS. METHODS: We studied 764 consecutive patients with ACS admitted to our institution from January 1999 to June 2000. Patients were identified prospectively and data were collected through chart review of all cases with an admission diagnosis of ACS. In order to assess the relationship of TnI and RI, we calculated the creatinine clearance (Cr-Cl) for all patients. We conducted an analysis of variance comparing TnI in quintiles of patients with lowest to highest Cr-Cl. RESULTS: Among 764 patients, 173 patients had a discharge diagnosis of ST elevation myocardial infarction and 591 had non-ST elevation myocardial infarction. There was no correlation between peak TnI levels and renal function as measured by Cr-Cl in the entire cohort with ACS and in the subgroups with ST elevation myocardial infarction and non ST elevation myocardial infarction. CONCLUSIONS: This large cohort study demonstrates that there appears to be no association between RI and positive TnI in patients with ACS.     

心电图对非ST段抬高型急性冠脉综合征危险分层的价值

目的探讨心电图变化对非ST段抬高型急性冠状动脉综合征患者危险分层的价值。方法自2006年1月-2007年7月，在我院因急性胸痛拟诊不稳定型心绞痛及非ST段抬高心肌梗死而收入住院且记录资料完整的616例患者。人院后采集病史、查体，并在10min内完成常规18导联心电图检查，将患者人院时心电图的改变分为ST段压低组（包括伴有T波倒置者）、单纯T波倒置组、尚不能诊断的心电图组及正常心电图组；又将ST段压低组分为：胸前导联（V4-V6）ST段压低合并负向T波、胸前导联ST段压低合并正向T波、其他导联ST段压低合并正向T波、其他导联ST段压低合并负向T波4组。观察各组住院期主要心血管事件（心脏性死亡、非致命性心肌梗死、反复缺血性心绞痛发作），并随访1-12（7．2±3．8）个月，观察主要心血管事件变化。结果与正常心电图组比较；ST段压低组的复合心血管事件明显增多。胸前导联ST段压低合并T波倒置组的患者较其他导联ST段压低合并或不合并T波倒置组的复合心血管事件明显增多。结论．心电图的ST段变化对非ST段抬高型急性冠状动脉综合征患者的危险分层及心血管事件预测均有重要价值。     

Management and outcome of patients with established coronary artery disease: the Euro Heart Survey on coronary revascularization.

AIMS: The purpose of the Euro Heart Survey Programme of the European Society of Cardiology is to evaluate to which extent clinical practice endorses existing guidelines as well as to identify differences in population profiles, patient management, and outcome across Europe. The current survey focuses on the invasive diagnosis and treatment of patients with established coronary artery disease (CAD). METHODS AND RESULTS: Between November 2001 and March 2002, 7769 consecutive patients undergoing invasive evaluation at 130 hospitals (31 countries) were screened for the presence of one or more coronary stenosis >50% in diameter. Patient demographics and comorbidity, clinical presentation, invasive parameters, treatment options, and procedural techniques were prospectively entered in an electronic database (550 variables+29 per diseased coronary segment). Major adverse cardiac events (MACE) were evaluated at 30 days and 1 year. Out of 5619 patients with angiographically proven coronary stenosis (72% of screened population), 53% presented with stable angina while ST elevation myocardial infarction (STEMI) was the indication for coronary angiography in 16% and non-ST segment elevation myocardial infarction or unstable angina in 30%. Only medical therapy was continued in 21%, whereas mechanical revascularization was performed in the remainder [percutaneous coronary intervention (PCI) in 58% and coronary artery bypass grafting (CABG) in 21%]. Patients referred for PCI were younger, were more active, had a lower risk profile, and had less comorbid conditions. CABG was performed mostly in patients with left main lesions (21%), two- (25%), or three-vessel disease (67%) with 4.1 diseased segments, on average. Single-vessel PCI was performed in 82% of patients with either single- (45%), two- (33%), or three-vessel disease (21%). Stents were used in 75% of attempted lesions, with a large variation between sites. Direct PCI for STEMI was performed in 410 cases, representing 7% of the entire workload in the participating catheterization laboratories. Time delay was within 90 min in 76% of direct PCI cases. In keeping with the recommendations of practice guidelines, the survey identified under-use of adjunctive medication (GP IIb/IIIa receptor blockers, statins, and angiotensin-converting enzyme-inhibitors). Mortality rates at 30 days and 1 year were low in all subgroups. MACE primarily consisted of repeat PCI (12%). CONCLUSION: The current Euro Heart Survey on coronary revascularization was performed in the era of bare metal stenting and provides a global European picture of the invasive approach to patients with CAD. These data will serve as a benchmark for the future evaluation of the impact of drug-eluting stents on the practice of interventional cardiology and bypass surgery.     

Improved adherence to practice guidelines yields better outcome in high-risk patients with acute coronary syndrome without ST elevation: findings from nationwide FINACS studies

OBJECTIVES: Treatment options for acute coronary syndrome (ACS) without ST elevation have evolved rapidly during the recent years, but the successful implementation of practice guidelines incorporating new treatments into practice has been challenging. In this study, we evaluate whether targeted educational intervention could improve adherence to treatment guidelines of ACS without ST elevation. DESIGN, SETTING AND SUBJECTS: A previous study, FINACS I, evaluated the treatment and outcome of 501 consecutive non-ST elevation ACS patients that were referred in early 2001 to nine hospitals, covering nearly half of the Finnish population. That study revealed poor adherence to ESC guidelines, so targeted educational intervention on optimal practice was arranged before the second study (FINACS II), which was performed in the same hospitals using the same protocol as FINACS I. FINACS II, undertaken in early 2003, evaluated 540 consecutive patients. Interventions. Targeted educational programmes on optimal practice. MAIN OUTCOME MEASURES: The use of evidence-based therapies in non-ST elevation ACS patients. In-hospital event-free (death, new myocardial infarction, refractory angina, readmission with unstable angina and transient cerebral ischaemia/stroke) survival, and event-free survival at 6 months. RESULTS: Baseline characteristics and risk markers were similar in both studies, and no significant changes in resources were seen. In 2003, the in-hospital use of statins, ACE-inhibitors, clopidogrel and glycoprotein (GP) IIb/IIIa receptor antagonists increased significantly, and in-hospital angiography was performed more often, especially in high-risk patients (59% vs. 45%, P < 0.05); waiting time also shortened (4.2 +/- 5.5 vs. 5.8 +/- 4.7 days, P < 0.01). Overall no significant change was seen in the frequency of death either in-hospital (2% vs. 4%, P = NS) or at 6 months (7% vs. 10%, P = NS) in FINACS II. However, the survival of high-risk patients improved both in-hospital (95% vs. 90%, P = 0.05) and at 6 months (89% vs. 78%, P = 0.05). CONCLUSION: In patients with non-ST elevation ACS-targeted educational interventions appeared to be associated with improved adherence to practical guidelines, which yielded a better outcome in high-risk ACS patients.     

Low-molecular-weight heparins for the treatment of acute coronary syndromes

Low-molecular-weight heparins (LMWHs) possess several advantages over unfractionated heparin (UFH) for the treatment of acute coronary syndromes (ACSs). Already a class I indication for the treatment of unstable angina/non-ST elevation myocardial infarction (UA/NSTEMI), LMWHs also show promise in the setting of ST elevation myocardial infarction (STEMI) and percutaneous coronary intervention (PCI). Moreover, a growing body of evidence has demonstrated equivalent safety of LMWH with concomitant use of glycoprotein IIb/IIIa inhibitors. Larger clinical studies are needed to confirm the safety and efficacy of LMWH as an antithrombin for the treatment across the spectrum of ACS.     

Role of mean platelet volume in triagging acute coronary syndromes

Background: Acute coronary syndromes, characterized by the rupture of unstable plaque and the subsequent thrombotic process involving platelets, have been increasing in relative frequency. The central role of platelet activation has long been noticed in this pathophysiology; hence, many therapies have been directed against it. In this study, we have aimed to search prospectively the value of mean platelet volume (MPV), which is a simple and accurate measure of the functional status of platelets, in patients hospitalized with diagnosis of acute coronary syndromes (ACS). Materials and methods: A total of 216 consecutive patients (156 male, 60 female) hospitalized with the diagnosis of non-ST segment elevation (NSTE) ACS within the first 24 h of their chest pain were enrolled. One hundred and twenty patients, matched according to sex and age, with stable coronary heart disease (CHD) (85 male, 35 female) were enrolled as a control group. Patients were classified into two group: those with unstable angina (USAP, n = 105) and those with non-ST segment elevation myocardial infarction (NSTEMI, n = 111). Results: MPVs were 10.4 +/- 0.6 fL, 10 +/- 0.7 fL, 8.9 +/- 0.7 fL consecutively for NSTEMI, USAP and stable CHD with significant differences. Patients with ischemic attacks in the first day of hospitalization accompanied by >0.05 mV ST segment shift had significantly higher MPV compared to those without such attacks (P = 0.001). Multivariable logistic regression analysis yielded that MPV (P = 0.016), platelet count (P < 0.001), and the presence of >0.05 mV ST segment depression at admission (P = 0.002) were independent predictors of development of NSTEMI in patients presenting with NSTE ACS. Conclusion: In patients presenting with NSTE ACS, higher MPV, though there are overlaps among subgroups, indicates not only more risk of having NSTEMI but also ischemic complications.