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Variations in myocardial supply area and hydrostatic pressure gradients result in greater likelihood of positive fractional flow reserve (FFR) in the left anterior descending (LAD) compared with the circumflex (Cx) and right coronary artery (RCA). However, the same FFR threshold for deferral of revascularization is applied to all arteries, without evidence that this results in equivalent outcomes. We assessed vessel-specific outcomes of deferred revascularization for the 3 major coronary arteries based on FFR > 0.8. In this retrospective study, data were obtained on consecutive patients who underwent indicated FFR assessment across 2 tertiary institutions. Patients with deferred revascularization were followed for 36 months for the primary end point of vessel-specific target lesion failure (TLF). Of 1,916 major coronary arteries (1,579 patients), the odds ratio of positive FFR was highest in the LAD (odds ratio 3.36, p <0.001). In total, 867 vessels (733 patients) with FFR > 0.8 had complete 3-year medical record follow-ups. The TLF rate for deferred vessels was 10.21%, 11.52%, and 10.96% for the LAD, Cx, and RCA respectively. In a multivariate analysis, there was no significant difference in the odds of TLF for the 0.84 (0.53 to 1.33, p = 0.459), 1.17 (0.68 to 2.01, p = 0.582), and 1.11 (0.62 to 2.00, p = 0.715) in the LAD, Cx, and RCA, respectively. In a multivariate analysis, diabetes mellitus was the only baseline characteristic significantly associated at risk of TLF (1.43 [1.01 to 2.02], p = 0.043). In conclusion, despite greater likelihood of positive FFR in the LAD, the FFR threshold for deferred revascularization resulted in equivalent outcomes in all 3 major coronary arteries, and patients with diabetes mellitus may represent a group that requires aggressive surveillance and risk factor modification after deferred revascularization., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Crown Copyright © 2023. Published by Elsevier Inc. All rights reserved.)

We assessed the association of BMI with all-cause and cardiovascular (CV) mortality in a contemporary acute coronary syndrome cohort. Patients from the Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events and Global Registry of Acute Coronary Events between 2009 and 2019, were divided into BMI subgroups (underweight: <18.5, healthy: 18.5 to 24.9, overweight: 25 to 29.9, obese: 30 to 39.9, extremely obese: >40). Logistic regression was used to determine the association between BMI group and outcomes of all cause and CV death in hospital, and at 6 months. 8,503 patients were identified, mean age 64 ± 13, 72% male. The BMI breakdown was: underweight- 95, healthy- 2,140, overweight- 3,258, obese- 2,653, extremely obese- 357. Obese patients were younger (66 ± 12 vs 67 ± 13), with more hypertension, diabetes, and dyslipidemia vs healthy (all p < 0.05). Obese had lower hospital mortality than healthy: all-cause: 1% versus 4%, aOR (95% CI): 0.49(0.27, 0.87); CV: 1% versus 3%, 0.51(0.27, 0.96). At 6-month underweight had higher mortality than healthy: all-cause: 11% versus 4%, 2.69(1.26, 5.76); CV: 7% versus 1%, 3.54(1.19, 10.54); whereas obese had lower mortality: all-cause: 1% versus 4%, 0.48(0.29, 0.77); CV: 0.4% versus 1%, 0.42(0.19, 0.93). When BMI was plotted as a continuous variable against outcome a U-shaped relationship was demonstrated, with highest event rates in the most obese (>60). In conclusion, BMI is associated with mortality following an acute coronary syndrome. Obese patients had the best outcomes, suggesting persistence of the obesity paradox. However, there was a threshold effect, and favorable outcomes did not extend to the most obese., (Crown Copyright © 2020. Published by Elsevier Inc. All rights reserved.)

Atrial fibrillation (AF) is a frequent complication of acute coronary syndromes (ACS) and is associated with an increased risk of in-hospital and long-term mortality. Our objective was to determine whether patients with previous AF and those who presented with or developed AF during their ACS hospitalization (new onset) have an associated increased risk of short- and mid-term cardiovascular events, death, or a composite. We included 7,228 patients from the Global Registry of Acute Coronary Events electrocardiogram core laboratory substudy, who presented with an ACS. Associated multivariable-adjusted risk of death and major adverse cardiovascular events (MACE) of death, re-infarction, or stroke in-hospital and at 6 months were estimated. New-onset AF and previous AF patients had higher rates of in-hospital mortality (14.9% and 10.9%, respectively) compared with patients without AF (3.8%; both p < 0.001). New-onset AF and previous AF patients had higher rates of 6-month mortality (22.3% and 21.3%, respectively) compared with patients without AF (7.0%; both p <0.001). After adjustment for clinical prognosticators, including those in the Global Registry of Acute Coronary Events risk model, new-onset AF was associated with higher mortality in-hospital (OR adj 1.87, 95% CI 1.30 to 2.70) and at 6 months (OR adj 1.75, 95% CI 1.29 to 2.39) as well as MACE at 6 months (OR adj 1.43, 95% CI 1.12 to 1.81) compared with patients without AF, but were at similar risk compared to those with previous AF (all p > 0.40). In conclusion, the risk of death and MACE after ACS in patients with new-onset and previous AF appears similar and significantly increased compared with patients without AF., (Copyright © 2018. Published by Elsevier Inc.)

We sought to characterize presenting electrocardiographic findings in patients with acute coronary syndromes (ACSs) and out-of-hospital cardiac arrest (OHCA). In the Global Registry of Acute Coronary Events and Canadian ACS Registry I, we examined presenting and 24- to 48-hour follow-up ECGs (electrocardiogram) of ACS patients who survived to hospital admission, stratified by presentation with OHCA. We assessed the prevalence of ST-segment deviation and bundle branch blocks (assessed by an independent ECG core laboratory) and their association with in-hospital and 6-month mortality among those with OHCA. Of the 12,040 ACS patients, 215 (1.8%) survived to hospital admission after OHCA. Those with OHCA had higher presenting rates of ST-segment elevation, ST-segment depression, T-wave inversion, precordial Q-waves, left bundle branch block (LBBB), and right bundle branch block (RBBB) than those without. Among patients with OHCA, those with ST-segment elevation had significantly lower in-hospital mortality (20.9% vs 33.0%, p = 0.044) and a trend toward lower 6-month mortality (27% vs 39%, p = 0.060) compared with those without ST-segment elevation. Conversely, among OCHA patients, LBBB was associated with significantly higher in-hospital and 6-month mortality rates (58% vs 22%, p <0.001, and 65% vs 28%, p <0.001, respectively). ST-segment depression and RBBB were not associated with either outcome. Sixty-three percent of bundle branch blocks (RBBB or LBBB) on the presenting ECG resolved by 24 to 48 hours. In conclusion, compared with ACS patients without cardiac arrest, those with OHCA had higher rates of ST-segment elevation, LBBB, and RBBB on admission. Among OHCA patients, ST-segment elevation was associated with lower in-hospital mortality, whereas LBBB was associated with higher in-hospital and 6-month mortality., (Copyright © 2017 Elsevier Inc. All rights reserved.)

We examined the relations between right bundle branch block (RBBB) and clinical characteristics, management, and outcomes among a broad spectrum of patients with acute coronary syndrome (ACS). Admission electrocardiograms of patients enrolled in the Global Registry of Acute Coronary Events (GRACE) electrocardiogram substudy and the Canadian ACS Registry I were analyzed independently at a blinded core laboratory. We performed multivariable logistic regression analysis to assess the independent prognostic significance of admission RBBB on in-hospital and 6-month mortality. Of 11,830 eligible patients with ACS (mean age 65; 66% non-ST-elevation ACS), 5% had RBBB. RBBB on admission was associated with older age, male sex, more cardiovascular risk factors, worse Killip class, and higher GRACE risk score (all p <0.01). Patients with RBBB less frequently received in-hospital cardiac catheterization, coronary revascularization, or reperfusion therapy (all p <0.05). The RBBB group had higher unadjusted in-hospital (8.8% vs 3.8%, p <0.001) and 6-month mortality rates (15.1% vs 7.6%, p <0.001). After adjusting for established prognostic factors in the GRACE risk score, RBBB was a significant independent predictor of in-hospital death (odds ratio 1.45, 95% CI 1.02 to 2.07, p = 0.039), but not cumulative 6-month mortality (odds ratio 1.29, 95% CI 0.95 to 1.74, p = 0.098). There was no significant interaction between RBBB and the type of ACS for either in-hospital or 6-month mortality (both p >0.50). In conclusion, across a spectrum of ACS, RBBB was associated with preexisting cardiovascular disease, high-risk clinical features, fewer cardiac interventions, and worse unadjusted outcomes. After adjusting for components of the GRACE risk score, RBBB was a significant independent predictor of early mortality., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: Short-term outcomes have been well characterized in acute coronary syndromes; however, longer-term follow-up for the entire spectrum of these patients, including ST-segment-elevation myocardial infarction, non-ST-segment-elevation myocardial infarction, and unstable angina, is more limited. Therefore, we describe the longer-term outcomes, procedures, and medication use in Global Registry of Acute Coronary Events (GRACE) hospital survivors undergoing 6-month and 2-year follow-up, and the performance of the discharge GRACE risk score in predicting 2-year mortality., Methods: Between 1999 and 2007, 70,395 patients with a suspected acute coronary syndrome were enrolled. In 2004, 2-year prospective follow-up was undertaken in those with a discharge acute coronary syndrome diagnosis in 57 sites., Results: From 2004 to 2007, 19,122 (87.2%) patients underwent follow-up; by 2 years postdischarge, 14.3% underwent angiography, 8.7% percutaneous coronary intervention, 2.0% coronary bypass surgery, and 24.2% were re-hospitalized. In patients with 2-year follow-up, acetylsalicylic acid (88.7%), beta-blocker (80.4%), renin-angiotensin system inhibitor (69.8%), and statin (80.2%) therapy was used. Heart failure occurred in 6.3%, (re)infarction in 4.4%, and death in 7.1%. Discharge-to-6-month GRACE risk score was highly predictive of all-cause mortality at 2 years (c-statistic 0.80)., Conclusion: In this large multinational cohort of acute coronary syndrome patients, there were important later adverse consequences, including frequent morbidity and mortality. These findings were seen in the context of additional coronary procedures and despite continued use of evidence-based therapies in a high proportion of patients. The discriminative accuracy of the GRACE risk score in hospital survivors for predicting longer-term mortality was maintained., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Although the adverse prognosis of Q-waves on electrocardiogram (ECG) has been demonstrated, the prognostic significance of prominent R wave (PRW) in V1 or V2 across a broad spectrum of acute coronary syndrome (ACS) has not been specifically studied. In the Global Registry of Acute Coronary Events (GRACE) and the Canadian ACS Registry I ECG substudies, admission ECGs were analyzed in an independent core ECG laboratory. PRW was defined as R wave >40 to 50 ms in V1 or V2, R/S ≥1 in V1, or R/S ≥1.5 in V2. Among 11,895 patients with ACS, 495 (4.2%) had PRW; they were less likely to have a history of hypertension or heart failure and had lower GRACE risk scores, but a higher incidence of ST-segment depression (all p ≤0.001). Patients with PRW had similar rates of in-hospital death (2.8% vs 4.1%, respectively, p = 0.15) but lower rates of in-hospital heart failure (8.5% vs 15.2%, respectively, p = 0.02) and 6-month mortality (4.6% vs 8.4%, respectively, p = 0.004). In multivariable analyses, PRW was not a significant independent predictor of in-hospital mortality (adjusted odds ratio = 0.99, 95% confidence interval 0.55 to 1.8) or 6-month mortality (adjusted odds ratio = 0.70, 95% confidence interval 0.43 to 1.15). Among 4,418 patients who underwent coronary angiography, those with PRW had a higher prevalence of left circumflex artery disease (62.5% vs 49.5%, respectively, p = 0.01). In conclusion, across the broad spectrum of patients with ACS, PRW provides no significant additional prognostic utility beyond comprehensive risk assessment using the GRACE risk score. PRW is more frequently associated with left circumflex artery disease., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Current guidelines recommend early oral beta-blocker administration in the management of acute coronary syndromes for patients who are not at high risk of complications., Methods: Data from patients enrolled between 2000 and 2007 in the Global Registry of Acute Coronary Events (GRACE) were used to evaluate hospital outcomes in 3 cohorts of patients admitted with ST-elevation myocardial infarction, based on beta-blocker use (early [first 24 hours] intravenous (IV) [± oral], only early oral, or delayed [after first 24 hours])., Results: Among 13,110 patients with ST-elevation myocardial infarction, 21% received any early IV beta-blockers, 65% received only early oral beta-blockers, and 14% received delayed (>24 hours) beta-blockers. Higher systolic blood pressure, higher heart rate, and chronic beta-blocker use were independent predictors of early beta-blocker use. Early beta-blocker use was less likely in older patients, patients with moderate to severe left ventricular dysfunction, and in those presenting with inferior myocardial infarction or Killip class II or III heart failure. IV beta-blocker use and delayed beta-blocker use were associated with higher rates of cardiogenic shock, sustained ventricular fibrillation/ventricular tachycardia, and acute heart failure, compared with oral beta-blocker use. In-hospital mortality was increased with IV beta-blocker use (propensity score adjusted odds ratio, 1.41; 95% confidence interval, 1.03-1.92) but significantly reduced with delayed beta-blocker administration (propensity adjusted odds ratio, 0.44; 95% confidence interval, 0.26-0.74)., Conclusions: Early beta-blocker use is common in patients presenting with ST-elevation myocardial infarction, with oral administration being the most prevalent. Oral beta-blockers were associated with a decrease in the risk of cardiogenic shock, ventricular arrhythmias, and acute heart failure. However, the early receipt of any form of beta-blockers was associated with an increase in hospital mortality., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The early diagnosis of acute coronary syndrome (ACS) remains challenging, and a considerable proportion of patients are diagnosed with "possible" ACS on admission. The Global Registry of Acute Coronary Events (GRACE/GRACE(2)) and Canadian Registry of Acute Coronary Events (CANRACE) enrolled 16,618 Canadian patients with suspected ACS in 1999 to 2008. We compared the demographic and clinical characteristics, use of cardiac procedures, prognostic accuracy of the GRACE risk score, and in-hospital outcomes between patients given an admission diagnosis of "definite" versus "possible" ACS by the treating physician. Overall, 11,152 and 5,466 patients were given an initial diagnosis of "definite" ACS and "possible" ACS, respectively. Patients with a "possible" ACS had higher GRACE risk score (median 130 vs 125) and less frequently received aspirin, clopidogrel, heparin, or β blockers within the first 24 hours of presentation and assessment of left ventricular function, stress testing, cardiac catheterization, and percutaneous coronary intervention (all p <0.05). Patients with "possible" ACS had greater rates of in-hospital myocardial infarction (9.0% vs 2.0%, p <0.05) and heart failure (12% vs 8.9%, p <0.05). The GRACE risk score demonstrated excellent discrimination for in-hospital mortality in both groups and for the entire study population. In conclusion, compared to patients with "definite" ACS on presentation, those with "possible" ACS had higher baseline GRACE risk scores but less frequently received evidence-based medical therapies within 24 hours of admission or underwent cardiac procedures during hospitalization. The GRACE risk score provided accurate risk assessment, regardless of the initial diagnostic impression., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Acute coronary syndromes (ACSs), which include ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, and unstable angina, present a considerable burden to the health care system. Furthermore, many patients with a first ACS event will develop another event within 1 year. To prevent this, higher-risk patients with ACS are revascularized when possible after presentation and then prescribed ongoing treatments to prevent recurrent vascular events. These include agents that prevent platelet aggregation and subsequent coronary thrombosis. However, some patients will develop a recurrent event despite treatment with these drugs, prompting a search for additional strategies to augment the effectiveness of current therapies. One such approach is add-on therapy with oral anticoagulant drugs. These agents may act synergistically with antiplatelet agents in preventing thrombosis. In conclusion, new oral anticoagulants might represent an attractive therapeutic strategy if they do not result in unacceptable bleeding., (Copyright © 2012 Elsevier Inc. All rights reserved.)

It is unclear if clinician risk stratification has changed with time. The aim of this study was to assess the temporal change in the concordance between patient presenting risk and the intensity of evidence-based therapies received for non-ST-segment elevation acute coronary syndromes over a 9-year period. Data from 3,562 patients with non-ST-segment elevation acute coronary syndromes enrolled in the Australian and New Zealand population of the Global Registry of Acute Coronary Events (GRACE) from 1999 to 2007 were analyzed. Patients were stratified to risk groups on the basis of the GRACE risk score for in-hospital mortality. Main outcome measures included in-hospital use of widely accepted evidence-based medications, investigations, and procedures. Invasive management was consistently higher in low-risk patients than in intermediate- or high-risk patients (coronary angiography 66.7% vs 63.5% vs 35.3%, p <0.001; percutaneous coronary intervention 31.1% vs 22.0% vs 12.9%, p <0.001). Absolute rates of angiography and percutaneous coronary intervention in the high-risk group remained 24% and 15% lower compared to the low-risk group in the most recent time period (2005 to 2007). In-hospital use of thienopyridine, low-molecular weight heparin, and glycoprotein IIb/IIIa inhibitors showed a similar inverse relation with risk. Prescription of aspirin, β blockers, statins, and angiotensin receptor blockers was inversely related to risk before 2004, although this inverse relation was no longer present in the most recent time period (2005 to 2007). Only in-hospital use of unfractionated heparin showed use concordant with patient risk status. In conclusion, despite an overall increase in the uptake of evidence-based therapies, most investigations and treatments are not targeted on the basis of patient risk. Clinician risk stratification remains suboptimal compared to objective measures of patient risk., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Animal models of myocardial ischemia have demonstrated reduction in arrhythmias using statins. It was hypothesized that previous statin therapy before hospitalization might be associated with reductions of in-hospital arrhythmic events in patients with acute coronary syndromes. In this multinational, prospective, observational study (the Global Registry of Acute Coronary Events [GRACE]), data from 64,679 patients hospitalized for suspected acute coronary syndromes (from 1999 to 2007) were analyzed. The primary outcome of interest was in-hospital arrhythmic events in previous statin users compared with nonusers. The 2 primary end points were atrial fibrillation and the composite end point of ventricular tachycardia, ventricular fibrillation, and/or cardiac arrest. In-hospital death was also examined. Of the 64,679 patients, 17,636 (27%) had received previous statin therapy. Those taking statins had higher crude rates of histories of angina (69% vs 46%), diabetes (34% vs 22%), heart failure (15% vs 8.4%), hypertension (74% vs 58%), atrial fibrillation (9.3% vs 7.0%), and dyslipidemia (85% vs 35%). Patients previously taking statins were less likely to have in-hospital arrhythmias. In propensity-adjusted multivariable models, previous statin use was associated with a lower risk for ventricular tachycardia, ventricular fibrillation, or cardiac arrest (odds ratio 0.81, 95% confidence interval 0.72 to 0.96, p = 0.002); atrial fibrillation (odds ratio 0.81, 95% confidence interval 0.73 to 0.89, p <0.0001); and death (odds ratio 0.82, 95% confidence interval 0.70 to 0.95, p = 0.010). In conclusion, patients previously taking statins had a lower incidence of in-hospital arrhythmic events after acute coronary syndrome than those not previously taking statins. Our study suggests another possible benefit from appropriate primary and secondary prevention therapy with statins.

Duration of delay in seeking medical care in persons with symptoms of evolving acute myocardial infarction (AMI) is of current interest given the time-dependent benefits associated with early use of coronary reperfusion approaches. The objectives of this multinational study were to describe geographic variation in the extent of and factors associated with prehospital delay in patients enrolled in the GRACE study. Data were collected from 44,695 patients hospitalized with an acute coronary syndrome in 14 countries from 2000 to 2006. The regions under study included Argentina and Brazil (n = 8,203), United States/Canada (n = 12,810), Europe (n = 19,354), and Australia/New Zealand (n = 4,328). Patients with ST-segment elevation AMI, non-ST-segment elevation AMI, and unstable angina comprised the study population. There were marked geographic differences in extent of prehospital delay in patients with ST-segment elevation AMI and those with non-ST-segment elevation AMI/unstable angina. In patients with ST-segment elevation AMI, the shortest duration of prehospital delay was observed in patients from Australia/New Zealand (median 2.2 hours), whereas patients from Argentina and Brazil delayed the longest (median 4.0 hours). Median duration of prehospital delay was shortest (2.5 hours) in patients with ST-segment elevation AMI, whereas patients with non-ST-segment elevation AMI/unstable angina showed considerably longer prehospital delay (3.1 hours). Several demographic and clinical characteristics were associated with prolonged delay overall and in the different geographic locations under study. In conclusion, results of this large multinational registry provided insights into contemporary patterns of care-seeking behavior in patients with acute coronary disease.

The incidence, prognosis, and factors associated with ventricular arrhythmia (VA) in acute coronary syndrome are unknown. We sought to examine the magnitude, predictors, and outcomes of in-hospital VA in patients with acute coronary syndrome. The population comprised 52,380 patients enrolled in the Global Registry of Acute Coronary Events from 1999 to 2005. The proportion who developed VA during hospitalization was 6.9% (1.8% with ventricular tachycardia, 5.1% with ventricular fibrillation or cardiac arrest). The incidence of in-hospital VA decreased over time (8.0% in 1999, 7.0% in 2002, 5.8% in 2005, p <0.001). In-hospital case-fatality rates were higher in patients with versus those without VA (52% vs 1.6%). Several demographic and clinical variables were associated with the occurrence of VA including ST deviation, Killip class, age, initial cardiac markers, serum creatinine and heart rate, and history of selected co-morbidities. Six-month postdischarge mortality was higher in survivors of in-hospital VA versus those who did not develop VA during hospitalization (odds ratio 1.57, 95% confidence interval 1.27 to 1.95). In conclusion, development of VA during hospitalization for acute coronary syndrome was associated with higher in-hospital and 6-month mortalities.

This aim of this study was to assess the clinical utility of quantitative ST-segment depression (STD) for refining the risk stratification of non-ST elevation acute coronary syndromes in the prospective, multinational Global Registry of Acute Coronary Events (GRACE). Quantitative measurements of STD on admission electrocardiograms were evaluated independently by a core laboratory, and their predictive value for in-hospital and cumulative 6-month mortality was examined. Although more severe STD is a marker of increased short- and long-term mortality, it is also associated with higher risk clinical features and biomarkers. Thus, after adjustment for these clinically important predictors, quantitative STD does not provide incremental prognostic value beyond simple dichotomous evaluation for the presence of STD. Furthermore, adopting quantitative instead of the prognostically proven qualitative evaluation of STD does not improve risk discrimination afforded by the validated GRACE risk models. In conclusion, the findings do not support the quantification of STD in routine clinical practice beyond simple evaluation for the presence of STD as an integral part of comprehensive risk stratification using the GRACE risk score.

The use of, factors associated with, and long-term outcomes related to statin therapy in patients with acute coronary syndromes and low-density lipoprotein (LDL) levels<100 mg/dl at the time of hospital presentation are unclear. This report describes the use of statins at hospital discharge in 8,492 patients with acute coronary syndromes enrolled in the Global Registry of Acute Coronary Events (GRACE; 1999 to 2005) according to baseline LDL levels (<100 vs>or=100 mg/dl) and compares 6-month outcomes in each group stratified by the use or nonuse of statin therapy. Seventy-two percent of patients with LDL levels>or=100 mg/dl, compared with 55% of patients with LDL levels<100 mg/dl, were discharged on statin therapy. Sociodemographic, clinical, and treatment variables varied between patients discharged on statins and those who were not. Patients receiving statins at discharge were twofold (LDL>or=100 mg/dl) to threefold (<100 mg/dl) more likely to be receiving statin therapy at 6 months compared with those not receiving statins at discharge. Statin use at discharge was associated with a significantly lower rate of 6-month cardiac complications in patients with LDL levels<100 mg/dl (adjusted odds ratio for the composite end point of myocardial infarction, stroke, and death 0.64, 95% confidence interval 0.47 to 0.88). In conclusion, data from this large observational study suggest that patients with acute coronary syndromes and LDL levels<100 mg/dl are much less likely to be prescribed statin therapy at hospital discharge or to be receiving statin therapy at 6 months but benefit from the prescription of statins at hospital discharge as much as patients with levels>or=100 mg/dl.

Relatively limited data are available, particularly from the perspective of a multinational registry, about the post-discharge outcomes and management practices of patients with an acute coronary syndrome (ACS). The objectives of this longitudinal study were to examine 6-month outcomes in a large multinational sample of patients hospitalized with an ACS. A total of 5,476 patients with ST-segment elevation acute myocardial infarction (STEAMI), 5,209 patients with non-ST-segment elevation acute myocardial infarction (NSTEAMI), and 6,149 patients with unstable angina pectoris discharged from 90 hospitals in 14 countries comprised the study population. The study sample was recruited from 18 cluster sites in 14 countries that are currently collaborating in the Global Registry of Acute Coronary Events (GRACE) study. The 6-month post-discharge death rates were 4.8% in patients with STEAMI, 6.2% in patients with NSTEAMI, and 3.6% in patients with unstable angina pectoris. Approximately 1 in 5 of each of our comparison groups were rehospitalized for heart disease during the 6-month follow-up, and approximately 15% of each of the respective study cohorts underwent coronary revascularization during follow-up. Demographic and clinical characteristics of post-discharge decedents were identified according to type of ACS. Our results suggest that a considerable proportion of patients who were discharged from the hospital after an ACS, with some differences noted according to type of ACS, remain at increased risk for adverse outcomes during the relatively brief post-discharge period. These data suggest the need for better long-term medical management and more intense follow-up of patients with an ACS to improve their long-term outlook.

The optimal strategy for administration of low molecular weight heparin in patients with acute coronary syndrome (ACS) undergoing coronary angiography without percutaneous coronary intervention remains unclear. We studied postangiographic vascular complications in 325 consecutive patients (210 men and 115 women, mean age 63 years) with ACS undergoing diagnostic coronary angiography via a femoral approach followed by immediate sheath removal. At the time of angiography, 44 patients were on intravenous unfractionated heparin (UFH), 229 on subcutaneous enoxaparin, and 52 on no heparin. Enoxaparin was withheld on the morning of angiography in 181 of 229 patients: the no A.M. dose group. Vascular complications were audited, including hematoma development at angiographic puncture sites; these complications were considered significant if >25 cm(2). Major vascular complications requiring transfusion or surgical interventions were infrequent in all groups. Patients receiving enoxaparin on the morning of angiography had a twofold increase in significant hematoma rate compared with the no A.M. dose group (31% vs 16%; p = 0.015). The no A.M. dose group had hematoma rates similar to UFH (20%; p = NS) and no anticoagulation (13.5%; p = NS). No significant increase in ischemic episodes occurred as a result of withholding enoxaparin in the no A.M. dose group. We conclude that omission of enoxaparin on the morning of cardiac catheterization results in vascular complications rates comparable to that of UFH without precipitating rebound ischemia. This is a practical, safe strategy for patients with ACS undergoing coronary angiography, allowing early mobilization for most patients who do not proceed to immediate percutaneous coronary intervention.

Our primary study aim was to examine extent of, and factors associated with, delay in seeking medical care in a large multinational registry of patients with acute myocardial infarction (AMI) and unstable angina pectoris. A secondary goal was to examine the relation between duration of prehospital delay and receipt and timing of coronary reperfusion strategies. Investigators from 14 countries are participating in the Global Registry of Acute Coronary Events (GRACE) project. The study sample consisted of 3,693 patients with ST-segment elevation AMI, 2,935 with non-ST-segment elevation AMI, and 3,954 patients with unstable angina hospitalized between 1999 and 2001. The average and median delay times were longest in patients with non-ST-segment elevation AMI (6.1 and 3.0 hours, respectively) followed by patients with unstable angina (5.6 and 3.0 hours) and those with ST-segment elevation AMI (4.7 and 2.3 hours). Approximately 41% of patients with ST-segment elevation AMI presented to the 94 study hospitals within 2 hours of the onset of acute coronary symptoms; this compared with approximately one third of patients with non-ST-segment elevation AMI and unstable angina. Several demographic and clinical characteristics were associated with prehospital delay. In patients with ST-segment elevation AMI, duration of prehospital delay was inversely related to the receipt of thrombolytic therapy, but was inconsistently related to the use of percutaneous coronary interventions. The results of this study demonstrate that a large proportion of patients continue to exhibit prolonged delay in seeking medical care after the onset of acute coronary symptoms and remain in need of targeted educational efforts to reduce extent of delay.

After 2 weeks of nicorandil therapy, time to ischemia on stress testing was significantly less than on day 1 and not different from placebo. These data are consistent with attenuation of the anti-ischemic effects of this drug and suggest that the potassium channel-opening properties do not compensate for development of attenuation to the nitrate component of nicorandil.

The primary objective of this study was to characterize a large cohort of patients receiving thrombolytic therapy for acute myocardial infarction with respect to the group with a prior event. Patients were randomly assigned to 1 of 4 thrombolytic strategies. Baseline characteristics, 30-day outcomes, and 1-year mortality were compared between patients with (n = 6,704) and without (n = 34,143) prior myocardial infarction. Patients with prior myocardial infarction presented to the hospital earlier than those having their first event, but institution of thrombolytic therapy was delayed. Mortality at 30 days (11.7% vs 5.9%, p = 0.001) and 1 year (17.3% vs 8.2%, p < 0.001) was greater among patients with prior infarction, and independent of other demographic variables. Accelerated alteplase was more effective than streptokinase or combination therapy (30-day mortality 10.4% vs 12.2%, p = 0.012; 1-year mortality 15.9% vs 17.8%, p = 0.041). Infarct vessel patency did not differ between those with and without prior myocardial infarction (67.3% vs 67% at 90 minutes, p = 0.92); however, recurrent ischemia was more common in patients with prior myocardial infarction. Patients with healed myocardial infarction should be educated to ensure early hospital admission if they develop symptoms suggestive of acute infarction, and upon hospital arrival should be promptly triaged to receive reperfusion therapy with accelerated alteplase.

This study reports on a predominantly noninvasive management program for neonatal transposition of the great arteries [TGA] incorporating balloon atrial septostomy [BAS] under echocardiographic control. BAS was performed in 25 consecutive patients presenting with TGA between April 1988 and April 1990. Structural and coronary anatomy was evaluated echocardiographically with angiographic supplementation only when additional data were required. This information was correlated, where possible, with direct anatomic findings and subsequent course. BAS was performed through the umbilicus in 17 patients (85% of patients in whom this approach was attempted). Thirteen patients did not require ventilation during BAS. There were minimal complications and satisfactory septostomies in all cases. Coronary anatomy was correctly predicted in all patients where anatomic correlation was available. Without invasive investigation 9 patients underwent neonatal arterial switch procedures and 2 underwent palliative procedures. BAS under echocardiographic control proved safe, effective, minimally traumatic and mostly possible via the umbilical vein. The umbilical vein, where patent, permitted rapid safe access for BAS. Echocardiographic diagnosis of the coronary artery, and structural and functional anatomy was reliable and allowed minimally invasive preoperative management in many patients.