Anemia for risk assessment of patients with acute coronary syndromes.

In patients admitted with acute coronary syndromes, those with anemia are at higher risk. However, current risk score systems do not take into account the presence of anemia. The impact of anemia on mortality was studied, and its incremental predictive value was evaluated. Demographic, clinical, and biologic characteristics at admission, as well as treatments and mortality, were recorded for 1,410 consecutive patients with acute coronary syndromes. The incremental value of adding anemia information to risk score evaluation was determined using changes in the appropriateness of Cox models when anemia was added. Anemia was detected in 381 patients (27%). They were older, had more co-morbidities, had higher Global Registry of Acute Coronary Events (GRACE) risk scores, received fewer guideline-recommended treatments, and, as a result, had 4-fold higher mortality. When included in a prediction model based on the GRACE risk score, anemia remained an independent predictor of mortality. The addition of anemia improved both the discriminatory capacity and calibration of the models. According to the GRACE risk score, the population was divided into 4 groups of different risk levels of <1%, 1% to <5%, 5% to <10%, and > or =10%. The addition of anemia to the model made it possible to reclassify 9%, 43%, 47%, and 23% of patients into the different risk categories, respectively. In conclusion, our data confirmed that anemia was an independent predictive factor of mortality and had incremental predictive value to the GRACE score system for early clinical outcomes.

Prognostic value of albuminuria on 1-month mortality in acute myocardial infarction.

RATIONALE: An increase in albuminuria occurs in the early days after acute myocardial infarction. The aim of this study was to assess the relation between albuminuria and 30-day mortality, as well as its incremental predictive value, on top of established prognostic parameters. METHODS AND RESULTS: Demographic, clinical, and biological characteristics at admission, as well as in-hospital treatments and 1-month survival, were recorded in 1,211 consecutive patients admitted for acute myocardial infarction. Albuminuria was assessed from an 8-hour overnight urine collection within the first 2 days using immunonephelemetry. The population was categorized into 3 groups according to albuminuria levels (<20, 20-200, and >200 microg/min). Among survivors on day 2, 52% (625/1,211) of patients had an albuminuria level <20 microg/min, 39% (477) between 20 and 200 microg/min, and 9% (109) >200 microg/min. High levels of albuminuria were associated with older age, peripheral vessel disease, systolic blood pressure, glucose, creatinine, troponin, B-type natriuretic peptide, and high-sensitivity C reactive protein levels, as well as use of angiography, angiotensin-converting enzyme inhibitors, and beta blockers. At 1 month, there was a significantly higher mortality rate in groups with higher albuminuria. After adjustment for baseline characteristics, patients with albuminuria level of >20 microg/min had a 2.7-fold higher 30-day mortality, and those with >200 microg/min had an almost 4-fold higher 30-day mortality compared to those with albuminuria level of <20 microg/min. The addition of albuminuria information improved the discrimination capacity of the model and the global risk prediction. CONCLUSIONS: Albuminuria level, taken as a quantitative or categorical variable, is an independent and powerful predictor of mortality after acute myocardial infarction.

Changes in management of elderly patients with myocardial infarction.

AIMS: Despite being at higher risk for mortality, elderly patients (>/=75 years) admitted for acute myocardial infarction (MI) often receive fewer effective therapies, because of contraindications or higher risk of drug-induced adverse events. The aim of this study was to assess the changes in the use of effective treatments between 2001 and 2006 in elderly patients, and the relation with 1-month mortality. METHODS AND RESULTS: Prospective, multicentre registry, considering two periods: 6 months between October 2000 and March 2001 (cohort 1) and 12 months between October 2005 and October 2006 (cohort 2). Demographic and clinical characteristics at admission, in-hospital treatment (reperfusion or early invasive therapy, oral antiplatelets, anticoagulants, angiotensin-converting enzyme (ACE)-inhibitors, beta-blockers, and statins), and 1-month survival were compared between the two cohorts, after adjustment on a propensity score (for being admitted in 2001). Eight hundred and sixty-eight elderly patients were included, 280 in cohort 1 and 588 in cohort 2. When compared with cohort 1, patients from cohort 2 presented with comparable characteristics, except for the Global Registry of Acute Coronary Events risk score and we observed a significant increase in the use of aspirin, clopidogrel, reperfusion therapy, ACE-inhibitors, and statins in cohort 2. One-month mortality was significantly lower in cohort 2 (13.6% in cohort 1 vs. 7.1% in cohort 2, P = 0.001), mainly driven by a decrease in the mortality among patients with ST-segment elevation MI (23.3% in cohort 1 vs. 9.2% in cohort 2, P < 0.001). Adjustment on the propensity score did not alter these results. By multivariable analysis, the three-fold higher mortality in patients from cohort 1 was offset when the rate of use of treatments was considered in the model, suggesting that the treatment intensity was related to lower mortality. CONCLUSION: Between 2001 and 2006, a significant increase in the use of guidelines-recommended treatments (GRTs) was observed, associated with lower 30-day mortality, in elderly patients. These data confirm that high-risk patients, such as the elderly, benefit from an increase in the use of GRTs.

Changes in unstable coronary atherosclerotic plaque composition after balloon angioplasty as determined by analysis of intravascular ultrasound radiofrequency.

The effects of balloon angioplasty (BA) on plaque distribution remain incompletely documented. In 20 patients with unstable angina pectoris, intravascular ultrasound gray scale and radiofrequency analyses were performed before and after BA. Composition of the plaque was 61% fibrotic tissue, 15% fibrofatty tissue, 15% necrotic tissue, and 7% dense calcium tissue. After BA, 35% of lumen enlargement was due to an increase in total vessel area and 65% to a significant decrease in plaque area. This resulted from a longitudinal redistribution of the tissue toward the reference segments. Radiofrequency analysis showed that the fibrous and fibrofatty tissues were able to redistribute longitudinally, whereas calcium remained at the same level. A third of necrotic tissue was lost after BA. In conclusion, in unstable plaques, BA resulted in a longitudinal redistribution of fibrotic and fibrofatty tissues and disappearance of 1/3 of necrotic tissue.