The No-Reflow Phenomenon: Clinical and Angiographic Correlates

No-reflow occurring during PCI has been associated with poor outcomes. The objectives of this study were to evaluate the incidence of no-reflow as independent predictor of adverse events and to assess whether baseline pre-procedural treatment options may affect clinical outcomes. Data were derived from the ISACS-TC (NCT01218776) registry, a prospective survey of patients presenting with ACS over a 5-year period. Data were prospectively collected from 5997 patients undergoing PCI, identifying those with no-reflow, and analyzed their treatments and outcomes. No-reflow was defined as post-PCI TIMI flow grade 0-1, in the absence of post-procedural significant (≥25%) residual stenosis, abrupt vessel closure, dissection, perforation, thrombus of the original target lesion, or epicardial spasm. The outcome measure was in-hospital mortality. No-reflow was identified in 128 (2.1%) patients. On multivariate analysis, patients with no-reflow were more likely to be older (OR:1.20, 95%CI:1.01–1.44) and to be admitted with a diagnosis of ST-elevation myocardial infarction (OR:2.96, 95%CI:1.85–4.72). No-reflow was highly predictive of in-hospital mortality (17.2% vs. 4.2%, P<0.001) and remained a significant independent predictor of death after adjustment for demographic and clinical variables (OR:4.60,95%CI:2.61–8.09). Multivariable regression analysis was also performed to identify independent relationship between pre-procedural treatment regimens, angiographic characteristics and no-reflow phenomenon. Administration of pre-procedural unfractioned heparin, showed a strong inverse predictive value in terms of post-PCI TIMI flow and no-reflow phenomenon (OR: 0.65, 95%CI:0.43–0.99). Similarly, a 600-mg loading dose of clopidogrel showed a trend associated with a reduction in the likehood of no-reflow (OR:0.61,95%CI:0.37–1.00). Angiographic characteristics associated with no-reflow phenomenon were stenosis≥50% of the right coronary artery, presence of multivessel coronary disease and pre-procedural TIMI blood flow grade 0-1. In conclusion, no-reflow during PCI is a strong independent predictor of mortality. Pre-procedural administration of 600-mg loading dose of clopidogrel and/or unfractioned heparin is associated with reduced incidence of no-reflow

Early Invasive Strategy for Unstable Angina: a New Meta-Analysis of Old Clinical Trials

Randomized controlled trials (RCTs) were conflicting to support whether unstable angina versus non-ST-elevation myocardial infarction (UA/NSTEMI) patients best undergo early invasive or a conservative revascularization strategy. RCTs with cardiac biomarkers, in MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials from 1975-2013 were reviewed considering all cause mortality, recurrent non-fatal myocardial infarction (MI) and their combination. Follow-up lasted from 6-24 months and the use of routine invasive strategy up to its end was associated with a significantly lower composite of all-cause mortality and recurrent non-fatal MI (Relative Risk [RR] 0.79; 95% confidence interval [CI], 0.70-0.90) in UA/NSTEMI. In NSTEMI, by the invasive strategy, there was no benefit (RR 1.19; 95%\u2009CI, 1.03-1.38). In the shorter time period, from randomization to discharge, a routine invasive strategy was associated with significantly higher odds of the combined end-point among UA/NSTEMI (RR 1.29; 95%\u2009CI, 1.05-1.58) and NSTEMI (RR 1.82; 95%\u2009CI, 1.34-2.48) patients. Therefore, in trials recruiting a large number of UA patients, by routine invasive strategy the largest benefit was seen, whereas in NSTEMI patients death and non-fatal MI were not lowered. Routine invasive treatment in UA patients is accordingly supported by the present study

Short term outcomes in the elderly patients with non-ST-elevation acute coronary syndromes undergoing early percutaneous coronary intervention: a report from the ISACS-TC registry

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Aspirin for primary prevention of ST segment elevation myocardial infarction in persons with diabetes and multiple risk factors

Controversy exists as to whether low-dose aspirin use may give benefit in primary prevention of cardiovascular (CV) events. We hypothesized that the benefits of aspirin are underevaluated. We investigated 12,123 Caucasian patients presenting to hospital with acute coronary syndromes as first manifestation of CV disease from 2010 to 2019 in the ISACS-TC multicenter registry (ClinicalTrials.gov, NCT01218776). Individual risk of ST segment elevation myocardial infarction (STEMI) and its association with 30-day mortality was quantified using inverse probability of treatment weighting models matching for concomitant medications. Estimates were compared by test of interaction on the log scale. The risk of STEMI was lower in the aspirin users (absolute reduction: 6·8%; OR: 0·73; 95%CI: 0·65-0·82) regardless of sex (p for interaction=0·1962) or age (p for interaction=0·1209). Benefits of aspirin were seen in patients with hypertension, hypercholesterolemia, and in smokers. In contrast, aspirin failed to demonstrate a significant risk reduction in STEMI among diabetic patients (OR:1·10;95%CI:0·89-1·35) with a significant interaction (p: <0·0001) when compared with controls (OR:0·64,95%CI:0·56-0·73). Stratification of diabetes in risk categories revealed benefits (p interaction=0·0864) only in patients with concomitant hypertension and hypercholesterolemia (OR:0·87, 95% CI:0·65-1·15), but not in smokers. STEMI was strongly related to 30-day mortality (OR:1·93; 95%CI:1·59-2·35) Low-dose aspirin reduces the risk of STEMI as initial manifestation of CV disease with potential benefit in mortality. Patients with diabetes derive substantial benefit from aspirin only in the presence of multiple risk factors. In the era of precision medicine, a more tailored strategy is required

Sex Differences in Heart Failure Following Acute Coronary Syndromes

Background: There have been conflicting reports regarding outcomes in women presenting with an acute coronary syndrome (ACS). Objectives: The objective of the study was to examine sex-specific differences in 30-day mortality in patients with ACS and acute heart failure (HF) at the time of presentation. Methods: This was a retrospective study of patients included in the International Survey of Acute Coronary Syndromes-ARCHIVES (ISACS-ARCHIVES; NCT04008173). Acute HF was defined as Killip classes ≥2. Participants were stratified according to ACS presentation: ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation ACS (NSTE-ACS). Differences in 30-day mortality and acute HF presentation at admission between sexes were examined using inverse propensity weighting based on the propensity score. Estimates were compared by test of interaction on the log scale. Results: A total of 87,812 patients were included, of whom 30,922 (35.2%) were women. Mortality was higher in women compared with men in those presenting with STEMI (risk ratio [RR]: 1.65; 95% CI: 1.56-1.73) and NSTE-ACS (RR: 1.18; 95% CI: 1.09-1.28; Pinteraction &lt;0.001). Acute HF was more common in women when compared to men with STEMI (RR: 1.24; 95% CI: 1.20-1.29) but not in those with NSTE-ACS (RR: 1.02; 95% CI: 0.97-1.08) (Pinteraction &lt;0.001). The presence of acute HF increased the risk of mortality for both sexes (odds ratio: 6.60; 95% CI: 6.25-6.98)

Statins for primary prevention among elderly men and women.

We undertook a propensity match-weighted cohort study to investigate whether statin treatment recommendations for statins translate into improved cardiovascular (CV) outcomes in the current routine clinical care of the elderly. We included in our analysis (ISACS Archives -NCT04008173) a total of 5619 Caucasian patients with no known prior history of CV disease who presented to hospital with a first manifestation of CV disease with age of 65 years or older. The risk of ST-segment elevation myocardial infarction (STEMI) was much lower in statin users than in non-users in both patients aged 65-75 years [14.7% absolute risk reduction; relative risk (RR): 0.55, 95% CI 0.45-0.66] and those aged 76 years and older (13.3% absolute risk reduction; RR: 0.58, 95% CI 0.46-0.72). Estimates were similar in patients with and without history of hypercholesterolaemia (interaction test; P-values = 0.24 and 0.35). Proportional reductions in STEMI diminished with female sex in the old (P for interaction = 0.002), but not in the very old age (P for interaction = 0.26). We also observed a remarkable reduction in the risk of 30 day mortality from STEMI with statin therapy in both age groups (10.2% absolute risk reduction; RR: 0.39; 95% CI 0.23-0.68 for patients aged 76 or over and 3.8% absolute risk reduction; RR 0.37; 95% CI 0.17-0.82 for patients aged 65-75 years old; interaction test, P-value = 0.46). Preventive statin therapy in the elderly reduces the risk of STEMI with benefits in mortality from STEMI, irrespective of the presence of a history of hypercholesterolaemia. This effect persists after the age of 76 years. Benefits are less pronounced in women. Randomized clinical trials may contribute to more definitively determine the role of statin therapy in the elderly.EMMACE was funded by the National Institute for Health Research and the British Heart Foundation.S

Sex-related Differences In Acute Coronary Care Among Patients With Myocardial Infarction: The Role Of Pre-hospital Delay

Background: We sought to investigate sex-related differences in access to care among patients with myocardial infarction (STEMI) in order to identify gender-related factors associated with outcomes. Methods: We studied 7457 patients enrolled in the ISACS-TC registry 2010-2014 (ClinicalTrials.gov NCT01218776). Outcome measures were: inhospital mortality, time delay to call emergency medical services (EMS), home-to-hospital delay using EMS, door-to-needle and door-to-balloon times and the overall time to treatment from symptom onset. Constant variables included in logistic regression analyses were: age, risk factors, severity of clinical presentation, reperfusion therapies, and concurrent acute medications. Time to treatment from symptom onset was used as dummy variable. Results: Women were less likely than men to receive care within the benchmark time for reperfusion therapy (time to treatment from symptom onset 60 min in 70.3% of women vs 29.7% of men. There were no significant differences in door-to-needle (median; 28 min vs 26 min) and door-to-balloon (median: 45 min vs 45 min) times. Major (z >4)determinants of poorer rates of reperfusion therapies included time to treatment from symptom onset >12 hours (adjusted OR: 5.37, CI: 4.58 - 6.31) Killip class > 2 (OR: 1.53, CI: 1.27-1.86) and history of prior heart failure (OR: 2.77, CI, 1.99 to 3.87). After adjustment, women had greater inhospital mortality rates than men (OR: 1.34, CI: 1.01-1.77). Sex differences in in-hospital mortality rates were no longer observed in the cohort, when time to treatment from symptom onset <12 hours was included in the multivariable analysis (OR: 1.31, CI: 0.98 -1.74). Conclusion: Sex differences in outcomes persist among STEMI patients, as fewer women receive timely reperfusion therapy. Pre-hospital delays in women experiencing STEMI remain unacceptably long

Sex-related Differences In Acute Coronary Care Among Patients With Myocardial Infarction: The Role Of Pre-hospital Delay

Background: We sought to investigate sex-related differences in access to care among patients with myocardial infarction (STEMI) in order to identify gender-related factors associated with outcomes. Methods: We studied 7457 patients enrolled in the ISACS-TC registry 2010-2014 (ClinicalTrials.gov NCT01218776). Outcome measures were: inhospital mortality, time delay to call emergency medical services (EMS), home-to-hospital delay using EMS, door-to-needle and door-to-balloon times and the overall time to treatment from symptom onset. Constant variables included in logistic regression analyses were: age, risk factors, severity of clinical presentation, reperfusion therapies, and concurrent acute medications. Time to treatment from symptom onset was used as dummy variable. Results: Women were less likely than men to receive care within the benchmark time for reperfusion therapy (time to treatment from symptom onset 60 min in 70.3% of women vs 29.7% of men. There were no significant differences in door-to-needle (median; 28 min vs 26 min) and door-to-balloon (median: 45 min vs 45 min) times. Major (z >4)determinants of poorer rates of reperfusion therapies included time to treatment from symptom onset >12 hours (adjusted OR: 5.37, CI: 4.58 - 6.31) Killip class > 2 (OR: 1.53, CI: 1.27-1.86) and history of prior heart failure (OR: 2.77, CI, 1.99 to 3.87). After adjustment, women had greater inhospital mortality rates than men (OR: 1.34, CI: 1.01-1.77). Sex differences in in-hospital mortality rates were no longer observed in the cohort, when time to treatment from symptom onset <12 hours was included in the multivariable analysis (OR: 1.31, CI: 0.98 -1.74). Conclusion: Sex differences in outcomes persist among STEMI patients, as fewer women receive timely reperfusion therapy. Pre-hospital delays in women experiencing STEMI remain unacceptably long

Barriers to risk stratification accuracy in ischemic heart disease in women: the role of non-obstructive coronary artery disease

Background: A substantial part of literature has been centered on sex differences in the clinical aspects of ischemic heart disease (IHD). Many reports have documented differences in the presentation and risk profile between women and men. Such differences drive sex-related inequalities in the referral and treatment of IHD. Yet data are insufficient to clarify the reasons for such disparities. The objective of this review is to analyze the main gender differences regarding symptoms, diagnosis, and risk stratification of coronary heart disease in order to identify \u201cgaps\u201d in existing literature that need to be addressed in future research efforts. Methods: We searched English-language studies on MEDLINE and the Cochrane Database of Systematic Reviews from the database start dates to January 2016. Evidence synthesis was based on cohort studies, registry data, and clinical trial data. Results: Women do not often participate in clinical studies. In a number of articles, authors have questioned how the "white male\u201d came to be the prototype of the human research subject. Consequently although many reports continue to describe differential treatment based on patients\u2019 sex, the extent to which such inequalities are due to true sex differences in pathophysiology or whether they reflects inaccuracy in risk stratification is unclear. Conclusion: Today, even the best database is incapable in and of itself of supplying answers to the question of whether women are being treated less compared with men by the medical community