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Clinical utility of the academic research consortium new proposed criteria for high bleeding risk definition in patients with acute coronary syndromes. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The Academic Research Consortium High Bleeding Risk (ARC-HBR) criteria have been proposed to stratify the bleeding risk of patients undergoing percutaneous coronary intervention (PCI). While most criteria were established, 4 criteria have been proposed on a de novo basis.
Purpose
We assessed the prevalence and prognosis of new ARC-HBR criteria in a contemporary, prospective, multicenter, quality-improvement registry of all-comers patients with acute coronary syndromes.
Methods
Between 2016 and 2020, consecutive subjects were enrolled; baseline characteristics and medications were prospectively collected, and patients were followed-up at 1 year. All clinical events (including bleeding) were adjudicated by an independent committee. All 17 ARC-HBR criteria were individually evaluated by reviewing patients' charts.
Results
Of the 2804 patients enrolled, 782 (28.0%) met the ARC-HBR definition and 47 (6%) of them experienced a major BARC 3 or 5) bleeding at 1-year. HBR patients had a significantly higher risk of BARC 3–5 bleedings (HR for: 3.07; 95% CI: 2.02–4.67; p<0.0001; Fig. 1A), BARC 2–5 (HR: 1.845; 95% CI: 1.4–2.42; p<0.0001). Fig. 1B indicates the proportion of patients meeting each criterion. Age, (moderate or severe) chronic kidney disease, (moderate or severe) anemia and oral anticoagulant therapy included 88% of HBR patients.
The 4 new ARC-HBR criteria, all together, were present in only 1.7% of our population: 1.0% was planned for major surgery while on dual antiplatelet therapy, 0.5% had a recent intracranial hemorrhage/ictus or brain arteriovenous malformations, 0.1% had hepatic cirrhosis with portal hypertension and 0.1% had a recent surgery or trauma. In a multivariable Cox regression analysis including individual ARC-HBR criteria, only CKD (major and minor criteria), anemia (major and minor criteria) and cancer were the independent predictors of BARC 3–5 events with a concordance-index for this model of 0.698 (p<0.001). In a second model including only CKD (major criterion), anemia (major criterion), age and oral anticoagulation therapy, all these criteria were independent predictors of BARC 3–5 events with a concordance index of 0.674 (pmodel<0.001 for the model) (Fig. 2).
Conclusion
Almost one third of contemporary ACS patients was at HBR according to the ARC-HBR definition and these patients presented a significantly higher risk of bleedings at 1-year. The most common 4 criteria (age, CKD, anemia, and oral anticoagulant therapy) allowed the identification of 88% of HBR patients. The newly proposed HBR criteria were extremely rare and therefore challenging to validate and of uncertain clinical utility. These data may inform and simplify clinical decision making and provide priority for future directions of HBR definitions.
Funding Acknowledgement
Type of funding sources: None. Figure 1Figure 2
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Barriers associated with emergency medical service activation in Italian patients with ST-segment elevation acute coronary syndromes. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Many ST-segment elevation acute coronary syndrome (STEACS) patients fail to activate the Emergency Medical System (EMS), with possible dramatic consequences. Prior studies focusing on barriers to EMS activation include patients with any acute coronary syndrome (ACS) without representation of southern European populations. However, barriers are influenced by the ACS type and by socio-demographic and racial factors.
Purpose
We aimed to investigate the barriers to EMS call for patients diagnosed for STEACS in Italy.
Methods
A prospective, single-center, survey-based study, including all the patients treated with primary percutaneous coronary intervention for STEACS in a tertiary hospital in northern Italy from 1st June 2018 to 31st May 2020.
Results
The questionnaire was filled out by 293 patients. The majority of the participants were males (74%), married (70.4%), with a high-school degree (38.4%) and with a median age of 62 years. Chest pain as a possible symptom related to a cardiovascular attack is known by most of the respondents (89%), and left arm pain/shake by 53.7% of them, whilst the other possible signs and symptoms (i.e. dyspnea, asthenia, sweating, nausea, vomiting, dizziness) were unknown to the majority of the participants. Only 191 (65.2%) of the participants activated the EMS after symptoms onset. The main reasons for not calling EMS were the perception that symptoms were not related to an important health problem (45.5%) and that a private vehicle is faster than EMS to reach the hospital (34.7%). The median time to first medical contact was 60 minutes, and it was significantly higher in the patients who did not called EMS compared to those who did (180 [60–420] mins vs 35 [15–120] mins, p<0.001). The patients who called a private doctor after symptoms onset did not called EMS more frequently than those who did not (5.9% vs 8.2%, p=0.3). Moreover, 30% of the patients who did not call the EMS would still act in the same way if a new episode occurred and the main reasons for this were that they think to be faster than EMS (57.1%) and to live close to the hospital (17.9%). Analyzing predictors of EMS activation, only prior history of cardiovascular disease has been demonstrated to be a predictor of calling the EMS in case of symptoms suspected for STEACS.
Conclusions
Our study, from the southern Europe, showed that a substantial percentage of patients with symptoms suspected for STEACS preferred private vehicle rather than activating the EMS. Our results highlight the need for information campaigns targeted to both the general population and medical doctors, stressing that the EMS is faster than a private vehicle to direct the patient to the right hospital and increasing the awareness of the people on the type of possible heart attack symptoms, which seem to be the most neglected issues by patients who did not call the EMS.
Funding Acknowledgement
Type of funding sources: None.
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