Role of central obesity in risk stratification after an acute coronary event: Does central obesity add prognostic value to the Global Registry of Acute Coronary Events (GRACE) risk score in patients with acute coronary syndrome?

BackgroundAccurate risk stratification is an important step in the initial management of acute coronary syndrome (ACS), and current guidelines recommend the use of risk scores, such as the Global Registry of Acute Coronary Events risk score (GRACE RS). Recent studies have suggested that abdominal obesity is associated with cardiovascular events in patients with ACS. However, little is known about the additional value of abdominal obesity beyond risk scores. The aim of our study was thus to assess whether waist circumference, a surrogate of abdominal adiposity, adds prognostic information to the GRACE RS.MethodsThis was a retrospective cohort study of ACS patients admitted consecutively to a cardiac care unit between June 2009 and July 2010. The composite of all-cause mortality or myocardial reinfarction within six months of index hospitalization was used as the endpoint for the analysis.ResultsA total of 285 patients were studied, 96.1% admitted for myocardial infarction (with or without ST elevation) and 3.9% for unstable angina. At the end of the follow-up period, 10 patients had died and the composite endpoint had been reached in 27 patients (9.5%). More than 70% of the study population were obese or overweight, and abdominal obesity was present in 44.6%. The GRACE RS showed poor predictive accuracy (area under the curve 0.60), and most of the GRACE variables did not reach statistical significance in multivariate analysis. The addition of waist circumference to the GRACE RS did not improve its discriminatory performance.ConclusionAbdominal obesity does not add prognostic information to the GRACE RS to predict six-month mortality or myocardial reinfarction.     

Sex-related characteristics in hospitalized patients with acute coronary syndromes – the Greek Study of Acute Coronary Syndromes (GREECS)

We studied the sex-specific distribution of various factors in hospitalized patients who presented with acute coronary syndromes (ACS), as well as the annual incidence and the in-hospital and short-term outcomes in males and females. A sample of six hospitals located in Greek urban and rural regions was selected. In these hospitals we recorded almost all nonfatal admissions with a first event of ACS, from October 2003 to September 2004. Sociodemographic, clinical, dietary, and other lifestyle characteristics were recorded. A total of 2 172 patients were included in the study (1 649, 76% male and 523, 24% female). The annual incidence rate was almost three times higher in males than in females (34 per 10 000 males and 10.9 per 10 000 females). The highest frequency of events was observed in winter, in both sexes. Females had higher in-hospital mortality rate as compared to males (5.7% vs 3.2%, P = 0.007), while the 30-day mortality and rehospitalization rate was 17% in male and 16% in female patients. The most common discharged diagnosis for males was Q-wave myocardial infraction (35%), while females were more likely to suffer from unstable angina (42%). Females were older than males, waited longer between seeking and receiving medical advice, and were more likely to have a history of hypertension, obesity, and diabetes mellitus as compared to males. On the other hand, males were more likely to be smokers, to follow a more typical Mediterranean diet, and to be more physically active (P < 0.05). We revealed a sex-related difference in the profile of clinical characteristics and other cardiovascular risk factors in hospitalized patients for ACS.     

The application of intravascular ultrasound on diagnosis and intervention of acute coronary syndromes

Objective To explore the application of intravascular ultrasound (IVUS) on diagnosis and intervention of acute coronary syndrom (ACS). Methods IVUS was performed in 41 patients with acute coronary syndrom and after coronary intervention (PLCA in 21 lesions,stent in 10 lesions).     

What do registries bring us? The example of acute coronary syndromes

Prospective, randomised trials are the key to evidence-based medicine. They have brought considerable progress to the field of cardiology. They have, however, methodological constraints that result in the inclusion of only a small proportion of patients presenting with a given disease. In contrast, registries include all patients, without any selection, and therefore reflect everyday practice in the "real world". They are the key to epidemiological data, but they can also be used to tackle questions or issues that are unresolved by randomised trials. Both approaches are complementary and should be used to define the optimal management of patients. Lessons derived from registry data in acute coronary syndromes in the recent past in France are presented.     

The management and investigation of elderly patients with acute coronary syndromes without ST elevation: an evidence-based approach? Results of the Prospective Registry of Acute Ischaemic Syndromes in the United Kingdom (PRAIS-UK)

BACKGROUND: In the elderly, acute coronary syndromes (ACS) without ST elevation are a frequent and important cause of admission. In the UK, practice patterns and outcomes in these patients need to be assessed. METHODS: We enrolled 1,046 patients admitted with ACS without ST elevation to 56 UK centres (20 consecutive patients per centre) and followed them for 6 months. We compared baseline characteristics, outcomes and treatments in those aged 80 and over (n = 119, 11%), from 70 to 79 (n = 301, 29%), from 60 to 69 (n = 283, 27%) with those below 60 (n = 343, 33%). RESULTS: The proportions of males were 40, 52, 67 and 70%, respectively (P < 0.001). There were no differences in the proportion of patients with diabetes (17% overall), treated hypertension (38%) or prior myocardial infarction (MI) (48%). The proportions with ST depression or bundle branch block on admission ECG were 40, 39%, and 28, 18% (P < 0.001), respectively. The rates of the composite endpoint of death or new MI at 6 months were 20, 18, 12 and 6% (P < 0.001), respectively. Heparin, beta blockers and statins were used in significantly higher proportions in younger patients compared with older patients. Similarly, older patients had significantly lower rates of angiography and revascularisation compared with younger patients. CONCLUSION: In this large population-based registry of UK patients admitted to hospital with ACS without ST elevation, those aged over 70 are at substantially higher risk of adverse events than younger patients. However, they are less likely to receive treatments of proven benefit or to be investigated with a view to revascularisation. A more aggressive approach to these patients may be more appropriate and is likely to result in substantial benefits.     

Acute coronary syndromes in patients with renal disease: What are the issues?

Patients with chronic kidney disease and acute coronary syndromes are at high risk for both bleeding and ischemic events. This risk increases with the severity of renal insufficiency. Management for acute coronary syndromes in the setting of kidney disease is a paradox; as the benefit of current treatment is high, so is the risk for complications. Patients with chronic renal disease are frequently excluded from randomized clinical trials, and therefore, the optimal treatment strategies are often speculative in this high-risk patient population. Additional research is needed to further refine the optimal management of patients with chronic kidney disease in the setting of acute coronary syndromes.     

Tryptase levels in patients after acute coronary syndromes: The potential new marker of an unstable plaque?

BACKGROUND: Mast cells (MCs) are multifunctional immune cells that produce a number of vasoactive or thromboactive mediators. Elevated numbers of human heart MCs are observed in the shoulder regions of coronary atherosclerotic plaques, suggesting that they play a role in plaque rupture. Cardiac MC degranulation after myocardial ischemia has been documented in animal models. Cardiac MCs are highly profibrinolytic cells and release tryptase, their specific protease, after ischemic events. HYPOTHESIS: Mast cell activation and release of tryptase may differentiate among patients with acute coronary syndromes (ACS), potentially determining the clinical course of ACS. Tryptase levels may indirectly reflect the fibrinolytic status of patients. METHODS: Mast cell activation after ACS was estimated in 10 controls and 52 patients by measuring the serum levels of tryptase in the acute phase, at 2 weeks, and at 3 months after the ACS episode. Total tryptase levels were determined by using the UniCAP system and analyzed with respect to the patients' clinical types of ACS on admission (ACS with persistent ST-segment elevation on electrocardiogram or with ST-segment depression). RESULTS: Significant differences in serum tryptase levels between the groups were found, with higher serum tryptase concentrations in the ST-segment depression group in the acute phase, and at follow-up. CONCLUSIONS: Serum tryptase concentration differences among patients with distinct types of ACS may indicate a more important role of human heart MCs in ACS with ST-segment depression pathogenesis. To our knowledge, this is the first report indicating that serum tryptase levels may differentiate patients with distinct types of ACS.     

Leptin in acute coronary syndromes: has the time come for its use in risk stratification?

Leptin, a recently discovered obesity gene product, is primarily involved in the regulation of food intake and energy expenditure. Recent observations suggest that leptin has a much broader biological role other than regulation of body weight and energy metabolism. It has been shown that leptin increases sympathetic nerve activity, stimulates generation of reactive oxygen species, induces platelet aggregation and promotes arterial thrombosis, and is an independent risk factor for coronary heart disease. In this paper, we discussed the role of leptin in the pathogenesis of acute coronary syndromes and its usefulness as a biomarker for risk stratification in acute coronary syndromes.     

Which factors are associated with the application of reperfusion therapy in ST-elevation acute coronary syndromes?. Lessons from the Euro Heart Survey on Acute Coronary Syndromes I

BACKGROUND/AIMS: A large proportion of patients with a ST-elevation acute coronary syndrome do not receive reperfusion therapy. In order to contribute to a better understanding of the clinical decision making process, we analyzed which factors are associated with the application of reperfusion therapy. METHODS: From the Euro Heart Survey of Acute Coronary Syndromes I, 4,260 patients with ST-elevation acute coronary syndrome were selected for the current analysis, of which 1,539 (36%) patients received fibrinolysis and 904 (21%) primary percutaneous coronary intervention (PCI). The analysis contained 32 variables on demographics, medical history, admission parameters and reperfusion therapy. RESULTS: A short pre-hospital delay, arrival in a hospital with PCI facilities, severe ST-elevation, and participation in a clinical trial were the strongest predictors for receiving reperfusion therapy. Primary PCI was more likely to be performed than fibrinolysis in patients with a long pre-hospital delay, arriving in a hospital with PCI facilities, not participating in a clinical trial, and with at least one previous PCI. CONCLUSION: Hospital facilities and culture, pre-hospital delay and infarction size play a major role in management decisions regarding reperfusion therapy in ST-elevation acute coronary syndrome. This analysis indicates which factors require special attention when implementing and reviewing the reperfusion guidelines.     

Can a nurse trained in coronary care expedite emergency department management of patients with acute coronary syndromes?

OBJECTIVE: The goal of this study was to determine the effect of a coronary care-trained nurse (CCTN) on transfer times of patients presenting with acute coronary syndromes (ACS) from the emergency department (ED) to the coronary care unit (CCU) for definitive cardiac treatment (DCT). DESIGN: This was a prospective randomized controlled study. SETTING: The study took place in the ED of a metropolitan public teaching hospital in South Australia. PATIENTS: The study sample was comprised of 893 patients who presented to the ED with a complaint of chest pain. INTERVENTION: An experienced senior CCTN was randomly assigned to work in an ED for 16 randomly selected hours per week; comparable hours over the same period without a CCTN in attendance were used as control data. The major endpoint was time to CCU transfer where DCT was completed for patients with ACS. RESULTS: Out of 893 patients assessed as having possible ACS, 91 (10%) were admitted to the CCU, 47 with a diagnosis of unstable angina pectoris (UAP) and 44 with a diagnosis of acute myocardial infarction. Nineteen patients required thrombolysis and/or percutaneous coronary angioplasty. Mean times (in minutes) to transfer for DCT (95% CI) were 102 (70-134) and 117 (95-139) in the presence and absence of a CCTN, respectively, for all ACS, and 33 (10-55) and 54 (25-82), respectively, for acute myocardial infarction requiring thrombolysis and/or percutaneous coronary angioplasty. CONCLUSIONS: These pilot data show a nonsignificant trend suggesting that DCT is expedited by assignment of senior CCTNs to EDs and provides direction for further study.     

Does chronic Chlamydia pneumoniae infection increase the risk of myocardial injury? Insights from patients with non-ST-elevation acute coronary syndromes

Background Cumulative evidence suggests a positive association between Chlamydia pneumoniae (Cpn) infection and risk of future coronary events among patients with stable coronary artery disease. However, its prognostic role in unstable coronary syndromes is less well defined. Because Cpn immunoglobulin A (IgA) may be a more reliable indicator of chronic infection than immunoglobulin G (IgG), we speculated that in patients with non-ST-elevation acute coronary syndromes (ACS), this marker might serve as a more useful prognostic tool. Accordingly, we evaluated plasma samples acquired at presentation in 178 patients with ACS for a possible association between Cpn IgA titer and biochemical evidence of myocardial injury. Methods Cpn IgG (positive if ≥1:32), and IgA titers (positive if ≥1:16) were measured by use of the microimmunofluorescence technique in 70 patients with ACS in whom myocardial injury developed associated with their presenting events (elevated CK-MB and/or troponin I); and in 108 patients with ACS without such injury. The odds ratios (ORs) for myocardial injury associated with consecutive antibody titers were determined for each of Cpn IgG and IgA. Multiple logistic regression was applied to adjust for key baseline characteristics. Results Median age of subjects was 64 years; 63% were male and 33% were smokers. The median antibody titers among those with and without myocardial injury respectively were as follows: IgG (1:128 vs 1:128), IgA (1:32 vs <1:16, P = .2). The adjusted ORs for myocardial injury associated with consecutive IgA titers were as follows: IgA ≥1:16, adjusted OR 1.49 (P = .22); ≥1:32, OR 1.95 (P = .04); ≥1:64, OR 1.37 (P = .38); ≥1:128, OR 0.77 (P = .55). No significant trend was found for any IgG titer. Conclusions Among patients with non-ST-elevation ACS, a Cpn IgA ≥1:32 at presentation was associated with a significantly higher risk of myocardial injury complicating the presenting event. (Am Heart J 2002;144:987-94.)