Socioeconomic and Ethnic Disparities in the Process of Care and Outcomes Among Cancer Patients With Acute Coronary Syndrome.

Cancer and acute coronary syndrome (ACS) are the leading causes of morbidity and mortality globally, with many shared risk factors. There are several challenges to the management of patients with cancer presenting with ACS, owing to their higher baseline risk profile, the complexities of their cancer-related therapies and prognosis, and their higher risk of adverse outcomes after ACS. Although previous studies have demonstrated disparities in the care of both cancer and ACS among patients from ethnic minorities and socioeconomic deprivation, there is limited evidence around the magnitude of such disparities specifically in cancer patients presenting with ACS. This review summarises the current literature on differences in prevalence and management of ACS among patients with cancer from ethnic minorities and socioeconomically deprived backgrounds, as well as the gaps in evidence around the care of this high-risk population and potential solutions.

Association between cytochrome P450 2C19 polymorphism and clinical outcomes in clopidogrel-treated Uygur population with acute coronary syndrome: a retrospective study.

BACKGROUND: Acute coronary syndrome (ACS) has become a vital disease with high mortality in the Uygur populations. Clopidogrel plays an important role in reducing the risk of recurrent cardiovascular events after ACS; however, it is a prodrug that requires biotransformation by cytochrome P450 (CYP450). OBJECTIVES: To determine the effect of genetic polymorphisms in CYP2C19*2, *3, and *17, and along with clinical, demographic factors, on variation in response to clinical outcomes in Uygur patients. METHODS: A total of 351 patients with ACS were treated with clopidogrel and aspirin for at least 12 months; we recorded major adverse cardiovascular events (MACE) or bleeding within 1 year. Multivariable logistic regression analyses were carried out to identify factors associated with MACE or bleeding. RESULTS: We analyze risk factors include age, BMI (body mass index), smoking, alcohol intake, NSTEMI (non-ST-segment elevation myocardial infarction), hypertension, dyslipidemia, concomitant medication, CYP2C19*2 carriers, CYP2C19*17 carriers and metabolizer phenotype. CYP2C19*2 carriers had an odds of having MACE of 2.51 (95% CI: 1.534-4.09) compared with noncarriers (P < .001). However, no factors were significantly associated with bleeding (P > 0.05). CONCLUSION: The CYP2C19*2 gene polymorphism contributes to the risk of MACE in dual clopidogrel-treated Uygur population with ACS with or without PCI (percutaneous coronary intervention). These data may provide valuable insights into the genetic polymorphisms affecting clopidogrel metabolism among minority groups in China.

Pharmacodynamic Profile and Prevalence of Bleeding Episode in East Asian Patients with Acute Coronary Syndromes Treated with Prasugrel Standard-Dose versus De-escalation Strategy: A Randomized A-MATCH Trial.

Compared with Caucasian patients, East Asian patients have the unique risk-benefit trade-off and different responsiveness to antithrombotic regimens. The aim of this study was to compare pharmacodynamic profile in East Asian patients with acute coronary syndromes (ACSs) treated with prasugrel standard-dose versus a de-escalation strategy. Before discharge, ACS patients with age <75 years or weight ≥60 kg (n = 255) were randomly assigned to the standard-dose (10-mg group) or de-escalation strategy (5-mg group or platelet function test [PFT]-guided group). After 1 month, VerifyNow P2Y12 assay-based platelet reactivity (P2Y12 reaction unit [PRU]) and bleeding episodes were evaluated. Primary endpoint was the percentage of patients with the therapeutic window (85 ≤ PRU ≤ 208). The 250 patients completed 1-month treatment. The percentage of patients within the therapeutic window was significantly lower in the 10-mg group (n = 85) compared with the 5-mg (n = 83) and PFT-guided groups (n = 82) (35.3 vs. 67.5 vs. 65.9%) (odds ratio [OR]: 3.80 and 3.54; 95% confidence interval [CI]: 2.01-7.21 and 1.87-6.69, respectively). Compared with the 10-mg group, the bleeding rate was tended to be lower with de-escalation strategies (35.3 vs. 24.1% vs. 23.2%) (hazard ratio [HR]: 0.58 and 0.55; 95% CI: 0.30-1.14 and 0.28-1.09, respectively). "PRU < 127" was the optimal cut-off for predicting 1-month bleeding events (area under the curve: 0.616; 95% CI: 0.543-0.689; p = 0.005), which criteria was significantly associated with early discontinuation of prasugrel treatment (HR: 2.00; 95% CI: 1.28-3.03; p = 0.001). In conclusion, compared with the standard-dose prasugrel, the prasugrel de-escalation strategy in East Asian patients presented with ACS showed a higher chance within the therapeutic window and a lower tendency toward bleeding episodes. REGISTRATION: URL: https://clinicaltrials.gov. Unique identifier:NCT01951001.

Clinically Significant Bleeding With Ticagrelor Versus Clopidogrel in Korean Patients With Acute Coronary Syndromes Intended for Invasive Management: A Randomized Clinical Trial.

BACKGROUND: Owing to the differential propensity for bleeding and ischemic events with response to antiplatelet therapy, the safety and effectiveness of potent P2Y12 inhibitor ticagrelor in East Asian populations remain uncertain. METHODS: In this multicenter trial, 800 Korean patients hospitalized for acute coronary syndromes with or without ST elevation and intended for invasive management were randomly assigned to receive, in a 1:1 ratio, ticagrelor (180 mg loading dose, 90 mg twice daily thereafter) or clopidogrel (600 mg loading dose, 75 mg daily thereafter). The primary safety outcome was clinically significant bleeding (a composite of major bleeding or minor bleeding according to PLATO (Platelet Inhibition and Patient Outcomes) criteria at 12 months. RESULTS: At 12 months, the incidence of clinically significant bleeding was significantly higher in the ticagrelor group than in the clopidogrel group (11.7% [45/400] vs 5.3% [21/400]; hazard ratio [HR], 2.26; 95% confidence interval [CI], 1.34 to 3.79; P=0.002). The incidences of major bleeding (7.5% [29/400] vs 4.1% [16/400], P=0.04) and fatal bleeding (1% [4/400] vs 0%, P=0.04) were also higher in the ticagrelor group. The incidence of death from cardiovascular causes, myocardial infarction, or stroke was not significantly different between the ticagrelor group and the clopidogrel group (9.2% [36/400] vs 5.8% [23/400]; HR, 1.62; 95% CI, 0.96 to 2.74; P=0.07). Overall safety and effectiveness findings were similar with the use of several different analytic methods and in multiple subgroups. CONCLUSIONS: In Korean acute coronary syndrome patients intended to receive early invasive management, standard-dose ticagrelor as compared with clopidogrel was associated with a higher incidence of clinically significant bleeding. The numerically higher incidence of ischemic events should be interpreted with caution, given the present trial was underpowered to draw any conclusion regarding efficacy. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02094963.

Acute coronary syndromes presentations and care outcomes in white, South Asian and Chinese patients: a cohort study.

OBJECTIVES: Successful treatment of acute coronary syndrome (ACS) relies on its rapid recognition. It is unclear whether the accepted presentation of chest pain applies to different ethnic groups. We thus examined potential ethnic variations in ACS symptoms and clinical care outcomes in white, South Asian and Chinese patients. DESIGN: Cross-sectional survey. SETTING: Participants were hospitalised at 1 of 12 Canadian centres across four provinces. PARTICIPANTS: 1334 patients with ACS (630 white; 488 South Asian; 216 Chinese). MAIN OUTCOME MEASURES: ACS presentation symptoms (classic/typical midsternal pain/discomfort with or without radiation to the left neck, shoulder or arm) were assessed by self-report. Clinical care outcomes (time to emergency room [ER] presentation, cardiac catheterisation; receipt of cardiac catheterisation, percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) were obtained by health record audit. RESULTS: The mean age of the sample was 62 years and 30% had ST-elevation myocardial infarction (STEMI). The most common presenting symptom was midsternal pain/discomfort of any intensity regardless of ethnic status. Yet, a substantial proportion of patients reported atypical symptoms (33% white, 19% South Asian, 20% Chinese; p<0.006). After adjustment for age, sex, education, current smoking, extent of coronary artery disease, presence of diabetes or chronic kidney disease and STEMI vs non-STEMI/unstable angina, South Asians were more likely to present with at least moderate intensity midsternal pain/discomfort (adjusted OR [AOR] 1.44; 95% CI 1.05 to 1.98), whereas Chinese were less likely to present with radiating symptoms (AOR 0.53; 95% CI 0.38 to 0.74) compared with whites. South Asians with atypical pain (relative to those with midsternal pain/discomfort) took significantly longer to present to the ER (p=0.037), and were less likely to receive PCI (p=0.008) or CABG (p=0.041). CONCLUSIONS: Atypical presentations were associated with greater delays in arrival to the emergency department and reduced invasive cardiovascular care in South Asians.

Tobacco Cessation Among Acute Coronary Syndrome Patients in Kerala, India: Patient and Provider Perspectives.

Tobacco cessation is an important intervention to reduce mortality from ischemic heart disease, the leading cause of death in India. In this study, we explored facilitators, barriers, and cultural context to tobacco cessation among acute coronary syndrome (ACS, or heart attack) patients and providers in a tertiary care institution in the south Indian state of Kerala, with a focus on patient trajectories. Patients who quit tobacco after ACS expressed greater understanding about the link between tobacco and ACS, exerted more willpower at the time of discharge, and held less fatalistic beliefs about their health compared to those who continued tobacco use. The former were motivated by the fear of recurrent ACS, strong advice to quit from providers, and determination to survive and financially provide for their families. Systemic barriers included inadequate training, infrequent prescription of cessation pharmacotherapy, lack of ancillary staff to deliver counseling, and stigma against mental health services.

Ticagrelor versus clopidogrel in East Asian patients with acute coronary syndrome: Systematic review and meta-analysis.

BACKGROUND: Bleeding complications are associated with unfavorable outcomes in patients with acute coronary syndrome (ACS). Compared to Whites, several studies demonstrated a higher risk of bleeding in Asians who present with acute myocardial infarction. To date, the efficacy and safety of ticagrelor in East Asian population have not been well established. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials that compared ticagrelor and clopidogrel in East Asian patients with acute coronary syndrome (ACS). We systematically searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and ClinicalTrial.gov database. RESULTS: Three randomized controlled trials, including a total of 1552 patients, met our inclusion criteria. Study countries included Japan, South Korea, and China. All studies defined primary efficacy endpoint and major bleeding events in accordance with the PLATO definition. Ticagrelor was associated with a numerically lower, albeit statistically nonsignificant, risk of primary efficacy endpoint defined as a composite of death from vascular causes, myocardial infarction, or stroke (odds ratio 0.84; 95% confidence interval 0.43-1.63; p = 0.60). Ticagrelor was associated with a significantly higher risk of PLATO-defined major bleeding compared to clopidogrel (odds ratio 1.52; 95% confidence interval 1.04-2.23; p = 0.03). CONCLUSIONS: Our meta-analysis demonstrated that ticagrelor was associated with a higher risk of major bleeding compared to clopidogrel in East Asian patients with ACS. Further studies evaluating the role of ticagrelor in management of ACS in East Asian patients are warranted.

Association of Polymorphisms (rs 1799782, rs25489 and rs25487) in XRCC1 and (rs 13181) XPD genes with Acute Coronary Artery Syndrome in Subjects from Multan, Pakistan.

Acute coronary artery syndrome (ACS) is the major cause of mortality in Pakistan with genetic and environmental influence on the incidence of the disease. This case-control study was designed to find out if a correlation is existing between ACS and single nucleotide polymorphisms (SNPs) in DNA repair genes XPD [at codon 751, rs 13181 (Lys to Gln)] and XRCC1 [at codon 399, rs25487 (Arg to Gln); 280, rs25489 (Arg to His) and 194, rs 1799782 (Arg to Trp)] either individually or in various combination with each other (haplotype analysis). The objective of this study was to find out the association of various studied risk factors and serum lipid profile of the subjects with the disease, if any. PCR-RFLP method was used to determine genotype at specific codon in 221 subjects (115 ACS patients and 106 healthy controls) from Southern Punjab population. Genotypic and allelic frequency distribution among the cases and controls revealed that all the studied SNPs were not individually associated with the ACS. Haplotype analysis revealed that subjects having wild type combination of all three XRCC1 SNPs had greater susceptibility to ACS than any other studied genotypic combinations. Analysis of risk factors revealed that hypertension (P<0.001), age (P=0.05), education (P<0.001), gender (P<0.001), family history (P=0.005), smoking habit (P=0.002) and diabetes (P<0.001) were significantly associated with the incidence of ACS. Serum lipid profile analysis indicated that cholesterol level was significantly higher (P=0.048) in patients (161.5mg/dL) than controls (142.1mg/dL) while triglyceride remained unaffected (P=0.87) when compared between the two treatments.

Inferiority of ticagrelor in the PHILO trial: Play of chance in East Asians or nightmare confirmation of PLATO-USA?

Long-awaiting PHILO trial, conducted in 2011-2012 has been submitted and published late in 2015. In contrast to overall PLATO results, but similar to PLATO-US cohort, PHILO revealed numerical inferiority of ticagrelor with regard to death, myocardial infarction, stroke, and bleeding over clopidogrel. Hence, we comprehend the PHILO results in light of the PLATO-US evidence. To assess the PHILO (n=801) outcomes, applied statistics, and trial conduct, matching them with the PLATO-US (n=1413) patients. The Asian, predominantly Japanese ticagrelor patients had worsened outcomes even when compared to the negative American cohort with regard to death (OR=1.44 (PHILO) vs. 1.17 (PLATO-US); myocardial infarction (OR=1.63 vs. 1.38); and composite primary endpoint (OR=1.60 vs. 1.27); but not for stroke (OR=1.51 vs. 1.75). Moreover, in contrast to the trend in PLATO-US (OR=1.11; CI=0.84-1.48, p=0.46), PHILO revealed significant excess of PLATO-defined composite of major and minor bleeding events (OR=1.83; CI=1.27-2.63,p=0.0014). PLATO-defined "net clinical benefit" in PHILO was also significantly (OR=1.61; CI=1.11-2.34, p=0.0145) inferior for ticagrelor. The "number needed to harm" suggests that for every 29 PHILO patients treated for 12months with ticagrelor instead of clopidogrel, one will suffer an additional major bleeding event. Finally, unexplained premature closure of PHILO just after 200-210days mean drug exposure, and short 240days mean follow-up seems deliberate and concerning with regard to unblinding. Aside from some information censoring, early trial closure, and creative statistics, Asian ticagrelor patients did consistently worse in PHILO, than even in the negative PLATO-US cohort. Especially alarming is a significant bleeding inferiority justifying a necessity for a separate outcome-driven low-dose ticagrelor trial in Asian post-PCI patients. This strategy was successfully implemented with the low-dose prasugrel in Japan. Regulatory authorities in Asia may consider conducting an independent review of PHILO dataset to ensure adequate ticagrelor safety.

Ticagrelor vs. clopidogrel in Japanese, Korean and Taiwanese patients with acute coronary syndrome -- randomized, double-blind, phase III PHILO study.

BACKGROUND: Few data on the relative efficacy and safety of new P2Y12inhibitors such as prasugrel and ticagrelor in Japanese, Taiwanese and South Korean patients with acute coronary syndromes (ACS) exist. METHODS AND RESULTS: The multicenter, double-blind, randomized PHILO trial compared the safety and efficacy of ticagrelor vs. clopidogrel in 801 patients with ACS (Japanese, n=721; Taiwanese, n=35; South Korean, n=44; unknown ethnicity, n=1). All were planned to undergo percutaneous coronary intervention and randomized within 24 h of symptom onset. Primary safety and efficacy endpoints were time to first occurrence of any major bleeding event and to any event from the composite of myocardial infarction, stroke or death from vascular causes, respectively.At 12 months, overall major bleeding occurred in 10.3% of ticagrelor-treated patients and in 6.8% of clopidogrel-treated patients (hazard ratio (HR), 1.54; 95% confidence interval (CI): 0.94-2.53); the composite primary efficacy endpoint occurred in 9.0% and in 6.3% of ticagrelor- and clopidogrel-treated patients, respectively (HR, 1.47; 95% CI: 0.88-2.44). For both analyses, the difference between groups was not statistically significant. CONCLUSIONS: In ACS patients from Japan, Taiwan and South Korea, event rates of primary safety and efficacy endpoints were higher, albeit not significantly, in ticagrelor-treated patients compared with clopidogrel-treated patients. This observation could be explained by the small sample size, imbalance in clinical characteristics and low number of events in the PHILO population.

A pharmacodynamic study of the optimal P2Y12 inhibitor regimen for East Asian patients with acute coronary syndrome.

BACKGROUND/AIMS: Newer P2Y12 inhibitors, such as prasugrel and ticagrelor, have greater antiplatelet efficacy but may increase the risk of bleeding. In this study, we compared the pharmacodynamic efficacy of prasugrel and ticagrelor in East Asian patients with acute coronary syndrome (ACS). METHODS: We selected 83 ACS patients undergoing percutaneous coronary intervention who were discharged with 90 mg ticagrelor twice daily (n = 24), 10 mg prasugrel daily (n = 39) or 5 mg prasugrel daily (n = 20). After 2 to 4 weeks, on-treatment platelet reactivity (OPR) was assessed in terms of P2Y12 reaction units (PRUs) using the VerifyNow P2Y12 assay (Accumetrics). We compared East Asian (85 < PRU ≤ 275) and Caucasian (85 < PRU ≤ 208) criteria for assessing the therapeutic window of OPR. RESULTS: OPR was lowest in the ticagrelor group, followed by the 10 mg prasugrel and 5 mg prasugrel groups (49.1 ± 29.9 vs. 83.7 ± 57.1 vs. 168.5 ± 60.8, respectively; p < 0.001). The 5 mg prasugrel group had the highest proportion of patients with OPR values within the therapeutic window, followed by the 10 mg prasugrel and ticagrelor groups (90.0% vs. 46.2% vs. 12.5%, respectively; p < 0.001 for East Asian criteria; 60.0% vs. 43.6% vs. 12.5%, respectively; p < 0.001 for Caucasian criteria). CONCLUSIONS: Short-term administration of 5 mg prasugrel facilitated maintenance within the therapeutic window of OPR compared with the 10 mg prasugrel and ticagrelor groups. Thus, 5 mg prasugrel daily may be the optimal antiplatelet regimen for stabilized East Asian ACS patients.

Ticagrelor versus clopidogrel in Asian patients with acute coronary syndrome: A retrospective analysis from the Platelet Inhibition and Patient Outcomes (PLATO) Trial.

BACKGROUND: In the PLATO trial, ticagrelor was superior to clopidogrel in reducing cardiovascular events among patients with acute coronary syndrome (ACS) at the expense of increased nonfatal bleeding. Because Asian patients, when compared with non-Asian patients, are believed to be more susceptible to bleeding, we evaluated the effects of ticagrelor compared with clopidogrel in Asian (n=1,106) and non-Asian (n=17,515) patients with acute coronary syndrome enrolled in the PLATO study. METHODS AND RESULTS: Interaction between Asian/non-Asian and primary efficacy end point (a composite of vascular death, myocardial infarction, and stroke) and net clinical benefit (composite of primary efficacy end point and coronary artery bypass graft [CABG] surgery or non-CABG-related major bleeding) were evaluated with a Cox proportional hazards model. Baseline demographics and comorbidities were different between Asians and non-Asians. The overall cardiovascular event rates were higher in Asians, but bleeding rates were similar. Despite these observed differences, the effects of ticagrelor versus clopidogrel were not significantly different between Asians and non-Asians with respect to the primary efficacy outcome (hazard ratio for Asians vs non-Asians, 0.84 [95% CI 0.61-1.17] vs 0.85 [95% CI 0.77-0.93], P=.974), net clinical benefit (0.85 [95% CI 0.65-1.11] vs 0.93 [95% CI 0.86-0.99], P=.521), or individual efficacy end points. There was no significant interaction for bleeding (PLATO major bleeding, 1.02 [95% CI 0.70-1.49] vs 1.04 [95% CI 0.95-1.14], P=.938) and other related adverse events with ticagrelor compared with clopidogrel between Asians and non-Asians. CONCLUSIONS: We observed consistency of effects in Asian patients receiving ticagrelor and clopidogrel in the PLATO study. The relatively modest number of Asian patients in this analysis supports further investigation of larger cohorts to confirm our observations.

Change in health behaviours following acute coronary syndrome: Arab-Jewish differences.

BACKGROUND: Health-promoting behaviours after acute coronary syndrome (ACS) are effective in preventing recurrence. Ethnicity impacts on such behaviours. We assessed the independent association of Arab vs. Jewish ethnicity with persistence of smoking and physical inactivity 6 months after ACS in central Israel. DESIGN: Prospective cohort study. METHODS: During their admission for ACS and subsequently 6 months later, 420 patients were interviewed about their smoking and exercise habits. The association of ethnicity with health-promoting behaviours was assessed by logistic regression adjusting for socio-demographic and clinical covariates. RESULTS: Smoking prevalence and physical inactivity were substantially higher among Arab patients than Jewish patients at admission (gender-adjusted prevalence rate ratio (RR) 2.25, 95% CI 1.80-2.81, p < 0.01 and RR 1.46, 95% CI 1.28-1.67, p < 0.001, respectively). The relative differences increased at 6 months (RR 2.94, 95% CI 2.13-4.07, p < 0.001 and RR 3.00, 95% CI 2.24-4.04, p < 0.001, respectively). Excess persistent smoking at 6 months among Arab vs. Jewish patients who were smokers at admission (adjusted OR 2.05, 95% CI 1.00-4.20, p = 0.049) was largely mediated through the 3.5-fold higher participation of Jewish patients in cardiac prevention and rehabilitation program (CPRP) (OR adjusted also for CPRP 1.31, 95% CI 0.59-2.93, p = 0.51). Greater persistent sedentary behaviour at 6 months among nonexercisers at admission among Arab patients (adjusted OR 3.68, 95% CI 1.93-7.02, p < 0.001) was partly mediated through attendance of CPRP (OR adjusted also for CPRP 2.38, 95% CI 1.19-4.76, p = 0.014). CONCLUSIONS: Culturally sensitive programmes need to be developed to enhance CPRP participation and favourable health-promoting changes among Arab patients. A comprehensive understanding of the determinants of the Arab-Jewish differences in efficacious health-promoting behaviours is crucial to inform appropriate ethnic-specific health-promoting strategies.

Management of acute coronary syndrome in special subgroups: female, older, diabetic and Indigenous patients.

While the evidence base for management of acute coronary syndrome (ACS) is extensive, some subgroups have been underrepresented or excluded from relevant clinical trials. These subgroups - such as women, older people, diabetic patients and Indigenous Australians - present clinical challenges for which there is limited evidence to guide optimal therapy. Women may have a different pattern of presentation, with potential for delays in diagnosis and worse outcomes in ST-elevation myocardial infarction, but there is no evidence that treatments affect them differently from men. Older people suffer from a high-risk, low-treatment paradox. This may be due to under-appreciation of the benefits of treatments for older people, or to good clinical judgement in avoiding harm from worsening age-related comorbidities. Patients with diabetes have a high risk of ACS and suffer worse outcomes. Moderate glycaemic control with close monitoring and avoidance of hypoglycaemia are recommended. Coronary artery bypass grafting is preferred to percutaneous coronary intervention for patients with diabetes and multivessel disease, although the latter is reasonable in single-vessel disease. Indigenous patients have a high prevalence of coronary disease, with more frequent coronary events at a young age, a heavy load of risk factors and poor outcomes after ACS. The complex sociocultural barriers to treatment are yet to be addressed adequately.

Endothelial lipase-384A/C polymorphism is associated with acute coronary syndrome and lipid status in elderly Uygur patients in Xinjiang.

OBJECTIVE: To explore the relationship between the endothelial lipase (EL) gene promoter -384A/C polymorphism and acute coronary syndrome (ACS) and lipid status in elderly Uygur patients in Xinjiang. METHODS: The polymerase chain reaction-restriction fragment length polymorphism method was used to detect the EL gene promoter -384A/C genotype in 341 cases of elderly patients with ACS and 380 healthy subjects. RESULTS: In an elderly Chinese Han population, the EL-384A/C genotype and allele frequency distribution were significantly different between the ACS group and the control group (p<0.05); the frequency of the CC genotype in the ACS group was significantly higher than that in the control group (p<0.05). After adjusting for gender, age, diabetes, hypertension, smoking, hyperlipidemia, and other cardiovascular risk factors, the difference remains statistically significant (p<0.05). In the ACS group, C allele carriers had significantly higher serum triglycerides, total cholesterol, and low-density lipoprotein cholesterol concentrations compared to AA genotypes (all p<0.05). CONCLUSION: EL-384A/C polymorphism was significantly associated with the ACS and lipids profile in an elderly Uygur population in Xinjiang.

Ethnicity and revascularisation following acute coronary syndromes: a 5-year cohort study (ANZACS-QI-3).

BACKGROUND: Prior studies have reported higher rates of coronary revascularisation in European compared with Maori and Pacific patients. Our aim was to define the current variation by ethnicity in investigation, revascularisation and pharmacotherapy after admission with an acute coronary syndrome (ACS). METHODS: Data from consecutive New Zealand residents <80 years of age admitted to the Middlemore Hospital coronary care unit with ACS (2007 to 2012) were collected prospectively. RESULTS: Of 2666 ACS patients <80y, 51.5% were European/Other, 14.2% Maori, 16.0% Pacific, 14.8% Indian, and 3.5% Asian. Cardiac risk factors and comorbidity varied markedly by ethnicity. The overall coronary angiography rate was high (89%). After adjustment for clinical factors which influence the decision to perform angiography, European/Other patients were about 5% more likely than Maori and Pacific patients to have angiography. Overall revascularisation was highest in Asian, Indian and European/Other (76.1%, 69.1% and 68.6%), and lower in Maori and Pacific patients (58.2% and 52.9%). Non-obstructive coronary disease was more common in Maori and Pacific (20.6 and 18.6%, respectively), than in European/Other, Indian and Asian patients (13.3%, 8.7% and 6.1%). After adjustment, Maori, Indian and Asian patients were as likely to receive revascularisation as European/Others, but revascularisation in Pacific patients was 13% lower. Discharge prescribing of triple preventive therapy was uniformly high across ethnic groups (overall 91%). CONCLUSIONS: There is a small unexplained variation in angiography rates across ethnic groups. Much of the observed variation in revascularisation may be due to differences in the coronary artery disease phenotype.

"East asian paradox": challenge for the current antiplatelet strategy of "one-guideline-fits-all races" in acute coronary syndrome.

Clinical experiences have suggested that East Asians show the higher risk of warfarin-related intracranial hemorrhage compared with Westerners. Therefore, different target of the International Normalized Ratio (INR) in East Asians (1.6-2.6) has been proposed and adapted in clinical practice. In terms with antiplatelet therapy, recent evidence has supported the concept of "therapeutic level of platelet reactivity" to balance clinical efficacy and safety in patients undergoing percutaneous coronary intervention (PCI) or those with acute coronary syndrome (ACS). In line with the warfarin experiences, multiple clinical and pharmacodynamic data from East Asians have shown their different therapeutic level of platelet reactivity following PCI or ACS ("East Asian Paradox"). Furthermore, like most cardiovascular drugs, P2Y12 receptor blockers have marked interethnic differences in the pharmacokinetics and pharmacodynamics. The currently performed clinical trials evaluating the clinical efficacy and safety of potent P2Y12 inhibitors mostly don't include enough number of East Asians to draw reliable conclusions. Therefore, dedicated research and guideline(s) for East Asians are required before we can apply Western recommendations for potent P2Y12 inhibitors in East Asian population. It is a time to consider the paradigm shift from "one-guideline-fits-all races" to "race-tailored antiplatelet therapy" in treating ACS patients.