High-sensitivity C-reactive protein is a predictor of in-hospital cardiac events in acute myocardial infarction independently of GRACE risk score

High-sensitivity CRP (hsCRP) is being increasingly used as a marker for cardiac risk assessment and as a prognostic tool in acute coronary syndrome. We analyzed the relation between hsCRP values at admission and in-hospital outcomes in 98 consecutive patients with acute myocardial infarction (AMI) undergoing catheterization. Patients with cardiac events had more advanced Killip class, more proportion of depressed left ventricular ejection fraction (LVEF), higher Global Registry of Acute Coronary Events (GRACE) risk score, and higher hsCRP levels. High-sensitivity CRP and GRACE risk score showed a significant positive correlation (r = .320, P = .002). In multivariate analysis, hsCRP resulted as a predictor of worse in-hospital outcomes independently of GRACE risk score (OR 1.122, CI95%:1.005-1.252, P = .040). The hsCRP value showing the maximum likelihood ratio for predicting cardiac events was 1.45 mg/dL. High levels of hsCRP were also associated with development of contrast-induced nephropathy but not with bleeding events.     

KAsH: A new tool to predict in-hospital mortality in patients with myocardial infarction

IntroductionComplex risk scores have limited applicability in the assessment of patients with myocardial infarction (MI). In this work, the authors aimed to develop a simple to use clinical score to stratify the in-hospital mortality risk of patients with MI at first medical contact.MethodsIn this single-center prospective registry assessing 1504 consecutively admitted patients with MI, the strongest predictors of in-hospital mortality were selected through multivariate logistic regression. The KAsH score was developed according to the following formula: KAsH=(Killip class×Age×Heart rate)/systolic blood pressure. Its predictive power was compared to previously validated scores using the DeLong test. The score was categorized and further compared to the Killip classification.ResultsThe KAsH score displayed excellent predictive power for in-hospital mortality, superior to other well-validated risk scores (AUC: KAsH 0.861 vs. GRACE 0.773, p<0.001) and robust in subgroup analysis. KAsH maintained its predictive capacity after adjustment for multiple confounding factors such as diabetes, heart failure, mechanical complications and bleeding (OR 1.004, 95% CI 1.001-1.008, p=0.012) and reclassified 81.5% of patients into a better risk category compared to the Killip classification.KAsH's categorization displayed excellent mortality discrimination (KAsH 1: 1.0%, KAsH 2: 8.1%, KAsH 3: 20.4%, KAsH 4: 55.2%) and better mortality prediction than the Killip classification (AUC: KAsH 0.839 vs. Killip 0.775, p<0.0001).ConclusionKAsH, an easy to use score calculated at first medical contact with patients with MI, displays better predictive power for in-hospital mortality than existing scores.     

Strong predictive value of TIMI risk score analysis for in-hospital and long-term survival of patients with right ventricular infarction.

BACKGROUND: While right ventricular myocardial infarction is associated with increased in-hospital morbidity and mortality, prognostic risk factors for in-hospital and long-term mortality are poorly defined. OBJECTIVES: To evaluate the prognostic value of TIMI (Thrombolysis in Myocardial Infarction) risk score analysis in patients with right ventricular myocardial infarction (RVI). DESIGN: Retrospective analysis of a community population. SETTING: Mayo Clinic Coronary Care Unit. PATIENTS: One hundred and two patients with RVI from 580 consecutive patients from Rochester, Minnesota admitted to the Coronary Care Unit with acute inferior or lateral wall myocardial infarction from January 1988 through March 1998. MEASUREMENT: Combined TIMI risk score analysis with in-hospital and long-term mortality. RESULTS: In-hospital morbidity (RVI: 54.9% vs non-RVI: 22.2%; P<0.001) and mortality (RVI: 21.6% vs non-RVI: 6.9%;P <0.001) were increased in patients with RVI. The TIMI risk score predicted risk (per one point increase in TIMI score) for in-hospital mortality (OR 1.23, 95% CI 1.02-1.51, P=0.037) and long-term mortality (OR 1.57, 95% CI 1.25-1.96, P<0.001). Patients with RVI whose TIMI risk score was >or=4 had significantly worse long-term survival compared to those patients with RVI and TIMI score <4 (P=0.006). CONCLUSIONS: In-hospital morbidity and mortality, and long-term mortality are increased by right ventricular infarction and can be accurately predicted by the initial TIMI risk score.     

A risk score to predict in-hospital mortality for percutaneous coronary interventions.

OBJECTIVES: Our purpose was to develop a risk score to predict in-hospital mortality for percutaneous coronary intervention (PCI) using a statewide population-based PCI registry. BACKGROUND: Risk scores predicting adverse outcomes after PCI have been developed from a single or a small group of hospitals, and their abilities to be generalized to other patient populations might be affected. METHODS: A logistic regression model was developed to predict in-hospital mortality for PCI using data from 46,090 procedures performed in 41 hospitals in the New York State Percutaneous Coronary Intervention Reporting System in 2002. A risk score was derived from this model and was validated using 2003 data from New York. RESULTS: The risk score included nine significant risk factors (age, gender, hemodynamic state, ejection fraction, pre-procedural myocardial infarction, peripheral arterial disease, congestive heart disease, renal failure, and left main disease) that were consistent with other reports. The point values for risk factors range from 1 to 9, and the total risk score ranges from 0 to 40. The observed and recalibrated predicted risks in 2003 were highly correlated for all PCI patients as well as for those in the higher-risk subgroup who suffered myocardial infarctions within 24 h before the procedure. The total risk score for mortality is strongly associated with complication rates and length of stay in the 2003 PCI data. CONCLUSIONS: The risk score accurately predicted in-hospital death for PCI procedures using future New York data. Its performance in other patient populations needs to be further studied.     

CHA2DS2-VASc评分对急性心肌梗死患者院内结局事件的预测价值——China PEACE回顾性急性心肌梗死研究

目的评估CHA₂DS₂-VASc评分对急性心肌梗死(AMI)患者院内结局事件的预测价值。方法回顾性分析冠心病医疗结果评价和临床转化研究(China PEACE)回顾性急性心肌梗死研究中23728例AMI患者的病历信息,按CHA₂DS₂-VASc评分分为低(0~3分)、中(4~6分)、高(7~9分)分值组。院内结局包括主要不良心血管事件、死亡、死亡或放弃治疗、再发心肌梗死、缺血性卒中等。采用多因素Cox回归分析CHA₂DS₂-VASc评分对AMI患者院内结局的影响。通过受试者工作特征(ROC)曲线,评估CHA₂DS₂-VASc评分对AMI患者院内死亡与死亡或放弃治疗的预测价值。结果入组患者年龄66(56,75岁)岁,女性占30.7%。CHA₂DS₂-VASc评分高分值组患者院内结局事件发生率更高,基础疾病更多(P值均<0.001);多因素logistic回归中,院内病死率(OR=6.13,95%CI 4.77~7.87,P<0.001)、院内死亡或放弃治疗率(OR=6.43,95%CI 5.16~8.00,P<0.001)、主要心血管事件发生率(OR=4.94,95%CI 4.06~6.01,P<0.001)明显高于其他两组。ROC曲线分析显示,无论院内病死率,还是死亡或放弃治疗率,CHA₂DS₂-VASc评分与简化版全球急性冠状动脉事件登记(global registry of acute coronary events,mini-GRACE)评分相比差异无统计学意义(ROC曲线下面积:0.699与0.696,P=0.752;0.708与0.713,P=0.489)。结论CHA₂DS₂-VASc评分是一种有效预测AMI患者院内风险的评估工具,该评分操作简单,预测价值与mini-GRACE评分相当。     

CHA2DS2-VASc评分对急性心肌梗死患者院内结局事件的预测价值——China PEACE回顾性急性心肌梗死研究

目的评估CHA₂DS₂-VASc评分对急性心肌梗死(AMI)患者院内结局事件的预测价值。方法回顾性分析冠心病医疗结果评价和临床转化研究(China PEACE)回顾性急性心肌梗死研究中23728例AMI患者的病历信息,按CHA₂DS₂-VASc评分分为低(0~3分)、中(4~6分)、高(7~9分)分值组。院内结局包括主要不良心血管事件、死亡、死亡或放弃治疗、再发心肌梗死、缺血性卒中等。采用多因素Cox回归分析CHA₂DS₂-VASc评分对AMI患者院内结局的影响。通过受试者工作特征(ROC)曲线,评估CHA₂DS₂-VASc评分对AMI患者院内死亡与死亡或放弃治疗的预测价值。结果入组患者年龄66(56,75岁)岁,女性占30.7%。CHA₂DS₂-VASc评分高分值组患者院内结局事件发生率更高,基础疾病更多(P值均<0.001);多因素logistic回归中,院内病死率(OR=6.13,95%CI 4.77~7.87,P<0.001)、院内死亡或放弃治疗率(OR=6.43,95%CI 5.16~8.00,P<0.001)、主要心血管事件发生率(OR=4.94,95%CI 4.06~6.01,P<0.001)明显高于其他两组。ROC曲线分析显示,无论院内病死率,还是死亡或放弃治疗率,CHA₂DS₂-VASc评分与简化版全球急性冠状动脉事件登记(global registry of acute coronary events,mini-GRACE)评分相比差异无统计学意义(ROC曲线下面积:0.699与0.696,P=0.752;0.708与0.713,P=0.489)。结论CHA₂DS₂-VASc评分是一种有效预测AMI患者院内风险的评估工具,该评分操作简单,预测价值与mini-GRACE评分相当。     

Prediction of outcome after percutaneous coronary intervention for the acute coronary syndrome

BACKGROUND: The seven-component Thrombolysis In Myocardial Infarction (TIMI) score has been used to risk stratify, and to guide the medical management of, patients with unstable angina or non-ST-elevation myocardial infarction. We assessed the usefulness of the risk score in predicting in-hospital and 30-day outcomes in such patients who were undergoing percutaneous coronary intervention. METHODS: Using the TIMI score, 2501 patients with unstable angina or non-ST-elevation myocardial infarction were divided into low-risk (zero to two risk factors; n = 974), intermediate-risk (three to four risk factors; n = 1339), and high-risk (five to seven risk factors; n = 188) groups, and outcomes were compared. RESULTS: Angiographic/clinical success and the rate of minor procedural events were similar among the three groups. A higher TIMI risk score was associated with more cardiac comorbid conditions and more complicated angiographic lesions: longer lesions (P = 0.0009), more thrombotic lesions (P = 0.03), more multivessel disease (P <0.0001), and more American College of Cardiology/American Heart Association type B2/C lesions (P = 0.05). Although the risk score did not predict interventional technical success or intraprocedural complications, a high score was associated with prolonged hospital stay, higher postprocedural peak troponin levels, and 30-day major adverse cardiac events. Stepwise logistic regression showed that in conjunction with lesion length and patient sex, a high score was an independent predictor of 30-day major adverse cardiac events (odds ratio = 2.3; 95% confidence interval: 1.1 to 4.1; C statistic = 0.62). CONCLUSION: Although a higher TIMI risk score in patients with unstable angina or non-ST-elevation myocardial infarction who were undergoing percutaneous coronary intervention correlated with adverse clinical outcome, the score alone cannot be used to guide diagnostic or therapeutic strategies.     

急性高血糖对ST段抬高性心肌梗死院内预后的影响

目的探讨急性高血糖对ST段抬高性心肌梗死（STEMI）患者院内预后的影响。方法连续人选356例北京地区17家三级和二级医院所有在24h内人院且符合STEMI诊断标准的患者。以入院血糖水平〉11mmol／L判定为高血糖,分为高血糖组和血糖正常组,观察两组患者院内死亡和心血管病事件的发生情况。院内心血管事件定义为院内再发心肌梗死、新发生的心力衰竭、严重心律失常及卒中。结果356例STEMI患者中,存在急性高血糖患者共81例（22．8％）。其院内病死率较无急性高血糖患者显著增加（13．6％比5．1％,P=0．009）,院内心血管事件发生率亦显著增多（32．1％比20．4％,P=0．027）。logistic回归分析示,人院急性高血糖（OR1．615,95％CI1．116～2．338,P=0．011）为STEMI患者院内不良预后的独立危险因素。结论STEMI急性高血糖患者院内死亡及发生院内心血管事件的危险性显著高于人院血糖正常者。人院高血糖为STEMI患者院内不良预后的独立危险因素。     

A clinical and echocardiographic score for assigning risk of major events after dobutamine echocardiograms

OBJECTIVES: We sought to develop and validate a risk score combining both clinical and dobutamine echocardiographic (DbE) features in 4890 patients who underwent DbE at three expert laboratories and were followed for death or myocardial infarction for up to five years. BACKGROUND: In contrast to exercise scores, no score exists to combine clinical, stress, and echocardiographic findings with DbE. METHODS: Dobutamine echocardiography was performed for evaluation of known or suspected coronary artery disease in 3156 patients at two sites in the U.S. After exclusion of patients with incomplete follow-up, 1456 DbEs were randomly selected to develop a multivariate model for prediction of events. After simplification of each model for clinical use, the models were internally validated in the remaining DbE patients in the same series and externally validated in 1733 patients in an independent series. RESULTS: The following score was derived from regression models in the modeling group (160 events): DbE risk = (age.0.02) + (heart failure + rate-pressure product <15000).0.4 + (ischemia + scar).0.6. The presence of each variable was scored as 1 and its absence scored as 0, except for age (continuous variable). Using cutoff values of 1.2 and 2.6, patients were classified into groups with five-year event-free survivals >95%, 75% to 95%, and <75%. Application of the score in the internal validation group (265 events) gave equivalent results, as did its application in the external validation group (494 events, C index = 0.72). CONCLUSIONS: A risk score based on clinical and echocardiographic data may be used to quantify the risk of events in patients undergoing DbE.     

危险评分对急性心肌梗死急诊介入干预患者远期预后的评价

目的 探讨心肌梗死(MI)溶栓疗法(TIMI)危险评分系统对ST段抬高的急性心肌梗死(STEMI)患者直接经皮冠状动脉介入干预(PCI)远期预后预测的价值。方法 应用TIMI危险评分系统的8个变量,分别累计各例的评分值,观察患者住院期并随访平均(23.9±3.8)个月的主要心血管事件(包括非致命心力衰竭、非致命再次心肌梗死、靶血管血运重建及心脏性死亡),分析入院时TIMI危险评分值对总心血管事件发生率的预测性。结果 373例STEMI患者随访期总心血管事件发生89例(平均发生率23.9％);随危险评分值的逐渐递增,其总心血管事件发生率进行性增高(对增高趋势,X2值统计,P<0.05);评分≥8分者总心血管事件是评分为0者的9倍;与<6分者比较,评分≥6分者心脏性死亡事件明显增高(25％比0,P<0.01),死亡 MI事件也显著增加(36.7％比2.6％,P<0.01)。无论患者入院时肌钙蛋白Ⅰ水平增高与否,其TIMI危险评分越高、则发生心脏不良事件的危险性越大。结论 入院时TIMI危险评分值增高,临床预后越差,TIMI危险评分法可能是对STEMI行直接PCI患者进行床旁定量危险评估与远期预后预测较为方便、实用的临床评价方法。     

Influence of concurrent renal dysfunction on outcomes of patients with acute coronary syndromes and implications of the use of glycoprotein IIb/IIIa inhibitors

OBJECTIVES: The purpose of this study was to examine the in-hospital outcome and influence of glycoprotein (GP) IIb/IIIa antagonists on patients with acute coronary syndromes (ACS) across a range of renal function. BACKGROUND: Recent studies demonstrate increasing cardiovascular risk with progressive renal dysfunction. Previous studies investigating GP IIb/IIIa antagonist use have excluded patients with renal dysfunction. METHODS: Patients presenting with ACS between January 1999 and May 2000 were identified, and data on demographics, in-hospital management, and clinical events were collected using standardized definitions. Patients were stratified according to renal function assessed by calculated creatinine clearance (CrCl) at presentation. Primary outcome measures included in-hospital mortality and major bleeding events. RESULTS: Renal insufficiency was present in 312 of 889 patients. There were 40 in-hospital deaths. In non-dialysis-dependent patients, as CrCl worsened, there was a decline in utilization of routine diagnostics and therapeutics, an increase in in-hospital mortality (p = 0.002), and an increase in major bleeding (p = 0.03). Although the use of GP IIb/IIIa antagonists was associated with an increase in major bleeding (p < 0.001), there was a protective effect on in-hospital mortality (p = 0.04) after controlling for CrCl. CONCLUSIONS: Renal dysfunction is present in a substantial proportion of patients with ACS and is associated with increased in-hospital death. Although GP IIb/IIIa antagonist use in patients with ACS and renal insufficiency resulted in increased bleeding events, its administration was associated with a decreased risk of in-hospital mortality. These preliminary findings need to be confirmed in future randomized clinical trials.     

Modelo de predicción de riesgo de mortalidad hospitalaria para pacientes con infarto de miocardio tratados con oxigenador extracorpóreo de membrana venoarterial

Introduction and objectivesThere are limited data to develop a risk prediction model of in-hospital mortality for acute myocardial infarction (AMI) patients treated with venoarterial (VA)-extracorporeal membrane oxygenation (ECMO). We aimed to develop a risk prediction model for in-hospital mortality in patients with AMI who were treated with VA-ECMO.MethodsA total of 145 patients with AMI who underwent VA-ECMO between May 2004 and April 2016 were included from the Samsung Medical Center ECMO registry. The primary outcome was in-hospital mortality. To develop a new predictive scoring system, named the AMI-ECMO score, backward stepwise elimination and β coefficient-based scoring were used based on logistic regression analyses. The leave-one-out cross-validation method was performed for internal validation.ResultsIn-hospital mortality occurred in 69 patients (47.6%). On multivariable logistic regression analysis, the AMI-ECMO score comprised 6 pre-ECMO or angiographic parameters: age > 65 years, body mass index > 25 kg/m², Glasgow coma score < 6, lactic acid > 8 mmol/L, anterior wall infarction, and no or failed revascularization. The C-statistic value of AMI-ECMO score for predicting in-hospital mortality was 0.880 (95%CI, 0.820-0.940). The incidence of in-hospital mortality after VA-ECMO insertion was 6.2%, 28.1%, 51.6%, and 93.8% for AMI-ECMO score quartiles (0 to 16, 17 to 19, 20 to 26, and > 26), respectively (P < .001 for trend). The AMI-ECMO scores were also significantly associated with the estimated rate of all-cause mortality during follow-up (per 1 increase, HR, 1.11; 95%CI, 1.08-1.14; P < .001).ConclusionsThe AMI-ECMO score can help predict early prognosis in AMI patients who undergo VA-ECMO.Full English text available from:www.revespcardiol.org/en     

Use of Machine Learning to Develop Prediction Models for Mortality and Stroke in Patients Undergoing Balloon Aortic Valvuloplasty

ObjectiveTo develop an artificial intelligence, machine learning prediction model for estimating in-hospital mortality and stroke in patients undergoing balloon aortic valvuloplasty (BAV).MethodsThe National Inpatient Sample (NIS) database was used to identify patients who underwent BAV from 2005 to 2017. Outcomes analyzed were in-hospital all-cause mortality and stroke after BAV. Predictors of mortality and stroke were selected using LASSO regularization. A conventional logistic regression and a random forest machine learning algorithm were used to train the models for predicting outcomes. The performance of all the modeling algorithms for predicting in-hospital mortality and stroke was compared between models using c-statistic, F1 score, brier score loss, diagnostic accuracy, and Kolmogorov-Smirnov plots.ResultsA total of 6962 patients with severe aortic stenosis who underwent BAV were identified. The performance of random forest classifier was comparable with logistic regression for predicting in-hospital mortality for all measures of performance (F1 score 0.422 vs 0.409, ROC-AUC 0.822 [95 % CI 0.787–0.855] vs 0.815 [95 % CI 0.779–0.849], diagnostic accuracy 70.42 % vs 70.93 %, KS-statistic 0.513 vs 0.494 and brier score loss 0.295 vs 0.291). The random forest algorithm significantly outperformed logistic regression in predicting in-hospital stroke with respect to all performance metrics: F1 score 0.225 vs 0.095, AUC 0.767 [0.662–0.858] vs 0.637 [0.499–0.754], brier score loss [0.399 vs 0.407], and KS-statistic [0.465 vs 0.254].ConclusionsThe good discrimination of machine learning models reveal the potential of artificial intelligence to improve patient risk stratification for BAV.     

Characteristics and Outcome in Acute Coronary Syndrome Patients with and without Established Modifiable Cardiovascular Risk Factors: Insights from the Nationwide AMIS Plus Registry 1997-2010

Objectives: Little is known about patients without known modifiable risk factors presenting initially with acute coronary syndrome (ACS). This study assessed baseline characteristics and outcomes of ACS patients with and without the known modifiable risk factors arterial hypertension, dyslipidemia, obesity, smoking or diabetes. Methods: All ACS patients enrolled in the AMIS Plus Registry between 1997 and 2010 were analyzed until hospital discharge; a subgroup was re-assessed at the 1-year follow-up. Outcome measures were in-hospital mortality and major adverse cardiac or cerebrovascular events (MACCE) defined as a composite outcome of mortality, re-infarction and cerebrovascular events. Results: Of 33,306 patients, 2,125 (6.4%) had none of these modifiable risk factors. They were older (males), had less moderate or severe comorbidities and were more frequently in Killip class I on admission. Treatment of ACS patients with or without modifiable risk factors was similar with regard to interventional therapies and use of antiplatelet agents. In-hospital mortality was lower in patients without modifiable risk factors but in-hospital MACCE and 1-year survival was similar. Conclusion: Lack of modifiable risk factors was an independent predictor of lower in-hospital mortality but not of MACCE in patients who presented with ACS.     

Supplemental value of troponin I combined with a clinical risk model to predict in-hospital events in intermediate and high risk patients with acute coronary syndromes

To evaluate the supplemental value of serial troponin I (Trp) measurements when combined with a clinical model composed of six clinical parameters in predicting in-hospital adverse event rates, a total of 118 consecutive patients admitted over a 23-month period with intermediate- or high-risk unstable angina or non-Q wave myocardial infarction (MI) as defined by AHCPR criteria who had coronary angiography within 72 hours of hospitalization were studied. Presenting clinical characteristics were graded using a previously validated variation of the Braunwald criteria (RUSH model). The RUSH model clinical score includes six clinical parameters: age, diabetes, intravenous nitroglycerin, pre-admission calcium-channel and beta-blocker, ST depression and post-MI angina (< 2 weeks), and creates an estimated probability of MI or death. The RUSH model was compared to serial Trp levels drawn at 6-hour intervals (0, 6 and 12 hours). An abnormal Trp value was defined as > 2.0 mg/dl. Outcome measures included death, MI, recurrent chest pain and new ST or T changes and enzyme elevation. One death, 23 MIs and 24 other adverse clinical events occurred. The event group had a RUSH score predictive of 12.7 12.4% risk and the no-event group had a score of 13.2 10.2% risk (p = 0.64). The Trp positive group had a clinical score predicting 14.2 13.2% risk and the Trp negative group had a score of 11.7 9.3% risk (p = 0.21). Patients with elevated Trp had an adverse event rate of 32/50 (64%) vs. 21/68 (31%) in patients with normal Trp (p < 0.0004). Elevated Trp had 60.4% sensitivity and 72.3% specificity, odds ratio of 3.97 (1.71 9.33), as well as 64% positive and 69.1% negative predictive values for predicting adverse events. Thus, there was significant incremental value to adding Trp to the clinical score when predicting outcomes in patients with intermediate- and high-risk clinical scores. When Trp was abnormal, it was useful when predicting higher risk; if Trp was normal, it was useful predicting lower but still elevated risk. Consequently, in a population selected for intermediate and high risk, the presence or absence of elevated Trp I is a sensitive and specific additive predictor to clinical score to predict need for revascularization and adverse in-hospital outcomes, as suggested in current guidelines.     

Development and validation of a clinical prediction rule for major adverse outcomes in coronary bypass grafting.

In this study, we develop and internally validate a clinical prediction rule for in-hospital major adverse outcomes, defined as death, renal failure, reinfarction, cardiac arrest, cerebrovascular accident, or coma, in patients who underwent coronary artery bypass grafting (CABG). All adult patients (n = 9,498) who underwent a CABG and no other concomitant surgery at 12 academic medical centers from August 1993 to October 1995 were included in the study. We assessed in-hospital major adverse outcomes and their predictors using information on admission, coronary angiography, and postoperative hospital course. Predictor variables were limited to information available before the procedure, and outcome variables were represented only by events that occurred postoperatively. We developed and internally validated a clinical prediction rule for any major adverse outcome after CABG. The rule's ability to discriminate outcomes and its calibration were assessed using receiver-operating characteristic analysis and the Hosmer-Lemeshow goodness-of-fit statistic, respectively. A major adverse outcome occurred in 6.5% of patients in the derivation set and 7.2% in the validation set. Death occurred in 2.5% of patients in the derivation set and 2.2% in the validation set. Sixteen variables were independently correlated with major adverse outcomes, with the risk score value attributed to each risk factor ranging from 2 to 12 points. The rule stratified patients into 6 levels of risk based on the total risk score. The spread in probability between the lowest and highest risk groups of having a major adverse outcome was 1.7% to 32.3% in the derivation set and 2.2% to 22.3% in the validation set. The prediction model performed well in both outcome discrimination and calibration. Thus, this clinical prediction rule allows accurate stratification of potential CABG candidates before surgery according to the risk of experiencing a major adverse outcome postoperatively.     

Cancer patients with acute coronary syndrome have non-superior bleeding risk compared to patients with similar characteristics – a propensity score analysis from the ProACS registry

IntroductionThe management of acute coronary syndrome (ACS) in malignancy is challenging due to higher bleeding risk.MethodsWe analyzed patients with cancer (active or in the previous five years) prospectively included in the ProACS registry between 2010 and 2019. Our aim was to assess safety (major bleeding, primary endpoint) and secondary efficacy endpoints (in-hospital mortality and combined in-hospital mortality, reinfarction and ischemic stroke) of ACS treatment. Propensity score matching analysis (1:1) was further performed to better understand predictors of outcomes.ResultsWe found 934 (5%) cancer patients out of a total of 18 845 patients with ACS. Cancer patients had more events: major bleeding (2.9% vs. 1.5%), in-hospital mortality (5.8% vs. 3.4%) and the combined endpoint (7.4% vs. 4.9%). The primary endpoint was related to cancer diagnosis (OR 1.97), previous bleeding (OR 7.09), hemoglobin level (OR 4.94), atrial fibrillation (OR 3.50), oral anticoagulation (OR 3.67) and renal dysfunction. Mortality and the combined secondary endpoint were associated with lower use of invasive coronary angiography and antiplatelet and neurohormonal blocker therapy. After propensity score matching (350 patients), there were no statistically significant differences in endpoints between the populations.ConclusionBleeding risk was not significant higher in the cancer population compared to patients with similar characteristics, nor were mortality or ischemic risk. The presence of cancer should not preclude simultaneous ACS treatment.     

Comparison of acute coronary syndrome in patients receiving versus not receiving chronic dialysis (from the Global Registry of Acute Coronary Events [GRACE] Registry)

Patients with end-stage renal disease commonly develop acute coronary syndromes (ACS). Little is known about the natural history of ACS in patients receiving dialysis. We evaluated the presentation, management, and outcomes of patients with ACS who were receiving dialysis before presentation for an ACS and were enrolled in the Global Registry of Acute Coronary Events (GRACE) at 123 hospitals in 14 countries from 1999 to 2007. Of 55,189 patients, 579 were required dialysis at presentation. Non-ST-segment elevation myocardial infarction was the most common ACS presentation in patients receiving dialysis, occurring in 50% (290 of 579) of patients versus 33% (17,955 of 54,610) of those not receiving dialysis. Patients receiving dialysis had greater in-hospital mortality rates (12% vs 4.8%; p <0.0001) and, among those who survived to discharge, greater 6-month mortality rates (13% vs 4.2%; p <0.0001), recurrent myocardial infarction (7.6% vs 2.9%; p <0.0001), and unplanned rehospitalization (31% vs 18%; p <0.0001). The outcome in patients receiving dialysis was worse than that predicted by their calculated GRACE risk score for in-hospital mortality (7.8% predicted vs 12% observed; p <0.05), 6-month mortality/myocardial infarction (10% predicted vs 21% observed; p <0.05). In conclusion, in the present large multinational study, approximately 1% of patients with ACS were receiving dialysis. They were more likely to present with non-ST-segment elevation myocardial infarction, and had markedly greater in-hospital and 6-month mortality. The GRACE risk score underestimated the risk of major events in patients receiving dialysis.     

A risk score to estimate the likelihood of coronary artery bypass surgery during the index hospitalization among patients with unstable angina and non-ST-segment elevation myocardial infarction

OBJECTIVES: A simple risk score on admission to estimate the likelihood of in-hospital coronary artery bypass graft surgery (CABG) might be useful in selecting patients for early clopidogrel therapy. BACKGROUND: Routine early use of clopidogrel in patients with unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI) is associated with increased risk of bleeding in patients who undergo early CABG. METHODS: The test cohort utilized to derive the score was the 2,220 patients with UA/NSTEMI enrolled in the Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction-18 (TACTICS-TIMI-18) trial. Patients who underwent CABG after randomization during index hospitalization were identified and were compared with patients who did not undergo in-hospital CABG. RESULTS: Overall, 362 patients (16.3%) underwent CABG during the index hospitalization. Patients with a history of prior CABG (n = 484) were significantly less likely to undergo in-hospital CABG (odds ratio [OR], 0.34). Five additional variables independently associated with CABG were identified: elevated troponin (OR, 3.9), prior stable angina (OR, 1.8), ST-segment deviation >or=0.5 mm (OR, 1.7), male gender (OR, 1.6), and history of peripheral arterial disease (OR, 1.6). A CABG risk score was generated by assigning numerical values to each of the variables based upon these odds ratios. Coronary artery bypass surgery rates increased significantly with increasing risk scores (6.2% for a risk score <3.0, 21.9% for 3 to 5, and 54.6% for >5.0). The association of the risk score with CABG was highly significant (p < 0.0001, c-statistic 0.72). The association remained significant in the validation cohorts from TIMI-11B trial and TIMI-III registry. CONCLUSIONS: Among patients with UA/NSTEMI, a novel risk score based on admission clinical variables can be used to estimate the likelihood of CABG. These data may assist in the identification of patients who might derive optimal benefit from early initiation of clopidogrel therapy.     

Percutaneous coronary intervention-associated nephropathy foreshadows increased risk of late adverse events in patients with normal baseline serum creatinine.

In patients with chronic renal insufficiency, further decline in renal function (DRF) after percutaneous coronary intervention (PCI) is accompanied not only by adverse in-hospital events but also by increased risk of mortality and myocardial infarction at 1 year. This analysis was undertaken to determine if patients with normal renal function who develop DRF after PCI have a comparable increase in risk of death and myocardial infarction at 1 year, and whether this risk is independent of in-hospital complications (death, myocardial infarction, urgent coronary artery bypass grafting). We performed a retrospective analysis of all patients from a single center who underwent successful PCI with no major in-hospital complications who had pre-PCI serum creatinine (SCr) /= 50% of baseline). They were more likely to be older, female, non-Caucasian, diabetic and/or hypertensive. They reported more prior cerebral or peripheral vascular events. They had undergone more complex PCI and were exposed to more radiographic contrast than the 96.5% who did not develop DRF. After adjustment for baseline variables, DRF remained an independent predictor of 1-year mortality, myocardial infarction, and target vessel revascularization. In patients without prior renal impairment, DRF post-PCI is rare but is associated with an increased risk of late adverse cardiac events similar to that in chronic renal insufficiency patients.