Implementation and evaluation of the clinical pathway for the diagnosis and treatment of acute coronary syndrome

Background: The clinical pathways have been developed to guide and standardize diagnosis, treatment of certain diseases, optimize smooth patient care, and its application has been proven to regulate the medical practice and to improve the quality of medical care in developed countries. Objective: To analyze and evaluate the diagnosis and treatment of acute coronary syndrome (ACS) after the implementation of clinical pathways and to identify the areas need to be improved in clinical practice in Xiangya Third Hospital of Central South University. Methods: 250 ACS patients, divided into five groups 50 in each, were collected from December 2009 to December 2011, the first group was considered as baseline and compared with other four group. All these data were compared and analyzed with other tertiary hospitals of china. Results: STEMI patients arriving within 12 hours of onset of symptoms was increased (P<0.05), and final diagnosis consistent with cardiac markers was also increased (P<0.05).Use of aspirin, clopidogrel, β-Blocker, ACEI /ARB, and statin was higher (P>0.05), but the use of clopidogrel and statin was significantly higher (P<0.05) than other hospitals; no significant difference (P>0.05) in Door-to-needle time or Door-to-balloon time, though longer than standard guidelines, but the door-to-needle time was shorter when compared with other hospitals. TIMI risk score of UA/NSTEMI patients and invasive therapy (PCI) was negatively correlated (r = -0.312, P<0.05), and results were similar when compared with other hospitals; high-risk patients increased, but no significant difference in mortality (P>0.05). Conclusion: Implementation of Clinical pathway may help to improve patient outcome with early invasive and medical therapy.

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Can Our Blood Groups Determine Our Life Expectancy?

Bakirkoy Tip Dergisi / Medical Journal of Bakirkoy ◽

10.5222/bmj.2021.43534 ◽

2021 ◽

Author(s):

Gülçin Şahingöz Erdal ◽

İsmail Bıyık ◽

Pınar Kasapoğlu ◽

Muhammet Hulusi Satılmışoğlu ◽

Nlgün Işıksaçan

Keyword(s):

Acute Coronary Syndrome ◽

Blood Group ◽

Blood Groups ◽

Term Survival ◽

Coronary Syndrome ◽

Study Results ◽

Significant Difference ◽

Balanced Distribution ◽

Tertiary Hospitals

Background/aim: In this study, we aimed to investigate the relationship between long-term mortality and survival with ABO blood group in patients with acute coronary syndrome. Materials and methods: This observational study was carried out in two tertiary hospitals. 192 patients followed for 72 months due to acute coronary syndrome, showing a balanced distribution for ejection fraction, additional diseases and age, were included in the study. Results: The survival rate was evaluated in 72 months follow-up. In the survival analysis according to individual blood groups; there was no statistically significant difference between the groups. When the patients were divided into two groups, there was 24.39% mortality in those with O blood group and 15.23% mortality in those without O blood group (p>0.05). Although it was not statistically significant, in patients with O blood group, an increasing tendency was observed in 72 month mortality (p>0.05). There was no association between Rh antigen and survival in this study (p=0.79). Conclusion: Although it was not able to reach statistically significance limit, a decreasing tendency in long-term survival was observed in patients with O blood group compared to those without O blood group in patients with acute coronary syndrome. The results should be confirmed by larger prospective studies.

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Diagnostic Utility of Neuregulin for Acute Coronary Syndrome

Disease Markers ◽

10.1155/2016/8025271 ◽

2016 ◽

Vol 2016 ◽

pp. 1-5

Author(s):

Maame Yaa A. B. Yiadom ◽

Jeremy Greenberg ◽

Holly M. Smith ◽

Douglas B. Sawyer ◽

Dandan Liu ◽

...

Keyword(s):

Myocardial Infarction ◽

Emergency Department ◽

Acute Coronary Syndrome ◽

Statistical Significance ◽

Signs And Symptoms ◽

Final Diagnosis ◽

Discharge Diagnosis ◽

Neuregulin 1 ◽

Coronary Syndrome ◽

Significant Difference

The purpose of this study was to determine the diagnostic test characteristics of serum neuregulin-1β(NRG-1β) for the detection of acute coronary syndrome (ACS). We recruited emergency department patients presenting with signs and symptoms prompting an evaluation for ACS. Serum troponin and neuregulin-1βlevels were compared between those who had a final discharge diagnosis of myocardial infarction (STEMI and NSTEMI) and those who did not, as well as those who more broadly had a final discharge diagnosis of ACS (STEMI, NSTEMI, and unstable angina). Of 319 study participants, 11% had evidence of myocardial infarction, and 19.7% had a final diagnosis of ACS. Patients with MI had median neuregulin levels of 0.16 ng/mL (IQR [0.16–24.54]). Compared to the median of those without MI, 1.46 ng/mL (IQR [0.16–15.02]), there was no significant difference in the distribution of results (P=0.63). Median neuregulin levels for patients with ACS were 0.65 ng/mL (IQR [0.16–24.54]). There was no statistical significance compared to those without ACS who had a median of 1.40 ng/mL (IQR [0.16–14.19]) (P=0.95). Neuregulin did not perform successfully as a biomarker for acute MI or ACS in the emergency department.

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Predictors for Long-Term Prognosis after Acute Coronary Syndrome

Journal of Biomedical and Clinical Research ◽

10.2478/jbcr-2021-0004 ◽

2021 ◽

Vol 14 (1) ◽

pp. 31-46

Author(s):

Krastina I. Doneva-Basheva ◽

Damyan P. Petrov ◽

Tatyana I. Vlaykova ◽

Snezhana T. Tisheva

Keyword(s):

Acute Coronary Syndrome ◽

Regression Analysis ◽

Systolic Function ◽

Developed Countries ◽

Elderly Age ◽

Term Survival ◽

Coronary Syndrome ◽

Significant Difference ◽

Grace Score

Summary Cardiovascular diseases (CVD) are the leading cause of invalidity and death in developed countries. Among them, the main cause of death is coronary artery disease. In this retrospective study, 172 patients with acute coronary syndrome (STEMI, NSTEMI, UA) are included. They had been hospitalized on an emergency basis in the Cardiology Department, Invasive Sector of Prof. Dr. St. Kirkovich Hospital in Stara Zagora, and the Cardiology Hospital -Yambol between January 2009 and February 2010. We found a significant difference in the age at acute coronary syndrome (ACS) occurrence by sex: earlier manifestation was observed in men (p=0.018). The univariant regression analysis showed that elderly age (p=0.005, OR 1.024), glomerular filtration <90 ml/h (p=0.006, OR 0.964), GRACE-score > 140 pt (p<0.001, OR 1.045), HF (Killip class ≥ II) (p=0.002, OR 15.6) and EF<40% (p=0.003, OR 1) were factors for adverse prognosis in the first, fifth and ninth year. Only GRACE-score was an independent predictor of death obtained by multivariate regression analysis in the study (p=0.002, OR 1.052). The factors influencing long-term survival adversely after ACS are age, smoking, chronic kidney disease, previously experienced myocardial infarction, diabetes mellitus, three-vessel coronary disease, and decreased systolic function of the left ventricle, and GRACE > 140 p.

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Long Term Prognostic Utility of Matrix Metalloproteinase-9 in Patients with Acute Coronary Syndrome – A Systematic Review

Current Pharmaceutical Biotechnology ◽

10.2174/1389201021666200703200736 ◽

2020 ◽

Vol 21 ◽

Author(s):

Anamika Das ◽

Melvin George ◽

Durga Jha ◽

Luxitaa Goenka

Keyword(s):

Acute Coronary Syndrome ◽

High Risk ◽

Matrix Metalloproteinase ◽

Developed Countries ◽

Left Ventricular ◽

Original Research ◽

Coronary Syndrome ◽

Potential Biomarker ◽

Prognostic Utility

Background: Acute coronary syndrome (ACS) is the leading cause for morbidity and mortality in developed countries. Numerous groups have explored single and multiple biomarker strategies to identify diagnostic prognosticators of ACS which will improve our ability to identify high-risk individuals. Matrix metalloproteinase (MMP-9) is one potential biomarker which has been widely studied in ACS. Recent reports have showed the prognostic utility of MMP-9, but due to inconsistent results, it has not been possible to draw firm conclusions. Objective: This review aims to explore the ability of MMP-9 to predict long-term prognosis of ACS. To clarify this issue, we conducted a literature review to provide a comprehensive assessment of MMP-9 levels in ACS patients. Method: We retrieved a total of 1501 articles from PubMed and Google Scholar. After thorough scrutiny, 12 original research articles were found fulfilling the inclusion exclusion criteria. MMP-9’s ability as a biomarker of prognostication post ACS was reviewed. PRISMA guidelines were used for reporting. Result: The results revealed that MMP-9, apart from being an efficient diagnostic biomarker for ACS, helps in predicting the future risk of ACS with disease outcome. Positive correlation was found between plasma MMP-9 and left ventricular remodeling. A positive association was also found between cardiovascular death and higher MMP-9 levels. Conclusion: MMP-9 can be a potential prognostic marker for ACS and aid in identifying high risk patients for intensive management during follow -up.

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The effect of obstructive sleep apnoea on timing of acute coronary syndrome

European Heart Journal ◽

10.1093/ehjci/ehaa946.1363 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M.H Muhmad Hamidi ◽

H Sani ◽

M.A Ibrahim ◽

K.S Ibrahim ◽

A.B Md Radzi ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

High Risk ◽

Systolic Function ◽

Strong Association ◽

Multiple Logistic Regression Analysis ◽

Sleep Apnoea ◽

Neck Circumference ◽

Coronary Syndrome ◽

Obstructive Sleep ◽

Significant Difference

Abstract Background and objective Acute coronary syndrome (ACS) remains the principal cause of death in Malaysia. It is estimated about 20% of ACS occurs at nighttime during sleep between 12am to 6am. Factors associated with nocturnal ACS are unknown. Acute nocturnal pathophysiological response to obstructive sleep apnea (OSA) may increase risk of nocturnal ACS. We hypothesized that OSA risk is associated with timing of ACS onset. Methodology This study included 200 patients with ACS who underwent coronary angiogram for which the time of chest pain onset was clearly identified and divided into 2 groups; nocturnal ACS (12am-5.59am) and non-nocturnal ACS (6am–11.59pm). Two validated questionnaires, STOP-BANG and Epworth Sleepiness Scale (ESS) were self-administered by subjects to determine OSA risk. All subjects timing of ACS onset, OSA risk, demography, anthropometric measurements, comorbidities and echocardiographic characteristics were analyzed. Results Acute coronary syndrome occurs nocturnally in 19% of ACS patients. The prevalence of high risk OSA individuals among ACS patients is 43%. There is significantly higher prevalence of high risk OSA individuals in nocturnal ACS group of 95% compared to 30% of high risk OSA individuals in non-nocturnal ACS group (p=0.001). Nocturnal ACS patients was significantly younger (50.1±8.7yrs, p=0.001), had higher BMI (33.9±4.3kg/m2, p=0.005), waist circumference (106.7±10.3cm, p=0.003) and larger neck circumference (44.6±3.3cm, p=0.001) compared to non-nocturnal ACS group. These groups had similar prevalence of other comorbidities for ACS and showed no significant difference between left and right ventricular systolic function. In multiple logistic regression analysis, the most significant predictors for nocturnal ACS are OSA risk, neck circumference and age. Conclusion There is a strong association between high risk OSA individuals and nocturnal ACS onset. Patient with nocturnal ACS onset should be screened for OSA and prioritized for polysomnography. OSA prevalence according to ACS onset Funding Acknowledgement Type of funding source: None

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Comparison of prasugrel and ticagrelor for patient with acute coronary syndrome: a systematic review and meta-analysis

European Heart Journal ◽

10.1093/ehjci/ehaa946.1434 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

L.C.W Fong ◽

N Lee ◽

A.T Yan ◽

M.Y Ng

Keyword(s):

Acute Coronary Syndrome ◽

Stent Thrombosis ◽

Meta Analysis ◽

Composite Endpoint ◽

Cardiovascular Death ◽

Coronary Syndrome ◽

Primary Composite Endpoint ◽

Significant Difference ◽

St Elevation

Abstract Background Prasugrel and ticagrelor are both effective anti-platelet drugs for patients with acute coronary syndrome. However, there has been limited data on the direct comparison of prasugrel and ticagrelor until the recent ISAR-REACT 5 trial. Purpose To compare the efficacy of prasugrel and ticagrelor in patients with acute coronary syndrome with respect to the primary composite endpoint of myocardial infarction (MI), stroke or cardiac cardiovascular death, and secondary endpoints including MI, stroke, cardiovascular death, major bleeding (Bleeding Academic Research Consortium (BARC) type 2 or above), and stent thrombosis within 1 year. Methods Meta-analysis was performed on randomised controlled trials (RCT) up to December 2019 that randomised patients with acute coronary syndrome to either prasugrel or ticagrelor. RCTs were identified from Medline, Embase and ClinicalTrials.gov using Cochrane library CENTRAL by 2 independent reviewers with “prasugrel” and “ticagrelor” as search terms. Effect estimates with confidence intervals were generated using the random effects model by extracting outcome data from the RCTs to compare the primary and secondary clinical outcomes. Cochrane risk-of-bias tool for randomised trials (Ver 2.0) was used for assessment of all eligible RCTs. Results 411 reports were screened, and we identified 11 eligible RCTs with 6098 patients randomised to prasugrel (n=3050) or ticagrelor (n=3048). The included trials had a follow up period ranging from 1 day to 1 year. 330 events on the prasugrel arm and 408 events on the ticagrelor arm were recorded. There were some concerns over the integrity of allocation concealment over 7 trials otherwise risk of other bias was minimal. Patients had a mean age of 61±4 (76% male; 50% with ST elevation MI; 35% with non-ST elevation MI; 15% with unstable angina; 25% with diabetes mellitus; 64% with hypertension; 51% with hyperlipidaemia; 42% smokers). There was no significant difference in risk between the prasugrel group and the ticagrelor group on the primary composite endpoint (Figure 1) (Risk Ratio (RR)=1.17; 95% CI=0.97–1.41; p=0.10, I2=0%). There was no significant difference between the use of prasugrel and ticagrelor with respect to MI (RR=1.24; 95% CI=0.81–1.90; p=0.31); stroke (RR=1.05; 95% CI=0.66–1.67; p=0.84); cardiovascular death (RR=1.01; 95% CI=0.75–1.36; p=0.95); BARC type 2 or above bleeding (RR=1.17; 95% CI =0.90–1.54; p=0.24); stent thrombosis (RR=1.58; 95% CI =0.90–2.76; p=0.11). Conclusion Compared with ticagrelor, prasugrel did not reduce the primary composite endpoint of MI, stroke and cardiovascular death within 1 year. There was also no significant difference in the risk of MI, stroke, cardiovascular death, major bleeding and stent thrombosis respectively. Figure 1. Primary Objective Funding Acknowledgement Type of funding source: None

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Impact of cardiac rehabilitation on 3 year outcomes amongst patients after acute coronary syndrome: (ACS) SNAPSHOT ACS follow-up study

European Heart Journal ◽

10.1093/ehjci/ehaa946.3108 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

J Redfern ◽

K Hyun ◽

D Brieger ◽

D Chew ◽

J French ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Cardiac Rehabilitation ◽

Data Linkage ◽

Research Network ◽

Funding Source ◽

Cardiovascular Research ◽

Coronary Syndrome ◽

Follow Up Study ◽

Significant Difference

Abstract Background Cardiovascular disease is the leading cause of disease burden globally. With advancements in medical and surgical care more people are surviving initial acute coronary syndrome (ACS) and are in need of secondary prevention and cardiac rehabilitation (CR). Increasing availability of high quality individual-level data linkage provides robust estimates of outcomes long-term. Purpose To compare 3 year outcomes amongst ACS survivors who did and did not participate in Australian CR programs. Methods SNAPSHOT ACS follow-up study included 1806 patients admitted to 232 hospitals who were followed-up by data linkage (cross-jurisdictional morbidity, national death index, Pharmaceutical Benefit Schedule) at 6 and 36 months to compare those who did/not attend CR. Results In total, the cohort had a mean age of 65.8 (13.4) years, 60% were male, only 25% (461/1806) attended CR. During index admission, attendees were more likely to have had PCI (39% v 14%, p<0.001), CABG (11% v 2%, p<0.001) and a diagnosis of STEMI (21% v 5%, p<0.001) than those who did not attend. However, there was no significant difference between CR attendees/non-attendees for risk factors (LDL-cholesterol, smoking, obesity). Only 19% of eligible women attended CR compared to 30% of men (p<0.001). At 36 months, there were fewer deaths amongst CR attendees (19/461, 4.1%) than non-attendees (116/1345, 8.6%) (p=0.001). CR attendees were more likely to have repeat ACS, PCI, CABG at both 6 and 36 months (Table). At 36 months, CR attendees were more likely to have been prescribed antiplatelets (78% v 53%, p<0.001), statins (91% 73%, p<0.001), beta-blockers (11% v 13%, p=0.002) and ACEI/ARBs (72% v 61%, p<0.001) than non-attendees. Conclusions Amongst Australian ACS survivors, participation in CR was associated with less likelihood of death and increased prescription of pharmacotherapy. However, attendance at CR was associated with higher rates of repeat ACS and revascularisation. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): New South Wales Cardiovascular Research Network, National Heart Foundation

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Assessing the Performance of a Novel Point-of-Care Qualitative Assay for Early Diagnosis of Acute Coronary Syndrome

Cardiology ◽

10.1159/000511435 ◽

2020 ◽

pp. 1-8

Author(s):

Ronny Alcalai ◽

Boris Varshisky ◽

Ahmad Marhig ◽

David Leibowitz ◽

Larissa Kogan-Boguslavsky ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Diagnostic Accuracy ◽

Diagnostic Performance ◽

Troponin I ◽

Point Of Care ◽

Final Diagnosis ◽

Cardiac Biomarkers ◽

Fatty Acid Binding ◽

Coronary Syndrome

Background: Early and accurate diagnosis of acute coronary syndrome (ACS) is essential for initiating lifesaving interventions. In this article, the diagnostic performance of a novel point-of-care rapid assay (SensAheart©) is analyzed. This assay qualitatively determines the presence of 2 cardiac biomarkers troponin I and heart-type fatty acid-binding protein that are present soon after onset of myocardial injury. Methods: We conducted a prospective observational study of consecutive patients who presented to the emergency department with typical chest pain. Simultaneous high-sensitive cardiac troponin T (hs-cTnT) and SensAheart testing was performed upon hospital admission. Diagnostic accuracy was computed using SensAheart or hs-cTnT levels versus the final diagnosis defined as positive/negative. Results: Of 225 patients analyzed, a final diagnosis of ACS was established in 138 patients, 87 individuals diagnosed with nonischemic chest pain. In the overall population, as compared to hs-cTnT, the sensitivity of the initial SensAheart assay was significantly higher (80.4 vs. 63.8%, p = 0.002) whereas specificity was lower (78.6 vs. 95.4%, p = 0.036). The overall diagnostic accuracy of SensAheart assay was similar to the hs-cTnT (82.7% compared to 76.0%, p = 0.08). Conclusions: Upon first medical contact, the novel point-of-care rapid SensAheart assay shows a diagnostic performance similar to hs-cTnT. The combination of 2 cardiac biomarkers in the same kit allows for very early detection of myocardial damage. The SensAheart assay is a reliable and practical tool for ruling-in the diagnosis of ACS.

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Predictive Value of Endocan Based on TIMI Risk Score on Major Adverse Cardiovascular Events After Acute Coronary Syndrome

Angiology ◽

10.1177/0003319718815241 ◽

2018 ◽

Vol 70 (10) ◽

pp. 952-959 ◽

Cited By ~ 3

Author(s):

Mojtaba Ziaee ◽

Sina Mashayekhi ◽

Samad Ghaffari ◽

Javad Mahmoudi ◽

Parvin Sarbakhsh ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Coronary Syndrome ◽

Risk Score ◽

Troponin I ◽

Multivariate Logistic Regression Analysis ◽

Major Adverse Cardiovascular Events ◽

Hospital Death ◽

Coronary Syndrome ◽

Creatine Kinase Mb ◽

Timi Risk Score

We assessed the prognostic value of serum levels of endocan in patients with the acute coronary syndrome (ACS) through its correlation with the Thrombolysis in Myocardial Infarction (TIMI) risk score and compared the possible association with clinical outcomes. In this prospective cross-sectional study, we enrolled 320 patients with documented ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), or unstable angina (UA) who underwent diagnostic coronary angiography. Endocan was measured soon after admission in the emergency department. In-hospital death, heart failure, and recurrent infarction were considered major adverse cardiac events (MACEs). There was a significant positive correlation between endocan level and TIMI risk score and MACE. The optimal cutoff values of endocan to predict clinical end points were 3.45 ng/mL in patients with STEMI and 2.85 ng/mL in patients with UA/NSTEMI. Multivariate logistic regression analysis indicated that endocan independently correlated with MACE. Moreover, cardiac troponin I, creatine kinase-MB, and circulating endocan were found to be independently associated with MACE in patients with ACS. In conclusion, a high endocan level on hospital admission is an independent predictor of worse cardiovascular outcomes and higher TIMI risk score in patients with ACS.

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