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

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

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

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

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

Understanding a woman's heart: Lessons from 14 177 women with acute coronary syndrome

INTRODUCTION: Coronary artery disease is becoming the leading cause of death in women in Western society. However, the available data shows that women are still underdiagnosed and undertreated with guideline-recommended secondary prevention therapy, leading to a significantly higher rate of in-hospital complications and in-hospital mortality. OBJECTIVE: The main objective of this work is to assess the approach to acute coronary syndrome (ACS) in Portugal, including form of presentation, in-hospital treatment and in-hospital complications, according to gender and in three different periods. METHODS: We performed an observational study with retrospective analysis of all patients included between 2002 and 2019 in the Portuguese Registry of Acute Coronary Syndromes (ProACS), a voluntary, observational, prospective, continuous registry of the Portuguese Society of Cardiology and the National Center for Data Collection in Cardiology. RESULTS: A total of 49 113 patients (34 936 men and 14 177 women) were included. Obesity, hypertension, diabetes (p<0.001 for all) and dyslipidemia (p=0.022) were all more prevalent in women, who were more frequently admitted for non-ST segment elevation ACS (p<0.001), and more frequently presented with atypical symptoms. Women had more time until needle and until reperfusion, which is less accessible to this gender (p<0.001). During hospitalization, women had a significantly higher risk of in-hospital mortality (OR 1.94 [1.78-2.12], p<0.001), major bleeding (OR 1.53 [1.30-1.80], p<0.001), heart failure (OR 1.87 [1.78-1.97], p<0.001), atrial fibrillation (OR 1.55 [1.36-1.77], p<0.001), mechanical complications (OR 2.12 [1.78-2.53], p<0.001), cardiogenic shock (OR 1.71 [1.57-1.87], p<0.001) and stroke (OR 2.15 [1.76-2.62], p<0.001). Women were more likely to have a normal coronary angiogram or coronary lesions with <50% luminal stenosis (p<0.001 for both), and thus a final diagnosis other than ACS. Both during hospitalization and at hospital discharge, women were less likely to receive guideline-recommended secondary prevention therapy. CONCLUSION: In women admitted for ACS, revascularization strategies are still underused, as is guideline-recommended secondary prevention therapy, which may explain their higher incidence of in-hospital complications and higher unadjusted mortality.Introduc¸ão: A doenc¸a arterial coronária está-se a tornar a principal causa de morte no mundo ocidental no género feminino. Contudo, os dados de que dispomos mostram que as mulheres são ainda subdiagnosticadas e subtratadas com as terapias de prevenc¸ão secundária recomendadas, levando a taxas significativamente mais altas de complicac¸ões intra-hospitalares e mortalidade intra-hospitalar. Objetivo: Avaliar a abordagem nacional às síndromas coronárias agudas, incluindo forma de apresentac¸ão, tratamento intra-hospitalar e complicac¸ões intra-hospitalares, de acordo com o género e em três períodos distintos. Métodos: Estudo observacional com análise retrospetiva de todos os doentes incluídos entre 2002 e 2019 no Registo Nacional de Síndromas Coronárias Agudas (RNSCA), um registo voluntário, observacional, prospetivo e contínuo da Sociedade Portuguesa de Cardiologia e do Centro Nacional de Colec¸ão de Dados em Cardiologia. Resultados: Foram incluídos 49 113 doentes (34 936 homens e 14 177 mulheres). Obesidade, hipertensão arterial, diabetes mellitus (p < 0,001 para todos) e dislipidémia (p = 0,022) foram mais prevalentes nas mulheres, que são mais frequentemente admitidas por síndroma coronária aguda sem supradesnivelamento do segmento ST (p < 0,001) e mais frequentemente se apresentam com sintomas atípicos. As mulheres têm tempos mais longos até agulha e até reperfusão, esta última menos frequente neste género (p < 0,001). Durante hospitalizac¸ão, as mulheres têm um risco significativamente maior de mortalidade intra-hospitalar (OR 1,94 [1,78;2,12], p < 0,001), hemorragia major (OR 1,53 [1,30;1,80], p < 0,001), insuficiência cardíaca (OR 1,87 [1,78;1,97], p < 0,001), fibrilhac¸ão auricular (OR 1,55 [1,36;1,77], p < 0,001), complicac¸ões mecânicas (OR 2,12 [1,78;2,53], p < 0,001), choque cardiogénico (OR 1,71 [1,57;1,87], p < 0,001) e acidente vascular cerebral (OR 2,15 [1,76;2,62], p < 0,001). É mais provável que as mulheres tenham uma coronariografia normal ou lesão coronárias com estenose luminal < 50% (p < 0,001 para ambos) e, assim, um diagnóstico final alternativo a síndroma coronária aguda. Seja durante hospitalizac¸ão ou à alta hospitalar, é menos provável que as mulheres recebam as terapias de prevenc¸ão secundária recomendadas. Conclusão: Em mulheres admitidas com síndroma coronária aguda as estratégias de revascularizac¸ão são subutilizadas, assim como as terapias de prevenc¸ão secundária recomendadas, podendo justificar a maior incidência de complicac¸ões intra-hospitalares e maior mortalidade não ajustada.info:eu-repo/semantics/publishedVersio

CD40 ligand inhibits endothelial cell migration by increasing production of endothelial reactive oxygen species

Background— The CD40/CD40 ligand system is involved in atherogenesis. Activated T lymphocytes and platelets, which express high amounts of CD40 ligand (CD40L) on their surface, contribute significantly to plaque instability with ensuing thrombus formation, leading to acute coronary syndromes. Because reendothelialization may play a pivotal role for plaque stabilization, we investigated a potential role of CD40L on endothelial cell (EC) migration

An uncommon clinical picture: Wellens' syndrome in a morbidly obese young man.

Comment in: The Wellens' Syndrome in the management of acute coronary syndromes. [Intern Emerg Med. 2012