Coronary care medicine: it's not your father's CCU anymore.
(1/1612)
The management of ST-elevation MI (STEMI) has gone through four phases: 1. The "clinical observation phase"; 2. the "coronary care unit phase"; 3. the "high-technology phase"; and 4. the "evidence-based coronary care phase". A significant advance in the care of patients with acute myocardial infarction that arose as an outgrowth of the evidence-based era was introduction of a lexicon that more accurately reflected contemporary concepts of the pathophysiology underlying myocardial ischemia and infarction. Although considerable improvement has occurred in the process of care for patient with STEMI, room for improvement exists. Despite strong evidence in the literature that prompt use of reperfusion therapy improves survival of STEMI patients such treatment is underutilized and often not administered in an expeditious timeframe relative to the onset of symptom. Even in the reperfusion era, left ventricular dysfunction remains the single most important predictor of mortality following STEMI. After administration of aspirin, initiating reperfusion strategies and, where appropriate, beta blockade all STEMI patients should be considered for inhibition of the renin-angiotensin-aldosterone system. Several adjunctive pharmacotherapies have been investigated to prevent inflammatory damage in the infarct zone. Contrary to earlier beliefs that the heart is a terminally differentiated organ without the capacity to regenerate, evidence now exists that human cardiac myocytes divide after STEMI and stem cells can promote regeneration of cardiac tissue. These observations open up the possibility of myocardial replacement therapy after STEMI. (+info)
Gender differences in management and outcome in non-ST-elevation acute coronary syndrome.
(2/1612)
OBJECTIVE: To study gender differences in management and outcome in patients with non-ST-elevation acute coronary syndrome. DESIGN, SETTING AND PATIENTS: Cohort study of 53 781 consecutive patients (37% women) from the Register of Information and Knowledge about Swedish Heart Intensive care Admissions (RIKS-HIA), with a diagnosis of either unstable angina pectoris or non-ST-elevation myocardial infarction. All patients were admitted to intensive coronary care units in Sweden, between 1998 and 2002, and followed for 1 year. MAIN OUTCOME MEASURES: Treatment intensity and in-hospital, 30-day and 1-year mortality. RESULTS: Women were older (73 vs 69 years, p<0.001) and more likely to have a history of hypertension and diabetes, but less likely to have a history of myocardial infarction or revascularisation. After adjustment, there were no major differences in acute pharmacological treatment or prophylactic medication at discharge. Revascularisation was, however, even after adjustment, performed more often in men (OR 1.15; 95% CI, 1.09 to 1.21). After adjustment, there was no significant difference in in-hospital (OR 1.03; 95% CI, 0.94 to 1.13) or 30-days (OR 1.07; 95% CI, 0.99 to 1.15) mortality, but at 1 year being male was associated with higher mortality (OR 1.12; 95% CI, 1.06 to 1.19). CONCLUSION: Although women are somewhat less intensively treated, especially regarding invasive procedures, after adjustment for differences in background characteristics, they have better long-term outcomes than men. (+info)
Association between plasma adiponectin levels and unstable coronary syndromes.
(3/1612)
AIMS: Obesity is a risk factor for an acute coronary syndrome (ACS). The association between elevated body mass index (BMI) and ACS is independent of most traditional risk factors, suggesting a possible contribution of other body fat-related mediators. This study evaluated the association between adiponectin and ACS. METHODS AND RESULTS: Four hundred and ninety-nine patients undergoing coronary angiography were divided into a subgroup without (n = 331) and with ACS (n = 168). In multiple regression analysis, higher adiponectin levels were independently associated with a lower risk of ACS [odds ratio (OR) = 0.61; 95% CIs: 0.46-0.81; P < 0.001]. In contrast, a higher BMI, a history of myocardial infarction, C-reactive protein, and angiographic coronary artery disease severity were all associated with a higher risk. The greatest increase in risk for ACS was seen at adiponectin levels < or = 5.5 microg/mL. CONCLUSION: Higher plasma adiponectin levels are independently associated with a lower risk of ACS. (+info)
Pregnancy-associated plasma protein A and proform eosinophilic major basic protein in the detection of different types of coronary artery disease.
(4/1612)
Kryptor system was proven to be a rapid, standard method for pregnancy-associated plasma protein A and proform eosinophilic major basic protein (PAPP-A/proMBP) complex detection in coronary artery disease (CAD). No age and/or gender differences in 51 controls and 110 stable coronary artery disease (SCAD) patients were found. SCAD patients did not differ from controls and no difference in PAPP-A/proMBP levels with regards to the number of affected vessels was found. In 21 unstable angina pectoris (UAP), in 35 without and 66 with ST elevation acute myocardial infarctions (NSTEMI, STEMI respectively) patients PAPP-A/proMBP levels were increased (P=0.004 and P<0.0005, respectively). PAPP-A/proMBP levels did not correlate with cardiac troponin I (cTnI) in STEMI and NSTEMI patients. PAPP-A/ proMBP increase was more frequent than cTnI (P=0.036) within the early phase of STEMI. In NSTEMI patients PAPP-A/proMBP positivity was present in 50% of cTnI negative cases. Receiver operating characteristic (ROC) analysis revealed the highest diagnostic accuracy of PAPP-A/proMBP (0.919) in STEMI cTnI positive cases. The highest specificity/sensitivity PAPP-A/proMBP levels for particular acute coronary syndrome (ACS) types were 10.65-14.75 mIU/l. Combination of PAPP-A/proMBP with cTnI increases their diagnostic efficacy within the early phase of ACS. Our results suggest that PAPP-A/proMBP complex is involved in processes preceding vulnerable plaque development in ACS. (+info)
Effects of revascularization within 14 days of hospital admission due to acute coronary syndrome on 1-year mortality in patients with previous coronary artery bypass graft surgery.
(5/1612)
AIMS: To determine whether revascularization within 14 days reduces 1-year mortality in patients with a previous CABG admitted for non-ST-elevation ACS. Current guidelines for patients with acute coronary syndrome (ACS) include early revascularization. The evidence is derived from studies, in which patients with previous coronary artery by-pass graft (CABG) surgery often were excluded and thus insufficient to support a similar strategy in these high-risk patients in whom coronary interventions are associated with lower success and higher complication rates. METHODS AND RESULTS: A cohort of 10 469 patients < 80 years old from a national registry, admitted to coronary care units in Sweden, was studied. We obtained 1-year mortality data from the Swedish National Cause of Death Registry. Relative risk (RR) in patients undergoing revascularization within 14 days (n = 4269) of admission compared to those who did not (n = 6200) was calculated by using multivariable logistic regression analyses and propensity scores for the likelihood of early revascularization. At 1-year, unadjusted mortality was 5.4% in the revascularized group and 13.1% in the conservatively treated group. In multiple regression analyses, revascularization was associated with a reduction of 1-year mortality (RR 0.67; 95% CI, 0.56-0.81; P < 0.001). CONCLUSION: In patients with a previous CABG admitted for ACS, revascularization within 14 days of hospital admission was associated with a marked reduction in 1-year mortality, supporting an early invasive approach also in this subset of patients. (+info)
Clinical use of clopidogrel in acute coronary syndrome.
(6/1612)
Several therapeutic approaches have been developed to improve the outcome among patients with acute coronary syndrome (ACS). However, treatment with antithrombotic therapies such as oral glycoprotein IIb/IIIa inhibitors has been limited by the lack of efficacy and excess bleeding complications. As the publication of the landmark study Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE), the clinical benefit of early and intermediate-term use of combined antiplatelet agents--clopidogrel plus aspirin--in non-ST-segment elevation myocardial infarction (NSTEMI) patients became evident. Pretreatment and intermediate-term therapy with clopidogrel in NSTEMI ACS patients undergoing percutaneous coronary intervention (PCI) was further supported by the PCI-CURE trial. Recently, the results of two major trials Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis in Myocardial Infarction 28, Clopidogrel and Metoprolol in Myocardial Infarction Trial established the pivotal role of clopidogrel in the other spectrum of ACS-STEMI. Coupled with the results from previous multicentre trials, these two studies provide a guide for the early and long-term use of clopidogrel in the whole spectrum of ACS. A review summarising the results of the recent clinical trials and a discussion on its implications for the clinical management of ACS is presented. (+info)
64-Slice CT coronary angiography in patients with non-ST elevation acute coronary syndrome.
(7/1612)
BACKGROUND: A high diagnostic accuracy of 64-slice CT coronary angiography (CTCA) has been reported in selected patients with stable angina pectoris, but only scant information is available in patients with non-ST elevation acute coronary syndrome (ACS). OBJECTIVES: To study the diagnostic performance of 64-slice CTCA in patients with non-ST elevation ACS. PATIENTS AND METHODS: 64-slice CTCA was performed in 104 patients (mean (SD) age 59 (9) years) with non-ST elevation ACS. Two independent, blinded observers assessed all coronary arteries for stenosis, using conventional quantitative angiography as a reference. Coronary lesions with >or=50% luminal narrowing were classified as significant. RESULTS: Conventional coronary angiography demonstrated the absence of significant disease in 15% (16/104) of patients, and the presence of single-vessel disease in 40% (42/104) and multivessel disease in 44% (46/104) of patients. Sensitivity for detecting significant coronary stenoses on a patient-by-patient analysis was 100% (88/88; 95% CI 95 to 100), specificity 75% (12/16; 95% CI 47 to 92), and positive and negative predictive values were 96% (88/92; 95% CI 89 to 99) and 100% (12/12; 95% CI 70 to 100), respectively. CONCLUSION: 64-slice CTCA has a high sensitivity to detect significant coronary stenoses, and is reliable to exclude the presence of significant coronary artery disease in patients who present with a non-ST elevation ACS. (+info)
Relationship between circulating endothelial cells and the predicted risk of cardiovascular events in acute coronary syndromes.
(8/1612)
AIMS: The quantification of circulating endothelial cells (CECs) in whole blood is a novel marker of direct endothelial injury and shows promise as a potential biomarker of cardiovascular (CV) risk. The inter-relationship(s) between CECs and predicted CV risk has not been explored in large cohort of 'high-risk' patients. We hypothesized that there would be a significant relationship between increasing CEC counts and predicted CV risk in a broad spectrum of patients presenting with acute coronary syndrome (ACS). METHODS AND RESULTS: We studied 197 patients (aged 40-80 years) admitted with a confirmed diagnosis of unstable angina (UA), non-ST-elevation myocardial infarction (MI, NSTEMI), or ST-elevation MI (STEMI). CEC counts were performed on venous whole blood using the immunobead technique. Four well-validated ACS risk scores [(PURSUIT and TIMI for NSTEMI/UA) TIMI (STEMI) and GRACE (all ACS)] were calculated from the initial clinical history and electrocardiogram, as well as from values of laboratory parameters collected within 12 h of admission. We included a healthy control (HC) group of 50 matched patients in order to quantify the accuracy of CEC counts for the diagnosis of ACS and to compare disease vs. HC counts. CEC counts were significantly higher in the disease group when compared with the HC group. CEC counts significantly increased with increasing severity of disease (that is, UA vs. NSTEMI vs. STEMI; P = 0.002). CEC counts were higher among patients with clinical evidence of heart failure (Killip Class II-IV) when compared with those without (Killip Class I) on admission (P < 0.0001). There was a significant correlation between CEC counts and predicted CV risk for each of the four ACS risk scoring schemes (all P < 0.05). The area under the receiver-operating characteristic (ROC) curve (AUC) for the entire ACS cohort was 0.82 (95% CI: 0.76-0.88; P < 0.0001). A CEC count of >or=7/mL provided a positive predictive value of 90.6% (95% CI: 85.6-95.7%) and a negative predictive value of 53.5% (41.9-65.1%) for the diagnosis of MI (NSTEMI/STEMI) in the presence of an appropriate clinical presentation. CONCLUSION: There is a significant and positive correlation between increasing CECs and increasing CV risk in ACS. The diagnostic accuracy of CECs in this setting is only 'moderate'. Whilst it is good at confirming the presence of MI, a CEC value of <7.0/mL is less reliable at confidently excluding patients without disease. (+info)