New antiplatelet therapies for acute coronary syndromes

Platelets play a central role in the pathophysiology of acute coronary syndromes (ACS). Dual antiplatelet therapy has resulted in significant advances in the treatment of ACS; however, ACS remains an important cause of morbidity and mortality. Important limitations exist among the current antiplatelet agents and therefore a pressing need for the development of improved antiplatelet agents exists. Three antiplatelet agents currently under investigation (prasugrel, AZD6140, and cangrelor) in clinical trials for the treatment of ACS appear promising.     

Relation of anemia at discharge to survival after acute coronary syndromes

Two-year survival rate was assessed among 1,038 patients who had acute coronary syndromes that were classified by discharge hematocrit values as normal (>39%, n = 360, 34.7%), mildly anemic (33.1% to 39%, n = 430, 41.4%), or moderately/severely anemic (< or = 33%, n = 248, 23.9%). Worsening anemia was associated with a decreased 2-year survival rate (normal 95.8%, mild anemia 91.2%, moderate/severe anemia 81.5%, p < 0.001). In multivariable analyses, adjusted hazard ratios for all-cause mortality were 1.57 (95% confidence interval 0.82 to 2.96) for mild anemia and 2.46 (95% confidence interval 1.25 to 4.85) for moderate/severe anemia.     

Cigarette smoking and acute coronary syndromes: a multinational observational study

PURPOSE: To determine the impact of cigarette smoking on the presentation, treatment, and in-hospital outcomes of patients admitted with the full spectrum of acute coronary syndromes. METHODS: GRACE is a multinational observational registry involving 94 hospitals in 14 countries. This analysis is based on 19,325 patients aged at least 18 years admitted for acute coronary syndromes as a presumptive diagnosis with at least one of the following: electrocardiographic changes consistent with acute coronary syndromes, serial increases in serum biochemical markers of cardiac necrosis, and/or documentation of coronary artery disease. The main outcomes measured were mode of presentation, treatment and in-hospital death in the ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, and unstable angina groups to assess the impact of smoking status. RESULTS: Smokers were more frequently diagnosed with ST-segment elevation myocardial infarction (46.0%) than former smokers (27.4%) and non-smokers (30.2%) (P<0.001). Smokers were mostly men, were younger and more aggressively treated than former smokers and non-smokers across the three acute coronary syndrome groups. Unadjusted in-hospital mortality rates were lower in smokers compared with former smokers and non-smokers in the study population (3.3%, 4.5%, and 6.9%, respectively, P<0.001), and in the ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction groups. However, by multivariate logistic analysis, the adjusted in-hospital mortality rate was similar regardless of smoking status. CONCLUSIONS: There is no survival advantage related to current or prior cigarette smoking in patients admitted with acute coronary syndromes, regardless of presentation. In this large multinational registry, the smokers' paradox does not exist.     

Current management of acute coronary syndromes in Australia: observations from the acute coronary syndromes prospective audit

Background: Acute coronary syndromes (ACS) management is now well informed by guidelines extrapolated from clinical trials. However, most of these data have been acquired outside the local context. We sought to describe the current patterns of ACS care in Australia. Methods: The Acute Coronary Syndrome Prospective Audit study is a prospective multi‐centre registry of ST‐segment elevation myocardial infarction (STEMI), high‐risk non‐ST‐segment elevation ACS (NSTEACS‐HR) and intermediate‐risk non‐ST‐segment elevation ACS (NSTEACS‐IR) patients, involving 39 metropolitan, regional and rural sites. Data included hospital characteristics, geographic and demographic factors, risk stratification, in‐hospital management including invasive services, and clinical outcomes. Results: A cohort of 3402 patients was enrolled; the median age was 65.5 years. Female and non‐metropolitan patients comprised 35.5% and 23.9% of the population, respectively. At enrolment, 756 (22.2%) were STEMI patients, 1948 (57.3%) were high‐risk NSTEACS patients and 698 (20.5%) were intermediate‐risk NSTEACS patients. Evidence‐based therapies and invasive management use were highest among suspected STEMI patients compared with other strata (angiography: STEMI 89%, NSTEACS‐HR 54%, NSTEACS‐IR 34%, P < 0.001) (percutaneous coronary intervention: STEMI 68.1%, NSTEACS‐HR 22.2%, NSTEACS‐IR 8.1%, P < 0.001). In hospital mortality was low (STEMI 4.0%, NSTEACS‐HR 1.8%, NSTEACS‐IR 0.1%, P < 0.001), as was recurrent MI (STEMI 2.4%, NSTEACS‐HR: 2.8%, NSTEACS‐IR 1.2%, P = 0.052). Conclusion: There appears to be an ‘evidence‐practice gap’ in the management of ACS, but this is not matched by an increased risk of in‐hospital clinical events. Objective evaluation of local clinical care is a key initial step in developing quality improvement initiatives and this study provides a basis for the improvement in ACS management in Australia.     

Adherence to guidelines in the treatment of acute coronary syndromes: progress over time

BACKGROUND: Treatment of acute coronary syndromes (ACS) has changed considerably in the last few years, as reflected in various proposals for guidelines by the ACC/AHA/ESC based on clinical evidence. We analyzed the clinical implementation of these recommendations in our patient population between 2002 and 2005. METHODS: This was a retrospective study of 368 patients admitted in 2002 and 420 patients admitted in 2005 for ACS (with and without ST-segment elevation). We analyzed clinical characteristics and treatment strategies. RESULTS: There were no differences in terms of age, gender ratio, risk factors for coronary artery disease, or previous myocardial revascularization. There was a decrease in the number of patients with previous myocardial infarction and renal insufficiency on admission, and an increase in patients with ST-segment elevation on admission. Treatment with clopidogrel (6% vs. 87%), beta-blockers (54% vs. 79%), angiotensin-converting enzyme inhibitors (72% vs. 84%) and statins (78% vs. 91%) increased (all with p < 0.001). On the other hand, there was a slight decrease in the use of aspirin (98% vs. 95%, p = 0.039) (with greater use of clopidogrel) and ticlopidine was no longer used (46% vs. 0%, p < 0.001). Use of glycoprotein IIb/IIIa receptor antagonists did not change significantly (66% vs. 67%, p = NS). Percutaneous coronary interventions increased (53% vs. 67% p < 0.001). There was no difference in in-hospital mortality (8.2% vs. 6.4%) or 30-day mortality (9.0% vs. 8.6%), but mortality was lower at one-year follow-up (17.1% vs. 11.7%, p = 0.039). Statins and beta-blockers are independent predictors of mortality during follow-up, with a protective effect. CONCLUSIONS: Between 2002 and 2005, treatment of ACS improved significantly according to existing guidelines, leading to improvement in medium-term mortality.     

Effect of use of combination evidence-based medical therapy after acute coronary syndromes on long-term outcomes

Several medications have individually been shown to reduce mortality in patients with acute coronary syndromes (ACS), but data on long-term outcomes related to the use of combinations of these medications are limited. For 2,684 consecutive patients admitted with ACS from January 1999 and January 2007, a composite score was calculated correlating with the use upon discharge of indicated evidence-based medications (EBMs): aspirin, β blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and lipid-lowering agents. Multivariate models were used to examine the impact of EBM score on 2-year events with adjustment for components of the Global Registry of Acute Coronary Events (GRACE) risk score, thienopyridine use, and year of discharge. Women were older, had more co-morbidities, and were less likely to receive all 4 EBMs (53% vs 64%, p < 0.0001) than men. Patients who received all 4 indicated EBMs had a significant 2-year survival benefit compared to patients who received ≤1 EBM (odds ratio 0.25, 95% confidence interval 0.15 to 0.41), which was observed when men and women were examined separately (for men, odds ratio 0.22, 95% confidence interval 0.11 to 0.44; for women, odds ratio 0.3, 95% confidence interval 0.15 to 0.63). A modest benefit, in terms of cardiovascular disease events (myocardial infarction, rehospitalization, stroke, and death), was observed only for men who received all 4 EBMs. In conclusion, a combination of cardiac medications at the time of ACS discharge is strongly associated with 2-year survival in men and women, suggesting that discharge is an important time to prescribe secondary preventative medications.     

Potential impact of evidence-based medicine in acute coronary syndromes: insights from GUSTO-IIb

Objectives. The purpose of this study to determine whether use of cardiac medications reflects evidence-based recommendations for patients with non–ST elevation acute coronary syndromes.

Background. Agency for Health Care Policy and Research practice guidelines for unstable angina recommend the use of cardiac medications based on evidence from randomized trials. It is unknown whether practitioners in the U.S., Canada and Europe follow these recommendations in patients with non–ST elevation acute coronary syndromes.

Methods. We studied 7,743 patients with non–ST elevation acute coronary syndromes enrolled in the international Global Use of Strategies to Open Occluded Arteries in Acute Coronary Syndromes trial. The use of aspirin, beta-adrenergic blocking agents, angiotensin-converting enzyme inhibitors and calcium channel blocking agents was determined at discharge for all patients and “ideal” patients (those with indications and no contraindications). Using published estimates of relative mortality reductions with these drugs, we calculated the lives that could have been saved at 1 year if discharge medication use had better matched guideline recommendations.

Results. Overall, guideline adherence at discharge in “ideal” patients was 85.6% for aspirin, 59.1% for beta-blockers and 51.7% for angiotensin-converting enzyme inhibitors. Calcium channel blockers were given to 26.7% of patients with a contraindication to these drugs. These rates were similar across locations of enrollment. Women and older patients less often received aspirin when “ideal,” and younger patients more often received calcium channel blockers when they were contraindicated. If medication use had been more evidence-based, 1-year mortality might have been reduced by a relative 22%.

Conclusions. There is significant room for improvement in the use of recommended drugs in patients with non–ST elevation acute coronary syndromes. Medication use that more closely follows recommendations could reduce mortality in this population.     

Complement use of Chinese herbal medicine after percutaneous coronary intervention: a prospective observational study

BACKGROUND Chinese herbal medicine is widely used as a complement or alternative treatment in coronary artery disease(CAD) patients after percutaneous coronary intervention(PCI) in China. We compared the incidence of the major adverse cardiovascular event(MACE) of CAD patients with or without the complement use of Chinese herbal medicine after PCI.METHODS In this prospective, observational study that was conducted from September 2016 to August 2019 in Fuwai Hospital(China), we followed up consec...