Evolution of hospital discharge medication and 6 months outcomes of ST-Segment Elevation Myocardial Infarction patients in Portugal over the years

Abstract Objectives To assess the evolution of hospital discharge management, 6 months hospitalization and mortality over the years of all patients admitted with ST segment elevation myocardial infarction (STEMI) in Portugal. Methods A nationwide electronic prospective registry that included all patients admitted to Portuguese hospitals with a diagnosis of Acute Coronary Syndrome since 2002 until 2018 was used to collect all data relative to patients admitted with a STEMI diagnosis during that time frame. Data on demographic data, clinical status, revascularization strategy, discharge medication and 6 months hospitalization and mortality were obtained. We compared the data and its evolution over the years to assess for trends. For statistical analysis, Qui-square tests were used to assess trends in categorical variables, and Kruskal-Wallis tests were used to assess trends in numerical variables. A p-value <0.05 was considered statistically significant. Results During the study, a total of 23807 patients were admitted for STEMI in Portuguese hospitals, 74.3% were male and average age of 63.9±13.6 years. We report a progressive and significant increase the use of primary angioplasty versus fibrinolysis (24.3% to 98.4%, p<0.001), in coronary angioplasties (36.4% to 73.2%, p<0.001), in the use of drug-eluting stents (0% to 70.1%, p<0.001), and a decrease in the patients that underwent surgery (6.8% to 1.3%, p<0.001) and intra-aortic balloon pump (1.8% to 0%, p=0.009), resulting in a decrease in in-hospital mortality from 9.9% to 6.1% (p<0.001). At discharge, we report a progressive increase in the prescription of P2Y12 inhibitors (21.1% to 95.2%, p<0.001), beta-blockers (68.8% to 83.8%, p<0.001), RAAS inhibitors (69.5% to 86.7%, p<0.001) and statins (79.6% to 94.9%, p<0.001), while the prescription of aspirin (94.1% para 94.8%, p=0.428), calcium channel blockers (5.3% to 5.6%, p<0.684) stayed stable, and there was a decrease in the prescription of nitrates (52.9% to 5.8%, p<0.001). Hospital admissions at 6 months consistently and progressively reduced over time (18.6% to 8.5%, p<0.001) as well as mortality (6.7% para 4.3%, p<0.001). Conclusion Post discharge treatment of STEMI patients in Portuguese hospitals has evolved according to guidelines, with higher prescription of medication proven to reduce outcomes, resulting in lower hospitalization rates and mortality. 6 Month Outcomes over the years Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Sociedade Portuguesa de Cardiologia

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Evolution of in-hospital management in ST Segment Elevation Myocardial Infarction in Portuguese hospitals over the years

European Heart Journal ◽

10.1093/ehjci/ehaa946.1619 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

J.P De Sousa Bispo ◽

T.F Mota ◽

R Fernandes ◽

P Azevedo ◽

D Carvalho ◽

...

Keyword(s):

Myocardial Infarction ◽

Hospital Management ◽

Public Institution ◽

Categorical Variables ◽

Funding Source ◽

St Segment Elevation ◽

Coronary Syndrome ◽

Segment Elevation Myocardial Infarction ◽

St Segment ◽

Complications And Mortality

Abstract Objectives To assess the evolution of in-hospital management of ST Segment Elevation Myocardial Infarction (STEMI) over the years in Portuguese hospitals and its impact on in-hospital complications and mortality Methods A nationwide electronic prospective registry that included all patients admitted to Portuguese hospitals with a diagnosis of acute coronary syndrome since 2002 until 2019 was used to collect all data relative to patients admitted with a STEMI diagnosis during that time frame. Data on demographic data, clinical data, revascularization strategy, medication during hospitalization. We compared the data and its evolution over the years to assess for trends. For statistical analysis, Qui-square tests were used to assess tendencies in categorical variables, and Kruskal-Wallis tests were used to assess tendencies in numerical variables. A p-value <0.05 was considered statistically significant. Results During the study, a total of 24425 patients were admitted for STEMI in Portuguese hospitals, 74.3% were male and average age of 63.9±13.6 years. We report a progressive increase in patients treated with aspirin, P2Y12 inhibitors (from 22.2% to 97.6% – p<0.001), beta blockers 62.% to 72.4% – p<0.001), ACE inhibitors (68.9% to 78.2% – p<0.001) and statins (72.1% to 88.4% – p<0.001), a progressive decrease in GP 2a3b inhibitors (20.9 to 14.6% – p<0.001), enoxaparin (55.2% to 29.9% – p<0.001), nitrates (82.7% to 16.1% – p<0.001), calcium channel blockers (5.0% to 3.1% – p<0.001) and inotropes (12.0% to 5.6% – p<0.001). There was an increase of the use primary coronary angioplasty (36.4% to 73.2% – p<0.001), and of drug eluting stents (0% to 70.1% – p<0.001) a decrease in the use of fibrinolysis (75.7% to 1.6% – p<0.001), bare metal stents (88.1% to 0.3% – p<0.001) and intra-aortic balloon pump (1.8% to 0% – p=0.009), but not in invasive mechanical ventilation (2.5% to 1.9% – p=0.142). Less patients had moderate to severely impaired left ventricle ejection fraction (28.8% to 14.9% – p<0.001), and there was a significant reduction in almost all in-hospital complications: re-infarction (2.0% to 1.0% – p<0.001); heart failure (36.2% to 9.9% – p<0.001); cardiogenic shock (10.8% to 3.9% – p<0.001); AV block (5.8% to 2.5% – p<0.001); mechanical complications (2.8% to 0.4% – p<0.001); stroke (1.3% to 0.4% – p<0.001); in-hospital mortality (9.9% to 3.8% – p<0.001); as well as length of stay ([4–10] days to [3–6] days – p<0.001). Exceptions were and increase in major bleeding (0.9% to 1.8% – p<0.001) and resuscitated cardiac arrest (3.9% to 4.5%, p=0.001). Conclusion In 17 years, we report a progressive evolution of the in-hospital treatment of STEMI patients in Portuguese hospitals, with a higher prescription of guideline recommended medications, use of invasive reperfusion techniques and last generation stents, resulting in a lower rate of in-hospital complications and mortality. In-hospital outcomes over the years Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Registo Nacional de Síndromes Coronárias Agudas - Sociedade Portuguesa de Cardiologia

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High-sensitivity cardiac troponin concentrations at presentation in patients with ST-segment elevation myocardial infarction

European Heart Journal ◽

10.1093/ehjci/ehaa946.1702 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

R Wereski ◽

K.K Lee ◽

S Smith ◽

A.R Chapman ◽

D Lowe ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Coronary Syndrome ◽

Cardiac Troponin ◽

High Sensitivity ◽

Funding Source ◽

St Segment Elevation ◽

Coronary Syndrome ◽

Segment Elevation Myocardial Infarction ◽

St Segment ◽

Rule Out

Abstract Background The widespread adoption of high-sensitivity cardiac troponin testing has encouraged the use of pathways to accelerate the rule-out and rule-in myocardial infarction in the Emergency Department. These pathways are not recommended for patients with ST-segment elevation, but there is a risk they may be applied incorrectly given that interpretation of the electrocardiogram is subjective, dependent on experience, and signs may be masked in those with posterior myocardial infarction. Methods Consecutive patients with suspected acute coronary syndrome were enrolled in a stepped-wedge cluster randomized controlled trial across ten hospitals in Scotland. The index diagnosis was adjudicated two clinicians independently in all patients with high-sensitivity cardiac troponin I concentrations above the sex-specific 99th centile on serial testing and abnormalities on the electrocardiogram recorded. The proportion of patients with ST-segment elevation myocardial infarction and concentrations below the rule-out threshold (<5 ng/L), 99th centile (<16 ng/L and <34 ng/L for women and men) and rule-in threshold (<52 ng/L) at presentation were determined. Results In total 48,282 patients were recruited between June 2013, and March 2016 of which 22% (10,360/48,282) had peak cardiac troponin concentrations above the 99th centile. The adjudicated diagnosis was type 1 myocardial infarction in 55% (4,981/9,115) of patients and 10% (925/9,115) had ST-segment elevation myocardial infarction (age 65 [14] years, 68% men). The majority presented within 6 hours of symptom onset (67%, 619/925), and 84% (772/925) had cardiac troponin concentrations above the 99th centile at presentation. However, troponin concentrations were below the rule-out threshold in 2% (20/925) and the rule-in threshold in 26% (240/925) of patients with ST-segment elevation myocardial infarction. Discussion In patients with suspected acute coronary syndrome who have a final diagnosis of ST-segment elevation myocardial infarction, high-sensitivity cardiac troponin concentrations are below the rule-out and rule-in threshold at presentation in 1 in 50 and 1 in 4 patients, respectively. Clinicians should not rely on cardiac troponin concentrations to guide initial treatment decisions in patients with possible ST-segment elevation myocardial infarction. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): British Heart Foundation

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Effect of PCSK9 E670G and R46L Polymorphisms on Major Adverse Cardio-Cerebrovascular Events in Patients with ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

International Journal of Angiology ◽

10.1055/s-0041-1722875 ◽

2021 ◽

Author(s):

Anwar Santoso ◽

Yulianto Yulianto ◽

Hendra Simarmata ◽

Abhirama Nofandra Putra ◽

Erlin Listiyaningsih

Keyword(s):

Myocardial Infarction ◽

Proportional Hazards Model ◽

Cox Proportional Hazards ◽

Cox Proportional Hazards Model ◽

St Segment Elevation ◽

Coronary Syndrome ◽

Segment Elevation Myocardial Infarction ◽

Cerebrovascular Events ◽

St Segment ◽

Significant Difference

AbstractMajor adverse cardio-cerebrovascular events (MACCE) in ST-segment elevation myocardial infarction (STEMI) are still high, although there have been advances in pharmacology and interventional procedures. Proprotein convertase subtilisin/Kexin type 9 (PCSK9) is a serine protease regulating lipid metabolism associated with inflammation in acute coronary syndrome. The MACCE is possibly related to polymorphisms in PCSK9. A prospective cohort observational study was designed to confirm the association between polymorphism of E670G and R46L in the PCSK9 gene with MACCE in STEMI. The Cox proportional hazards model and Spearman correlation were utilized in the study. The Genotyping of PCSK9 and ELISA was assayed.Sixty-five of 423 STEMI patients experienced MACCE in 6 months. The E670G polymorphism in PCSK9 was associated with MACCE (hazard ratio = 45.40; 95% confidence interval: 5.30–390.30; p = 0.00). There was a significant difference of PCSK9 plasma levels in patients with previous statin consumption (310 [220–1,220] pg/mL) versus those free of any statins (280 [190–1,520] pg/mL) (p = 0.001).E670G polymorphism of PCSK9 was associated with MACCE in STEMI within a 6-month follow-up. The plasma PCSK9 level was higher in statin users.

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Analysis of risk factors for different subtypes of acute coronary syndrome

Journal of International Medical Research ◽

10.1177/03000605211008326 ◽

2021 ◽

Vol 49 (5) ◽

pp. 030006052110083

Author(s):

Lei Zhang ◽

Juledezi Hailati ◽

Xiaoyun Ma ◽

Jiangping Liu ◽

Zhiqiang Liu ◽

...

Keyword(s):

Risk Factors ◽

Myocardial Infarction ◽

Acute Coronary Syndrome ◽

Brain Natriuretic Peptide ◽

Left Ventricular ◽

St Segment Elevation ◽

Amino Terminal ◽

Coronary Syndrome ◽

Segment Elevation Myocardial Infarction ◽

St Segment

Aims To investigate the different risk factors among different subtypes of patients with acute coronary syndrome (ACS). Methods A total of 296 patients who had ACS were retrospectively enrolled. Blood and echocardiographic indices were assessed within 24 hours after admission. Differences in risk factors and Gensini scores of coronary lesions among three groups were analyzed. Results Univariate analysis of risk factors for ACS subtypes showed that age, and levels of fasting plasma glucose, amino-terminal pro-brain natriuretic peptide, and creatine kinase isoenzyme were significantly higher in patients with non-ST-segment elevation myocardial infarction (NSTEMI) than in those with unstable angina pectoris (UAP). Logistic multivariate regression analysis showed that amino-terminal pro-brain natriuretic peptide and the left ventricular ejection fraction (LVEF) were related to ACS subtypes. The left ventricular end-diastolic diameter was an independent risk factor for UAP and ST-segment elevation myocardial infarction (STEMI) subtypes. The severity of coronary stenosis was significantly higher in NSTEMI and STEMI than in UAP. Gensini scores in the STEMI group were positively correlated with D-dimer levels (r = 0.429) and negatively correlated with the LVEF (r = −0.602). Conclusion Different subtypes of ACS have different risk factors. Our findings may have important guiding significance for ACS subtype risk assessment and clinical treatment.

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Clots Kill: Hematologic Pharmacology for ST-Segment Elevation Myocardial Infarction

Critical Care Nurse ◽

10.4037/ccn2012104 ◽

2012 ◽

Vol 32 (6) ◽

pp. 35-41

Author(s):

Stacy H. James

Keyword(s):

Myocardial Infarction ◽

Acute Coronary Syndrome ◽

Antiplatelet Agents ◽

Thrombin Inhibitors ◽

Fibrinolytic Agents ◽

St Segment Elevation ◽

Coronary Syndrome ◽

Segment Elevation Myocardial Infarction ◽

St Segment

Drugs that work on the hematologic system play an important role in helping to limit the morbidity and mortality that can be associated with an acute coronary syndrome. The pharmacology of the fibrinolytic agents, thrombin inhibitors, and antiplatelet agents is described. A case study of a woman having an ST-segment elevation myocardial infarction is reviewed to highlight the importance of drugs that work on the hematologic system.

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Unstable Angina and Other Acute Coronary Syndromes

10.2310/7900.1060 ◽

2013 ◽

Author(s):

R Scott Wright ◽

Joseph G Murphy

Keyword(s):

Myocardial Infarction ◽

Coronary Artery ◽

Risk Stratification ◽

Unstable Angina ◽

The United States ◽

Cardiac Biomarkers ◽

St Segment Elevation ◽

Coronary Syndrome ◽

Segment Elevation Myocardial Infarction ◽

St Segment

Patients with coronary artery disease (CAD) present clinically when their disease enters an unstable phase known as an acute coronary syndrome (ACS), in which the cap of a previously stable atheromatous coronary plaque ruptures or erodes, which in turn activates a thrombotic cascade that may lead to coronary artery occlusion, myocardial infarction (MI), cardiogenic shock, and patient death. There are nearly 2 million episodes of ACS in the United States annually; it is the most common reason for hospitalization with CAD and is the leading cause of death in the developed world. ACS patients include those with unstable angina (UA), non–ST segment elevation myocardial infarction (non-STEMI), and ST segment elevation myocardial infarction (STEMI) and patients who die suddenly of an arrhythmia precipitated by coronary occlusion. The distinction among various ACS subgroups reflects varying characteristics of clinical presentation (presence or absence of elevated cardiac biomarkers) and the type of electrocardiographic (ECG) changes manifested on the initial ECG at the time of hospitalization. This chapter focuses on UA and non-STEMI. A graph outlines mortality risks faced by patients with varying degrees of renal insufficiency. An algorithm describes the suggested management of patients admitted with UA or non-STEMI. Tables describe the risk stratification of the patient with chest pain, categories of Killip class, examination findings of a patient with high-risk ACS, diagnosis of MI, causes of troponin elevation other than ischemic heart disease, initial risk stratification of ACS patients, and long-term medical therapies and goals in ACS patients. This review contains 2 highly rendered figures, 11 tables, and 76 references.

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Loeffler’s endocarditis and possible coronary spasm secondary to eosinophilic coronary periarteritis with ECG change mimicking acute non-ST-segment elevation myocardial infarction: A case report

10.21203/rs.2.24315/v1 ◽

2020 ◽

Author(s):

Fan-xin Kong ◽

Meng Li ◽

Chun-Yan Ma ◽

Ping-ping Meng ◽

Yong-huai Wang ◽

...

Keyword(s):

Myocardial Infarction ◽

Differential Diagnosis ◽

Coronary Artery ◽

Troponin I ◽

Hypereosinophilic Syndrome ◽

Coronary Spasm ◽

St Segment Elevation ◽

Coronary Syndrome ◽

Segment Elevation Myocardial Infarction ◽

St Segment

Abstract Background Loeffler’s endocarditis is an inflammatory cardiac condition of hypereosinophilic syndrome which rarely involves coronary artery. When coronary artery is involved, known as eosinophilic coronary periarteritis, the clinical presentation, electrocardiographic changes and troponin level are extremely nonspecific and may mimic acute coronary syndrome. It is very important to make differential diagnosis for ECPA in order to avoid the unnecessary further invasive coronary angiography. Case presentation We report a case with chest pain, ST-segment depression in electrocardiogram and increased troponin-I mimicking acute non-ST-segment elevation myocardial infarction. However, quick echocardiography showed endomyocardial thickening with normal regional wall motion, which corresponded to the characteristics of Loeffler’s endocarditis. Emergent blood analysis showed marked increase in eosinophils and computed tomography angiography found no significant stenosis of coronary artery. Manifestations of magnetic resonance imaging consisted with findings of echocardiography. Finally, the patient was diagnosed as Loeffler’s endocarditis and possible coronary spasm secondary to eosinophilic coronary periarteritis. Conclusion This case exhibits the crucial use of quick transthoracic echocardiography and the emergent hematological examination for differential diagnosis in such scenarios as often if electrocardiogram change mimicking myocardial infarction.

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Takotsubo Cardiomyopathy and Non-ST-Segment Elevation Myocardial Infarction: Predictors of Left Ventricular Dysfunction

Clinical Medicine Insights Cardiology ◽

10.1177/1179546817716103 ◽

2017 ◽

Vol 11 ◽

pp. 117954681771610

Author(s):

Andrew Hinojos ◽

Thomas E Vanhecke ◽

Susan Enright ◽

Nathan Elg ◽

Kristina Gifft ◽

...

Keyword(s):

Myocardial Infarction ◽

Left Ventricular ◽

Retrospective Case ◽

St Segment Elevation ◽

Coronary Syndrome ◽

Segment Elevation Myocardial Infarction ◽

Lv Dysfunction ◽

St Segment ◽

Artery Disease ◽

Control Study

Background: Acute coronary syndrome (ACS) from non-ST-segment elevation myocardial infarction (NSTEMI) and Takotsubo (TK) cardiomyopathy present with similar initial clinical features and can result in left ventricular (LV) dysfunction and acute heart failure. Methods: This study was a retrospective case-control study that identified patients aged 18 years and older who presented with ACS and underwent cardiac catheterization. Results: There were a total of 321 patients in the TK group and 1031 patients in the NSTEMI group. There was significantly worse LV dysfunction in the TK group with average ejection fraction (EF) of 44.35% (±15.11%) versus NSTEMI with an average EF of 47.36% (±13.5%) ( P < .001). The presence of TK yielded of an odds ratio (OR) of 2.373 (95% confidence interval [CI]: 1.165-3.618) and presence of peripheral artery disease (PAD) yielded an OR of 2.053 (95% CI: 1.165-3.618). Conclusions: The presence of TK cardiomyopathy and PAD were independent predictors of patients who had LVEF of <35% and elevated B-type natriuretic peptide levels.

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Good Practices in the Clinical Management of Patients with Acute Coronary Syndrome: Retrospective Analysis in a Third-Level Hospital in Mexico

Cardiology Research and Practice ◽

10.1155/2020/9624283 ◽

2020 ◽

Vol 2020 ◽

pp. 1-7

Author(s):

Héctor E. Flores-Salinas ◽

Fidel Casillas-Muñoz ◽

Yeminia Valle ◽

Cesar M. Guzmán-Sánchez ◽

Jorge Ramon Padilla-Gutiérrez

Keyword(s):

Risk Factors ◽

Myocardial Infarction ◽

Percutaneous Coronary Intervention ◽

Heart Surgery ◽

Coronary Intervention ◽

St Segment Elevation ◽

Coronary Syndrome ◽

Segment Elevation Myocardial Infarction ◽

St Segment ◽

Percutaneous Coronary

Introduction and Objective. In Mexico, there has been an increase in the risk of cardiovascular disease due to rising life expectancy, westernized lifestyle, lack of prevention, and industrialized exposure. This article describes the pharmacological treatment, surgical interventions, and associated clinical complications in patients diagnosed with acute coronary syndrome (ACS) and their impact on in-hospital mortality frequency in a Cardiology Unit in Instituto Mexicano del Seguro Social. Methods. This is a retrospective study including male and female patients aged ≥18 years who were diagnosed with ACS. The collected data included demographic characteristics, risk factors, medications, electrocardiograms, surgical procedures, and in-hospital deaths. Results. There are at least 20% more diagnoses of ST-segment elevation myocardial infarction in this hospital compared to the latest national reports in Mexico. The most common risk factors were type 2 diabetes mellitus, hypertension, smoking, and dyslipidaemia. Diabetic patients with a clinical history of percutaneous coronary intervention had a higher risk of non-ST-segment elevation myocardial infarction than nondiabetics (OR: 2.34; p=0.013), also smoking patients with previous heart surgery than nonsmokers (OR: 7.73; p=0.0007). The average in-hospital mortality was 3.6% for ACS. Conclusions. There is a higher percentage of coronary interventionism and improvement in pharmacological treatment, which is reflected in lower mortality. The substantial burden of T2DM could be related to a higher number of cases of STEMI. Diabetics with precedent percutaneous coronary intervention and smokers with previous heart surgery have an increased risk of subsequent infarction.

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