Risk scores for risk stratification in acute coronary syndromes: useful but simpler is not necessarily better.

AIMS: Our objectives were (i) to compare the discriminatory performance of the Thrombolysis in Myocardial Infarction risk score (TIMI RS), Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy risk score (PURSUIT RS), and Global Registry of Acute Cardiac Events risk score (GRACE RS) for in-hospital and 1 year mortality across the broad spectrum of non-ST-elevation acute coronary syndromes (ACS) and (ii) to determine their incremental prognostic utility beyond overall risk assessment by physicians. METHODS AND RESULTS: We calculated the TIMI RS, PURSUIT RS, and GRACE RS for 1,728 patients with non-ST-elevation ACS in the prospective, multicentre, Canadian ACS II Registry. Discriminatory performance was measured by the c-statistic (area under receiver-operating characteristic curve) and compared by the method described by DeLong. TIMI RS, PURSUIT RS, and GRACE RS all demonstrated good discrimination for in-hospital death (c-statistics = 0.68, 0.80, 0.81, respectively, all P < 0.001) and 1 year mortality (c-statistics = 0.69, 0.77, 0.79, respectively, all P < 0.0001). However, PURSUIT RS and GRACE RS performed significantly better than the TIMI RS in predicting in-hospital (P = 0.036 and 0.02, respectively) and 1 year (P = 0.006 and 0.001, respectively) outcomes. In multivariable analysis adjusting for the use of in-hospital revascularization, stratification by tertiles of risk scores (into low, intermediate, and high-risk groups) furnished independent and greater prognostic information compared with risk assessment by treating physicians for 1 year outcome. CONCLUSION: Compared with TIMI RS, both PURSUIT RS and GRACE RS allow better discrimination for in-hospital and 1 year mortality in patients presenting with a wide range of ACS. All three risk scores confer additional important prognostic value beyond global risk assessment by physicians. These validated risk scores may refine risk stratification, thereby improving patient care in routine clinical practice.     

Association of the PURSUIT risk score with predischarge ejection fraction, angiographic severity of coronary artery disease, and mortality in a nonselected, community-based population with non-ST-elevation acute myocardial infarction

Background

The Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) risk score was derived from the PURSUIT trial population for 30-day mortality prediction.

Methods

The PURSUIT risk score was calculated for 337 consecutive Olmsted County residents with non-ST-elevation acute myocardial infarction admitted to the coronary care unit of our institution from 1988 through 1998. Predischarge ejection fraction (EF) measurement was available for 246 patients (73%). After excluding patients with prior coronary artery bypass graft surgery (n = 42), 219 patients (65%) had coronary angiography within 30 days of admission. Mortality at 30 days was 8.9%. Among 30-day survivors, mortality at 1 year was 7.9%.

Results

Mean age was 70 ± 13 years, and 37% of patients were women. Mean predischarge EF was 52% ± 16%. Patients with higher PURSUIT risk score had lower EF (P < .001). Three-vessel (≥70% stenosis in all 3 coronary arteries) or left main (≥50% stenosis) coronary artery disease was present in 60 of 219 patients (27%) who had coronary angiography. Higher PURSUIT risk score was associated with greater likelihood of 3-vessel or left main disease (P < .001). The PURSUIT risk score had very good predictive accuracy for both early (30-day, C-statistic = 0.78) and late (30-day to 1-year, C-statistic = 0.77) mortality.

Conclusions

The PURSUIT risk score correlates with EF, angiographic severity of coronary artery disease, and short- and long-term mortality of nonselected patients with non-ST-elevation acute myocardial infarction.     

Use of clopidogrel post-coronary artery bypass surgery in canadian patients with acute coronary syndromes

Background

Randomized trials have established the efficacy of clopidogrel in acute coronary syndromes (ACS). The benefit of clopidogrel has also been observed in the subgroup of ACS patients who subsequently undergo coronary artery bypass surgery (CABG); however, this therapy is discontinued preoperatively and the frequency with which clopidogrel is restarted post-CABG is unknown.

Methods

We examined the pattern of clopidogrel use in the Canadian Global Registry of Acute Coronary Events (GRACE), GRACE2, and CANRACE (2003-2008) post-CABG ACS patients. We stratified the patients according to whether they underwent CABG during their index hospitalization for ACS and whether they were prescribed clopidogrel at discharge.

Results

Among those patients in whom clopidogrel status at discharge was known, 5904 (60%) of 9841 were discharged from hospital on clopidogrel. Use of clopidogrel at discharge was observed in 2222 (40.8%) of 5443 patients who were medically managed (ie, did not undergo percutaneous coronary intervention [PCI] or CABG) and in 3585 (90.1%) of 3980 patients who underwent in-hospital PCI. Overall, 455 (3.3%) of 13,776 patients underwent CABG during the index hospitalization; 255 (56%) patients were started on clopidogrel during the first 24 hours, and 66 of these patients (25.9%) were discharged on clopidogrel. In contrast, 5681 (61.3%) of the 9262 patients who did not undergo in-hospital CABG were discharged on clopidogrel.

Conclusions

Although current guidelines recommend the use of clopidogrel post-CABG in patients with ACS, our observations suggest that only 1 in 4 or 5 Canadian patients are discharged on this therapy.     

Le profil de risque dans l’infarctus du myocarde : une évaluation indispensable pour la comparaison des populations

Objective

The aim of this study is to show that differences of mortality, in acute myocardial infarction, observed between hospitals are not necessarily linked to a bad application of guidelines but can be linked to differences in the risk profile of the populations.

Methods

Two populations admitted for ST and non-ST elevation myocardial infarction in the same region in 2006 were compared: the population of Chalon-sur-Saône’s hospital with a standard population from the observatoire des Infarctus de Côte d’Or (RICO). The risk profile of the two populations has been realised with the risk scores GRACE, EMMACE and the Simple Risk Index (SRI).

Results

The three scores are applicable for our populations according to the “C statistic”. Moreover, there is a significant difference of in-hospital mortality between Chalon-sur-Saône and RICO. But, the population of Chalon-sur-Saône presents a higher risk. Finally, in-hospital rate mortality expected by the three scores is not different from the actual mortality.

Conclusion

GRACE, EMMACE and SRI are valid scores for the comparison of risk profile of populations in acute myocardial infarction. Comparisons between hospitals are only possible after risk adjustment of the populations.     

Evaluating the benefits of glycoprotein IIb/IIIa inhibitors in heart failure at baseline in acute coronary syndromes

Background

We evaluated whether the use of glycoprotein IIb/IIIa receptor inhibitors, in addition to heparin and aspirin, imparts an incremental benefit in a subgroup of patients with acute coronary syndromes (ACS) who had congestive heart failure (CHF) symptoms at presentation.

Methods

We analyzed patients enrolled in the Platelet IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial, a randomized, double-blind, placebo-controlled study evaluating the use of eptifibatide versus placebo for patients with ACS without persistent ST-elevation. We compared the clinical characteristics and 30-day outcomes for 861 patients who had Killip class II or III CHF symptoms with those of 8558 patients who had no CHF symptoms.

Results

Odds ratios for the primary end point, 30-day death or non-fatal myocardial infarction, in the placebo group versus the eptifibatide group were similar for patients with and without CHF (odds ratio, 1.11; 95% CI, 0.8-1.5; odds ratio, 1.13; 95% CI, 1.0-1.3). However, adverse events were almost twice as frequent for patients with CHF compared with patients with no CHF (24.5% vs 14%).

Conclusions

Although patients with non-ST-segment elevation ACS who have CHF have markedly worse outcomes than patients without CHF symptoms, we did not find an incremental benefit from the use of eptifibatide in this seriously ill subgroup.     

Dynamic prognostication in non-ST-elevation acute coronary syndromes: insights from GUSTO-IIb and PURSUIT

Background

Risk assessment in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) traditionally focuses on and is limited to admission findings. The objective of the current study was to develop an approach to predicting outcome in NSTE-ACS that could account for the changing nature of risk.

Methods

In 7294 of 8010 patients with NSTE-ACS and complete electrocardiographic data in the GUSTO-IIb trial, we predicted the mortality probability at days 0-2, 0-30, 3-30, 5-30, and 7-30 using multiple logistic regression. Resulting risk estimates were incorporated into a composite, dynamic model to estimate the effects of changing probabilities over time. These models were validated against an independent sample of 9461 patients from the PURSUIT trial.

Results

As time passed after admission, the risk of 30-day death declined in stable patients. This risk, which was 3.72% at baseline, declined to 1.92% in 6-day survivors, and the risk reduction was greatest for those with the highest baseline risk. Importantly, however, the development of inhospital complications modified these trends. The use of dynamic models not only allowed us to estimate early (<48 h) mortality with a high degree of accuracy (C-index of 0.87), but also to continuously update the longer-term prognosis with increasing accuracy: the C-index increased from 0.75 for the day 0-30 model to 0.81 and 0.82 for the composite and day 7-30 models, respectively.

Conclusions

Dynamic risk assessment is feasible and reliable. This approach can improve risk assessment and provide valuable guidance for management of patients with NSTE-ACS.     

The Bleeding Risk Score as a Mortality Predictor in Patients with Acute Coronary Syndrome

Background

It is well known that the occurrence of bleeding increases in-hospital mortality in patients with acute coronary syndromes (ACS), and there is a good correlation between bleeding risk scores and bleeding incidence. However, the role of bleeding risk score as mortality predictor is poorly studied.

Objective

The main purpose of this paper was to analyze the role of bleeding risk score as in-hospital mortality predictor in a cohort of patients with ACS treated in a single cardiology tertiary center.

Methods

Out of 1,655 patients with ACS (547 with ST-elevation ACS and 1,118 with non-ST-elevation ACS), we calculated the ACUITY/HORIZONS bleeding score prospectively in 249 patients and retrospectively in the remaining 1,416. Mortality information and hemorrhagic complications were also obtained.

Results

Among the mean age of 64.3 ± 12.6 years, the mean bleeding score was 18 ± 7.7. The correlation between bleeding and mortality was highly significant (p < 0.001, OR = 5.296), as well as the correlation between bleeding score and in-hospital bleeding (p < 0.001, OR = 1.058), and between bleeding score and in-hospital mortality (adjusted OR = 1.121, p < 0.001, area under the ROC curve 0.753, p < 0.001). The adjusted OR and area under the ROC curve for the population with ST-elevation ACS were, respectively, 1.046 (p = 0.046) and 0.686 ± 0.040 (p < 0.001); for non-ST-elevation ACS the figures were, respectively, 1.150 (p < 0.001) and 0.769 ± 0.036 (p < 0.001).

Conclusions

Bleeding risk score is a very useful and highly reliable predictor of in-hospital mortality in a wide range of patients with acute coronary syndromes, especially in those with unstable angina or non-ST-elevation acute myocardial infarction.     

Non-ST-elevation acute coronary syndrome in the elderly: treatment strategies and 30-day outcome

Background

The purpose of this study was to assess the current care of elderly patients with non-ST-elevation acute coronary syndrome (ACS), with particular regard to the rate of use of antiplatelet drugs and the type of strategy, aggressive or conservative, in a population of consecutive patients admitted to 76 Coronary Care Units in Italy.

Methods

Prospective registry of patients admitted to Coronary Care Units with a diagnosis of non-ST-elevation ACS during a 2-month period. Thirty-day follow-up was available in all patients.

Results

Of 1581 patients enrolled in the registry, 564 were 75 years or older. As compared with the 1017 younger patients, elderly patients had a greater prevalence of female sex (42% vs 27%, P < .001), hypertension (70% vs 59%, P < .001), prior myocardial infarction (MI) (41% vs 29%, P < .001), prior angina (18% vs 13%, P < .01), prior use of aspirin (49% vs 39%, P < .001), ST-segment depression (54% vs 43%, P < .001), and troponin positivity (66% vs 59%, P < .05). The higher-risk profile of elderly patients was confirmed by the greater number of patients with a high TIMI risk score (37% vs 22%, P < .001). GPIIb/IIIa inhibitors were less frequently used in elderly patients (P < .05). An aggressive strategy (coronary arteriography within 4 days of admission, followed by revascularization, if feasible) was adopted in 39% elderly patients and in 56% younger patients (P < .001). An interventional procedure within 30 days was performed in 30% of elderly patients and 48% of younger patients (P < .001). Elderly patients had a more unfavorable 30-day outcome compared with younger ones, as shown by the higher rates of death (6.4% vs 1.7%), acute myocardial infarction (7.1% vs 5%), and stroke (1.3% vs 0.5%). Multivariate analysis of the elderly group identified a conservative strategy (OR, 2.31; 95% CI, 1.20 to 4.48) and a diagnosis of non-Q-wave MI (OR, 2.27; 95% CI, 1.32 to 3.93) as independent predictors of 30-day events.

Conclusions

The elderly represent a very high-risk subgroup among patients with non-ST-elevation ACS, with a nearly 4-fold as high 30-day death rate as that of younger patients. These data call for a greater attention to such population, both in terms of an improved representation in clinical research and of the assessment of the outcome of different strategies in appropriately designed randomized trials.     

Accuracy of the Global Registry of Acute Coronary Events (GRACE) Risk Score in Contemporary Treatment of Patients With Acute Coronary Syndrome

Background

Global Registry of Acute Coronary Events (GRACE) score has been routinely used for risk stratification in acute coronary syndromes (ACS). We aimed to investigate whether the GRACE score has remained relevant with contemporary treatment of patients with ACS.

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.     

Validation of the GRACE Risk score for hospital mortality in patients with acute coronary syndrome in the Arab Middle East

Our objective was to validate the Global Registry of Acute Coronary Events (GRACE) risk score for in-hospital mortality in a Middle Eastern acute coronary syndrome (ACS) population enrolled in the Gulf Registry of Acute Coronary Events (Gulf RACE). Out of 8176, unselected, consecutive patients with ACS, during 6 months in 2006 and 2007 from 63 hospitals in 6 Arab countries in the Middle East Gulf region, 7709 (94.3%) with available data were included. The main outcome measures were discriminatory performance (using C-index) and calibration of the GRACE risk score (in-hospital mortality predicted by GRACE risk score versus the actual mortality). In-hospital mortality in the Gulf RACE was 3.09% (n = 238). The discriminatory performance of the GRACE risk scores in the Gulf RACE was good overall (C-index = 0.86). Observed and predicted risk corresponded well in each stratum of risk of in-hospital mortality. This suggests its suitability for clinical use in this patient population.     

HEART危险评分对急性冠脉综合征预后的评价作用

目的探讨HEART危险评分（Rs）对急性冠脉综合征（ACS）的预后评价作用。方法回顾性分析327例ACS患者随访住院期间、出院后1年主要不良心血管事件（MACE）发生情况,分别描绘三种评分受试者特征曲线,并计算曲线下面积（AUC）;评价三种RS的拟合优度,比较采用三种Rs分组间MACE发生率的差异。结果HEARTRS预测住院期间及1年MACE的准确度优于GRACE、PURSUITRS（P〈0．05或〈0．01）;三种RS准确度的两两比较,HEARTRS预测住院期间MACE的准确度优于GRACERS、PURSUITRS（P均〈0．05）;三种Rs有较好的拟合优度。HEARTRS高危组预测住院期间MACE发生率优于低、中危组（P均〈0．01）。结论HEARTRS预测ACS患者短期MACE的准确性较好。     

Elevated leukocyte count and adverse hospital events in patients with acute coronary syndromes: findings from the Global Registry of Acute Coronary Events (GRACE)

Objective

To examine the association between elevated leukocyte count and hospital mortality and heart failure in patients enrolled in the multinational, observational Global Registry of Acute Coronary Events (GRACE).

Background

Elevated leukocyte count is associated with adverse hospital outcomes in patients presenting with acute myocardial infarction (AMI). The association of this prognostic factor with hospital mortality and heart failure in patients with other acute coronary syndromes (ACS) is unclear.

Methods

We examined the association between admission leukocyte count and hospital mortality and heart failure in 8269 patients presenting with an ACS. This association was examined separately in patients with ST-segment elevation AMI, non-ST-segment elevation AMI, and unstable angina. Leukocyte count was divided into 4 mutually exclusive groups (Q): Q1 <6000, Q2 = 6000-9999, Q3 = 10,000-11,999, Q4 >12,000. Multiple logistic regression analysis was performed to examine the association between elevated leukocyte count and hospital events while accounting for the simultaneous effect of several potentially confounding variables.

Results

Increasing leukocyte count was significantly associated with hospital death (adjusted odds ratio [OR] 2.8, 95% CI 2.1-3.6 for Q4 compared to Q2 [normal range]) and heart failure (OR 2.7, 95% CI 2.2-3.4) for patients presenting with ACS. This association was seen in patients with ST-segment elevation AMI (OR for hospital death 3.2, 95% CI 2.1-4.7; OR for heart failure 2.4, 95% CI 1.8-3.3), non-ST-segment elevation AMI (OR for hospital death 1.9, 95% CI 1.2-3.0; OR for heart failure 1.7, 95% CI 1.1-2.5), or unstable angina (OR for hospital death 2.8, 95% CI 1.4-5.5; OR for heart failure 2.0, 95% CI 0.9-4.4).

Conclusion

In men and women of all ages with the spectrum of ACS, initial leukocyte count is an independent predictor of hospital death and the development of heart failure.     

Prognostic Value of TIMI Score versus GRACE Score in ST-segment Elevation Myocardial Infarction

Background

The TIMI Score for ST-segment elevation myocardial infarction (STEMI) was created and validated specifically for this clinical scenario, while the GRACE score is generic to any type of acute coronary syndrome.

Objective

Between TIMI and GRACE scores, identify the one of better prognostic performance in patients with STEMI.

Methods

We included 152 individuals consecutively admitted for STEMI. The TIMI and GRACE scores were tested for their discriminatory ability (C-statistics) and calibration (Hosmer-Lemeshow) in relation to hospital death.

Results

The TIMI score showed equal distribution of patients in the ranges of low, intermediate and high risk (39 %, 27 % and 34 %, respectively), as opposed to the GRACE Score that showed predominant distribution at low risk (80 %, 13 % and 7%, respectively). Case-fatality was 11%. The C-statistics of the TIMI score was 0.87 (95%CI = 0.76 to 0.98), similar to GRACE (0.87, 95%CI = 0.75 to 0.99) - p = 0.71. The TIMI score showed satisfactory calibration represented by χ2 = 1.4 (p = 0.92), well above the calibration of the GRACE score, which showed χ2 = 14 (p = 0.08). This calibration is reflected in the expected incidence ranges for low, intermediate and high risk, according to the TIMI score (0 %, 4.9 % and 25 %, respectively), differently to GRACE (2.4%, 25% and 73%), which featured middle range incidence inappropriately.

Conclusion

Although the scores show similar discriminatory capacity for hospital death, the TIMI score had better calibration than GRACE. These findings need to be validated populations of different risk profiles.     

Early and long-term outcomes after percutaneous coronary intervention of unprotected left main coronary disease with drug-eluting stents in patients with non-ST-elevation acute coronary syndrome

Background

Patients presenting with non-ST-elevation acute coronary syndrome (NSTE-ACS) and unprotected left main coronary disease (ULMCD) are among the highest risk patients but current consensus guidelines do not address the optimal timing and mode of revascularization for these individuals.

Methods

In this single-centre registry, we evaluated the clinical outcomes of 151 consecutive patients with NSTE-ACS and ULMCD who underwent percutaneous coronary intervention with drug-eluting stents from 2005 to 2009.

Results

Overall in-hospital major adverse cardiac event (MACE) rate was 5.3%, mortality rate was 0.7%. At 30 months ± 15 months, 30 patients (19.9%) experienced MACE. The 4-year cumulative survival rate of no MACE was 73.2% and cumulative survival rate was 90.6%. Left ventricular ejection fraction (hazard ratio [HR] 0.947; 95% confidence interval [CI], 0.898-0.998; P = 0.043) and SYNTAX [SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery] score ≥ 33 (HR 1.28; 95% CI, 1.025-1.433; P = 0.029) were associated with MACE, while only left ventricular ejection fraction (HR 0.82; 95% CI, 0.69-0.973; P = 0.023) was associated with mortality.

Conclusions

Our study demonstrates the feasibility of percutaneous coronary intervention with drug-eluting stents in patients with NSTE-ACS and ULMCD. The early and long-term outcomes were acceptable. Left ventricular ejection fraction and SYNTAX score ≥ 33 predict MACE and only left ventricular ejection fraction predicts mortality.     

Short- and long-term prognostic value of the corrected QT interval in the non-ST-elevation acute coronary syndrome

Background and purpose

Myocardial ischemia prolongs the QTc interval. Very little data exists about its prognostic implications in the non-ST-elevation acute coronary syndromes (NST-ACS).

Methods

This is and observational and prospective study in which we evaluated the prognostic implications of the QTc obtained at admission (AQTc) in the short- and long-term of the NST-ACS. The median of the follow-up was 17 months.

Results

AQTc correlated adequately with the incidence of adverse events in the short- and long-term (P < .001), with the best cut-off point in 450 milliseconds. Patients with AQTc ≥450 presented higher frequency of in-hospital death: 8.8% vs 1.2%; P = .001, and MACE (death, recurrent ischemia, or urgent coronary revascularization): 72% vs 25%; P < .001. In a Cox regression analysis, we found 3 independent predictors of cardiovascular death after discharge: AQTc ≥450 (14.7% vs 2.1%; P < .0001), age >65 years and left ventricular ejection fraction <40%. Coronary revascularization reduced the risk of posthospitalary cardiovascular death in AQTc ≥450 milliseconds (5% vs 24%; P < .0001) but had no significant effect in AQTc<450 milliseconds.

Conclusion

These findings provide a new evidence supporting the prognostic value of the AQTc in predicting unfavorable events in the short- and long-term of the NST-ACS.     

Regional outcomes after admission for high-risk non-ST-segment elevation acute coronary syndromes

Purpose

An analysis of reginal variation across the United States in the treatment and outcomes of patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) has not been previously performed.

Subjects and Methods

We assessed contemporary practice and outcomes in 56,466 high-risk patients with NSTE ACS (positive cardiac markers and/or ischemic ST-segment changes) admitted to 310 hospitals across four defined regions in the United States from January 1, 2001, to September 30, 2003. Patient clinical characteristics, acute (<24 hours) and discharge medications, in-hospital procedures, and in-hospital case-fatality rates were evaluated.

Results

Statistically significant but clinically small differences in baseline characteristics including age, gender, rates of diabetes, hypertension, and smoking, as well as medical treatment, including a greater than 5% variation in acute use of beta-blockers, clopidogrel, and statins use, were noted across regions. Adjusted rates of revascularization were similar across regions. Overall in-hospital case-fatality rate was 4.1%, with the highest rates in the Midwest (4.6%) and the lowest in the Northeast (3.5%). Adjusted odds ratios (OR) (95% confidence interval [CI] for death were significantly higher in the Midwest (OR 1.42, CI 1.19-1.70), West (OR 1.40 CI 1.05-1.87), and South (OR 1.33, CI 1.08-1.62), compared with the Northeast.

Conclusions

Management of high-risk patients with NSTE ACS is relatively uniform across the United States. However, in-hospital case-fatality rates vary significantly by region, and the differences are not explained by adjustment for standard clinical variables.     

Influence of endothelial nitric oxide synthase gene polymorphisms (G894T, 4a4b, T-786C) and hyperhomocysteinemia on the predisposition to acute coronary syndromes

Background

Nitric oxide is an endothelium-derived relaxing factor that contributes significantly to vascular tone regulation. In this study we investigated the role of endothelial nitric oxide synthase (eNOS) polymorphisms as predisposing factors to acute coronary syndromes (ACS).

Methods

In 477 consecutive patients admitted to the coronary intensive therapy unit of the University of Florence and in 537 unrelated controls, genotypes of eNOS G894T and T-786C polymorphisms were determined by polymerase chain reaction-restriction fragment length polymorphism analysis and the repeat polymorphism 4a/4b was analyzed by polymerase chain reaction. The genotype distribution was in Hardy-Weinberg equilibrium for all variants.

Results

The multivariate analysis showed that the homozygosity for the eNOS 4a rare variant represented an independent predisposition factor to ACS (odds ratio [OR] 2.5, 95% CI 1.1-5.4, P = .02) and in particular influenced the risk of acute myocardial infarction (OR 3.6, 95% CI 1.2-11.5, P = .03). Subjects carrying the 4a4a/-786CC haplotype showed a higher predisposition to the disease (OR 6.1, 95% CI 1.3-29.6, P = .02). The contemporary presence of hyperhomocysteinemia and homozygosity for the -786C variant influenced the predisposition to ACS (OR 9.1, 95% CI 1.7-46.7, P = .008).

Conclusions

The presence of the eNOS 4a4a genotype represents a predisposing condition to ACS and in particular to acute myocardial infarction. Moreover, our data provide the evidence that the -786CC pattern modulates the susceptibility to ACS in 4a4a homozygotes and in hyperhomocysteinemic patients.     

Comparative study of ambient air particles in patients hospitalized for heart failure and acute coronary syndrome

Introduction and objectives

Currently air pollution is considered as an emerging risk factor for cardiovascular disease. Our objective was to study the concentrations of particulate matter in ambient air and analyze their relationship with cardiovascular risk factors in patients admitted to a cardiology department of a tertiary hospital with the diagnosis of heart failure or acute coronary syndrome (ACS).

Methods

We analyzed 3950 consecutive patients admitted with the diagnosis of heart failure or ACS. We determined the average concentrations of different sizes of particulate matter (<10, <2.5, and <1 μm and ultrafine particles) from 1 day or up to 7 days prior to admission (1 to 7 days lag time).

Results

There were no statistically significant differences in mean concentrations of particulate matter <10, <2.5 and <1 μm in size in both populations. When comparing the concentrations of ultrafine particles of patients admitted due to heart failure and acute coronary syndrome, it was observed that the former had a tendency to have higher values (19 845.35 ± 8 806.49 vs 16 854.97 ± 8005.54 cm⁻³, P <.001). The multivariate analysis showed that ultrafine particles are a risk factor for admission for heart failure, after controlling for other cardiovascular risk factors (odds ratio = 1.4; confidence interval 95%, from 1.15 to 1.66 P = .02).

Conclusions

In our study population, compared with patients with ACS, exposure to ultrafine particles is a precipitating factor for admission for heart failure.Full English text available from: www.revespcardiol.org