Long-term survival following acute heart failure: The Acute Heart Failure Database Main registry (AHEAD Main)

We evaluated data on blacks and whites with acute ST-segment-elevation myocardial infarction treated with either fibrinolysis or primary percutaneous coronary intervention from the National Registry of Myocardial Infarction (NRMI)-4 and -5 participating centers between July 2000 and December 2006 to determine race-related differences in bleeding and outcomes. We found that among patients with ST-segment-elevation myocardial infarction receiving fibrinolysis, the bleeding rates were higher for blacks (n2283) than whites (n42 243; 10.9% versus 10.3%; adjusted odds ratio, 1.21; 95% confidence interval, 1.02-1.43). Similarly, in patients receiving primary percutaneous coronary intervention, the bleeding rates were higher in blacks (n2826) than whites (n46 332; 10.3% versus 7.8%; adjusted odds ratio, 1.33; 95% confidence interval, 1.13-1.56). Bleeding was associated with a higher risk of death in both ethnic groups. However, there was no overall racial difference in in-hospital mortality among those with bleeding or without bleeding treated with either fibrinolysis or primary percutaneous coronary intervention. We concluded that race-related differences existed in bleeding risk among patients with ST-segmentelevation myocardial infarction receiving reperfusion therapy that portend poor prognosis. Thus, the efficacy and safety of many new drugs or treatment strategies for any disease observed in clinical trials that enroll predominantly white patients may not be similar in other ethnic groups that are underrepresented in these trials.

792 Acute Coronary Syndrome in Patients With Normal or Non-Obstructive Coronary Artery Disease: Patient Characteristics and Long-Term Outcomes

To facilitate interpretation of this algorithm and a more detailed discussion in the text, each box is assigned a letter code that reflects its level in the algorithm and a number that is allocated from left to right across the diagram on a given level. ACC/AHA American College of Cardiology/American Heart Association; ACS acute coronary syndrome; ECG electrocardiogram; LV left ventricular. Anderson et al ACC/AHA UA/NSTEMI Guideline Revision e159 Downloaded from http://ahajournals.org by on August 29, 2023 a 12-lead ECG and biomarker determination (e.g., an ED or other acute care facility). (Level of Evidence: C) 2. Patients with symptoms of ACS (chest discomfort with or without radiation to the arm[s], back, neck, jaw or epigastrium; shortness of breath; weakness; diaphoresis; nausea; lightheadedness) should be instructed to call 9-1-1 and should be transported to the hospital by ambulance rather than by friends or relatives. (Level of Evidence: B) 3. Health care providers should actively address the following issues regarding ACS with patients with or at risk for CHD and their families or other responsible caregivers: a. The patient's heart attack risk; (Level of Evidence: C) b. How to recognize symptoms of ACS; (Level of Evidence: C) c. The advisability of calling 9-1-1 if symptoms are unimproved or worsening after 5 min, despite feelings of uncertainty about the symptoms and fear of potential embarrassment; (Level of Evidence: C) d. A plan for appropriate recognition and response to a potential acute cardiac event, including the phone number to access EMS, generally 9-1-1 (74). (Level of Evidence: C) 4. Prehospital EMS providers should administer 162 to 325 mg of ASA (chewed) to chest pain patients suspected of having ACS unless contraindicated or already taken by the patient. Although some trials have used enteric-coated ASA for initial dosing, more rapid buccal absorption occurs with non-enteric-coated formulations. (Level of Evidence: C) 5. Health care providers should instruct patients with suspected ACS for whom nitroglycerin [NTG] has been prescribed previously to take not more than 1 dose of NTG sublingually in response to chest discomfort/pain. If chest discomfort/pain is unimproved or is worsening 5 min after 1 NTG dose has been taken, it is recommended that the patient or family member/friend/caregiver call 9-1-1 immediately to access EMS before taking additional NTG. In patients with chronic stable angina, if symptoms are significantly improved by 1 dose of NTG, it is appropriate to instruct the patient or family member/friend/caregiver to repeat NTG every 5 min for a maximum of 3 doses and call 9-1-1 if symptoms have not resolved completely. (Level of Evidence: C) 6. Patients with a suspected ACS with chest discomfort or other ischemic symptoms at rest for greater than 20 min, hemodynamic instability, or recent syncope or presyncope should be referred immediately to an ED. Other patients with suspected ACS who are experiencing less severe symptoms and who have none of the above high-risk features, including those who respond to an NTG dose, may be seen initially in an ED or an outpatient facility able to provide an acute evaluation. (Level of Evidence: C) CLASS IIa 1. It is reasonable for health care providers and 9-1-1 dispatchers to advise patients without a history of ASA allergy who have symptoms of ACS to chew ASA (162 to 325 mg) while awaiting arrival of prehospital EMS providers. Although some trials have used entericcoated ASA for initial dosing, more rapid buccal absorption occurs with non-enteric-coated formulations. (Level of Evidence: B) 2. It is reasonable for health care providers and 9-1-1 dispatchers to advise patients who tolerate NTG to repeat NTG every 5 min for a maximum of 3 doses while awaiting ambulance arrival. (Level of Evidence: C) 3. It is reasonable that all prehospital EMS providers perform and evaluate 12-lead ECGs in the field (if available) on chest pain patients suspected of ACS to assist in triage decisions. Electrocar-diographs with validated computer-generated interpretation algorithms are recommended for this purpose. (Level of Evidence: B) 4. If the 12-lead ECG shows evidence of acute injury or ischemia, it is reasonable that prehospital ACLS providers relay the ECG to a predetermined medical control facility and/or receiving hospital. (Level of Evidence: B) Downloaded from http://ahajournals.org

Promena paradigme za stabilnu koronarnu bolest u hronični koronarni sindromi - novine u vodiču Evropskog udruženja kardiologa iz 2019. godine

Risks and Benefits of Antiplatelet Therapy in Uremic Patients

Since the initial scientific statement on Secondary Prevention of Coronary Heart Disease (CHD) in the Elderly was published in 2002,1 several trends have continued that make an update highly appropriate. First, the graying of the US population and those of other industrialized countries has progressed unabated because more adults are surviving into their senior years. The number of Americans aged ≥75 years was estimated at 18.6 million in 2010, representing ≈6% of the population,2 and it is expected to double by 2050. The population aged ≥85 years is growing the most rapidly, with numbers expected to reach 19.5 million by 2040. In 2008, 67% of the 811 940 cardiovascular deaths in the United States occurred in people aged ≥75 years.3 In parallel to this increase in the older adult demographic, the number of Americans with CHD has increased to an estimated 16.3 million, more than half of whom are >65 years of age.3 Similarly, 7 million have had a stroke, the incidence of which approximately doubles with successive age decades after 45 to 54 years.3 Peripheral artery disease (PAD) affects 8 to 10 million Americans, the majority of whom are >65 years of age. Between 2015 and 2030, annual US costs related to atherosclerotic cardiovascular disease (ASCVD) are projected to increase from $84.8 billion to $202 billion.3 Moreover, given that ASCVD often undermines functional capacity and independence and increases reliance on long-term care, indirect expenses related to ASCVD are also expected to increase. Thus, the need for effective secondary prevention measures in the older adult population with known ASCVD has never been greater. Notably, the 2011 American Heart Association (AHA)/American College of Cardiology Foundation (ACCF) updated guidelines for secondary prevention of CHD broadened …

Funding Acknowledgements Type of funding sources: None. Background/Introduction: Previous clinical studies have underlined the prognostic role of platelet indices in acute coronary syndrome (ACS). However, the effect of their dynamic change during hospitalization has not thoroughly been examined. Purpose: We aimed to investigate the association between platelet indices on admission, on discharge and their change during hospitalization and the long-term prognosis of patients with ACS. Methods: Data from a randomized controlled trial recruiting ACS patients were analyzed in a survival analysis. Platelet count (PC), mean platelet volume (MPV), platelet distribution width (PDW) and plateletcrit (PCT) on admission and on discharge dichotomized at the median value, as well as the change between admission and discharge of each variable dichotomized at the zero value. Primary endpoints were major adverse cardiac events (MACE), defined as occurrence of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke or hospitalization for unstable angina, while secondary endpoints were all-cause mortality, all-cause hospitalization and major or minor bleeding events. Results: The study included 252 individuals who were followed-up for a median of 39 months. In the univariate Cox regression analysis, only PC at discharge (HR 2.20, 95% CI 1.10-4.40), MPV at discharge (HR 0.48, 95% CI 0.25-0.94) and PC reduction during the hospitalization (HR 0.25, 95% CI 0.13-0.51) predicted MACE. PC reduction correlated with a lower MACE occurrence (adjusted HR 0.27, 95%CI 0.14-0.54) and lower risk of all-cause hospitalization (adjusted HR 0.36, 95%CI 0.19-0.68) in the multivariable Cox-regression analysis. Conclusion: PC change during hospitalization can be a substantial independent predictor of long-term prognosis of ACS patients. Baseline and admission characteristics Characteristic Statistic Overall, N = 252 Negative Platelet Difference, N = 98 Postive Platelet Difference, N = 154 p-value Age, years median (IQR) 60 (53, 72) 62 (55, 74) 60 (53, 72) 0.2 Hypertension n(%) 147(58.3%) 58(59.2%) 89(57.8%) >0.9 Diabetes n(%) 71(28.2%) 27(27.6%) 44(28.6%) >0.9 Cardiovascualr Disease (CVD) n(%) 100(39.7%) 43(43.9%) 57(37.0%) 0.3 Primary Coronary Intervention (PCI) treatment n(%) 200(79.4%) 71(72.4%) 129(83.8%) 0.045 Number of vessels n 0.6 1 n(%) 107(59.1%) 38(59.4%) 69(59.0%) ≥2 n(%) 68(37.6%) 25(39.1%) 43(36.8%) Platelets at admission, K/μL mean(SD) 257179(71031) 237020(62555) 270006(73282) 0.001 Platelets at dischage, K/μL mean(SD) 250952(70263) 279153(75159) 233006(60698) <0.001 Abstract Figure. MACE univariate / multivariate analysis

STUDY OBJECTIVE: Although recent studies have examined the effect of weather on acute coronary syndrome and heart failure, few have examined the influence of extreme weather and rapid temperature change on emergency department admissions for acute coronary syndrome and heart failure, METHODS: We reviewed presentations of acute coronary syndrome (n = 2381) and heart failure (n = 1802) for the years 2003 to 2006 at an urban Level I Trauma Center and Accredited Chest Pain Center, examining presentation frequency on the warmest and coldest days of their respective years. In addition, we examined the frequency of presentation on days where the absolute difference between the mean temperature of one day and the next differed by 5, 10, and 15 degrees Fahrenheit. For each of these sample sets, we analyzed the data by gender and age. RESULTS: Frequency of presentation did not significantly change on the hottest and coldest days of the year for acute coronary syndrome (p = 0.89 hot, p = 0.63 cold) or heart failure (p = 0.51 cold, p = 0.66 hot). No significant correlation was noted between gender and temperature extremes for acute coronary syndrome (p = 0.71 cold, p = 0.62 hot) or for heart failure (p = 0.83 cold, p = 0.59 hot). Age was not significantly correlated with temperature extremes for presentations of acute coronary syndrome (p = 0.72 cold, p = 0.63 hot) or heart failure (p = 0.95 cold, p = 0.99 hot). Changes in presentation frequency for either acute coronary syndrome (ACS) or heart failure (HF) at ΔT = 5°F were not significant (p = 0.70 ACS, p = 0.67 HF), nor were they significant at ΔT = 10°F (p = 0.97 ACS, p = 0.26 HF) or ΔT = 15°F (p = 0.17 ACS, p = 0.57 HF). CONCLUSIONS: In theses patients, no significant correlations were noted between extreme weather events, temperature change and the presentation of acute coronary syndrome. In addition, no significant correlations were found between temperature differentials of 5, 10, or 15 °F and a diagnosis of acute coronary syndrome or heart failure.

Background: Heart failure is a complex clinical syndrome that arises secondary to abnormalities of cardiac structure and/or function (inherited or acquired) that impair the ability of the left ventricle to fill or eject blood. There is a paucity of data on characteristics of the patients of heart failure admitted in hospitals in terms of demographic and etiological information. So, this study aimed to see the disease burden of heart failure patients and the age and sex specific prevalence of heart failure among patients admitted into NICVD and to identify the etiological pattern of diseases leading to heart failure with associated comorbid factors.
 Methods: It was a cross sectional study carried out at National Institute of Cardiovascular Diseases (NICVD) Dhaka Bangladesh and was conducted from January 2015 to December 2015. Total 400 heart failure patients were taken.
 Results: The mean age of the patients were 54 ± 14 years ranging from 16 to 95 years with a high preponderance of male. Most the patient population was in the age group of 51- 60 years (29.5%). 79% of the cases were male & 21% female by gender specification. Ischaemic cardiomyopathy (ICM) was found to be the common cause of heart failure (n=153, 40.75%) followed by Acute coronary syndrome (32.5%) and Valvular heart disease (18.25%). The patients with heart failure having acute coronary syndrome (n=107) had hypertension (46.8%) as the most prevalent major risk factor. In the present study only 11% patient had heart failure with preserved ejection fraction. Mortality rate of the study population were 6.3%.
 Conclusion: In this study, the most common cause of heart failure is ischaemic heart disease. So, patients of acute and chronic ischemic heart disease patients should be treated and follow up with care. Clinical and epidemiological studies are needed to explore further.
 Cardiovasc. j. 2021; 13(2): 172-176

1. Wayne Gade, PhD MT(ASCP)[⇑][1] 1. is assistant Professor of Clinical Laboratory Science, University of Illinois at Springfield, Springfield IL 2. Charis Hainaut, CLS(NCA) 1. is a CLS in the Clinical Laboratory, Decatur Memorial Hospital, Decatur IL 3. Jean Gade, MS RN 1. is an Instructor in the Chemistry Department, Northern Kentucky University, Highland Heights, KY 1. Address for correspondence: Wayne Gade PhD MT(ASCP) Clinical Laboratory Science Program, HSB 314, University of Illinois at Springfield, Springfield, IL 62703-5407. (217) 206-7349. After reading the following articles, the reader will demonstrate his/her understanding of the material by achieving the following: 1. Describe the biochemistry of the BNP and the other natriuretic peptides. 2. Describe the major physiologic responses to the elevation of BNP levels. 3. Discuss the mechanism by which the binding of BNP to the target cell results in alteration of Na+ and water reabsorption. 4. Describe the formation of arterial plaque and the development of coronary artery disease and acute coronary syndromes (ACS). 5. Describe the physiological conditions that develop into CHF and cause the release of BNP. 6. Describe and interpret the diagnostic accuracy, sensitivity, specificity, and negative predictive values reported for rapid BNP assays. 7. Describe the trend toward “accelerated cardiac protocols,” including which markers are suggested, and the suggested time-course of sequential testing. 8. Evaluate patient data and derive appropriate diagnostic conclusions. 9. Discuss the use of BNP for prognosis and screening of patients for LV dysfunction. 10. Discuss the interpretations of slightly elevated levels of troponin and C - reactive protein (CRP) as they relate to ACS and risk analysis. This paper illustrates the diagnostic dilemmas in a small hospital emergency department when four patients present with similar symptoms of dyspnea, angina, and edema. These cases illustrate a new role for the clinical laboratory, as the new cardiac markers and protocols help overcome the ambiguity of symptoms, delays in diagnosis, and high costs of imaging tests that may be unavailable in many small hospitals. Frequently, dyspnea and chest pain are associated with cardiac disorders such as congestive heart failure (CHF), unstable angina, and acute myocardial infarction (MI). However, these same presenting symptoms may also be seen in obstructive pulmonary disorders, pulmonary embolism, pneumonia, and non-pulmonary disorders as diverse as anemia and anxiety. The recent addition of troponin and myoglobin to cardiac panels and the increasing use of accelerated cardiac protocols have improved speed and accuracy in the diagnosis of MI. While certain aspects of the interpretation of troponin data remain controversial, the use of accelerated testing protocols is gaining acceptance, following the recommendations of the National Academy of Clinical Biochemistry in 1999. With the introduction of rapid laboratory testing for B-type natriuretic peptide (BNP) in 2000, the diagnosis of CHF has also become faster, easier, and more reliable. A companion paper in this issue reviews plaque development, acute coronary syndromes (ACS), and pathophysiology of CHF.1 In addition, the biochemistry and physiology of BNP, and the clinical evidence supporting its use in the diagnosis, risk stratification, staging, and therapeutic monitoring of CHF patients are also reviewed. Rapid BNP assays and high… ABBREVIATIONS: ABG = arterial blood gas; ACS = acute coronary syndromes; BNP = B-type natriuretic peptide; CBC = complete blood count; CHD = coronary heart disease; CHF = congestive heart failure; CLS = clinical laboratory science; CMP = comprehensive metabolic profile; COPD = chronic obstructive pulmonary disease; ECG = electrocardiogram; ED = emergency department; EMT = emergency medical technician; hsCRP = high sensitivity C-reative protein; MI = myocardial infarction; NPV = negative predictive value; RAAS = renin-angiotensin-aldosterone system; UA = urinalysis; WBC = white blood count;. After reading the following articles, the reader will demonstrate his/her understanding of the material by achieving the following: 1. Describe the biochemistry of the BNP and the other natriuretic peptides. 2. Describe the major physiologic responses to the elevation of BNP levels. 3. Discuss the mechanism by which the binding of BNP to the target cell results in alteration of Na+ and water reabsorption. 4. Describe the formation of arterial plaque and the development of coronary artery disease and acute coronary syndromes (ACS). 5. Describe the physiological conditions that develop into CHF and cause the release of BNP. 6. Describe and interpret the diagnostic accuracy, sensitivity, specificity, and negative predictive values reported for rapid BNP assays. 7. Describe the trend toward “accelerated cardiac protocols,” including which markers are suggested, and the suggested time-course of sequential testing. 8. Evaluate patient data and derive appropriate diagnostic conclusions. 9. Discuss the use of BNP for prognosis and screening of patients for LV dysfunction. 10. Discuss the interpretations of slightly elevated levels of troponin and C - reactive protein (CRP) as they relate to ACS and risk analysis. [1]: #corresp-1

Background: Patients with LVEF≤35% and NYHA class II or III heart failure under optimal medical treatment have an indication of an ICD in primary prevention. Data regarding the magnitude of improvement of LVEF after intensive optimization of heart failure medical treatment are scarce. Purpose: To assess the clinical, echocardiographic and biological impact of intensive optimization of heart failure medical treatment in patients with severe left ventricular systolic dysfunction. Methods: This is an observational prospective study in which patients visited in a heart failure unit with LVEF≤35%, without an ICD, with heart failure and non-optimal heart failure medical treatment are included. Up-titration of beta blockers, ACE inhibitors/ARB and aldosterone antagonist are gradually performed in the day hospital of the heart failure unit up to 100% of the target dose or the maximum tolerated dose. At 6 month after completion of drug up-titration the echocardiography is repeated and clinical follow-up assessed again. Results: 85 patients have been already included. 34/85 are still being up-titraded. 3/85 died during follow-up. The 6 month follow-up has been accomplished in 48/85 patients, age 65±14 years, 9 (19%) female, 20 (42%) with ischemic heart disease. Patients on 100% of target dose of beta blockers, ACE inhibitors/ARB and aldosterone antagonists increased from 8%, 23% and 17% to 81%, 77% and 72%, respectively, with up-titration. NYHA class diminished at 6 month: 2,1±0,6 vs 1,5±0,6, p 35% in 25/48 (52%) patients at 6 month after up-titration. Consequently, patients with an ICD indication were reduced: 44 (92%) vs 12 (25%) when comparing before and after 6 month of completion of optimization of heart failure medical therapy. Moreover, pro-BNP levels were also reduced: 2676±227 vs 1754±1804 pg/ml before and after 6 month of up-titration completion. Conclusions: Intensive optimization of heart failure medical therapy in patients with severe systolic left ventricular impairment improves symptoms and quality of life and reduces hospital admissions. Furthermore LVEF increases in the majority of patients and ICD indications are accordingly reduced.

<i>Circulation</i> Editors’ Picks

T he cardiovascular disease (CVD) risk associated with diabetes mellitus (DM) has become increasingly evident, accounting for Ϸ80% of deaths among patients with this disease 1 and making CVD risk modification a key therapeutic objective in diabetic patients.2][3][4] The rapidly increasing global burden of DM, 5 coupled with the associated CVD risk, underscores the imperative for continued generation and application of evidence-based therapies to reduce CVD risk in this high-risk cohort.In this 2-part series, we first review the CVD effects of the thiazolidinedione medications, the most broadly investigated class of antihyperglycemic drugs evaluated in the context of CVD risk.In the second part, we review the modulators of the incretin axis that have most recently achieved US Food and Drug Administration approval, with a focus on CVD considerations; introduce selected drugs in advanced development; summarize glucose control strategies for cardiovascular patients; and discuss the regulatory review of glucose-lowering medications.

The Complex Relationship Between Ischemic Heart Disease and COPD Exacerbations

Background Iron is essential for a number of metabolic and physiological processes and the role of iron deficiency (ID) as an adverse prognostic indicator in heart failure is well established. The suitability of the international guideline definition for prognosticating adverse events in heart failure has recently been brought into question due to the inclusion of ferritin, given its reduced specificity during intercurrent inflammation. As inflammation plays an active role in coronary disease, and acute coronary syndromes in particular, we sought to further explore whether ID according to the current guideline definition or alternative definitions without reliance on ferritin is a predictor of clinical outcomes in patients with coronary artery disease. Purpose The aims are to assess whether a)ID is associated with increased all-cause mortality in patients with coronary artery disease requiring percutaneous coronary intervention (PCI) and b) whether different definitions of ID have a stronger association with mortality in these patients. Methods All patients in a UK PCI registry who had full iron studies within thirty days of their index procedure were included. ID was defined according to three different criteria: 1) International guideline criteria (ferritin &amp;lt;100 ng/ml or transferrin saturations (TSATs) &amp;lt;20% if ferritin 100-299 ng/ml), 2) TSATs &amp;lt;20%, or 3) serum iron &amp;lt;13μmol/L. Mortality data was obtained from Hospital Episodes Statistics. Ethical approval was obtained from the Northwest Haydock Research Committee. Results Some 390 patients were included in this analysis. The mean age was 72.5 (62-86) and 33.0% were female. 28.7% of patients presented with a STEMI, 39.7% with an acute coronary syndrome and 31.5% had stable angina. ID according to the serum iron and TSAT definitions were associated with increased all-cause mortality, HR 1.61 (CI 1.07-2.41), p=0.02 and HR 1.64 (CI 1.13-2.37), p=0.009 respectively. However, ID as determined by the international guideline definition was not predictive of increased all-cause mortality, HR 0.99 (CI 0.69-1.42), p=0.97. Conclusions Here we show that ID, defined by serum iron and TSATs but not by the current guideline definition of ID, is associated with increased all-cause mortality in patients with coronary artery disease, undergoing PCI. A randomised controlled trial into treating ID in patients with coronary disease is warranted to determine whether intravenous iron replacement is beneficial in this patient group. The current study supports the growing evidence that alternatives to the current guideline definition of ID may be better suited to identify patients with adverse prognosis and who, in turn, may benefit most from intravenous iron replacement therapy.