Predicting two-year mortality from discharge after acute coronary syndrome: An internationally-based risk score.

BACKGROUND: Long-term risk of post-discharge mortality associated with acute coronary syndrome remains a concern. The development of a model to reliably estimate two-year mortality risk from hospital discharge post-acute coronary syndrome will help guide treatment strategies. METHODS: EPICOR (long-tErm follow uP of antithrombotic management patterns In acute CORonary syndrome patients, NCT01171404) and EPICOR Asia (EPICOR Asia, NCT01361386) are prospective observational studies of 23,489 patients hospitalized for an acute coronary syndrome event, who survived to discharge and were then followed up for two years. Patients were enrolled from 28 countries across Europe, Latin America and Asia. Risk scoring for two-year all-cause mortality risk was developed using identified predictive variables and forward stepwise Cox regression. Goodness-of-fit and discriminatory power was estimated. RESULTS: Within two years of discharge 5.5% of patients died. We identified 17 independent mortality predictors: age, low ejection fraction, no coronary revascularization/thrombolysis, elevated serum creatinine, poor EQ-5D score, low haemoglobin, previous cardiac or chronic obstructive pulmonary disease, elevated blood glucose, on diuretics or an aldosterone inhibitor at discharge, male sex, low educational level, in-hospital cardiac complications, low body mass index, ST-segment elevation myocardial infarction diagnosis, and Killip class. Geographic variation in mortality risk was seen following adjustment for other predictive variables. The developed risk-scoring system provided excellent discrimination (c-statistic=0.80, 95% confidence interval=0.79-0.82) with a steep gradient in two-year mortality risk: >25% (top decile) vs. ~1% (bottom quintile). A simplified risk model with 11 predictors gave only slightly weaker discrimination (c-statistic=0.79, 95% confidence interval =0.78-0.81). CONCLUSIONS: This risk score for two-year post-discharge mortality in acute coronary syndrome patients ( www.acsrisk.org ) can facilitate identification of high-risk patients and help guide tailored secondary prevention measures

Global geographical variations in ST-segment elevation myocardial infarction management and post-discharge mortality.

BACKGROUND: There is a shortage of information on regional variations in ST-segment elevation myocardial infarction (STEMI) management and prognosis at a global level. We aimed to compare patient profiles, in-hospital management and post-discharge mortality across several world regions. METHODS: In total, 11,559 patients with STEMI were enrolled in two prospective studies of acute coronary syndrome survivors: EPICOR (4943 patients from 555 hospitals in 20 countries in Europe and Latin America recruited between September 2010 and March 2011) and EPICOR Asia (6616 patients from 218 hospitals in eight Asian countries recruited between June 2011 and May 2012). Comparisons were performed by eight pre-defined regions: Northern Europe (NE), Southern Europe (SE), Eastern Europe (EE), Latin America (LA), China (CN), India (IN), Southeast Asia (SA), and South Korea/Hong Kong/Singapore (KS). RESULTS: Reperfusion therapy rates ranged between 53.9% (IN) and 81.2% (SE), primary percutaneous coronary intervention (PCI) between 24.8% (IN) and 65.6% (NE) and fibrinolysis between 8.1% (CN) and 34.2% (SA). Median time to primary PCI (h) ranged from 3.9 (NE) to 20.9 (IN) and to fibrinolysis from 2.4 (SE) to 6.3 (IN). Two-year mortality ranged between 2.5% in NE and 7.4% in LA. Regional variations in mortality persisted after adjustment for reperfusion therapy and known prognostic factors. CONCLUSIONS: Among patients with STEMI, there is a wide regional variation in clinical profiles, hospital care and mortality. Substantial room for improvement remains at a global level for increasing reperfusion rates, reducing delays and post-discharge mortality in patients with STEMI

Prolonged dual antiplatelet therapy in patients with non-ST-segment elevation myocardial infarction: 2-year findings from EPICOR Asia.

BACKGROUND: Patients with non-ST-segment elevation myocardial infarction (NSTEMI) have a generally poor prognosis and antithrombotic management patterns (AMPs) used post-acute coronary syndrome (ACS) remain unclear. Duration of dual antiplatelet therapy (DAPT) and patient characteristics was evaluated in NSTEMI patients enrolled in EPICOR Asia. HYPOTHESIS: Patients stopping DAPT early may benefit from more intensive monitoring. METHODS: EPICOR Asia was a prospective, real-world, primary data collection, cohort study in adults with an ACS, conducted in eight countries/regions in Asia, with 2 year follow-up. Eligible patients were hospitalized within 48 hours of symptom onset and survived to discharge. We describe AMPs and baseline characteristics in NSTEMI patients surviving ≥12 months with DAPT duration ≤12 and > 12 months post-discharge. Clinical outcomes (composite of death, myocardial infarction, and stroke; and bleeding) were also explored. RESULTS: At discharge, 90.8% of patients were on DAPT (including clopidogrel, 99%). At 1- and 2-year follow-up, this was 79.2% and 60.0%. Patients who stopped DAPT ≤12 months post-discharge tended to be older, female, less obese, have prior cardiovascular disease, and have renal dysfunction. While causality cannot be inferred, the incidence of the composite endpoint over the subsequent 12 months was 10.6% and 3.1% with shorter vs longer use of DAPT, and mortality risk over the same period was 8.4% and 1.6%. CONCLUSIONS: Over 90% of NSTEMI patients were discharged on DAPT, with 60% on DAPT at 2 years. Patients stopping DAPT early were more likely to have higher baseline risk and may therefore benefit from more intensive monitoring during long-term follow-up

Predictors of high-cost hospitalization in the treatment of acute coronary syndrome in Asia: findings from EPICOR Asia.

BACKGROUND: The EPICOR Asia (long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients in Asia) study (NCT01361386) was an observational study of patients hospitalized for acute coronary syndromes (ACS) enrolled in 218 hospitals in eight countries/regions in Asia. This study examined costs, length of stay and the predictors of high costs during an ACS hospitalization. METHODS AND RESULTS: Data for patients hospitalized for an ACS (n = 12,922) were collected on demographics, medical history, event characteristics, socioeconomic and insurance status at discharge. Patients were followed up at 6 weeks' post-hospitalization for an ACS event to assess associated treatment costs from a health sector perspective. Primary outcome was the incurring of costs in the highest quintile by country and index event diagnosis, and identification of associated predictors. Cost data were available for 10,819 patients. Mean length of stay was 10.1 days. The highest-cost countries were China, Singapore, and South Korea. Significant predictors of high-cost care were age, male sex, income, country, prior disease history, hospitalization in 3 months before index event, no dependency before index event, having an invasive procedure, hospital type and length of stay. CONCLUSIONS: Substantial variability exists in healthcare costs for hospitalized ACS patients across Asia. Of concern is the observation that the highest costs were reported in China, given the rapidly increasing numbers of procedures in recent years. TRIAL REGISTRATION: NCT01361386

Long-term antiplatelet therapy in medically managed non-ST-segment elevation acute coronary syndromes: The EPICOR Asia study

OBJECTIVES: To describe long-term antithrombotic management patterns (AMPs) in medically managed Asian patients with non-ST-segment myocardial infarction (NSTEMI) or unstable angina (UA). BACKGROUND: Current guidelines support an early invasive strategy in NSTEMI and UA patients, but many are medically managed, and data are limited on long-term AMPs in Asia. METHODS: Data were analyzed from medically managed NSTEMI and UA patients included in the prospective, observational EPICOR Asia study (NCT01361386). Survivors to hospital discharge were enrolled (June 2011 to May 2012) from 8 countries/regions across Asia. Baseline characteristics and AMP use up to 2 years post-discharge were collected. Outcomes were major adverse cardiovascular events (MACE: myocardial infarction, ischemic stroke, and death) and bleeding. RESULTS: Among 2289 medically managed patients, dual antiplatelet therapy (DAPT) use at discharge was greater in NSTEMI than in UA patients (81.8% vs 65.3%), and was significantly associated with male sex, positive cardiac markers, and prior cardiovascular medications (p < 0.0001). By 2 years, 57.9% and 42.6% of NSTEMI and UA patients, respectively, were on DAPT. On multivariable Cox regression analysis, risk of MACE at 2 years was most significantly associated with older age (HR [95% CI] 1.85 [1.36, 2.50]), diagnosis of NSTEMI vs UA (1.96 [1.47, 2.61]), and chronic renal failure (2.14 [1.34, 3.41]), all p ≤ 0.001. Risk of bleeding was most significantly associated with region (East Asia vs Southeast/South Asia) and diabetes. CONCLUSIONS: Approximately half of all patients were on DAPT at 2 years. MACE were more frequent in NSTEMI than UA patients during follow-up

Long-Term Antithrombotic Therapy and Clinical Outcomes in Patients with Acute Coronary Syndrome and Renal Impairment: Insights from EPICOR and EPICOR Asia.

BACKGROUND: Information is lacking on long-term management of patients with acute coronary syndrome (ACS) and chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m2). OBJECTIVES: Our objectives were to describe antithrombotic management patterns and outcomes in patients with ACS with varying renal function from the EPICOR (long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients; NCT01171404) and EPICOR Asia (NCT01361386) studies. METHODS: EPICOR and EPICOR Asia were prospective observational studies of patients who survived hospitalization for ACS and were enrolled at discharge in 28 countries across Europe, Latin America, and Asia. The studies were conducted from 2010 to 2013 and from 2011 to 2014, respectively. This analysis evaluated patient characteristics and oral antithrombotic management patterns and outcomes up to 2 years post-discharge according to admission eGFR: ≥ 90, 60-89, 30-59, or < 30 mL/min/1.73 m2. RESULTS: Among 22,380 patients with available data, eGFR < 60 mL/min/1.73 m2 was observed in 16.7%. Patients with poorer renal function were older, were at greater cardiovascular risk, and had more prior cardiovascular disease and bleeding. Patients with CKD underwent fewer cardiovascular interventions and had more in-hospital cardiovascular and bleeding events. Dual antiplatelet therapy was less likely at discharge in patients with eGFR < 30 (82.3%) than in those with ≥ 90 (91.3%) mL/min/1.73 m2 and declined more sharply during follow-up in patients with low eGFR (p < 0.0001). An adjusted proportional hazards model showed that patients with lower eGFR levels had a higher risk of cardiovascular events and bleeding. CONCLUSIONS: The presence of CKD in patients with ACS was associated with less aggressive cardiovascular management and an increased risk of cardiovascular events

An Overview of Regional Experiments on Biomass Burning Aerosols and Related Pollutants in Southeast Asia: From BASE-ASIA and the Dongsha Experiment to 7-SEAS

By modulating the Earth-atmosphere energy, hydrological and biogeochemical cycles, and affecting regional-to-global weather and climate, biomass burning is recognized as one of the major factors affecting the global carbon cycle. However, few comprehensive and wide-ranging experiments have been conducted to characterize biomass-burning pollutants in Southeast Asia (SEA) or assess their regional impact on meteorology, the hydrological cycle, the radiative budget, or climate change. Recently, BASEASIA (Biomass-burning Aerosols in South-East Asia: Smoke Impact Assessment) and the 7-SEAS (7- South-East Asian Studies) Dongsha Experiment were conducted during the spring seasons of 2006 and 2010 in northern SEA, respectively, to characterize the chemical, physical, and radiative properties of biomass-burning emissions near the source regions, and assess their effects. This paper provides an overview of results from these two campaigns and related studies collected in this special issue, entitled Observation, modeling and impact studies of biomass burning and pollution in the SE Asian Environment. This volume includes 28 papers, which provide a synopsis of the experiments, regional weatherclimate, chemical characterization of biomass-burning aerosols and related pollutants in source and sink regions, the spatial distribution of air toxics (atmospheric mercury and dioxins) in source and remote areas, a characterization of aerosol physical, optical, and radiative properties, as well as modeling and impact studies. These studies, taken together, provide the first relatively complete dataset of aerosol chemistry and physical observations conducted in the sourcesink region in the northern SEA, with particular emphasis on the marine boundary layer and lower free troposphere (LFT). The data, analysis and modeling included in these papers advance our present knowledge of source characterization of biomass-burning pollutants near the source regions as well as the physical and chemical processes along transport pathways. In addition, we raise key questions to be addressed by a coming deployment during springtime 2013 in northern SEA, named 7-SEASBASELInE (Biomass-burning Aerosols Stratocumulus Environment: Lifecycles and Interactions Experiment). This campaign will include a synergistic approach for further exploring many key atmospheric processes (e.g., complex aerosol-cloud interactions) and impacts of biomass burning on the surface-atmosphere energy budgets during the lifecycles of biomass burning emissions

Development of a direct transformation method by GFP screening and in vitro whole plant regeneration of Capsicum frutescens L.

Background Capsicum is a genus of important spice crop that belongs to the chili lineage. However, many Capsicum species (family Solanaceae) are known to be recalcitrant to genetic transformation and in vitro regeneration, thus hampering the effort in using Capsicum species for detailed biological investigation. In this study, we have developed an optimized protocol for the direct transformation of Capsicum frutescens L. cv. Hot Lava via a biolistic particle delivery system. In addition, in vitro whole plant regeneration from the hypocotyl explants of C. frutescens was established. Results In this biolistic system study, explant target distance, bombardment helium (He) pressure and the size of microcarrier were the key parameters to be investigated. The optimized parameters based on screening of GFP expression were determined to be 6 cm target distance, 1350 psi of helium pressure and 1.6 μm of gold particle (microcarrier) size. The greatest number of shoots were obtained from hypocotyl as explant using Murashige and Skoog medium supplemented with 5.0 mg/L BAP and 0.1 mg/L NAA. An average of 5 shoots per explant were formed. Out of which, one shoot managed to form root and developed into whole plant. Conclusions We have obtained an optimized protocol for the biolistic transformation of chili and in vitro regeneration of chili plantlets. The establishment of the protocols will provide a platform for molecular breeding and biological studies of the chili plants

2021 Asian Pacific Society of Cardiology Consensus Recommendations on the Use of P2Y12 Receptor Antagonists in the Asia-Pacific Region: Special Populations

Advanced age, diabetes, and chronic kidney disease not only increase the risk for ischaemic events in chronic coronary syndromes (CCS) but also confer a high bleeding risk during antiplatelet therapy. These special populations may warrant modification of therapy, especially among Asians, who have displayed characteristics that are clinically distinct from Western patients. Previous guidance has been provided regarding the classification of high-risk CCS and the use of newer-generation P2Y12 inhibitors (i.e. ticagrelor and prasugrel) after acute coronary syndromes (ACS) in Asia. The authors summarise evidence on the use of these P2Y12 inhibitors during the transition from ACS to CCS and among special populations. Specifically, they present recommendations on the roles of standard dual antiplatelet therapy, shortened dual antiplatelet therapy and single antiplatelet therapy among patients with coronary artery disease, who are either transitioning from ACS to CCS; elderly; or with chronic kidney disease, diabetes, multivessel coronary artery disease and bleeding events during therapy