Temporal trends in all-cause mortality according to smoking status: Insights from the Global Registry of Acute Coronary Events

Objective: Smoking has been shown to be a risk factor for heart disease. However, it was recently reported that despite the evolution in therapy for acute coronary syndrome (ACS), smokers have not demonstrated improved outcomes.The aim of the present study was to evaluate the temporal trends in the treatments and outcomes across a broad spectrum of ACS patients (STEMI and non-ST-elevation ACS [NSTEACS]) according to smoking status on presentation in the Global Registry of Acute Coronary Events (GRACE). Methods Our cohort was stratified into 3 groups: current smokers, former smokers and never smokers. We evaluated trends in demographics, treatment modalities and outcomes in these 3 groups from 1999 to 2007.ResultsThe study population comprised a total of 63,015 patients admitted to hospital with an ACS and with identifiable baseline smoking status. Smokers presented with STEMI more often than non-smokers. There was an unadjusted decline in 30-day mortality in all 3 groups. However, the adjusted decline was not statistically significant among current smokers (HR = 0.98 per study year, 95% CI 0.94–1.01, p = 0.20). A subgroup analysis of 22,894 STEMI patients demonstrated no reduction in annual adjusted 30-day mortality rates among smokers (HR = 1.01, 95% CI 0.96–1.06 (Table 5), whereas former and never smokers' mortality declined...

Late Consequences of Acute Coronary Syndromes: Global Registry of Acute Coronary Events (GRACE)Follow-up

PURPOSE: Short-term outcomes have been well characterized in acute coronary syndromes; however,longer-term follow-up for the entire spectrum of these patients, including ST-segment-elevation myocardialinfarction, non-ST-segment-elevation myocardial infarction, and unstable angina, is more limited. Therefore,we describe the longer-term outcomes, procedures, and medication use in Global Registry of AcuteCoronary Events (GRACE) hospital survivors undergoing 6-month and 2-year follow-up, and the performanceof the discharge GRACE risk score in predicting 2-year mortality.METHODS: Between 1999 and 2007, 70,395 patients with a suspected acute coronary syndrome wereenrolled. In 2004, 2-year prospective follow-up was undertaken in those with a discharge acute coronarysyndrome diagnosis in 57 sites.RESULTS: From 2004 to 2007, 19,122 (87.2%) patients underwent follow-up; by 2 years postdischarge,14.3% underwent angiography, 8.7% percutaneous coronary intervention, 2.0% coronary bypass surgery,and 24.2% were re-hospitalized. In patients with 2-year follow-up, acetylsalicylic acid (88.7%), betablocker(80.4%), renin-angiotensin system inhibitor (69.8%), and statin (80.2%) therapy was used. Heartfailure occurred in 6.3%, (re)infarction in 4.4%, and death in 7.1%. Discharge-to-6-month GRACE riskscore was highly predictive of all-cause mortality at 2 years (c-statistic 0.80).CONCLUSION: In this large multinational cohort of acute coronary syndrome patients, there were importantlater adverse consequences, including frequent morbidity and mortality. These findings were seen in thecontext of additional coronary procedures and despite continued use of evidence-based therapies in a highproportion of patients. The discriminative accuracy of the GRACE risk score in hospital survivors forpredicting longer-term mortality was maintained.

Late Consequences of Acute Coronary Syndromes: Global Registry of Acute Coronary Events (GRACE)Follow-up

PURPOSE: Short-term outcomes have been well characterized in acute coronary syndromes; however,longer-term follow-up for the entire spectrum of these patients, including ST-segment-elevation myocardialinfarction, non-ST-segment-elevation myocardial infarction, and unstable angina, is more limited. Therefore,we describe the longer-term outcomes, procedures, and medication use in Global Registry of AcuteCoronary Events (GRACE) hospital survivors undergoing 6-month and 2-year follow-up, and the performanceof the discharge GRACE risk score in predicting 2-year mortality.METHODS: Between 1999 and 2007, 70,395 patients with a suspected acute coronary syndrome wereenrolled. In 2004, 2-year prospective follow-up was undertaken in those with a discharge acute coronarysyndrome diagnosis in 57 sites.RESULTS: From 2004 to 2007, 19,122 (87.2%) patients underwent follow-up; by 2 years postdischarge,14.3% underwent angiography, 8.7% percutaneous coronary intervention, 2.0% coronary bypass surgery,and 24.2% were re-hospitalized. In patients with 2-year follow-up, acetylsalicylic acid (88.7%), betablocker(80.4%), renin-angiotensin system inhibitor (69.8%), and statin (80.2%) therapy was used. Heartfailure occurred in 6.3%, (re)infarction in 4.4%, and death in 7.1%. Discharge-to-6-month GRACE riskscore was highly predictive of all-cause mortality at 2 years (c-statistic 0.80).CONCLUSION: In this large multinational cohort of acute coronary syndrome patients, there were importantlater adverse consequences, including frequent morbidity and mortality. These findings were seen in thecontext of additional coronary procedures and despite continued use of evidence-based therapies in a highproportion of patients. The discriminative accuracy of the GRACE risk score in hospital survivors forpredicting longer-term mortality was maintained.

Risk stratification in the setting of non-ST elevation acute coronary syndromes 1999-2007

It is unclear if clinician risk stratification has changed with time. The aim of this study was to assess the temporal change in the concordance between patient presenting risk and the intensity of evidence-based therapies received for non-ST-segment elevation acute coronary syndromes over a 9-year period. Data from 3,562 patients with non-ST-segment elevation acute coronary syndromes enrolled in the Australian and New Zealand population of the Global Registry of Acute Coronary Events (GRACE) from 1999 to 2007 were analyzed. Patients were stratified to risk groups on the basis of the GRACE risk score for in-hospital mortality. Main outcome measures included in-hospital use of widely accepted evidence-based medications, investigations, and procedures. Invasive management was consistently higher in low-risk patients than in intermediate- or high-risk patients (coronary angiography 66.7% vs 63.5% vs 35.3%, p <0.001; percutaneous coronary intervention 31.1% vs 22.0% vs 12.9%, p <0.001). Absolute rates of angiography and percutaneous coronary intervention in the high-risk group remained 24% and 15% lower compared to the low-risk group in the most recent time period (2005 to 2007). In-hospital use of thienopyridine, low-molecular weight heparin, and glycoprotein IIb/IIIa inhibitors showed a similar inverse relation with risk. Prescription of aspirin, â blockers, statins, and angiotensin receptor blockers was inversely related to risk before 2004, although this inverse relation was no longer present in the most recent time period (2005 to 2007). Only in-hospital use of unfractionated heparin showed use concordant with patient risk status. In conclusion, despite an overall increase in the uptake of evidence-based therapies, most investigations and treatments are not targeted on the basis of patient risk. Clinician risk stratification remains suboptimal compared to objective measures of patient risk.

Has the frequency of bleeding changed over time for patients presenting with an acute coronary syndrome? The Global Registry of Acute Coronary Events

To determine whether changes in practice, over time, are associated with altered rates of major bleeding in acutecoronary syndromes (ACS). Methodsand results Patients from the Global Registry of Acute Coronary Events were enrolled between 2000 and 2007. The main outcome measureswere frequency ofmajor bleeding, including haemorrhagic stroke, over time, after adjustment for patient characteristics,and impact of major bleeding on death and myocardial infarction.Of the 50 947 patients, 2.3% sustained a majorbleed; almost half of these presented with ST-elevation ACS (44%, 513). Despite changes in antithrombotic therapy (increasing use of low molecular weight heparin, P, 0.0001), thienopyridines (P, 0.0001), and percutaneous coronary interventions (P, 0.0001), frequency of major bleeding for all ACS patients decreased (2.6 to 1.8%; P , 0.0001). Most decline was seen in ST-elevation ACS (2.9 to 2.1%, P » 0.02). The overall decline remained after adjustment for patient characteristics and treatments (P » 0.002, hazard ratio 0.94 per year, 95%confidence interval 0.91–0.98).Hospital characteristics were an independent predictor of bleeding (P , 0.0001). Patients who experienced major bleeding were at increased risk of death within 30 days from admission, even after adjustment for baseline variables.Conclusion Despite increasing use of more intensive therapies, there was a decline in the rate of major bleeding associated with changes in clinical practice. However, individual hospital characteristics remain an important determinant of the frequency of major bleeding.

Pulmonary artery catheterization in patients with acute coronary syndromes

Background There are limited recent data evaluating the use of the pulmonary artery catheter (PAC) in patients hospitalized with an acute coronary syndrome (ACS). Using data from the multinational Global Registry of Acute Coronary Events, we examined trends in PAC use among patients hospitalized for an ACS and the association between PAC andhospital outcomes. Methods Trends in PAC utilization between 2000 and 2007 were examined through the review of data contained in hospital medical records. We identified factors associated with PAC utilization and compared differences in the length ofhospitalization and in-hospital death rates between patients undergoing PAC during the index hospitalization (PAC+, n = 2,879) and those managed without PAC (PAC−, n = 56,091). Results The utilization of PAC during hospitalization for an ACS declined over time such that 3.0% of patients underwent PAC in 2007 compared with 5.4% in 2000. Admission Killip classification was the strongest factor associated with PACinsertion. The duration of hospitalization was significantly longer among PAC+ (median = 10.0 days) as compared with PAC− patients (median = 5.0 days). In-hospital death rates were significantly higher among PAC+ patients after adjustment for differences in baseline characteristics (odds ratio 4.00, 95% CI 3.41-4.70). Conclusions The frequency of PAC utilization in “real-world” patients hospitalized with ACS has declined during recent years. Our finding of increased in-hospital mortality among patients undergoing PAC is consistent with prior studies and mayfurther challenge the efficacy of PAC in the setting of ACS.

Mortality following placement of drug-eluting and bare-metal stents for ST-segment elevation acute myocardial infarction in the Global Registry of Acute Coronary Events

To assess mortality after drug-eluting stent (DES) or bare-metal stent (BMS) for ST-segment elevation myocardialinfarction (STEMI). Methodsand results In this multinational registry, 5093 STEMI patients received a stent: 1313 (26%) a DES and 3780 (74%) only BMS. Groups differed in baseline characteristics, type, or timing of percutaneous coronary intervention, with a higher baseline risk for patients receiving BMS. Two-year follow-up was available in 55 and 60% of the eligible BMS and DES patients, respectively. Unadjusted mortality was lower during hospitalization, similar for the first 6 months after discharge, and higher from 6 months to 2 years, for DES patients compared with that of BMS patients. Overall, unadjusted 2-year mortality was 5.3 vs. 3.9% for BMS vs. DES patients (P » 0.04). In propensity- and risk-adjusted survival analyses (Cox model), post-discharge mortality was not different up to 6 months (P » 0.21) or 1 year (P » 0.34). Late post-discharge mortality was higher in DES patients from 6 months to 2 years (HR 4.90, P » 0.01) or from 1 to 2 years (HR 7.06, P » 0.02). Similar results were observed when factoring in hospital mortality. Conclusion The observation of increased late mortality with DES vs. BMS suggests that DES should probably be avoided inSTEMI, until more long-term data become available.

Unprotected left main revascularizationin patients with acute coronary syndromes

In acute coronary syndromes (ACS), the optimal revascularization strategy for unprotected left main coronary disease (ULMCD) has been little studied. The objectives of the present study were to describe the practice of ULMCD revascularization in ACS patients and its evolution over an 8-year period, analyse the prognosis of this population and determine the effect of revascularization on outcome. Methods and results Of 43 018 patients enrolled in the Global Registry of Acute Coronary Events (GRACE) between 2000 and 2007, 1799 had significant ULMCD and underwent percutaneous coronary intervention (PCI) alone (n » 514), coronary artery bypass graft (CABG) alone (n » 612), or no revascularization (n » 673). Mortality was 7.7% in hospital and 14% at 6 months. Over the 8-year study, the GRACE risk score remained constant, but there was a steady shift to more PCI than CABG over time. Patients undergoing PCI presented more frequently with ST-segment elevationmyocardial infarction (STEMI), after cardiac arrest, or in cardiogenic shock; 48% of PCI patients underwent revascularization on the day of admission vs. 5.1% in the CABG group. After adjustment, revascularization was associated with an early hazard of hospital death vs. no revascularization, significant for PCI (hazard ratio (HR) 2.60, 95% confidence interval (CI) 1.62–4.18) but not for CABG (1.26, 0.72–2.22). From discharge to 6 months, both PCI (HR 0.45, 95% CI 0.23–0.85) and CABG (0.11, 0.04–0.28) were significantly associated with improved survival in comparison with an initial strategy of no revascularization...

Use of proven therapies in non-ST-elevation acute coronary syndromes according to evidence-based risk stratification / Use of proven therapies in non-ST-elevation acute coronary syndromes according to evidence-based risk stratification

Background Current guidelines advise the use of risk stratification to determine wich patients should receive more aggressive antithrombotic and invasive therapies. Our objective was to evaluatethe relationship between risk stratification and therapeutic decision makeing in patients with non-ST-segment elevation the relationship between risk stratification and therapeutic decision making patients with no-ST-segment elevation acute coronaru syndromes. Methods We analizes data from 15026 patients with acute coronary syndrome who were enrolled into the GRACE registry between 1999 and 2003. We assessed the evidence-based use od antithrombotic therapy and early invasive strategy according to risk profile defined by baseline troponin elevation, presenting ST-segment depression...