International Prospective Registry of Acute Coronary Syndromes in Patients With COVID-19

BackgroundPublished data suggest worse outcomes in acute coronary syndrome (ACS) patients and concurrent coronavirus disease 2019 (COVID-19) infection. Mechanisms remain unclear.ObjectivesThe purpose of this study was to report the demographics, angiographic findings, and in-hospital outcomes of COVID-19 ACS patients and compare these with pre–COVID-19 cohorts.MethodsFrom March 1, 2020 to July 31, 2020, data from 55 international centers were entered into a prospective, COVID-ACS Registry. Patients were COVID-19 positive (or had a high index of clinical suspicion) and underwent invasive coronary angiography for suspected ACS. Outcomes were in-hospital major cardiovascular events (all-cause mortality, re–myocardial infarction, heart failure, stroke, unplanned revascularization, or stent thrombosis). Results were compared with national pre–COVID-19 databases (MINAP [Myocardial Ischaemia National Audit Project] 2019 and BCIS [British Cardiovascular Intervention Society] 2018 to 2019).ResultsIn 144 ST-segment elevation myocardial infarction (STEMI) and 121 non–ST-segment elevation acute coronary syndrome (NSTE-ACS) patients, symptom-to-admission times were significantly prolonged (COVID-STEMI vs. BCIS: median 339.0 min vs. 173.0 min; p < 0.001; COVID NSTE-ACS vs. MINAP: 417.0 min vs. 295.0 min; p = 0.012). Mortality in COVID-ACS patients was significantly higher than BCIS/MINAP control subjects in both subgroups (COVID-STEMI: 22.9% vs. 5.7%; p < 0.001; COVID NSTE-ACS: 6.6% vs. 1.2%; p < 0.001), which remained following multivariate propensity analysis adjusting for comorbidities (STEMI subgroup odds ratio: 3.33 [95% confidence interval: 2.04 to 5.42]). Cardiogenic shock occurred in 20.1% of COVID-STEMI patients versus 8.7% of BCIS patients (p < 0.001).ConclusionsIn this multicenter international registry, COVID-19–positive ACS patients presented later and had increased in-hospital mortality compared with a pre–COVID-19 ACS population. Excessive rates of and mortality from cardiogenic shock were major contributors to the worse outcomes in COVID-19 positive STEMI patients.     

Impact of admission serum acid uric levels on in-hospital outcomes in patients with acute coronary syndrome

BackgroundTo assess the association between admission serum uric acid (SUA) levels and in-hospital outcomes in a real-world patients population with acute coronary syndrome (ACS) and to investigate the potential incremental prognostic value of SUA added to GRACE score (GRACE-SUA score).MethodsThe data of consecutive ACS patients admitted to Coronary Care Unit of San Paolo and Niguarda hospitals in Milan (Italy) were retrospectively analyzed.Results1088 patients (24% female) were enrolled. Mean age was 68 years (IQR 60–78). STEMI and NSTE-ACS patients were 504 (46%) and 584 (54%) respectively. SUA (OR 1.72 95%CI 1.33–2.22, p < 0.0001) and GRACE score (OR 1.04 95%CI 1.02–1.06, p < 0.0001) were significantly associated with an increased risk of in-hospital death at the multivariate analysis. Admission values of SUA were stratified in four quartiles. Rates of acute kidney injury, implantation of intra-aortic balloon pump and non-invasive ventilation use were significantly higher in the last quartile compared to Q1, Q2 and Q3 (p < 0.01). The areas under the ROC curve (AUC) for GRACE score and for SUA were 0.91 (95% CI 0.89–0.93, p < 0.0001) and 0.79 (95% CI 0.76–0.81, p < 0.0001) respectively. The AUC was larger for predicting in-hospital mortality with the GRACE-SUA score (0.94; 95% CI 0.93–0.95).ConclusionsHigh admission levels of SUA are independently associated with in-hospital adverse outcomes and mortality in a contemporary population of ACS patients. The inclusion of SUA to GRACE risk score seems to lead to a more accurate prediction of in-hospital mortality in this study population.     

Patterns of cardiovascular diseases in COVID-19 patients admitted to tertiary cardiac care centre

ObjectivesTo analyse the pattern of cardiovascular diseases (CVDs) in COVID-19 patients admitted to tertiary cardiac care centre.MethodsWe retrospectively analysed 511 adult patients admitted between July 1, 2020, and November 30, 2020, with COVID-19 infection and having either new onset or pre-existing CVDs. Clinical features, electrocardiogram (ECG), echocardiography, chest X-ray, biomarkers, haematological and biochemical parameters were analysed.ResultsThe mean age of the patients was 56.62 ± 14.74 years. Male: Female ratio was 2.78:1. Pre-existing CVDs were present in 258 patients (50.5%). The most common cardiovascular manifestation was acute coronary syndrome (ACS), seen in 259 patients (50.7%). ST-segment elevation myocardial infarction (STEMI) was more common than non-ST-segment elevation ACS (NSTE-ACS). Possible myocarditis was seen in 52 patients (10.1%). Rhythm and conduction abnormalities were noted in 144 patients (28.2%), the most common being QT prolongation, seen in 51 patients (10%). In-hospital mortality occurred in 97 patients (18.9%). Age, serum Ferritin level, D-dimer, NT-pro-BNP and total leukocyte count were significantly higher among patients with in-hospital mortality compared to survival group. Blood lymphocyte count and Haemoglobin level were significantly lower in mortality-group, compared to survival-group. Incidence of pre-existing CVDs, cardiogenic shock, heart failure, atrial fibrillation (AF), and renal failure were significantly higher in mortality-group compared to survival-group.ConclusionThe most common CVD in COVID-19 patients in our study was ACS. STEMI was more common than NSTE-ACS. Advanced age, elevated serum ferritin, D-dimer, NT pro-BNP, leucocytosis, lymphopenia, lower haemoglobin, pre-existing CVDs heart failure, cardiogenic shock, AF and renal failure were associated with increased mortality in these patients.     

Why some patients with acute coronary syndrome hospitalized in a university tertiary centre do not undergo coronary angiography? Results from the AHEAD ACS registry

BackgroundTo evaluate in-hospital and long-term mortality of patients with acute coronary syndromes (ACS) not having selective coronary angiography (CAG) during hospitalization and to analyze the reasons for conservative approach.Methods and patientsA single-centre retrospective study using registry data. Over the period from January 2005 to April 2009, a total of 193 ACS patients did not have in-hospital CAG. Fifty-five (28.5%) patients had recent CAG (within the last 12 months) or the procedure was planned after discharge (invasive group “I”). In 138 (71.5%) patients, CAG was not considered at all (conservative approach, group “C”). These subgroups were compared in terms of in-hospital parameters and long-term mortality.ResultsST-segment elevation myocardial infarction (STEMI) was diagnosed in 50 (25.9%) patients. The most frequent reasons for not performing CAG included serious comorbidities affecting the prognosis (22%) and pharmacological stabilization in very old individuals with non-STEMI (21%). One in ten (11%) patients died before the CAG was performed, the same proportion of patients refused to have CAG or had a long ischaemia time (STEMI subgroup). A temporary contraindication to CAG was found in 8%, a recent CAG finding not suitable for revascularization in 8%, while a limiting neurological disease was present in 6% of patients. In-hospital mortality was 30.1%, being higher in Group C (34.1% vs. 20.0%; p = 0.049), 6-year mortality was as high as 78.8%, also with higher rates in Group C (86.2% vs. 60.2%; p < 0.001). Patients receiving conservative therapy were older, with a higher proportion of limiting comorbidities that contraindicated CAG, and had a more serious course of hospitalization.ConclusionThe most common reasons for not performing CAG in ACS patients included advanced age, serious and often extra-cardiac comorbidities, and a complicated hospitalization course. The short- and long-term mortality rates in these patients are high.     

Prognostic role of neutrophil-to-lymphocyte ratio in patients with ST-elevation myocardial infarction undergoing to pharmaco-invasive strategy

ObjectivesWe sought to determine the relationship between in-hospital mortality and the neutrophil-to-lymphocyte ratio (NLR) in patients with ST-elevation myocardial infarction (STEMI) undergoing with pharmaco-invasive strategy (PIS).BackgroundIncreased levels of white blood cells have been associated with adverse clinical outcomes in patients with (STEMI). NLR has recently emerged as a potent and more specific prognostic marker in predicting short- and long-term mortalityin patients undergoing primary percutaneous coronary intervention. This association has never been reported in patients managed with PIS.MethodsBetween March 2010 and October 2016, 1860 STEMI patients managed with PIS were consecutively included in a dedicated database. The study population was divided into tertiles based on the admission NLR values (lower: <4.0, intermediate: 4.0 to <7.3, and upper: ≥7.3). Co-primary endpoints were in-hospital mortality and MACE (death, non-fatal reinfarction or stent thrombosis).ResultsPatients in the upper NLR tertile had significantly higher in-hospital mortality (9.0% vs. 4.8% versus. 1.8%, p < 0.001) and MACE (11.6% vs. 8.0% versus 2.9%, p < 0.001) than patients with intermediate or low NLR. By multivariable logistic regression analysis, the upper NLR tertile was an independent predictor of MACE (odds radio [OR] 4.19, 95% confidence interval [95% CI] 2.23–7.88, p < 0.001) and in-hospital mortality [OR 3.32, 95% CI 1.19–9.28, p = 0.02].ConclusionHigh NLR values were independently associated with in-hospital MACE and death in STEMI patients submitted to a PIS. NLR might be a simple and useful risk stratification tool in this high-risk population.     

Acute kidney injury in hospitalized patients with COVID-19: A Portuguese cohort

IntroductionThe incidence of acute kidney injury (AKI) in coronavirus disease 2019 (COVID-19) patients ranges from 0.5% to 35% and has been associated with worse prognosis. The purpose of this study was to evaluate the incidence, severity, duration, risk factors and prognosis of AKI in hospitalized patients with COVID-19.MethodsWe conducted a retrospective single-center analysis of 192 hospitalized COVID-19 patients from March to May of 2020. AKI was diagnosed using the Kidney Disease Improving Global Outcome (KDIGO) classification based on serum creatinine (SCr) criteria. Persistent and transient AKI were defined according to the Acute Disease Quality Initiative (ADQI) workgroup definitions.ResultsIn this cohort of COVID-19 patients, 55.2% developed AKI (n = 106). The majority of AKI patients had persistent AKI (n = 64, 60.4%). Overall, in-hospital mortality was 18.2% (n = 35) and was higher in AKI patients (28.3% vs. 5.9%, p < 0.001, unadjusted OR 6.03 (2.22–16.37), p < 0.001). In this multivariate analysis, older age (adjusted OR 1.07 (95% CI 1.02–1.11), p = 0.004), lower Hb level (adjusted OR 0.78 (95% CI 0.60–0.98), p = 0.035), duration of AKI (adjusted OR 7.34 for persistent AKI (95% CI 2.37–22.72), p = 0.001) and severity of AKI (adjusted OR 2.65 per increase in KDIGO stage (95% CI 1.32–5.33), p = 0.006) were independent predictors of mortality.ConclusionAKI was frequent in hospitalized patients with COVID-19. Persistent AKI and higher severity of AKI were independent predictors of in-hospital mortality.     

Clinical profile and 30-day outcome of women with acute coronary syndrome as a first manifestation of ischemic heart disease: A single-center observational study

BackgroundGender disparity, with respect to women receiving less medical therapy, undergoing fewer invasive procedures, and experiencing worse outcome than men, has been noted in various observational and randomized trials, though guidelines on acute coronary syndrome (ACS) are gender-neutral. Indian data with focus on women with ACS are lacking.AimThis study was undertaken to give us an insight on the clinical presentation, risk factors, and in-hospital outcome of ACS in women and at 30 days.Materials and methods133 successive cases of women presenting with ACS, who met the inclusion criteria between 2012 and 2014, were included. Cases were grouped into ST elevation myocardial infarction (STEMI), non ST elevation myocardial infarction (NSTEMI), and unstable angina (UA).Results and conclusionThe mean age was 64.4 ± 11 years. The mean BMI was 23.64 ± 3.23 kg/m². Diabetes was present in 58.3% in NSTEMI, 65.1% in STEMI, and 57.1% in UA group. Hypertension was found in 75% of NSTEMI, 60.2% of STEMI, and 71.4% of UA group. Severe MR was found in 11.1% of NSTEMI and 3.6% of STEMI patients. 8.3% of NSTEMI and 15.7% of STEMI patients presented in Killips class IV. Single vessel disease was most commonly found across the spectrum of ACS. 68.7% patients in STEMI group underwent primary angioplasty. 5.6% of NSTEMI and 7.2% in STEMI group had contrast-induced nephropathy (CIN). All deaths were noted in STEMI group with eight in-hospital deaths and three during 30-day follow-up period. Killips class III and IV and higher grace score (>150) were predictors of in-hospital mortality. Chronic kidney disease, ischemic mitral regurgitation, LV clot, and in-hospital cardiac arrest were associated with higher risk.     

Nutritional Risk Screening 2002 was associated with acute kidney injury and mortality in patients with acute coronary syndrome: Insight from the REACP study

Background and aimsAcute kidney injury (AKI) is a common complication of acute coronary syndrome (ACS), and is associated with increased risk of morbidity and mortality. We aimed to evaluate the impact of malnutrition risk at admission assessed using Nutritional Risk Screening 2002 (NRS-2002) on AKI and mortality in patients with ACS.Methods and resultsWe enrolled 3185 ACS patients from the retrospective multi-centre study. AKI was defined as criteria of the 2012 Kidney Disease Improving Global Outcomes. Risk of malnutrition was defined as NRS-2002 score ≥3. The end points were AKI and all-cause mortality. There were 926 (29.1%) patients with risk of malnutrition and 481 (15.1%) patients complicated with AKI during hospitalisation, and 378 (12.0%) patients died during the 13.1 (8.5–20.4) months of follow-up. Patients with NRS-2002 score ≥3 had a higher incidence of AKI and all-cause mortality (P < 0.001). Multivariate logistic and Cox regression analysis showed that the adjusted odd ratios and hazard ratios of categorised NRS-2002 (<3 vs. ≥3) for AKI and mortality were 1.643 (95% confidence interval: 1.242–2.172, P < 0.001) and 2.026 (95% confidence interval: 1.491–2.753, P < 0.001), respectively. In structural equation modelling, the indirect effects of NRS-2002 on mortality via AKI were 54.1% (P < 0.001).ConclusionThe risk of malnutrition assessed using NRS-2002 was useful in identifying high-risk patients with AKI and mortality, and patients with ACS may benefit from further nutritional intervention and prevention of AKI.Registration numberChiCTR1900024657.     

The effect of obesity on in-hospital mortality among patients with COVID-19 receiving corticosteroids

Background and aimsObesity has been reported to be one of the most frequent comorbidities in COVID-19 patients and associated with higher rates of in-hospital mortality compared to non-obese patients. Acute kidney injury (AKI) is also known to be a complication associated with obesity in critically-ill COVID-19 patients. We aimed to investigate whether obesity was associated with increased risk of in-hospital mortality and AKI among patients with COVID-19 treated with corticosteroids.MethodsWe utilized 9965 hospitalized COVID-19 patient data and divided patients who were treated with corticosteroids into 6 groups by body mass index (BMI) (less than 18.5, 18.5–25, 25–30, 30–35, 35–40, 40 kg/m² or greater). The association between BMI and in-hospital mortality and between BMI and incidence rate of AKI during admission among COVID-19 patients receiving corticosteroids were retrospectively investigated.ResultsThere were 4587 study participants receiving corticosteroids (mean age 66.5 ± 15.5 years, men 56.6%, mean BMI 29.0 ± 7.2 kg/m²). The smooth spline curve suggested a J-shape association between BMI and in-hospital mortality. Patients with BMI above 40 kg/m² exhibited a higher in-hospital mortality and higher incidence rate of AKI during admission compared to patients with BMI between 25 and 30 kg/m². The differences in in-hospital mortality and the rate of AKI were larger among patients with severe COVID-19.ConclusionsClass III obesity was associated with high in-hospital mortality and AKI in patients with COVID-19 treated by corticosteroids. Clinicians must stay vigilant on the impact of class III obesity and development of AKI to disease trajectory of COVID-19 patients.     

Use of Intravascular Imaging in Patients With ST-Segment Elevation Acute Myocardial Infarction

BackgroundThe use and impact of intravascular imaging in ST-elevation myocardial infarction (STEMI) patients has received limited study.MethodsWe queried the National Inpatient Sample database (NIS) between January 2016 and December 2017 to identify hospitalizations of STEMI patients who underwent percutaneous coronary intervention (PCI). We used a 1:2 propensity-score (PS) matched analysis to compare in-hospital outcomes in patients with vs. without use of intravascular imaging. We conducted a multivariable regression analysis to identify variables independently associated with in-hospital mortality.ResultsWe identified 252,970 weighted discharges of PCI in STEMI patients, 5.5% of which included intravascular imaging. Patients in whom intravascular imaging was used were more likely to have acute stent thrombosis (4.7% vs. 1.4%, p < 0.001) and present with anterior STEMI (48.1% vs. 39.1%, p < 0.001). After PS matching (intravascular imaging n = 14,015, no intravascular imaging n = 28,025), the use of intravascular imaging was associated with lower in-hospital mortality (3.6% vs. 4.8%, p = 0.010). The risk of in-hospital complications and discharge to a facility (nursing facility or short-term acute hospital) was similar between both groups before and after PS matching. The use of intravascular imaging was associated with a higher index hospitalization cost [$25,218 vs. $20,515, p < 0.001]. On multivariable analysis, intravascular imaging was independently associated with lower in-hospital mortality [OR 0.735 (95% CI 0.662–0.816), p < 0.001].ConclusionIntravascular imaging was used in 5.5% of PCIs in STEMI patients and was independently associated with lower in-hospital mortality and higher index hospitalization cost.     

Multicenter HP ACS Registry

BackgroundNo population representative data on characteristics, treatment, and outcome were available in acute coronary syndrome (ACS) patients.MethodsThe clinical characteristics, treatment, and in-hospital outcome of 5180 ACS patients registered in multicenter ACS Registry across 33 hospitals in the state since January 2012 to December 2014 are reported. ACS was diagnosed using standard criteria.Result70.8% were men; mean age was 60.9 ± 12.1. NSTEMI was more frequent than STEMI (54.5% vs. 45.5%). 83.3% of the ACS population were from rural area. Pre-hospital delay was long, with a median of 780 min. 35.6% of STEMI patients received thrombolytic therapy. Evidence-based treatment was prescribed in more than 80% of ACS patients, and the treatment was similar in men and women across all types of health care centers. In-hospital mortality was 7.6%, and was more frequent in STEMI than in NSTEMI (10.8% vs. 5.0%, p < 0.001).InterpretationPre-hospital delay was long, and use of reperfusion therapy was significantly lower. The in-hospital death rates are higher.     

Sex Differences in Acute Coronary Syndrome in a Multiethnic Asian Population: Results of the Malaysian National Cardiovascular Disease Database—Acute Coronary Syndrome (NCVD-ACS) Registry

BackgroundSex differences in acute coronary syndrome (ACS) have been well studied in major registries and clinical trials in Western populations. Limited studies have examined the sex differences in ACS using a large number of Asian women as the subjects.ObjectivesThe aim was to study the sex differences in ACS using the NCVD-ACS (National Cardiovascular Disease Database—Acute Coronary Syndrome) registry.MethodsWe analyzed 13,591 ACS patients, of which 75.8% were men and 24.2% were women, from March 2006 to February 2010. Data were collected on demographic characteristics, risk factors, anthropometrics, treatments, procedures, mortalities, and complications. The results were compared among 3 cohorts of ACS (ST-segment elevation myocardial infarction [STEMI], non–STEMI, and unstable angina).ResultsWomen were older and more likely to have diabetes, hypertension, previous heart failure, and cerebral vascular accidents than men were. Women were less likely to receive in-hospital administration of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers, and they were less likely to undergo angiography and percutaneous coronary intervention. In STEMI, a significantly lower proportion of women than men received primary percutaneous coronary intervention (6.2% vs. 6.7%, respectively, p = 0.000) and fibrinolysis (64.4% vs. 74.6%, respectively, p = 0.000). In addition, with regard to STEMI, women had a significantly higher unadjusted in-hospital mortality rate than men did (15.0% vs. 8.1%, respectively, p < 0.000). There was no statistically significant in-hospital mortality difference between sexes for non-STEMI and unstable angina. After adjustment for age and other covariates, a multivariate analysis showed no sex differences in the in-hospital mortality in all spectrums of ACS.ConclusionsOur study showed significant sex differences in the demographic characteristics, risk factors, treatments, and outcomes of ACS. More importantly, in ACS patients, we found evidence of suboptimal treatments and interventions in women versus men. Our findings provide an opportunity to narrow the sex gap in the care of women with ACS in Malaysia.     

Transient vs In-Hospital Persistent Acute Kidney Injury in Patients With Acute Coronary Syndrome

BackgroundThe occurrence of acute kidney injury (AKI) among patients with acute coronary syndrome (ACS) undergoing invasive management is associated with worse outcomes. However, the prognostic implications of transient or in-hospital persistent AKI may differ.ObjectivesThe aim of this study was to evaluate the prognostic implications of transient or in-hospital persistent AKI in patients with ACS.MethodsIn the MATRIX (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox) trial, 203 subjects were excluded because of incomplete information or end-stage renal disease, with a study population of 8,201 patients. Transient and persistent AKI were defined as renal dysfunction no longer or still fulfilling the AKI criteria (>0.5 mg/dL or a relative >25% increase in creatinine) at discharge, respectively. Thirty-day coprimary outcomes were the out-of-hospital composite of death, myocardial infarction, or stroke (major adverse cardiovascular events [MACE]) and net adverse cardiovascular events (NACE), defined as the composite of MACE or Bleeding Academic Research Consortium type 3 or 5 bleeding.ResultsPersistent and transient AKI occurred in 750 (9.1%) and 587 (7.2%) subjects, respectively. After multivariable adjustment, compared with patients without AKI, the risk for 30-day coprimary outcomes was higher in patients with persistent AKI (MACE: adjusted HR: 2.32; 95% CI: 1.48-3.64; P < 0.001; NACE: adjusted HR: 2.29; 95% CI: 1.48-3.52; P < 0.001), driven mainly by all-cause mortality (adjusted HR: 3.43; 95% CI: 2.03-5.82; P < 0.001), whereas transient AKI was not associated with higher rates of MACE or NACE. Results remained consistent when implementing the KDIGO (Kidney Disease Improving Global Outcomes) criteria.ConclusionsAmong patients with ACS undergoing invasive management, in-hospital persistent but not transient AKI was associated with higher risk for 30-day MACE and NACE. (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox [MATRIX]; NCT01433627)     

Impacto de las diferencias de sexo y los sistemas de red en la mortalidad hospitalaria de pacientes con infarto agudo de miocardio con elevación del segmento ST

Introduction and objectivesNetwork systems have achieved reductions in both time to reperfusion and in-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI). However, the data have not been disaggregated by sex. The aim of this study was to analyze the influence of network systems on sex differences in primary percutaneous coronary intervention (pPCI) and in-hospital mortality from 2005 to 2015.MethodsThe Minimum Data Set of the Spanish National Health System was used to identify patients with STEMI. Logistic multilevel regression models and Poisson regression analysis were used to calculate risk-standardized in-hospital mortality ratios and incidence rate ratios (IRRs).ResultsOf 324 998 STEMI patients, 277 281 were selected after exclusions (29% women). Even when STEMI networks were established, the use of reperfusion therapy (PCI, fibrinolysis, and CABG) was lower in women than in men from 2005 to 2015: 56.6% vs 75.6% in men and 36.4% vs 57.0% in women, respectively (both P < .001). pPCI use increased from 34.9% to 68.1% in men (IRR, 1.07) and from 21.7% to 51.7% in women (IRR, 1.08). The crude in-hospital mortality rate was higher in women (9.3% vs 18.7%; P < .001) but decreased from 2005 to 2015 (IRRs, 0.97 for men and 0.98 for women; both P < .001). Female sex was an independent risk factor for mortality (adjusted OR, 1.23; P < .001). The risk-standardized in-hospital mortality ratio was lower in women when STEMI networks were in place (16.9% vs 19.1%, P < .001). pPCI and the presence of STEMI networks were associated with lower in-hospital mortality in women (adjusted ORs, 0.30 and 0.75, respectively; both P < .001).ConclusionsWomen were less likely to receive pPCI and had higher in-hospital mortality than men throughout the 11-year study period, even with the presence of a network system for STEMI.     

Admission glycemia: a predictor of death after acute coronary syndrome in non-diabetic patients?

BACKGROUND: Previous studies have demonstrated that acute phase hyperglycemia is associated with increased in-hospital mortality in diabetic patients admitted with acute coronary syndrome (ACS), but this has not been clearly demonstrated in non-diabetic patients. The present study was designed to determine whether admission hyperglycemia (AG) is an independent predictor of in-hospital and six-month mortality after ACS in non-diabetic patients. METHODS: This was a retrospective cohort study of 426 non-diabetic patients consecutively admitted with ACS. The patients were stratified into quartile groups according to AG, which was also analyzed as a continuous variable. Vital status was obtained at six-month follow-up in 96.8% of the patients surviving hospitalization. Logistic regression analysis was used to identify independent predictors of in-hospital and six-month death. RESULTS: Of the 426 patients included in the study (age 62.6 years+/-13.1, 77% male), 22 (5.4%) patients died during hospitalization and 20 (5.2% of the patients surviving hospitalization) within six months of ACS. Mean AG was 134.89 mg/dl+/-51.95. The higher the AG, the more probable was presentation with ST-segment elevation ACS (STEMI), anterior STEMI, higher heart rate, Killip class higher than one (KK >1), higher serum creatinine and greater risk of in-hospital and six-month death. In multivariate analysis, only age (OR=1.10; 95% CI 1.04-1.17), STEMI (OR=3.02; 95% CI 1.07-8.50), AG (OR=1.073; 95% CI 1.004-1.146), serum creatinine (OR=1.10; 95% CI 1.009-1.204) and KK >1 on admission (OR=4.65; 95% CI 1.59-13.52) were independently associated with in-hospital death. Age (OR=1.07; 95% CI 1.03-1.12), serum creatinine (OR=1.09; 95% CI 1.01-1.18) and in-hospital development of heart failure (OR=2.34; 95% CI 1.07-5.10) were independently associated with higher risk of death within six months of ACS. CONCLUSIONS: AG is an independent predictive factor of in-hospital death after ACS in non-diabetic patients. Although it did not show an independent association with higher risk of six-month death, AG appears to contribute to it, since the risk is greater the higher the AG. Its predictive value may have been blunted by the insufficient power of the sample and/or by the time interval between acquisition of AG and the evaluated endpoint.     

Incidence and Outcomes of Acute Coronary Syndrome After Transcatheter Aortic Valve Replacement

ObjectivesThis study sought to address a knowledge gap by examining the incidence, timing, and predictors of acute coronary syndrome (ACS) after transcatheter aortic valve replacement (TAVR) in Medicare beneficiaries.BackgroundEvidence about incidence and outcomes of ACS after TAVR is scarce.MethodsWe identified Medicare patients who underwent TAVR from 2012 to 2017 and were admitted with ACS during follow-up. We compared outcomes based on the type of ACS: ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina. In patients with non–ST-segment elevation ACS, we compared outcomes based on the treatment strategy (invasive vs. conservative) using inverse probability weighting analysis.ResultsOut of 142,845 patients with TAVR, 6,741 patients (4.7%) were admitted with ACS after a median time of 297 days (interquartile range: 85 to 662 days), with 48% of admissions occurring within 6 months. The most common presentation was NSTEMI. Predictors of ACS were history of coronary artery disease, prior revascularization, diabetes, valve-in-TAVR, and acute kidney injury. STEMI was associated with higher 30-day and 1-year mortality compared with NSTEMI (31.4% vs. 15.5% and 51.2% vs. 41.3%, respectively; p < 0.01). Overall, 30.3% of patients with non–ST-segment elevation ACS were treated with invasive approach. On inverse probability weighting analysis, invasive approach was associated with lower adjusted long-term mortality (adjusted hazard ratio: 0.69; 95% confidence interval: 0.66 to 0.73; p < 0.01) and higher risk of repeat revascularization (adjusted hazard ratio: 1.29; 95% confidence interval: 1.16 to 1.43; p < 0.001).ConclusionsAfter TAVR, ACS is infrequent (<5%), and the most common presentation is NSTEMI. Occurrence of STEMI after TAVR is associated with a high mortality with nearly one-third of patients dying within 30 days. Optimization of care is needed for post-TAVR ACS patients and if feasible, invasive approach should be considered in these high-risk patients.     

Identificación y cuantificación del efecto fin de semana y festivos en la atención del síndrome coronario agudo en el Sistema Nacional de Salud

Introduction and objectivesTo analyze whether admission on weekends or public holidays (WHA) influences the management (performance of angioplasty, percutaneous coronary intervention [PCI]) and outcomes (in-hospital mortality) of patients hospitalized for acute coronary syndrome in the Spanish National Health System compared with admission on weekdays.MethodsRetrospective observational study of patients admitted for ST-segment elevation myocardial infarction (STEMI) or for non–ST-segment elevation acute coronary syndrome (NSTEACS) in hospitals of the Spanish National Health system from 2003 to 2018.ResultsA total of 438 987 episodes of STEMI and 486 565 of NSTEACS were selected, of which 28.8% and 26.1% were WHA, respectively. Risk-adjusted models showed that WHA was a risk factor for in-hospital mortality in STEMI (OR, 1.05; 95%CI,1.03-1.08; P < .001) and in NSTEACS (OR, 1.08; 95%CI, 1.05-1.12; P < .001). The rate of PCI performance in STEMI was more than 2 percentage points higher in patients admitted on weekdays from 2003 to 2011 and was similar or even lower from 2012 to 2018, with no significant changes in NSTEACS. WHA was a statistically significant risk factor for both STEMI and NSTEACS.ConclusionsWHA can increase the risk of in-hospital death by 5% (STEMI) and 8% (NSTEACS). The persistence of the risk of higher in-hospital mortality, after adjustment for the performance of PCI and other explanatory variables, probably indicates deficiencies in management during the weekend compared with weekdays.     

Spectrum of acute coronary syndrome in North Eastern India – A study from a major center

AimSpectrum of acute coronary syndrome (ACS) has not been reported from North Eastern India. The present study was undertaken to study the clinical spectrum of ACS.MethodsWe prospectively collected data of 704 ACS patients from February 2011 to August 2012 in Gauhati Medical College, a tertiary care center. We evaluated data on clinical characteristic, treatment, and outcome in ACS patients.ResultsOf the 704 ACS patients, 72.4% presented with STEMI and 27.6% presented with NSTEMI/UA. Mean age of presentation was 56.5 years. Mean time to presentation was 11.42 h and was higher in NSTEMI/UA than STEMI (12.86 h vs. 9.98 h, p < 0.001). Treatment for STEMI did not differ much from NSTEMI/UA with ≥90% of patients in both groups receiving antiplatelets, statin, and anticoagulants. 39% of STEMI received thrombolytic therapy and percutaneous coronary intervention (PCI) rates were higher in STEMI. The 30-day mortality was found to be 10.22%, with STEMI having higher mortality than NSTEM/UA (11.76% vs. 6.18%, p = 0.03).ConclusionThese data represent the first reported study on spectrum of ACS in North Eastern India and has noted few key differences from the national registry CREATE, with greater percentage of STEMI patients, greater delay in seeking treatment, greater 30-day mortality, and lesser percentage of patients receiving reperfusion therapy.     

不同性别急性冠脉综合征住院患者的临床特征及治疗现状

目的评价中国不同性别急性冠脉综合征（ACS）住院患者的临床特点及住院治疗现状。方法中国急性冠脉事件注册研究人选12家三级甲等医院,从2001年1月起截止到2003年10月,总共1301例ACS患者人选该研究。结果（1）患者年龄为27-93（63．13±10．89）岁,包括318（例）女性和983（例）男性患者;女性平均年龄显著高于男性（67．23岁比61．80岁）。（2）女性患者心绞痛、心力衰竭、糖尿病和高血压病史显著高于男性（分别为73．6％比62．3％,8．2％比5．7％,30．8％比18．6％,和66．4％比56．8％）,但女性患者吸烟比例显著低于男性（6．6％比66．2％）;（3）患者ST段抬高心肌梗死（STEMI）的男性患者比例显著高于女性（48．5％比39％）。（4）除B受体阻滞剂以外,ACS患者住院期间阿司匹林、血管紧张素转换酶抑制剂、调脂药及低分子肝素的应用在两性之间无显著性差异;对于非ST段抬高ACS（NSTE-ACS）患者,女性住院期间使用8受体阻滞剂的比例显著低于男性（63．4％比75．1％）。（5）所有女性ACS患者住院期间未接受再灌注治疗的比例显著高于男性（STEMI：37．1％比26．8％;NSTE-ACS：53．6％比37．2％）。（6）女性住院期间再发心绞痛、充血性心力衰竭的发生率显著高于男性ACS患者。（7）住院期间,女性ACS患者的死亡率与男性比较没有显著差异（STEMI：5．6％比7．1％,NSTE-ACS：2．1％比1．4％）。结论我国治疗水平较高地区ACS患者女性年龄要显著高于男性,女性合并更多的危险因素（高血压、糖尿病等）,女性ACS患者住院期间接受再灌注治疗的比例低于男性ACS患者,但住院期间两性之间死亡率并无显著差异。     

Low serum albumin levels and in-hospital outcomes in patients with ST segment elevation myocardial infarction

Background and aimsLow serum albumin (SA) is associated with an increased risk of long-term adverse events (AEs) among patients with chronic coronary syndromes. Its prognostic role in patients with ST-elevation myocardial infarction (STEMI) is less clear. To investigate the association between low SA and in-hospital AEs in STEMI patients.Methods and resultsMulticenter retrospective cohort study of 220 STEMI patients undergoing primary percutaneous coronary intervention within 12 h from the onset of symptoms. Hypoalbuminemia was defined by serum SA <35 g/L. SA. In-hospital AEs were defined as cardiogenic shock, resuscitated cardiac arrest and death. Median SA was 38 (IQR 35.4–41.0) g/L and 37 (16.8%) patients showed hypoalbuminemia (<35 g/L) on admission. Patients with hypoalbuminemia were older, more frequently women and diabetics, prior CAD and HF. Furthermore, they showed lower hemoglobin levels and impaired renal function. At multivariable logistic regression analysis, diabetes (odds ratio [OR]:4.59, 95% confidence interval [CI] 1.71–12.28, p = 0.002) and haemoglobin (OR:0.52, 95%CI 0.37–0.72, p < 0.001) were associated with low SA. In a subgroup of 132 patients, SA inversely correlated with D-Dimer (rS −0.308, p < 0.001). Globally, twenty-eight (14.6%) AEs were recorded. Hypoalbuminemia (OR:3.43, 95%CI 1.30–9.07, p = 0.013), high-sensitive (HS)-Troponin peak above median (OR:5.41, 95%CI 1.99–14.7, p = 0.001), C-reactive protein (CRP) peak above median (OR:6.03, 95%CI 2.02–18.00, p = 0.001), and in-hospital infection (OR:3.61, 95%CI 1.21–10.80, p = 0.022) were associated with AEs.ConclusionLow SA levels are associated with worse in-hospital AEs in STEMI patients, irrespective of HS-troponin and CRP plasma levels. Our findings suggest that low SA may contribute to the pro-thrombotic phenotype of these patients.