Sex Differences in Cardiovascular Outcomes in Patients With Kidney Failure.

BACKGROUND: Cardiovascular disease is the leading cause of mortality in patients with kidney failure, and their risk of cardiovascular events is 10 to 20 times higher as compared with the general population. METHODS AND RESULTS: We evaluated 508 822 patients who initiated dialysis between January 1, 2005 and December 31, 2014 using the United States Renal Data System with linked Medicare claims. We determined hospitalization rates for cardiovascular events, defined by acute coronary syndrome, heart failure, and stroke. We examined the association of sex with outcome of cardiovascular events, cardiovascular death, and all-cause death using adjusted time-to-event models. The mean age was 70±12 years and 44.7% were women. The cardiovascular event rate was 232 per thousand person-years (95% CI, 231-233), with a higher rate in women than in men (248 per thousand person-years [95% CI, 247-250] versus 219 per thousand person-years [95% CI, 217-220]). Women had a 14% higher risk of cardiovascular events than men (hazard ratio [HR], 1.14 [95% CI, 1.13-1.16]). Women had a 16% higher risk of heart failure (HR, 1.16 [95% CI, 1.15-1.18]), a 31% higher risk of stroke (HR, 1.31 [95% CI, 1.28-1.34]), and no difference in risk of acute coronary syndrome (HR, 1.01 [95% CI, 0.99-1.03]). Women had a lower risk of cardiovascular death (HR, 0.89 [95% CI, 0.88-0.90]) and a lower risk of all-cause death than men (HR, 0.96 [95% CI, 0.95-0.97]). CONCLUSIONS: Among patients undergoing dialysis, women have a higher risk of cardiovascular events of heart failure and stroke than men. Women have a lower adjusted risk of cardiovascular mortality and all-cause mortality.

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.

Frailty in acute coronary syndromes. A systematic review and narrative synthesis of frailty assessment tools and interventions from randomised controlled trials.

AIM: We aimed to review all randomised controlled trial (RCT) data to explore optimal identification and treatment strategies of frail patients with Acute Coronary Syndromes (ACS). METHODS: The protocol was preregistered (PROSPERO - CRD42021250235). We performed a systematic review including RCT's that 1; used at least one frailty assessment tool to assess frailty and its impact on outcomes in patients diagnosed with ACS and 2; used at least one intervention where change in frailty was measured in patients diagnosed with ACS. The Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE were searched on the 1st April 2021 and updated on 4th July 2023. Owing to low search output results are presented as a narrative synthesis of available evidence. RESULTS: A single RCT used a frailty assessment tool. A single RCT specifically targeted frailty with their intervention. This precluded further quantitative analysis. There was indication of selection bias against frail participants, and a signal of value for physical activity measurement in frail ACS patients. There was a high level of uncertainty and low level of robustness of this evidence. CONCLUSIONS: Data from RCT's alone is inadequate in answering the reviews question. Future RCT's need to address ways to incorporate frail participants, whilst mitigating selection biases. Physical performance aspects of the frailty syndrome appear to be high yield modifiable targets that improve outcomes. Intervention trials should consider using change in frailty status as an outcome measure. Any trials that include frail participants should present data specifically attributable to this group.

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.

A systematic assessment of the characteristics of randomized controlled trials cited by acute coronary syndrome clinical practice guidelines.

AIMS: The aim of this study was to describe the methodological features of the randomized controlled trials (RCTs) cited in American and European clinical practice guidelines (CPGs) for ST elevation myocardial infarction (STEMI) and non-ST elevation acute coronary syndrome (NSTE-ACS). METHODS AND RESULTS: Out of 2128 non-duplicated references cited in the 2013 and 2014 American College of Cardiology/American Heart Association and 2017 and 2020 European Society of Cardiology CPGs for STEMI and NSTE-ACS, we extracted data for 407 RCTs (19.1% of total references). The majority were multicenter studies (81.8%), evaluated pharmacological interventions (63.1%), had a 2-arm (82.6%), and superiority (90.4%) design. Most RCTs (60.2%) had an active comparator, and 46.2% were funded by industry. The median observed sample size was 1001 patients (84.2% of RCTs achieved ≥80% of the intended sample size). Most RCTs had a single primary outcome (90.9%), which was a composite in just over half (51.9%). Among the RCTs testing for superiority, 44.0% reported a P-value of ≥0.05 for the primary outcome and 61.9% observed a risk reduction of >15%. The observed treatment effect was lower-than-expected in 67.6% of RCTs, with 34.4% having at least a 20% lower-than-expected treatment effect. The calculated post hoc statistical power was ≥80% for 33.9% of cited RCTs. CONCLUSIONS: This analysis demonstrates that RCTs cited by CPGs can still have significant methodological issues and limitations, highlighting that a better understanding of the methodological aspects of RCTs is crucial in order to formulate recommendations relevant to clinical practice.

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.

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.

Exploring the potential cost-effectiveness of a novel platelet assay for guiding dual antiplatelet therapy duration in acute coronary syndrome patients following percutaneous coronary intervention.

OBJECTIVE: Duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) influences ischemic and bleeding events. Platelet expression of constant fragment of immunoglobulin, low affinity IIa, receptor (FcγRIIa) independently predicts risk of ischemic complications and is proposed as a tool to guide individualized care. METHODS: We used a Markov model to predict lifetime ischemic and bleeding events and healthcare costs in acute myocardial infarction (MI) patients treated with PCI and DAPT and to project cost-effectiveness of platelet FcγRIIa-assay-guided care (30:3 months DAPT for patients at high: low ischemic risk) versus current standard care (12 months DAPT) from the perspective of the US healthcare system. Model inputs included assay sensitivity and specificity, ischemic and bleeding event rates, and impacts on quality of life, mortality, and costs. Assay cost was $90. Sensitivity analyses were conducted over a range of plausible clinical and cost assumptions. RESULTS: Under base case assumptions, platelet FcγRIIa-assay-guided DAPT duration was projected to increase lifetime costs by $19 versus standard care, with an associated incremental cost-effectiveness ratio (ICER) of $436 per quality-adjusted life-year (QALY) gained. Assay-guided DAPT duration was consistent with high-value care (ICER < $50 000/QALY gained) over a broad range of alternative assumptions. CONCLUSION: Based on a decision-analytic model, for patients with MI treated with PCI, the additional costs of the platelet FcγRIIa assay for guiding DAPT duration would be largely offset by reductions in downstream event-related costs, and assay-guided care would be highly cost-effective by current standards. These findings require confirmation in prospective studies and in a randomized clinical trial of assay-guided versus nonassay-guided DAPT duration.

Inpatient cardiac care for acute coronary syndromes in the Top End of Australia.

BACKGROUND: Disparities in cardiovascular outcomes between Aboriginal and Torres Strait Islander Australians and non-Indigenous Australians persist. This has previously been attributed to a combination of differences in burden of cardiovascular disease risk factors, and inpatient access to guideline-recommended care. AIMS: To assess differences in inpatient access to guideline-recommended acute coronary syndrome (GR-ACS) treatment between Aboriginal and Torres Strait Islander and non-indigenous patients admitted to Royal Darwin Hospital (RDH) with index ACS event. METHODS: This retrospective study included index ACS admissions (n = 288) to RDH between January 2016 and June 2017. Outcomes included rates of coronary angiography, percutaneous coronary intervention (PCI), surgical revascularisation, GR-ACS medications prescribed on discharge and short-term outcomes (30-day mortality and ACS readmissions; 12-month all cardiac-related readmissions). RESULTS: Two hundred and eighty-eight patients, including 109 (37.85%) Aboriginal and Torres Strait Islander patients, were included. Compared with non-indigenous patients, they were younger (median age 48 years vs 60 years; P < 0.01), with a greater burden of comorbidities, including diabetes (39% vs 19%; P < 0.01), smoking (68% vs 35%; P < 0.01) and chronic kidney disease (29% vs 5%; P < 0.01). There were no differences in rates of coronary angiography (98% vs 96%; P = 0.24) or PCI (47% vs 57%; P = 0.12), although there was a trend towards surgical revascularisation in Aboriginal and Torres Strait Islander patients (16% vs 8%; P = 0.047). There were no differences in 30-day mortality (1.8% vs 1.7%; P = 0.72), 12-month ACS readmissions (7% vs 4%; P = 0.20) or 12-month cardiac-related readmissions (7% vs 13%; P = 0.11). CONCLUSIONS: Aboriginal and Torres Strait Islander patients received similar inpatient ACS care and secondary prevention medication at discharge, with similar short-term mortality outcomes as non-indigenous patients. While encouraging, these outcomes may not persist long term. Further outcomes research is required, with differences compelling consideration of other primary and secondary prevention contributors.

Spontaneous Reperfusion in Patients with Transient ST-Elevation Myocardial Infarction-Prevalence, Importance and Approaches to Management.

Patients with transient ST-elevation myocardial infarction (STEMI) or spontaneous resolution (SpR) of the ST-segment elevation on electrocardiogram could potentially represent a unique group of patients posing a therapeutic management dilemma. In this review, we discuss the potential mechanisms underlying SpR, its relation to clinical outcomes and the proposed management options for patients with transient STEMI with a focus on immediate versus early percutaneous coronary intervention. We performed a structured literature search of PubMed and Cochrane Library databases from inception to December 2020. Studies focused on SpR in patients with acute coronary syndrome were selected. Available data suggest that deferral of angiography and revascularization within 24-48 h in these patients is reasonable and associated with similar or perhaps better outcomes than immediate angiography. Further randomized trials are needed to elucidate the best pharmacological and invasive strategies for this cohort.

Structure, Process, and Mortality Associated with Acute Coronary Syndrome Management in Guatemala's National Healthcare System: The ACS-GT Registry.

Background: Acute coronary syndromes (ACS) include ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA). The leading cause of mortality in Guatemala is acute myocardial infarction (AMI) and there is no established national policy nor current standard of care. Objective: Describe the factors that influence ACS outcome, evaluating the national healthcare system's quality of care based on the Donabedian health model. Methods: The ACS-Gt study is an observational, multicentre, and prospective national registry. A total of 109 ACS adult patients admitted at six hospitals from Guatemala's National Healthcare System were included. These represent six out of the country's eight geographic regions. Data enrolment took place from February 2020 to January 2021. Data was assessed using chi-square test, Student's t-test, or Mann-Whitney U test, whichever applied. A p-value < 0.05 was considered statistically significant. Results: One hundred and nine patients met inclusion criteria (80.7% STEMI, 19.3% NSTEMI/UA). The population was predominantly male, (68%) hypertensive (49.5%), and diabetic (45.9%). Fifty-nine percent of STEMI patients received fibrinolysis (alteplase 65.4%) and none for primary Percutaneous Coronary Intervention (pPCI). Reperfusion success rate was 65%, and none were taken to PCI afterwards in the recommended time period (2-24 hours). Prognostic delays in STEMI were significantly prolonged in comparison with European guidelines goals. Optimal in-hospital medical therapy was 8.3%, and in-hospital mortality was 20.4%. Conclusions: There is poor access to ACS pharmacological treatment, low reperfusion rate, and no primary, urgent, or rescue PCI available. No patient fulfilled the recommended time period between successful fibrinolysis and PCI. Resources are limited and inefficiently used.

[Combined use of the GRACE ACS risk score and comorbidity indices to increase the effectiveness of hospital mortality risk assessment in patients with acute coronary syndrome].

AIM: To assess the possibilities of using comorbidity indices together with the GRACE (Global Registry of Acute Coronary Events) scale to assess the risk of hospital mortality in acute coronary syndrome (ACS). MATERIALS AND METHODS: The registry study included 2,305 patients with ACS. The frequency of coronary angiography was 54.0%, percutaneous coronary intervention (PCI) 26.9%. Hospital mortality with ACS was 4.8%, with myocardial infarction 9.4%. All patients underwent a comorbidity assessment according to the CIRS system (Cumulative Illness Rating Scale), according to the CCI (Charlson Comorbidity Index) and the CDS (Chronic Disease Score) scale, according to their own scale, which is based on the summation of 9 diseases (diabetes mellitus, atrial fibrillation, stroke, arterial hypertension, obesity, peripheral atherosclerosis, thrombocytopenia, anemia, chronic kidney disease). All patients underwent a mortality risk assessment using the GRACE ACS Risk scale. RESULTS: It was found that the CDS and CIRS indices are not associated with the risk of hospital mortality. With CCI3, the frequency of death outcomes increased from 4.1 to 6.1% (2=4.12, p=0.042). With an increase in the severity of comorbidity from minimal (no more than 1 disease) to severe (4 or more diseases) according to its own scale, hospital mortality increased from 1.2 to 7.4% (2=23.8, p0.0001). In contrast to other scales of comorbidity, our own model more efficiently estimates the hospital prognosis both in the conservative treatment group (2=8.0, p=0.018) and in the PCI group (2=28.5, p=0.00001). It was in the PCI subgroup that the comorbidity factors included in their own model made it possible to increase the area under the ROC curve of the GRACE scale from 0.80 (0.740.87) to 0.90 (0.850.95). CONCLUSION: CCI and its own comorbidity model, but not CDS and CIRS, are associated with the risk of hospital mortality. The model for assessing comorbidity on a 9-point scale, but not CCI, CDS and CIRS, can significantly improve the predictive value of the GRACE scale.

Outcomes Following Acute Coronary Syndrome in Patients With and Without Rheumatic Immune-Mediated Inflammatory Diseases.

Background Rheumatic immune mediated inflammatory diseases (IMIDs) are associated with high risk of acute coronary syndrome. The long-term prognosis of acute coronary syndrome in patients with rheumatic IMIDs is not well studied. Methods and Results We identified Medicare beneficiaries admitted with a primary diagnosis of myocardial infarction (MI) from 2014 to 2019. Outcomes of patients with MI and concomitant rheumatic IMIDs including systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, dermatomyositis, or psoriasis were compared with propensity matched control patients without rheumatic IMIDs. One-to-three propensity-score matching was done for exact age, sex, race, ST-segment-elevation MI, and non-ST-segment-elevation MI variables and greedy approach on other comorbidities. The study primary outcome was all-cause mortality. The study cohort included 1 654 862 patients with 3.6% prevalence of rheumatic IMIDs, the most common of which was rheumatoid arthritis, followed by systemic lupus erythematosus. Patients with rheumatic IMIDs were younger, more likely to be women, and more likely to present with non-ST-segment-elevation MI. Patients with rheumatic IMIDs were less likely to undergo coronary angiography, percutaneous coronary intervention or coronary artery bypass grafting. After propensity-score matching, at median follow up of 24 months (interquartile range 9-45), the risk of mortality (adjusted hazard ratio [HR], 1.15 [95% CI, 1.14-1.17]), heart failure (HR, 1.12 [95% CI 1.09-1.14]), recurrent MI (HR, 1.08 [95% CI 1.06-1.11]), and coronary reintervention (HR, 1.06 [95% CI, 1.01-1.13]) (P<0.05 for all) was higher in patients with versus without rheumatic IMIDs. Conclusions Patients with MI and rheumatic IMIDs have higher risk of mortality, heart failure, recurrent MI, and need for coronary reintervention during follow-up compared with patients without rheumatic IMIDs.

Estimating the economic impact of acute coronary syndrome in New Zealand over time (ANZACS-QI 64): a national registry-based cost burden study.

OBJECTIVES: To estimate the changes in costs associated with acute coronary syndrome (ACS) admissions in New Zealand (NZ) public hospitals over a 12-year period. DESIGN: A cost-burden study of ACS in NZ was conducted from the NZ healthcare system perspective. SETTING: Hospital admission costs were estimated using relevant diagnosis-related groups and their costs for publicly funded casemix hospitalisations, and applied to 190 364 patients with ACS admitted to NZ public hospitals between 2007 and 2018 identified from routine national hospital datasets. Trends in the costs of index ACS hospitalisation, hospital admissions costs, coronary revascularisation and all-cause mortality up to 1 year were evaluated. All costs were presented as 2019 NZ dollars. PRIMARY OUTCOME MEASURES: Healthcare costs attributed to ACS admissions in NZ over time. RESULTS: Between 2007 and 2018, there was a 42% decrease in costs attributed to ACS (NZ$7.7 million (M) to NZ$4.4 M per 100 000 per year), representing a decrease of NZ$298 827 per 100 000 population per year. Mean admission costs associated with each admission declined from NZ$18 411 in 2007 to NZ$16 898 over this period (p<0.001) after adjustment for key clinical and procedural characteristics. These reductions were against a background of increased use of coronary revascularisation (23.1% (2007) to 38.1% (2018)), declining ACS admissions (366-252 per 100 000 population) and an improvement in 1-year survival post-ACS. Nevertheless, the total ACS cost burden remained considerable at NZ$237 M in 2018. CONCLUSIONS: The economic cost of hospitalisations for ACS in NZ decreased considerably over time. Further studies are warranted to explore the association between reductions in ACS cost burden and changes in the management of ACS.

Supportive Psychotherapy for Healthcare Professionals in The Management of Acute Coronary Syndrome: The Use of Delphi Technique.

BACKGROUND: Supportive psychotherapy (SP) may increase the benefit of acute coronary syndrome (ACS) management, but there is no structured SP as a guideline for healthcare professionals. This study aimed to develop structured SP as a guideline for implementing psychotherapy in the management of ACS patients in intensive cardiac care unit (ICCU). METHODS:  This qualitative study used Delphi technique as a modified Delphi method to reach a consensus among experts of structured SP for healthcare professionals in the management of ACS during hospitalized in ICCU. This was developed using self-reflection, observation, and interview of SP implementation in daily psychosomatic practice, gathering literature reviews, doing focus group discussion (FGD) and interview with ACS survivors. During the Delphi rounds, we interviewed 50 informants as source people using valid questionnaires, to proceed a draft of the SP framework and the structured sessions. The SP framework draft and the structured sessions were evaluated and corrected by experts anonymously until the consensus was reached. The validity of the consensus was tested, using Likert psychometric scale to reach an agreement. Cronbach alpha test was used to assess construct validity with SPSS 20. RESULTS:  All of preparations conducted before the Delphi rounds showed that ACS patients had psychosomatic disorders during in ICCU, that required support. SP is very helpful to reduce the negative impact of this disorders.Off 50 informants answered a valid and reliable questionnaire which supports the above statement. The draft was made based on the above process. The development of SP for healthcare professionals of ACS managements was reached in a consensus of expert panelists in the second round of the Delphi with Cronbach alpha of 0.9. CONCLUSION: Supportive psychotherapy (SP) for healthcare professionals in the management of ACS in ICCU were developed and may be applied in clinical practice and research.

The importance of clinical risk assessment in reducing the pathway of acute coronary syndrome / A klinikai kockázatbecslés jelentosége az akut coronaria szindróma betegút csökkentésében

Introduction: Early diagnosis of acute coronary syndrome is emergency providers' task. In the last decade, vast amounts of clinical risk stratification scores were developed to decrease the hospital load of patients by selecting them properly. Objective: Together with the diagnostic and therapeutic challenges, decreasing treatment duration is essential for the improvement of acute coronary syndrome prognosis. Our aim was to assess the HEART score's time-and therapy -related effects on acute coronary syndrome detection as a decision support system. Method: We conducted a retrospective, quantitative study at a county state emergency department amongst patients with the myocardial infarction ICD codes. We assessed their admission time, the way they were delivered to the hos-pital, their presenting symptoms, vital parameters, chronic medical conditions, laboratory and imaging results and the time of their admission to the percutan intervention center. We calculated the HEART score retrospectively from the collected data. Results: Our sample size consisted of 360 people. Coronary artery disease (80%) and hypertension (73.3%) were the most common risk factors, while chest pain (80%) and shortness of breath (48.6%) were the most common com-plaints. Coronary artery disease, hypertension and diabetes are not related to percutan coronary intervention admis-sion times (p = 0.110; p = 0.173; p = 0.507). We found a correlation between the presence of chest pain and mortal-ity (p = 0.009). The calculated HEART score had a correlation with the fact of coronary intervention admission (p = 0.005). Conclusion: We conclude that the retrospectively calculated HEART score correlates with percutan coronary inter-vention admission. Choosing the proper risk stratification can increase the lifespan of the patients and hospital cost-efficiency.

Prehospital risk assessment in patients suspected of non-ST-segment elevation acute coronary syndrome: a systematic review and meta-analysis.

OBJECTIVE: To review, inventory and compare available diagnostic tools and investigate which tool has the best performance for prehospital risk assessment in patients suspected of non-ST-segment elevation acute coronary syndrome (NSTE-ACS). METHODS: Systematic review and meta-analysis. Medline and Embase were searched up till 1 April 2021. Prospective studies with patients, suspected of NSTE-ACS, presenting in the primary care setting or by emergency medical services (EMS) were included. The most important exclusion criteria were studies including only patients with ST-elevation myocardial infarction and studies before 1995, the pretroponin era. The primary end point was the final hospital discharge diagnosis of NSTE-ACS or major adverse cardiac events (MACE) within 6 weeks. Risk of bias was evaluated by the Quality Assessment of Diagnostic Accuracy Studies Criteria. MAIN OUTCOME AND MEASURES: Sensitivity, specificity and likelihood ratio of findings for risk stratification in patients suspected of NSTE-ACS. RESULTS: In total, 15 prospective studies were included; these studies reflected in total 26 083 patients. No specific variables related to symptoms, physical examination or risk factors were useful in risk stratification for NSTE-ACS diagnosis. The most useful electrocardiographic finding was ST-segment depression (LR+3.85 (95% CI 2.58 to 5.76)). Point-of-care troponin was found to be a strong predictor for NSTE-ACS in primary care (LR+14.16 (95% CI 4.28 to 46.90) and EMS setting (LR+6.16 (95% CI 5.02 to 7.57)). Combined risk scores were the best for risk assessment in an NSTE-ACS. From the combined risk scores that can be used immediately in a prehospital setting, the PreHEART score, a validated combined risk score for prehospital use, derived from the HEART score (History, ECG, Age, Risk factors, Troponin), was most useful for risk stratification in patients with NSTE-ACS (LR+8.19 (95% CI 5.47 to 12.26)) and for identifying patients without ACS (LR-0.05 (95% CI 0.02 to 0.15)). DISCUSSION: Important study limitations were verification bias and heterogeneity between studies. In the prehospital setting, several diagnostic tools have been reported which could improve risk stratification, triage and early treatment in patients suspected for NSTE-ACS. On-site assessment of troponin and combined risk scores derived from the HEART score are strong predictors. These results support further studies to investigate the impact of these new tools on logistics and clinical outcome. FUNDING: This study is funded by ZonMw, the Dutch Organisation for Health Research and Development. TRIAL REGISTRATION NUMBER: This meta-analysis was published for registration in PROSPERO prior to starting (CRD York, CRD42021254122).