早期介入治疗与NSTEMI患者长期预后的关系

目的:分析急性非ST段抬高心肌梗死(NSTEMI)患者介入治疗时机与长期结局的关系。方法:选择948例急性NSTEMI患者纳入研究。根据NSTEMI介入治疗方案分为早期介入治疗(48h内接受介入治疗,411例)组及晚期介入治疗(≥48h接受介入治疗,537例)组。根据TIMI危险评分又分为低危、中危、高危三个亚组,比较各组的长期临床结局。结果:随访1年,与晚期介入组比较,早期介入组住院死亡率(4.8%比2.2%)和主要不良心血管事件发生率(MACE,13.4%比10.0%)明显降低(P均0.01);早期介入组中,中低危患者住院死亡率显著低于高危患者(3.3%比8.9%,P0.01)。多元回归分析结果表明,老年及高Killip分级、左室射血分数减低、高TIMI危险评分、晚期介入治疗是NSTEMI患者长期临床结局的独立危险因素(OR=1.027~2.079,P0.05或0.01)。结论:早期介入治疗对于高危险的急性非ST段抬高型心肌梗死患者有改善预后的作用。     

SYNERGY研究：高危NSTEACS患者接受冠脉造影时间和预后的关系

目前，对于急性非ST抬高急性冠脉综合征（NSTEACS）患者接受早期介入治疗的最佳时间仍不明确。美国学者Tricoci等的SYNERGY研究拟评价对于高危的急性NSTEACS患者，从其住院到接受冠脉造影检查的时间对其预后的影响，所有患者均在住院后48h内接受冠脉造影检查。     

不同性别急性冠状动脉综合征患者的临床特征与预后

目的 比较不同性别非ST段抬高急性冠状动脉(冠脉)综合征(NSTEACS)患者临床特征和介入治疗对预后的影响.方法 814例NSTEACS患者,随机接受早期(＜24 h)或延迟(＞36 h)介入治疗,随访6个月,主要联合终点为死亡、心肌梗死(MI)和卒中.结果 女性患者年龄较大、更多有高血压、糖尿病、冠心病史和慢性心绞痛史.但入院时心肌标记物升高者较少,现吸烟者少.女性患者冠脉造影非阻塞性病变的比例高,左主干和(或)3支病变的比例与男性相似.经多因素回归分析,既往MI和严重冠脉病变为女性发生主要终点事件的独立预测因素.严重冠脉病变,延迟介入及至少3种冠心病危险因素是男性发生主要终点事件的独立预测因素.结论 不同性别NSTEACS患者影响预后的因素不同,严重冠脉病变为预后的独立预测因素,早期介入治疗有益于降低男性患者180 d心血管病事件风险,但对女性患者预后无影响.     

早期介入治疗对高危非ST段抬高型心肌梗死患者短期预后的影响

目的 比较早期与择期介入治疗对高危非ST段抬高型心肌梗死（NSTEMI）患者短期预后的影响。方法 纳入西京医院心血管内科行介入治疗的高危NSTEMI患者,根据手术实施时间分为早期介入组（入院24 h内）和择期介入组（24~48 h）。比较两组患者围手术期并发症、住院期间死亡、PCI成功率、住院时间以及费用,对患者随访6个月,观察再发心绞痛、因冠心病再住院 、主要心血管不良事件（MACE）的发生和左心室射血分数（LVEF）改善的情况。结果 与择期介入组比较,早期介入组围手术期并发症、住院期间死亡、PCI成功率与MACE发生率差异无统计学意义,早期介入组住院时间、住院费用、再发心绞痛及因冠心病再住院率低于择期介入组,两组LVEF均明显提高,早期介入组高于择期介入组。结论 高危NSTEMI患者早期介入治疗的短期预后优于择期介入治疗。     

高分级颅内动脉瘤破裂患者不同时机介入治疗的效果研究

目的探讨高分级颅内动脉瘤破裂患者不同时机介入治疗的效果。方法选取2014年1月～2018年6月符合入选标准的Hunt-HessⅣ、Ⅴ级颅内动脉瘤破裂并接受介入栓塞术的患者115例,根据介入治疗时间分为早期治疗组(发病后72h进行栓塞治疗)60例和延期治疗组(发病≥72h后进行栓塞治疗)55例,术后观察并发症发生情况,采用巴塞尔指数(BI)评分、生活质量指标调查表(DLQI)评分、格拉斯哥昏迷评分(GCS)和格拉斯哥预后评分(GOS)判断患者预后和疗效。结果早期治疗组并发症发生率低于延期治疗组(20.0%vs 36.4%,P 0.01);早期治疗组术后3个月BI评分明显高于延期治疗组[(25.4±1.7)分vs (6.5±1.9)分,P0.05],早期治疗组治疗后DLQI评分总分明显低于延期治疗组[(8.5±0.5)分vs (13.6±1.3)分,P0.05],术后GCS和出院时GOS高于延期治疗组[(6.5±1.5)分vs (5.8±1.4)分,(3.1±0.2)分vs (2.3±0.1)分,P0.05]。结论在8h内对高分级颅内动脉瘤破裂患者进行介入治疗效果理想,值得在临床上进一步推广应用。     

急性冠状动脉综合征患者全球急性冠状动脉事件注册危险评分系统与载脂蛋白的相关研究

目的探讨急性冠状动脉综合征(ACS)患者全球急性冠状动脉事件注册危险评分系统(Grace)与载脂蛋白(apo)的关系。方法选择ACS患者692例(ACS组),非冠心病患者99例(对照组)。对患者的一般情况:年龄、性别、吸烟史、高血压史等进行详细记录。同时测定血清apoA、apoB、apoB/apoA及其他血清学指标。同时根据Grace评分将ACS组患者分为低危组220例、中危组240例、高危组232例,比较不同组间血清apoA、apoB、apoB/apoA水平与Grace评分的相关性。结果 ACS组空腹血糖、餐后2h血糖、糖化血红蛋白、TG、TC、LDL-C、脂蛋白(a)、apoB、apoB/apoA、年龄、高血压史、吸烟史、男性、Grace评分明显高于对照组,apoA、HDL-C明显低于对照组(P<0.05,P<0.01)。与低危组比较,中危组和高危组apoB、apoB/apoA明显升高,apoA明显降低(P<0.05)。相关性分析显示,Grace评分与apoB、apoB/apoA、高血压史、吸烟史、男性呈正相关(r=0.374,P=0.000;r=0.312,P=0.000;r=0.163,P=0.031;r=0.172,P=0.044;r=0.212,P=0.005),与apoA呈负相关(r=-0.300,P=0.016);多元线性回归分析,血清apoB、apoB/apoA对Grace评分影响最大。结论血清apoA、apoB、apoB/apoA与ACS危险程度密切相关。在ACS患者中,联合运用这些危险因素评估,可能对早期危险分层预后评估及诊疗方案的选择有重要临床参考价值。     

非ST段抬高型心肌梗死Grace评分与同型半胱氨酸(HCY)浓度相关性研究

目的探讨非ST段抬高型心肌梗死Grace评分与同型半胱氨酸(HCY)浓度的相关性,为NSTEMI患者预后判断寻找可靠的评价指标。方法 选择2013年07月～2016年06月我院非ST段抬高型心肌梗死患者160例为研究对象,排除心肌梗死患者200例为对照组,采用同型半胱氨酸检测测试剂盒(酶法)测定同型半胱氨酸浓度,比较两组Hcy浓度水平。结果 对照组、低危组、中危组、高危组Hcy浓度差异有统计学意义(P0.05);各组间两两比较,Hcy浓度差异有统计学意义(P0.05);NSTEMIT血清Hcy水平与Grace评分明显相关。结论非ST段抬高型心肌梗死Hcy浓度水平与Grace评分明显正相关,Grace评分赵高且伴有血清Hcy水平明显增高患者,患者死亡风险显著提升。     

早期与延迟介入治疗对颅内破裂动脉瘤患者的疗效和DCI发生率的差异

目的探讨不同介入治疗时机对颅内破裂动脉瘤患者的疗效及迟发性脑缺血（DCI）发生率的影响,并分析导致术后DCI发生的危险因素。 方法回顾性分析自2014年1月至2018年6月于右江民族医学院附属医院神经外科行介入治疗的颅内破裂动脉瘤患者98例的临床资料,按照介入手术的时机将所有患者资料分为早期组（n=57）和延迟组（n=41）。其中所有患者均在常规治疗的基础上行介入治疗,其中早期组介入时间在发病后72 h内,而延迟组介入时间超过发病后72 h。比较2组患者治疗效果,术后并发症及预后情况之间的差异,并对导致患者术后DCI的危险因素进行单因素及多因素Logistic分析。 结果2组患者治疗后2周时NIHSS评分之间差异无统计学意义（6.27±2.19 vs 5.76±1.94,P>0.05）,早期组完全栓塞率显著高于延迟组（91.23% vs 73.17%,P<0.05）,2组患者术后DCI、CVS、再破裂出血、脑水肿及下肢静脉栓塞发生率差异无统计学意义（P>0.05）,早期组随访3个月时预后良好率及巴塞尔指数评分显著高于延迟组[80.70% vs 70.73%,（63.51±13.42）vs （52.78±12.65）,P<0.05],本次研究中患者治疗后DCI发生率为12.44%,低蛋白血症、Fisher分级Ⅲ~Ⅳ及WFNS分级Ⅲ~Ⅴ级是DCI发生的独立危险因素（OR=4.29、5.48、8.074,P<0.05）。 结论早期介入能提升栓塞效果的同时有效改善患者预后,低蛋白血症、Fisher分级Ⅲ~Ⅳ及WFNS分级Ⅲ~Ⅴ级是颅内动脉瘤介入术后发生DCI的独立危险因素。     

肌钙蛋白I对非ST段抬高急性冠状动脉综合征临床转归的预测价值

目的　前瞻、多中心、随机对照研究肌钙蛋白(Tn)I阳性的非ST段抬高急性冠状动脉综合征病人(NSTEACS)发生心血管事件的危险程度,探讨TnI对其临床预后的预测价值。方法在10个医院入选起病后24h内就诊的NSTEACS患者,随机接受早期介入或保守治疗。随访30d和6个月,观察终点为心血管事件,包括心脏性死亡、非致命性心肌梗死、非致命性心力衰竭、因反复心绞痛发作住院。结果　6个月时,TnI阳性组患者因反复心绞痛住院及复合心血管事件明显增多,与TnI阴性组比较,差异有统计学意义(P<0 01)。早期介入干预可明显降低TnI阳性患者30d及6个月的复合心血管事件发生率(P值均<0 01)。结论　TnI阳性患者6个月心血管事件较TnI阴性者明显增加,TnI阳性是NSTEACS患者的预后预测因素。早期介入干预治疗能减少TnI阳性患者随访期内心血管事件的发生,不能使TnI阴性患者从中受益。     

ABCD~3-I评分预测短暂性脑缺血发作后早期脑卒中复发风险的价值

目的探讨ABCD3-I评分预测短暂性脑缺血发作(TIA)后早期脑卒中复发风险的价值。方法选择162例TIA患者,分别用ABCD2、ABCD3-I和Essen卒中风险分层量表(ESRS)评分进行危险分层,ABCD3-I评分中,低危24例、中危97例、高危41例,发病7d、随访90d观察脑卒中复发情况,通过ROC曲线下面积(AUC)比较3种评分的预测价值。结果发病7d有13例(8.0%)患者脑卒中复发;90d随访有26例(16.0%)脑卒中复发。ABCD3-I评分中,与低危患者比较,中危和高危患者随访90d脑卒中复发率明显升高(14.4%vs 0,P=0.037,29.3%vs 0,P=0.002,)。ABCD3-I评分预测发病7d脑卒中复发的AUC为0.73(95%CI:0.62~0.82),随访90d脑卒中复发的AUC为0.71(95%CI:0.60~0.79),高于ABCD2、ESRS评分预测发病7d、随访90d脑卒中复发风险的AUC。结论 ABCD3-I评分预测TIA后早期脑卒中复发风险的价值优于ABCD2和ESRS评分。     

Differential prognostic effect of revascularization according to a simple comorbidity index in high-risk non-ST-segment elevation acute coronary syndrome

Background:

Data on the effect of revascularization on outcome in patients with high‐risk non–ST‐segment elevation acute coronary syndrome (NSTEACS) and significant comorbidities are scarce. Recently, a simple comorbidity index (SCI) including 5 comorbidities (renal failure, dementia, peripheral artery disease, heart failure, and prior myocardial infarction [MI]) has shown to be a useful tool for risk stratification. Nevertheless, therapeutic implications have not been derived.

Hypothesis:

We sought to evaluate the prognostic effect attributable to revascularization in NSTEACS according the SCI score.

Methods:

We included 1017 consecutive patients with NSTEACS. The effect of revascularization on a combined end point of all‐cause mortality or nonfatal MI was evaluated by Cox regression according to SCI categories.

Results:

A total of 560 (55.1%), 236 (23.2%), and 221 (21.7%) patients showed 0, 1, and ≥2 points according to the SCI, respectively. Coronary angiography was performed in 725 patients (71.5%), and 450 patients (44.3%) underwent revascularization. During a median follow‐up of 16 months (interquartile range, 12–36 months), 305 (30%) patients experienced the combined end point (202 deaths [19.9%] and 170 MIs [16.7%]). In multivariate analysis, a differential prognostic effect of revascularization was observed comparing SCI ≥2 vs 0 (P for interaction = 0.008). Thus, revascularization was associated with a greater prognostic benefit in patients with SCI ≥2 (hazard ratio [HR]: 0.51, 95% confidence interval [CI]: 0.29–0.89), P = 0.018), whereas no significant benefit was observed in those with 0 and 1 point (HR: 1.31, 95% CI: 0.88–1.94, P = 0.171 and HR: 1.11, 95% CI: 0.70–1.76, P = 0.651, respectively).

Conclusions:

In NSTEACS, the SCI score appears to be a useful tool for identifying a subset of patients with a significant long‐term death/MI risk reduction attributable to revascularization. © 2011 Wiley Periodicals, Inc. This study was supported by a grant from the Ministerio de Sanidad y Consumo, Instituto de Salud Carlos III, RED HERACLES (FEDER) RD06/0009/1001 (Madrid, Spain). The authors have no other funding, financial relationships, or conflicts of interest to disclose.     

Asia-Pacific Working Group consensus on non-variceal upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB), especially peptic ulcer bleeding, remains one of the most important cause of hospitalisation and mortality world wide. In Asia, with a high prevalence of Helicobacter pylori infection, a potential difference in drug metabolism, and a difference in clinical management of UGIB due to variable socioeconomic environments, it is considered necessary to re-examine the International Consensus of Non-variceal Upper Gastrointestinal Bleeding with emphasis on data generated from the region. The working group, which comprised experts from 12 countries from Asia, recommended the use of the Blatchford score for selection of patients who require endoscopic intervention and which would allow early discharge of patients at low risk. Patients' comorbid conditions should be included in risk assessment. A pre-endoscopy proton pump inhibitor (PPI) is recommended as a stop-gap treatment when endoscopy within 24 h is not available. An adherent clot on a peptic ulcer should be treated with endoscopy combined with a PPI if the clot cannot be removed. Routine repeated endoscopy is not recommended. High-dose intravenous and oral PPIs are recommended but low-dose intravenous PPIs should be avoided. COX-2 selective non-steroidal anti-inflammatory drugs combined with a PPI are recommended for patients with very high risk of UGIB. Aspirin should be resumed soon after stabilisation and clopidogrel alone is no safer than aspirin plus a PPI. When dual antiplatelet agents are used, prophylactic use of a PPI reduces the risk of adverse gastrointestinal events.     

Early prognostic usefulness of C-reactive protein added to the Thrombolysis In Myocardial Infarction risk score in acute coronary syndromes

The aim of the present study was to evaluate whether an elevated plasma C-reactive protein (CRP) level provides any additional prognostic information to the validated Thrombolysis In Myocardial Infarction (TIMI) risk score in patients with acute coronary syndromes. For this purpose, 1,846 consecutive patients with either acute ST-segment elevation myocardial infarction (STEMI; 861 patients) or non-ST-segment elevation acute coronary syndrome (NSTEACS; 985 patients) were included. The incidence of 30-day death and 14-day composite of death, myocardial infarction (or repeat myocardial infarction) and recurrent ischemia was the prespecified primary end point in the STEMI and NSTEACS cohorts, respectively. The incidence of the primary end point was 9.8% and 23.6% in the STEMI and NSTEACS cohorts, respectively. A significantly increased risk of the primary end point was present with an increase in the STEMI and NSTEACS TIMI risk score (p(trend) < 0.001 for the 2 groups). A plasma CRP value of > or = 5 and > or = 3 mg/L (defined by receiver-operating characteristic analysis) was associated with a significantly increased risk of the primary end point in the STEMI and NSTEACS cohorts, respectively (p < 0.001 for the 2 cohorts), and it was true throughout the subgroups of STEMI and NSTEACS TIMI risk scores. In conclusion, an elevated plasma CRP level appears to be a marker that adds prognostic information to the validated STEMI and NSTEACS TIMI risk score. The plasma CRP and TIMI risk score may be used together for enhanced risk stratification in the setting of acute coronary syndromes.     

Coronariografía precoz y mortalidad a largo plazo en infarto agudo de miocardio de alto riesgo. Registro CARDIOCHUS-HUSJ

Introduction and objectivesThis study sought to analyze the association of early coronary angiography with all-cause mortality and cardiovascular mortality in patients with non–ST-segment elevation acute coronary syndrome (NSTEACS) using a large contemporary cohort of patients with NSTEACS from 2 Spanish tertiary hospitals.MethodsThis retrospective observational study included 5673 consecutive NSTEACS patients from 2 Spanish hospitals between 2005 and 2016. We performed propensity score matching to obtain a well-balanced subset of patients with the same probability of undergoing an early strategy, resulting in 3780 patients. Survival analyses were performed by Cox regression models once proportional risk test were verified.ResultsAmong the study participants, only 2087 patients (40.9%) underwent early invasive coronary angiography. The median follow-up was 59.0 months [interquartile range, 25.0-80.0 months]. All-cause mortality was 19.0%, cardiovascular mortality was 12.8%, and 51.1% patients experienced at least 1 major cardiovascular adverse event in the follow-up. After propensity score matching, the early strategy was associated with significantly lower mortality (hazard ratio: 0.79; 95% confidence interval 0.62-0.98) in high-risk NSTEACS patients. The early strategy showed a nonsignificant inverse tendency in patients with GRACE score < 140.ConclusionsIn high-risk (GRACE score ≥ 140) NSTEACS patients in a contemporary real-world registry, early coronary angiography (first 24 hours after hospital admission) may be associated with reduced all- cause mortality and cardiovascular mortality at long-term follow-up.     

Sex-related differences in long-term mortality and heart failure in a contemporary cohort of patients with NSTEACS. The cardiochus-HSUJ registry

Introduction and objectivesThere is insufficient data regarding sex-related prognostic differences in patients with a non-ST elevation acute coronary syndrome (NSTEACS). We performed a sex-specific analysis of cardiovascular outcomes after NSTEACS using a large contemporary cohort of patients from two tertiary hospitals.MethodsThis work is a retrospective analysis from a prospective registry, that included 5,686 consecutive NSTEACS patients from two Spanish University hospitals between the years 2005 and 2017. We performed a propensity score matching to obtain a well-balanced subset of individuals with the same clinical characteristics, resulting in 3,120 patients. Cox regression models performed survival analyses once the proportional risk test was verified.ResultsAmong the study participants, 1,572 patients (27.6%) were women. The mean follow-up was 60.0 months (standard deviation of 32 months). Women had a higher risk of cardiovascular mortality compared with men (OR (Odds ratio) 1.27, CI (confidence interval) 95% 1.08-1.49), heart failure (HF) hospitalization (OR 1.39, CI 95% 1.18-1.63) and risk of all-cause mortality (OR 1.10, CI 95% 1.08-1.49). After a propensity score matching, female gender was associated with a significant reduction in the risk of total mortality (OR 0.77, CI 95% 0.65-0.90) with a similar risk of cardiovascular mortality (OR 0.86, CI 0.71-1.03) and HF hospitalization (OR 0.92, CI 95% 0.68-1.23). After baseline adjustment, the risk of all-cause mortality and cardiovascular mortality was lower in women, whereas the risk of HF remained similar among sexes.ConclusionsIn a contemporary cohort of patients with NSTEACS, women are at similar risk of developing early and late HF admissions, and have better survival compared with men, with a lower risk of all-cause mortality and cardiovascular mortality. The implementation of NSTEACS guideline recommendations in women, including early revascularization, seems to be accompanied by improved early and long-term prognosis.     

Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology.

In patients with stable CAD, PCI can be considered a valuable initial mode of revascularization in all patients with objective large ischaemia in the presence of almost every lesion subset, with only one exception: chronic total occlusions that cannot be crossed. In early studies, there was a small survival advantage with CABG surgery compared with PCI without stenting. The addition of stents and newer adjunctive medications improved the outcome for PCI. The decision to recommend PCI or CABG surgery will be guided by technical improvements in cardiology or surgery, local expertise, and patients' preference. However, until proved otherwise, PCI should be used only with reservation in diabetics with multi-vessel disease and in patients with unprotected left main stenosis. The use of drug-eluting stents might change this situation. Patients presenting with NSTE-ACS (UA or NSTEMI) have to be stratified first for their risk of acute thrombotic complications. A clear benefit from early angiography (<48 h) and, when needed, PCI or CABG surgery has been reported only in the high-risk groups. Deferral of intervention does not improve outcome. Routine stenting is recommended on the basis of the predictability of the result and its immediate safety. In patients with STEMI, primary PCI should be the treatment of choice in patients presenting in a hospital with PCI facility and an experienced team. Patients with contra-indications to thrombolysis should be immediately transferred for primary PCI, because this might be their only chance for quickly opening the coronary artery. In cardiogenic shock, emergency PCI for complete revascularization may be life-saving and should be considered at an early stage. Compared with thrombolysis, randomized trials that transferred the patients for primary PCI to a 'heart attack centre' observed a better clinical outcome, despite transport times leading to a significantly longer delay between randomization and start of the treatment. The superiority of primary PCI over thrombolysis seems to be especially clinically relevant for the time interval between 3 and 12 h after onset of chest pain or other symptoms on the basis of its superior preservation of myocardium. Furthermore, with increasing time to presentation, major-adverse-cardiac-event rates increase after thrombolysis, but appear to remain relatively stable after primary PCI. Within the first 3 h after onset of chest pain or other symptoms, both reperfusion strategies seem equally effective in reducing infarct size and mortality. Therefore, thrombolysis is still a viable alternative to primary PCI, if it can be delivered within 3 h after onset of chest pain or other symptoms. Primary PCI compared with thrombolysis significantly reduced stroke. Overall, we prefer primary PCI over thrombolysis in the first 3 h of chest pain to prevent stroke, and in patients presenting 3-12 h after the onset of chest pain, to salvage myocardium and also to prevent stroke. At the moment, there is no evidence to recommend facilitated PCI. Rescue PCI is recommended, if thrombolysis failed within 45-60 min after starting the administration. After successful thrombolysis, the use of routine coronary angiography within 24 h and PCI, if applicable, is recommended even in asymptomatic patients without demonstrable ischaemia to improve patients' outcome. If a PCI centre is not available within 24 h, patients who have received successful thrombolysis with evidence of spontaneous or inducible ischaemia before discharge should be referred to coronary angiography and revascularized accordingly--independent of 'maximal' medical therapy.     

Prognostic significance of heart fatty acid binding protein in patients with non-ST elevation acute coronary syndrome: results of follow-up for twelve months

Value of heart fatty acid binding protein (FABP) for medium term prognosis in patients with non-ST elevation acute coronary syndrome (NSTEACS) is not well established. AIM: To compare prognostic value of FABP levels with those of troponin I (TnI) and creatine kinase MB (CK MB) activity in patients with NSTEACS. METHODS: Serum FABP and TnI levels (HyTest), CK MB activity (Biocon) were measured in 203 patients with NSTEACS (mean age 63.9+/-11.5 years, 52.2% male). Blood was sampled at admission within 12 (median 3.83) hours and in 6 and 12 hours after onset of pain. Upper limits of normal range (ULN) for TnI and CK MB were 0.4 ng/ml and 25 U/l, respectively. Serum FABP was measured in 53 healthy volunteers (mean age 44.3+/-13.3) and 95th percentile was used as ULN (4.67 ng/ml). Deaths and nonfatal MIs (events) were registered during one year follow-up. RESULTS: There were 47 events (23%, 23 deaths and 24 nonfatal MIs). Patients with events compared with those without events had significantly higher TnI and CK MB 12 hours after onset of pain and significantly higher FABP at all time points of blood sampling. Multivariate (step-up) analysis selected the following independent predictors of events: elevated FABP 6 hours after pain onset (OR 2.45, 95% CI 1.14-5.24; p=0.021), T-wave inversion on admission ECG, age >65 and regular use of nitrates before hospitalization. Sensitivity of elevated FABP 6 hours after pain onset was 78.4%, specificity -- 45.1%. After exclusion from analysis of all or just admission and 6 hours FABP data elevated TnI 12 hours after onset of pain became an independent predictor of events. CONCLUSION: In this group of patients with NSTEACS among markers of myocardial necrosis (FABP, TnI, MB CK) obtained serially during first 12 hours after pain onset elevated FABP was the best predictor of events during 1 year follow up for subjects in whom blood sample could be done 6 hours after pain onset.     

Can we improve length of hospitalization in ST elevation myocardial infarction patients treated with primary percutaneous coronary intervention?

BACKGROUND:

Patients with ST elevation myocardial infarction have traditionally been hospitalized for five to seven days to monitor for serious complications such as heart failure, arrhythmias, reinfarction and death. The Zwolle primary percutaneous coronary intervention (PCI) index is an externally validated risk score that has been used to identify low-risk primary PCI patients who can safely be discharged from the hospital within 48 h to 72 h.

METHODS:

The Zwolle score was retrospectively applied to all ST elevation myocardial infarction patients treated with primary PCI between April 2004 and February 2006 at a large Canadian teaching hospital. The goal was to characterize length of stay (LOS) in low-risk patients and to identify variables that correlate with patients who were hospitalized longer than expected.

RESULTS:

Data were collected on 255 patients. The mean LOS was 7.2±7.7 days (median 5.0 days [interquartile range 3.5 days]). A total of 179 patients (70%) had a Zwolle score of 3 or lower, identifying them as low risk. There was one death in the low-risk group (0.6% 30-day mortality) and 15 deaths in the higher-risk group (19.7% 30-day mortality), validating the Zwolle score in the population. A contraindication to early discharge was identified in 34 of the low-risk patients. Among the 144 remaining low-risk patients, the mean LOS was 5.1±3.3 days (median 4.0 days [interquartile range 3.0 days]). Only 8% were discharged within 48 h and only 28% within 72 h. It was determined that fewer patients were discharged on weekends and Wednesdays (when medical residents were away for teaching) than on other weekdays. LOS was longer among patients who were discharged on warfarin (7.6 days versus 4.6 days, P=0.006), and among patients who were transferred back to their presenting hospital rather than being discharged directly from the hospital where PCI was performed (5.6 days versus 4.0 days, P<0.001).

CONCLUSIONS:

Seventy-two per cent of low-risk primary PCI patients were hospitalized longer than 72 h. The following three factors were identified as correlating with prolonged LOS in this population: fewer discharges on days when there was less resident staffing; the use of warfarin at discharge; and transfer of patients back to their presenting hospital rather than discharging them directly from the PCI-performing hospital. A programmed approach to the identification and early discharge of low-risk patients could have significant cost savings and should be investigated prospectively.     

Prognostic value of clinical variables at presentation in patients with non-ST-segment elevation acute coronary syndromes: results of the Proyecto de Estudio del Pronóstico de la Angina (PEPA)

Patients with suspected non-ST-segment elevation acute coronary syndromes (NSTEACS) constitute a heterogeneous population with variable outcomes. Risk stratification in this population of patients is difficult due to the complexity in patient risk profile. We conducted this study to characterize the value of clinical and electrocardiographic variables for risk stratification in an unselected population of consecutive patients with NSTEACS on admission. Thirty-five clinical and electrocardiographic variables at presentation in the emergency room of 18 hospitals were prospectively analyzed in 4,115 patients with NSTEACS and related with the outcomes at 90 days. We also developed a risk score using the variables found to be independent predictors of ischemic events to facilitate risk stratification. Cardiovascular mortality was 4.3% and the rate for the outcome of either cardiovascular death or nonfatal myocardial infarction was 6.9%. The only independent predictors of mortality were age, diabetes, peripheral vascular disease, postinfarction angina, Killip class > or = 2, ST-segment depression, and elevation of cardiac markers. A risk profile using the variables found to be independent predictors of events was calculated for cardiovascular mortality and for the combination of either death or nonfatal myocardial infarction. Event rates increased significantly in all subgroups of patients based on the number of independent risk factors as the risk score increased. Using these factors, 90-day mortality ranged from as low as 0.4% in patients with no risk factors to 21.1% for those with more than 4 risk factors. In conclusion, simple clinical and electrocardiographic data obtained at hospital admission allow an accurate risk stratification of patients with NSTEACS. In the PEPA registry, simple variables easy to obtain at admission appear to be a valuable tool in discerning between patients at very low and very high risk according to the cluster of factors for each patient. The risk score developed was obtained from an unselected population, representative of the whole spectrum of patients with NSTEACS, allowing identification of patients at different risks for adverse outcomes, and, therefore, permitting optimization of therapy.     

Diagnostic value of heart fatty-acid binding protein in early hospitalized patients with non ST elevation acute coronary syndrome

BACKGROUND: Heart fatty-acid-binding protein (FABP) is supposed to be the most sensitive biomarker of myocardial necrosis in patients with Q-wave myocardial infarction (MI) and non-diagnostic ECG during first hours after onset of symptoms. However, diagnostic value of FABP in patients with non-ST elevation acute coronary syndrome (NSTEACS) is not well established. AIM: To elucidate diagnostic value of FABP in patients with NSTEACS hospitalized within time interval considered to be too early for a majority of biochemical tests. MATERIAL AND METHODS: FABP levels were measured by immunofluorometry (HyTest, Finland) in 44 patients (26 men, mean age 69+/-8.9 years) at admission within 6 hours (median - 2 h) from onset of index attack of angina and in 6, 12, 24 hours after onset of pain. Cut off FABP level was 12 ng/ml. Serum cardiac troponin I was measured for diagnosis of MI on admission and twice during first 24 hours of hospital stay. Cut off TnI level was 0.4 ng/ml. RESULTS: Acute MI was diagnosed by TnI above cut off in 31 patients (70.5%). There were no new-Q-wave MIs. Average ratio of observed serum FABP level to diagnostic cut off value on admission and in 6, 12, 24 hours after onset of pain was higher in patients with MI than in patients with unstable angina (1.01, 1.53, 0.81, 0.66 and 0.78, 0.51, 0.65, 0.56, respectively). The difference was maximally significant in 6 hours after onset of pain (p=0.018). Among patients with MI admission FABP compared with admission TnI more frequently exceeded diagnostic level (in 18 vs 9 patients, respectively, p=0.009). Sensitivity and specificity of admission levels of FABP and TnI for diagnosis of MI were 58 and 85%, 29% and 100%, respectively. CONCLUSION: In patients with NSTEACS during first 6 hours after pain onset FABP compared with TnI has greater sensitivity for detection of MI and sufficient specificity. FABP can be used as additional diagnostic tool for MI detection in early admitted patients with NSTEACS.