心肌梗死溶栓疗法危险评分在无ST段抬高急性冠状动脉综合征患者危险分层中的作用

目的　探讨心肌梗死溶栓疗法 (TIMI)危险评分在无ST段抬高的急性冠状动脉综合征 (ACS)患者危险分层及预后预测中的作用。方法　连续收入住院且随访资料齐全的无ST段抬高的ACS患者 2 4 8例 ,仔细询问病史、体检、心电图检查及检测心肌损伤标志物变化。按TIMI危险评分的 7个变量进行计分 ,将患者分成不同的危险层次。分析患者危险评分值对住院期与随访期复合心血管事件的影响。结果　复合心血管事件 (共 4 1例 )的发生随评分增加而呈进行性增高。对比分析TIMI危险评分与肌钙蛋白I(cTnI)水平对复合心血管事件的预测性 ,显示 4 1例复合心血管事件中cTnI阳性组占 38例 ,cTnI阳性患者的复合心血管事件发生率也随TIMI危险评分值增加而逐渐增高。结论　TIMI危险评分用于无ST段抬高ACS患者的危险分层与预后预测操作方便、实用、有效 ,且较单用cTnI检测或许更能显示出对危险分层与预后预测的量化特性     

非ST段抬高急性冠脉综合征的预后危险因素及危险分层的比较

目的通过随访非ST段抬高急性冠脉综合征(NSTE-ACS)患者住院期间和1年的终点事件,探讨影响NSTE-ACS患者近、远期预后的危险因素,分别分析和比较不同危险分层方法预测预后的价值。在我国急性冠脉综合征(ACS)患者中,NSTE-ACS患者占较大的比例。由于NSTE-ACS患者的临床表现轻重不一,预后差异很大,因此对诊断为NSTE-ACS的患者应进行早期危险分层,便于制定有针对性的治疗策略,从而能够最大限度的改善患者的预后。临床一线迫切需要一种简易且具有较高敏感度和特异度的危险分层方法用于患者严重性及预后的评估。方法 (1)选取本院2006年1月至2008年12月NSTE-ACS患者197例,其中包括不稳定型心绞痛(UA)134例,非ST段抬高心肌梗死63例。随访患者住院期间及1年的终点事件(全因死亡和非致死性心肌梗死)。(2)根据随访情况进行分组,分别分为住院期间事件组(n=15)、住院期间无事件组(n=182)和1年事件组(n=33)、1年无事件组(n=164),行单因素分析,将有统计学意义的危险因子进行多变量回归分析,筛查影响患者住院期间及1年预后的危险因素。(3)根据入院时的各项临床指标分别计算每例患者的心肌梗死溶栓治疗临床试验(TIMI)评分、血小板糖蛋白Ⅱb/Ⅲa受体拮抗剂依替巴肽治疗急性冠脉综合征(PURSUIT)评分、全球急性冠状动脉事件注册(GRACE)评分和进行传统2000年美国心脏病学会/美国心脏病协会(ACC/AHA)指南临床分层,分别描绘四种危险分层方法ROC曲线并计算曲线下面积(AUC),分别分析和比较四种分层方法预测终点事件的准确度。结果 (1)随访住院期间,死亡5例(2.5%),发生非致死性心肌梗死10例(5.1%);随访1年时总死亡14例(7.1%),总非致死性心肌梗死19例(9.6%),共发生终点事件33例(16.8%)。(2)预测住院期间发生终点事件的独立危险因素包括:血肌酐(OR=1.015;P=0.005)、左心室射血分数P=0.006),预测1年?     

非ST段抬高急性冠状动脉综合征患者TIMI危险积分与血浆脑钠肽的相关性

目的探讨非ST段抬高急性冠状动脉综合征（NSTEACS）患者TIMI危险积分与血浆脑钠肽（BNP）水平的相关性。方法收集85例非ST段抬高急性冠状动脉综合征患者，以临床预测变量对其进行TIMI危险评分积分，并进行危险层次分层，酶联免疫吸附法检测患者血浆脑钠尿肽水平，分析其与TIMI危险积分不同层次之间的关系。结果血浆BNP水平与TIMI危险积分呈正相关（r=0．71，P〈0．05）；随着TIMI危险积分评分值增加，患者血浆BNP水平亦逐渐升高，随访期主要心血管事件发生率也增多（P〈0．05）。结论TIMI危险评分与BNP水平呈正相关，并与NSTACS预后有关，能够对NSTEACS患者进行危险分层。     

非ST段抬高急性冠状动脉综合征心肌梗死溶栓试验危险评分的临床验证

目的评价TIMI危险评分系统对非ST段抬高急性冠状动脉综合征(ACS)非选择病例的有效性。方法将以"非ST段抬高ACS"入院的1298例患者在入院后24h内,根据TIMI危险评分系统,分为TIMI0～2分组(534例)、TIMI3～4分组(632例)、TIMI5～7分组(132例)。观察2周有无心肌梗死、心脏性死亡发生。结果随着TIMI危险评分的增加,患者心脏事件的发生率和心脏性死亡发生率也随之升高,分别为TIMI0～2分组1.7%和0.6%;TIMI3～4分组6.2%和2.8%;TIMI5～7分组12.9%和8.3%,差异有统计学意义(P<0.01)。结论TIMI危险评分能准确、量化地评估非ST段抬高ACS的危险。     

GRACE危险评分与N-末端脑钠肽前体在非ST段抬高急性冠脉综合征患者中的临床研究

目的 探讨非ST段抬高急性冠脉综合征(NSTE-ACS)患者血浆N-末端脑钠肽前体(NT-proBNP)水平与全球急性冠状动脉事件注册(GRACE)评分的相关性及其与临床预后的关系.方法 入选136例我院住院的NSTE-ACS患者,其中不稳定型心绞痛(UA)89例,非ST段抬高心肌梗死(NSTEMI)47例,对其进行GRACE危险评分并进行危险分层,采用免疫荧光法测定血浆NT-ProBNP数值,分析患者血浆NT-ProBNP水平与GRACE危险积分不同层次之间的相关性,并随访所有患者主要心血管事件发生情况.结果 血浆NT-ProBNP水平与GRACE危险积分分值呈正相关关系(r=0.72,P＜0.05);随着GRACE评分值越高,血浆NT-ProBNP浓度水平亦增高,随访期主要心血管事件发生率也随之增高(P＜0.05).结论 NT-ProBNP水平越高,GRACE积分越高,在NSTE-ACS患者中,联合运用GRACE危险积分与NT-ProBNP水平检测,在对其进行早期危险分层、评估预后方面有重要临床价值.     

胎盘生长因子和白细胞介素10水平与急性冠状动脉事件的相关性

目的通过对急性冠状动脉综合征患者血清胎盘生长因子和白细胞介素10水平的测定,探讨其在急性冠状动脉综合征的早期预测及预后判断中的价值。方法将90例患者分为ST段抬高型急性心肌梗死组(n=26)、非ST段抬高型急性心肌梗死/不稳定型心绞痛组(n=36)、稳定型心绞痛组(n=14)和对照组(n=14)。采用ELISA法检测各组血清胎盘生长因子和白细胞介素10水平;随访并观察各组30天、90天后主要心血管事件(死亡、再梗死和紧急血运重建)的发生。结果ST段抬高型急性心肌梗死患者和非ST段抬高型急性心肌梗死/不稳定型心绞痛患者血清胎盘生长因子水平较稳定型心绞痛患者明显升高,而白细胞介素10水平显著降低(P(0.01)。具有高水平血清胎盘生长因子的患者在随访30天及90天的心血管事件发生率明显增加,而具有高水平白细胞介素10的患者心血管事件发生率明显降低。相关性分析显示,血清胎盘生长因子与白细胞介素10水平呈负相关。结论血清胎盘生长因子可能是早期预测急性冠状动脉综合征的有力指标,血清胎盘生长因子与白细胞介素10两者之间的平衡,可能是预测急性冠状动脉综合征患者预后转归的重要因素。     

非ST段抬高急性冠状动脉综合征的危险因素分析及早期干预

目的　探讨非ST段抬高急性冠状动脉综合征(ACS)的临床高危因素及早期有创干预的价值。方法　在 2001年 10月至 2003年 10月期间连续入院的非ST段抬高的ACS患者共 545例,随机分成早期保守治疗组与早期有创干预组;随访 30天与 6个月患者的复合心血管事件 (包括心脏性死亡、非致命性心肌梗死、非致命性心力衰竭、因反复缺血性心绞痛发作住院 )发生率,将患者一般临床特征及辅助检查指标对复合心血管事件做多变量回归分析,筛查主要的高危因素;评价早期保守治疗与早期有创干预对患者预后的影响。结果　随访 513例患者, 30天与 6个月的复合心血管事件发生率分别为 14 0%与 25 7%;多变量Logistic回归分析,显示ST段压低、肌钙蛋白Ⅰ (TnI)水平升高、高敏C反应蛋白(hs CRP)增高、左室射血分数(LVEF)值下降以及心肌梗死溶栓疗法(TIMI)危险评分高分者与 6个月的复合心血管事件增高密切相关,它们分别是患者复合心血管事件危险性增加的独立预测因子;与早期保守治疗组比较,早期有创干预组随访 30天时反复心绞痛发作住院率减少,复合心血管事件减少;随访 6个月时复合心血管事件也减少 (P均 <0 05)。结论　ST段压低、TnI水平升高、hs CRP增高、LVEF值下降或TIMI危险评分增高是非ST段抬高ACS患者的高危因素,早期有创干预能     

肌钙蛋白Ⅰ结合心电图aVR导联ST段变化对非ST段抬高型急性冠状动脉综合征临床预后的评估

目的结合实验室检测肌钙蛋白Ⅰ与心电图aVR导联ST段抬高情况,探讨二者在非ST段抬高型急性冠状动脉综合征患者的预后评估中的价值。方法入选非ST段抬高型急性冠状动脉综合征患者255例,采血检验肌钙蛋白Ⅰ,并详细测量心电图AVR导联ST段抬高情况,均行冠脉造影,根据具体情况分别行冠脉介入治疗、冠脉搭桥手术及药物保守治疗,随访6个月,观察终点为不良心血管事件,包括心肌梗死(包括再梗)、心血管死亡和血运重建。结果在随访的6个月内,肌钙蛋白Ⅰ值(OR=7.01,95%CI=1.22～12.63,P=0.02)和aVR导联ST段抬高值(OR=1.38,95%CI=1.084～1.751,P=0.009)是患者发生死亡和心肌梗死(包括再梗)的独立危险因素;同时,肌钙蛋白Ⅰ值(OR=1.249,95%CI=1.114～1.501,P0.01)和aVR导联ST段抬高值(OR=2.03,95%CI=1.20～4.29,P=0.04)亦是患者不良心血管事件(包括死亡、心肌梗死及血运重建术)发生的独立危险因素。在NSTE-ACS患者中,肌钙蛋白Ⅰ的升高的同时aVR导联ST段抬高者,其左主干病变或三支冠状动脉血管病变发生,以及不良心血管事件(包括死亡、心肌梗死、再梗、血运重建)的发生均是最高的。结论在临床中结合肌钙蛋白Ⅰ和心电图aVR导联ST段变化,可以早期应用于非ST段抬高型急性冠状动脉综合征患者预后的判断。     

联合检测肌钙蛋白T、高敏C反应蛋白和B型钠尿肽对非ST段抬高的急性冠状动脉综合征预后诊断的价值

目的探讨联合检测肌钙蛋白T、高敏C反应蛋白、B型钠尿肽对非ST段抬高的急性冠状动脉综合征预后诊断的价值。方法检测145例经冠状动脉造影证实的非ST段抬高的急性冠状动脉综合征患者肌钙蛋白T、高敏C反应蛋白、B型钠尿肽的水平。随访急性冠状动脉综合征患者12个月，观察终点为心肌梗死新发或再发和心源性死亡。结果多因素logistic回归分析发现肌钙蛋白T、高敏C反应蛋白、B型钠尿肽可独立预测非ST段抬高急性冠状动脉综合征患者远期预后。经过已知的临床危险因素校正后，心脏生化标志物异常的数目仍然是其心血管事件重要危险因子。结论联合检测肌钙蛋白T、高敏C反应蛋白、B型钠尿肽对急性冠状动脉综合征患者长期预后有重要的临床价值。     

GRACE危险评分与非ST段抬高型急性冠状动脉综合征患者冠状动脉病变的关系

目的探讨非ST段抬高型急性冠状动脉综合征（NSTE-ACS）患者GRACE危险评分与冠状动脉病变的关系,评价GRACE危险评分对冠状动脉病变预测的价值。方法收集2008年6月~2009年12月住院的NSTE-ACS患者154例,对其进行GRACE危险评分,以评分差异分组,分析不同组别中患者冠状动脉病变的特点及与GRACE危险评分之间的关系。结果随着GRACE危险评分分值的增加,冠状动脉狭窄的支数及程度呈增加趋势,冠状动脉病变的性质趋向于B型和C型。结论 GRACE危险评分对冠状动脉病变支数、严重程度、病变性质有一定的预测价值。     

TIMI, PURSUIT, and GRACE risk scores: sustained prognostic value and interaction with revascularization in NSTE-ACS.

AIMS: Regarding prognosis, patients with a non-ST elevation acute coronary syndrome (ACS) are a very heterogeneous population, with varying risks of early and long-term adverse events. Early risk stratification at admission seems to be essential for a tailored therapeutic strategy. We sought to compare the prognostic value of three ACS risk scores (RSs) and their ability to predict benefit from myocardial revascularization performed during initial hospitalization. METHODS AND RESULTS: We studied 460 consecutive patients admitted to our coronary care unit with an ACS [age: 63+/-11 years, 21.5% female, 55% with myocardial infarction (MI)]. For each patient, the Thrombolysis In Myocardial Infarction (TIMI), Platelet glycoprotein IIb/IIIa in Unstable agina: Receptor Suppression Using Integrilin (PURSUIT), and Global Registry of Acute Coronary Events (GRACE) RSs were calculated using specific variables collected at admission. Their prognostic value was evaluated by the combined endpoint of death or MI at 1 year. The best cut-off value for each RS, calculated with receiver operating characteristic curves, was used to assess the impact of myocardial revascularization on the combined incidence of death or MI. Death or MI at 1 year was 15.4% (32 deaths/49 MIs). The best predictive accuracy for death or MI at 1 year was obtained by the GRACE RS (AUC) [area under the curve: 0.715; confidence interval (CI: 0.672-0.756)] but the performance of the PURSUIT RS (AUC: 0.630; CI: 0.584-0.674), and TIMI RS (AUC: 0.585; CI: 0.539-0.631) was also good. We found a statistically significant interaction between the risk stratified by the best cut-off value for the GRACE and PURSUIT RSs and myocardial revascularization, with a better prognosis for the high-risk patients. The high-risk patients represented 36.7, 28.7, and 57.8% of the population, for the GRACE, PURSUIT, and TIMI RSs, respectively. CONCLUSION: The RSs studied demonstrated a good predictive accuracy for death or MI at 1 year and enabled the identification of high-risk subsets of patients who will benefit most from myocardial revascularization performed during initial hospital stay.     

Modified Thrombolysis in Myocardial Infarction (TIMI) risk score to risk stratify patients in the emergency department with possible acute coronary syndrome

Objective To assess the prognostic utility of the Thrombolysis in Myocardial Infarction (TIMI) risk score in patients in the emergency department (ED) evaluated for possible acute coronary syndrome (ACS). Background The ability of the TIMI risk score to risk stratify patients at initial presentation in the ED with chest pain of unclear etiology is uncertain. Methods We investigated the prognostic utility of the TIMI risk score in 947 consecutive patients evaluated in the ED for possible ACS. A multivariate analysis was done to evaluate the independent predictive power of the individual components of the TIMI risk score to predict an adverse event at 30 days (all-cause death, myocardial infarction, and coronary revascularization). Results There were 151 (16%) patients diagnosed with ACS. At 30 days there were 48 (5%) deaths, 84 (9%) myocardial infarctions, and 49 (5%) coronary revascularization procedures. The mean TIMI risk score was significantly higher in patients with an adverse event compared with those without (2.6 ± 1.3 vs. 1.7 ± 1.2, P < 0.0001). Four of the 7 TIMI risk factors (age ≥65 years, ST segment deviation ≥0.5 mm elevated troponin I, and coronary stenosis ≥50%) were independently associated with adverse events. A simplified TIMI risk score was computed and was found to have similar prognostic ability as the 7 variable TIMI risk score. Conclusion A modified TIMI risk score may simplify risk stratification of ED patients with undifferentiated chest pain.     

Usefulness of TIMI Risk Score in assessing the prognosis in patients with acute coronary syndromes without ST elevation assigned to early percutaneous coronary intervention. Comparison of the high-risk and the moderate-risk patients

Risk stratification in acute coronary syndromes (ACS) without ST segment elevation plays an important role in choosing treatment strategy and making further prognosis. We aimed at 1) assessing the usefulness of TIMI Risk Score in risk stratification and prognosis in unselected patients with ACS without ST elevation who underwent early percutaneous revascularization, 2) comparing the frequency of adverse events (death, MI, repeat revascularization in high-risk and moderate-risk patients during 14 days from revascularization, 3) comparing the efficacy of percutaneous revascularization in the high-risk and in the moderate-risk group. High-risk (TIMI Risk Score > or = 5 points) and moderate-risk (TIMI Risk Score 3-4 points) group comprised 324 and 240 patients respectively. High-risk group comprised older patients, fewer men, more diabetics and hypertensive patients. Peripheral vessel disease and prior MI was also more frequent in the high-risk group. More high-risk patients had initial TIMI flow < 3 in target vessel, as well TIMI 3 flow after revascularization was achieved in fewer high-risk patients. During 14-day follow-up the frequency of combined end-point (death, MI, repeat revascularization) was more frequent in the high-risk group (8.95% vs 1.67%). TIMI Risk Score is an easy to use and useful method in risk stratification and prediction of adverse events in patients with ACS without ST segment elevation assigned to early percutaneous intervention in the early post-procedure period.     

Does Continuous ST‐Segment Monitoring Add Prognostic Information to the TIMI,PURSUIT, and GRACE Risk Scores?

Background: Recurrent ischemia is frequent in patients with non‐ST‐elevation acute coronary syndromes (NST‐ACS), and portends a worse prognosis. Continuous ST‐segment monitoring (CSTM) reflects the dynamic nature of ischemia and allows the detection of silent episodes. The aim of this study is to investigate whether CSTM adds prognostic information to the risk scores (RS) currently used. Methods: We studied 234 patients with NST‐ACS in whom CSTM was performed in the first 24 hours after admission. An ST episode was defined as a transient ST‐segment deviation in ≥1 lead of ≥ 0.1 mV, and persisting ≥1 minute. Three RS were calculated: Thrombolysis in Myocardial Infarction (TIMI; for NST‐ACS), Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Supression Using Integrilin (PURSUIT; death/MI model), and Global Registry of Acute Coronary Events (GRACE). The end point was defined as death or nonfatal myocardial infarction (MI), during 1‐year follow‐up. Results: ST episodes were detected in 54 patients (23.1%) and associated with worse 1‐year outcome: 25.9% end point rate versus 12.2% (Odds Ratio [OR]= 2.51; 95% Confidence Interval [CI], 1.18–5, 35; P = 0.026). All three RS predicted 1‐year outcome, but the GRACE (c‐statistic = 0.755; 95% CI, 0.695–0.809) was superior to both TIMI (c‐statistic = 0.632; 95% CI, 0.567–0.694) and PURSUIT (c‐statistic = 0.644; 95% CI: 0.579–0.706). A GRACE RS > 124 showed the highest accuracy for predicting end point. The presence of ST episodes added independent prognostic information the TIMI RS (hazard ratio [HR]= 2.23; 95% CI, 1.13–4.38) and to PURSUIT RS (HR = 2.03; 95% CI, 1.03–3.98), but not to the GRACE RS. Conclusions: CSTM provides incremental prognostic information beyond the TIMI and PURSUIT RS, but not the GRACE risk score. Hence, the GRACE risk score should be the preferred stratification model in daily practice. Ann Noninvasive Electrocardiol 2011;16(3):239–249     

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.     

Os Escores HEART,TIMI e GRACE para Predição de Eventos Cardiovasculares Adversos Maiores no Período de 30 Dias na Era de Troponina I de Alta Sensibilidade

BackgroundMultiple scoring systems have been designed to calculate the risk of major adverse cardiovascular events (MACE) in patients with chest pain. There is no data on whether the HEART score outperforms TIMI and GRACE in the prediction of MACE, especially in the era of high-sensitivity troponin assay and in an exclusively Latin-American population.ObjectiveTo compare the performance of the HEART, TIMI, and GRACE scores for predicting major cardiovascular events at 30 days of follow-up, in patients who consult for chest pain in the emergency department.MethodsHEART, TIMI, and GRACE scores were analyzed in 519 patients with chest pain at the emergency department. The primary endpoint was the occurrence of MACE within 30 days. The performance of the HEART score was compared with the TIMI and GRACE scores using the DeLong test with p values of 0.05 considered statistically significant.ResultsA total of 224 patients (43%) had MACE at 30 days. The C statistic for the HEART, TIMI, and GRACE score was 0.937, 0.844, and 0.797 respectively (p < 0.0001). A HEART score of 3 or less had a sensitivity of 99.5% and a negative predictive value of 99% to classify low risk patients correctly; both values were higher than those obtained by the other scores.ConclusionThe HEART score more effectively predicts cardiovascular events at 30 days of follow-up compared to the other scores. High-sensitivity troponins maintain this score’s previously demonstrated superiority. This score offers more precise identification of low-risk patients. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)     

Impact of Acute Coronary Syndrome Classification and Procedural Technique on Clinical Outcomes in Patients With Coronary Bifurcation Lesions Treated With Drug‐Eluting Stents

Background:

We examined the impact of non–ST‐segment elevation acute coronary syndrome (NSTE‐ACS) on clinical outcomes in patients with bifurcation lesions treated with drug‐eluting stents.

Hypothesis:

We hypothesized that NSTE‐ACS would be attributable to the increased risk of major adverse cardiac events (MACE) in bifurcation percutaneous coronary intervention.

Methods:

We enrolled 1668 patients, using data from a multicenter real‐world bifurcation registry. The primary objective was to compare the 2‐year cumulative risk of MACE in patients with NSTE‐ACS to those with stable angina. Major adverse cardiac events were defined as the composite endpoint of cardiac death, myocardial infarction (MI), and target‐lesion revascularization.

Results:

Non–ST‐segment elevation acute coronary syndrome was seen in 969 (58.1%) patients and stable angina in 699. Major adverse cardiac events occurred in 7.3% of NSTE‐ACS patients and in 5.2% with stable angina (P = 0.042). However, cardiac death, MI, and target‐lesion revascularization were similar between the 2 groups. We stratified patients with NSTE‐ACS into those with non–ST‐segment elevation MI and those with unstable angina. Cumulative risks of 2‐year MACEs were 7.0% in non–ST‐segment elevation MI patients and 7.5% in unstable angina patients (P = 0.87). In the NSTE‐ACS cohort, the baseline lesion length in the side branch (adjusted hazard ratio [HR]: 1.04, 95% confidence interval [CI]: 1.01‐1.07, P = 0.022), paclitaxel‐eluting stents in the main vessel (adjusted HR: 2.02, 95% CI: 1.21‐3.40, P = 0.008), and final kissing ballooning (adjusted HR: 1.88, 95% CI: 1.10‐3.21, P = 0.021) were independent predictors of MACE.

Conclusions:

Compared with stable angina patients, the NSTE‐ACS patients who underwent bifurcation percutaneous coronary intervention had an increased risk of MACE during the 2‐year follow‐up. Clin. Cardiol. 2012 doi: 10.1002/clc.22020 Drs Pil Sang Song and Dong Ryeol Ryu contributed equally to this work. Coronary Bifurcation Stenting (COBIS) Registry in South Korea, US Department of Health and Human Services, US National Institutes of Health, ClinicalTrials.gov no. NCT00851526. This work was supported by the Korean Society of Interventional Cardiology, Seoul, South Korea. The authors have no other funding, financial relationships, or conflicts of interest to disclose.     

Differences in the management and prognosis of women and men who suffer from acute coronary syndromes.

OBJECTIVES: The purpose of this research was to determine if sex and gender differences in the management of acute coronary syndromes (ACS) are associated with differences in prognosis after ACS. BACKGROUND: Previous investigators have reported sex/gender differences in the management of patients with ACS, but the impact of these differences on prognosis is unclear. METHODS: We analyzed data from the Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) trial, which enrolled 4,836 women and 7,726 men with ACS. Patients were classified into risk strata using the Thrombolysis In Myocardial Infarction (TIMI) score. RESULTS: Women underwent fewer invasive procedures including angiography, angioplasty, and coronary artery bypass graft (CABG) surgery (47.6% vs. 60.5%; p = 0.0001) compared to men. No significant differences in cardiovascular death, myocardial infarction (MI), or stroke were observed (9.8% vs. 10.9%; p = 0.04), although women were more likely than men to develop refractory ischemia and to be rehospitalized for chest pain during follow-up (16.6% vs. 13.9%; p = 0.0001). These differences were particularly evident among TIMI high-risk women. A significant interaction between TIMI risk and gender for the outcome of refractory angina and rehospitalization for angina was present. CONCLUSIONS: Compared to men, high-risk women with ACS undergo less coronary angiography, angioplasty, and CABG surgery, and while they do not have higher incidence cardiovascular death, recurrent MI, or stroke, they suffer an increased rate of refractory ischemia and rehospitalization. All high-risk women and men with ACS should receive optimal medical management, and be considered for coronary angiography with possible revascularization if their coronary anatomy warrants it.     

Improved predictive value of GRACE risk score combined with platelet reactivity for 1-year cardiovascular risk in patients with acute coronary syndrome who underwent coronary stent implantation

Both high platelet reactivity (HPR) and Global Registry of Acute Coronary Events (GRACE) risk score have moderate predictive value for major adverse cardiovascular disease (CVD) events in patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI), whereas the prognostic significance of GRACE risk score combined with platelet function testing remains unclear. A total of 596 patients with non-ST elevation ACS who underwent PCI were enrolled. The P2Y₁₂ reaction unit (PRU) value was measured by VerifyNow P2Y₁₂ assay and GRACE score was calculated by GRACE risk 2.0 calculator. Patients were stratified by a pre-specified cutoff value of PRU 230 and GRACE score 140 to assess 1-year risk of cardiovascular death, non-fatal myocardial infarction (MI), and stent thrombosis. Seventy-two (12.1%) patients developed CVD events during 1-year follow-up. Patients with CVD events had a higher PRU value (244.6 ± 50.9 vs. 203.7 ± 52.0, p < 0.001) and GRACE score (185.2 ± 45.6 vs. 149.7 ± 40.1, p < 0.001) than those without events. Multivariate logistic analysis showed that both platelet reactivity and GRACE score were associated with 1-year CVD risk independently. Compared to patients with normal platelet reactivity (NPR) and GRACE score < 140, those with HPR and GRACE score ≥ 140 were exposed to significantly elevated CVD risk (HR: 5.048; 95% CI: 2.268–11.237; p < 0.001). Adding platelet reactivity on the top of GRACE risk score yielded superior risk predictive capacity beyond GRACE score alone, which is shown by improved c-statistic value (0.871, p = 0.002) as well as net reclassification improvement (NRI 0.263, p < 0.001) and integrated discrimination improvement (IDI 0.018, p = 0.002). In patients with NSTE-ACS who underwent PCI, high on-treatment platelet reactivity and high GRACE score led to greater risk of adverse CVD events. The combination of platelet function testing and GRACE score predicted 1-year CVD risk better.