Impact of income status on prognosis of acute coronary syndrome patients during Greek financial crisis.

BACKGROUND: The effect of income status on patient outcome merits investigation during periods of financial crisis. We evaluated the impact of income status on out-of-hospital prognosis in a cohort of acute coronary syndrome (ACS) patients, included in a countrywide study during a period of financial crisis. METHODS: The study is a secondary analysis of a prospective, multicenter, observational study-the PHAETHON study-enrolling consecutive ACS patients in 37 hospitals in Greece. Patients were classified as low or high income based on the reported net annual household income using as a cut-off point the relative poverty threshold for Greece of 12,000 Euros. The outcome measure was survival free of the primary composite endpoint (cardiovascular death, myocardial infarction, stroke/transient ischemic attack, urgent revascularization and urgent hospitalization due to cardiovascular causes). RESULTS: The study population included 794 patients. The administration rate of evidence-based medications was similar in the low- (n = 455) and high-income (n = 339) groups during hospitalization and upon discharge. In a median follow-up of 189 days (interquartile range: 180-212 days), low-income patients had 92 % higher risk of the combined endpoint as compared to high-income patients [Hazard ratio (HR):1.92, 95 % CI:1.25-2.94, p = 0.003]. The effect of low-income status on the combined outcome remained significant after adjustment for age, gender and depression (HR:1.59, 95 % CI:1.02-2.49; p = 0.043). CONCLUSIONS: In a period of financial crisis, low income is a significant and independent predictor of poor out-of-hospital outcome in ACS patients. This association has profound implications and should be taken into consideration by public health policy makers.

Management of atrial fibrillation in Greece: the MANAGE-AF study.

BACKGROUND: Although atrial fibrillation (AF) is a highly prevalent health problem with high morbidity and mortality, data regarding the clinical characteristics and management of AF in the Greek population are scarce. The "Current Clinical Practice in the MANAGEment of Atrial Fibrillation in Greece" study (MANAGEAF) aimed to assess the epidemiological features as well as the daily clinical practice in the management of Greek patients with AF. METHODS: Taking into consideration the distribution of the Greek population, 603 consecutive patients over 18 years of age, with any type of AF, presenting at the emergency departments or outpatient clinics of 27 different centers, were included in our study. RESULTS: The mean age of the patients was 68.5 ± 12.1 years, with male patients representing 52.5% of the study population. The most common AF type in our cohort was non-paroxysmal AF (60%), including the patients with permanent (24.1%), persistent (17.4%), long-standing (4.8%) and first diagnosed AF (13.8%). Hypertension was the most common comorbidity (70.3%). A history of stroke or transient ischemic attack was detected in 9.2% of the patients, while 6.2% had a history of gastrointestinal bleeding. About half of the patients (49.3%) were treated with anticoagulant drugs, mainly vitamin K antagonists (46.9%), while 34.2% were on antiplatelet drugs, aspirin and/or clopidogrel. The mean INR level (1.7 ± 0.8) was sub-therapeutic, although the mean values for CHADS2 and CHA2DS2-VASc scores were 1.6 ± 1.2 and 3.0 ± 1.7, respectively. CONCLUSION: The MANAGE-AF baseline results indicate unsatisfactory levels of compliance with the current guidelines for the management of AF in Greece. Considering the undisputed effectiveness of anticoagulant treatment for preventing AF-related strokes, MANAGE-AF demonstrates the need for optimization of our therapeutic strategies for the management of cardioembolic stroke risk.

Inadequate heart rate control is associated with worse quality of life in patients with coronary artery disease and chronic obstructive pulmonary disease. The RYTHMOS study.

INTRODUCTION: Significant evidence shows that elevated heart rate (HR) is an independent risk factor in patients with coronary artery disease (CAD) and influences their prognosis. In addition, patients with chronic obstructive pulmonary disease (COPD) have more frequent episodes of angina and their compliance with heart rate agents, such as beta blockers, is poor. The purpose of the multicenter observational RYTHMOS study was to evaluate the role of heart rate management in the prognosis and quality of life in patients with CAD and COPD. METHODS: Baseline data from 280 patients, enrolled in 22 hospitals representing all types of hospital and all geographical areas of the country, were analyzed. All patients had either a prior myocardial infarction or angiographically documented CAD, and COPD verified either after spirometry or from a clinical evaluation by pulmonologists. RESULTS: The mean age of the enrolled patients was 71.8 ± 9.3 years, 76% were males, mean body mass index was 28.6 ± 7.9 kg/m2, 76.3% had hypertension, 31% had diabetes mellitus, and 53.5% of them suffered from heart failure. About 31% of the patients had an angina episode the week before the enrollment and the Canadian Cardiovascular Society (CSS) classification was class I, II, III and IV in 55%, 30%, 14% and 1%, respectively. The mean resting HR was 72.5 bpm; 51% of the patients had resting HR>70 bpm and 22% of them had HR80 bpm. Only 52.8% of the study patients were receiving beta-blockade (BB) therapy; they were more likely to have resting HR70 bpm (57.4% vs. 42.7%, p<0.001). 16.4% of the patients were receiving ivabradine and they had a higher initial HR compared to the others (78.5 vs. 71.3, p<0.001). Multivariate analysis showed that diabetes mellitus was independently associated with HR>70 bpm. Patients with resting HR>70 bpm had significantly more frequent angina episodes (p<0.001), were less satisfied with treatment (p<0.001), and had a lower quality of life (p<0.001). CONCLUSION: The baseline data of this study showed that patients with CAD and COPD present inadequate HR control and frequent angina episodes. Apart from the special characteristics of these patients related to COPD management, underuse of BB therapy largely contributes to the inadequate control of HR. Patients with HR>70 bpm had significantly worse quality of life.

Epidemiological characteristics and in-hospital management of acute coronary syndrome patients in Greece: results from the TARGET study.

INTRODUCTION: Conduction of national surveys is needed to depict temporal trends in the risk profile, type of implemented treatment strategy and outcome of patients with acute coronary syndromes (ACS). The TARGET study is a multicenter, observational study that aimed to evaluate the epidemiological characteristics, management pattern and outcome of ACS patients in Greece. METHODS: A total of 418 consecutive patients with ACS (44.7% STEMI, 34.2% NSTEMI, 21.1% unstable angina) from 17 centers (52.9% with catheterization facilities) were enrolled in the study (78.0% males, 63.9 ± 12.9 years). RESULTS: Overall, 67.9% of the patients had hypertension, 27.5% were diabetics and 57.4% had dyslipidemia. Thrombolytic therapy (60.7% tenecteplase, 38.2% reteplase) was administered in 22.7% of the study population, while invasive management was performed in 40.2% of patients (27.0% PCI and 1.0% CABG) during the index hospitalization. In-hospital all-cause mortality was 1.9%, with 12.2% of patients experiencing adverse clinical events. Evidence-based medications were prescribed to the majority of enrolled patients during hospitalization and upon discharge (97% and 94% received aspirin, 93% and 84% clopidogrel, 87% and 86% beta-blockers, 96% and 93% statins, respectively). CONCLUSION: The prevalence of modifiable risk factors exhibits an increasing trend among ACS patients in Greece. The prescription pattern of evidence-based medications has improved considerably, while there remains considerable room for improvement in expanding the implementation of invasive management in realworld clinical practice.

Do we reperfuse those in most need? Clinical characteristics of ST-elevation myocardial infarction patients receiving reperfusion therapy in the countrywide registry HELIOS.

INTRODUCTION: we analysed the clinical profile of patients with an ST-elevation myocardial infarction (STEMI) who arrived in hospital within 12 hrs from pain onset and either received reperfusion therapy (PCI or fibrinolytic therapy) or remained without reperfusion. METHODS: the Hellenic Infarction Observation Study (HELIOS) was a countrywide registry of acute myocardial infarction, conducted during 2005-2006. The registry enrolled 1840 patients with myocardial infarction from 31 hospitals, with a proportional representation of all types of hospitals and all geographical areas. RESULTS: of 870 patients with STEMI who were admitted within 12 hrs from pain onset, Group A received no reperfusion (n=289, 33.2%), group B underwent primary PCI (n=84, 9.7%) and group C received fibrinolysis (n=497, 57.1%). In groups A, B and C, respectively, mean age was 73 ± 13, 61 ± 12 and 62 ± 13 years (p<0.001). The prevalence of female sex was 33%, 14%, 18%, of diabetes 40%, 23%, 21%, of prior MI 23%, 10%, 11% and of Killip class 2-4 at admission 32%, 11%, 13%, respectively (all p<0.001). In a multivariate analysis, advanced Killip class, age, diabetes and pain to admission time >3 hrs were all independent variables related to no reperfusion therapy. CONCLUSION: reperfusion therapies are applied to relatively lower-risk patients. If a survival advantage is to be expected at the national level, more high-risk patients, such as the elderly, women, diabetics, and mainly those with advanced Killip class, should be considered for reperfusion strategies.

Epidemiological characteristics, management and early outcome of acute myocardial infarction in Greece: the HELlenic Infarction Observation Study.

INTRODUCTION: Taking into consideration the need for an updated survey on acute myocardial infarction (AMI) in Greece, we conducted the HELIOS study (HELlenic Infarction Observation Study), aiming to recruit a cohort of AMI patients that would be representative of the total AMI population. METHODS: The HELIOS study is a countrywide registry of AMI, conducted during 2005-2006 by the Prevention Working Group of the Hellenic Cardiological Society. We enrolled 1840 AMI pts from 31 hospitals (mean age 68 +/- 13 years, 75% men, 1096 ST-elevation myocardial infarction [STEMI] patients), with a proportional representation of all types of hospitals and of all geographical areas. The study recruited 10% of the total number of AMI cases that occur per year on a countrywide basis, taking into consideration the seasonal variations of the population in each geographical area. RESULTS: Despite demographic changes, there is still a male predominance among AMI patients and an increasing prevalence of cardiometabolic risk factors, (obesity, diabetes, hypertension) compared to previous AMI studies in the Greek population. Almost 60% of STEMI patients received reperfusion therapy, but the median value of the pain-to-door time was 180 minutes. The rates of administration of evidence-based medications during hospitalisation or upon discharge and the short-term mortality rates were in accordance with those observed in other international AMI registries. CONCLUSIONS: The HELIOS study provided valuable insights into the epidemiology, clinical characteristics, management and outcome of patients with AMI in the Greek population. Although there are notable advances compared to previous reports, there is still considerable room for improvement and we should particularly focus on minimising the time delay between arrival at the emergency department and performance of reperfusion, by either pharmacological or catheter-based approaches.