Épidémiologie du syndrome coronaire aigu en Europe

Epidemiological data concerning acute coronary syndromes in Europe are based on national registries, studies by the European Society of Cardiology within the framework of the EuroHeart Survey and on the study of European population sub-groups in large international cohorts. In this article, recently published studies will be reviewed, and the principal developments in different countries as well as the characteristics and particularities of the most recent epidemiological data will be highlighted. In Europe, the presentation of acute coronary syndromes (ACS) has evolved considerably over the last ten years. This evolution is characterized by a reduction in the proportion of acute coronary syndromes with ST-segment elevation (STEMI) and by ageing populations.     

Epidemiology of acute coronary syndrome in Europe

Epidemiological data concerning acute coronary syndromes in Europe are based on national registries, studies by the European Society of Cardiology within the framework of the EuroHeart Survey and on the study of European population sub-groups in large international cohorts. In this article, recently published studies will be reviewed, and the principal developments in different countries as well as the characteristics and particularities of the most recent epidemiological data will be highlighted. In Europe, the presentation of acute coronary syndromes (ACS) has evolved considerably over the last ten years. This evolution is characterized by a reduction in the proportion of acute coronary syndromes with ST-segment elevation (STEMI) and by ageing populations.     

碱性磷酸酶与白蛋白比值对急性冠脉综合征患者介入治疗预后的影响

目的 评估碱性磷酸酶(ALP)与白蛋白(ALB)比值(APAR)对急性冠脉综合征(ACS)患者预后的影响.方法 按前瞻队列研究连续入选2015年1月至2016年12月就诊于中国医科大学附属盛京医院确诊为ACS并择期进行经皮冠状动脉支架植入术(PCI)治疗的患者共2162例.根据入院次日APAR分成两组,收集所有患者临床...     

直接冠状动脉内支架术在急性冠状动脉综合征中的应用

目的　探讨急性冠状动脉综合征 (ACS)患者直接冠状动脉支架术治疗的可行性和安全性。方法　选择 ACS患者 6 8例 ,依据冠状动脉造影的结果采取直接支架术。用定量冠状动脉造影分析支架术前和术后即刻的造影结果 ,并随访观察术后近期临床疗效。结果　直接支架置入术成功率为 94 .1%。其中不稳定型心绞痛者成功率为96 .0 % ,急性心肌梗死成功率 88.9%。支架术后血管狭窄程度较术前明显减轻。慢复流的发生率为 7.8%。未发生与介入操作相关的严重并发症。术后近期随访无严重心血管事件发生。结论　对经选择的 ACS患者采取直接支架术治疗成功率高 ,并发症低 ,可以取得较满意的近期临床疗效     

The second Euro Heart Survey on acute coronary syndromes: Characteristics, treatment, and outcome of patients with ACS in Europe and the Mediterranean Basin in 2004.

AIMS: Our study aimed to examine the management of acute coronary syndromes (ACS) in Europe and the Mediterranean basin, and to compare adherence to guidelines with that reported in the first Euro Heart Survey on ACS (EHS-ACS-I), 4 years earlier. METHODS AND RESULTS: In a prospective survey conducted in 2004 (EHS-ACS-II), data describing the characteristics, treatment, and outcome of 6385 patients diagnosed with ACS in 190 medical centres in 32 countries were collected. ACS with ST-elevation was the initial diagnosis in 47% of patients, no ST-elevation in 48%, and undetermined electrocardiographic pattern in 5% of patients. Comparison of data collected in 2000 and 2004 showed similar baseline characteristics, but greater use of recommended medications and coronary interventions in EHS-ACS-II. Among patients with ST-elevation, the use of primary reperfusion increased slightly (from 56 to 64%), with a significant shift from fibrinolytic therapy to primary percutaneous coronary intervention (PPCI). The use of PPCI rose from 37 to 59% among those undergoing primary reperfusion therapy. Analysis of data in 34 centres that participated in both surveys showed even greater improvement with respect to the use of recommended medical therapy, interventions, and outcome. CONCLUSION: Data from EHS-ACS-II suggest an increase in adherence to guidelines for treatment of ACS in comparison with EHS-ACS-I.     

Comparison of baseline characteristics, management and outcome of patients with non-ST-segment elevation acute coronary syndrome in versus not in clinical trials

Previous studies have questioned the external validity of randomized controlled trial results of acute coronary syndrome (ACS) because of potential selection bias toward healthier patients. We sought to evaluate differences in clinical characteristics and management of patients admitted with non-ST-elevation ACS according to participation in clinical trials over the previous decade. The Canadian ACS I (1999 to 2001), ACS II (2002-2003), GRACE (2004-2007), and CANRACE (2008) were prospective, multicenter registries of patients admitted to hospitals with ACS. We examined 13,556 patients with non-ST-elevation ACS, of whom 1,126 (8.3%) participated in clinical trials. Data were collected on baseline characteristics, medication use at admission and discharge, in-hospital procedures, and in-hospital adverse events. Patients enrolled in clinical trials were younger, more likely to be men, and had fewer co-morbidities. They were significantly more likely to be on several guideline-recommended medications and were significantly more likely to undergo invasive procedures, including coronary angiography, percutaneous coronary intervention, and coronary bypass surgery (all p values <0.001). Unadjusted in-hospital (2.1% vs 0.7%, p = 0.001) and 1-year (8.9% vs 6.3%, p = 0.037) mortality rates were higher in non-enrolled patients. In multivariable analysis, patients who were older, women, had a history of heart failure, and increased creatinine levels on presentation were less likely to be enrolled into clinical trials. In conclusion, significant differences persist in baseline characteristics, treatment, and outcomes between patients enrolled and those not enrolled in clinical trials. Consequently, generalization of ACS clinical trials over the previous decade to the "real-world" patient may remain in question.     

The effect of cardiac troponin testing on clinical care in a veterans population

BACKGROUND: Cardiac troponin is more accurate than creatine kinase (CK) testing for detecting myocardial injury in patients with acute coronary syndromes (ACS), but its effects on clinical care compared with CK testing alone is open to question. OBJECTIVE: To test the effects of troponin I on medical decisions for patients undergoing cardiac enzyme testing. DESIGN: Randomized, controlled trial. SETTING: Urban academic Veterans Affairs medical center. PATIENTS: Three hundred ninety-two patients presenting to the emergency department (ED) and outpatient settings with symptoms and/or electrocardiograms suggestive but not diagnostic of ACS. INTERVENTION: Random assignment to linked CK-troponin I (CKTnI) testing or CK testing alone. MEASUREMENTS: ED discharge and cardiac catheterization incidence (primary); ED medication use, inpatient noninvasive testing, revascularization procedures, discharge medications, and 8-week ED visits, hospitalizations, and procedures (secondary). RESULTS: Groups were similar in all variables except history of heart failure (CK 26.8% vs CKTnI 17.0%). ACS comprised 12.2% of the cohort. ED discharge incidence was greater in the CKTnI arm (18% vs 9.6%; relative risk [RR], 1.83; 95% CI, 1.08 to 3.31; P=.02; number needed to test=12.6; 95% CI, 4.5 to 130). Troponin testing had no significant effect on catheterization incidence (18.2% vs 14.5%; RR, 1.19; 95% CI, 0.72 to 1.92; P>.20) or other outcomes except follow-up echocardiography (13.4% vs 7.4%; RR, 2.24; 95% CI, 1.11 to 4.69; P=.02). CONCLUSIONS: In a veterans population undergoing cardiac enzyme testing, CKTnI testing led to more ED discharges than CK testing alone but had no effect on inpatient care and was associated with more echocardiograms in a follow-up period.     

合并血小板减少的急性冠状动脉综合征患者经皮冠状动脉介入治疗和抗血小板治疗及随访

目的 探讨合并血小板减少的急性冠状动脉综合征（ACS）患者的临床特点、治疗及预后.方法 2012年3月至2013年3月北京友谊医院共完成PCI术1186例,有11例术前血小板低于100×10^9/L的ACS患者,占总例数的0.93％,回顾性分析11例患者的相关临床情况.结果 11例患者中,急性ST段抬高心肌梗死（STEMI）6例（54.5％）,非急性ST段抬高心肌梗死（NSTEMI）3例（27.3％）,不稳定型心绞痛（UAP）2例（18.2％）.5例（45.5％） STEMI患者行急诊PCI治疗,其余6例（54.5％）行择期PCI治疗.造影显示左主干＋三支血管病变3例（27.3％）,其余8例（72.7％）均为三支血管病变.术后随访（14.4±2.3）个月,期间3例（27.3％）发生出血并发症,3例（27.3％）发生主要不良心血管事件.结论 本组患者的冠状动脉病变以多支病变、复杂病变为主,临床预后不良.     

Outcome of patients with acute coronary syndromes and moderate coronary lesions undergoing deferral of revascularization based on fractional flow reserve assessment.

OBJECTIVES: To determine the outcome of consecutive patients with and without acute coronary syndromes (ACS) in whom revascularization was deferred on the basis of fractional flow reserve (FFR). BACKGROUND: FFR < 0.75 correlates with ischemia on noninvasive tests and deferral of treatment on the basis of FFR is associated with low event rates in selected populations. Whether these low event rates apply to patients undergoing assessment of moderate stenoses in association with an ACS is not known and is an important clinical question. METHODS: Retrospective analysis and 12 month follow-up of consecutive, moderate (50-70%) de novo coronary lesions assessed with FFR. RESULTS: Revascularization was deferred in 120 lesions (111 patients) with FFR > or = 0.75. ACS was present in 35 patients (40 lesions). The clinical, angiographic and coronary hemodynamic characteristics of patients with and without ACS were similar. Among the 35 patients with ACS, there were 3 deaths, 1 MI, and 6 target vessel revascularizations (TVRs) (15% of lesions). Among the 76 patients without ACS, there were 5 deaths, 1 MI, and 7 TVR's (9% of lesions). CONCLUSIONS: Deferral of revascularization based on FFR in patients with ACS and moderate coronary stenoses is associated with acceptable and low event rates at 1 year.     

Predictors of 90-day outcome in patients stabilized after acute coronary syndromes.

AIMS: We investigated predictors of 90-day risk among patients surviving the early period after an acute coronary syndrome (ACS). METHODS AND RESULTS: The study population included 15 904 stabilized ST-segment elevation or non-ST-segment elevation ACS patients randomized in SYMPHONY and 2nd SYMPHONY. We developed risk models for death, death or myocardial infarction (MI), and death, MI, or severe recurrent ischaemia (SRI) using Cox proportional-hazards techniques. Demographic, history, and pre-randomization clinical and medication variables were tested. Validation techniques included development of individual trial models, backward elimination and bootstrapping. Of 118 variables, 17 independently predicted mortality. The strongest associations included greater age (chi(2)=31.1), higher randomization heart rate (chi(2)=27.4), and heart failure (HF) variables (HF between qualifying event and randomization, chi(2)=21.8; history of HF, chi(2)=12.2). Higher creatinine clearance (chi(2)=17.7) and percutaneous coronary intervention between qualifying event and randomization (chi(2)=11.1) most strongly predicted lower risk. Similar characteristics entered the double and triple composite models, but HF variables and age less strongly predicted these end-points. CONCLUSIONS: In patients stabilized after ACS, those at highest risk over the next 90 days can be identified. Typical clinical markers are better at identifying risk of death than non-fatal MI or SRI. Novel risk markers are needed for these outcomes.     

老年急性冠脉综合征患者药物洗脱支架内亚急性血栓原因分析

目的分析老年急性冠脉综合征（ACS）患者在经皮冠状动脉介入（PCI）治疗后药物洗脱支架内发生亚急性血栓的原因。方法本研究所自2004年1月至2008年1月在行PCI治疗的464例老年ACs患者,记录发生亚急性血栓形成患者的一般情况、冠脉病变特点、PCI治疗情况及抗血小板药物治疗情况,分析其发生亚急性血栓形成的原因。结果在连续464例接受药物洗脱支架治疗的老年ACS患者中,有3例患者（0．65％）在PCI治疗后1周内发生了经冠脉造影证实的支架内亚急性血栓。分析其主要相关因素有：靶病变钙化、病变复杂、多支架植入、无高压后扩张、无血管内超声或光学相干断层成像指导,这些因素的共同特征是都可以导致支架贴壁不良。3例患者中有2例在急诊PCI时死亡,1例经急诊PCI治疗后康复出院。结论老年ACS患者行PCI治疗后发生亚急性血栓的原因可能主要与术中支架的贴壁不良密切相关。     

Safety and efficacy of drug-eluting stents and bare metal stents in acute coronary syndrome

Compared with medical therapy, percutaneous coronary intervention has been shown to reduce the rates of death and recurrent ischemia in patients presenting with acute coronary syndromes (ACS). In the current interventional era, both drug-eluting stents (DES) and bare-metal stents (BMS) have been widely used, despite the fact that the use of DES in the context of ACS was initially an “off-label” indication and that ACS has been associated with stent thrombosis (ST). In contrast to the wealth of data available for the use of DES in patients with ST-elevation myocardial infarction, data regarding the performance of DES in non–ST-elevation ACS is restricted to a handful of registries with conflicting data. The aim of this review was to summarize the safety and efficacy of DES in the entire spectrum of ACS.     

依洛尤单抗对急性冠状动脉综合征患者经皮冠状动脉介入术后不良心血管事件的影响

目的:探讨在他汀类药物应用基础上短期内使用依洛尤单抗能否降低急性冠状动脉综合征(ACS)患者经皮冠状动脉介入术(PCI)术后主要不良心血管事件(MACEs)的发生风险。方法:回顾性分析2019年1月—2019年10月于同济大学附属第十人民医院CCU收治的128例ACS患者为研究对象,根据是否使用依洛尤单抗分为试验组(41例)和对照组(87例),收集并比较两组患者人口统计学信息、实验室检查、基本临床信息、超声心动图结果、冠状动脉造影结果、基线血脂水平和PCI术后1个月血脂水平。对所有患者进行6个月随访,比较两组患者6个月MACEs发生情况,采用Kaplan-Meier生存分析法比较两组患者6个月随访期间MACEs和再发心肌梗死累积发生率。结果:试验组患者PCI术后1个月低密度脂蛋白胆固醇(LDL-C)水平显著低于对照组[0.83(0.54,1.54)mmol/L∶1.71(0.98,2.30)mmol/L,P=0.004]。经过6个月随访,试验组5例(12.2%)发生MACEs,对照组13例(14.9%)发生MACEs,两组患者在MACEs、死亡、卒中、靶血管再灌注等方面差异无统计学意义(P>0.05);其中试验组再发心肌梗死0例,对照组再发心肌梗死9例(10.3%),差异有统计学意义(P=0.027)。Kaplan-Meier生存分析显示两组患者累积再发心肌梗死发生率差异有统计学意义(Log-Rank检验P=0.039)。结论:ACS患者在他汀类药物应用基础上短期内使用依洛尤单抗能有效地降低LDL-C水平,同时能降低ACS患者PCI术后6个月再发心肌梗死风险。     

Características clínicas,angiográficas e evolução a longo prazo em pacientes com arterite de Takayasu e síndrome coronária aguda

IntroductionMonitoring of disease activity and the best therapeutic approach are a challenge in Takayasu arteritis (TA). When associated with acute coronary syndromes (ACS), the best interventional treatment has not been established. The objective of this study was to describe the baseline characteristics, clinical manifestations, treatment and long-term outcome of patients with TA and ACS.MethodsWe retrospectively analyzed eight patients between 2004 and 2010. The following data were obtained: age, gender, clinical and electrocardiographic manifestations, Killip class, risk factors for ACS, markers of myocardial necrosis (CK-MB and troponin), creatinine clearance, left ventricular ejection fraction, inflammatory markers (C-reactive protein and erythrocyte sedimentation rate [ESR]), medication during hospital stay, angiographic findings, treatment (medical, percutaneous or surgical) and long-term outcome. Statistical data were expressed as percentages and absolute values.ResultsAll eight patients were women, median age 49 years. Typical chest pain was present in 37.5%. Elevated ESR was observed in 85.7%. Three patients underwent coronary artery bypass grafting, three underwent percutaneous coronary angioplasty (two with bare-metal stents and one with a drug-eluting stent) and two were treated medically. In-hospital mortality was 25%. There were no deaths during a mean follow-up of 30 months.ConclusionsIn our study, patients who were discharged home had good outcomes in long-term follow-up with medical, percutaneous or surgical treatment. ESR appears to be associated with ACS in TA.     

Percutaneous transluminal therapeutic ultrasound for high-risk thrombus-containing lesions in native coronary arteries.

We assessed the short-term outcome of percutaneous coronary ultrasound thrombolysis (CUT) for high-risk thrombus-containing lesions in native coronaries in the setting of acute coronary syndromes (ACS). Data were prospectively collected in a multicenter (n = 32) registry of consecutive ACS patients. The study population (n = 126) had mostly (84%) totally occluded vessels. The mean age of clot was 5.7 +/- 9.5 days (range, 0-60 days). CUT (41 kHz, 18 W) led to device success in 112 (89%) patients, with a residual stenosis of 69% +/- 20%. Adjunct PTCA or stenting was used in 97% of the patients. Procedural success was achieved in 124 (98%) patients, with a final residual stenosis of 6% +/- 10%. There were no major adverse clinical events during hospitalization. Ultrasound thrombolysis is a feasible procedure that offers a safe and probably effective adjuvant device solution for the treatment of high-risk, thrombus-containing lesions in the native coronary arteries.     

高龄急性冠状动脉综合征患者经皮冠状动脉介入治疗的临床观察

目的评价高龄急性冠状动脉综合征(ACS)患者行经皮冠状动脉介入治疗(PCI)的效果和预后。方法收集入住本院的61例行PCI术的高龄ACS患者的临床资料,其中男性38例,女性23例,年龄为80~88(82±2)岁。19例行急诊PCI术,42例为择期PCI术,观察近期(住院期间)和远期主要不良心脑血管事件(MACCE)的发生和临床预后。结果61例患者中3支血管病变39例(64%),双支血管病变16例(26%),单支血管病变6例(10%);完全闭塞病变25例(41%);14例(34%)患者合并肾动脉狭窄。手术操作成功率97%,术后心肌梗死溶栓试验3级达97%,术后并发症发生率13%,其中造影剂肾病6例(10%)。住院期间MACCE发生率3%,均为心源性死亡,4个月至4年9个月随访期间MACCE发生率22%,包括3例心脑源性死亡、2例其他原因死亡。结论高龄ACS患者行PCI术手术操作成功率高,住院期间病死率和随访期间MACCE发生率较低,但患者病变重,并发症尤其是造影剂肾病发生率相对较高。     

Decrease in annual incidence of acute coronary syndrome and restructuring of coronary care in Latvia

IntroductionImprovement in coronary heart disease prevention and treatment, as well as availability of coronary care facilities, is important for the reduction of acute coronary syndrome (ACS) incidence. Centralized acute coronary care system is crucial to provide optimal hospitalization and management algorithm for ACS patients.AimThe aim of the current report was to assess the annual incidence of ACS and the quality of acute coronary care in Latvia.MethodsThe Data from The Latvian Registry of Acute Coronary Syndromes were analyzed covering the time period from 2005 to 2010.ResultsSince the year 2005 the annual incidence of hospitalization due to ACS decreased significantly in Latvia. The annual incidence of non-ST-elevation ACS (NSTE-ACS) decreased from 8019 to 4613 in absolute numbers based on the registry data during six years. Improvement in the use of guidelines based therapy and early invasive strategy in ACS patients was observed. Increase in primary percutaneous coronary intervention was achieved from 7.9% in 2005 to 57.0% in 2010, contributing to reduction in the proportion of STEMI patients without any reperfusion (from 45% in 2005 to 21% in 2010).ConclusionsThe annual incidence of hospitalized ACS, especially NSTE-ACS, decreased and guidelines based management of ACS improved from 2005 to 2010 in Latvia.     

Rates and causes of death from non-ST elevation acute coronary syndromes: Ten year follow-up of the PRAIS-UK registry

Background

Long term nationally representative mortality rates following acute coronary syndrome (ACS) admissions are lacking beyond 5 years. We report rates and causes of mortality at approximately 10 years from PRAIS-UK.

Methods

PRAIS-UK was a prospective registry of 1046 non-ST-elevation ACS admissions to 56 UK hospitals between 1998 and 1999. 493 patients surviving to 6 months were consented to long term follow-up. We identified deaths and causes (ICD codes) via the UK central death register and examined the influence of baseline characteristics and early revascularisation procedures. A modified GRACE risk score was constructed to determine the association of baseline score with long term risk of death.

Results

The mean age was 66 years and 40% were women. After a median follow-up of 11.6 years (IQR 6.3–11.9), 46% (225) of patients had died with 55% being classified as cardiovascular. In a multivariate analysis, the following variables were associated with higher mortality (hazard ratio [HR] and 95% confidence intervals [CI]): age (10 years increase) 2.14 (1.87 to 2.45), ST depression or bundle branch block (compared to normal ECG) 1.68 (1.06 to 2.67), and history of heart failure (compared to no HF) 1.81 (1.28 to 2.56). The HR for risk of death in patients who received a revascularisation procedure (versus those who did not) in the first 6 months was 0.41 (0.24 to 0.69). The mean adapted GRACE score was 99.3 ± 26.4, associated with approximately 50% mortality at 10 years.

Conclusions

Non-ST elevation ACS is associated with about 50% mortality over 10 years that may be improved by early revascularisation. Well designed long-term registries can provide key data to determine prognosis and burden of disease.     

临床表型对冠状动脉病变低危患者介入治疗远期预后的影响

目的:探讨急性冠状动脉综合征(ACS)和稳定性冠心病(SCAD)对不同性别冠状动脉病变SYNTAX评分≤22分患者介入治疗远期预后的影响.方法:纳入2013年1月至12月在中国医学科学院阜外医院行经皮冠状动脉介入治疗(PCI)且SYNTAX评分≤22分的患者9458例.按临床表型将不同性别的患者分为ACS和SCAD患者...     

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.