Evaluation of metabolic syndrome in adults of Talca city, Chile

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Benefit of early invasive therapy for diabetic patients with NSTE ACS. A landmark study from the ISACS-TC registry

Background: Diabetic (DM) patients are at increased risk of cardiovascular events after an acute coronary syndrome, yet it remains unknown whether they derive enhanced benefit from an invasive strategy. Objective: We investigated the relation between coronary revascularization by percutaneus coronary intervention (PCI) and in-hospital survival of DM patients admitted to hospitals with a diagnosis of Unstable angina/ Non-ST-elevation myocardial infarction (UA/NSTEMI). Methods: This was a prospective cohort study using data from the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACSTC, NCT01218776) registry on patients admitted to the coronary care units of 58 Eastern European hospitals from January 2010 to February 2015. A total of 4,996 first-day survivors who were admitted with a diagnosis of UA/NSTEMI were included. To avoid survival bias, a landmark time was set to 24 hours after hospital admission. Patients who died before the landmark time were excluded. Patients, who had undergone coronary artery bypass grafting, were also excluded leaving a final study population of 4,965 patients. Results: The study populations consisted of 4,965 NSTE-ACS patients. There were 1,381 patients (27.8%) with DM. Patients with DM were older and prevalently women, and had higher rates of hypercholesterolemia, hypertension, prior cardiovascular events and chronic kidney disease. They had more severe clinical presentation and higher rates of atypical chest pain. Patients with DM underwent less (p<0.001) PCI (58.9% versus 65.9%) and had significantly higher (p<0.001) in-hospital mortality (6.2% versus 3.7%) than their non- DM counterpart. Multivariate regression analyses showed DM as a predictor of in-hospital mortality in patients who did not undergo PCI (odds ratio [OR] 2.21, 95% confidence interval [CI] 1.18–4.13, p=0.013), but not in those who underwent revascularization (OR: 1.79, 95% CI: 0.60–5.32, p=0.29). Conclusions: There is an independent association between DM and in hospital mortality in UA/NSTEMI patients who were not offered coronary revascularization. An invasive strategy has significant effect in reducing the likelihood of cardiovascular death in diabetic patients

Inaccurate treatment and poor outcome in patients with ACS and atypical symptoms

Purpose: We explored clinical characteristics and outcome associated with atypical chest pain (CP) in patients with diagnosis of ACS. Methods: Data of 8947 patients (32.4% women) from the International Survey of Acute Coronary Syndrome in Transitional Country (ISACS-TC) were reviewed in our comprehensive coordinating center. Only patients with admission and discharge diagnosis of ACS were considered. Results: There were 778 patients with atypical CP for the index event. These patients were significantly (p12 hrs to arrive to hospital; absence of typical CP doubled the probability (OR: 2.18; CI: 1.89–2.55) to late hospital presentation. Interestingly, patients without typical CP were significantly more likely to exhibit signs of heart faliure (42.8% vs. 22.1%), although they less frequently had STEMI as index even. In-hospital mortality rate was in the overall cohort 8.2% (STEMI: 9.1%, NSTEMI: 8.8%, UA: 2.1%). Yet, the mortality was significantly greater for patients with atypical CP (STEMI: 19.8%, NSTEMI: 19.3%) than for those with typical CP (STEMI: 6.7%, NSTEMI: 7.1%). It should be noted, however, that patients with atypical CP were less likely (p<0.001) to receive medications (aspirin 90.4% vs. 96.2%; beta-blockers 66.9% vs. 78.9%) and invasive procedures (21% vs. 47.6%) than patients with typical CP. Conclusions: ACS without typical CP is not a rare experience and it is associated many co-morbidity and poor outcome, both in women and men. Strategies to avoid underestimation of atypical symptoms represent potential opportunities for improving the outcome of these patients

Atypical presentation and comorbidities mutually influence management of ACS patients

Background: Limited data are available on the association between comorbidities and acute myocardial ischemia with atypical presentation. Purpose: The aim of this study was to investigate the impact of comorbidities on the management and outcomes of ACS patients with atypical presentation (i.e. ACS without chest pain). Methods: Between 2010 and 2016, 11458 ACS patients were admitted at 57 hospitals included in the network of the ISACS-TC registry (ClinicalTrials.gov, NCT01218776). There were 1394 (12.2%) patients with unstable angina, 2855 (24.9%) with NSTEMI, and 7203 (62.9%) with STEMI. Results: 995 (8.7%) ACS patients have atypical presentation at the initial evaluation, and the 40.2% of the overall study population have comorbidities (diabetes mellitus, heart failure, CKD, COPD, stroke, PAD, GERD or active cancer). Patients with comorbidities were not equally distributed: 38.7% were with typical presentation and 55.2% without typical presentation, (p<0.001). In-hospital mortality rate was much higher in patients with atypical presentation than in patients with the typical one (15.5% vs 6.3%, p<0.001). As well, mortality rate was lower for ACS patients with no-comorbidities than for ACS patients with comorbidities (5.1% versus 10.1%, p<0.001). Stratifying the population by the presence/absence of comorbiditis and the presence/absence typical presentation, we found a decreasing trend in use of evidence base treatment (aspirin, beta-blocker, statin and reperfusion) and invasive procedure. Compare to patients with typical presentation and no-comorbidities (OR: 1, referent), patients with typical presentation and comorbidities (OR: 0.70), as well as those with atypical presentation and no-comorbidities (OR: 0.23), and those with atypical presentation and comorbidities (OR: 0.18) had a significant (p<0.001) lower probability to undergo in-hospital cardiac catheterization. On the opposite, there was an increasing trend (p<0.001) over subgroups in the risk of death (OR:1 referent, typical ACS presentation and no-comorbid; OR:2.00 typical ACS presentation and comordidities; OR: 2.52 atypical ACS presentation and no-comorbid; OR: 4.83 atypical ACS presentation and comordidities). Conclusions: The presence of comorbidities and atypical ACS presentation dramatically influence the process of care. Patients with atypical presentation and comorbidities are those who receive the lowest treatment and those who have the highest risk of in-hospital death

Acute coronary syndromes without typical chest pain: the role of comorbidities

Background: Not all patients exhibit the classic symptoms of chest pain. Patients who present with acute coronary syndrome (ACS) without typical chest pain have a very high in-hospital mortality. Purpose: To investigate the impact of atypical symptoms on management and outcomes of ACS patients. Methods: Between 2010 and 2016, 11458 ACS patients were admitted at 57 hospitals included in the network of the ISACS-TC registry (ClinicalTrials.gov, NCT01218776). Of these patients 8.7% did not have typical chest pain at the initial evaluation. Results: More women (10.5%) than men (7.8%) exhibit ACS without typical presentation. ACS patients with atypical presentation were older (67.8\ub112.2 vs 62.9\ub112.1, p<0.001). Patients with comorbidities were not equally distributed: 38.7% were with typical presentation and 55.2% without typical presentation, (p<0.001). The probability of having ACS without typical presentation was greater as the number of comorbidities increased (OR: 1.64 for one comorbid; OR: 2.52 for two comorbidities; and OR: 4.57 for three or more comorbidities). Stepwise logistic analysis showed that the absence of ST elevation (OR 2.98), Killip class 652 (OR 2.12, history of stroke (OR 1.78), peripheral artery disease (OR 1.68), chronic kidney disease (OR 1. 56), diabetes mellitus (OR 1.36), age (OR 1.02 per year) were all independent predictors of ACS without typical presentation. Conversely smoking habit (OR 0.75) and hypercholesterolemia (OR 0.72) had protective effect (p<0.01). In-hospital mortality rate was much higher in patients without typical presentation than in patients with the typical presentation (15.5% versus 6.3%, p<0.001). The presence of atypical presentation increased the risk of death either in non ST segment elevation acute coronary syndrome (NSTE-ACS) (OR 2.57, 95% CI 1.91\u20133.47) or ST segment elevation myocardial infarction (STEMI) patients (OR 3.48, 95% CI 2.70\u20134.49). The presence of comorbidities was also independently associated with an increased risk of death, both in NSTE ACS (OR 2.24, 95% CI 1.70\u20132.93) and in STEMI (OR 2.22, 95% CI 1.56\u20132.63) patients. Conclusions: Patients with ACS who present without typical chest pain are at increased risk of dying. Atypical presentation is frequently found in patients with comorbidities. The unfavorable outcomes of ACS without chest pain may be partly attributable to concomitant diseases

Acute coronary syndrome in octogenarian patients: results from the international registry of acute coronary syndromes in transitional countries (ISACS-TC) registry

We sought to investigate characteristics, treatment, and outcome of octogenarian patients during hospital stay for acute coronary syndrome (ACS) in a transitional country. This is a cohort study of 437 patients 65 80 years old, consecutively admitted with a diagnosis of ACS at 14 hospitals in 8 Eastern European countries reporting data to ISACS-TC registry. The primary endpoint was in-hospital mortality. The mean age of the study population was 83.5 years; 50.1% of the patients were women. Females, less frequently than males, had a history of myocardial infarction, smoking habit, and episodes of typical chest pain. But they were more often admitted with left ventricular dysfunction. The rate of reperfusion treatment (29.5%) was very low in patients with STelevation myocardial infarction (STEMI). Also, most of the overall study population had a non-invasive approach (women, 79% vs. men, 70.6%; P= 0.042). However, when the coronary anatomy was known, there were no differences in the rates of revascularization between genders. There was no difference in the rates of death between male (21%) and female (21.1%) patients. Univariate and multivariate analyses revealed that the independent predictors (P <0.05) of death in octogenarians were systolic blood pressure ,100 mmHg (odds ratio [OR], 2.74), Killip class 65 2 (OR, 1.71), and STEMI as an index event (OR, 2.01). Evidence-based drugs (beta-blockers, statins, and ACE-inhibitors) had all independent significant protective effect on the hospital outcome. In conclusion, age is relevant in the prognosis of ACS, but its importance should be considered not secondary to other clinical factors

Perspectives: Rationale and design of the ISACS-TC (International Survey of Acute Coronary Syndromes in Transitional Countries) project

During the past 10 years, the health of people in Eastern Europe and the former Soviet Union has undergone changes very different from the health patterns seen in their Western counterparts. Mortality from cardiovascular disease has been decreasing continuously in the USA and many Western European countries, but it has increased or remained unchanged in many of the states of Eastern Europe. Analysis of this phenomenon has been hindered by insufficient information. The International Registry of Acute Coronary Syndromes registry study in Transitional Countries (ISACS-TC) is both a retrospective - over a 1-year period - and prospective study which was designed in order to obtain data of patients with acute coronary syndromes (ACSs) in countries with economy in transition in Central and Eastern Europe, and herewith control and optimize internationally guideline recommended therapies in these countries. Adhesion to the project was given by 112 Collaborating Centres in 17 countries with economy in transition (Albania, Bosnia and Herzegovina, Belarius, Bulgaria, Croatia, Hungary, Kosovo, Latvia, Lithuania, Macedonia, Moldova, Montenegro, Romania, Russian Federation, Serbia, Slovakia, Slovenia, and Ukraine). A total of 47 cluster sites in 11 countries in Central and Eastern Europe are currently collaborating in ISACS-TC. The registry encourages optimal individualization of evidence-based therapies and the international patient body ensures good representation of multiple practice patterns. It may help to make an additional improvement in clinical outcomes of countries with economy in transition

ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC).

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