Coronary Artery Plaque Phenotype and 5-Year Clinical Outcomes in Older Patients with Non-ST Elevation Acute Coronary Syndrome.

Background: Lesions with thin-cap fibroatheroma (TCFA), small luminal area and large plaque burden (PB) have been considered at high risk of cardiovascular events. Older patients were not represented in studies which demonstrated correlation between clinical outcome and plaque characteristics. This study aims to investigate the prognostic role of high-risk plaque characteristics and long-term outcome in older patients presenting with non-ST elevation acute coronary syndrome (NSTEACS). Methods: This study recruited older patients aged ≥ 75 years with NSTEACS undergoing virtual-histology intravascular ultrasound (VH-IVUS) imaging from the Improve Clinical Outcomes in high-risk patieNts with acute coronary syndrome (ICON-1). Primary endpoint was the composite of major adverse cardiovascular events (MACE) consisting of all-cause mortality, myocardial infarction (MI), and any revascularisation. Every component of MACE and target vessel failure (TVF) including MI and any revascularisation were considered as secondary endpoints. Results: Eighty-six patients with 225 vessels undergoing VH-IVUS at baseline completed 5-year clinical follow-up. Patients with minimal lumen area (MLA) ≤ 4 mm 2 demonstrated increased risk of MACE (hazard ratio [HR] 2.37, 95% confidence interval [CI] 1.00-5.59, p = 0.048) with a worse event-free survival (Log Rank 4.17, p = 0.041) than patients with MLA > 4 mm 2 . Patients with combination of TCFA, MLA ≤ 4 mm 2 and PB ≥ 70% showed high risk of MI (HR 5.23, 95% CI 1.05-25.9, p = 0.043). Lesions with MLA ≤ 4 mm 2 had 6-fold risk of TVF (HR 6.16, 95% CI 1.24-30.5, p = 0.026). Conclusions: Small luminal area appears as the major prognostic factor in older patients with NSTEACS at long-term follow-up. Combination of TCFA, MLA ≤ 4 mm 2 and PB ≥ 70% was associated with high risk of MI. Clinical Trial Registration: NCT01933581.

The association of inflammatory biomarkers and long-term clinical outcomes in older adults with non-ST elevation acute coronary syndrome.

BACKGROUND: The prognostic significance of inflammatory markers on the long-term risk of major adverse cardiovascular and cerebrovascular events (MACCE) in older NSTEACS patients remains unclear. METHODS: NSTEACS patients aged 75 and older were recruited to the multicentre cohort study Improve Cardiovascular Outcomes in High-Risk PatieNts with Acute Coronary Syndrome (ICON1). Inflammatory markers including interleukin-6 (IL-6), myeloperoxidase (MPO), high-sensitivity C-reactive protein (hsCRP), fibrinogen and tumor necrosis factor-alpha (TNF-α) were collected at baseline. Primary outcome was MACCE consisting of all-cause mortality, reinfarction, stroke/transient ischaemic attack, urgent revascularization, and significant bleeding at 5-year follow-up. RESULTS: There were 230 patients with baseline IL-6 (median age 80.9 [interquartile range (IQR):78.2-83.9] years). High IL-6 was not associated with MACCE, but it was independently associated with all-cause mortality (adjusted hazard ratio [aHR]: 2.26 [95% Confidence Interval (CI):1.34-3.82]; P = 0.002). For patients with hsCRP (n = 260, median age 80.9 [IQR:77.9-84.1] years), higher levels were significantly associated with increased risk of MACCE (aHR:1.77 [95% CI:1.26-2.49], P = 0.001). In the cohort with MPO (230 patients, median age 80.9 [IQR:78.2-83.9] years), lower MPO was independently associated with the risk of MACCE (aHR: 0.67 [95%CI:0.46-0.96]; P = 0.029). There was no prognostic significance with fibrinogen and TNF-α. CONCLUSION: Among older NSTEACS patients, elevated IL-6 and hsCRP were associated with increased risk of all-cause mortality and MACCE, respectively. Low MPO levels were associated with higher MACCE. Further studies are required to determine how these biomarkers should influence treatment strategy in this understudied subset. CLINICAL TRIAL REGISTRATION: NCT01933581.

Non-ST-elevation acute coronary syndromes with previous coronary artery bypass grafting: a meta-analysis of invasive vs. conservative management.

BACKGROUND AND AIMS: A routine invasive strategy is recommended in the management of higher risk patients with non-ST-elevation acute coronary syndromes (NSTE-ACSs). However, patients with previous coronary artery bypass graft (CABG) surgery were excluded from key trials that informed these guidelines. Thus, the benefit of a routine invasive strategy is less certain in this specific subgroup. METHODS: A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted. A comprehensive search was performed of PubMed, EMBASE, Cochrane, and ClinicalTrials.gov. Eligible studies were RCTs of routine invasive vs. a conservative or selective invasive strategy in patients presenting with NSTE-ACS that included patients with previous CABG. Summary data were collected from the authors of each trial if not previously published. Outcomes assessed were all-cause mortality, cardiac mortality, myocardial infarction, and cardiac-related hospitalization. Using a random-effects model, risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. RESULTS: Summary data were obtained from 11 RCTs, including previously unpublished subgroup outcomes of nine trials, comprising 897 patients with previous CABG (477 routine invasive, 420 conservative/selective invasive) followed up for a weighted mean of 2.0 (range 0.5-10) years. A routine invasive strategy did not reduce all-cause mortality (RR 1.12, 95% CI 0.97-1.29), cardiac mortality (RR 1.05, 95% CI 0.70-1.58), myocardial infarction (RR 0.90, 95% CI 0.65-1.23), or cardiac-related hospitalization (RR 1.05, 95% CI 0.78-1.40). CONCLUSIONS: This is the first meta-analysis assessing the effect of a routine invasive strategy in patients with prior CABG who present with NSTE-ACS. The results confirm the under-representation of this patient group in RCTs of invasive management in NSTE-ACS and suggest that there is no benefit to a routine invasive strategy compared to a conservative approach with regard to major adverse cardiac events. These findings should be validated in an adequately powered RCT.

The impact of patient-reported frailty on cardiovascular outcomes in elderly patients after non-ST-acute coronary syndrome.

BACKGROUND: As life expectancy increases, the population of older individuals with coronary artery disease and frailty is growing. We aimed to assess the impact of patient-reported frailty on the treatment and prognosis of elderly early survivors of non-ST-elevation acute coronary syndrome (NSTE-ACS). METHODS: Frailty data were obtained from two prospective trials, POPular Age and the POPular Age Registry, which both assessed elderly NSTE-ACS patients. Frailty was assessed one month after admission with the Groningen Frailty Indicator (GFI) and was defined as a GFI-score of 4 or higher. In these early survivors of NSTE-ACS, we assessed differences in treatment and 1-year outcomes between frail and non-frail patients, considering major adverse cardiovascular events (MACE, including cardiovascular mortality, myocardial infarction, and stroke) and major bleeding. RESULTS: The total study population consisted of 2192 NSTE-ACS patients, aged ≥70 years. The GFI-score was available in 1320 patients (79 ± 5 years, 37% women), of whom 712 (54%) were considered frail. Frail patients were at higher risk for MACE than non-frail patients (9.7% vs. 5.1%, adjusted hazard ratio [HR] 1.57, 95% confidence interval [CI] 1.01-2.43, p = 0.04), but not for major bleeding (3.7% vs. 2.8%, adjusted HR 1.23, 95% CI 0.65-2.32, p = 0.53). Cubic spline analysis showed a gradual increase of the risk for clinical outcomes with higher GFI-scores. CONCLUSIONS: In elderly NSTE-ACS patients who survived 1-month follow-up, patient-reported frailty was independently associated with a higher risk for 1-year MACE, but not with major bleeding. These findings emphasize the importance of frailty screening for risk stratification in elderly NSTE-ACS patients.

Impact of non-gated computed tomography on the timing of invasive strategy of patients with non-ST-elevation acute coronary syndrome.

Background: This study aimed to examine the clinical role of non-gated computed tomography (CT) in ruling out fatal chest pain in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), with a focus on the time of arrival at the hospital to coronary angiography (CAG) and peak creatine kinase (CK) levels. Methods: We retrospectively examined 196 NSTE-ACS patients who were admitted with urgently diagnosed NSTE-ACS and underwent percutaneous coronary intervention between March 2019 and October 2022. The patients were divided into three groups, namely, non-CT group, CT and defect- group, and CT and defect+ group, based on whether they underwent a CT scan and the presence or absence of perfusion defects on the CT image. Results: After the initial admission for NSTE-ACS, 40 patients (20.4%) underwent non-gated CT prior to CAG. Among these 40 patients, 27 had a perfusion defect on the CT scan. The incidence of contrast-induced nephropathy was not different among the three groups. The CT and defect+ group had a shorter arrival-to-CAG time than that of the non-CT group. In NSTE-ACS patients with elevated CK levels, the CT and defect+ group had lower peak CK levels than those in the non-CT group. Conclusion: NSTE-ACS patients with perfusion defects on non-gated CT had a shorter time from arrival to CAG, which might be associated with a lower peak CK. Non-gated CT might be useful for early diagnosis and early revascularization in the clinical setting of NSTE-ACS.

Serum cystatin C predicts the risk of non-ST-elevation acute coronary syndrome.

OBJECTIVE: Inflammation markers have been proposed as the predictors of adverse cardiac events in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). This study aimed to investigate prognostic value of serum cystatin C (Cys-C) for NSTE-ACS patients. METHODS: Cys-C, neutrophil to lymphocyte ratio (NLR) and high-sensitivity C-reactive protein (hsCRP) were examined in 212 NSTE-ACS patients and 60 controls. Global registry of acute coronary events (GRACE) score and major adverse cardiac events (MACE) in NSTE-ACS patients were recorded. RESULTS: Cys-C level in the serum was significantly higher in NSTE-ACS patients than in control, and was positively correlated with hsCRP level and NLR as well as GRACE score at admission and 6 months after discharge in NSTE-ACS patients. Serum Cys-C level was identified as a new predictor of MACE. CONCLUSION: Serum Cys-C level may be an inflammation biomarker in patients with NSTE-ACS, and could be used as an independent predictor of MACE.

Comprehensive evaluation of time-varied outcomes for invasive and conservative strategies in patients with NSTE-ACS: a meta-analysis of randomized controlled trials.

Background: Results from randomized controlled trials (RCTs) and meta-analyses comparing invasive and conservative strategies in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) are highly debatable. We systematically evaluate the efficacy of invasive and conservative strategies in NSTE-ACS based on time-varied outcomes. Methods: The RCTs for the invasive versus conservative strategies were identified by searching PubMed, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov. Trial data for studies with a minimum follow-up time of 30 days were included. We categorized the follow-up time into six varied periods, namely, ≤6 months, 1 year, 2 years, 3 years, 5 years, and ≥10 years. The time-varied outcomes were major adverse cardiovascular event (MACE), death, myocardial infarction (MI), rehospitalization, cardiovascular death, bleeding, in-hospital death, and in-hospital bleeding. Risk ratios (RRs) and 95% confidence intervals (Cis) were calculated. The random effects model was used. Results: This meta-analysis included 30 articles of 17 RCTs involving 12,331 participants. We found that the invasive strategy did not provide appreciable benefits for NSTE-ACS in terms of MACE, death, and cardiovascular death at all time points compared with the conservative strategy. Although the risk of MI was reduced within 6 months (RR 0.80, 95% CI 0.68-0.94) for the invasive strategy, no significant differences were observed in other periods. The invasive strategy reduced the rehospitalization rate within 6 months (RR 0.69, 95% CI 0.52-0.90), 1 year (RR 0.73, 95% CI 0.63-0.86), and 2 years (RR 0.77, 95% CI 0.60-1.00). Of note, an increased risk of bleeding (RR 1.80, 95% CI 1.28-2.54) and in-hospital bleeding (RR 2.17, 95% CI 1.52-3.10) was observed for the invasive strategy within 6 months. In subgroups stratified by high-risk features, the invasive strategy decreased MACE for patients aged ≥65 years within 6 months (RR 0.68, 95% CI 0.58-0.78) and 1 year (RR 0.75, 95% CI 0.62-0.91) and showed benefits for men within 6 months (RR 0.71, 95% CI 0.55-0.92). In other subgroups stratified according to diabetes, ST-segment deviation, and troponin levels, no significant differences were observed between the two strategies. Conclusions: An invasive strategy is superior to a conservative strategy in reducing early events for MI and rehospitalizations, but the invasive strategy did not improve the prognosis in long-term outcomes for patients with NSTE-ACS. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021289579, identifier PROSPERO 2021 CRD42021289579.

The Role of Neutrophil to Lymphocyte Ratio and its Common Clinical Outcomes Among Patients with Non-ST Elevation Acute Coronary Syndrome.

Objectives: To evaluate the admission neutrophil-to-lymphocyte ratio (NLR) for risk stratification for in-hospital outcomes and complications in non-ST-elevation acute coronary syndrome (non-ST-ACS) patients. Methods: We recruited consecutive patients with non-ST-ACS. The NLR was obtained and stratified as low, intermediate, and high-risk based on <3.0, 3.0-6.0, and >6.0, respectively. The new ST-T changes, arrhythmias, contrast-induced nephropathy (CIN), and mortality were recorded. Results: Median NLR was 3 [2.1-5.3] for 346 patients with 19.9% and 30.6% in high- and intermediate-risk group. New ST-T changes were observed in 3.5% (12) out of which 8, 3, and 1 patient in low, intermediate, and high-risk group (p = 0.424), respectively. Arrhythmias were observed in 5.8% (20) with 7, 5, and 8 patients in low, intermediate, and high-risk group (p = 0.067), respectively. CIN was observed in 4.9% (17) with 5, 5, and 7 in low, intermediate, and high-risk group (p = 0.064), respectively. In-hospital mortality was recorded in 1.4% (5) with 2 and 3 patients in high and low-risk group (p = 0.260), respectively. Conclusion: A significant number of non-ST-ACS patients fall in the high-risk category of NLR. Although, the association between NLR and in-hospital mortality and adverse events was not statistically significant but relatively higher rates of events were observed in high risk group.

Early vascular healing after neXt-generation drug-eluting stent implantation in Patients with non-ST Elevation acute Coronary syndrome based on optical coherence Tomography guidance and evaluation (EXPECT): study protocol for a randomized controlled trial.

Background: There is limited evidence about vessel wall healing response following implantation of next-generation drug-eluting stents (DES) in patients admitted with a non-ST elevation acute coronary syndrome (NSTE-ACS). Cumulative data indicate that optical coherence tomography (OCT) imaging can optimize percutaneous coronary intervention results and expedite stent endothelialization in the general population but there is lack of data in NSTE-ACS patients. Methods: The EXPECT study is an investigator-initiated, prospective, randomized trial to assess early vascular healing response following next-generation DES implantation in patients admitted with NSTE-ACS based on OCT guidance and evaluation. Sixty patients are randomized at 1:1:1 ratio to OCT-guided percutaneous coronary intervention (PCI) with 3-month follow-up OCT imaging (O3 group, n = 20), to angiography-guided PCI with 3-month follow-up OCT imaging (A3 group, n = 20) and to angiography-guided PCI with 6-month follow-up OCT imaging (A6 group, n = 20). The primary endpoint of the study is stent strut coverage rate at 3- or 6- month follow-up in the studied groups. The secondary endpoints of the study include OCT imaging endpoints, clinical endpoints, and molecular biology endpoints at the different time points. The clinical endpoints comprised of major cardiovascular adverse events and individual components. The molecular biology endpoints comprised of lipid levels and the levels of inflammatory indicators. Discussion: The findings of the EXPECT study are anticipated to provide novel insights into vessel wall healing in NSTE-ACS population following implantation of next-generation DES, underscore the value of OCT imaging in expediting strut coverage in this setting, and explore the potential of an early discontinuation of dual antiplatelet therapy (DAPT) in this population. Clinical Trial Registration: ClinicalTrials.gov, NCT04375319.

A Case of Spontaneous Multivessel Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) is a non-traumatic separation of the epicardial coronary arterial wall leading to luminal obstruction with subsequent myocardial ischemia and infarction. Herein, we describe an interesting case of acute coronary syndrome due to multivessel SCAD without an underlying susceptibility or trigger, and review the literature for SCAD management.

The association between tissue doppler-derived E/(e's') ratio and coronary atherosclerosis severity measured by the SYNTAX score in patients with non-ST elevation-acute coronary syndrome.

BACKGROUND: The prognosis of patients hospitalized with non-ST elevation-acute coronary syndrome (NSTE-ACS) is typically determined by the existence and severity of myocardial necrosis and left ventricular (LV) remodeling. AIM: The present study was to assess the association between the E/(e's') ratio and the coronary atherosclerosis severity, measured by the SYNTAX score, in patients with NSTE-ACS. METHODS: Utilizing a descriptive correlational research design, this study was prospectively conducted on 252 patients with NSTE-ACS, undergoing an echocardiography to determine the left ventricular ejection fraction (LVEF), the left atrial (LA) volume, the pulsed-wave (PW) Doppler-derived transmitral early (E) and late (A) diastolic velocities, and the tissue Doppler (TD)-derived mitral annular early diastolic (e') and peak systolic (s') velocities. After that, a coronary angiography (CAG) was performed, and the SYNTAX score was calculated. RESULTS: The patients were divided into two groups, viz., those with the E/(e's') ratio < 1.63 and the cases with the ratio ≥ 1.63. The results revealed that the patients with a high ratio were older, had a higher prevalence of females, a SYNTAX score ≥ 22, and a lower glomerular filtration rate than those with a low ratio (p-value < 0.001). Besides, these patients had larger indexed LA volume and lower LVEF than others (p-value: 0.028 and 0.023, respectively). Furthermore, the multiple linear regression outcomes established a positive independent association between the E/(e's') ratio ≥ 1.63 (B = 5.609, 95% CI 2.324-8.894, p-value = 0.001) and the SYNTAX score. CONCLUSION: The study results demonstrated that the patients hospitalized with NSTE-ACS and the E/(e's') ratio ≥ 1.63 had worse demographic, echocardiographic, and laboratory profiles and a higher prevalence of a SYNTAX score ≥ 22 than those with a lower ratio.

Effects of TCFA on stent neointimal coverage at 9 months after EXCEL drug-eluting stent implantation assessed by OCT.

BACKGROUND: The aim of this study was to investigate the effects of thin-cap fibroatheromas (TCFAs) on stent neointimal coverage at the 9­month follow-up after EXCEL stent implantation assessed by optical coherence tomography (OCT). METHODS: A total of 93 patients with non-ST elevation acute coronary syndrome (NSTEACS) who underwent EXCEL stent implantation were prospectively enrolled in the study and divided into a TCFA group (n = 47) and a non-TCFA group (n = 46) according to whether EXCEL stents covered the TCFAs. A TCFA was defined as a plaque with lipid content in more than one quadrant and fibrous cap thickness measuring less than 65 µm. The effect of TCFAs on stent neointimal coverage at the 9­month follow-up after stent implantation was evaluated by OCT. The primary study endpoints were the incidence of neointimal uncoverage and stent malapposition. RESULTS: At the 9­month follow-up, the minimal lumen diameter of the TCFA group tended to be smaller (2.8 ± 0.8 vs. 2.1 ± 0.8, p = 0.08) and the diameter of stenosis in the TCFA group tended to be larger (15.1 ± 10.3% vs. 26.3 ± 15.1%, p = 0.08) than those in the non-TCFA group. The mean intimal thickness of the TCFA group was significantly lower than that of the non-TCFA group (67.2 ± 35.5 vs. 145.1 ± 48.7, p < 0.001). The uncovered struts (10.1 ± 9.7 vs. 4.8 ± 4.3, p = 0.05) and malapposed struts (2.1 ± 4.7 vs. 0.3 ± 0.5, p = 0.003) in the TCFA group were more significant than those in the non-TCFA group. Multivariate analysis showed that TCFAs and lesion types were independent predictors of incomplete neointimal coverage (p < 0.05), and lesion types were independent predictors of stent malapposition (p < 0.05). CONCLUSION: In patients with NSTEACS, TCFAs delayed endothelium coverage at 9 months after stent implantation, and TCFAs were independent predictors of incomplete neointimal coverage of the stent.

Frequency Of Hyperuricemia In Subjects With Unstable Angina/Myocardial Infarction And Their Prognosis.

BACKGROUND: Inhibition of nitric oxide synthesis and stimulation of smooth muscle proliferation by increased serum levels of uric acid play an important role in accelerated atherogenesis in the vessels of patients with hyperuricemia. The objective of the study was to determine the frequency of hyperuricemia in patients with acute coronary syndrome and their in-hospital outcomes. METHODS: This cross-sectional study was conducted in the cardiology department of Ayub Teaching Hospital, Abbottabad from 1st September, 2018 to 28th February, 2019. A total of 199 patients diagnosed with acute coronary syndrome (ACS) were enrolled in this study using non-probability consecutive sampling. Diagnosis of ACS was made on history, electrocardiogram (ECG) findings and on the presence of elevated cardiac biomarkers. Serum uric acid was checked within 24 hours of presentation and patients were grouped into hyperuricemic and normouricemic groups according to uric acid levels. Next in-hospital outcomes were compared between the two groups by comparing the presence or absence of complications. The data was collected on a structured proforma and was analyzed statistically by using SPSS version 16. RESULTS: Out of 199 patients, 146 (73.37%) were male and 53 (26.63%) were female. The mean age of the study participants was 57.99 ± 6.07 years with a range of 48-68 years. Hyperuricemia was diagnosed in 50 (25.13%) study participants. Among complications, 15 patients (7.94%) had cardiogenic shock, 27 (13.57%) had heart failure, 10 (5.03%) had cardiac arrhythmias, 16 (8.04%) had conduction defects and hyperuricemia was diagnosed in 50 (25.13%) patients. Cardiogenic shock was more common in patients with hyperuricemia (p < 0.05). CONCLUSIONS: Hyperuricemia is associated with a number of significant adverse outcomes for patients with an acute coronary event. Regular screening / monitoring of serum uric acid level in general population can prevent the direct and indirect morbidity associated with hyperuricemia.

The role of 12-lead electrocardiogram in the risk stratification of non-ST elevation acute coronary syndrome and the correlation with coronary angiography - The CINCHONa study - A prospective cohort study in Northern India.

Background: Clinical guidelines recommend risk stratification of non-ST elevation acute coronary syndrome (NST-ACS) using the GRACE risk score. However, the GRACE risk score is not followed widely in clinical practice due to various reasons. Our primary objectives of this study were to correlate the presenting electrocardiogram (ECG) of NST-ACS with coronary angiography (CAG) findings and to identify specific ECG changes that are suggestive of severe coronary artery disease (CAD) thus helping to triage all patients with NST-ACS. Materials and Methods: This prospective observational study was undertaken on patients diagnosed with NST-ACS in a medical college hospital, in Northern India over one and a ½ years. The admission ECG of the patients was compared with CAG findings to find out the correlation between the two with respect to severity of CAD. Categorical and quantitative variables were compared using the Chi-square test and independent t-test, respectively. Odds ratio (OR) were calculated using the univariate logistic regression analysis. Results: On comparing the two groups with normal and abnormal ECG, we found that smokers had significantly higher odds of having an abnormal ECG (OR 3.31; 95% confidence interval [CI] [1.29-8.50]). Patients with an abnormal ECG had significantly lower left ventricular ejection fraction compared to those with normal ECG (52.01 ± 10.56 vs. 55.96 ± 6.13%, P = 0.045). The patients with severe CAD on CAG had significantly higher odds of abnormal ECG (OR 3.68, 95% CI [1.2311.04]). Of the specific ECG abnormalities, ST depression and T-wave inversion in same or different leads were significantly associated with severity of CAD (OR 0.13, 95% CI [0.04-0.43], P = 0.001 and OR 0.13, 95% CI [0.03-0.46], P = 0.002, respectively). Conclusion: The identification of ECG changes suggestive of high-risk CAD can dictate to transfer such patients without delay to a percutaneous coronary intervention capable hospital for urgent CAG with intent to revascularization, thus helping in risk stratification of NST-ACS at the community level.

Résumé Contexte: Les directives cliniques recommandent la stratification du risque de syndrome coronarien aigu sans élévation du segment ST (SCA-NST) à l'aide du GRACE cote de risque. Cependant, le score de risque GRACE n'est pas largement suivi dans la pratique clinique pour diverses raisons. Nos objectifs premiers de cette étude étaient de corréler l'électrocardiogramme (ECG) de présentation du NST-ACS avec les résultats de l'angiographie coronarienne (CAG) et de identifier les modifications spécifiques de l'ECG qui suggèrent une maladie coronarienne (CAD) sévère, aidant ainsi au triage de tous les patients atteints de NST-ACS. Matériels et Méthodes: Cette étude observationnelle prospective a été entreprise sur des patients diagnostiqués avec un NST-ACS dans une faculté de médecine. hôpital, dans le nord de l'Inde pendant un an et demi. L'ECG d'admission des patients a été comparé aux résultats du CAG pour déterminer la corrélation entre les deux par rapport à la sévérité de la coronaropathie. Les variables catégorielles et quantitatives ont été comparées à l'aide du test du Chi-carré et test t indépendant, respectivement. Les rapports de cotes (OR) ont été calculés à l'aide de l'analyse de régression logistique univariée. Résultats: En comparant les deux groupes avec un ECG normal et anormal, nous avons constaté que les fumeurs avaient une probabilité significativement plus élevée d'avoir un ECG anormal (OR 3,31 ; Intervalle de confiance à 95 % [IC] [1,29­8,50]). Les patients avec un ECG anormal avaient une fraction d'éjection ventriculaire gauche significativement inférieure à à ceux ayant un ECG normal (52,01 ± 10,56 vs 55,96 ± 6,13 %, P = 0,045). Les patients atteints de coronaropathie sévère sur CAG avaient des taux significativement plus élevés risque d'ECG anormal (OR 3,68, IC à 95 % [1,2311,04]). Parmi les anomalies spécifiques de l'ECG, le sous-décalage du segment ST et l'inversion de l'onde T dans le même ou différentes dérivations étaient significativement associées à la sévérité de la coronaropathie (OR 0,13, IC 95 % [0,04­0,43], P = 0,001 et OR 0,13, IC 95 % [0,03­0,46], P = 0,002, respectivement). Conclusion: L'identification des modifications de l'ECG suggérant une coronaropathie à haut risque peut dicter le transfert de ces patients sans délai vers un hôpital capable d'intervention coronarienne percutanée pour CAG urgent avec intention de revascularisation, contribuant ainsi au risque stratification du NST-ACS au niveau communautaire. Mots-clés: Syndrome coronarien aigu, coronarographie, électrocardiogramme, score de risque GRACE, coronarien aigu sans sus-décalage du segment ST syndrome.

Sex differences in long-term outcomes in older adults undergoing invasive treatment for non-ST elevation acute coronary syndrome: An ICON-1 sub-study.

Background: Cardiovascular disease is the leading cause of mortality for females globally, yet females are underrepresented in studies of acute coronary syndrome (ACS). Studies investigating sex-related differences in clinical outcomes of patients with non-ST elevation ACS (NSTEACS) have reported divergent results, and it is unknown whether long-term outcomes for older people with NSTEACS differ between males and females. Methods: The multi-centre prospective cohort study, ICON-1, consisted of patients aged ≥75 years undergoing coronary angiography following NSTEACS. The primary composite endpoint was all-cause mortality, myocardial infarction, unplanned revascularisation, stroke, and bleeding. We report outcomes at five-years by sex. Results: Of 264 patients, 102 (38.6%) females and 162 (61.4%) males completed the five-year follow-up and were included in the analytic cohort. At admission, females were older than males (82 ± 4.3 years vs 80.0 ± 4.1 years p = 0.018). Co-morbidity profile and GRACE score were similar between the groups. There were no differences in the provision of invasive or pharmacological treatments between sexes. At five-years, there were no association between sex and the primary outcome. Conclusion: In older adults with invasive treatment of NSTEACS, provision of guideline-indicated care and long-term clinical outcomes were similar between males and females.

Outcomes after coronary angiography for unstable angina compared to stable angina, myocardial infarction and an asymptomatic general population.

Background: The outcomes of real-world unstable angina (UA) in the high-sensitivity troponin era are unclear. We aimed to investigate the outcomes of UA referred to coronary angiography compared to stable angina (SA), non-ST-segment elevation myocardial infarction (NSTEMI), STEMI and a general population. Methods: We included the 9,694 patients with no prior coronary artery disease (CAD) referred to invasive or CT coronary angiography from 2013 to 2018 in Northern Norway (51% SA, 12% UA, 23% NSTEMI and 14% STEMI), and 11,959 asymptomatic individuals recruited from the Tromsø Study. We used Cox models to estimate the hazard ratios (HR) for all-cause mortality and major adverse cardiovascular events (MACE), defined as cardiovascular death, MI or obstructive CAD. Results: The median follow-up time was 2.8 years. The incidence rate of death was 8.5 per 1000 person-years (95 % confidence interval [CI] 8.0-9.0) in the general population, 9.7 (95 % CI 8.3-11.5) in SA, 14.9 (95 % CI 11.4-19.6) in UA, 29.7 (95 % CI 25.6-34.3) in NSTEMI and 36.5 (95 % CI 30.9-43.2) in STEMI. In multivariable adjusted analyses, compared with UA, SA had a 38 % lower risk of death and a non-significant lower risk of MACE (HR 0.62, 95 % CI 0.44-0.89; HR 0.86, 95 % CI 0.66-1.11). NSTEMI had a 2.4-fold higher risk of death (HR 2.39, 95 % CI 1.38-4.14) and a 1.6-fold higher risk of MACE (HR 1.62, 95 % CI 1.11-2.38) compared tox UA during the first year after coronary angiography, but a similar risk thereafter. There was no difference in the risk of death for UA with non-obstructive CAD and obstructive CAD (HR 0.78, 95 % CI 0.39-1.57). Conclusion: UA had a higher risk of death but a similar risk of MACE compared to SA and a lower 1-year risk of death and MACE compared to NSTEMI.

Timing of invasive strategy in non-ST-elevation acute coronary syndrome: a meta-analysis of randomized controlled trials.

AIMS: The optimal timing of an invasive strategy (IS) in non-ST-elevation acute coronary syndrome (NSTE-ACS) is controversial. Recent randomized controlled trials (RCTs) and long-term follow-up data have yet to be included in a contemporary meta-analysis. METHODS AND RESULTS: A systematic review of RCTs that compared an early IS vs. delayed IS for NSTE-ACS was conducted by searching MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. A meta-analysis was performed by pooling relative risks (RRs) using a random-effects model. The primary outcome was all-cause mortality. Secondary outcomes included myocardial infarction (MI), recurrent ischaemia, admission for heart failure (HF), repeat re-vascularization, major bleeding, stroke, and length of hospital stay. This study was registered with PROSPERO (CRD42021246131). Seventeen RCTs with outcome data from 10 209 patients were included. No significant differences in risk for all-cause mortality [RR: 0.90, 95% confidence interval (CI): 0.78-1.04], MI (RR: 0.86, 95% CI: 0.63-1.16), admission for HF (RR: 0.66, 95% CI: 0.43-1.03), repeat re-vascularization (RR: 1.04, 95% CI: 0.88-1.23), major bleeding (RR: 0.86, 95% CI: 0.68-1.09), or stroke (RR: 0.95, 95% CI: 0.59-1.54) were observed. Recurrent ischaemia (RR: 0.57, 95% CI: 0.40-0.81) and length of stay (median difference: -22 h, 95% CI: -36.7 to -7.5 h) were reduced with an early IS. CONCLUSION: In all-comers with NSTE-ACS, an early IS does not reduce all-cause mortality, MI, admission for HF, repeat re-vascularization, or increase major bleeding or stroke when compared with a delayed IS. Risk of recurrent ischaemia and length of stay are significantly reduced with an early IS.

Deceleration Capacity Improves Prognostic Accuracy of Relative Increase and Final Coronary Physiology in Patients With Non-ST-Elevation Acute Coronary Syndrome.

Background: Both coronary physiology and deceleration capacity (DC) showed prognostic efficacy for patients with acute coronary syndrome (ACS). This retrospective cohort study was performed to evaluate the prognostic implication of DC combined with the relative increase and final coronary physiology as detected by quantitative flow ratio (QFR) for patients with non-ST-elevation ACS (NSTE-ACS) who underwent complete and successful percutaneous coronary intervention (PCI). Methods: Patients with NSTE-ACS who underwent PCI with pre- and post-procedural QFR in our department between January 2018 and November 2019 were included. The 24-hour deceleration capacity (DC 24h) was obtained via Holter monitoring. The incidence of major adverse cardiac and cerebrovascular events (MACCEs) during follow up was defined as the primary outcome. The optimal cutoffs of the relative increase, final QFR, and DC 24h for prediction of MACCEs were determined via receiver operating characteristic (ROC) analysis and the predictive efficacies were evaluated with multivariate Cox regression analysis. Results: Overall, 240 patients were included. During a mean follow up of 21.3 months, 31 patients had MACCEs. Results of multivariate Cox regression analyses showed that a higher post-PCI QFR [adjusted hazard ratio (HR): 0.318; 95% confidence interval (CI): 0.129-0.780], a higher relative QFR increase (HR: 0.161; 95% CI: 0.066-0.391], and a higher DC (HR: 0.306; 95% CI: 0.134-0.701) were all independent predictors of lower risk of MACCEs. Subsequently, incorporating low DC (≤2.42) into the risk predicting model with clinical variables, the predictive efficacies of low relative QRS increase (≤23%) and low post-PCI QFR (≤0.88) for MACCEs were both significantly improved. Conclusions: The DC combined with relative increase and final coronary physiology may improve the predictive efficacy of existing models based on clinical variables for MACCEs in NSTE-ACS patients who underwent complete and successful PCI.

Gender Particularities and Prevalence of Atypical Clinical Presentation in Non-ST Elevation Acute Coronary Syndrome.

Clinical presentation is one of the factors that can influence how quickly a patient with an acute coronary syndrome is treated, particularly if it is atypical. The purposes of this study are to explore gender-related differences in patients presenting with non-ST elevation acute coronary syndromes (NSTEACS) from the perspective of a series of common risk factors as well as treatment strategies and to evaluate the prevalence of atypical clinical presentation of NSTEACS in the study group. In addition, we explored the differences between the two entities that define NSTEACS: unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI). We conducted a retrospective study by reviewing discharge documents of patients admitted in the cardiology department of the Clinical Rehabilitation Hospital in Cluj-Napoca with NSTEACS between January 2014 and December 2015. We retrieved demographic data, clinical presentation and history, laboratory tests, and coronary angiography records as well as the implemented treatment strategies. Women in the study group were more frequently hypertensive than men (89.5% vs. 75.4%; p = 0.043), had a higher mean serum HDL cholesterol value (43 vs. 38 mg/dL p = 0.022), were more frequently diagnosed with microvascular coronary heart disease (32% vs. 9.8%, p = 0.036), and were more often treated conservatively (49.1% vs. 30.8%, p = 0.038), while men were significantly more prone to smoking than women (30.8% vs. 14%, p = 0.028) and had higher mean serum creatinine (1.2 vs. 0.8 mg/dL; p = 0.022) and uric acid values (6.9 vs. 6.2 mg/dL; p = 0.048). Out of the 122 included patients, 109 had documented information regarding symptoms. The prevalence of atypical presentation was 4.6% (95% CI 0.7-8.5%). In our study group, patients with UA had a more frequent history of cardiovascular ischemic diseases (77.4% vs. 56.7%, p = 0.015), the mean value for BUN was higher in NSTEMI patients compared to patients with UA (47 vs. 39 mg/dL, p = 0.038) and NSTEMI patients more frequently received interventional treatment compared to patients with UA (60% vs. 41.9%; p = 0.046).