Association of Contemporary Statin Pretreatment Intensity and LDL-C Levels on the Incidence of STEMI Presentation.

Constituting hypolipidemic and pleiotropic effects, statins stabilize coronary artery plaque and may prevent STEMI events. This study investigated the association between contemporary statin pretreatment intensity, low-density lipoprotein cholesterol (LDL-C) levels, and the type of acute coronary syndrome (ACS) presentation: STEMI vs. NSTE-ACS. Data were drawn from the ACS Israeli Survey (ACSIS), a biennial prospective national survey that took place in 2008-2018. The rate of STEMI vs. NSTE-ACS was calculated by statin use, including statin intensity (high-intensity statin therapy (HIST) and low-intensity statin therapy (LIST) prior to the index ACS event. Among 5103 patients, 2839 (56%) were statin-naive, 1389 (27%) used LIST and 875 (17%) used HIST. Statin pretreated patients were older and had a higher rates of co-morbidities, cardiovascular disease history and pretreatment with evidence-based medications. STEMI vs. NSTE-ACS was lower among HIST vs. LIST vs. statin-naive patients (31.0%, 37.8%, and 54.0%, respectively, p for trend < 0.001). Multivariate analysis revealed that HIST was independently associated with lower STEMI presentation (ORadj 0.70; 95% CI 0.57-0.86), while LIST (ORadj 0.92; 95% CI 0.77-1.10) and LDL-C < 70 mg/dL (ORadj 0.96; 95% CI 0.82-1.14) were not. In conclusion, among patients admitted with ACS, pretreatment with HIST was independently associated with a lower probability of STEMI presentation, while LIST and LDL-C < 70 mg/dL were not.

Sex Differences in the Management and 5-Year Outcome of Young Patients (<55 Years) with Acute Coronary Syndromes.

BACKGROUND: Young women are usually protected against coronary artery disease due to hormonal and risk-factor profile. Previous studies have suggested poorer outcome in women hospitalized with acute coronary syndrome as compared with men. However, when adjusted for age and other risk factors, this difference does not remain significant. We compared the risk profile and outcome between young (≤55 years) women and men admitted with acute coronary syndrome. METHODS: We analyzed clinical characteristics, management strategies, and outcomes of men and women ≤55 years of age enrolled in the biennial Acute Coronary Syndrome Israeli Surveys between 2000 and 2013. RESULTS: Among 11,536 patients enrolled, 3949 (34%) were ≤55 years old (407 women, 3542 men). Women were slightly older (48.9 ± 5.7 vs 48.3 ± 5.5, P = .007) and suffered more from diabetes (34% vs 24%) and hypertension (47% vs 37%, P <.001 for both). Rates of prior myocardial infarction were high in both sexes (18% vs 21%). Women presented less often with ST-elevation myocardial infarction (50% vs 57%, P = .007) and with typical chest pain (73% vs 80%, P = .004), and had higher rates of Global Registry of Acute Coronary Events (GRACE) score ≥140 (19% vs 12%, P = .007). After adjustment for GRACE score, diabetes, and enrollment year, women had a lower likelihood to undergo coronary angiography during hospitalization (odds ratio 0.6, P = .007). Female sex was independently associated with higher risk of in-hospital mortality (hazard ratio [HR] 4.1; 95% confidence interval [CI], 1.15-14.0), 30-day major adverse cardiac and cerebral events (HR 2.1; 95% CI, 1.31-3.36), and 5-year mortality (HR 1.96; 95% CI, 1.3-2.8). CONCLUSIONS: Young women admitted with acute coronary syndrome are a unique high-risk group that presents a diagnostic challenge for clinicians. Women receive less invasive therapy during hospitalization and have worse in-hospital and long-term outcomes.

Association between statin treatment and LDL-cholesterol levels on the rate of ST-elevation myocardial infarction among patients with acute coronary syndromes: ACS Israeli Survey (ACSIS) 2002-2010.

BACKGROUND: STEMI is thought to occur as a result of a vulnerable coronary plaque rupture. Statins possess hypolipidemic and pleotropic effects that stabilize coronary plaque. We sought to determine the association between LDL-C levels, statin use prior to the index event on the type of acute coronary syndrome (ACS) presentation: STEMI vs. non-STEMI/unstable angina. METHODS: Data was drawn from the ACS Israeli Survey (ACSIS), a biennial prospective survey of ACS patients hospitalized in all CCU/Cardiology departments during 2002-2010. RESULTS: Among 6790 patients, 2760 (41%) reported statin use prior to the index ACS event. The proportion of STEMI was significantly lower among statin treated vs. statin naive patients (36% vs. 57%, p<0.0001). At each LDL-C level, the proportion of STEMI was significantly lower only among statin treated patients (p<0.0001). LDL-C<70 mg/dL was associated with a lower proportion of STEMI only among statin treated but not among statin naive patients (33% vs. 57%, p<0.0001). Multivariate analysis revealed that statin use was independently associated with a lower probability of presenting with STEMI (ORadj=0.73, p=0.007), but not LDL-C<70 mg/dL (ORadj=1.13, p=0.32). Patients on high-intensity statin therapy (HIST) were less likely to present with STEMI as compared with low-intensity statin therapy (LIST) or statin naive patients (27%, 38%, 56%, respectively, p for trend <0.0001; HIST ORadj=0.28, p=0.01; LIST ORadj=0.48, p=0.026). CONCLUSIONS: Among patients admitted with ACS, statin use but not LDL-C level, was associated with a lower probability of presenting with STEMI. Patients on HIST had the lowest likelihood of presenting with STEMI.

Aspiration thrombectomy in patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention (from the Acute Coronary Syndrome Israeli Survey 2010).

We assessed the impact of aspiration thrombectomy (AT) in patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention (PPCI) on major adverse cardiac events at 30 days and 1-year mortality in 517 consecutive patients who were included in the prospective, nationwide, multicenter, observational Acute Coronary Syndrome Israeli Survey in 2010. Two hundred seventeen patients (42%) underwent AT (AT-PPCI) and 300 patients conventional (C) PPCI. Both groups had similar infarct-related artery distribution and ostial or proximal culprit lesion. Patients in AT-PPCI versus C-PPCI had lower systolic blood pressure and worse Killip class on admission, more frequent Thrombolysis In Myocardial Infarction flow 0 or 1 before PPCI (80% vs 56%), less frequent restoration of flow after indwelling a guidewire in the infarct-related artery (32% vs 52%), and more use of IIb/IIIa glycoprotein inhibitors (69% vs 49%), respectively (p ≤0.05 for all comparisons). Thirty-day major adverse cardiac events was similar in the AT-PPCI and C-PPCI groups, 10.6% versus 9.7%, p = 0.73; adjusted odds ratio 0.97, 95% confidence interval 0.45 to 2.10, p = 0.95. One-year mortality was lower in the AT-PPCI versus C-PPCI group, 3.7% versus 6.7%, p = 0.13; adjusted hazard ratio 0.31, 95% confidence interval 0.10 to 0.96, p = 0.042. In conclusion, this study of consecutive patients with ST elevation myocardial infarction undergoing PPCI demonstrates that AT was an independent predictor of reduced 1-year mortality.

Age differences in the adherence to treatment guidelines and outcome in patients with ST-elevation myocardial infarction.

The aim of this study was to assess age differences in the utilization of class-I treatment guidelines and its effect on mortality in patients with ST-elevation myocardial infarction (STEMI). The study included 1026 consecutive patients from the prospective nationwide Acute Coronary Syndrome Israeli Survey (ACSIS). Primary reperfusion was used less often among elderly (age>75 years) patients than among those aged 65-74 and <65 years (46%, 63%, 64%, respectively, p (for trend)=0.004). Class-I evidence-based medications (EBM) at discharge (aspirin, ß-blockers, angiotensin converting-enzyme inhibitors=ACEI, angiotensin receptor-blockers=ARBs and statins) were less frequently prescribed to elderly compared to younger age-subgroup (44%, 61%, 57%, respectively; adjusted odds ratio (OR)=0.62; 0.40-0.97 for age ≥ 75 vs. age<65 years). Early and 1-year mortality rates were 3-5-fold higher among the elderly compared to patients <65 years. In the entire cohort use of primary reperfusion was associated with lower 1-year mortality (OR=0.69; 0.47-1.01), as was the use of EBM (OR=0.26; 0.17-0.41). These effects were similar across all age-subgroups but with a greater impact among the elderly, as the number of patients needed to treat (NNT) was significantly lower with advancing age. Better adherence to treatment guidelines may improve the prognosis of elderly patients with STEMI.

Contemporary treatment and adherence to guidelines in women and men with acute coronary syndromes.

BACKGROUND: Historically gender differences existed in treatment and outcome of patients with acute myocardial infarction (MI). AIM: To assess gender aspects of contemporary treatment and adherence to ACC/AHA Class-I Treatment Guidelines in patients with acute coronary syndrome (ACS). METHODS: We studied 2024 consecutive patients (519 women, 26%); 1026 (51%) with ST-elevation (STE)-MI and 998 (49%) patients with non-STE (NSTE), during a nationwide ACS-survey, conducted during 2-months in 2004. RESULTS: Women were older than men (71 vs. 59 in STEMI; 71 vs. 64 years in NSTE-ACS patients), and had worse cardiovascular risk profiles. In STEMI-patients, acute reperfusion was less frequent in women than in men (53% vs. 63%, respectively, p=0.01; non-significant after age-adjustment). At discharge, fewer women received ACE-inhibitors/ARBs (71% vs. 75%, respectively; OR(age-adj)=0.69[0.48-0.98]). Among NSTE-ACS patients, fewer women received IIb/IIIa-inhibitors (12% vs. 21%, respectively, p=0.007; OR(age-adj)=0.58[0.36-0.96]) and clopidogrel at discharge (49% vs. 59%, respectively, p=0.005; OR(age-adj) 0.75[0.56-1.01]). No gender differences were noted in utilization of aspirin, beta-blockers or statins. Age-adjusted and covariate-adjusted mortality rates were comparable in women and men with STEMI (at 7-days 4.3% vs. 4.1%; OR(adj)=0.95[0.47-1.87] and at 1-year 13.8% vs. 9.8%, hazard ratio [HR(adj)]=1.11[0.73-1.70], respectively); in women and men with NSTE-ACS (at 7-days 1.3% vs. 2.1%, OR(adj)=0.65[0.20-1.76], and at 1-year 12.0% vs. 11.3%; HR(adj)=1.19[0.80-1.77], respectively). CONCLUSIONS: In 2004, adherence to ACC/AHA Class-I Treatment Guidelines in ACS-patients was satisfactory. Relative underutilization of acute reperfusion was noted among STEMI patients, without gender differences after age-adjustment. At discharge, less women received ACE-inhibitors/ARBs. Among NSTE-ACS patients, less women than men received IIb/IIIa-inhibitors, and clopidogrel at discharge. Contemporary ACS management was associated with similar adjusted outcome in women and men.

Management and outcomes of elderly women and men with acute coronary syndromes in 2000 and 2002.

BACKGROUND: Previous studies have suggested that women with myocardial infarction are treated less aggressively and have worse outcomes compared with men. The objective of this study was to evaluate sex differences in the management and outcomes of elderly (age > or = 70 years) women and men with acute coronary syndromes (ACSs) in the new millennium. METHODS: This study includes 1331 consecutive elderly patients with ACSs admitted to all intensive coronary care units and cardiology departments in Israel from 2 prospective nationwide ACS surveys conducted in 2000 and 2002. RESULTS: The mean age of women vs men was comparable (79 vs 78 years). Comorbidities were more frequent in women, whereas previous coronary disease and typical anginal pain on admission were more frequent in men. Medical treatments and revascularization procedures during the index hospitalization were comparable in both groups. Crude and covariate-adjusted mortality rates were higher in women at 7 days (12% vs 7%; P = .007; adjusted odds ratio [OR], 1.83; 95% confidence interval [CI], 1.15-2.91) but not at 6 months (21% vs 19%; adjusted OR, 1.10; 95% CI, 0.79-1.52). This difference was attributed to ST elevation (STE)-ACS in women vs men (19% vs 12%; P = .007; adjusted OR, 1.97; 95% CI, 1.14-3.46). Seven-day mortality rates were highest in patients with STE-ACS denied coronary angiography, especially women (23% vs 15%; P = .06). CONCLUSIONS: In the 2000s, elderly women and men with ACSs are receiving similar medical and invasive management during the index hospitalization; however, women with STE-ACS have higher mortality rates at 7 days but not at 6 months. Mortality rates are highest in patients with STE-ACS denied coronary angiography. The benefit of invasive procedures on mortality rates in elderly patients with STE-ACS needs further investigation.

Results of coronary artery stenting in women versus men: a single center experience.

BACKGROUND: Prior studies have suggested that women are at higher risk for morbidity and mortality during coronary angioplasty, although long-term prognosis is similar after successful procedures. OBJECTIVES: To examine the role of gender in coronary stenting, including immediate procedural success as well as early and late outcomes. METHODS: The study group comprised 560 consecutive patients (119 women and 441 men) who had undergone stenting over a 3 year period. RESULTS: The indications for coronary stenting were similar among women and men, and stents were successfully deployed at similar rates without complications (92 vs. 90% respectively). Cardiac death or myocardial infarction within 30 days of the procedure was observed in 5% of women and men, whereas none of the women, compared to 1.4% of men, had early revascularization. Bleeding complications occurred in 4% of women and 2% of men. During 10 +/- 2.8 months of follow-up, 58% of women and men underwent repeat cardiac catheterization, revealing similar rates of restenosis, 36 vs. 32% respectively. During the study period, 3.3% of women as compared to 0.9% of men had a cardiac death (not significant). Cardiac death or myocardial infarction was observed in 7% of women and 8% of men, and the combined endpoint of death, myocardial infarction or revascularization, was noted in 24% and 26% respectively. Multivariate Cox analyses of the clinical, angiographic and procedural characteristics revealed that multiple stent deployment was the only predictor of major adverse cardiac event among men, whereas none of these characteristics predicted outcome in women. CONCLUSION: Coronary stenting is performed with similar success rates among women and men, with similar restenosis rates as well as early and late major adverse cardiac events.