Search

Abstract: Aim: In 2002 the ACC/AHA guidelines for the management of patients with unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI) were updated. We aimed to answer whether the implementation of updated guidelines was capable of influencing short- and long-term mortality in these patients. Methods: We analyzed data on 812 consecutive patients who were admitted with either UA or NSTEMI between 2001 and 2004. Patients admitted in the two years before the implementation of updated guidelines (UA01/02 group and NSTEMI01/02 group) were compared to patients admitted in the two years thereafter (UA03/04 group and NSTEMI03/04 group). Yearly follow-up concerning all-cause mortality was obtained up to four years. Results: The rate of revascularizations, the percentage of procedures performed within 48h of admission, and the administration of clopidogrel increased significantly. However, still many – especially high-risk – patients did not receive revascularization. Patients of both UA groups had an identical in-hospital mortality rate. Differences in mortality between groups gained statistical significance over time (four-year mortality; 15.1% for the UA03/04 group vs. 26.5% for the UA01/02 group, p=0.014; HR 0.49 95% CI 0.28–0.87). In patients with NSTEMI in-hospital mortality decreased from 18.4% in the NSTEMI01/02 group to 9.6% in the NSTEMI03/04 group (p=0.011; HR 0.47 95% CI 0.26–0.84), and 1-year mortality from 34.7% to 25.1% (p=0.038; HR 0.63 95% CI 0.41–0.98), respectively. Mortality rates beyond one year were still lower in the NSTEMI03/04 group as compared to the NSTEMI01/02 group but it did not reach statistical significance. Multivariate Cox-regression analysis revealed furthermore that also patients with higher age and/or renal dysfunction benefit from an early invasive strategy. Conclusion: The implementation of updated guidelines for NSTE-ACS had significant impact on short- and long-term mortality. However, an early invasive strategy is still withheld to a significant number of high-risk patients, who would benefit from an invasive treatment. [Copyright &y& Elsevier]

Abstract: Objectives: To assess the effect of renal impairment (RI) and diabetes (DM) on outcomes in non-ST-segment elevation acute coronary syndromes (NSTE-ACS). Methods: Data were pooled from 13,126 patients in five NSTE-ACS TIMI trials (TIMI 11A and B, TIMI 12, OPUS-TIMI 16, and TACTICS-TIMI 18). Patients were divided based on DM status and RI (none, mild, or moderate if the glomerular filtration rate (GFR, ml/min/1.73 m2) was ≥90, 60–89 and 30–59 respectively). Results: Patients with DM and moderate RI (n =609) were older and had more prior MI (p <0.01 for all) than other subgroups. Compared with no RI/DM (n =3,832), the 12-month adjusted risks of death, MI, and death/MI increased with advancing RI and were highest with DM and moderate RI (H.R. 1.7, (1.2–2.4), p =0.002; H.R. 2.0 (1.5–2.6), p <0.001; and H.R. 1.7 (1.3–2.2), p <0.001 respectively). These events were also increased with DM and mild RI (H.R. 1.4, (1.0–1.9), p =0.06, H.R. 1.4 (1.1–1.8), p =0.006 and H.R. 1.3 (1.1–1.7), p =0.007 respectively) but not with 1) mild or moderate RI without DM or 2) DM without RI. The interaction terms for RI and DM in their association with MI and death/MI were significant. Conclusions: In the absence of DM, RI and in the absence of RI, DM did not increase the risk of MI or death/MI. However, the combination of RI and DM was associated with a particularly high risk of MI and death/MI suggesting that attention to preserving renal function may be of particular benefit for reducing cardiovascular risk in diabetic patients. [Copyright &y& Elsevier]