Comparing TIMI, HEART, and GRACE Risk Scores to Predict Angiographic Severity of Coronary Artery Disease and 30-Day Major Adverse Cardiac Events in Emergency Department Patients with NSTEACS.

BACKGROUND: Acute coronary syndromes (ACS) are hard to diagnose because their clinical presentation is broad. Current guidelines suggest early clinical risk stratification to the optimal site of care. The aim of this study was to investigate the ability of Thrombolysis in Myocardial Infarction (TIMI); History, Electrocardiogram, Age, Risk Factors, Troponin (HEART); and Global Registry of Acute Coronary Events (GRACE) risk scores to predict the development of major adverse cardiac events (MACE) and the angiographic severity of coronary artery disease (CAD) in patients diagnosed with non-ST-segment elevation acute coronary syndrome (NSTEACS) in the emergency department (ED). In addition, independent variables associated with the development of MACE were also examined. METHODS: This study is a prospective, observational, single-center study. All patients over 18 years of age who were planned to be hospitalized for pre-diagnosed NSTEACS (NSTEMI + UAP) were included in the study consecutively. Patients' demographic information and all variables necessary for calculating risk scores (TIMI, HEART, and GRACE) were recorded. Two experienced cardiologists evaluated all coronary angiograms and calculated the Gensini score. RESULTS: The median age was 60 (IQR: 18) years, and 220 (61.6%) were male of the 357 patients included in the study. In this study, 91 MACE (52 percutaneous coronary interventions [PCI], 28 coronary artery bypass graft [CABG], three cerebrovascular disease [CVD], and eight deaths) occurred. The 30-day MACE rate was 25.5%. The low-risk group constituted 40.0%, 1.4%, and 68.0% of the population, respectively, in TIMI, HEART, and GRACE scores. Multiple logistic regression models for predicting MACE, age (P = .005), mean arterial pressure (MAP; P = .015), and High-Sensitive Troponin I (P = .004) were statistically significant. CONCLUSION: The ability of the GRACE, HEART, and TIMI risk scores to predict severe CAD in patients with NSTEACS is similar. In patients with NSTEACS, the HEART and GRACE risk scores can better predict the development of MACE than the TIMI risk score. When low-risk groups are evaluated according to the three risk scores, the HEART score is more reliable to exclude the diagnosis of NSTEACS.

Gender-related clinical and management differences in patients with chronic heart failure with reduced ejection fraction.

AIM: Gender-related differences have been described in the clinical characteristics and management of patients with chronic heart failure with reduced ejection fraction (HFrEF). However, published data are conflictive in this regard. METHODS: We investigated differences in clinical and management variables between male and female patients from the ATA study, a prospective, multicentre, observational study that included 1462 outpatients with chronic HFrEF between January and June 2019. RESULTS: Study population was predominantly male (70.1%). In comparison to men, women with chronic HFrEF were older (66 ± 11 years vs 69 ± 12 years, P < .001), suffered more hospitalisations and presented more frequently with NYHA class III or IV symptoms. Ischaemic heart disease was more frequent in men, whereas anaemia, thyroid disease and depression were more frequent in women. No difference was seen between genders in the use rate of renin-angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists, or ivabradine, or in the proportion of patients achieving target doses of these drugs. Regarding device therapies, men were more often treated with an implantable cardioverter-defibrillator (ICD) and women received more cardiac resynchronisation therapy. CONCLUSION: In summary, although management seemed to be equivalent between genders, women tended to present with more symptoms, require hospitalisation more frequently and have different comorbidities than men. These results highlight the importance of gender-related differences in HFrEF and call for further research to clarify the causes of these disparities. Gender-specific recommendations should be included in future guidelines in HFrEF.

Adherence to guideline-directed medical and device Therapy in outpAtients with heart failure with reduced ejection fraction: The ATA study.

OBJECTIVE: Despite recommendations from heart failure guidelines on the use of pharmacologic and device therapy in patients with heart failure with reduced ejection fraction (HFrEF), important inconsistencies in guideline adherence persist in practice. The aim of this study was to assess adherence to guideline-directed medical and device therapy for the treatment of patients with chronic HFrEF (left ventricular ejection fraction ≤40%). METHODS: The Adherence to guideline-directed medical and device Therapy in outpAtients with HFrEF (ATA) study is a prospective, multicenter, observational study conducted in 24 centers from January 2019 to June 2019. RESULTS: The study included 1462 outpatients (male: 70.1%, mean age: 67±11 years, mean LVEF: 30%±6%) with chronic HFrEF. Renin-angiotensin system (RAS) inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and ivabradin were used in 78.2%, 90.2%, 55.4%, and 12.1% of patients, respectively. The proportion of patients receiving target doses of medical treatments was 24.6% for RAS inhibitors, 9.9% for beta-blockers, and 10.5% for MRAs. Among patients who met the criteria for implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT), only 16.9% of patients received an ICD (167 of 983) and 34% (95 of 279) of patients underwent CRT (95 of 279). CONCLUSION: The ATA study shows that most HFrEF outpatients receive RAS inhibitors and beta-blockers but not MRAs or ivabradin when the medical reasons for nonuse, such as drug intolerance or contraindications, are taken into account. In addition, most eligible patients with HFrEF do not receive target doses of pharmacological treatments or guideline-recommended device therapy.

Prevalence of inappropriate sinus tachycardia and the comparison of the heart rate variability characteristics with propensity score-matched controls.

OBJECTIVE: Inappropriate sinus tachycardia (IST) is a syndrome characterized by an elevated resting heart rate with distressing symptoms and no secondary cause of sinus tachycardia. This study was conducted to evaluate both the prevalence of IST among symptomatic patients and heart rate variability (HRV) characteristics. METHODS: The records of all consecutive symptomatic patients who had undergone 24-hour Holter monitoring between September 2015 and November 2016 at a single center were retrospectively evaluated. IST was defined as a 24-hour mean heart rate (HR) of ≥90 beats/minute and a resting HR of ≥100 beats/minute in the absence of any secondary cause of sinus tachycardia. All of the study data related to clinical characteristics, symptoms, concomitant diseases, and Holter electrocardiogram parameters were obtained from the electronic hospital records. A propensity age- and sex-matched control group was selected from a non-IST patient cohort. RESULTS: A total of 1865 consecutive patients were evaluated and 32% were excluded due to an inadequate Holter recording period or insufficient quality, atrial fibrillation episodes, atrioventricular block, or >1% atrial or ventricular extrasystoles. Among 1265 patients with sinus rhythm, 4.98% (n=63) had IST. The IST patients were younger (39.6±17.4 vs. 50.2±17.2 years; <0.001), and female gender was more prominent (60.3% vs. 43.8%; p=0.009). All of the time and frequency domain parameters of HRV except the low frequency/high frequency ratio were significantly reduced in the IST group compared with the propensity-matched controls. CONCLUSION: The IST prevalence among symptomatic patients in sinus rhythm was 4.98%. IST was primarily seen in younger women, and they had diminished time and frequency domain HRV parameters.

Survival Benefit of Implantable-Cardioverter Defibrillator Therapy in Ambulatory Patients With Left Ventricular Assist Device.

BACKGROUND: Analysis of the prognostic effect of concomitant use of left ventricular assist devices (LVADs) and implantable -cardioverter defibrillators (ICDs) is lacking. The aim of this study is to define the survival effects of ICD therapy in ambulatory patients with LVAD. METHODS AND RESULTS: Patients with continuous-flow (cf) LVAD in a single tertiary center from December 2010 to May 2016 were retrospectively analyzed. Over a 6-year period, 257 patients had cf-LVAD implantation, 227 of them survived to discharge after the first month of LVAD implantation and were included in the study. The median follow-up time was 14 months, and 104 (45.8%) patients had ICD. One hundred and thirty-two (58.1%) patients were still under LVAD support at the end of the study period. Forty (17.6%) patients had heart transplantation, and 55 (24.2%) died. There was no significant difference between groups with ICD and without ICD for baseline characteristics except for higher pulmonary pressures and amiodarone use in the ICD group. Survival analysis showed significant survival benefit of ICD therapy (P = .02). After multivariate analyses including age, sex, left ventricular ejection fraction, and ß-blocker usage, the benefit of ICD continued (hazard ratio: 0.54; 95% confidence interval, 0.303-0.975; P = .041). CONCLUSIONS: Ventricular arrhythmias (VAs) do not cause acute hemodynamic deterioration in patients with LVAD. However, VAs might be associated with poor prognosis. The present study showed that ICD therapy may improve survival among ambulatory patients with cf-LVAD-supported heart failure.

Transient Contrast Neurotoxicity After Percutaneous Coronary Intervention Mimicking Subarachnoid Hemorrhage in a Patient With Chronic Kidney Disease.

Transient contrast neurotoxicity is a rare but well-recognized complication of angiography that is due to neurotoxicity of the contrast agent. Patients with renal dysfunction may be inclined to develop contrast medium neurotoxicity due to delayed elimination of the contrast medium in renal metabolism. In this report, we present an unusual case of transient neurotoxicity in a patient with severe chronic kidney disease following percutaneous coronary intervention mimicking clinically and radiologically subarachnoid hemorrhage. The patient's clinical symptoms improved rapidly and fully recovered after hemodialysis and conservative treatment. We believe that performing early hemodialysis is an effective treatment to improve symptoms in end-stage renal disease patients with contrast-induced encephalopathy.