Acute Coronary Syndrome

To determine, among patients who present to the emergency department with symptoms suggestive of acute coronary syndrome (ACS), predictors of short-term revascularization. A prospective descriptive trial was performed. Potential predictors for revascularization were measured by means of a questionnaire of providers, serum for cardiac biomarkers, and an initial ECG. The primary outcome of revascularization (coronary bypass graft or percutaneous intervention) was determined through a medical record review. Potential predictors of revascularization were entered into a family of logistic regressions. 341 eligible subjects were enrolled, of whom 14% underwent revascularization. The predictors of revascularization included ST elevation on initial ECG (odds ratio 12.0), and an elevation in troponin I (odds ratio 8.9), CKMB (odds ratio 6.8), or myoglobin (odds ratio 4.7) on admission. When all three biomarkers competed in the same model, troponin I appeared to be the strongest predictor of short-term revascularization. In a single site study, among emergency department patients with symptoms suggestive of ACS, ST elevation on initial ECG and an elevation in troponin I, CK-MB, and myoglobin upon presentation all predicted short -term revascularization. Among the three biomarkers, elevation in troponin I was the strongest predictor. ABBREVIATED ABSTRACT: We conducted a prospective descriptive trial to identify predictors of short-term revascularization among 341 emergency department patients who presented with symptoms suggestive of ACS. Fourteen percent of the study population received revascularization. Predictors of revascularization included ST elevation on initial ECG (odds ratio 12.0.), and an elevation in troponin I (odds ratio 8.9), CKMB (odds ratio 6.8), or myoglobin (odds ratio 4.7) on admission. When all three biomarkers competed in the same model, troponin I appeared to be the strongest predictor of short-term revascularization.

The appropriate treatment target for systolic blood pressure (SBP) in older patients with hypertension remains uncertain. To evaluate the effects of intensive (<120 mm Hg) compared with standard (<140 mm Hg) SBP targets in persons aged 75 years or older with hypertension but without diabetes. A multicenter, randomized clinical trial of patients aged 75 years or older who participated in the Systolic Blood Pressure Intervention Trial (SPRINT). Recruitment began on October 20, 2010, and follow-up ended on August 20, 2015. Participants were randomized to an SBP target of less than 120 mm Hg (intensive treatment group, n = 1317) or an SBP target of less than 140 mm Hg (standard treatment group, n = 1319). The primary cardiovascular disease outcome was a composite of nonfatal myocardial infarction, acute coronary syndrome not resulting in a myocardial infarction, nonfatal stroke, nonfatal acute decompensated heart failure, and death from cardiovascular causes. All-cause mortality w...

Background: Most patients are recommended secondary prevention pharmacotherapies following an acute coronary syndromes (ACS).
Aim: To identify predictors of adherence at 6 months and strategies to improve adherence to these therapies.
Methods: Patients in the CONCORDANCE registry who were discharged on evidence‐based medications were stratified into those receiving ≥75% (‘adherent’) or <75% (‘non‐adherent’) of indicated medications at 6 months. Baseline characteristics, hospital and post‐discharge care were compared between groups. Multivariable logistic analysis identified independent predictors of adherence. The relative contribution of each clinical or treatment factor to ‘adherence’ was determined using an adequacy measure method.
Results: Follow‐up data were available for 6595 patients, 4492 (68.1%) of whom were ‘adherent’. Clinical factors predictive of adherence included previous stroke, percutaneous coronary intervention (PCI) and hypertension (odds ratios (OR) 1.36–1.56); factors predictive of non‐adherence included discharge diagnosis of non–ST‐segment elevation myocardial infarction (vs unstable angina) (OR 0.51) and atrial fibrillation (OR 0.59). Discharge on ≥75% of indicated medications was a strong predictor of adherence at 6 months (OR 10.23, 95% confidence interval 7.89−13.27); in‐hospital management factors predicting non‐adherence were medical management alone (OR 0.34) and coronary artery bypass graft (OR 0.50) (both vs PCI). Post‐discharge predictors of adherence included cardiac rehabilitation (OR 1.36) and general practitioner attendance (OR 1.40).
Conclusion: Failure to discharge patients on indicated therapies is the most important modifiable predictor of adherence failure 6 months after an ACS. Implementing protocols to automate prescription of indicated discharge therapies, has the potential to reduce non‐adherence dramatically in the 6 months following discharge.

Coronary artery bypass grafting (CABG) is an established revascularization procedure for the treatment of advanced atherothrombotic coronary artery disease.1 The National Center for Health Statistics estimated that 427,000 procedures were performed on 249,000 patients in the ...

Optical coherence tomography (OCT) is the &#39;new kid on the block&#39; in coronary imaging. This technology offers clinicians a high resolution (approximately 15 μm), that is ten times higher than the currently accepted gold standard of intravascular ultrasound and has emerged as the ideal imaging tool for the assessment of superficial components of coronary plaques and stent struts. Novel OCT systems can perform quick and safe scanning of coronary arteries with a non-occlusive technique. A brief summary containing the key physical principles of OCT technology with particular attention to the novel Fourier domain system is presented. This review will focus on clinical and research applications of OCT in interventional cardiology. The two main fields of OCT in vivo: coronary atherosclerosis assessment and the study of vessel wall response to stent implantation in terms of strut coverage and apposition will be delineated. Limitations and future perspectives of the technique are pres...

ABSTRACT Heart fatty-acid binding protein (h-FABP) is a small cytosolic protein (15 kDa) that is abundant in the heart. Its concentration in the plasma of healthy persons is relatively low (&amp;lt;6 μg/L). The h-FABP is rapidly released into the circulation from damaged myocardium and is cleared from the circulation by the kidney with a plasma half-time of 20 min. Analysis of the release kinetics of h-FABP revealed that levels were elevated above the cutoff level within 2 h after the onset of acute myocardial infarction, peaked at 4 h, and were complete within 20 h. Several studies indicate its usefulness in cardiology: exclusion of acute myocardial infarction, detection of reperfusion, prognostic value… Additional studies are needed to confirm these data and to specify its diagnostic and prognostic usefulness in patients with acute coronary syndromes (ACS). The use of this biological test seems to be most interesting in the prehospital phase than in the hospital phase.

Background: Structured risk-stratification to guide clinician assessment and engagement with evidence-based therapies may reduce care variance and improve patient outcomes for Acute Coronary Syndrome (ACS). The Australian Grace Risk score Intervention Study (AGRIS) explored the impact of the GRACE Risk Tool for stratification of ischaemic and bleeding risk in ACS.  While hospitals in the active arm had a higher overall rate of invasive ACS management, there was neutral impact on important secondary prevention prescriptions/referrals, hospital performance measures, myocardial infarction and 12-month mortality leading to early trial cessation. Given the Grace Risk Tool is under investigation internationally, this process evaluation study provides important insights into the possible contribution of implementation fidelity on the AGRIS study findings. 
Methods: Using maximum variation sampling, five hospitals were selected from the 12 centres enrolled in the active arm of AGRIS. From these facilities, 16 local implementation stakeholders (Cardiology advanced practice nurses, junior and senior doctors, study coordinators) consented to a semi-structured interview guided by the Theoretical Domains Framework. Directed Content Analysis of qualitative data was structured using the Capability/Opportunity/Motivation-Behaviour (COM-B) model.
Results: Physical capability was enhanced by tool usability. While local stakeholders supported educating frontline clinicians, non-cardiology clinicians struggled with specialist terminology.  Physical opportunity was enhanced by the paper-based format but was hampered when busy clinicians viewed risk-stratification as one more thing to do, or when form visibility was neglected. Social opportunity was supported by a culture of research/evidence yet challenged by clinical workflow and rotating medical officers.  Automatic motivation was strengthened by positive reinforcement. Reflective motivation revealed the GRACE Risk Tool as supporting but potentially overriding clinical judgment. Divergent professional roles and identity were a major barrier to integration of risk-stratification into routine Emergency Department practice. The cumulative result revealed poor form completion behaviors and a failure to embed risk-stratification into routine patient assessment, communication, documentation, and clinical practice behaviors.
Conclusions: Numerous factors negatively influenced AGRIS implementation fidelity.  Given the prominence of risk assessment recommendations in United States, European and Australian guidelines, strategies that strengthen collaboration with Emergency Departments and integrate automated processes for risk-stratification may improve future translation internationally.