Temporal trends in the treatment of over 1.5 million patients with myocardial infarction in the US from 1990 through 1999: the National Registry of Myocardial Infarction 1, 2 and 3

The Average Age of Atrioventricular Block Onset in Middle Eastern Patients with Cardiac Rhythm Devices Adjusted for the Overall Young Population: Insights from a Multicenter International Registry

Background

Previous registries have shown a younger average age at presentation with cardiovascular diseases in the Middle East (ME), but no study has examined atrioventricular block (AVB). Moreover, these comparisons are confounded by younger populations in the ME. We sought to describe the average age at presentation with AVB in ME and quantify the effect of being from ME, adjusted for the overall younger population.

Methodology

This was a retrospective analysis of PANORAMA registries, which collected data on patients who underwent cardiac rhythm device placement worldwide. Countries with a median population age of ≤30 were considered 'young countries'. Multivariate linear regression was performed to assess the effect of being from ME, adjusted for being from a 'young country', on age at presentation with AVB.

Results

The study included 5,259 AVB patients, with 640 (8.2%) from the ME. Mean age at presentation was seven years younger in ME than in other regions (62.9 ± 17.8 vs. 70 ± 14.1, P < 0.001). Being from a 'young country' was associated with 5.6 years younger age at presentation (95%CI -6.5--4.6), whereas being from ME was associated with 3.1 years younger age at presentation (95%CI -4.5--1.8), (P < 0.001 for both).

Conclusion

The average age at presentation with AVB in the ME is seven years younger than in other regions. While this is mostly driven by the overall younger population, being from the ME appears to be independently associated with younger age. Determinants of the earlier presentation in ME need to be assessed, and care should be taken when applying international recommendations.

The Changing Epidemiology of the Cardiac Intensive Care Unit

Coronary care units (CCUs) were originally designed to monitor and treat peri-infarction ventricular arrhythmias but have evolved into highly specialized cardiac intensive care units (CICUs) that provide care to a patient population that is increasingly heterogeneous and complex. Paralleling broader epidemiologic trends, patients admitted to contemporary CICUs are older and have a greater burden of cardiovascular and non-cardiovascular comorbidities. Moreover, contemporary CICU patients have high illness severity and often present with acute noncardiac organ dysfunction. In addition to these shifting demographic patterns, there have been important epidemiologic changes in CICU technologies, multidisciplinary systems of care, and physician staffing and training.

The Association Between High CHA2DS2-VASc Scores and Short and Long-Term Mortality for Coronary Care Unit Patients

Background

The CHA₂DS₂-VASc score has been associated with the prognosis of cardiovascular diseases. This study aimed to explore the association between the CHA₂DS₂-VASc score and all-cause mortality in coronary care unit (CCU) patients.

Methods

The study was based on the Medical Information Mart for Intensive Care (MIMIC) III database. CCU patients were divided into two groups according to CHA₂DS₂-VASc score: 0-3 (low risk)，4-9 (intermediate and high risk). The primary outcome was 30-day mortality, and the secondary endpoints included in-hospital, 1-year, and 5-year mortality. Propensity score matching (PSM) and sensitivity analyzes for the confounders were also performed. The restricted cubic splines flexibility model was used to demonstrate the relation between red blood cell volume distribution width (RDW), blood urea nitrogen (BUN), platelet, white blood cell (WBC), hemoglobin, phosphorus, glucose, potassium, sodium and 30-day mortality in the 0-3 score versus the 4-9 score groups after PSM.

Results

Among 4491 eligible patients, 988 patients with low CHA₂DS₂-VASc scores and 988 patients with intermediate and high CHA₂DS₂-VASc scores had similar propensity scores and were included in the analyzes. In the survival analysis, the patients with intermediate and high CHA₂DS₂-VASc scores were associated with higher 30-day mortality [hazard ratio (HR): 1.11; 95% confidence interval (CI), 1.02–1.20, P = .014], 1-year mortality [HR: 1.13; 95%CI, 1.06–1.19, P < .001], and 5-year mortality [HR: 1.13; 95%CI, 1.07–1.18, P < .001]. The interaction for 30-day mortality among subgroups was not significant between the 0-3 score versus the 4-9 score groups. The restricted cubic splines for 30-day mortality demonstrated an L-shaped trajectory for platelets and hemoglobin, a J-shaped trajectory for WBC, glucose and potassium, and a U-shaped trajectory for sodium, respectively (all nonlinear P <.001).

Conclusions

A high CHA₂DS₂-VASc score was an independent risk for 30-day, 1-year, and 5-year mortality for CCU patients.

Valosin Containing Protein as a Specific Biomarker for Predicting the Development of Acute Coronary Syndrome and Its Complication

Background

Acute coronary syndrome (ACS) consists of a range of acute myocardial ischemia-related manifestations. The adverse events of ACS are usually associated with ventricular dysfunction (VD), which could finally develop to heart failure. Currently, there is no satisfactory indicator that could specifically predict the development of ACS and its prognosis. Valosin-containing protein (VCP) has recently been proposed to protect against cardiac diseases. Hence, we aimed to assess whether VCP in serum can serve as a valuable biomarker for predicting ACS and its complication.

Methods

Human serum samples from 291 participants were collected and classified into four groups based on their clinical diagnosis, namely healthy control (n = 64), ACS (n = 40), chronic coronary syndrome (CCS, n = 99), and nonischemic heart disease (non-IHD, n = 88). Clinical characteristics of these participants were recorded and their serum VCP levels were detected by enzyme-linked immunosorbent assay (ELISA). Association of serum VCP with the development of ACS and its complication VD was statistically studied. Subsequently, GWAS and eQTL analyses were performed to explore the association between VCP polymorphism and monocyte count. A stability test was also performed to investigate whether VCP is a stable biomarker.

Results

Serum VCP levels were significantly higher in the ACS group compared with the rest groups. Besides, the VCP levels of patients with ACS with VD were significantly lower compared to those without VD. Multivariate logistic regression analysis revealed that VCP was associated with both the risk of ACS (P = 0.042, OR = 1.222) and the risk of developing VD in patients with ACS (P = 0.035, OR = 0.513) independently. The GWAS analysis also identified an association between VCP polymorphism (rs684562) and monocyte count, whereas the influence of rs684562 on VCP mRNA expression level was further verified by eQTL analysis. Moreover, a high stability of serum VCP content was observed under different preservation circumstances.

Conclusion

Valosin-containing protein could act as a stable biomarker in predicting the development of ACS and its complication VD.

Platelet-lymphocyte ratio as a new predictor of in-hospital mortality in cardiac intensive care unit patients

It has been discovered that both inflammation and platelet aggregation could cause crucial effect on the occurrence and development of cardiovascular diseases. As a combination of platelet and lymphocyte, platelet-lymphocyte ratio (PLR) was proved to be correlated with the severity as well as prognosis of cardiovascular diseases. Exploring the relationship between PLR and in-hospital mortality in cardiac intensive care unit (CICU) patients was the purpose of this study. PLR was calculated by dividing platelet count by lymphocyte count. All patients were grouped by PLR quartiles and the primary outcome was in-hospital mortality. The independent effect of PLR was determined by binary logistic regression analysis. The curve in line with overall trend was drawn by local weighted regression (Lowess). Subgroup analysis was used to determine the relationship between PLR and in-hospital mortality in different subgroups. We included 5577 CICU patients. As PLR quartiles increased, in-hospital mortality increased significantly (Quartile 4 vs. Quartile 1: 13.9 vs. 8.3, P < 0.001). After adjusting for confounding variables, PLR was proved to be independently associated with increased risk of in-hospital mortality (Quartile 4 vs. Quartile 1: OR 95% CI 1.55, 1.08–2.21, P = 0.016, P for trend < 0.001). The Lowess curves showed a positive relationship between PLR and in-hospital mortality. The subgroup analysis revealed that patients with low Acute Physiology and Chronic Health Evaluation IV (APACHE IV) or with less comorbidities had higher risk of mortality for PLR. Further, PLR quartiles had positive relation with length of CICU stay (Quartile 4 vs. Quartile 1: 2.7, 1.6–5.2 vs. 2.1, 1.3–3.9, P < 0.001), and the length of hospital stay (Quartile 4 vs. Quartile 1: 7.9, 4.6–13.1 vs. 5.8, 3.3–9.8, P < 0.001). PLR was independently associated with in-hospital mortality in CICU patients.

Length of Stay and Short-Term Outcomes in Patients with ST-Segment Elevation Myocardial Infarction After Primary Percutaneous Coronary Intervention: Insights from the China Acute Myocardial Infarction Registry

Background

Length of stay (LOS) in patients with ST-segment elevation myocardial infarction (STEMI) is directly associated with financial pressure and medical efficiency. This study aimed to determine impact of LOS on short-term outcomes and associated factors of LOS in patients with ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PPCI).

Methods

A total of 3615 patients with STEMI after PPCI in the China Acute Myocardial Infarction registry were included in the analysis. Predictors of prolonged LOS were analyzed by multivariate logistic regression model with generalized estimating equation. The impact of LOS on 30-day clinical outcomes was assessed.

Results

The median LOS was 9 (7, 12) days. Patients with a longer LOS (>7 days) were older, more often in lower-level hospitals, had more periprocedural complications and hospitalization expense. Fourteen variables, such as weekend admission and lower-level hospitals, were identified as independent associated factors of prolonged LOS. There were no significant difference in 30-day major adverse cardiac and cerebrovascular events (MACCE), readmission, and functional status between patients with LOS≤7d and LOS>7d after multivariate adjustment and propensity score matching. However, patients who discharged over one week had better medication adherence (adjusted odds ratio: 0.817, 95% confidence interval: 0.687-0.971, P=0.022). Significant interaction was observed in medication use between gender and LOS (P_interaction=0.038).

Conclusion

Patients with STEMI undergoing PPCI experienced a relatively long LOS in China, which resulted in more medical expenses but no improvement on 30-day MACCE, readmission, and functional recovery. Poor 30-day medication adherence with short LOS reflects unsatisfying transition of management from hospital to community. More efforts are needed to reduce LOS safely and improve the efficiency of medical care.

'Routine' versus 'Smart Phone Application Based - Intense' follow up of patients with acute coronary syndrome undergoing percutaneous coronary intervention: Impact on clinical outcomes and patient satisfaction

Background

Acute coronary syndrome (ACS) refers to the spectrum of clinical presentation of coronary artery disease (CAD). As a routine practice at our institute, following PCI, ACS patients are called for the first follow up after two weeks. This period of two weeks can be full of anxieties, concerns and medical issues. In this study, we planned to assess the feasibility/acceptability of smart phone application (app) based system for patient follow-up and its comparison to routine practice among patients with ACS who have undergone a PCI.

Methods

A randomized controlled trial (RCT) was conducted over a period of one year from January to December 2017. After the PCI was deemed successful, patients were recruited and enrolled based on the understanding of basic English language and operation of a smart phone. Those who consented to be part of study were then randomly allocated either the conventional follow up group or the intense follow up (routine + smart phone app based follow up) group. First co- primary outcome was composite of clinical outcomes (mortality, myocardial infarction, stroke, target vessel revascularisation, heart failure admission and emergency visit). Second co- primary outcome was patient satisfaction. The overall patient satisfaction was assessed by the patients using a five-point patient satisfaction survey instrument containing five questions with 5 marks each, in which higher scores meant more satisfaction. Secondary outcome was controlled hypertension in hypertensive patients. It was defined as systolic BP less than 130 and diastolic BP less than 80 mmHg.

Results

A cohort of 228 patients (109 in intense app-based arm; 119 in routine follow up arm) were analyzed. The result showed significant improvement in blood pressure control in hypertensive population in intense app based follow up group (76.2%) when compared to routine follow up group (45%) with p value 0.0062. The satisfaction score was significantly higher in the intense app based follow up (20.7 ± 1.29) as compared to routine follow up (16.5 ± 2.68); p value 0.0001. In the intense app based follow up 72.5% patient felt it was excellent tool (score 21-25) while 27.5% categorized it as good (score 16-20). While the routine follows up was perceived as good by most (91.6%) of the patients. Only 4.2% graded it as excellent and an equal number (4.2%) graded it as a poor way of follow up.

Conclusions

App based system shows higher satisfaction rate and comparable clinical outcome when compared to traditional hospital based follow up protocol alone. It has a high acceptance rate and thus this system should be explored further to optimize long term patient care.

Management of ST Elevation Myocardial Infarction (STEMI) in Different Settings

ST-segment elevation myocardial infarction (STEMI) is a life-threatening condition that requires emergent, complex, well-coordinated treatment. Although the primary goal of treatment is simple to describe-reperfusion as quickly as possible-the management process is complicated and is affected by multiple factors including location, patient, and practitioner characteristics. Hence, this narrative review will discuss the recommended management and treatment strategies of STEMI in the circumstances.

The changing landscape of cardiac rehabilitation; from early mobilisation and reduced mortality to chronic multi-morbidity management

AIM

This paper aims to demonstrate how the rationale and delivery of cardiac rehabilitation (CR), in those countries with long term established standards of practice, has changed over the past eight decades.

METHODS

A narrative report based on the evolution of key published guidelines, systematic reviews and medical policies since the 1940s.

RESULTS

Case reports of the value of exercise in cardiac disease can be dated back to 1772. Formative groundwork for exercise-based CR was published between 1940 and 1970. However, it was not until the late 1980s that a large enough data set of controlled trials was available to show significant reductions in premature all-cause and cardiac mortality. Since the mid 1990s, cardiac mortality has been greatly reduced due to enhanced public health, emergency care and more sensitive diagnostic techniques and aggressive treatments. As a result, there appears to be an associated reduced potency of CR to affect mortality. New rationales for why, how and where CR is delivered have emerged including: adapting to a longer surviving ageing multi-morbid population, where healthcare cost savings and quality of life have become increasingly important.

CONCLUSIONS

In light of these results, an emerging focus for CR, and in some cases "pre-habilitation", is that of a chronic disability management programme increasingly delivered in community and home settings. Within this delivery model, the use of remote personalised technologies is now emerging, especially with new needs accelerated by the pandemic of COVID-19.

IMPLICATIONS FOR REHABILITATIONWith continued advances in medical science and better long term survival, the nature of cardiac rehabilitation has evolved over the past eight decades. It was originally an exercise-focused intervention on short term recovery and reducing cardiac and all-cause mortality, to now being one part of a multi-factor lifestyle, behavioural, and medical chronic disease management programme.Throughout history, the important influence of psycho-social well-being and human behaviour has, however, always been of key importance to patients.The location of rehabilitation can now be suited to patient need, both medically and socially, where the same components can be delivered in either a traditional outpatient clinic, community settings, at home and more recently all of these being supported or augmented with the advent of mobile technology.

Clinical and Angiographic Features of Patients With Out-of-Hospital Cardiac Arrest and Acute Myocardial Infarction

BACKGROUND

Sudden cardiac arrest is a serious complication of acute myocardial infarction (MI). Although in-hospital mortality from MI has decreased, the mortality of MI patients complicated with out-of-hospital cardiac arrest (OHCA) remains high. However, the features of acute MI patients with OHCA have not been well known.

OBJECTIVES

We sought to characterize the clinical and angiographic features of acute MI patients with OHCA comparing with those without OHCA.

METHODS

We retrospectively analyzed 480 consecutive patients with acute MI undergoing percutaneous coronary intervention. Patients complicated with OHCA were compared with patients without OHCA.

RESULTS

Of the patients, 141 (29%) were complicated with OHCA. Multivariate analysis revealed that age (odds ratio [OR]: 0.8; 95% confidence interval [CI]: 0.7 to 0.9 per 5 years; p < 0.001), estimated glomerular filtration rate (OR: 0.8; 95% CI: 0.7 to 0.8 per 10 ml/min/1.73 m²; p < 0.001), peak creatine kinase-myocardial band (OR: 1.3; 95% CI: 1.2 to 1.4 per 10² U/l; p < 0.001), calcium-channel antagonists use (OR: 0.4; 95% CI: 0.2 to 0.7; p = 0.002), the culprit lesion at the left main coronary artery (OR: 5.3; 95% CI: 1.9 to 15.1; p = 0.002), and the presence of chronic total occlusion (OR: 2.9; 95% CI: 1.5 to 5.7; p = 0.001) were significantly associated with OHCA.

CONCLUSIONS

Younger age, no use of calcium-channel antagonists, worse renal function, larger infarct size, culprit lesion in the left main coronary artery, and having chronic total occlusion were associated with OHCA.

New Strategy to Prevent Acute Myocardial Infarction by Public Education - A Position Statement of the Committee on Public Education About Emergency Medical Care of the Japanese Circulation Society

Although many efforts have been made to prevent death from acute myocardial infarction (MI) by quick revascularization therapy and use of mechanical circulation support devices, and to prevent the occurrence of acute MI by optimal medical therapy, acute MI is still a leading cause of death worldwide. Because the majority of fatal MI cases occur outside hospital and death occurs so rapidly after MI onset, it is difficult to effectively prevent deaths from acute MI by improving the in-hospital treatment strategy of acute MI or by reducing the prehospital delay in the treatment. Therefore, we need a new strategy to prevent death from acute MI, mainly by preventing the occurrence of acute MI itself. In this review, we summarize the present status and propose a new strategy, the "STOP MI Campaign", to prevent acute MI by public education.

How to Improve Patient Safety Literacy?

The aim of this comparative study involving pre- and post-tests was to analyze the effectiveness of patient safety educational materials developed for the Comprehensive Plans for Patient Safety in Korea (2018–2022), and to suggest how to improve patient safety literacy. A face-to-face survey interview comprising items related to general information and patient safety literacy was completed by 217 patients and their families who visited three general hospitals in Seoul and one general hospital in Gyeonggi-do for treatment between 25 October and 15 November 2019. In the interview, the patients were asked questions about whether the patient safety educational materials were “easy to understand,” provided “help in safe hospitalization,” and enabled patients to practice patient safety independently (“do it yourself”). The literacy of the patient safety educational materials was analyzed using a paired t-test with a p value of 0.05. The comparison between patient safety literacy on pre- and post-tests revealed that among all participants, there were significant differences in “easy to understand,” “help in safe hospitalization,” and “do it yourself” scores. To improve patient safety literacy, patient education materials need to optimize communication by improving patients’ knowledge, skills, and attitudes for maintaining and promoting healthy living.

Age Differences in the Chief Complaint Associated With a First Acute Myocardial Infarction and Patient's Care-Seeking Behavior

BACKGROUND

This study set out to describe age differences in patient's chief complaint related to a first myocardial infarction and how the "typicality" of patient's acute symptoms relates to extent of prehospital delay.

METHODS

The medical records of 2586 residents of central Massachusetts hospitalized at 11 greater Worcester medical centers with a first myocardial infarction on a biennial basis between 2001 and 2011 were reviewed.

RESULTS

The average age of the study population was 66.4 years, 39.6% were women, 40.2% were diagnosed with a ST-elevation myocardial infarction (STEMI), and 72.0 % presented with typical symptoms of myocardial infarction, namely acute chest pain or pressure. Patients were categorized into 5 age strata: >55 years (23%), 55-64 years (20%), 65-74 years (19%), 75-84 years (22%), and ≥85 years (16%). The lowest proportion (11%) of atypical symptoms of myocardial infarction was observed in patients <55 years, increasing to 17%, 28%, 40%, and 51% across the respective age groups. The most prevalent chief complaint reported at the time of hospitalization was chest pain, but the proportion of patients reporting this symptom decreased from the youngest (83%) to the oldest patient groups (45%). There was a slightly increased risk of prehospital delay across the different age groups (higher in the oldest old) in those who presented with atypical, rather than typical, symptoms of myocardial infarction.

CONCLUSIONS

The present results provide insights to the presenting chief complaint of patients hospitalized with a first myocardial infarction according to age and the relation of symptom presentation to patient's care-seeking behavior.

Transitioning from a coronary to a critical cardiovascular care unit: trends over the past three decades

BACKGROUND

Coronary care units were established in the 1960s to reduce acute-phase mortality in acute coronary syndrome. In the 21st century, the original coronary care unit concept has evolved into an intensive cardiovascular care unit. The aim of this study was to analyse trend changes in characteristics and mortality of patients admitted to a coronary care unit over the past three decades.

METHOD

Between February 1989 and December 2017, a total of 18,334 patients was consecutively admitted to the coronary care unit of a university hospital in Barcelona. Data were analysed in five time frames: 1989-1994, 1995-1999, 2000-2004, 2005-2009 and 2010-2017. We analysed demographic profile, diagnoses at admission and trend changes in mortality across periods.

RESULTS

During the periods, the patients' ages and comorbidities increased. Diagnoses at admission have evolved. Acute coronary syndrome cases declined from the first to the last period (72.6% vs. 62.8%) while heart failure (6.0% vs. 8.6%) and malignant arrhythmias (0.8% vs. 4.0%) increased significantly. Overall, coronary care unit mortality decreased 34% from the first to the last period (6.8% vs. 4.5%, P<0.001). Furthermore, the cause of death has changed, those due to acute coronary syndrome declining (66.7% vs. 45.5%), and death from malignant arrhythmias increasing (1.9% vs. 16.2%) from the first to the last period.

CONCLUSIONS

Although acute coronary syndrome remained the main diagnosis, heart failure and arrhythmias have increased. Despite the aging and comorbidities, overall mortality in the coronary care unit decreased by 34% in the past three decades. Deaths due to acute coronary syndrome have declined, whereas those due to malignant arrhythmias have increased.

Myocardial Viability Testing by Positron Emission Tomography: Basic Concepts, Mini-Review of the Literature and Experience From a Tertiary PET Center

Ischemic heart disease ranges in severity from slightly reduced myocardial perfusion with preserved contractile function to chronic occlusion of coronary arteries with myocardial cells replaced by acontractile scar tissue-ischemic heart failure (iHF). Progression towards scar tissue is thought to involve a period in which the myocardial cells are acontractile but still viable despite severely reduced perfusion. This state of reduced myocardial function that can be reversed by revascularization is termed "hibernation." The concept of hibernating myocardium in iHF has prompted an increasing amount of requests for preoperative patient workup, but while the concept of viability is widely agreed upon, no consensus on clinical testing of hibernation has been established. Therefore, a variety of imaging methods have been used to assess hibernation including morphology based (MRI and ultrasound), perfusion based (MRI, SPECT, or PET) and/or methods to assess myocardial metabolism (PET). Regrettably, the heterogeneous body of literature on the subject has resulted in few robust prospective clinical trials designed to assess the impact of preoperative viability testing prior to revascularization. However, the PARR-2 trial and sub-studies has indicated that >5% hibernating myocardium favors revascularization over optimized medical therapy. In this paper, we review the basic concepts and current evidence for using PET to assess myocardial hibernation and discuss the various methodologies used to process the perfusion/metabolism PET images. Finally, we present our experience in conducting PET viability testing in a tertiary referral center.

Evaluation of Tpeak to end/QT and Tpeak to end/QTc ratios in patients with STEMI undergoing percutaneous intervention vs. thrombolytic therapy

INTRODUCTION

The patients with ST-segment Elevation Myocardial Infarction (STEMI) are significantly at increased risk of arrhythmia. Repolarization of myocardium has been evaluated by a series of electrical parameters including T wave peak to T wave end (Tp-Te) and Tp-Te/QT ratio. Which were compared with survival outcomes between two groups of STEMI patients treated with Primary Percutaneous Coronary Intervention (PPCI) and recombinant Tissue Plasminogen Activator (r-TPA).

METHODS

In this prospective study, 188 patients with STEMI were included in the study. 12‑Lead ECGs were obtained from all patients on time of admission and after 24 h after treatment. After dividing the patients into two groups based on their type of treatment (PPCI or r-TPA), The Tp-Te/QT and Tp-Te/QTc ratios were calculated using ECG records. The survival outcomes were compared between two groups.

RESULTS

95 patients (50.5%) underwent PPCI and 93 patients (49.5%) received r-TPA. Tp-Te/QT and Tp-Te/QTc ratios after administration of the treatments were significantly decreased in both groups (P-value = .001) with lower Tp-Te/QT and Tp-Te/QTc ratios in PPCI group (P-value = .001). 7 patients in PPCI group (7.3%) and 16 patients in r-TPA group (17.2%) were died during their hospitalization period (P-value = .04). The best combination of sensitivity and specificity of post treatment Tp-Te/QT ratio was at cutoff points of 29.4 with 82% sensitivity and 83% specificity.

CONCLUSION

Our study demonstrated that Tp-Te/QT and Tp-Te/QTc ratios decrease significantly after both PPCI and r-TPA therapies, but with PPCI these indexes decrease more than r-TPA, resulting a better survival outcome in patients with STEMI.

Lifestyle Interventions and Carotid Plaque Burden: A Comparative Analysis of Two Lifestyle Intervention Programs in Patients with Coronary Artery Disease

BACKGROUND

The cardioprotective effects of intensive lifestyle regimens in primary prevention have been elucidated; however, there is a paucity of data comparing the effects of different lifestyle regimens in patients with established coronary artery disease (CAD) or CAD equivalent, specifically vis-à-vis carotid plaque regression.

METHODS

We performed a randomized, single-center, single-blind study in 120 patients with established CAD. Patients were randomly assigned to either 9 months of the Complete Health Improvement Program (CHIP), an outpatient lifestyle enrichment program that focuses on improving dietary choices, enhancing daily exercise, increasing support systems, and decreasing stress; or to 9 months of an ad hoc, nonsequential combination of various healthy living classes offered separately through a health maintenance organization and referred to as the Healthy Heart program. Baseline and 9-month change in carotid intima-media thickness (CIMT) were measured.

RESULTS

Among 120 participants, data were analyzed for 79, of which 68 (86%) completed the study. Both average CIMT and average maximum CIMT increased over 9 months, but the changes between groups were insignificant. There were marked differences in the mean body mass index favoring the CHIP group (-1.9 [standard deviation = 1.9]; p < 0.001) and statistically significant within-group improvements in blood pressure, triglyceride level, 6-minute walk test result, self-assessment well-being score, and Patient Health Questionnaire-9 score that were not observed between groups.

CONCLUSION

Neither the CHIP nor Healthy Heart was effective in inducing plaque regression in patients with established CAD after a 9-month period. However, both were effective in improving several CAD risk factors, which shows that the nonsequential offering of healthy lifestyle programs can lead to similar outcomes as a formal, sequential, established program (CHIP) in many aspects. These results have important implications as to how lifestyle changes will be implemented as tertiary prevention measures in the future.

Hospitalization Length after Myocardial Infarction: Risk-Assessment-Based Time of Hospital Discharge vs. Real Life Practice

According to guidelines, it is safe for low-risk patients with myocardial infarction (MI) to be discharged within 72 h of hospitalization. However, results coming from registries show that the hospital stay is often much longer in a real-life situation. Data on the length of the hospital stay (LOS) of MI patients in Polish centers are lacking. We enrolled 212 consecutive patients with acute MI. Low-risk patients were defined according to PAMI II criteria: age <70 years, left ventricular ejection fraction (LVEF) >45%, no persistent ventricular arrhythmia, and no multi-vessel disease (MVD). The median of the hospitalization length was eight days (Q1: 6; Q3: 9). In low-risk patients (25%), the median of LOS was six days (Q1: 5; Q3: 7) (p < 0.001). In a logistic regression analysis patients age, LVEF, ST-segment-elevation MI and the presence of MVD were independent predictors of longer hospitals stay (≥8 days). During follow up, there were no significant differences in the rates of clinical events between patients with shorter (<8 days) and longer (≥8 days) hospitalization. In a real-life situation, the LOS, even in low-risk patients is much longer than recommended in the guidelines.

Acute Coronary Syndrome Management in Cancer Patients

PURPOSE OF REVIEW

Coronary artery disease and cancer often co-exist. Patients with cancer have been excluded by most major cardiology trials and registries and their management remains largely empiric. Cancer patients experience an approximately 10-times increased mortality compared to the general population. Conservative therapy of ACS in cancer therapy results in 1-year mortality of 74%. This review article aims to describe the mechanisms of acute coronary syndromes in cancer patients, their clinical presentation, and their management.

RECENT FINDINGS

Newer studies have shed light on the mechanisms of ACS in cancer patients, which are different and related to the type of malignancy and its associated therapy. Medication-specific coronary effects (vasospasm, endothelial dysfunction, spontaneous thrombosis, accelerated atherosclerosis), radiation vasculitis, cancer cell coronary embolism, and coronary compression from thoracic malignancies are unique ACS mechanisms in cancer patients. Close collaboration between oncologists and cardiologists for thoughtful patient selection and decision making strategies is necessary to provide optimal medical care.

Discharge timing and outcomes after uncomplicated non-ST-segment elevation acute myocardial infarction

BACKGROUND

Length of stay after non-ST-segment elevation myocardial infarction (NSTEMI) continues to decrease, but information to guide duration of hospitalization is limited.

METHODS

We used landmark analyses, in which the landmark defined potential days of discharge, to estimate complication rates on the first day the patient would have been out of the hospital, and estimated associations between timing of discharge and 30-day and 1-year event-free survival after discharge among NSTEMI patients.

RESULTS

Among 20,410 NSTEMI patients, median length of stay was 7 (4, 12) days; 3,209 (15.7%) experienced a cardiac complication on days 0 to 2 and 1,322 (6.5%) were discharged without complications during hospital days 0 to 2. At the start of day 3, 15,879 patients (77.8%) were still hospitalized without complications. Of these, 1,689 (10.6%) were discharged event-free on day 3. Adjusted event-free survival rates of death or myocardial infarction from day 4 to 30 days after among the 1,689 patients was 99.1% compared with 93.1% for the 14,190 who remained hospitalized at the end of day 3. For 1-year mortality, these rates were 98.1% and 96.4%, respectively. Among 13,334 patients hospitalized without complications at the start of day 4, 1,706 were discharged event-free that day. Adjusted survival rates among these patients, compared with those still hospitalized at the end of day 4, were 98.0% versus 93.7% for 30-day death or myocardial infarction and 97.8% versus 96.1% for 1-year mortality.

CONCLUSIONS

Patients with NSTEMI who had no serious complications during the first 2 hospital days were at low risk of subsequent short- and intermediate-term death or ischemic events.

Racial/ethnic disparities among Asian Americans in inpatient acute myocardial infarction mortality in the United States

Background

Acute myocardial infarction (AMI) is a common high-risk disease with inpatient mortality of 5% nationally. But little is known about this outcome among Asian Americans (Asians), a fast growing racial/ethnic minority in the country. The objectives of the study are to obtain near-national estimates of differences in AMI inpatient mortality between minorities (including Asians) and non-Hispanic Whites and identify comorbidities and sociodemographic characteristics associated with these differences.

Method

This is a retrospective analysis of 2010–2011 state inpatient discharge data from 10 states with the largest share of Asian population. We identified hospitalization with a primary diagnosis of AMI using the ICD-9 code and used self-reported race/ethnicity to identify White, Black, Hispanic, and Asian. We performed descriptive analysis of sociodemographic characteristics, medical comorbidities, type of AMI, and receipt of cardiac procedures. Next, we examined overall inpatient AMI mortality rate based on patients’ race/ethnicity. We also examined the types of AMI and a receipt of invasive cardiac procedures by race/ethnicity. Lastly, we used sequential multivariate logistic regression models to study inpatient mortality for each minority group compared to Whites, adjusting for covariates.

Results

Over 70% of the national Asian population resides in the 10 states. There were 496,472 hospitalizations with a primary diagnosis of AMI; 75% of all cases were Whites, 10% were Blacks, 12% were Hispanics, and 3% were Asians. Asians had a higher prevalence of cardiac comorbidities, including hypertension, diabetes, and kidney failure compared to Whites (p-value< 0.01). There were 158,623 STEMI (ST-elevation AMI), and the proportion of hospitalizations for STEMI was the highest for Asians (35.2% for Asians, 32.7% for Whites, 25.3% for Blacks, and 32.1% for Hispanics). Asians had the highest rates of inpatient AMI mortality: 7.2% for Asians, 6.3% for Whites, 5.4% for Blacks, and 5.9% for Hispanics (ANOVA p-value < 0.01). In adjusted analyses, Asians (OR = 1.11 [95% CI: 1.04–1.19]) and Hispanics (OR = 1.14 [1.09–1.19]) had a higher likelihood of inpatient mortality compared to Whites.

Conclusions

Asians had a higher risk-adjusted likelihood of inpatient AMI mortality compared to Whites. Further research is needed to identify the underlying reasons for this finding to improve AMI disparities for Asians.

Hospital evaluation of health literacy and associated outcomes in patients after acute myocardial infarction

BACKGROUND

Low health literacy is common in the United States and may affect outcomes after myocardial infarction (MI). How often hospitals screen for low health literacy is unknown.

METHODS

We surveyed 122 hospitals in the TRANSLATE-ACS study and divided them into those that reported routinely (>75% of patients), selectively (1%-75%), or never (0%) screening MI patients for low health literacy prior to discharge. We performed logistic regression with random intercepts to compare 6-week and 6-month patient-reported medication adherence and multivariable Cox regression to compare 1-year major adverse cardiovascular events and all-cause readmission risks between hospital groups.

RESULTS

Overall, 25 (20.5%), 47 (38.5%), and 50 (41.0%) hospitals reported routinely, selectively, or never screening patients for low health literacy, respectively. Patients discharged from hospitals that routinely screened were more likely to report 6-week medication adherence [routinely: adjusted odds ratio (OR) 1.26, 95% CI 1.01-1.57; selectively: adjusted OR 1.19, 95% CI 1.00-1.43, both referenced to those discharged from hospitals that never screened]. Compared with hospitals that never screened health literacy, 1-year major adverse cardiovascular events were similar for hospitals that reported routinely screening (adjusted HR 0.92, 95% CI 0.75-1.14) or selectively screening (adjusted HR 1.01, 95% CI 0.84-1.21). Hospitals that reported selectively screening health literacy were associated with a lower adjusted risk of 1-year all-cause readmission (adjusted HR 0.89, 95% CI 0.79-1.00, P=.041).

CONCLUSION

Only a minority of US hospitals routinely screen MI patients for low health literacy. Hospital screening was associated with higher medication adherence and lower readmission risk. Further investigation is needed to understand how inpatient screening can be implemented to improve longitudinal post-MI care.

Relationship of Hospital Teaching Status with In-Hospital Outcomes for ST-Segment Elevation Myocardial Infarction

BACKGROUND

Prior analyses have largely shown a survival advantage with admission to a teaching hospital for acute myocardial infarction. However, most prior studies report data on patients hospitalized over a decade ago. It is important to re-examine the association of hospital teaching status with outcomes of acute myocardial infarction in the current era.

METHODS

We queried the 2010 to 2014 National Inpatient Sample databases to identify all patients aged ≥18 years hospitalized with the principal diagnosis of ST-segment elevation myocardial infarction (STEMI). Multivariable logistic regression models were constructed to compare rates of reperfusion and in-hospital outcomes between patients admitted to teaching vs nonteaching hospitals.

RESULTS

Of 546,252 patients with STEMI, 273,990 (50.1%) were admitted to teaching hospitals. Compared with patients admitted to nonteaching hospitals, those at teaching hospitals were more likely to receive reperfusion therapy during the hospitalization (86.7% vs 81.5%; adjusted odds ratio [OR] 1.41; 95% confidence interval [CI], 1.39-1.44; P < .001) and had lower risk-adjusted in-hospital mortality (4.9% vs 6.9%; adjusted OR 0.84; 95% CI, 0.82-0.86; P < .001). After further adjustment for differences in use of in-hospital reperfusion therapy, the association of teaching hospital status with lower risk-adjusted in-hospital mortality was significantly attenuated but remained statistically significant (adjusted OR 0.97; 95% CI, 0.94-0.99; P = .02).

CONCLUSIONS

Patients admitted to teaching hospitals are more likely to receive reperfusion and have lower risk-adjusted in-hospital mortality after STEMI compared with those admitted to nonteaching hospitals. Our results suggest that hospital performance for STEMI continues to be better at teaching hospitals in the contemporary era.

Identification of Risk Factors Influencing In-Stent Restenosis with Acute Coronary Syndrome Presentation

Although the angiographic rates of in-stent restenosis (ISR) at later months have reduced dramatically with the introduction of drug-eluting stents (DESs), some patients with ISR after implantation of DES present with acute coronary syndrome (ACS). Here, we sought to identify parameters influencing the likelihood of restenosis with ACS presentation after DES implantation. Stented patients (n=3,817) with DESs in the Korea University Anam Hospital percutaneous coronary intervention registry were reviewed retrospectively for inclusion. In this database, 247 age- and sex-matched patients (6.5%) with ISR were allocated to either the Stable ISR group (n=78) or the ACS ISR group (n=73). Predictors of in-stent restenosis were identified with Cox regression analyses. Age (hazard ratio [HR], 1.14; 95% confidence interval [CI], 1.02 to 1.27; p=0.026), diabetes (HR, 8.40; 95% CI, 1.30 to 54.1; p=0.025), use of aspirin (HR, 0.003; 95% CI, 0.0001 to 0.63; p=0.03), clopidogrel (HR, 0.005; 95% CI, 0.001 to 0.121; p=0.001), renin-angiotensin system (RAS) blocker (HR, 0.02; 95% CI, 0.003 to 0.14; p<0.001), use of first -generation DES (HR, 0.07; 95% CI, 0.009 to 0.59; p=0.014), and matrix metalloproteinase 2 (MMP-2) levels (HR, 1.120; 95% CI, 1.001 to 1.190; p=0.004) during follow-up angiograms were significant predictors of ISR with ACS presentation during the 3 year follow-up. Age, diabetes, the use of first generation DES, and increased MMP-2 levels were significant predictors of ISR with ACS presentation; moreover, the use of aspirin, clopidogrel, RAS blocker, and the use of second generation DESs prevented ISR with ACS presentation.

Optimal Antiplatelet Therapy in ST-Segment Elevation Myocardial Infarction

Cardiovascular disease is the leading cause of death worldwide. Case-fatality rates for myocardial infarction (MI) in the United States have decreased over the past decades, in large part due to advances in the treatment of acute MI and secondary preventive therapy after MI. Antiplatelet therapy remains the cornerstone of treatment of MI. This article reviews the current state of antiplatelet therapy in ST-segment elevation MI.

A comparison of rescue and primary percutaneous coronary interventions for acute ST elevation myocardial infarction

Objective

To perform a comparative analysis of in-hospital results obtained from patients with acute ST elevation myocardial infarction (STEMI), who underwent rescue or primary percutaneous coronary intervention (PCI). The aim is to determine rescue PCI as a practical option for patients with no immediate access to primary PCI.

Methods

From the Cardiology PCI Clinic of the National Hospital of Sri Lanka (NHSL), we selected all consecutive patients presenting with acute STEMI </ = 24 h door-to-balloon delay for primary PCI and </ = 72 h door-to-balloon delay, (90 min after failed thrombolysis) for rescue PCI, from March 2013 to April 2015 and their in-hospital results were analyzed, comparing rescue and primary PCI patients.

Results

We evaluated 159 patients; 78 underwent rescue PCI and 81 underwent primary PCI. The culprit left anterior descending (LAD) vessel (76.9% vs. 58.8%; P = 0.015) was more prevalent in rescue than in primary patients. Thrombus aspiration was less frequent in rescue group (19.2% vs. 40.7%; p = 0.004). The degree of moderate-to-severe left ventricular dysfunction reflected by the ejection fraction <40% (24.3% vs. 23.7%; P = 0.927) and prevalence of multivessel disease (41.0% vs. 43.8%; P = 0.729) revealed no significant difference. Coronary stents were implanted at similar rates in both strategies (96.2% vs. 92.6%; P = 0.331). Procedural success (97.4% vs. 97.5%; P = 0.980) and mortality rates (5.1% vs. 3.8%; P = 0.674), were similar in the rescue and primary groups.

Conclusion

In-hospital major adverse cardiac events (MACE) are similar in both rescue and primary intervention groups, supporting the former as a practical option for patients with no immediate access to PCI facilities.

Decade-Long Trends (2001 to 2011) in the Use of Evidence-Based Medical Therapies at the Time of Hospital Discharge for Patients Surviving Acute Myocardial Infarction

Optimization of medical therapy during discharge planning is vital for improving patient outcomes after hospitalization for acute myocardial infarction (AMI). However, limited information is available about recent trends in the prescribing of evidence-based medical therapies in these patients, especially from a population-based perspective. We describe decade-long trends in the discharge prescribing of aspirin, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β blockers, and statins in hospital survivors of AMI. The study population consisted of 5,253 patients who were discharged from all 11 hospitals in central Massachusetts after AMI in 6 biennial periods from 2001 to 2011. Combination medical therapy (CMT) was defined as the prescription of all 4 cardiac medications at hospital discharge. The average age of this patient population was 69.2 years and 57.7% were men. Significant increases were observed in the use of CMT, from 25.6% in 2001 to 48.7% in 2011, with increases noted for each of the individual cardiac medications examined. Subgroup analysis also showed improvement in discharge prescriptions for P2Y12 inhibitors in patients who underwent a percutaneous coronary intervention. Presence of a do-not-resuscitate order, before co-morbidities, hospitalization for non-ST-segment elevation myocardial infarction, admission to a nonteaching hospital, and failure to undergo cardiac catheterization or a percutaneous coronary intervention were associated with underuse of CMT. In conclusion, our study demonstrates encouraging trends in the prescribing of evidence-based medications at hospital discharge for AMI. However, certain patient subgroups continue to be at risk for underuse of CMT, suggesting the need for strategies to enhance compliance with current practice guidelines.

Primary percutaneous coronary intervention for acute ST elevation myocardial infarction: Outcomes and determinants of outcomes: A tertiary care center study from North India

Background

Primary percutaneous coronary intervention (PCI) is the current standard of care for acute ST elevation myocardial infarction (STEMI). Most of the data on primary PCI in acute STEMI is from western countries. We studied the outcomes of primary PCI for acute STEMI at a tertiary care center in North India.

Methods

Consecutive patients undergoing primary PCI for STEMI were prospectively studied during the period from February 2103 to May 2015. The outcomes assessed were all cause in hospital mortality, factors associated with mortality, major adverse cardiac and cerebrovascular event rate (composite of all cause in hospital mortality, non-fatal re infarction and stroke) and procedural complications.

Results

371 patients underwent primary PCI during the study period. The mean age was 54 years and 82.7% were males. The mean total ischemia time and door to balloon times were 6.8 h and 51 min respectively. 96.4% patients underwent successful primary PCI. The total in hospital mortality was 12.9%. Mortality with cardiogenic shock at presentation was 66.7% while non-shock mortality was 2.6%. In hospital MACCE rate was 13.5%. Factors significantly associated with mortality were KILLIP class (OR: 8.4), door to balloon time (OR 1.02), final TIMI flow (OR 0.44) and severe LV dysfunction (OR 22.0). Procedure related adverse events were rare and there was no non-CABG associated major TIMI bleeding.

Conclusion

Primary PCI for acute STEMI is feasible in our setup and associated with high success rate, low mortality in non-shock patients and low complication rates.

Door to Needle Times Bulls' Eye or Just Bull? The Effect of Reducing Door to Needle Times on the Appropriate Administration of Thrombolysis: Implications and Recommendations

The provision of thrombolysis in a timely fashion is the mainstay of treatment for acute myocardial infarction. With the publication of the National Service Framework (NSF) for Coronary Heart Disease increasing efforts have been put into the reduction of the ‘pain to needle time’. Of the various parts of the patient journey the time delays in hospital are the easiest to resolve. Published research shows that the time taken for the patient to call for help is intractable at present. Therefore, the obvious target for the reduction in the overall time from pain to treatment is the in hospital portion of the delay (the door to needle time). There are several methods that have been recommended for the reduction of the door to needle time. However, the increasing focus on the door to needle time is leading health care providers away from other issues such as the safety and accuracy of assessment by a non-cardiologist. Furthermore, the standards for audit of the door to needle time have not been set by the NSF and this has led to the presentation of selected data and the avoidance of discussing issues of accuracy and appropriateness.

Components and determinants of therapeutic delay in patients with acute ST-elevation myocardial infarction: A tertiary care hospital-based study

Background

Delayed reperfusion is associated with worse outcomes in ST-segment elevation myocardial infarction (STEMI). This study was conducted to assess the components and determinants of therapeutic delay in STEMI patients of our state.

Methods

This study included consecutive patients of STEMI admitted to the coronary care units of two tertiary care hospitals in Srinagar, between 2012 and 2015. Various components of treatment delay including the patient’s decision to delay, referral delay, transportation delay, prehospital delay, and door-to-needle time were calculated. Factors associated with delayed treatment and clinico-demographic correlates of late presentation were identified.

Results

During a period of 3 years, 523 patients (mean age, 57.6 ± 10.5 years) were enrolled in this study. Thrombolysis was administered to 60.2% patients, while 39.8% of patients could not be thrombolysed because of late presentation. The median treatment delay was 250 minutes. Prehospital delay constituted about 83.8% of total treatment delay. Patient’s decision to delay, referral delay, and transport delay constituted 59%, 16%, and 25% of prehospital delay, respectively. Median door-to-needle time was 40 minutes. Residence in rural areas [odds ratio (OR), 2.35; 95% confidence interval (CI), 1.60–3.46], absence of prior coronary artery disease (OR, 1.54; 95% CI, 1.00–2.39), and negative family history of coronary artery disease (OR; 2.76; 95% CI, 1.86–4.10), were identified as independent predictors of delayed presentation (p < 0.001). Interestingly, 44.7% of the patients presented late due to misdiagnosis by local healthcare providers.

Conclusion

The standard of STEMI management in our state is far from ideal, and calls for a lot of improvement. Major efforts to reduce prehospital and in-hospital treatment delays are urgently needed.

Clinical management and hospital outcomes of acute coronary syndrome patients in Mexico: The Third National Registry of Acute Coronary Syndromes (RENASICA III)

OBJECTIVE

To describe current management and clinical outcomes in patients hospitalized with an acute coronary syndrome (ACS) in Mexico.

METHODS

RENASICA III was a prospective multicenter registry of consecutive patients hospitalized with an ACS. Patients had objective evidence of ischemic heart disease; those with type II infarction or secondary ischemic were excluded. Study design conformed to current quality recommendations.

RESULTS

A total of 123 investigators at 29 tertiary and 44 community hospitals enrolled 8296 patients with an ACS (4038 with non-ST-elevation myocardial infarction/unstable angina [NSTEMI/UA], 4258 with ST-elevation myocardial infarction [STEMI]). The majority were younger (62±12years) and 76.0% were male. On admission 80.5% had ischemic chest pain lasting >20min and clinical stability. Left ventricular dysfunction was more frequent in NSTEMI/UA than in those with STEMI (30.0% vs. 10.7%, p<0.0001). In STEMI 37.6% received thrombolysis and 15.0% primary PCI. PCI was performed in 39.6% of NSTEMI/UA (early strategy in 10.8%, urgent strategy in 3.0%). Overall hospital death rate was 6.4% (8.7% in STEMI vs. 3.9% in NSTEMI/UA, p<0.001). The strongest independent predictors of hospital mortality were cardiogenic shock (odds ratio 22.4, 95% confidence interval 18.3-27.3) and ventricular fibrillation (odds ratio 12.5, 95% confidence interval 9.3-16.7).

CONCLUSION

The results from RENASICA III establish the urgent need to develop large-scale regional programs to improve adherence to guideline recommendations in ACS, including rates of pharmacological thrombolysis and increasing the ratio of PCI to thrombolysis.

Study of differences in presentation, risk factors and management in diabetic and nondiabetic patients with acute coronary syndrome

OBJECTIVES

To compare clinical characteristics, treatment, and utilization of evidence-based medicines at discharge from hospital in acute coronary syndrome (ACS) patients with or without diabetes at a tertiary care cardiac center in India.

METHODS

We performed an observational study in consecutive patients discharged following management of ACS. We obtained demographic details, comorbid conditions, and cardiovascular risk factors, physical and biochemical parameters, and management. Descriptive statistics are reported.

RESULTS

We enrolled 100 patients (diabetics = 28) with mean age of 59.0 ± 10.8 years (diabetics 59.3 ± 11.6, nondiabetics 58.9 ± 8.5). Forty-nine patients had ST-elevation myocardial infarction (STEMI) (diabetics = 14, 28.7%) while 51 had nonSTEMI/unstable angina (diabetics = 14, 27.4%) (P = nonsignificant). Among diabetics versus nondiabetics there was greater prevalence (%) of hypertension (78.6% vs. 44.4%), obesity (25.0% vs. 8.3%), abdominal obesity (85.7% vs. 69.4%) and sedentary activity (89.2% vs. 77.8%), and lower prevalence of smoking/tobacco use (10.7% vs. 25.0%) (P < 0.05). In STEMI patients 28 (57.1%) were thrombolysed (diabetes 17.8% vs. 31.9%), percutaneous coronary interventions (PCI) was in 67.8% diabetics versus 84.7% nondiabetics and coronary bypass surgery in 21.4% versus 8.3%. At discharge, in diabetics versus nondiabetics, there was similar use of angiotensin converting enzyme inhibitors (67.9% vs. 69.4%) and statins (100.0% vs. 98.6%) while use of dual antiplatelet therapy (85.7% vs. 95.8%) and beta-blockers (64.3% vs. 73.6%) was lower (P < 0.05).

CONCLUSIONS

Diabetic patients with ACS have greater prevalence of cardiometabolic risk factors (obesity, abdominal obesity, and hypertension) as compared to nondiabetic patients. Less diabetic patients undergo PCIs and receive lesser dual anti-platelet therapy and beta-blockers.

Multicenter HP ACS Registry

BACKGROUND

No population representative data on characteristics, treatment, and outcome were available in acute coronary syndrome (ACS) patients.

METHODS

The clinical characteristics, treatment, and in-hospital outcome of 5180 ACS patients registered in multicenter ACS Registry across 33 hospitals in the state since January 2012 to December 2014 are reported. ACS was diagnosed using standard criteria.

RESULT

70.8% were men; mean age was 60.9±12.1. NSTEMI was more frequent than STEMI (54.5% vs. 45.5%). 83.3% of the ACS population were from rural area. Pre-hospital delay was long, with a median of 780min. 35.6% of STEMI patients received thrombolytic therapy. Evidence-based treatment was prescribed in more than 80% of ACS patients, and the treatment was similar in men and women across all types of health care centers. In-hospital mortality was 7.6%, and was more frequent in STEMI than in NSTEMI (10.8% vs. 5.0%, p<0.001).

INTERPRETATION

Pre-hospital delay was long, and use of reperfusion therapy was significantly lower. The in-hospital death rates are higher.

Characteristics of chest pain and its acute management in a low-middle income country: analysis of emergency department surveillance data from Pakistan

BACKGROUND

Chest pain is one of the most frequent causes of emergency department (ED) visits in high-income countries. Little is known about chest pain patients presenting to EDs of low- and middle-income countries (LMICs). The objective of this study was to describe the characteristics of chest pain patients presenting to emergency departments (EDs) of Pakistan and to determine the utilization of ED resources in the management of chest pain patients and their outcomes.

METHODS

This study used pilot active surveillance data from seven major EDs in Pakistan. Data were collected on all patients presenting to the EDs of the participating sites to seek emergency care for chest pain.

RESULTS

A total of 20,435 patients were admitted to the EDs with chest pain. The majority were males (M 60%, F 40%) and the mean age was 42 years (SD+/- 14). The great majority (97%, n = 19,164) of patients were admitted to the EDs of public hospitals compared to private hospitals and only 3% arrived by ambulance. Electrocardiograms (ECGs) were used in more than half of all chest pain patients (55%, n = 10,890) while cardiac enzymes were performed in less than 5% of cases. Chest X-rays were the most frequently performed radiological procedure (21%, n = 4,135); more than half of the admitted chest pain patients were discharged from the EDs and less than 1% died in the ED.

CONCLUSION

Chest pain is a common presenting complaint in EDs in Pakistan. The majority received an ECG and the use of diagnostic testing, such as cardiac enzymes, is quite uncommon.

Aggressive Measures to Decrease "Door to Balloon" Time and Incidence of Unnecessary Cardiac Catheterization: Potential Risks and Role of Quality Improvement

OBJECTIVE

To assess the impact of an aggressive protocol to decrease the time from hospital arrival to onset of reperfusion therapy ("door to balloon [DTB] time") on the incidence of false-positive (FP) diagnosis of ST-segment elevation myocardial infarction (STEMI) and in-hospital mortality.

PATIENTS AND METHODS

The study population included 1031 consecutive patients with presumed STEMI and confirmed ST-segment elevation who underwent emergent catheterization between July 1, 2008, and December 1, 2012, On July 1, 2009, we instituted an aggressive protocol to reduce DTB time. A quality improvement (QI) initiative was introduced on January 1, 2011, to maintain short DTB while improving outcomes. Outcomes were compared before and after the initiation of the DTB time protocol and similarly before and after the QI initiative. Outcomes were DTB time, the incidence of FP-STEMI, and in-hospital mortality. A review of the emergency catheterization database for the 10-year period from January 1, 2001, through December 31, 2010, was performed for historical comparison.

RESULTS

Of the 1031 consecutive patients with presumed STEMI who were assessed, 170 were considered to have FP-STEMI. The median DTB time decreased significantly from 76 to 61 minutes with the aggressive DTB time protocol (P=.001), accompanied by an increase of FP-STEMI (7.7% vs 16.5%; P=.02). Although a nonsignificant reduction of in-hospital mortality occurred in patients with true-positive STEMI (P=.60), a significant increase in in-hospital mortality was seen in patients with FP-STEMI (P=.03). After the QI initiative, a shorter DTB time (59 minutes) was maintained while decreasing FP-STEMI in-hospital mortality.

CONCLUSION

Aggressive measures to reduce DTB time were associated with an increased incidence of FP-STEMI and FP-STEMI in-hospital mortality. Efforts to reduce DTB time should be monitored systematically to avoid unnecessary procedures that may delay other appropriate therapies in critically ill patients.

Contributions of risk factors and medical care to cardiovascular mortality trends

Ischaemic heart disease, stroke, and other cardiovascular diseases (CVDs) lead to 17.5 million deaths worldwide per year. Taking into account population ageing, CVD death rates are decreasing steadily both in regions with reliable trend data and globally. The declines in high-income countries and some Latin American countries have been ongoing for decades without slowing. These positive trends have broadly coincided with, and benefited from, declines in smoking and physiological risk factors, such as blood pressure and serum cholesterol levels. These declines have also coincided with, and benefited from, improvements in medical care, including primary prevention, diagnosis, and treatment of acute CVDs, as well as post-hospital care, especially in the past 40 years. These variables, however, explain neither why the decline began when it did, nor the similarities and differences in the start time and rate of the decline between countries and sexes. In Russia and some other former Soviet countries, changes in volume and patterns of alcohol consumption have caused sharp rises in CVD mortality since the early 1990s. An important challenge in reaching firm conclusions about the drivers of these remarkable international trends is the paucity of time-trend data on CVD incidence, risk factors throughout the life-course, and clinical care.

Trends in mortality and recurrent coronary heart disease events after an acute myocardial infarction among Medicare beneficiaries, 2001-2009

BACKGROUND

Few contemporary studies examine trends in recurrent coronary heart disease (CHD) events and mortality after acute myocardial infarction (AMI) and whether these trends vary by race or sex.

METHODS

We used data from the national 5% random sample of Medicare fee-for-service beneficiaries for 1999 to 2010. We included beneficiaries who experienced an AMI (International Classification of Disease [ICD] 9 410.xx, except 410.x2) between January 1, 2001, and December 31, 2009. Each beneficiary's first AMI was included as their index event. Outcomes included all-cause mortality, recurrent AMI, and recurrent CHD events during the 365days after discharge for the index AMI. To examine secular trends, we pooled calendar years into 3 periods (2001-2003, 2004-2006, and 2007-2009).

RESULTS

Among 48,688 beneficiaries with index AMIs from 2001 to 2009, we observed decreases in the age-adjusted rates for mortality (-3.8% for each 3-year period, 95% CI -6.1% to -1.6%, P trend = .001), recurrent AMI (-15.0%, 95% CI -18.6% to -11.2%, P trend < .001), and recurrent CHD events (-11.1%, 95% CI -14.0% to -8.0%, P trend < .001) in the 365days after the index AMI. In 2007 to 2009, blacks had excess risk relative to whites for mortality and recurrent AMI (black/white incidence rate ratio of 1.38 for mortality [95% CI 1.21-1.57] and 1.38 for recurrent AMI [95% CI 1.07-1.79]).

CONCLUSIONS

Despite overall favorable trends in lower mortality and recurrent events after AMI, efforts are needed to reduce racial disparities.

Incidence and outcome of first myocardial infarction according to gender and age in Denmark over a 35-year period (1978-2012)

Aims

To examine temporal changes in incidence and 1-year mortality of first myocardial infarction (MI) in different age groups for both genders in Denmark over a 35-year period (1978-2012).

Methods and results

Patients aged 30 years or older admitted with first MI in Denmark from 1978 to 2012 were included (n = 316 790). Overall, first MI incidence per 100 000 person-years (/105 p.y.) decreased significantly from 500 to 297/105 p.y. for males and from 229 to 156/105 p.y. for females. The decline was greatest among men aged 70-79 from 1460 to 643/105 p.y. (-56%). The majority of age groups also experienced declining incidence. However, men aged 30-39 and ≥90 years as well as females aged 30-49 and ≥90 years had increasing incidence during the study period. Moreover, the incidence decreased from 1978 to 1996 among males aged 40-49 and females aged 50-59 years, but increased in the remainder of the study period. One-year case-fatality declined significantly from 50 to 9% of MI male patients, and from 53 to 15% of MI female patients when comparing 1978 to 2012. Statistical analysis with Poisson models demonstrated that the mortality rate increased with age and decreased with time and indicated no significant difference between genders.

Conclusions

During the period from 1978 to 2012, there was a significant decline in MI incidence among most age groups for both genders; however, an incidence increase was observed in men under 50 and women under 60 years, and ≥90 years for both genders. One-year case-fatality decreased constantly during the study period.

Emergency care in 59 low- and middle-income countries: a systematic review

Objective

To conduct a systematic review of emergency care in low- and middle-income countries (LMICs).

Methods

We searched PubMed, CINAHL and World Health Organization (WHO) databases for reports describing facility-based emergency care and obtained unpublished data from a network of clinicians and researchers. We screened articles for inclusion based on their titles and abstracts in English or French. We extracted data on patient outcomes and demographics as well as facility and provider characteristics. Analyses were restricted to reports published from 1990 onwards.

Findings

We identified 195 reports concerning 192 facilities in 59 countries. Most were academically-affiliated hospitals in urban areas. The median mortality within emergency departments was 1.8% (interquartile range, IQR: 0.2–5.1%). Mortality was relatively high in paediatric facilities (median: 4.8%; IQR: 2.3–8.4%) and in sub-Saharan Africa (median: 3.4%; IQR: 0.5–6.3%). The median number of patients was 30 000 per year (IQR: 10 296–60 000), most of whom were young (median age: 35 years; IQR: 6.9–41.0) and male (median: 55.7%; IQR: 50.0–59.2%). Most facilities were staffed either by physicians-in-training or by physicians whose level of training was unspecified. Very few of these providers had specialist training in emergency care.

Conclusion

Available data on emergency care in LMICs indicate high patient loads and mortality, particularly in sub-Saharan Africa, where a substantial proportion of all deaths may occur in emergency departments. The combination of high volume and the urgency of treatment make emergency care an important area of focus for interventions aimed at reducing mortality in these settings.

Unfractionated heparin-clopidogrel combination in ST-elevation myocardial infarction not receiving reperfusion therapy

OBJECTIVE

We sought explore the relative benefits of unfractionated heparin (UFH) compared with enoxaparin, alone or in combination with clopidogrel, in ST-segment elevation myocardial infarction (STEMI) patients not undergoing reperfusion therapy.

METHODS

This is a propensity score study from The International Survey on Acute Coronary Syndromes in Transition Countries (ISACS-TC/NCT01218776) on patients admitted between October 2010-June 2013. There were a total of 1175 STEMI patients who did not receive mechanical or pharmacological reperfusion. Of these, 1063 were eligible for the aim of the study, being treated with UFH (522/1175; 44.4%) or enoxaparin (541/1175; 46%). Clopidogrel in combination with UFH or enoxaparin was given to 751 (63.9%) patients. The primary endpoint was in-hospital mortality. Secondary endpoints were intracranial hemorrhages, and clinically relevant bleedings.

RESULTS

After adjustment for any confounders, UFH was associated with a lower risk of in-hospital mortality in clopidogrel users (multivariate adjusted regression analysis: odds ratio [OR]: 0.62, 95% Confidence Interval [CI] 0.41-0.94) as compared with clopidogrel non-users (OR: 0.94, 95% CI 0.55-1.60). The observed effect was not associated with combined enoxaparin and clopidogrel therapy. Major bleeding events were comparable in the enoxaparin group and UFH group (0.4% and 1.5% respectively, p = 0.06). The risk of major hemorrhage was nearly similar with combined UFH-clopidogrel therapy (1.4%) as compared with UFH alone (1.9%), p = 0.67.

CONCLUSION

UFH - Clopidogrel combination was associated with a large mortality reduction in STEMI patients not undergoing reperfusion therapy and did not significantly increase the risk of major bleeding.

Role of revascularization to improve left ventricular function

Coronary revascularization to improve left ventricular (LV) function and improve mortality in patients with ischemic cardiomyopathy remains controversial, especially in the absence of angina or ischemia. A large body of observational evidence suggests that patients with dysfunctional but viable myocardium may experience improvement in mortality and LV function after revascularization. However, results of randomized trials conducted in the last decade dispute the value of viability testing or coronary revascularization in improving outcomes of patients with ischemic cardiomyopathy. However, because of the numerous methodological limitations of these studies, clinical equipoise persists regarding the role of coronary revascularization in certain patients.

Scoparone interferes with STAT3-induced proliferation of vascular smooth muscle cells

Scoparone, which is a major constituent of Artemisia capillaries, has been identified as an anticoagulant, hypolipidemic, vasorelaxant, anti-oxidant and anti-inflammatory drug, and it is used for the traditional treatment of neonatal jaundice. Therefore, we hypothesized that scoparone could suppress the proliferation of VSMCs by interfering with STAT3 signaling. We found that the proliferation of these cells was significantly attenuated by scoparone in a dose-dependent manner. Scoparone markedly reduced the serum-stimulated accumulation of cells in the S phase and concomitantly increased the proportion of cells in the G0/G1 phase, which was consistent with the reduced expression of cyclin D₁, phosphorylated Rb and survivin in the VSMCs. Cell adhesion markers, such as MCP-1 and ICAM-1, were significantly reduced by scoparone. Interestingly, this compound attenuated the increase in cyclin D promoter activity by inhibiting the activities of both the WT and active forms of STAT3. Similarly, the expression of a cell proliferation marker induced by PDGF was decreased by scoparone with no change in the phosphorylation of JAK2 or Src. On the basis of the immunofluorescence staining results, STAT3 proteins phosphorylated by PDGF were predominantly localized to the nucleus and were markedly reduced in the scoparone-treated cells. In summary, scoparone blocks the accumulation of STAT3 transported from the cytosol to the nucleus, leading to the suppression of VSMC proliferation through G1 phase arrest and the inhibition of Rb phosphorylation. This activity occurs independent of the form of STAT3 and upstream of kinases, such as Jak and Src, which are correlated with abnormal vascular remodeling due to the presence of an excess of growth factors following vascular injury. These data provide convincing evidence that scoparone may be a new preventative agent for the treatment of cardiovascular diseases.