Angiographic characteristics of culprit lesions in infarct related artery and correlation of TIMI score with SYNTAX score to predict extent and severity of coronary artery disease in patients undergoing primary percutaneous coronary interventions.

Objective: The current study was designed to explore the relationship of TIMI and SYNTAX risk score to predict the CAD extent and severity in STEMI patients. Methods: For this cross-sectional study, 304 STEMI patients undergoing PPCI were enrolled at Department of Interventional Cardiology NICVD Karachi from September 2021 to January 2022. and the TIMI risk score was determined at enrolment. Based on these scorings, the patients were grouped as low, intermediate, and high risk, i.e., a score of ≤ 3, 4 to 7, and ≥ 8, respectively. The SYNTAX scores were utilized to assess the extent of CAD. Results: Statistically significant difference was found in symptoms to balloon time (p=0.001), history of diabetes (p=0.006), angina (p=0.011), obesity (p=0.048), STEMI type (p=0.003), Killip classes (p=0.000), Infarct-Related Artery (p=0.006), number of diseased vessels (p<0.01), LMS > 50% (p=0.000), PCI type (p<0.01), collateral circulation (p<0.01), In-hospital mortality (p<0.01), LV support (p<0.01), and post-procedural TIMI flow (p=0.013), among the three TIMI risk groups. Significant correlation was found among TIMI risk score and SYNTAX score. Conclusion: It is observed that the TIMI risk scores are highly correlated with the SYNTAX Score in predicting the CAD severity in STEMI patients.

The association between cardiovascular risk profile and ocular microvascular changes in patients with non-ST elevation myocardial infarction.

PURPOSE: We aimed to evaluate the association between ocular microvasculature (vascular density) on optical coherence tomography-angiography (OCT-A) and the cardiovascular risk profile of patients hospitalized for non-ST-elevation myocardial infarction (NSTEMI) patients. METHODS: Patients admitted to the intensive care unit with the diagnosis of NSTEMI and undergoing coronary angiography were divided into 3 groups as low, intermediate, and high risk according to the SYNTAX score. OCT-A imaging was performed in all three groups. Right-left selective coronary angiography images of all patients were analyzed. The SYNTAX and TIMI risk scores of all patients were calculated. RESULTS: This study included opthalmological examination of 114 NSTEMI patients. NSTEMI patients with high SYNTAX risk scores had significantly lower deep parafoveal vessel density (DPD) than patients with low-intermediate SYNTAX risk scores (p < 0.001). ROC curve analysis found that a DPD threshold below 51.65 % was moderately associated with high SYNTAX risk scores in patients with NSTEMI. In addition, NSTEMI patients with high TIMI risk scores had significantly lower DPD than patients with low-intermediate TIMI risk scores (p < 0.001). CONCLUSIONS: OCT-A may be a non-invasive useful tool to assess the cardiovascular risk profile of NSTEMI patients with a high SYNTAX and TIMI score.

Circulating IGF-1 and IGFBP-2 may be biomarkers for risk stratification in patients with acute coronary syndrome: A prospective cohort study.

BACKGROUND AND AIM: The involvement of insulin-like growth factor-1 (IGF-1) and insulin-like growth factor binding protein-2 (IGFBP-2) following acute coronary syndrome (ACS) is rarely studied in clinical practice. Therefore, we sought to evaluate the relationship between IGF-1 and IGFBP-2 concentrations at admission and risk stratification based on the Thrombolysis in Myocardial Infarction (TIMI) risk score in patients with ACS. METHODS AND RESULTS: In all, 304 patients diagnosed with ACS were included in this study. Plasma IGF-1 and IGFBP-2 were measured using commercially available ELISA kits. The TIMI risk score was calculated and the study population was stratified into high (n = 65), medium (n = 138), and low (n = 101) risk groups. Levels of IGF-1 and IGFBP-2 were analyzed for their predictive ability of risk stratification based on the TIMI risk scores. Correlation analysis showed that IGF-1 levels were negatively correlated with TIMI risk levels (r = -0.144, p = 0.012), while IGFBP-2 levels were significantly and positively correlated with TIMI risk levels (r = 0.309, p < 0.001). In multivariate logistic regression analysis, IGF-1 (odds ratio [OR]: 0.995; 95% confidence interval [CI]: 0.990-1.000; p = 0.043) and IGFBP-2 (OR: 1.002; 95%CI: 1.001-1.003; p < 0.001) were independent predictors of high TIMI risk levels. In receiver operating characteristic curves, the area under the curve values for IGF-1 and IGFBP-2 in the prediction of high TIMI risk levels were 0.605 and 0.723, respectively. CONCLUSIONS: IGF-1 and IGFBP-2 levels are excellent biomarkers for risk stratification in patients with ACS, which provides further guidance for clinicians to identify patients at high risk and to lower their risk.

The prognostic value of MELD-XI in elderly patients with ST-segment elevation myocardial infarction: an observational study.

BACKGROUND: The model for end-stage liver disease excluding international normalized ratio (MELD-XI) is a simple score for risk assessment. However, the prognostic role of MELD-XI and its additional value to current risk assessment in elderly patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) is uncertain. METHODS: In all, 1029 elderly patients with STEMI undergoing PCI were consecutively included and classified into three groups according to the TIMI risk score: low-risk (≤ 3, n = 251); moderate-risk (4-6, n = 509); and high-risk (≥ 7, n = 269) groups. Multivariate analysis was performed to identify risk factors for adverse events. RESULTS: The overall in-hospital mortality was 5.3% and was significantly higher in the high-risk group (1.2% vs. 3.3% vs. 13.0%, p < 0.001). The optimal cut-off of the TIMI risk score and MELD-XI for in-hospital death was 7 and 13, respectively. MELD-XI was associated with in-hospital (adjusted odds ratio = 1.09, 95% CI = 1.04-1.14, p = 0.001) and one-year (adjusted hazard ratio = 1.05, 95% CI = 1.01-1.08, p = 0.005) mortality independently of the TIMI risk score. Combining TIMI risk score and MELD-XI exhibited better predictive power for in-hospital death than TIMI risk score (area under the curve [AUC] = 0.810 vs. 0.753, p = 0.008) or MELD-XI alone (AUC = 0.810 vs. 0.750, p = 0.018). Patients with TIMI risk score ≥ 7 and MELD-XI ≥ 13 had the worst prognosis. CONCLUSION: MELD-XI could be considered as a risk-stratified tool for elderly patients with STEMI undergoing PCI. It had an additive prognostic value to TIMI risk score.

Prognostic Value of sLOX-1 Level in Acute Coronary Syndromes Based on Thrombolysis in Myocardial Infarction Risk Score and Clinical Outcome.

BACKGROUND: Biomarkers possess important diagnostic and prognostic value in acute coronary syndromes (ACSs). Soluble lectin-like oxidized low-density lipoprotein receptor-1 (sLOX-1) is one of the markers involved in atherosclerotic plaque vulnerability and rupture. OBJECTIVE: This study aimed to evaluate the prognostic value of sLOX-1 through its correlation with Thrombolysis in Myocardial Infarction (TIMI) risk score and its possible association with clinical outcomes in 2 major spectrums of ACS. METHODS: A prospective cross-sectional study was planned, and 320 patients who underwent diagnostic coronary angiography were selected (in first 24 h after coronary angiography): those with documented ST elevation myocardial infarction or unstable angina/non-ST elevation myocardial infarction. sLOX-1 was measured immediately after administration in the emergency department. The TIMI risk score was calculated separately for both groups. In hospital death, heart failure and recurrent infarction were considered major adverse cardiac events. RESULTS: There was a significant positive correlation between sLOX-1, TIMI risk score, major adverse cardiac events, and heart failure. The optimal cutoff value of sLOX-1 to predict clinical endpoints was 1.75 ng/mL in patients with ST elevation myocardial infarction and 1.35 ng/mL in patients with unstable angina/non-ST elevation myocardial infarction. CONCLUSIONS: Circulating sLOX-1 could be used as a biomarker to predict major adverse cardiac events in patients with ACS and may be clinically useful in the triage and management of these patients.

TIMI and GRACE Risk Scores Predict Both Short-Term and Long-Term Outcomes in Chinese Patients with Acute Myocardial Infarction.

BACKGROUND: Little is known about the long-term prognostic values of both thrombolysis in myocardial infarction (TIMI) and Global Registry of Acute Cardiac Events (GRACE) risk scores (RSs) to the Asian ethnicity. The purpose of this study is to compare the usefulness of these two scores in risk stratification and prediction of long-term (up to 3 years) outcomes for Chinese patients with myocardial infarction (MI). METHODS: We calculated the TIMI and GRACE RSs for 726 consecutive patients with MI [55.6% with ST-segment elevation (STEMI) and 44.4% with non-ST-segment elevation (NSTEMI)]. RESULTS: Although the risk profile of our population (median TIMI score = 5 for STEMI, 4 for NSTEMI, and median GRACE score = 164) was higher, the in-hospital mortality (7.1% for NSTEMI and 6.7% for STEMI) was comparable to that predicted by GRACE RS. The GRACE RS worked well in predicting short-term and long-term death (C-statistics range 0.710 to 0.789) and triple (death, MI, and stroke) endpoints (C-statistics range 0.695 to 0.764) in both subsets of MI. GRACE RS performed significantly better than the TIMIRS in predicting 3-year mortality in NSTEMI (p = 0.035) and 1-year and 3-year mortality in STEMI (p = 0.028 and 0.009, respectively). Stratification by tertiles of GRACERS furnished greater prognostic information versus risk assessment by the TIMI RS. CONCLUSIONS: The use of RSs revealed a fair to good discriminatory accuracy in predicting both short-term and long-term major adverse cardiac events in Asian patients with MI. Compared with the simpler TIMI RS, the GRACERS was more accurate in predicting long-term mortality.

Epidemiology of heart failure hospitalization in patients with stable atherothrombotic disease: Insights from the TRA 2°P-TIMI 50 trial.

BACKGROUND: Heart failure (HF) is a growing public health problem and ischemic heart disease is an important risk factor. Understanding the epidemiology of HF in patients with atherosclerosis may help identify subgroups at greater risk who have the potential to derive greater benefit from preventive strategies. METHODS AND RESULTS: The TRA 2°P-TIMI 50 trial randomized 26,449 patients with stable atherosclerosis to the antiplatelet agent vorapaxar versus placebo. Hospitalization for HF (HHF) endpoints were adjudicated from serious adverse events by blinded structured review using established definitions. HHF incidence was estimated using Kaplan-Meier analysis. Independent predictors of HHF risk were identified using multivariable logistic regression. The effect of vorapaxar on HHF risk was explored using Cox regression. The estimated incidence of HHF at 3 years was 1.6%. Independent predictors of HHF included prior HF (adjusted odds ratio [adj-OR]: 8.31; 95% confidence interval [CI]: 6.56-10.54), age (adj-OR [per 10 years]: 1.67; 95% CI: 1.47-1.89), type 2 diabetes mellitus (T2DM; adj-OR: 2.55; 95% CI: 2.01-3.24), polyvascular disease (two-territory disease, adj-OR: 1.89; 95% CI: 1.46-2.44; three-territory disease, adj-OR: 2.68; 95% CI: 1.94-3.70), chronic kidney disease (CKD; adj-OR: 1.65; 95% CI: 1.30-2.11), body mass index (BMI; adj-OR [per 5 kg/m2 ]: 1.15; 95% CI: 1.03-1.27), prior myocardial infarction (MI) (adj-OR: 1.35; 95% CI: 1.03-1.78), and hypertension (adj-OR: 1.44; 95% CI: 1.02-2.04). Patients who experienced HHF during follow-up had higher rates of subsequent rehospitalization and death. Vorapaxar did not modify the risk of HHF. CONCLUSIONS: In patients with stable atherosclerosis, prior HF, age, T2DM, polyvascular disease, CKD, BMI, prior MI, and hypertension are important predictors of HHF risk.

Correlation between plasma glutathione peroxidase 4 and N-acetylneuraminic acid levels with clinical risk stratification and prognosis of patients with acute coronary syndrome.

OBJECTIVES: To investigate the correlation between plasma glutathione peroxidase 4 (GPX4) and N-acetyl-neuraminic acid (Neu5Ac) with clinical risk stratification and outcomes of acute coronary syndrome (ACS) patients. METHODS: Between October 2018 and July 2019, 413 patients that were scheduled for coronary angiography were enrolled in this prospective study at the First Affiliated Hospital of Bengbu Medical College, Bengbu, China. Patients were divided into control and ACS groups. Patients with ACS were divided into 3 risk levels based on their thrombolysis in myocardial infarction risk score. After discharge, ACS patients were followed for the incidence of major adverse cardiac events (MACEs). For the analysis of cumulative endpoint event occurrences, the Kaplan-Meier method was applied. RESULTS: The ACS group had lower plasma GPX4 but higher Neu5Ac levels than the control group. There was a greater increase in plasma Neu5Ac in the high-risk group when compared with the medium-risk and low-risk groups, while GPX4 levels were higher in the low-risk group. The MACEs group had higher plasma Neu5Ac but lower GPX4 levels than the non-MACEs group. The plasma Neu5Ac was an independent risk factor but GPX4 was a protective factor for MACEs. CONCLUSION: Glutathione peroxidase 4 and Neu5Ac levels in plasma can be used to diagnose, stratify risks, and predict long-term outcomes in patients with ACS.

Prognostic performance of GRACE and TIMI risk scores in critically ill patients with sepsis and a concomitant myocardial infarction.

BACKGROUND: Identifying which patients with acute myocardial infarction (AMI) during sepsis are at risk of poor outcome is a clinical challenge. AIM: To evaluate Global Registry of Acute Coronary Events (GRACE) and Thrombolysis In Myocardial Infarction (TIMI) risk scores to predict in-hospital mortality and severe ischaemic events in this setting. METHODS: In this single-centre retrospective study conducted from 2012 to 2016, all consecutive adults hospitalized in the intensive care unit for sepsis who had a concomitant AMI (within 72hours of admission) were enrolled. AMI was defined by an elevated cardiac troponin I value associated with at least one sign (clinical, electrocardiographic or echocardiographic) suggestive of myocardial ischaemia. The primary outcome was in-hospital mortality from any cause. Secondary outcomes were in-hospital occurrence of severe ischaemic events (cardiac arrest with resuscitation, ischaemic stroke and myocardial reinfarction) and major bleeding events. RESULTS: Among 856 patients hospitalized for sepsis, 120 (14.5%) had a concomitant AMI (37.5% women; median age 65 years; median Sequential Organ Failure Assessment [SOFA] score 8). Severe ischaemic events occurred in 15 patients (12.5%), and 39 (33%) died in hospital. Neither the GRACE score (median 192, interquartile range 154-223) nor the TIMI score (median 3, interquartile range 2-4) was associated with occurrence of severe ischaemic events. Only the GRACE score was associated with in-hospital mortality (odds ratio 1.01, 95% confidence interval 1.00-1.02 per 1 point increase). Multivariable analysis identified previous aspirin use and SOFA score as independent factors associated with in-hospital mortality. CONCLUSIONS: GRACE and TIMI scores did not predict in-hospital severe ischaemic events and mortality in patients with AMI during sepsis. Among individual components of both scores, previous aspirin use was associated with poor prognosis. However, because of lack of statistical power, we cannot formally rule out the usefulness of these scores in this setting.

Association of neutrophil to lymphocyte ratio (NLR) with angiographic SYNTAX score in patients with non-ST-Segment elevation acute coronary syndrome (NSTE-ACS).

Introduction: Considering the role of inflammation in pathogenesis of atherosclerosis, we aimed to investigate the association of presentation neutrophil to lymphocyte ratio (NLR) with complexity of coronary artery lesions determined by SYNTAX score in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). Methods: From March 2018 to March 2019, we recruited 202 consecutive patients, who were hospitalized for NSTE-ACS and had undergone percutaneous coronary intervention in our hospital. The association of presentation NLR with SYNTAX score was determined in univariate and multivariate linear regression analysis. Results: Higher NLR was significantly associated with higher SYNTAX score (beta = 0.162, P = 0.021). In addition, older age, having hypertension, higher TIMI score, and lower ejection fraction on echocardiographic examination were significantly associated with higher SYNTAX score. TIMI score had the largest beta coefficient among the studied variables (TIMI score beta = 0.302, P < 0.001). In two separate multivariate linear regression models, we assessed the unique contribution of NLR in predicting SYNTAX score in patients with NSTE-ACS. In the first model, NLR was significantly contributed to predicting SYNTAX score after adjustment for age, sex, and hypertension as covariates available on patient presentation (beta = 0.142, P = 0.040). In the second model, NLR was not an independent predictor of SYNTAX score after adjustment for TIMI score (beta = 0.121, P = 0.076). Conclusion: In NSTE-ACS, presentation NLR is associated with SYNTAX score. However, NLR does not contribute significantly to the prediction of SYNTAX score after adjustment for TIMI score. TIMI risk score might be a better predictor of the SYNTAX score in comparison to NLR.

Early or deferred cardiovascular magnetic resonance after ST-segment-elevation myocardial infarction for effective risk stratification.

AIMS: In ST-segment-elevation myocardial infarction (STEMI), cardiovascular magnetic resonance (CMR) holds the potentiality to improve risk stratification in addition to Thrombolysis in Myocardial Infarction (TIMI) risk score. Nevertheless, the optimal timing for CMR after STEMI remains poorly defined. We aim at comparing the prognostic performance of three stratification strategies according to the timing of CMR after STEMI. METHODS AND RESULTS: The population of this prospective registry-based study included 492 reperfused STEMI patients. All patients underwent post-reperfusion (median: 4 days post-STEMI) and follow-up (median: 4.8 months post-STEMI) CMR. Left ventricular (LV) volumes, function, infarct size, and microvascular obstruction extent were quantified. Primary endpoint was a composite of all-death and heart failure (HF) hospitalization. Baseline-to-follow-up percentage increase of LV end-diastolic (EDV; ΔLV-EDV) ≥20% or end-systolic volumes (ESV; ΔLV-ESV) ≥15% were tested against outcome. Three multivariate models were developed including TIMI risk score plus early post-STEMI (early-CMR) or follow-up CMR (deferred-CMR) or both CMRs parameters along with adverse LV remodelling (paired-CMRs). During a median follow-up of 8.3 years, the primary endpoint occurred in 84 patients (47 deaths; 37 HF hospitalizations). Early-CMR, deferred-CMR, and paired-CMR demonstrated similar predictive value for the primary endpoint (C-statistic: 0.726, 0.728, and 0.738, respectively; P = 0.663). ΔLV-EDV ≥20% or ΔLV-ESV ≥15% were unadjusted outcome predictors (hazard ratio: 2.020 and 2.032, respectively; P = 0.002 for both) but lost their predictive value when corrected for other covariates in paired-CMR model. CONCLUSION: In STEMI patients, early-, deferred-, or paired-CMR were equivalent stratification strategies for outcome prediction. Adverse LV remodelling parameters were not independent prognosticators.

No-Reflow after PPCI-A Predictor of Short-Term Outcomes in STEMI Patients.

The no-reflow phenomenon following primary percutaneous coronary intervention (PPCI) in acute ST-elevation myocardial infarction (STEMI) patients is a predictor of unfavorable prognosis. Patients with no-reflow have many complications during admission, and it is considered a marker of short-term mortality. The current research emphasizes the circumstances of the incidence and complications of the no-reflow phenomenon in STEMI patients, including in-hospital mortality. In this case-control study, conducted over two and a half years, there were enrolled 656 patients diagnosed with STEMI and reperfused through PPCI. Several patients (n = 96) developed an interventional type of no-reflow phenomenon. One third of the patients with a no-reflow phenomenon suffered complications during admission, and 14 succumbed. Regarding complications, the majority consisted of arrhythmias (21.68%) and cardiogenic shock (16.67%). The anterior localization of STEMI and the left anterior descending artery (LAD) as a culprit lesion were associated with the highest number of complications during hospitalization. At the same time, the time interval >12 h from the onset of the typical symptoms of myocardial infarction (MI) until revascularization, as well as multiple stents implantations during PPCI, correlated with an increased incidence of short-term complications. The no-reflow phenomenon in patients with STEMI was associated with an unfavorable short-term prognosis.

Predictive Value of Endocan Based on TIMI Risk Score on Major Adverse Cardiovascular Events After Acute Coronary Syndrome.

We assessed the prognostic value of serum levels of endocan in patients with the acute coronary syndrome (ACS) through its correlation with the Thrombolysis in Myocardial Infarction (TIMI) risk score and compared the possible association with clinical outcomes. In this prospective cross-sectional study, we enrolled 320 patients with documented ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), or unstable angina (UA) who underwent diagnostic coronary angiography. Endocan was measured soon after admission in the emergency department. In-hospital death, heart failure, and recurrent infarction were considered major adverse cardiac events (MACEs). There was a significant positive correlation between endocan level and TIMI risk score and MACE. The optimal cutoff values of endocan to predict clinical end points were 3.45 ng/mL in patients with STEMI and 2.85 ng/mL in patients with UA/NSTEMI. Multivariate logistic regression analysis indicated that endocan independently correlated with MACE. Moreover, cardiac troponin I, creatine kinase-MB, and circulating endocan were found to be independently associated with MACE in patients with ACS. In conclusion, a high endocan level on hospital admission is an independent predictor of worse cardiovascular outcomes and higher TIMI risk score in patients with ACS.

Comparison of the predictive value of four-dimensional speckle tracking imaging risk classification and the TIMI system after STEMI reperfusion therapy.

The predictive value of four-dimensional speckle tracking imaging (4D-STI) risk classification and TIMI risk scores for the prognosis of patients with ST-segment elevation myocardial infarction (STEMI) after reperfusion therapy were investigated. One hundred and twenty patients with STEMI after reperfusion therapy were involved. At 12 h after reperfusion therapy, 2nd and 3rd day, the three-dimensional longitudinal strain (LS), circumferential strain (CS) and radial strain (RS), area strain (AS), as well as other 4D-STI detection indicators, were collected. The patients were followed up for one year, and were divided into good prognosis group and poor prognosis group. LS, CS, RS and AS indicators were analyzed between these two groups. The ROC curve was drawn to establish the 4D-STI risk classification and its predictive value for poor prognosis and mortality were compared with TIMI risk scores. AS, LS and RS at 12 h after reperfusion treatment, and AS and RS at 2nd and 3rd day had a certain degree of prediction accuracy in STEMI patients in the poor prognosis group. In the 4D-STI and TIMI risk scores, the risk of death and adverse prognosis significantly increased as the risk scores increased (P<0.01). The 4D-STI risk score for predicting poor prognosis and mortality was greater than the TIMI risk score. 4D-STI risk scores are superior to TIMI risk scores in predicting poor prognosis and mortality in patients with STEMI after reperfusion therapy.

Low T3 syndrome improves risk prediction of in-hospital cardiovascular death in patients with acute myocardial infarction.

BACKGROUND: Low triiodothyronine (T3) syndrome (LT3S) is frequently seen in patients with acute myocardial infarction (AMI). We examined the association between LT3S and severity of myocardial injury and determined whether LT3S adds predictive value over thrombolysis in myocardial infarction (TIMI) risk score for in-hospital cardiovascular (CV) death. METHODS: Of 2459 AMI patients, 529 pairs of euthyroid and LT3S individuals with similar baseline characteristics were identified using 1:1 propensity score matching. LT3S was defined as free T3 (fT3) <2.36pg/mL, normal values of thyroid-stimulating hormone and free thyroxin. Primary outcome was in-hospital CV death. Receiver operating characteristic curves were generated to assess the predictive effects of fT3, TIMI risk score, and TIMI-LT3S risk score on in-hospital CV death. RESULTS: LT3S was found in 23.3% of patients with AMI. The peak values of cardiac troponin I in ng/mL and N-terminal pro-brain natriuretic peptide in ng/mL were significantly higher in LT3S: 6.6 (1.3-19.6) vs. 3.5 (0.8-12.1), p<0.001 and 3625 (1046-12,776) vs. 2158 (774-6759), p<0.001. Patients with LT3S had significantly higher rate of in-hospital CV death than those without (4.7% vs. 1.7%, p=0.005). Lower levels of fT3 yielded an area under the curve (AUC) of 0.741 for predicting CV death. LT3S, when added to the TIMI risk score, significantly increased AUC for in-hospital CV death than TIMI risk score alone (0.775 vs. 0.738, p=0.005). CONCLUSIONS: LT3S was associated with more severe myocardial injury and increased in-hospital CV mortality in patients with AMI. Furthermore, it improved risk prediction of in-hospital CV death post-AMI when it was added to the TIMI risk score.

Identification of coronary artery calcification can optimize risk stratification in patients with acute chest pain.

BACKGROUND: The number of patients presenting to the emergency department (ED) with suspected acute coronary syndrome (ACS) is substantial. We tested whether identification of coronary artery calcium (CAC) can improve the negative predictive value (NPV) of clinical risk assessment for ACS in patients with acute chest pain. METHODS AND RESULTS: We included 826 consecutive patients (mean age: 53±11years; 42% female) without known coronary artery disease (CAD) or initially elevated serum biomarkers, whom underwent non-contrast CT, to assess the CAC score, and CT angiography (CTA), to detect coronary stenosis. We analyzed the diagnostic performance of CAC and the Thrombolysis In Myocardial Infarction (TIMI) risk score for our primary outcomes (ACS and obstructive CAD). No CAC was found in 54% (n=444) of all patients, 63% (n=524) had a TIMI score of 0 and 40% (n=328) had both. The prevalence of obstructive CAD was 16% for ≥50% stenosis and 8.7% for ≥70% stenosis. The incidence of ACS was 7.9%, (MI=11, UAP=54). The NPV of CAC=0 was 99.5% for ACS. The NPV of a combination of TIMI score=0 and no CAC was 89% for any CAD (any plaque or stenosis) and 99.7% for ≥50% stenosis. A 100% NPV was found for ≥70% stenosis and ACS, correctly identifying 328 (40%) patients. CONCLUSIONS: The exclusion of CAC, in combination with clinical risk assessment, has high clinical value in patients with acute chest pain, as it identifies patients at low risk for ACS and obstructive CAD more accurately as compared to clinical risk assessment alone.

Risk Scores After Acute Coronary Syndrome.

Acute coronary syndrome (ACS) is associated with both short- and long-term unfavorable prognosis. Therefore, medical societies developed risk scores for predicting mortality and assessing decision-making regarding early aggressive treatment in patients presenting an ACS. The Thrombolysis In Myocardial Infarction and the Global Registry of Acute Coronary Events risk scores are the most extensively investigated scores for ACS. Clinical judgment is also important. Significant differences in aggressive treatment of ACS still exist with respect to gender, age, and ethnicity. The reasons for these discrepancies need to be further elucidated in future studies. Therefore, generalizability of stratifications and risk scores in certain populations should be performed with caution.

[Acupuncture combined with medication for blood-stasis in unstable angina patients with different thrombolysis in myocardial infarction risk stratification].

OBJECTIVE: To observe the intervention effects of acupuncture combined with standardized treatment of western medicine on blood-stasis syndrome in unstable angina (UA) patients with different thrombolysis in myo-cardial infarction (TIMI) risk stratification. METHODS: According to TIMI risk score, a total of 72 UA patients were included, 24 cases in low-risk (0 to 2 points) group, 24 cases in moderate-risk (3 to 4 points) group and 24 cases in high-risk (5 to 7 points) group. Based on routine standardized treatment of western medicine, acupuncture was applied at Xinshu (BL 15), Xuehai (SP 10), Geshu (BL 17), Danzhong (CV 17), Jueyinshu (BL 14), Ximen (PC 4) and Neiguan (PC 6) in three groups. Acupuncture was given once a day, 14 days as a session. After one session, each symptom score and total score of blood stasis syndrome were observed. RESULTS: One patient dropped out respectively, and 23 patients in each group were included in the analysis. After treatment, the score of angina symptom and total score of blood stasis syndrome were significantly improved in three groups (all P<0.01). The improvements of each score and total score of blood stasis syndrome in the high-risk group were superior to those in the low-risk group and moderate-risk group (P<0.05, P<0.01). CONCLUSIONS: With the higher TIMI scores, the blood stasis syndrome is aggravated accordingly. Acupuncture combined with standardized treatment of western medicine could effectively intervene blood stasis syndrome, especially for the score of blood stasis syndrome of patients in high-risk group.

Predictive value of NT-proBNP for 30-day mortality in patients with non-ST-elevation acute coronary syndromes: a comparison with the GRACE and TIMI risk scores.

BACKGROUND: The biomarker N-terminal pro-brain natriuretic peptide (NT-proBNP) predicts outcome in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). Whether NT-proBNP has incremental prognostic value beyond established risk strategies is still questionable. PURPOSE: To evaluate the predictive value of NT-proBNP for 30-day mortality over and beyond the Global Registry of Acute Coronary Events (GRACE) and Thrombolysis In Myocardial Infarction (TIMI) risk scores in patients with NSTE-ACS. METHODS: Patients included in our ACS registry were candidates. NT-proBNP levels on admission were measured and the GRACE and TIMI risk scores were assessed. We compared the predictive value of NT-proBNP to both risk scores and evaluated whether NT-proBNP improves prognostication by using receiver operator curves and measures of discrimination improvement. RESULTS: A total of 1324 patients were included and 50 patients died during follow-up. On logistic regression analysis NT-proBNP and the GRACE risk score (but not the TIMI risk score) both independently predicted mortality at 30 days. The predictive value of NT-proBNP did not differ significantly compared to the GRACE risk score (area under the curve [AUC]) 0.85 vs 0.87 p=0.67) but was considerably higher in comparison to the TIMI risk score (AUC 0.60 p<0.001). Adjustment of the GRACE risk score by adding NT-proBNP did not improve prognostication: AUC 0.86 (p=0.57), integrated discrimination improvement 0.04 (p=0.003), net reclassification improvement 0.12 (p=0.21). CONCLUSION: In patients with NSTE-ACS, NT-proBNP and the GRACE risk score (but not the TIMI risk score) both have good and comparable predictive value for 30-day mortality. However, incremental prognostic value of NT-proBNP beyond the GRACE risk score could not be demonstrated.

The relationship of TIMI risk index with SYNTAX and Gensini risk scores in predicting the extent and severity of coronary artery disease in patients with STEMI undergoing primary percutaneous coronary intervention.

OBJECTIVE: The prognostic value of the Global Registry of Acute Coronary Events (GRACE) risk score (GRS) and the Thrombolysis in Myocardial Infarction (TIMI) risk index (TRI) have been reported in patients with coronary artery disease (CAD). In this study, we sought to evaluate the association between TRI and the extent and severity of CAD evaluated by SYNTAX score (SS) and Gensini score in patients with ST elevation myocardial infarction (STEMI). METHODS: A total of 290 patients with STEMI were included in the study. GRS and TRI were calculated on admission using specified variables. The extent and severity of CAD were evaluated using the SS and Gensini scores. The patients were divided into low (TRI ⩽19), intermediate (TRI 19-30), and high (TRI ⩾30) risk groups. A Pearson correlation analysis was used for the relationship between TRI, GRS, Gensini score and SS. RESULTS: There were significant differences in the mean age (p < 0.001), admission heart rate (p < 0.001), admission systolic blood pressure (p = 0.009), SS (p < 0.001), GRS (p < 0.001) and in-hospital major adverse cardiac events (MACE) in all patients between the low, intermediate and high TRI risk groups. There was a positive significant correlation between TRI and SS (r = 0.24, p < 0.001), Gensini score (r = 0.18, p = 0.002), GRS (r = 0.74, p = 0.001) and in-hospital MACE (r = 0.29, p < 0.001). CONCLUSION: TRI is significantly related to SS and Gensini score in predicting the extent and severity of CAD in patients with STEMI.