Impact of early coronary artery bypass graft in an unselected acute coronary syndrome patient population

BACKGROUND: Performance of coronary artery bypass graft (CABG) during an acute coronary syndrome (ACS) is mainly used in high-risk patients. Although potentially life-saving, patients undergoing early CABG are traditionally associated with a worse outcome than those not requiring CABG. Is this really true in an unselected ACS population? The aim of this study was to evaluate, in an ACS population, if the performance of CABG during the index hospitalization influences in-hospital outcome. METHODS AND RESULTS: Retrospective analysis of a nationwide database of 12,988 ACS patients admitted since 2002. Of those, 267 patients underwent CABG during the index hospitalization (group A) and 12,721 did not (group B). Group B patients were further divided in 2 subgroups: those submitted to percutaneous coronary interventions (PCI) (group B1; n=3948) during the index hospitalization and those not submitted to mechanical revascularization (group B2; n =8773). Patients from group A more frequently had diabetes, hypercholesterolemia, hypertension, and previous angina; they were also more often on cardiovascular medication before admission. Patients that underwent CABG were more often in Killip class IV at admission (4.8% versus 1.4% versus 2.0%); they also received more nitrates and catecholamines. Left ventricular function was better in group B1. Group A patients were more often on mechanical ventilation and intra-aortic pump and they had more in-hospital complications (31.1% versus 18.7% versus 17.3%), namely recurrent angina, re-infarction, and mechanical complications. They had a more severe coronary anatomy and the culprit lesion was more frequently on the left main (7.7% versus 0.5% versus 2.2%). However, their in-hospital mortality was significantly lower (1.1% versus 2.2% versus 6.8%; P<0.001). Multivariate analysis showed that performance of early CABG was an independent predictor of lower mortality (odds ratio of 0.12), as were the use of low-molecular-weight heparins, beta-blockers, and angiotensin-converting enzyme inhibitors. CONCLUSIONS: In unselected patients admitted for ACS, performance of early CABG, despite being performed in higher-risk patients, is associated with very low in-hospital mortality, even when compared with the mortality of lower-risk population not submitted to early CABG. Therefore, early performance of this procedure should be considered more often in eligible patients

The Use of Coronary CT Angiography for the Evaluation of Chest Pain

Coronary computed tomography angiography (CCTA) may improve the diagnosis and management of acute and stable chest pain syndromes. The key for caregivers of patients presenting with acute chest pain is the early identification and management of life-threatening conditions, such as acute coronary syndromes, pulmonary embolism, and acute aortic dissection. The main goal in stable chest pain syndromes is to determine the extent and severity of coronary artery disease. This review article will critically evaluate the current literature supporting the evidence for the clinical use of CCTA in acute and stable chest pain syndromes, considering the latest innovations in CCTA technology and their potential impact on patient care

Qualitative assay of C-reactive proteins in acute coronary syndromes

Introduction: Acute coronary syndromes (ACS) are the major causes of mortality in coronary care units. Inflammation plays an important role in ACS.&nbsp; C-reactive protein (CRP) is one of the inflammatory markers, which plays a key role in the pathogenesis. This study aimed at assessing C-reactive protein levels in acute coronary syndromes, and determining its significance in prognosis. Methods: Fifty patients admitted with the diagnosis of ACS were included in the study. Qualitative C - reactive protein assay was done at the time of admission. Patients were followed up for the complications till discharge. Results: Age group between 41 to 70 years constituted 40 (80%) patients. Out of 50 patients with acute coronary syndromes 36 patients had elevated CRP. Thirty patients (83.33%) of them met with complications. Of the 14 patients with low CRP only two (14.28%) patients met with the complications. Conclusions: Qualitative plasma CRP estimation gives valuable prognostic information in acute coronary syndromes

An unexpected complication of a percutaneous coronary angioplasty

Takotsubo cardiomyopathy (TCM) is characterized by transient ventricular dysfunction, classically in its apical and mid segments in the absence of coronary lesions, and is often observed after intense stressful events and occasionally associated to an acute medical illness. We describe a case of TCM associated with coronary artery disease and triggered by a percutaneous coronary angioplasty. This case highlights the concept that a medical procedure can lead, in certain conditions, to TCM and provides new interesting insights on the pathophysiology of coronary syndromes

Brain natriuretic peptide as an indicator of left ventricle dysfunction and a predictor of cardiovascular events in acute coronary syndromes

Background: Acute coronary syndromes can cause systolic and diastolic left ventricle (LV) dysfunction. Determination of LV dysfunction in ACS provides benefit to stratification and optimizing therapy. Brain Natriuretic Peptide (BNP) is secreted primarily from and synthesized in left ventricle in response to increased myocardial stretch. BNP increase in heart failure. BNP increase in the 24 hours in acute myocardial infarction. We hypothesized that BNP level could be as an indicator of systolic and diastolic dysfunction and a predictor of cardiovascular events in acute coronary syndromes. Objective: To investigate plasma level of BNP in systolic and diastolic dysfunction in acute coronary syndromes hospitalized to ICCU. To investigate plasma level of BNP as a predictor of cardiovascular events in acute coronary syndromes. Method and Result: We measured BNP in plasma specimen obtained 3 days after the onset of ischemic symptoms in 25 patients of acute coronary syndromes and prospectively followed the patients for 30 days. Patients diagnosed with evidence of systolic LV dysfunction had a mean BNP concentration of 301.11 ± 189.62 pg/ml, higher than those patients with normal LV function (42.67 ± 22.44 pg/ml, p = 0.003). Patients diagnosed with evidence of diastolic LV dysfunction had a mean BNP concentration of 273.70 ± 146.27 pg/ml, higher than those patients with normal LV function (42.67 ± 22.44 pg/ml, p = 0.006). Patients with cardiovascular events had a mean BNP concentration of 392.30 ± 157.14 pg/ml, higher than patients without cardiovascular events (118.67 ± 78.53 pg/ml, p < 0.0001). In patients with cardiovascular events, minimum plasma BNP level (248 pg/ml) was higher than maximum plasma BNP level in patients without cardiovascular events (234 pg/mL). Conclusion: Plasma BNP level can reliably detect the presence of diastolic or systolic LV dysfunction on echocardiography in acute coronary syndromes. Moreover, plasma BNP level can also predict patients with cardiovascular events in 30-days after acute coronary syndromes

Platelet glycoprotein IIb/IIIa receptor blockers in clinical practice

I n this thesis, platelet glycoprotein (GP) IIb/IIIa receptor blockers are discussed for use in patients with acute coronary syndromes without persistent ST-segment elevation but also for use in patients with overt myocardial infarction. Furthermore, the role of intervention, and more specifically, the role of timing of percutaneous coronary intervention is descnOed in patients 'With acute coronary syndromes without persistent ST-segment elevation incorporating use of platelet GP IIb/IIIa receptor antagonists

Acute coronary syndromes

In the UK, there are over 80,000 admissions annually with acute coronary syndromes (ACS). Management of ST-elevation myocardial infarction (STEMI) involves primary percutaneous coronary intervention (PCI), which is delivered via dedicated heart attack centres. Non-ST elevation-ACS (NSTE-ACS) accounts for two-thirds of ACS presentations, affecting an older cohort of patients - often with more complex comorbidities. Initial management is with anti-thrombotic therapy with a view to PCI within 24 hours for the most acute cases and within 72 hours for all others. However, varying management pathways and access to specialist cardiology services results in variable times to definitive treatment. Advances in the sensitivity of cardiac biomarkers and the use of risk assessment tools now enable rapid diagnosis within a few hours of symptom onset. Advances in invasive management and drug therapy have resulted in improved clinical outcomes with resultant decline in mortality associated with ACS

Acute Coronary Syndromes

This book has been written with the intention of providing an up-to-the minute review of acute coronary syndromes. Atherosclerotic coronary disease is still a leading cause of death within developed countries and not surprisingly, is significantly rising in others. Over the past decade the treatment of these syndromes has changed dramatically. The introduction of novel therapies has impacted the outcomes and surviving rates in such a way that the medical community need to be up to date almost on a "daily bases". It is hoped that this book will provide a timely update on acute coronary syndromes and prove to be an invaluable resource for practitioners seeking new and innovative ways to deliver the best possible care to their patients

Fondaparinux in Percutaneous Coronary Intervention for the Treatment of Acute Coronary Syndrome

ABSTRACTBackgroundFondaparinux is an agent that has a well-established safety and efficacy profile in the treatment of non-ST segment elevation acute coronary syndromes. When used alone, however, it is associated with a higher incidence of thrombotic complications during invasive coronary procedures, requiring the supplementation of an anti-IIa agent. This study aimed to evaluate the efficacy and safety of percutaneous coronary intervention (PCI) in patients with non-ST segment elevation acute coronary syndromes that were previously treated with fondaparinux.MethodsThis was a prospective, controlled registry, enrolling 127 consecutive patients submitted to an early invasive stratification during treatment with fondaparinux with the supplementation of intravenous unfractionated heparin at a dose of 85 U/kg at the time of PCI.ResultsThe composite primary endpoint rate, including death, acute myocardial infarction, stroke, stent thrombosis, or emergency myocardial revascularisation was 3.2%. The cumulative incidence of major bleeding and vascular complications was 3.2%. There were no cases of guide catheter thrombosis or abrupt vessel closure.ConclusionsPCI in patients with acute coronary syndromes receiving fondaparinux was associated with a low rate of major adverse cardiovascular ischaemic events and severe haemorrhagic complications. Supplementation with unfractionated heparin during the invasive procedures eliminated the risk of catheter-related thrombosis