Autoimmune blistering disorders and cardiovascular risks: A population-based cohort study.

BACKGROUND: Autoimmune blistering disorders (ABDs) might elevate cardiovascular risk, but studies are lacking. OBJECTIVE: The objective of this study was to examine if ABDs elevate the risk of atherosclerotic cardiovascular disease, heart failure, arrhythmia, venous thromboembolism, and cardiovascular death. METHODS: A population-based cohort of Danish patients with ABD (≥18 years of age) diagnosed during 1996-2021 (n = 3322) was compared with an age- and sex-matched comparison cohort from the general population (n = 33,195). RESULTS: Compared with the general population, patients with ABDs had higher 1-year risks of atherosclerotic cardiovascular disease (3.4% vs 1.6%), heart failure (1.9% vs 0.7%), arrhythmia (3.8% vs 1.3%), venous thromboembolism (1.9% vs 0.3%), and cardiovascular death (3.3% vs 0.9%). The elevated risk persisted after 10 years for all outcomes but arrhythmia. The hazard ratios associating ABDs with the outcomes during the entire follow-up were 1.24 (1.09-1.40) for atherosclerotic cardiovascular disease, 1.48 (1.24-1.77) for heart failure, 1.16 (1.02-1.32) for arrhythmia, 1.87 (1.50-2.34) for venous thromboembolism, and 2.01 (1.76-2.29) for cardiovascular death. The elevated cardiovascular risk was observed for both pemphigus and pemphigoid. LIMITATIONS: Our findings might only generalize to patients with ABDs without prevalent cardiovascular diseases. CONCLUSION: Patients with ABDs had an elevated cardiovascular risk compared with age- and sex-matched controls.

De-escalação de inibidores dos receptores P2Y12 após intervenção coronária percutânea / P2Y12 inhibitor de-escalation after percutaneous coronary interventions

Em pacientes que apresentam síndromes coronárias agudas e são tratados com intervenção coronária percutânea, a prescrição do esquema antiplaquetário duplo, composto de ácido acetilsalicílico e um inibidor dos receptores P2Y12, é mandatória, contribuindo para a redução de eventos cardíacos maiores. No entanto, ao mesmo tempo em que previne eventos isquêmicos, essa associação pode precipitar complicações hemorrágicas maiores, o que é mais comumente observado quando são prescritos os medicamentos mais potentes, como o prasugrel ou o ticagrelor. Essas constatações levaram à procura de alternativas terapêuticas capazes de manter a proteção contra eventos isquêmicos e, ao mesmo tempo, prevenir a ocorrência de hemorragias. Uma das estratégias que está em estudo é a de-escalação dos inibidores P2Y12, que consiste no uso dos medicamentos mais potentes numa fase precoce após o procedimento, com substituição deles pelo clopidogrel, após um período de, em geral, 30 dias de evolução; outra possibilidade seria a simples redução da dose do fármaco de maior potência, algo que, até o momento, só pode ser cogitado com o prasugrel. A de-escalação pode ser feita de forma guiada, utilizando testes de mensuração objetiva da agregação plaquetária ou exames para avaliar o perfil genético dos pacientes, ou não guiada, na qual o cardiologista simplesmente faz a substituição ou redução da dose ao fim do período estipulado, sem o auxílio de exames complementares. A literatura contempla ensaios clínicos com essas duas opções de estratégia, os quais são discutidos nesta revisão. Até o momento, nenhuma diretriz médica recomenda de forma explícita o uso regular dessa alternativa terapêutica.

In patients who have acute coronary syndromes and are treated with percutaneous coronary intervention, the prescription of a dual antiplatelet regimen, consisting of acetylsalicylic acid and a P2Y12 receptor inhibitor, is mandatory, contributing to the reduction of major cardiac events. However, while preventing ischemic events, this association may precipitate major bleeding complications, which is more commonly seen when more potent drugs, such as prasugrel or ticagrelor, are prescribed. These findings led to the search for therapeutic alternatives that could maintain the protection against ischemic events and, at the same time, prevent the occurrence of hemorrhages. One of the strategies being studied is de-escalation of P2Y12 inhibitors, which consists of the use of more potent drugs in an early phase after the procedure, replacing them with clopidogrel, after a period of, in general, 30 days of clinical course. Another possibility would be to simply reduce the dose of the most potent drug, which so far can only be considered with prasugrel. De-escalation can be done in a guided way, using objective measuring tests of platelet aggregation or exams to assess the genetic profile of patients, or unguided, in which the cardiologist simply replaces or reduces the dose at the end of the stipulated period, with no ancillary tests. The literature includes clinical trials with these two strategy options, which are discussed in this review. So far, no medical guideline explicitly recommends the regular use of this therapeutic alternative.

Study on the distribution law of TCM syndrome types and influencing factors based on 1 684 patients with unstable angina pectoris of coronary heart disease / 国际中医中药杂志

Objective:To investigate the distribution law of TCM syndrome types and the differences in influencing factors among different syndrome types in unstable angina pectoris (UA), so as to provide an objective basis for TCM syndrome differentiation and treatment of UA.Methods:A retrospective study chose 1 684 inpatients in the Department of Cardiovascular Medicine of the First Affiliated Hospital of Henan University of Chinese Medicine from August 2015 to April 2019. Epidata 3.0 software was used to input general information of patients [gender, age, length of hospital stay, BMI, systolic blood pressure (SBP), diastolic blood pressure (DBP)], laboratory indicators[TC, TG, HDL-C, LDL-C, fibrinogen (FIB), thrombin time (TT), D-dimer (D-dimer), HbA1c], TCM syndrome types (qi and yin deficiency syndrome, phlegm turbidity and obstruction syndrome, qi deficiency and blood stasis syndrome, heart blood stasis syndrome, qi stagnation and blood stasis syndrome, heart and kidney yang deficiency syndrome) and other information. A database was established to analyze the distribution of TCM syndrome types and the relationship with the general information of patients, blood lipids, blood sugar and coagulation indexes. Logistic regression was used to analyze the influencing factors of different syndrome types.Results:The distribution of syndrome types in 1 684 UA patients was as follows: qi and yin deficiency syndrome (44.7%), phlegm turbidity and obstruction syndrome (35.3%), qi deficiency and blood stasis syndrome (7.4%), heart blood stasis syndrome (5.3%), qi stagnation and blood stasis syndrome (4.6%), heart and kidney yang deficiency syndrome (2.6%); more men than women ( P<0.05); there were significant differences in the distribution of gender, age, BMI, TC, and HDL-C among the 6 syndrome types ( P<0.05); the age of patients with phlegm turbidity and obstruction syndrome was younger than that of qi and yin deficiency syndrome and heart blood stasis syndrome ( P<0.05); the age of patients with qi stagnation and blood stasis syndrome was younger than that of qi and yin deficiency syndrome, heart blood stasis syndrome, and heart kidney yang deficiency syndrome ( P<0.05); BMI of patients with phlegm turbidity and obstruction syndrome was higher than that of qi and yin deficiency syndrome and qi stagnation and blood stasis syndrome ( P<0.05); the level of TC in patients with phlegm turbidity and obstruction syndrome was lower than that of qi and yin deficiency syndrome and qi deficiency and blood stasis syndrome ( P<0.05); the level of HDL in patients with qi and yin deficiency syndrome was lower than that in qi deficiency and blood stasis syndrome and qi stagnation and blood stasis syndrome. Binary Logistic regression analysis found that TC [ OR(95% CI)=0.761(0.592, 0.978)] and HDL-C [ OR(95% CI)=2.131(1.145, 3.966)] were independent influencing factors for predicting qi deficiency and blood stasis syndrome ( P<0.05); age[ OR(95% CI)=1.017 (1.008, 1.026)], length of hospital stay [ OR(95% CI)=1.019 (1.001, 1.038)], DBP [ OR(95% CI)=0.984(0.975, 0.993)] and HDL-C [ OR(95% CI)=0.984(0.975, 0.993)] were independent influencing factors for predicting qi and yin deficiency syndrome ( P<0.05); age [ OR(95% CI)=0.965 (0.946, 0.985)], and HDL-C [ OR(95% CI)=2.329(1.206, 4.500)] were independent influencing factors for predicting qi stagnation and blood stasis syndrome ( P<0.05); age [ OR(95% CI)=0.982 (0.973, 0.991)], length of hospital stay [ OR(95% CI)= 0.978 (0.958, 0.997)], BMI [ OR(95% CI)=1.048 (1.015, 1.082)], DBP [ OR(95% CI)=1.014 (1.004, 1.024)] and HDL-C [ OR(95% CI)=0.505 (0.351, 0.726)] were independent influencing factors for predicting phlegm turbidity and obstruction syndrome ( P<0.05); age [ OR(95% CI)=1.031(1.003, 1.060)] and DBP [ OR(95% CI)=1.028(1.001, 1.056)] were independent influencing factors for predicting heart kidney yang deficiency syndrome ( P<0.05). Conclusion:The distribution of TCM syndrome types in UA shows a certain regularity, among which qi and yin deficiency syndrome and phlegm turbidity and obstruction syndrome are more common. Gender, age, BMI, TC, HDL-C are different among TCM syndrome types, which can provide some reference for UA TCM syndrome differentiation and treatment.

Ácido acetilsalicílico versus inibidores dos receptores P2Y12 para prevenção secundária em pacientes tratados por meio de intervenção coronária percutânea / Aspirin versus P2Y12 inhibitors for secondary prevention after percutaneous coronary intervention

Na atualidade, as intervenções coronárias percutâneas com implante de um stent farmacológico constituem o principal método de revascularização miocárdica em centros hospitalares terciários, independentemente da forma clínica de apresentação da doença arterial coronária. É de conhecimento geral que, para sua efetivação, há necessidade do uso de um esquema antiplaquetário duplo, constituído pela associação do ácido acetilsalicílico e um inibidor dos receptores plaquetários P2Y12, que é o cerne da prevenção das tromboses após implantes das endopróteses, sendo também indicado para prevenir a ocorrência de eventos aterotrombóticos na evolução clínica tardia, qualquer que seja o modelo de stent utilizado. Após período variável de tempo, independentemente de fatores como forma clínica de apresentação da coronariopatia e do tipo de stent implantado, esse esquema é interrompido, e, na atualidade, as principais diretrizes preconizam a suspensão do inibidor dos receptores P2Y12 e a manutenção do ácido acetilsalicílico em longo prazo como uma das principais medidas farmacológicas de prevenção secundária da aterosclerose. No entanto, recentemente, em razão de sua maior potência antiplaquetária e provável menor potencial de causar hemorragias significantes, em especial no tubo digestivo, os inibidores P2Y12 têm sido considerados alternativa válida e atraente como antiplaquetário de utilização em longo prazo, alternativa ainda não referendada pelas diretrizes. Esta revisão discute os pormenores relacionados a essa importante decisão que deve ser tomada pelo cardiologista no momento da interrupção dos diferentes esquemas antitrombóticos inicialmente utilizados após uma intervenção coronária percutânea. Em princípio, a escassez de estudos clínicos conclusivos e normativos, em especial na população tratada por meio de uma intervenção percutânea, faz com que o ácido acetilsalicílico ainda se mantenha como o único antiagregante plaquetário com indicação classe I com a finalidade de prevenção secundária da aterosclerose.

Currently, percutaneous coronary intervention with a drug-eluting stent implantation is the main method of myocardial revascularization in tertiary care hospitals, regardless of the clinical presentation of coronary artery disease. It is well known that to be effective, it requires the use of a dual antiplatelet therapy, which is a combination of acetylsalicylic acid and a P2Y12 platelet receptor inhibitor, which plays a key role in preventing thromboses after endoprosthesis implantation and is also indicated to prevent atherothrombotic events in the late clinical course, regardless of the stent model used. After a variable period of time, depending on some factors, such as the clinical presentation of coronary artery disease and the type of stent implanted, this therapy is discontinued, and the main current guidelines recommend interrupting the P2Y12 receptor inhibitor and maintaining acetylsalicylic acid in the long term, as one of the main pharmacological measures for secondary prevention of atherosclerosis. However, recently, due to their greater antiplatelet potency and probable lower potential for significant bleeding, especially in the digestive tract, P2Y12 inhibitors have been considered a valid and attractive option as an antiplatelet agent for long-term use; but this alternative has not been endorsed by guidelines yet. This review discusses the details related to this important decision that must be made by cardiologists when discontinuing the different antithrombotic therapies initially used after percutaneous coronary intervention. In principle, the scarcity of conclusive and normative clinical studies, especially in the population treated by percutaneous intervention, means that acetylsalicylic acid is the only antiplatelet agent with class I indication for secondary prevention of atherosclerosis.

Is coronary artery tortuosity a predisposing factor for drug-eluting stent restenosis?

BACKGROUND: Coronary artery tortuosity (CAT) is a relatively common finding on coronary angiography and may be associated with impaired left ventricular relaxation and coronary ischemia However, the significance of CAT remains unknown. This study aimed to investigate whether the severity of tortuosity in the targeted coronary segment is a predictor of stent restenosis. METHODS: The study included a total of 637 patients undergoing drug-eluting stent implantation due to stable or unstable angina and who had no native coronary artery stenosis on their last coronary angiogram. The patients were separated into two groups: 312 patients with in-stent restenosis and 325 patients without in-stent restenosis. All patients underwent computed tomography (CT) coronary angiography after invasive angiography and CAT was calculated using the computer software. RESULTS: Patients with in-stent restenosis had higher CAT than those without restenosis (1.25 ± 0.11 vs. 1.11 + 0.07, p < 0.001). Multivariate Cox regression analysis showed that the tortuosity index (hazard ratio [HR]: 1.246 95% confidence interval [CI]: 1.127-1.376 p < 0.001) and the circumflex lesion (HR: 1.437 95% CI: 1.062-1.942 p = 0.019) were independently associated with in-stent restenosis. With the threshold value of severe tortuosity set at 1.15, the prediction of could be made with 81% sensitivity and 80% specificity. CONCLUSION: The severity of tortuosity is proportional to coronary in-stent stenosis in patients with stable and unstable angina pectoris undergoing drug-eluting stent implantation for a severe single coronary artery.

Acute coronary syndrome in a hospital in southern Brazil: peak of hospitalizations on Mondays and severe cases on weekends and at night.

INTRODUCTION: Ischemic heart disease is the leading cause of death in Brazil and worldwide. The term acute coronary syndrome (ACS) generically represents the acute myocardial ischemic events. These events are clinically divided into three types: acute myocardial infarction (AMI) with ST-segment elevation, AMI without ST-segment elevation, and unstable angina. Although cardiovascular ischemic events occur acutely, studies describe cyclic patterns of ACS, mainly on circadian and weekly variation. OBJECTIVE: The aim of this study was to analyze the circadian and weekly variation of hospitalizations for ACS in a hospital in southern Brazil in 2019. METHODS: Observational, cross-sectional type study. The population was the patients hospitalized at the Nossa Senhora da Conceição Hospital (NSCH) in Tubarão (SC, Brazil) with the international classification of diseases (ICD) code referring to ACS in the year 2019, corresponding to 579 patients. RESULTS: After applying the exclusion criteria, 512 patients hospitalized for ACS were analyzed, 55.1% were male with a median (p25-p75) age of 62.0 (56.0-69.0) years. The main ICDs of hospitalization were: I20.0 (76.2%), I21.9 (16.6%), I21.3 (3.1%) and the most prevalent comorbidities were high blood pressure (82.6%), diabetes (30.1%) and previous AMI (23.6%). The median (p25-p75) time of admission was 14 h (10-18) h and length of stay was 5 (3-9) days. Death occurred in 18 hospitalizations (3.5%) of cases. CONCLUSION: We conclude that in the present study there was a peak of hospitalizations for ACS on Mondays, proportionally reducing throughout the week and with a significant decrease on the weekend.

Ticagrelor combined with atorvastatin for the treatment of unstable angina pectoris / 中国基层医药

Objective:To investigate the efficacy of ticagrelor combined with atorvastatin in the treatment of unstable angina pectoris and its effects on cardiac function, brain natriuretic peptide (BNP) level, lipoprotein-associated phospholipase A2 (Lp-PLA2) activity, and glycosylated hemoglobin (HbAlc) level in patients with unstable angina pectoris.Methods:A total of 200 patients with unstable angina pectoris who received treatment in the Sahzu International Medical Center from January 2017 to January 2019 were included in this study. These patients were randomly assigned to receive either clopidogrel combined with atorvastatin (control group, n = 100) or ticagrelor combined with atorvastatin (observation group, n = 100) for 1 month. The clinical efficacy,BNP level, Lp-PLA2 activity, HbAlc level, clinical symptom, cardiac function, and adverse reactions were compared between control and observation groups. Results:Effective rate was significantly higher in the observation group than in the control group [95% (95/100) vs. 75% (75/100), χ2 = 15.69, P < 0.001]. After treatment, BNP level and Lp-PLA2 activity in the observation group were (101.21 ± 40.13) ng/L and (105.56 ± 12.56) pg/L, respectively, which were significantly lower than those in the control group [(151.57 ± 37.29) ng/L, (137.52 ± 16.88) pg/L, t = 9.19, 15.19, P < 0.001]. After treatment, the duration and frequency of angina pectoris in the observation group were (1.84 ± 0.49) minutes/time and (1.32 ± 0.21) times/week, respectively, which were significantly lower than those in the control group [(5.23 ± 1.72) minutes/time and (3.58 ± 0.71) times/week, t = 18.95, 30.52, both P < 0.001]. After treatment, the left ventricular end-diastolic diameter and left ventricular end-systolic diameter in the observation group were (33.28 ± 1.21) mm and (47.89 ± 5.61) mm respectively, which were significantly lower than those in the control group [(37.56 ± 2.14) mm, (53.25 ± 5.07) mm, t = 17.41, 7.09, both P < 0.001]. Left ventricular ejection fraction was significantly higher in the observation group than in the control group [(48.59 ± 5.81)% vs. (41.16 ± 5.83)%, t = 9.03, P < 0.001]. The incidence of adverse reactions was significantly higher in the observation group than in the control group [1% (1/100) vs. 12% (12/100), χ2 = 9.96, P = 0.002]. Conclusion:Ticagrelor combined with atorvastatin is highly effective for unstable angina pectoris in coronary heart disease because it greatly decreases BNP level and Lp-PLA2 activity. Therefore, the combined therapy deserves clinical promotion.

Serum Levels of Growth Differentiation Factor-15 as an Inflammatory Marker in Patients with Unstable Angina Pectoris.

Background: Growth differentiation factor-15 (GDF-15), a member of transforming growth factors, is a stress-responsive marker whose levels may significantly increase in response to pathological stresses associated with inflammatory tissue injuries such as unstable angina pectoris (USAP). This study evaluated the diagnostic value of GDF-15 in patients with USAP. Methods: The present cross-sectional study recruited 39 patients with USAP criteria and 30 patients with stable angina pectoris (SAP), referred to Shahid Beheshti Hospital, Kashan, Iran. All the patients with USAP had at least 1 coronary artery stenosis (>50%) in angiography. The control group comprised 42 healthy individuals. The serum levels of GDF-15 were measured in all the participants by ELISA. Also analyzed were the relationship between GDF-15 levels and thrombolysis in myocardial infarction (TIMI) and the Global Registry of Acute Coronary Events (GRACE) risk scores in the patients with USAP to determine the severity of the disease. Result: The study population consisted of 111 subjects, 62 women and 49 men, divided into 3 groups of USAP (n=39, mean age=60.07±14.10 y), SAP (n=30, mean age=67.56±9.88 y), and control (n=42, mean age=61.21±7.76 y). The mean serum level of GDF-15 in the USAP group was significantly different from the other 2 groups (P<0.001), while no significant difference was observed in this regard between the SAP and control groups (P=0.797). No correlation was found between the mean GDF-15 serum level and the GRACE (P=0.816) and TIMI (P=0.359) risk scores in the USAP group. Conclusion: The mean serum level of GDF-15 exhibited a rise in our patients with USAP. GDF-15 may be a diagnostic biomarker of USAP and its severity.

Efficacy of Nicorandil in the treatment of unstable angina pectoris in 30 patients / 中国基层医药

Objective:To investigate the efficacy of Nicorandil in the treatment of unstable angina pectoris.Methods:Sixty patients with unstable angina pectoris who received treatment in Department of Cardiovascular Disease, Suixi Hospital of Traditional Chinese Medicine, China during January-July 2020 were included in this study. They were randomly assigned to receive either conventional treatment including antiplatelet, increasing coronal blood flow velocity, lipid-lowering treatment and stabilization of atherosclerotic plaque (control group, n = 30) or Nicorandil treatment and conventional treatment (observation group, n = 30). Clinical efficacy was compared between the two groups. Angina attack, electrocardiogram changes and adverse reactions in each group were analyzed before and after treatment. Results:Total effective rate in the observation group was significantly higher than that in the control group [88.67% (26/30) vs. 53.33% (16/30), χ2 = 7.937, P = 0.005]. The frequency and duration of angina pectoris in the observation group were (1.53 ± 0.62) times/week, (1.93 ± 0.78) minutes, which were significantly lower or shorter than those in the control group [(1.97 ± 0.71) times /week, (2.60 ± 1.00) minutes, t = -2.359, -3.162, P = 0.025, 0.004). The total effective rate of electrocardiogram in the observation group was significantly higher than that in the control group [70.00% (22/30) vs. 43.34% (13/30), χ2 = 5.554, P = 0.018]. There was no significant difference in the incidence of adverse drug reactions such as nausea, dizziness and palpitation between the two groups (all P > 0.05). Conclusion:Based on conventional treatment, Nicorandil treatment for unstable angina pectoris can improve the clinical symptoms and electrocardiogram changes, exhibit remarkable efficacy, and therefore deserve clinical promotion.

Underuse of beta-blockers by patients with COPD and co-morbid acute coronary syndrome: A nationwide follow-up study in New Zealand.

BACKGROUND AND OBJECTIVE: Clinical guidelines recommend the use of beta-blockers and other cardiovascular prevention drugs in patients with acute coronary syndrome (ACS). Studies in several countries have found that beta-blockers are underused in patients with chronic obstructive pulmonary disease (COPD) and co-morbid heart disease, although most have only examined use in subgroups of patients. We undertook a nationwide follow-up study in New Zealand to describe the use of beta-blockers and other cardiovascular prevention drugs in patients with COPD and ACS. METHODS: National health and pharmaceutical dispensing data were used to derive the study cohort, identify patients who were admitted to hospital with ACS and/or heart failure before cohort entry and during follow-up, and ascertain drug use. RESULTS: The study cohort included 83 435 patients aged ≥45 years, with 290 400 person-years of follow-up. Among 2637 patients with ≥1 ACS admission during follow-up, only 56.6% received a beta-blocker in the 6 months following the first admission, while 87.7% and 81%, respectively, received aspirin and a statin. Patients with higher COPD severity were less likely to receive a beta-blocker than those with lower severity, as were those with no history of previous ACS and/or heart failure. CONCLUSION: Use of beta-blockers following an ACS admission was much lower than expected based on the findings of general audits of ACS management in New Zealand. Along with the higher proportions using aspirin and statins, and the differences in beta-blocker dispensing by COPD severity, this suggests a particular reluctance to prescribe beta-blockers to patients with COPD.

Incidence and Predictors of Obstructive Coronary Artery Disease and the Role of Cardiac Troponin Assays in Patients with Unstable Angina.

In a time when cardiac troponin assays are widely used to detect myocardial injury, data remain scarce concerning the incidence and predictors of substantial obstructive coronary artery disease that causes unstable angina. This retrospective single-center study included consecutive patients hospitalized for unstable angina from January 2015 through January 2016. Patients with troponin I levels above the upper reference limit and those who did not undergo angiography were excluded. Multivariate logistic regression analysis was used to identify predictors of obstructive coronary artery disease that warranted revascularization and of major adverse cardiac events up to 6 months after discharge from the hospital. Of the 114 patients who met the inclusion criteria, 46 (40%) had obstructive coronary artery disease. In the univariate analysis, male sex, white race, history of coronary artery disease, prior revascularization, hyperlipidemia, chronic kidney disease, aspirin use, long-acting nitrate use, and Thrombolysis in Myocardial Infarction score ≥3 were associated with obstructive coronary artery disease. History of coronary artery disease, prior revascularization, hyperlipidemia, and long-acting nitrate use were associated with major adverse cardiac events. Male sex was an independent predictor of obstructive coronary artery disease (adjusted odds ratio=4.82; 95% CI, 1.79-13; P=0.002) in the multivariate analysis. Our results showed that coronary artery disease warranting revascularization is present in a considerable proportion of patients who have unstable angina. The association that we found between male sex and obstructive coronary artery disease suggests that the risk stratification of patients presenting with unstable angina may need to be refined to improve outcomes.

Effectiveness and safety of oral Chinese patent medicines as adjuvant treatment for unstable angina pectoris on the national essential drugs list of China: a protocol for a systematic review and network meta-analysis.

INTRODUCTION: Achieving efficacious and safe treatments for unstable angina pectoris (UAP) is still a challenging clinical problem. The availability of different oral Chinese patent medicines frequently poses a practical challenge to clinicians, namely, which one to choose as first-line regimen for treatment. This study aims to examine the comparative effectiveness and safety of oral Chinese patent medicines for UAP on the national essential drugs list of China. METHODS AND ANALYSIS: We will conduct a network meta-analysis (NMA) of all randomised controlled trials to evaluate the use of oral Chinese patent medicines as adjuvant for the treatment of UAP. We will explore eight electronic databases from their inception to June 2018 and search for grey literature. Primary outcomes include mortality and the cardiovascular events. Secondary outcomes include: (1) symptom improvement; (2) ECG improvement; (3) frequency of acute angina attack; (4) duration of angina; (5) adverse effects. Two independent authors will screen titles and abstracts, review full texts, extract data, assess the risk of bias using the Cochrane risk of bias tool and assess the quality of evidence and strength of the recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). If adequate data are available, NMA will be performed with Bayesian analysis methods. ETHICS AND DISSEMINATION: The NMA will help us to reduce the uncertainty of interventions and help clinicians to make optimal and more accurate therapeutic decisions for adults with UAP. Therefore, we will publish the findings of this study in a peer-reviewed journal. No ethics approval is necessary for this study based on the nature of its design. TRIAL REGISTRATION NUMBER: CRD42018092822.

Performance of cardiovascular risk scores in mortality prediction ten years after Acute Coronary Syndromes

SUMMARY BACKGROUND The objective of this study was to evaluate the performance of the Framingham risk score (FRS) and risk score by the American College of Cardiology/American Heart Association (SR ACC/AHA) in predicting mortality of patients ten years after acute coronary syndrome (ACS). METHODS This is a retrospective cohort study that included patients aged ≥ 18 years with ACS who were hospitalized at the Coronary Intensive Care Unit (ICU) of the Botucatu Medical School Hospital from January 2005 to December of 2006. RESULTS A total of 447 patients were evaluated. Of these, 118 were excluded because the mortality in 10 years was not obtained. Thus, 329 patients aged 62.9 ± 13.0 years were studied. Among them, 58.4% were men, and 44.4% died within ten years of hospitalization. The median FRS was 16 (14-18) %, and the ACC/AHA RS was 18.5 (9.1-31.6). Patients who died had higher values of both scores. However, when we classified patients at high cardiovascular risk, only the ACC/AHA RS was associated with mortality (p <0.001). In the logistic regression analysis, both scores were associated with mortality at ten years (p <0.001). CONCLUSIONS Both FRS and SR ACC/AHA were associated with mortality. However, for patients classified as high risk, only the ACC/AHA RS was associated with mortality within ten years.

RESUMO OBJETIVO Avaliar a performance do escore de risco de Framingham (ERF) e do escore proposto pela American College of Cardiology/American Heart Association (ER ACC/AHA) em predizer a mortalidade em pacientes dez anos após síndrome coronariana aguda (SCA). MÉTODOS Trata-se de um estudo de coorte retrospectivo que incluiu pacientes com idade ≥18 anos, com SCA, que estiveram internados na Unidade de Terapia Intensiva Coronariana (UTI) do Hospital das Clínicas de Botucatu, no período de janeiro de 2005 a dezembro de 2006. RESULTADOS Foram avaliados 447 pacientes. Destes, 118 foram excluídos, pois a mortalidade em dez anos não foi obtida. Logo, 329 pacientes com idade de 62,9±13,0 anos foram estudados. Dentre eles, 58,4% eram homens e 44,4% morreram no período de dez anos após a internação. A mediana do ERF foi de 16 (14-18)%, e do ER ACC/AHA foi 18,5 (9,1-31,6)%. Os pacientes que evoluíram a óbito apresentaram maiores valores dos escores. No entanto, quando classificamos os pacientes em alto risco cardiovascular, apenas o ER ACC/AHA foi associado com a mortalidade (p<0,001). Na análise de regressão logística, ambos os escores foram associados com a mortalidade em dez anos (p<0,001). CONCLUSÕES Tanto o ERF quanto o ER ACC/AHA foram associados com a mortalidade. No entanto, para os pacientes classificados como alto risco, apenas o ER ACC/AHA foi associado com a mortalidade em dez anos.

Validación del score GRACE (Global Registry of Acute Coronary Events) para predecir mortalidad intrahospitalaria en el síndrome coronario agudo en Buenos Aires / Validation of GRACE score (Global Registry of Acute Coronary Events) as a predictor of in hospital mortality in acute coronary syndromes in Buenos Aires

RESUMEN Introducción: El score GRACE (SG) estima el riesgo de mortalidad intrahospitalaria (MIH) al ingreso de los pacientes con síndrome coronario agudo (SCA). La validación externa de este puntaje es necesaria, dadas las variaciones en las características de los pacientes y los sistemas de salud, además de las diferencias socioeconómicas y los cambios en el tratamiento. Recientemente se publicó la guía TRIPOD para estandarizar la metodología de estos estudios de validación. El objetivo del presente trabajo fue determinar si el SG predice adecuadamente la MIH en pacientes con SCA asistidos en el Hospital Dr. Juan A. Fernández (grupo de validación, GV). Material y métodos: Estudio de validación retrospectivo de cohorte, ingreso hospitalario entre 2001 y 2016. Se evaluó la discriminación con el área bajo la curva (ABC) y la calibración con la prueba de Hosmer-Lemeshow (H-L), se obtuvo la calibración general, la pendiente de calibración, el gráfico de validación y el cinturón de calibración. Se analizaron subgrupos según el tipo de SCA documentado: con supradesnivel del ST (SCA-ST) o sin este (SCA-no ST). Resultados: Se analizaron 2104 pacientes. Se observó mayor proporción de infarto con supradesnivel del ST (40,4%) y de MIH (5,56%) en el GV que en la cohorte a partir de la cual se desarrolló el SG (32% y 4,6%, respectivamente). El modelo mostró falta de calibración por subestimación de riesgos entre probabilidades del 3% y 13%. La pendiente de calibración fue adecuada, lo que indica que la magnitud del efecto de los predictores sobre la MIH fue similar a la del modelo. El ABC fue 0,86. En el SCA-ST, se observó subestimación de riesgos en probabilidades entre el 5% y 23%, con adecuada discriminación. En el SCA-no ST, tanto la calibración como la discriminación fueron adecuadas. Conclusiones: A pesar de la falta de validez estadística en la población total, las variables del modelo fueron predictoras de MIH en la población del GV. Se considera que el score G es clínicamente relevante, pero se sugiere su recalibración en nuestra población.

ABSTRACT Background: GRACE score (G) estimates in-hospital mortality risk (IHM) in patients with acute coronary syndromes (ACS). Given the variability of patients´ characteristics, health systems, socioeconomic environment and changes in treatment; external validation should be performed. The TRIPOD statement was published to standardize validation studies´ methodology. The objective of this study is to asses if G predicts IHM with precision in patients with acute coronary syndrome at Juan A. Fernández Hospital (validation cohort -V-). Methods: Retrospective validation study. Consecutive patients admitted between 2001 and 2016 were included. Discrimination was evaluated using the area under the ROC curve (AUC) and calibration was evaluated using de Hosmer-Lemeshow test, calibration-in-the-large, calibration slope, validation graph and calibration belt. Subgroup analysis by type of ACS was performed. Results: A total of 2104 patients were analyzed. Myocardial infarction with ST elevation (40.4% and 32%) and IHM (5.56% and 4.6%) was more prevalent than G estimation. Calibration was poor, risks were underestimated between probabilities of 3 and 13%. The calibration slope was adequate, therefore the overall effect and magnitude of predictors on IHM was similar to G. The AUC was 0.86. The model performed with underestimation of risk between probabilities of 5% and 23% in patients with ACS and ST elevation, the discrimination was good. Calibration and discrimination performed well in patients with non ST elevation ACS. Conclusions: Despite the lack of statistical validity of the model in the total population, the variables were predictors of IHM in the validation cohort. Therefore, G score is clinically relevant, but should be recalibrated in our population.

Acute Isolated Right Ventricular Infarction: Unusual Presentation of Anterior ST-Segment-Elevation Myocardial Infarction.

Acute right ventricular infarction presenting with ST-segment elevation in the anterior precordial electrocardiographic leads is an unusual event. Anterior ST-segment elevation typically suggests occlusion of the left anterior descending coronary artery. It should be recognized, however, that occlusion of a right coronary artery branch can cause isolated ST-segment elevation in leads V1 and V2 on a standard 12-lead electrocardiogram. We describe the cases of 2 patients who presented with acute chest syndrome with isolated ST-segment elevation in leads V1 and V2. Emergency coronary angiograms revealed that acute thrombotic occlusion of the right ventricular marginal branch of the dominant right coronary artery caused the clinical manifestations in the first patient, whereas occlusion of the proximal nondominant right coronary artery was the culprit lesion in the second patient. Both lesions caused right ventricular myocardial infarction. The patients underwent successful primary percutaneous coronary intervention. These cases illustrate the importance of carefully reviewing angiographic findings to accurately diagnose an acute isolated right ventricular myocardial infarction, which may mimic the electrocardiographic features of an anterior-wall myocardial infarction.

[Predictive value of NT-proBNP on admission on left ventricular ejection fraction and in-patients major adverse cardiac and cerebrovascular events in hospitalized patients with unstable angina].

Objective: To explore the predictive value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) on admission on left ventricular ejection fraction (LVEF) and the in-hospital major adverse cardiac and cerebrovascular events (MACCE) in hospitalized patients with unstable angina (UA). Methods: Data of 2 972 consecutive hospitalized patients with UA in Beijing Friendship Hospital from January 2013 to September 2017 were retrospective analyzed. Patients were divided into 4 groups according to the level of NT-proBNP on admission: 733 cases with NT-proBNP lower than 61 ng/L, 749 cases with NT-proBNP between 61 and 133 ng/L, 747 cases with NT-proBNP between 133 and 326 ng/L, and 743 cases with NT-proBNP higher than 326 ng/L. LVEF and in-hospital MACCE were compared among 4 groups and the predictive value of NT-proBNP on admission on LVEF and in-hospital MACCE was determined by multiple logistical regression analysis. Results: LVEF value became lower with increasing on admission NT-proBNP value ((68.4±4.8)%, (68.2±5.2)%, (67.2±6.7)% and (62.6±10.4)%, F=77.98, P<0.01), while in-hospital MACCE was higher with increasing on admission NT-proBNP value (3.4% (25/733), 3.5% (26/749), 5.5% (41/747) and 7.3% (54/743), χ(2)=16.23, P<0.01) in NT-proBNP lower than 61 ng/L, NT-proBNP between 61 and 133 ng/L, NT-proBNP between 133 and 326 ng/L, and NT-proBNP higher than 326 ng/L group. Multiple logistic regression analysis showed that on admission NT-proBNP was an independent predictor for LVEF<50% (Exp(ß)=5.875, 95%CI 3.382-10.207, P<0.001), but not predictor for in-hospital MACCE (Exp(ß)=0.783, 95%CI 0.400-1.996, P=0.783). Conclusion: The on admission NT-proBNP level is an independent predictor of left ventricular systolic dysfunction (LVEF<50%), but not an independent predictor of total in-hospital MACCE in hospitalized patients with UA.

Trimethylamine N-Oxide and Cardiovascular Outcomes in Patients with ESKD Receiving Maintenance Hemodialysis.

BACKGROUND AND OBJECTIVES: Trimethylamine N-oxide (TMAO), a compound derived from byproducts of intestinal bacteria, has been shown to accelerate atherosclerosis in rodents. To date, there are conflicting data regarding the association of serum TMAO with cardiovascular outcomes in patients with ESKD, a population exhibiting both high serum TMAO and excessive atherosclerosis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We measured baseline serum TMAO concentrations in a subset of participants (n=1243) from the Evaluation of Cinacalcet Hydrochloride Therapy to Lower Cardiovascular Events (EVOLVE) trial and conducted post hoc analyses evaluating the association between baseline serum TMAO and cardiovascular outcomes. RESULTS: We observed a wide distribution of serum TMAO in our cohort, with approximately 80% of participants exhibiting TMAO concentrations ≥56 µM and a maximum TMAO concentration of 1103.1 µM. We found no association between TMAO and our primary outcome, a composite of cardiovascular mortality, myocardial infarction, peripheral vascular event, stroke, and hospitalization for unstable angina. Moreover, in unadjusted and adjusted analyses, we observed no relation between TMAO and all-cause mortality, the independent components of our composite outcome, or the original EVOLVE primary outcome. Although we did observe higher TMAO concentrations in white participants, further subgroup analyses did not confirm the previously identified interaction between TMAO and race observed in a prior study in patients receiving dialysis. CONCLUSIONS: We found no evidence linking TMAO to adverse clinical outcomes in patients receiving maintenance hemodialysis with moderate to severe secondary hyperparathyroidism.

Effects of Wenxin granules and bisoprolol fumarate combined with aerobic exercise on serum matrix metallo-proteinase-1 and N-terminal pro-brain natriuretic peptide levels in patients with unstable angina pectoris / 中国基层医药

Objective To investigate the influence of Wenxin granules and bisoprolol fumarate combined with aerobic exercise on serum matrix metalloproteinase－1(MMP－1) and N－terminal pro－brain natriuretic peptide (NT－proBNP) levels in patients with unstable angina pectoris.Methods From January 2016 to February 2018, 92 patients with unstable angina pectoris in Lishui Hospital of Traditional Chinese Medicine were selected and randomly divided into control group(n=46) and study group(n=46) according to the digital table.On the basis of routine intervention,the control group was given bisoprolol fumarate for 2 weeks and aerobic exercise for 1 month, while the study group was given bisoprolol fumarate,aerobic exercise and Wenxin granules for 2 weeks.The frequency and duration of angina pectoris before and after 1 month of treatment,clinical efficacy,serum MMP－1 and NT－proBNP levels,blood rheology index(plasma viscosity,whole blood high shear viscosity,total blood low－cut viscosity,fibrinogen) and incidence of adverse reactions were observed.Results After 1 month of treatment,the frequency of angina pectoris was lower than that before treatment,and the duration was shorter than that before treatment,which in the study group [(2.09 ± 0.65)times/week,(2.24 ± 0.83)min/time] were better than those in the control group(t1=10.898,t2= 9.302,all P<0.05).The total effective rate of the study group(91.30% ) was higher than that of the control group (73.91% )(χ2 =4.842,P<0.05).After 1 month of treatment,the serum levels of MMP－1 and NT－proBNP in the two groups were lower than those before treatment,which in the study group [(196.10 ± 55.01) g/L,(403.82 ± 114.15)ng/L] were lower than those in the control group ( t1 =3. 619, t2 =4. 185, P <0. 05 ). At the end of treatment,the plasma viscosity,whole blood high－viscosity,whole blood low－cut viscosity,fibrinogen level in the two groups were lower than those before treatment,which in the study group were lower than those in the control group(all P<0.05).The incidence rate of adverse reactions in the study group was 15.22% ,which in the control group was 10.87% ,there was no statistically significant difference between the two groups (χ2 =0.383,P>0.05).Conclusion The combination of Wenxin granules, bisoprolol fumarate and aerobic exercise for patients with unstable angina pectoris not only can reduce the frequency of angina pectoris,MMP－1 and NT－proBNP levels,but also can improve the treatment of disease.Besides,it does not increase the risk of adverse reactions.