Simplified echocardiographic assessment of regional left ventricular wall motion pattern in patients with takotsubo and acute coronary syndrome: The randomized blinded Two-chamber Apical Kinesis Observation (TAKO) study.

BACKGROUND: Differentiating Takotsubo cardiomyopathy (TTC) from acute coronary syndrome involving the left anterior descending coronary artery (LAD-ACS) is difficult due to left ventricular apical wall motion abnormality pattern in both and typically requires an invasive coronary angiography (ICA) study for diagnostic confirmation. OBJECTIVES: To identify differences in the regional wall motion abnormality (RWMA) pattern using a comprehensive comparative analysis of the transthoracic echocardiographic (TTE) findings in patients with TTC versus LAD-ACS. METHODS: This was a retrospective, randomized, blinded comparison study including a derivation cohort of 105 patients with TTC (N=52) or LAD-ACS (N=53) with concomitant TTE and ICA identified from our institutional database. A comprehensive echocardiographic wall motion analysis was performed (unblinded) to search for subtle differences in RWMA patterns by marking the exact locations of the end-systolic hinge points (HP) - defined as the intersection between the normal and abnormal regional myocardial thickening - in all apical views. The HP location relative to mitral annulus in each apical view was compared for symmetry and the apical 2-chamber (A2C) view was identified as having the most consistent, quantitative difference between TTC and LAD-ACS. This A2C quantitative model was then prospectively studied in a randomized, blinded, validation cohort of 30 subjects with either TTC or LAD-ACS by eight echocardiographic readers with all levels of clinical experience. RESULTS: In the unblinded derivation cohort, the A2C view showed that the ratio (1.02) and the absolute distance between the anterior HP (3.57 cm) and the inferior HP (3.53 cm) in TTC was significantly different than the ratio (0.761) and the absolute differences between the AHP (4.5 cm) and the IHP (5.93 cm) in LAD-ACS. An AHP: IHP of 0.96 for men and 0.84 for women was able to correctly categorize 84.8% of male and 91.7% of female patients. When applied to the validation cohort, the model showed fairly accurate results with a 74% prediction rate in diagnosing TTC in female patients. CONCLUSION: We propose a relatively simple 2-D TTE diagnostic tool emphasizing subtle differences in the RWMA pattern in the A2C view alone as a semi-quantitative imaging parameter to help differentiate TTC from LAD-ACS.

The Relationship Between Controlling Nutritional Assessment Score and Mortality in Patients with Chronic Coronary Syndrome: A Retrospective Study from Türkiye.

BACKGROUND: Controlling Nutritional Assessment (CONUT) score has been shown to have a higher predictive value compared to other nutritional scores in acute coronary syndrome. AIM: To determine the relationship between CONUT score and long-term mortality in patients with chronic coronary syndrome (CCS). METHODS: Between 2017 and 2020, 585 consecutive patients newly diagnosed and proven to have CCS by coronary angiography were included in the study. CONUT score and demographic and laboratory data of all patients were evaluated. The relationship between results and mortality was evaluated. RESULTS: The mean age of the patients was 64 years and 75% were male. Mortality was observed in 56 (9.6%) patients after a median follow-up period of 3.5 years. The median CONUT score was significantly higher in patients with mortality (P < 0.001). In multivariate regression analysis, the CONUT score was associated with mortality (Hazard ratio (HR): 1.63 (95% confidence interval (CI): 1.34-1.98 P < 0.001)). The area under curve (AUC) for long-term mortality estimation for the CONUT score was 0.75 (95% CI 0.67-0.82 P < 0.001). When the CONUT score value was accepted as 0.5, the sensitivity was 78% and the specificity was 60. CONCLUSION: CONUT score was found to be predictive of mortality in long-term follow-up of patients with CCS.

Randomized Trial of Remote Assessment of Patients After an Acute Coronary Syndrome.

BACKGROUND: Telemedicine programs can provide remote diagnostic information to aid clinical decisions that could optimize care and reduce unplanned readmissions post-acute coronary syndrome (ACS). OBJECTIVES: TELE-ACS (Remote Acute Assessment of Patients With High Cardiovascular Risk Post-Acute Coronary Syndrome) is a randomized controlled trial that aims to compare a telemedicine-based approach vs standard care in patients following ACS. METHODS: Patients were suitable for inclusion with at least 1 cardiovascular risk factor and presenting with ACS and were randomized (1:1) before discharge. The primary outcome was time to first readmission at 6 months. Secondary outcomes included emergency department (ED) visits, major adverse cardiovascular events, and patient-reported symptoms. The primary analysis was performed according to intention to treat. RESULTS: A total of 337 patients were randomized from January 2022 to April 2023, with a 3.6% drop-out rate. The mean age was 58.1 years. There was a reduced rate of readmission over 6 months (HR: 0.24; 95% CI: 0.13-0.44; P < 0.001) and ED attendance (HR: 0.59; 95% CI: 0.40-0.89) in the telemedicine arm, and fewer unplanned coronary revascularizations (3% in telemedicine arm vs 9% in standard therapy arm). The occurrence of chest pain (9% vs 24%), breathlessness (21% vs 39%), and dizziness (6% vs 18%) at 6 months was lower in the telemedicine group. CONCLUSIONS: The TELE-ACS study has shown that a telemedicine-based approach for the management of patients following ACS was associated with a reduction in hospital readmission, ED visits, unplanned coronary revascularization, and patient-reported symptoms. (Telemedicine in High-Risk Cardiovascular Patients Post-ACS [TELE-ACS]; NCT05015634).

Assessment and Application of the Hear Score in Remote Emergency Medicine Outposts in Bosnia and Herzegovina.

Background and Objectives. In emergency departments, chest pain is a common concern, highlighting the critical importance of distinguishing between acute coronary syndrome and other potential causes. Our research aimed to introduce and implement the HEAR score, specifically, in remote emergency outposts in Bosnia and Herzegovina. Materials and Methods. This follow-up study conducted a retrospective analysis of a prospective cohort consisting of patients who were admitted to the remote emergency medicine outposts in Canton Sarajevo and Zenica from 1 November to 31 December 2023. Results. This study comprised 103 (12.9%) patients with low-risk HEAR scores and 338 (83.8%) with high-risk HEAR scores, primarily female (221, 56.9%), with a mean age of 63.5 ± 11.2). Patients with low-risk HEAR scores were significantly younger (50.5 ± 15.6 vs. 65.9 ± 12.1), had fewer smokers (p < 0.05), and exhibited a lower incidence of cardiovascular risk factors compared to those with high-risk HEAR scores. Low-risk HEAR score for prediction of AMI had a sensitivity of 97.1% (95% CI 89.9-99.6%); specificity of 27.3% (95% CI 22.8-32.1%); PPV of 19.82% (95% CI 18.67-21.03%), and NPV of 98.08% (95% CI 92.80-99.51%). Within 30 days of the admission to the emergency department outpost, out of all 441 patients, 100 (22.7%) were diagnosed with MACE, with AMI 69 (15.6%), 3 deaths (0.7%), 6 (1.4%) had a CABG, and 22 (4.9%) underwent PCI. A low-risk HEAR score had a sensitivity of 97.0% (95% CI 91.7-99.4%) and specificity of 27.3% (95% CI 22.8-32.1%); PPV of 25.5% (95% CI 25.59-28.37%); NPV of 97.14% (95% CI 91.68-99.06%) for 30-day MACE. Conclusions. In conclusion, the outcomes of this study align with existing research, underscoring the effectiveness of the HEAR score in risk stratification for patients with chest pain. In practical terms, the implementation of the HEAR score in clinical decision-making processes holds significant promise.

Temporal trends in admission for cardiac rehabilitation after an acute coronary syndrome in France from 2009 to 2021: Persistent sex, age and social disparities.

BACKGROUND: Cardiac rehabilitation after an acute coronary syndrome is recommended to decrease patient morbidity and mortality and to improve quality of life. AIMS: To describe time trends in the rates of patients undergoing cardiac rehabilitation after an acute coronary syndrome in France from 2009 to 2021, and to identify possible disparities. METHODS: All patients hospitalized for acute coronary syndrome in France between January 2009 and June 2021 were identified from the national health insurance database. Cardiac rehabilitation attendance was identified within 6 months of acute coronary syndrome hospital discharge. Age-standardized cardiac rehabilitation rates were computed and stratified for sex and acute coronary syndrome subtypes (ST-segment elevation and non-ST-segment elevation). Patient characteristics and outcomes were described and compared. Factors independently associated with cardiac rehabilitation attendance were identified. RESULTS: In 2019, among 134,846 patients with an acute coronary syndrome, 22.3% underwent cardiac rehabilitation within 6 months of acute coronary syndrome hospital discharge. The mean age of patients receiving cardiac rehabilitation was 62 years. The median delay between acute coronary syndrome hospitalization and cardiac rehabilitation was 32 days, with about 60% receiving outpatient cardiac rehabilitation. Factors significantly associated with higher cardiac rehabilitation rates were male sex, younger age (35-64 years), least socially disadvantaged group, ST-segment elevation, percutaneous coronary intervention and coronary artery bypass graft. Between 2009 and 2019, cardiac rehabilitation rates increased by 40% from 15.9% to 22.3%. Despite greater upward trends in women, their cardiac rehabilitation rate was significantly lower than that for men (14.8% vs. 25.8%). In 2020, cardiac rehabilitation attendance dropped because of the coronavirus disease 2019 pandemic. CONCLUSIONS: Despite the health benefits of cardiac rehabilitation, current cardiac rehabilitation attendance after acute coronary syndrome remains insufficient in France, particularly among the elderly, women and socially disadvantaged people.

Could Computed Tomography Coronary Angiography Replace Invasive Coronary Angiography as a First-Line Diagnostic Investigation in Suspected Acute Coronary Syndromes? A Decision-Analytic Model.

BACKGROUND: The implementation of high-sensitivity cardiac troponin (hs-cTn) assays into clinical practice has resulted in the identification of a novel cohort of patients with modestly increased troponin concentrations. Subsequent increases in rates of coronary angiography have been observed, without significant increases in rates of coronary revascularisation. Computed tomography coronary angiography (CTCA) is a non-invasive investigation that offers the opportunity to decouple investigation from the impetus to revascularise, and may provide an alternative, more risk-appropriate initial investigative strategy for the cohort with low to moderate hs-cTn increases. This analysis seeks to define the threshold of pre-test probability of coronary revascularisation in patients with suspected acute coronary syndrome at which a strategy of initial CTCA is safe and a more cost-effective approach than standard invasive coronary angiography (ICA). METHODS: A cost-benefit evaluation was conducted using a decision-analytic model. The primary outcome measure was the incremental cost-effectiveness ratio (ICER) of CTCA in comparison with ICA as an initial diagnostic investigation for patients with hs-cTnT levels between 5 and 100 ng/L. Secondary outcome measures of costs, patient outcomes, and quality-adjusted life years were analysed. RESULTS: Median base case ICER over 1,000 trials was $17,163 AUD but demonstrated large variability. Sensitivity analysis demonstrated that CTCA was cost-effective until the probability of requiring revascularisation was ∼60%, beyond which point CTCA was associated with higher costs and poorer outcomes than ICA. CONCLUSIONS: Computed tomography coronary angiography may be a cost-effective first-line investigation for patients with moderate hs-cTnT rises until/up to a 60% pre-test probability for receiving coronary revascularisation. To objectively assess the optimal circumstances of cost-effectiveness, prospective evaluation incorporating the estimated probability of revascularisation will be required.

Nationwide time trends in patients hospitalized for acute coronary syndrome: a worrying generational and social effect among women.

AIMS: To estimate the time trends in the annual incidence of patients hospitalized for acute coronary syndrome (ACS) in France from 2009 to 2021 and to analyse the current sex and social differences in ACS, management, and prognosis. METHODS AND RESULTS: All patients hospitalized for ACS in France were selected from the comprehensive National Health Insurance database. Age-standardized rates were computed overall and according to age group (over or under 65 years), sex, proxy of socioeconomic status, and ACS subtype [ST-segment elevation (STSE) and non-ST-segment elevation]. Patient characteristics and outcomes were described for patients hospitalized in 2019. Differences in management (coronarography, revascularization), and prognosis were analysed by sex, adjusting for cofonders. In 2019, 143,670 patients were hospitalized for ACS, including 53,227 STSE-ACS (mean age = 68.8 years; 32% women). Higher standardized incidence rates among the most socially deprived people were observed. Women were less likely to receive coronarography and revascularization but had a higher excess in-hospital mortality. In 2019, the age-standardized rate for hospitalized ACS patients reached 210 per 100 000 person-year. Between 2009 and 2019, these rates decreased by 11.4% (men: -11.2%; women: -14.0%). Differences in trends of age-standardized incidence rate have been observed according to sex, age, and social status. Middle aged women (45-64 years) showing more unfavourable trends than in other age classes or in men. In addition, among women the temporal trends were more unfavourable as social deprivation increased. CONCLUSION: Despite encouraging overall trends in patients hospitalized for ACS rates, the increasing trends observed among middle-aged women, especially socially deprived women, is worrying. Targeted cardiovascular prevention and close surveillance of this population should be encouraged.

The burden of acute coronary syndrome remains important in France. Moreover, there are significant social and sex disparities in the epidemiology of this disease, especially in the 45- to 64-year-old generation. The rate of coronary angiography, revascularization, cardiac complications, and inhospital mortality differed between men and women, regardless of age, comorbidities, and social status.

Prehospital risk assessment and direct transfer to a percutaneous coronary intervention centre in suspected acute coronary syndrome.

OBJECTIVE: Prehospital risk stratification and triage are currently not performed in patients suspected of non-ST-segment elevation acute coronary syndrome (NSTE-ACS). This may lead to prolonged time to revascularisation, increased duration of hospital admission and higher healthcare costs. The preHEART score (prehospital history, ECG, age, risk factors and point-of-care troponin score) can be used by emergency medical services (EMS) personnel for prehospital risk stratification and triage decisions in patients with NSTE-ACS. The aim of the current study was to evaluate the effect of prehospital risk stratification and direct transfer to a percutaneous coronary intervention (PCI) centre, based on the preHEART score, on time to final invasive diagnostics or culprit revascularisation. METHODS: Prospective, multicentre, two-cohort study in patients with suspected NSTE-ACS. The first cohort is observational (standard care), while the second (interventional) cohort includes patients who are stratified for direct transfer to either a PCI or a non-PCI centre based on their preHEART score. Risk stratification and triage are performed by EMS personnel. The primary endpoint of the study is time from first medical contact until final invasive diagnostics or revascularisation. Secondary endpoints are time from first medical contact until intracoronary angiography (ICA), duration of hospital admission, number of invasive diagnostics, number of inter-hospital transfers and major adverse cardiac events at 7 and 30 days. RESULTS: A total of 1069 patients were included. In the interventional cohort (n=577), time between final invasive diagnostics or revascularisation (42 (17-101) hours vs 20 (5-44) hours, p<0.001) and length of hospital admission (3 (2-5) days vs 2 (1-4) days, p=0.007) were shorter than in the observational cohort (n=492). In patients with NSTE-ACS in need for ICA or revascularisation, healthcare costs were reduced in the interventional cohort (€5599 (2978-9625) vs €4899 (2278-5947), p=0.02). CONCLUSION: Prehospital risk stratification and direct transfer to a PCI centre, based on the preHEART score, reduces time from first medical contact to final invasive diagnostics and revascularisation, reduces duration of hospital admission and decreases healthcare costs in patients with NSTE-ACS in need for ICA or revascularisation. TRIAL REGISTRATION: NCT05243485.

Usefulness of the Quick-Sepsis Organ Failure Assessment Score in Cardiovascular Intensive Care Unit to Predict Prognosis in Acute Coronary Syndrome.

Triage of patients with acute coronary syndrome (ACS) at high risk of in-hospital complications is essential. In this study, we evaluated the quick sepsis organ failure assessment (qSOFA) score as a tool for predicting the prognosis of 964 patients admitted to the cardiovascular intensive care unit (CICU) with ACS over a 4-year period. In total, out of 964 patients included, with a percentage of 4.6% for 30-day mortality. The risk of 30-day mortality was independently associated with qSOFA ≥ 2 at admission (hazard ratio = 2.76, 95% CI 1.32-5.74, p = 0.007). For MACEs, qSOFA ≥ 2 at admission was a predictive factor with (odds ratio = 2.42, 95% CI 1.37-4.36, p = .002). A qSOFA ≥ 2 on admission had an AUC of 0.729 (95% CI [0.694, 0.762]), with a good specificity of 91.6%. For 30-day mortality, an AUC of 0.759 (95%CI [0.726, 0.792]) for cardiogenic shock with specificity of 92.5%. For MACEs, an AUC of 0.702 (95% CI [0.64, 0.700] with a specificity of 95%. Concerning the different scores tested, we found no significant difference between the Zwolle score and the qSOFA score for predicting prognosis, whereas the CADILLAC score was better than qSOFA for predicting 30-day mortality (AUC = 0.829 and De long test = 0.03). However, there was no difference between qSOFA and CADILLAC scores for predicting cardiogenic shock (De Long test at 0.08). This is the first study to evaluate qSOFA as a predictive score for 30-day mortality and MACEs, and the results are very encouraging, particularly for cardiogenic shock.

Differences in risk and costs between prehospital identified low-risk men and women with chest pain.

OBJECTIVE: Prehospital rule-out of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in low-risk patient with a point-of-care troponin measurement reduces healthcare costs with similar safety to standard transfer to the hospital. Risk stratification is performed identical for men and women, despite important differences in clinical presentation, risk factors and age between men and women with NSTE-ACS. Our aim was to compare safety and healthcare costs between men and women in prehospital identified low-risk patients with suspected NSTE-ACS. METHODS: In the Acute Rule-out of non-ST-segment elevation acute coronary syndrome in the (pre)hospital setting by HEART (History, ECG, Age, Risk factors and Troponin) score assessment and a single poInt of CAre troponin randomised trial, the HEAR (History, ECG, Age and Risk factors) score was assessed by ambulance paramedics in suspected NSTE-ACS patients. Low-risk patients (HEAR score ≤3) were included. In this substudy, men and women were compared. Primary endpoint was 30-day major adverse cardiac events (MACE), secondary endpoints were 30-day healthcare costs and the scores for the HEAR score components. RESULTS: A total of 863 patients were included, of which 495 (57.4%) were women. Follow-up was completed in all patients. In the total population, MACE occurred in 6.8% of the men and 1.6% of the women (risk ratio (RR) 4.2 (95% CI 1.9 to 9.2, p<0.001)). In patients with ruled-out ACS (97% of the total population), MACE occurred in 1.4% of the men and in 0.2% of the women (RR 7.0 (95% CI 2.0 to 14.2, p<0.001). Mean healthcare costs were €504.55 (95% CI €242.22 to €766.87, p<0.001) higher in men, mainly related to MACE. CONCLUSIONS: In a prehospital population of low-risk suspected NSTE-ACS patients, 30-day incidence of MACE and MACE-related healthcare costs were significantly higher in men than in women. TRIAL REGISTRATION NUMBER: NCT05466591.

Increasing Incidence of ST-Elevation Acute Coronary Syndrome in Young South Asian Population, a Challenge for the World? An Assessment of Clinical and Angiographic Patterns and Hospital Course of Premature Acute Myocardial Infarction.

The incidence of premature ischemic heart disease (IHD) is increasing because of urbanization, a sedentary lifestyle, and various other unexplored factors, especially in South Asia. This study aimed to assess the distribution of premature ST-elevation acute coronary syndrome (STE-ACS) with its clinical and angiographic pattern along with hospital course in a contemporary cohort of patients who underwent primary percutaneous intervention at a tertiary care center in the South Asian region. We included consecutive patients of either gender diagnosed with STE-ACS and who underwent primary percutaneous intervention. Patients were stratified based on age as ≤40 years (young) and >40 years (old). Clinical characteristics, angiographic patterns, and hospital course were compared between the 2 groups. Of the total of 4,686 patients, 466 (9.9%) were young (≤40 years). Young patients had a lower prevalence of hypertension (40.8% vs 54.5%, p <0.001), diabetes (26.6% vs 36.4%, p <0.001), metabolic syndrome (14.8% vs 24%, p <0.001), history of IHD (5.8% vs 9.3%, p = 0.013) and a higher frequency of smoking (33% vs 24.7%, p <0.001), positive family history (8.2% vs 3.2%, p <0.001), and single-vessel involvement (60.1% vs 33.2%, p <0.001). The composite adverse clinical outcome occurrence was significantly lower in young patients (14.2% vs 19.5%, p = 0.006). On multivariable analysis, history of IHD in young, whereas age, Killip class III/IV, intubated, arrhythmias on arrival, diabetes, history of IHD, pre-procedure left ventricular end-diastolic pressure, ejection fraction <40%, and slow flow/no-reflow during the procedure were found to be the independent predictors of adverse clinical outcome in old patients. In conclusion, we have a substantial burden of premature STE-ACS, mostly in male patients potentially driven by smoking and positive family history. Despite favorable pathophysiology, with mostly single-vessel hospital courses of STE-ACS in the young equally lethal in nature.

Focused Chest Pain Assessment for Early Detection of Acute Coronary Syndrome: Development of a Cardiovascular Digital Health Intervention.

Background: Chest pain misinterpretation is the leading cause of pre-hospital delay in acute coronary syndrome (ACS). This study aims to identify and differentiate the chest pain characteristics associated with ACS. Methods: A total of 164 patients with a primary complaint of chest pain in the ER were included in the study. ACS diagnosis was made by a cardiologist based on the WHO criteria, and the patients were interviewed 48 hours after their admission. Furthermore, every question was analysed using the crosstabs method to obtain the odds ratio, and logistic regression analysis was applied to identify the model of focused questions on chest pain assessment. Results: Among the samples, 50% of them had an ACS. Four questions fitted the final model of ACS chest pain focused questions: 1) Did the chest pain occur at the left/middle chest? 2) Did the chest pain radiate to the back? 3) Was the chest pain provoked by activity and relieved by rest? 4) Was the chest pain provoked by food ingestion, positional changes, or breathing? This model has 92.7% sensitivity, 84.1% specificity, 85% positive predictive value (PPV), 86% negative predictive value (NPV), and 86% accuracy. After adjusting for gender and diabetes mellitus (DM), the final model has a significant increase in Nagelkerke R-square to 0.737 and Hosmer and Lemeshow test statistic of 0.639. Conclusion: Focused questions on 1) left/middle chest pain, 2) retrosternal chest pain, 3) exertional chest pain that is relieved by rest, and 4) chest pain from food ingestion, positional changes, or breathing triggering can be used to rule out ACS with high predictive value. The findings from this study can be used in health promotion materials and campaigns to improve public awareness regarding ACS symptoms. Additionally, digital health interventions to triage patients' suffering with chest pain can also be developed.

Assessment of systemic immune-inflammation index as an independent surrogate biomarker of no-reflow phenomenon in acute coronary syndrome patients with coronary artery bypass grafting undergoing percutaneous coronary intervention of saphenous vein graft.

OBJECTIVE: Numerous mechanisms have been proposed for the no-reflow phenomenon (NRP) in the literature including leukocyte intravascular plugging, microembolisms, and extrinsic coagulation pathway activation. Some of the more recent studies suggested a relationship between NRP and systemic immune-inflammation index (SII) in different contexts. To this end, the objective of this study was to investigate the relationship between NRP and SII in acute coronary syndrome (ACS) patients with coronary artery bypass grafting (CABG) who underwent percutaneous transluminal coronary angioplasty (PTCA) or percutaneous coronary intervention (PCI) of saphenous vein graft (SVG). PATIENTS AND METHODS: The sample of this retrospective study consisted of 124 ACS patients with CABG who underwent PTCA/PCI of SVG. RESULTS: The incidence of NRP in the study group was 30.6% (n=38). The results of the multivariate logistic regression analysis indicated that ST-elevation myocardial infarction (STEMI) and SII were independent predictors for NRP (p<0.05). The receiver operating characteristic (ROC) curve analysis revealed that the optimal cut-off value of SII in predicting the development of NRP in patients undergoing PTCA/PCI of SVG and the sensitivity and specificity values thereof are 975, 74%, and 80%, respectively [Area under the curve (AUC): 0.84, 95% confidence interval (CI): 0.76-0.91, p-value <0.001]. CONCLUSIONS: The study findings indicated that SII, which can be easily calculated from a single complete blood count test, is an independent predictor of the development of NRP in ACS patients undergoing PTCA/PCI of the SVG.

ASSESSMENT OF CORONARY COLLATERAL CIRCULATION PREDICTORS AMONG PATIENTS WITH ACUTE CORONARY SYNDROME IN POPULATION GEORGIA.

Coronary collateral circulation (CCC) has been shown to have a prognostic role in acute myocardial infarction (MI). We aimed to identify factors associated with CCC development in patients with acute myocardial ischemia. In the present analysis, 673 consecutive patients aged 27 - 94 years (64.7±11.48) with acute coronary syndrome (ACS), who underwent coronary angiography within the first 24 hours after symptom onset were included. Baseline data, including sex, age, cardiovascular risk factors, medication, antecedent angina, prior coronary revascularization, EF%, blood pressure levels were obtained from patient medical records. The study individuals were divided into two groups: patients with Rentrop grade 0 to 1 were classified as the poor collateral group (456 patients), and the patients with grade 2 to 3 - as the good collateral group (217 patients). Prevalence of good collaterals of 32% was found. Odds of good collateral circulation increases with higher eosinophil count - OR=17.36 (95% CI: 3.25-92.86); history of MI (OR=1.76; 95% CI:1.13-2.75); multivessel disease - OR=9.78 (95% CI: 5.65-16.96); culprit vessel stenosis - OR=3.91 (95% CI: 2.35-6.52); presence of angina pectoris > 5 years - OR=5.55 (95% CI:2.66-11.57) and decreases with high N/L- OR=0.37 (95% CI:0.31-0.45) and male gender - OR=0.44 (95% CI:0.29-0.67). High N/L is a predictor of poor collateral circulation, with 68.4 sensitivity and 72.8% specificity (cutoff: 2.73*109). Relative chance of good collateral circulation increases with the higher number of eosinophils, presence of angina pectoris with duration of more than 5 years, history of past myocardial infarction, culprit vessel stenosis, multivessel disease, and reduces if patient is male and has high N/L ratio. Peripheral blood parameters may serve as an additional simple risk assessment tool in ACS patients.

Death rates following emergency department chest pain assessment.

OBJECTIVES: We sought to define the rate of unexpected death from acute coronary syndrome or arrhythmia in chest pain patients directly discharged from the ED. METHODS: Retrospective audit of all chest pain patients at a tertiary ED for 7 years. Medical and post-mortem records of the deceased were reviewed with independent cardiologist adjudication to determine outcomes. Primary outcome measure was 28-day unexpected death secondary to acute coronary syndrome or arrhythmia. RESULTS: During the study period, 25 924 patients presented with chest pain, 292 (1.1%, 95% confidence interval [CI] 0.99-1.01%) died within 28 days. Of these, 16 680(64%, 95% CI 63.88-64.12%) were discharged by ED, two (0.01%, 95% CI 0-0.011%) of this group died from the primary outcome. CONCLUSION: Unexpected death is very uncommon after ED discharge of chest pain patients.

Validity of Diagnostic Algorithms for Cardiovascular Diseases in Japanese Health Insurance Claims.

BACKGROUND: We aimed to validate a claims-based diagnostic algorithm to identify hospitalized patients with acute major cardiovascular diseases (CVDs) from health insurance claims in Japan.Methods and Results: This retrospective multicenter validation study was conducted at 4 institutes, including Japanese Circulation Society-certified and uncertified hospitals in Japan. Data on patients with CVDs in departmental lists or with International Classification of Diseases, 10th Revision (ICD-10) codes for CVDs hospitalized between April 2018 and March 2019 were extracted. We examined the sensitivity and positive predictive value of a diagnostic algorithm using ICD-10 codes, medical examinations, and treatments for acute coronary syndrome (ACS), acute heart failure (HF), and acute aortic disease (AAD). We identified 409 patients with ACS (mean age 70.6 years; 24.7% female), 615 patients with acute HF (mean age 77.3 years; 46.2% female), and 122 patients with AAD (mean age 73.4 years; 36.1% female). The respective sensitivity and positive predictive value for the algorithm were 0.86 (95% confidence interval [CI] 0.82-0.89) and 0.95 (95% CI 0.92-0.97) for ACS; 0.74 (95% CI 0.70-0.77) and 0.79 (95% CI 0.76-0.83) for acute HF; and 0.86 (95% CI 0.79-0.92) and 0.83 (95% CI 0.76-0.89) for AAD. CONCLUSIONS: The validity of the diagnostic algorithm for Japanese claims data was acceptable. Our results serve as a foundation for future studies on CVDs using nationwide administrative data.

Comparison of Evolocumab and Ezetimibe, Both Combined with Statin Therapy, for Patients with Recent Acute Coronary Syndrome: A Cost-Effectiveness Analysis from the Chinese Healthcare Perspective.

PURPOSE: To assess the cost-effectiveness of evolocumab, a PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitor, compared with ezetimibe, both added to background statin therapy in patients with recent acute coronary syndrome (ACS) events (in the past 12 months) and low-density lipoprotein cholesterol (LDL-C) levels ≥ 100 mg/dL in China. METHODS: A health economic evaluation was performed from a Chinese healthcare perspective, using a Markov model over a lifetime horizon based on a baseline cardiovascular (CV) event rate from claims database data and efficacy from the FOURIER trial. The health benefit was reflected in the decrease of LDL-C level, which led to a decrease of cardiovascular events. The costs of cardiovascular events and the utility value of each health state were derived from the published literature. Sensitivity analyses were conducted to evaluate the effects of uncertainty in parameters and the robustness of the model. The cost-effectiveness of evolocumab was also explored in patients with recent myocardial infarction (MI), at very high risk (VHR) of atherosclerotic cardiovascular disease (ASCVD), and homozygous familiar hypercholesterolemia (HoFH). RESULTS: In patients with recent ACS, evolocumab was associated with incremental quality-adjusted life-years (QALYs) of 1.33 and incremental costs of 115,782 yuan versus ezetimibe, both with background statin therapy, resulting in an incremental cost-effectiveness ratio (ICER) of 87,050 yuan per QALY gained. The probability of evolocumab + statins being cost-effective at a threshold of 217,341 yuan (three times per capita GDP, 2020), compared with ezetimibe + statins, was 100% in patients with recent ACS, recent MI, VHR ASCVD, and HoFH. CONCLUSION: Compared with ezetimibe + statins, the combination of evolocumab + statins was found to be cost-effective at a threshold of 217,341 yuan (three times per capita GDP, 2020) in patients with recent ACS events in China.