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Aims: To evaluate the impact of cardiac rehabilitation (CR) on optimization of secondary prevention treatments for acute coronary syndrome (ACS), medication persistence, medical follow-up, rehospitalization, and all-cause mortality., Methods and Results: The National Health Insurance database was used to identify all patients hospitalized for ACS in France in 2019 and those among them who received CR. Patients' characteristics and outcomes were described and compared between CR and non-CR patients. Poisson regression models were used to identify the impact of CR after adjusting for confounders. A Cox model was fitted to identify the variables related to mortality after adjustment for medication persistence and cardiologic follow-up. In 2019, 22% of 134 846 patients hospitalized for ACS in France received CR within 6 months of their discharge. After 1 year, only 60% of patients who did not receive CR were still taking BASI (combination of beta-blockers, antiplatelet agents, statins, and renin-angiotensin-aldosterone system inhibitors) drugs. This rate and the medical follow-up rate were higher in patients who received CR. Two years after the ACS event, patients who received CR had better medical follow-up and lower mortality risk, after adjusting for cofounding variables [adjusted hazard ratio all-cause mortality = 0.65 (0.61-0.69)]. After adjustment for the dispensing of cardiovascular drugs and cardiologic follow-up, the independent effect of CR was not as strong but remained significant [hazard ratio = 0.90 (95% confidence interval: 0.84-0.95)]., Conclusion: Patients who received CR after hospitalization for ACS had a better prognosis. Optimization of efficient secondary prevention strategies, improved medication persistence, and enhanced cardiologic follow-up seemed to play a major role., Competing Interests: Conflict of interest: J.B. reports, outside the submitted work, personal fees and/or non-financial support from AstraZeneca, Bayer, Gedeon Richter, Elkendi, Hikma, Leurquin, Omron, Organon, Sanofi, ViiV, Vivactis, and Vivoptim. M.-C.I. reports, outside the submitted work, personal fees from AstraZeneca, Novartis, Sanofi, and Servier. A.C. reports, outside the submitted work, non-financial support from Amgen SAS. C.G., A.G., P.T., and V.O. have nothing to report., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Since the 1960s, cardiologists have adopted several binary classification systems for acute myocardial infarction (MI) that facilitated improved patient management. Conversely, for chronic stable manifestations of myocardial ischemia, various classifications have emerged over time, often with conflicting terminology-eg, "stable coronary artery disease" (CAD), "stable ischemic heart disease," and "chronic coronary syndromes" (CCS). While the 2019 European guidelines introduced CCS to impart symmetry with "acute coronary syndromes" (ACS), the 2023 American guidelines endorsed the alternative term "chronic coronary disease." An unintended consequence of these competing classifications is perpetuation of the restrictive terms "coronary" and 'disease', often connoting only a singular obstructive CAD mechanism. It is now important to advance a more broadly inclusive terminology for both obstructive and non-obstructive causes of angina and myocardial ischemia that fosters conceptual clarity and unifies dyssynchronous nomenclatures across guidelines. We, therefore, propose a new binary classification of "acute myocardial ischemic syndromes" and "non-acute myocardial ischemic syndromes," which comprises both obstructive epicardial and non-obstructive pathogenetic mechanisms, including microvascular dysfunction, vasospastic disorders, and non-coronary causes. We herein retain accepted categories of ACS, ST-segment elevation MI, and non-ST-segment elevation MI, as important subsets for which revascularization is of proven clinical benefit, as well as new terms like ischemia and MI with non-obstructive coronary arteries. Overall, such a more encompassing nomenclature better aligns, unifies, and harmonizes different pathophysiologic causes of myocardial ischemia and should result in more refined diagnostic and therapeutic approaches targeted to the multiple pathobiological precipitants of angina pectoris, ischemia, and infarction., Competing Interests: None.

Background: The length of hospital stay in patients with acute coronary syndrome (ACS) is crucial for determining clinical outcomes, managing healthcare resources, controlling costs, and ensuring patient well-being. This study aimed to explore the impact of treatment approaches on the length of stay (LOS) for ACS patients., Methods: A total of 7109 ACS cases were retrospectively recruited from a hospital between 2018 and 2023. Demographical baseline data, laboratory examinations, and diagnostic and treatment information of the included subjects were extracted from electronic medical records to investigate the factors contributing to extended hospitalization and further explore the impact of treatment management on the LOS., Results: Advanced age, female sex, and elevated levels of B-type natriuretic peptide, C-reactive protein and higher low-density lipoprotein cholesterol were identified as risk factors for extended hospitalization. At the 0.2-0.9 quantile of LOS, compared with the non-invasive group, the percutaneous transluminal coronary angioplasty group and the stent implantation group exhibited decreases in LOS of 0.37-2.37 days and 0.12-2.28 days, respectively. Stratified analysis based on diagnosis showed that percutaneous coronary intervention decreased hospitalization time in the high quantile of LOS but conversely increased it in the low quantile., Conclusion: Percutaneous coronary intervention is important for reducing hospitalization duration, particularly for patients susceptible to prolonged stays. Early and assertive management intervention, incorporating elements such as lipid-lowering therapy, and anti-inflammatory agents, is essential for improving outcomes within high-risk groups., (© 2024. The Author(s).)

Aims: Although dual antiplatelet therapy with aspirin and a potent P2Y12 receptor inhibitor is currently recommended in patients with acute coronary syndrome (ACS), its use in elderly patients remains challenging. The aim of this trial is to evaluate the pharmacodynamic and pharmacokinetic profile of ticagrelor 60 vs. 90 mg twice daily among elderly patients (≥75 years) with ACS undergoing percutaneous coronary intervention (PCI)., Methods and Results: PLINY The ELDER (NCT04739384) was a randomized, crossover trial testing the non-inferiority of a lower vs. standard dose of ticagrelor with respect to the primary endpoint of P2Y12 inhibition as determined by pre-dose P2Y12 reaction units (PRU) using the VerifyNow-P2Y12 (Accumetrics, San Diego, CA, USA). Other pharmacodynamic tests included light transmittance aggregometry, multiple electrode aggregometry, and response to aspirin. Plasma levels of ticagrelor and its active metabolite AR-C124910XX were also evaluated. A total of 50 patients (mean age 79.6 ± 4.0 years, females 44%) were included in the trial. Ticagrelor 60 mg was non-inferior to ticagrelor 90 mg according to VerifyNow-P2Y12 results (PRU 26.4 ± 32.1 vs. 30.4 ± 39.0; least squares mean difference: -4; 95% confidence interval: -16.27 to 8.06; P for non-inferiority = 0.002). Other pharmacodynamic parameters were similar between the two ticagrelor doses and there were no differences in response to aspirin. Plasma levels of ticagrelor (398.29 ± 312.36 ng/mL vs. 579.57 ± 351.73 ng/mL, P = 0.006) and its active metabolite were significantly lower during treatment with ticagrelor 60 mg., Conclusion: Although plasma concentrations were lower, ticagrelor 60 mg twice daily provided a similar magnitude of platelet inhibition compared with ticagrelor 90 mg twice daily among elderly patients undergoing PCI., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: P2Y12 inhibitor monotherapy after a short course of dual antiplatelet therapy (DAPT) may balance ischaemic and bleeding risks in patients with acute coronary syndrome (ACS). However, it remains uncertain how different P2Y12 inhibitors used as monotherapy affect outcomes., Methods and Results: Randomized controlled trials comparing P2Y12 inhibitor monotherapy after a short course of DAPT (≤3 months) vs. 12-month DAPT in ACS were included. The primary endpoint was major adverse cardiovascular events (MACE). All analyses included an interaction term for the P2Y12 inhibitor used as monotherapy. Trial sequential analyses were run to explore whether the effect estimate of each outcome may be affected by further studies. Seven trials encompassing 27 284 ACS patients were included. Compared with 12-month DAPT, P2Y12 inhibitor monotherapy after a short course of DAPT was associated with no difference in MACE [odds ratio (OR) 0.92, 95% confidence interval (CI) 0.76-1.12] and a significant reduction in net adverse clinical events (NACE) (OR 0.75; 95% CI 0.60-0.94), any bleeding (OR 0.54, 95% CI 0.43-0.66), and major bleeding (OR 0.47, 95% CI 0.37-0.60). Significant interactions for subgroup difference between ticagrelor and clopidogrel monotherapy were found for MACE (Pint = 0.016), all-cause death (Pint = 0.042), NACE (Pint = 0.018), and myocardial infarction (Pint = 0.028). Trial sequential analysis showed conclusive evidence of improved NACE with ticagrelor, but not with clopidogrel monotherapy, compared with standard DAPT., Conclusions: In patients with ACS, P2Y12 inhibitor monotherapy after short DAPT halves bleeding without increasing ischaemic events compared with standard DAPT. Ticagrelor, but not clopidogrel monotherapy, reduced MACE, NACE, and mortality compared with standard DAPT, supporting its use after aspirin discontinuation., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Older adults with non-ST-segment-elevation acute coronary syndrome are less likely to undergo an invasive strategy compared with younger patients. Randomized controlled trials traditionally exclude older adults because of their high burden of geriatric conditions., Methods and Results: We searched for randomized controlled trials comparing invasive versus medical management or a selective invasive (conservative) strategy for older patients (age≥75 years) with non-ST-segment-elevation acute coronary syndrome. Fixed effects meta-analysis was conducted to estimate the odds ratio (OR) with 95% CI for the composite of death or myocardial infarction (MI) and individual secondary end points of all-cause death, cardiovascular death, MI, revascularization, stroke, and major bleeding. Nine studies with 2429 patients (invasive: 1228 versus control: 1201) with a mean follow-up of 21 months were included. An invasive strategy was associated with a significantly decreased risk of a composite of death and MI (OR, 0.67 [95% CI, 0.54-0.83], P <0.001), MI (OR, 0.56 [95% CI, 0.45-0.70], P <0.001) and subsequent revascularization (OR, 0.27 [95% CI, 0.16-0.48], P <0.001). There was no difference in all-cause death (OR, 0.84 [95% CI, 0.65-1.10], P =0.21), cardiovascular death (OR, 0.85 [95% CI, 0.63-1.15], P =0.30), stroke (OR, 0.74 [95% CI, 0.38-1.47], P =0.39), or major bleeding (OR, 1.24 [95% CI, 0.42-3.66], P =0.70)., Conclusions: In older patients ≥75 years old with non-ST-segment-elevation acute coronary syndrome, an invasive strategy reduced the risk of a composite of death and MI, MI, and subsequent revascularization compared with a conservative strategy alone. Older adults with higher burden of geriatric conditions should be included in future trials to improve generalizability to this growing population.

Background: Multivessel disease(MVD) is linked to a poorer prognosis, increased complications, longer hospital stays, and higher in-hospital mortality when compared to single-vessel disease(SVD).The purpose of this study is to explore the clinically relevant predictors of acute cornary syndrome (ACS) combined with MVD., Methods: This multicenter retrospective study included 68,378 ACS patients from 240 hospitals.The clinical data were retrospectively analyzed with univariate and multivariate analyses to identify the predictive factors for MVD., Results: When compared to SVD group, the MVD group showed a higher incidence of Major Adverse Cardiovascular Events(MACCEs), including all-cause death, myocardial infarction, stent thrombosis, and ischemic stroke during hospitalization, These differences were found to be statistically significant (P < 0.05) .The multivariate analysis revealed that age over 75 years (OR: 1.246, 95% CI: 1.176, 1.319), LDL/HDL ratio > 1.98 (OR: 1.245, 95% CI: 1.192, 1.302), history of heart failure (OR: 1.446, 95% CI: 1.143, 1.829), hypertension (OR: 1.274, 95% CI: 1.225, 1.325), diabetes (OR: 1.341, 95% CI: 1.278, 1.406), eGFRs < 60 ml/min·1.73m2 (OR: 1.179, 95% CI: 1.112, 1.249), family history of CAD (OR: 1.236, 95% CI: 1.108, 1.379), and high homocysteine levels (OR: 1.209, 95% CI: 1.029, 1.420) are independent predictors of MVD. The incidence of multivessel disease increased from 37.7 to 58.6% with an increase in the number of predictive factors, while the incidence of single vessel disease decreased from 62.3 to 41.4%. This trend was statistically significant (P trend < 0.001)., Conclusions: MVD is strongly correlated with a range of risk factors including diabetes, hypertension, LDL/HDL ratio greater than 1.98, hyperhomocysteinemia, family history of CAD, reduced glomerular filtration rate (< 60 ml/(min·1.73m 2 ), age over 75 years, and a history of heart failure. Furthermore, as the number of predictive factors increases, the odds ratio (OR) for patients with MVD also increases, reaching 2.344 times the OR for patients without any predictive factors., (© 2024. The Author(s).)

Background: To evaluate the clinical performance and effectiveness of a multiplex apolipoprotein panel in the context of cardiovascular precision diagnostics, clinical samples of patients with recent acute coronary syndrome in the ODYSSEY OUTCOMES trial were measured by quantitative clinical chemistry proteomics (qCCP). The ISO15189-accredited laboratory setting, including the total testing process (TTP), served as a foundation for this study. Consequently, tailored quality assurance measures needed to be designed and implemented to suit the demands of a multiplex LC-MS/MS test., Methods: Nine serum apolipoproteins were measured in 23 376 samples with a laboratory-developed multiplex apolipoprotein test on 4 Agilent 6495 LC-MS/MS systems. A fit-for-purpose process was designed with tailored additions enhancing the accredited laboratory infrastructure and the TTP. Quality assurance was organized in 3 steps: system suitability testing (SST), internal quality control (IQC) evaluation with adjusted Westgard rules to fit a multiplex test, and interpeptide agreement analysis. Data was semi-automatically evaluated with a custom R script., Results: LC-MS/MS analyses were performed with the following between-run CVs: for apolipoprotein (Apo) (a) 6.2%, Apo A-I 2.3%, Apo A-II 2.1%, Apo A-IV 2.9%, Apo B 1.9%, Apo C-I 3.3%, Apo C-II 3.3%, Apo C-III 2.7%, and for Apo E 3.3% and an average interpeptide agreement Pearson r of 0.981., Conclusions: This is the first study of its kind in which qCCP was performed at this scale. This research successfully demonstrates the feasibility of high-throughput LC-MS/MS applications in large clinical trials. ClinicalTrials.gov Registration Number: NCT01663402., (© Association for Diagnostics & Laboratory Medicine 2024.)

Background: In the AUGUSTUS trial (An Open-Label, 2 x 2 Factorial, Randomized Controlled, Clinical Trial to Evaluate the Safety of Apixaban vs Vitamin K Antagonist and Aspirin vs Aspirin Placebo in Patients With Atrial Fibrillation and Acute Coronary Syndrome or Percutaneous Coronary Intervention), the combination of dual antiplatelet therapy plus oral anticoagulation increased the risk of bleeding without reducing ischemic events compared with a P2Y12 inhibitor plus oral anticoagulation among patients with atrial fibrillation and acute coronary syndrome or elective percutaneous coronary intervention. However, AUGUSTUS enrolled patients up to 14 days after acute coronary syndrome or percutaneous coronary intervention, and there may be a benefit to dual antiplatelet therapy plus oral anticoagulation early after an ischemic event., Methods: In this secondary analysis of AUGUSTUS, we divided patients into groups based on whether they were enrolled <6 days (early) or ≥6 days (later) after their index acute coronary syndrome or percutaneous coronary intervention, and tested the interaction between time from the index event to enrollment and randomized treatment (apixaban versus vitamin K antagonist and aspirin versus placebo) on 30-day and 6-month clinical outcomes using Cox proportional hazards models., Results: Among 4605 patients enrolled in AUGUSTUS with data available on time from the index event to enrollment, the median time from the index event to enrollment was 6 (range, 0-14) days. There were no significant interactions between time from the index event and aspirin versus placebo on clinical outcomes at 30 days or 6 months, though patients with time from the index event <6 days had a nominally significant reduction in death or ischemic events at 30 days with aspirin (hazard ratio, 0.55 [95% CI, 0.30-0.99]), whereas patients with time from the index event ≥6 days did not (hazard ratio, 0.88 [95% CI, 0.54-1.43]; interaction P =0.23). There were no significant interactions between time from the index event and apixaban versus vitamin K antagonist on clinical outcomes., Conclusions: Among patients with atrial fibrillation with acute coronary syndrome or undergoing percutaneous coronary intervention, there was no difference in the relative benefit of apixaban versus vitamin K antagonist or aspirin versus placebo when patients were enrolled early versus later after their index event., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02415400., Competing Interests: Dr Fanaroff: research grants from the American Heart Association, National Institutes of Health, and Cardiovascular Systems Inc; and consulting fees from Intercept Pharmaceuticals and Abbott Laboratories. Dr Granger: research grants from Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Daiichi Sankyo, Janssen, Pfizer, Armetheon, AstraZeneca, US Food and Drug Administration (FDA), GlaxoSmithKline, The Medicines Company, Medtronic Foundation, Medtronic, Inc, and Novartis; consulting fees from Bayer, Boehringer Ingelheim, Boston Scientific, Bristol Myers Squibb, Daiichi Sankyo, Janssen, Pfizer, Abbvie, Armetheon, AstraZeneca, Eli Lilly, Gilead, GlaxoSmithKline, Hoffmann-La Roche, The Medicines Company, National Institutes of Health (NIH), Novartis, Sirtex, Verseon, Apple, Medscape, LLC, Merck, Novo Nordisk, Roche Diagnostics, and Rho Pharmaceuticals. Dr Goodman: research grant support and speaker/consulting honoraria from Amgen, Anthos Therapeutics, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, CSL Behring, CYTE, Ltd, Daiichi-Sankyo/American Regent, Eli Lilly, Esperion, Ferring Pharmaceuticals, HLS Therapeutics, JAMP Pharma, Merck, Novartis, Novo Nordisk A/C, Pendopharm/Pharmascience, Pfizer, Regeneron, Sanofi, Servier, Tolmar Pharmaceuticals, and Valeo Pharma; salary support/honoraria from the Heart and Stroke Foundation of Ontario/University of Toronto (Polo) Chair, Canadian Heart Failure Society, Canadian Heart Research Centre and MD Primer, Canadian Virtual Coordinating Centre for Global Collaborative Cardiovascular Research, Cleveland Clinic Coordinating Centre for Clinical Research, Duke Clinical Research Institute, New York University Clinical Coordinating Centre, Baim Institute for Clinical Research, and Thrombolysis in Myocardial Infarction Study Group (Brigham Health). Dr Aronson: employee of Bristol Myers Squibb. Dr Windecker: research, travel, or educational grants to the institution without personal remuneration from Abbott, Abiomed, Amgen, AstraZeneca, Bayer, Braun, Biotronik, Boehringer Ingelheim, Boston Scientific, Bristol Myers Squibb, Cardinal Health, CardioValve, Cordis Medical, Corflow Therapeutics, CSL Behring, Daiichi Sankyo, Edwards Lifesciences, Farapulse, Inc, Fumedica, Guerbet, Idorsia, Inari Medical, InfraRedx, Janssen-Cilag, Johnson & Johnson, MedAlliance, Medicure, Medtronic, Merck Sharp & Dohm, Miracor Medical, Novartis, Novo Nordisk, Organon, OrPha Suisse, Pharming Tech, Pfizer, Polares, Regeneron, Sanofi-Aventis, Servier, Sinomed, Terumo, Vifor, and V-Wave; advisory board member and steering/executive group member of trials funded by Abbott, Abiomed, Amgen, AstraZeneca, Bayer, Boston Scientific, Biotronik, Bristol Myers Squibb, Edwards Lifesciences, MedAlliance, Medtronic, Novartis, Polares, Recardio, Sinomed, Terumo, and V-Wave, with payments to the institution but no personal payments; steering/executive committee group member of several investigator-initiated trials funded by industry without impact on his personal remuneration. Dr Mehran: institutional research grants from AstraZeneca, Bayer, Beth Israel Deaconess, Bristol Myers Squibb/Sanofi, CSL Behring, Eli Lilly/Daiichi Sankyo, Medtronic, Novartis, and OrbusNeich; consulting fees from Boston Scientific, Abbott Vascular, Medscape, Siemens Medical Solutions, Roivant Sciences, Inc, and Sanofi; consulting (no fees) to Regeneron Pharmaceuticals, Inc; institutional consulting fees from Abbott Vascular, Spectranetics/Phillips/Volcano Corporation, Bristol Myers Squibb, Novartis, and Watermark Research; executive committee member for Janssen Pharmaceuticals and Bristol Myers Squibb; <1% equity in Claret Medical and Elixir Medical. Dr Alexander: research grants from Bristol Myers Squibb, Boehringer Ingelheim, AstraZeneca, CryoLife, CSL Behring, US FDA, NIH, Sanofi, and VoluMetrix; consulting fees from Pfizer, Bristol Myers Squibb, AbbVie Pharmaceuticals, CSL Behring, Novo Nordisk, Portola Pharmaceuticals, Quantum Genomics, Teikoku Pharmaceuticals, VA Cooperative Studies, and Zafgen. Dr Lopes: research grants from Bristol Myers Squibb, Pfizer, Amgen, Inc, GlaxoSmithKline, Medtronic PLC, and Sanofi Aventis; consulting fees from Bristol Myers Squibb, Pfizer, Boehringer Ingelheim, and Bayer AG. The other authors report no conflicts.

Takotsubo syndrome is a condition characterised by temporary acute left ventricular dysfunction with regional wall abnormalities extending beyond a single coronary artery territory. Initially thought to be benign, this condition, which is challenging to distinguish from acute coronary syndrome, has substantial morbidity and mortality. The mechanism behind this condition remains elusive, but multiple theories have been proposed. Although beta blockers and angiotensin-converting enzyme inhibitors are used as treatments for left ventricular dysfunction, currently, there are no randomised controlled trials to support their use. In this paper, we review the latest evidence regarding aetiologies, pathophysiology, diagnostic criteria, prognosis, complications and management of Takotsubo syndrome., (© 2024 Royal Australasian College of Physicians.)

Background: Triage nurses' pivotal role in initial assessment makes their competence crucial. However, the specific impact on Acute Coronary Syndrome (ACS) recognition and outcomes remains unclear in Jordanian healthcare. Understanding this relationship could enhance ACS management and patient outcomes in Jordanian Emergency Departments (EDs)., Objective: To assess how triage nurses' recognition of ACS diagnosis affects patient outcomes in Jordan., Methods: This retrospective study examined records of 150 ACS patients admitted to the coronary care unit (CCU). Data extraction assessed triage nurses' accuracy in recognizing ACS symptoms and the timelines for diagnosis procedures (e.g., electrocardiogram [ECG]) and treatment provision (e.g., thrombolytic) based on triage decisions. It also evaluated the impact on treatment outcomes, including length of stay in the ED and hospital. Multiple linear regression analyses quantified the influence of under-triage on treatment outcomes., Results: The sample comprised 150 patients. Most were female (78.7%), aged 45-59.9 years (37.3%). ACS classifications: unstable angina (52.0%), STEMI (38.0%), NSTEMI (10.0%). The study included a cohort of ACS patients, with findings indicating varying degrees of under-triage by triage nurses. Analysis of timelines revealed significant delays in diagnosis and treatment initiation for patients subjected to under-triage. Multiple linear regression analyses demonstrated a robust association between under-triage and prolonged time to essential treatment outcomes, including delays in physician assessment, ECG performance, thrombolytic administration, and extended ED length of stay., Conclusion: Triage nurses' knowledge and competency are crucial determinants of accurate ACS recognition and subsequent clinical outcomes for patients presenting to the ED in Jordan. Investing in ongoing education and training programs for triage nurses may lead to improved ACS recognition rates and better patient outcomes in Jordanian healthcare settings., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Aim: The aim of this study was to determine the best clinical predictors of acute heart failure needing mechanical ventilation (MV) in the first 48 h of evolution of patients admitted because of acute coronary syndrome (ACS)., Methods: We analyzed a cohort of patients admitted for ACS between February 2017 and February 2018. A pulmonary ultrasound was performed on admission and was considered positive (PE+) when there were three or more B-lines in two quadrants or more of each hemithorax. It was compared with N-terminal pro-B-type natriuretic peptide (NT-proBNP), peak troponin T-us value GRACE (Global Registry of Acute Coronary Events), CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology and American Heart Association guidelines - Bleeding Score), CACS (Canada Acute Coronary Syndrome risk score), and HAMIOT (Heart Failure after Acute Myocardial Infarction with Optimal Treatment score) scores, shock index, ejection fraction, chest X-ray, and Killip class at admission as predictors of MV in the first 48 h of admission., Results: A total of 119 patients were included: 54.6% with ST elevation and 45.4% without ST elevation. Twelve patients (10.1%) required MV in the first 48 h of evolution. The sensitivity of PE+ was 100% (73.5-100%), specificity 91.6% (84.6-96.1%), and area under the curve was 0.96 (0.93-0.96). The sensitivity of an NT-proBNP value more than 3647 was 88.9% (51.9-99.7%), specificity 92.1% (84.5-96.8%), and area under the curve was 0.905 (0.793-1). The κ statistic between both predictors was 0.579. All the other scores were significantly worse than PE + ., Conclusion: Lung ultrasound and a high NT-proBNP (3647 ng/L in our series) on admission are the best predictors of acute heart failure needing MV in the first 48 h of ACS. The agreement between both tests was only moderate., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The SYNTAX score is a score that grades the severity and complexity of coronary lesions. In this study, we aimed to investigate the relationship between triglyceride/high-density lipoprotein cholesterol (triglyceride/HDL-C) ratio and SYNTAX scores in patients presenting with non-ST elevation myocardial infarction (NSTEMI)., Methods: This prospective study included 258 patients who presented at our center with STEMI, and underwent coronary angiography (CAG). The triglyceride/HDL-C ratio was calculated, and the relationship of this ratio with the SYNTAX score was determined with univariate and multivariate linear regression analyses., Results: The patients were separated into two groups according to the triglyceride/HDL-C ratios as low (<3.88) and high (≥3.88). The SYNTAX scores of the group with a high triglyceride/HDL-C score were determined to be significantly high ( P  < 0.001). When the SYNTAX scores were separated into two groups as low (≤22) and high (>23), a statistically significant correlation was determined between a high SYNTAX score and a high triglyceride/HDL-C ratio ( P  < 0.001). Logistic regression analysis was performed for the SYNTAX score, and the BMI value [odds ratio (OR) = 0.91, 95% confidence interval (CI): 0.85-0.98] and the triglyceride/HDL-C ratio (OR = 6.86, 95% CI: 3.45-13.65) alone were determined to be independent determinants of the SYNTAX score., Conclusion: The most important result obtained from this study was that the triglyceride/HDL-C ratio, which is an index that has recently started to be frequently used, was a marker of greater coronary anatomic complexity (SYNTAX score >22), independently of other parameters in patients who presented with NSTEMI and underwent CAG., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

The present study investigated the characteristics of rare but often fatal cases of acute coronary syndrome and aortic dissection and the factors affecting mortality. HEART score, aortic dissection detection risk score, and Global Registry of Acute Coronary Event (GRACE) Score were calculated by evaluating biochemical tests and symptoms/signs of the 20 patients who were admitted to our clinic with a preliminary diagnosis of acute myocardial infarction and subsequently diagnosed with aortic dissection. The assumption of normal distribution was checked with the Shapiro-Wilk test, and independent group comparisons were made with the t test or the Mann-Whitney U test. Relationships between qualitative variables were analyzed with chi-square tests. Relationships between quantitative variables were analyzed with Pearson or Spearman correlation coefficients. Patients with conditions like hypertension and diabetes are at higher risk for aortic dissection. We recommend the use of the GRACE Score with the risk parameters we have determined for the prediction of operative mortality. We suggest that the axillary region and antegrade cerebral perfusion may be preferred as the cannulation area in dissection repair. We emphasize preliminary risk assessment according to the aortic dissection detection risk score and remind physicians that ECG ST-T and troponin changes may be misleading., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The importance of prehospital (PH) electrocardiograms (ECG) recorded by emergency medical services (EMS) for diagnosing coronary artery spasm-induced acute coronary syndrome (CS-ACS) remains unclear., Methods and Results: We enrolled 340 consecutive patients with ACS who were transported by EMS within 12 h of symptom onset. According to Japanese Circulation Society guidelines, CS-ACS (n=48) was diagnosed with or without a pharmacological provocation test (n=34 and n=14, respectively). Obstructive coronary artery-induced ACS (OC-ACS; n=292) was defined as ACS with a culprit lesion showing 99% stenosis or >75% stenosis with plaque rupture or thrombosis observed via angiographic and intravascular imaging. Ischemic ECG findings included ST-segment deviation (elevation or depression) and negative T and U waves. In CS-ACS, the prevalence of ST-segment deviation decreased significantly from PH-ECG to emergency room (ER) ECG (77.0% vs. 35.4%; P<0.001), as did the prevalence of overall ECG abnormalities (81.2% vs. 45.8%; P<0.001). Conversely, in OC-ACS, there was a similar prevalence on PH-ECG and ER-ECG of ST-segment deviations (94.8% vs. 92.8%, respectively; P=0.057) and abnormal ECG findings (96.9% vs. 95.2%, respectively; P=0.058). Patients with abnormal PH-ECG findings that disappeared upon arrival at hospital without ER-ECG or troponin abnormalities were more frequent in the CS-ACS than OC-ACS group (20.8% vs. 1.0%; P<0.001)., Conclusions: PH-ECG is valuable for detecting abnormal ECG findings that disappear upon arrival at hospital in CS-ACS patients.

Background: Since 2000, the definition of myocardial infarction (MI) has evolved with reliance on cardiac troponin (cTn) tests. The implications of this change on trends of acute coronary syndrome (ACS) subtypes obtained from routinely collected hospital morbidity data are unclear. Using person-linked hospitalisation data, we compared International Classification of Diseases (ICD)-coded data with biomarker-classified admission rates for ST-segment elevation MI (STEMI), non-STEMI (NSTEMI) and unstable angina (UA) in Western Australia (WA)., Methods: We used linked hospitalisation data from all WA tertiary hospitals to identify patients with a principal diagnosis of STEMI, NSTEMI or UA between 2002 and 2016. Linked biomarker results were classified as 'diagnostic' for MI according to established criteria. We calculated age-standardised and sex-standardised rates (ASSRs) for ICD-coded versus biomarker-classified admissions by ACS subtypes and estimated annual change in admissions using Poisson regression adjusting for age and sex., Results: There were 37 272 ACS admissions in 30 683 patients (64.2% male), and 96% of cases had linked biomarker data, predominantly conventional cTn at the start and high-sensitive cTn from late 2013. Despite lower ASSRs, trends in MI classified with a diagnostic biomarker were concordant with ICD-coded admissions rates for both STEMI and NSTEMI. Between 2002 and 2010, STEMI rates declined by 4.1% (95% CI 5.0%, 3.1%) and 3.4% (95% CI 4.6%, 2.3%) in ICD-coded and biomarker-classified admissions, respectively, and both plateaued thereafter. For NSTEMI between 2002 and 2010, the ICD-coded and biomarker-classified rates increased 8.0% per year (95% CI 7.2%, 8.9%) and 8.0% (95% CI 7.0%, 9.0%), respectively, and both subsequently declined. For UA, both ICD-coded and biomarker-classified UA admission rates declined in a steady and concordant manner between 2002 and 2016., Conclusions: The present study supports the validity of using administrative data to monitor population trends in ACS subtypes as they appear to generally reflect the redefinition of MI in the troponin era., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

To better align with the clinical setting, the European Society of Cardiology has published new guidelines covering the whole spectrum of the acute coronary syndrome, including ST-elevation myocardial infarction, non-ST-elevation myocardial infarction and unstable angina.

Background: Acute coronary syndrome and atrial fibrillation are common cardiovascular diseases in elderly individuals. Patients with comorbidities face increased risks of bleeding and ischemia; however, there is a lack of prognostic models for quantifying these risks in this special population., Methods and Results: In this retrospective cohort study, 1851 patients (≥65 years old) with acute coronary syndrome and atrial fibrillation from 2 hospitals in China were included in the development cohort (1252 individuals) and 2 external validation cohorts (284 and 315 individuals). During 1-year follow-up, 96 Bleeding Academic Research Consortium type 3 or 5 bleeding events and 245 thromboembolic events were observed. In the development cohort, the concordance indexes for bleeding at 3, 6, and 12 mo ranged from 0.737 to 0.845 and for ischemia ranged from 0.723 to 0.777. The calibration curve and decision curve analysis indicated adequate calibration and clinical practicability. The concordance indexes varied from 0.679 to 0.809 in the validation cohorts. Subgroup analyses focusing on anticoagulant drugs and antithrombotic therapy were conducted, revealing similar discrimination and calibration. Kaplan-Meier curves demonstrated significant differences (log-rank P <0.001). Additionally, the models outperformed conventional models in concordance indexes, integrated discrimination improvement, and net reclassification improvement., Conclusions: Our study provides 2 robust prognostic models with easily available clinical factors for predicting bleeding and ischemia in elderly patients with acute coronary syndrome and atrial fibrillation. Furthermore, we provide online calculators to facilitate individualized risk evaluation and clinical decision-making., Registration: URL: www.chictr.org.cn/. Unique Identifier: ChiCTR2200067185.

A single high-sensitivity troponin-T (hs-TnT) measurement may be sufficient to risk-stratify emergency department (ED) patients with possible acute coronary syndrome (ACS) using the recalibrated History, Electrocardiogram, Age, Risk Factors, Troponin (rHEART) score. We sought to validate this approach in a multiethnic population of United States patients and investigate gender-specific differences in performance. We conducted a secondary analysis of a prospective cohort study of adult ED patients with possible ACS at a single, urban, academic hospital. We investigated the diagnostic performance of rHEART for the incidence of type-1 acute myocardial infarction (AMI) and other major adverse cardiac events (MACE) at 30 days, using both single (19 ng/L) and gender-specific (14 ng/L for women, 22 ng/L for men) 99th percentile hs-TnT thresholds. The 821 patients included were 54% women, 57% Hispanic, and 26% Black. Overall, 4.6% of patients had MACE, including 2.4% with AMI. Single-threshold rHEART ≤3 had a sensitivity of 94.4% (95% confidence interval 81% to 99%) and negative predictive values of 99.3% (98% to 100%) for MACE; gender-specific thresholds performed nearly identically. Sensitivity and negative predictive values for AMI were 90.0% (67% to 98%) and 99.3% (97% to 100%). Excluding patients presenting <3 hours from symptom onset improved sensitivity for MACE and AMI to 97.0% (84% to 100%) and 94.1% (71% to 100%). Logistic regression demonstrated odds of MACE increased with higher rHEART scores at a similar rate for men and women. In conclusion, a single initial hs-TnT and rHEART score can be used to risk-stratify male and female ED patients with possible ACS, especially when drawn >3 hours after symptom onset., Competing Interests: Declaration of competing interest Edward Suh reports a relationship with Roche Diagnostics that includes: funding grants. Bryn Mumma reports a relationship with Roche Diagnostics that includes: consulting or advisory. Marc Probst reports a relationship with Roche Diagnostics that includes: non-financial support. Andrew Einstein reports a relationship with Ionetix that includes: speaking and lecture fees. Andrew Einstein reports a relationship with WL Gore and Associates that includes: consulting or advisory and funding grants. Andrew Einstein reports a relationship with Canon Medical Systems Corporation that includes: consulting or advisory and funding grants. Lauren Ranard reports a relationship with Boston Scientific Corporation that includes: funding grants. Andrew Einstein reports a relationship with Attralus, Inc. that includes: funding grants. Andrew Einstein reports a relationship with BridgeBio that includes: funding grants. Andrew Einstein reports a relationship with GE Healthcare that includes: funding grants. Andrew Einstein reports a relationship with Intellia Therapeutics Inc that includes: funding grants. Andrew Einstein reports a relationship with Ionis Pharmaceuticals Inc that includes: funding grants. Andrew Einstein reports a relationship with Neovasc Inc that includes: funding grants. Andrew Einstein reports a relationship with Roche Medical Systems that includes: funding grants. Andrew Einstein reports a relationship with Pfizer that includes: funding grants. Co-author, AJE, has recieved authorship fees from Wolters Kluwer Healthcare - UpToDate. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

This review focuses on time-critical cardiological conditions which are significant health challenges in the Western world. It covers conditions ranging from those manageable electively to those requiring immediate medical or surgical intervention, including acute coronary syndrome, pulmonary embolism, acute heart failure, aortic dissection, and acute arrhythmias. The purpose is to provide an understanding of the characteristics of these conditions, their impact on patient prognosis, and current treatment strategies in critical situations., (Published under Open Access CC-BY-NC-BD 4.0. https://creativecommons.org/licenses/by-nc-nd/4.0/.)

Background: Acute coronary syndrome (ACS) is frequently reported in patients with coronavirus disease 2019 (COVID-19). Cytokine storm induced by interleukin-6 (IL-6) has been suggested to potentially cause myocardial injury in COVID-19. We investigated the association between baseline level of IL-6 and development of ACS in COVID-19 patients., Methods: Demographic and clinical data of hospitalized COVID-19 patients from 2020 to 2022 were reviewed. Extracted data including patient characteristics, laboratory biomarkers, and systemic inflammation indexes in patients with or without ACS were reviewed and analyzed. Logistic regression models were applied to analyze predictors of ACS development and receiver-operating characteristic (ROC) curves were used to assess discriminatory power of IL-6 and other risk factors for predicting ACS development., Results: Among 1,753 COVID-19 patients, 37 cases experienced ACS and 159 patients without main COVID-19 complications were randomly selected as controls. ACS patients were older (p = 0.001) and suffered from more comorbidities including diabetes (43% vs. 18%, p = 0.001), hypertension (40.5% vs. 24.5%, p = 0.050), ischemic heart disease (49% vs. 9%, p = 0.001), and hyperlipidemia (19% vs. 5%, p = 0.010). Also, decreased level of consciousness (31.6% vs. 2.5%, p = 0.001), ICU admission (65% vs. 2%, p = 0.001), and mortality events (70% vs. 0.6%, p = 0.001) were more prevalent in the ACS group. Baseline levels of IL-6 (p = 0.001), D-dimer (p = 0.026), troponin (p = 0.001), blood urea nitrogen (p = 0.002), and creatinine (p = 0.008) were higher in ACS patients but erythrocyte sedimentation rate (p = 0.013), hemoglobin (p = 0.033), and red blood cells (p = 0.028) were lower compared with controls. Also, age (OR: 1.06, p = 0.019), IL-6 (OR: 1.44, p = 0.047), and cardiovascular disease (CVD) (OR: 3.66, p = 0.043) were associated with ACS development. The area under the curve (AUC) of IL-6 and combined predictors respectively was 0.661 (p = 0.002) and 0.829 (p = 0.001)., Conclusions: High IL-6 concentration at baseline is a strong predictor for ACS development in COVID-19 patients. Also, elderly and concurrent CVD are significantly associated with ACS development., (© 2024. The Author(s).)

Acute coronary syndrome remains the leading cause of death in both patients with coronary artery disease and patients with other diseases (such as diabetes mellitus, chronic kidney disease, inflammatory diseases of various etiologies, and others). Early diagnosis of cardiomyocyte damage and necrosis opens up wide opportunities to improve the prognosis of patients with atherosclerotic lesions of the coronary arteries, and also makes it possible to discharge patients without acute cardiovascular pathology from intensive care units with a high degree of probability. The article discusses the evolution of the research and introduction into broad clinical practice of markers of myocardial damage and necrosis, which have largely improved modern clinical practice.

Introduction: Adult-onset Still's disease is a rare systemic autoinflammatory disease. We present a case of a young man with a constellation of symptoms and myopericarditis as a complication of this disease., Case: A 36-year-old Hispanic man with no significant past medical history developed a quotidian fever pattern following an upper respiratory tract infection. He initially presented with chest pain concerning for myocardial infarction and underwent cardiac catheterization, which revealed non-obstructive coronary artery disease. He was found to have myopericarditis, significant neutrophilic leukocytosis, and hyperferritinemia. He improved on high-dose corticosteroids but developed steroid-induced psychosis, and 4 months from symptom onset, he finally received tocilizumab, which eventually induced remission without adverse reactions., Discussion: Adult-onset Still's disease should be considered in a patient with fevers of undetermined origin. Due to its multisystemic involvement, adult-onset Still's disease is often a diagnosis arrived at after an extensive cardiac, hematologic, malignant, and infectious workup. Imaging, laboratory testing, and bone marrow biopsy were necessary to rule out alternative etiologies of this patient's presentation. Steroids are the mainstay of treatment because they are easily affordable, although the high risk of adverse effects makes them less desirable. Interleukin-1 inhibitors (anakinra or canakinumab) and interleukin-6 inhibitor tocilizumab are the steroid-sparing biologic agents of choice but are cost-prohibitive., Conclusion: Adult-onset Still's disease should be considered in the differential diagnoses of fever of undetermined origin. Early identification and initiation of treatment are critical to faster recovery and prevention of progression to severe complications. Steroids remain the standard first-line therapy and should be followed by disease-modifying steroid sparing drugs. The social determinants of health may preclude their timely initiation and should alert providers of proactive ways to avoid further delays., (© 2024. The Author(s).)

Background: Reduced estimated glomerular filtration rate (eGFR) is associated with lower use of invasive management and increased mortality after acute coronary syndrome (ACS). The reasons for this are unclear., Methods: A retrospective clinical cohort study was performed using data from the English National Institute for Health Research Health Informatics Collaborative (2010-2017). Multivariable logistic regression was used to investigate whether eGFR<90 mL/min/1.73 m 2 was associated with conservative ACS management and test whether (a) differences in care could be related to frailty and (b) associations between eGFR and mortality could be related to variation in revascularisation rates., Results: Among 10 205 people with ACS, an eGFR of <60 mL/min/1.73m 2 was found in 25%. Strong inverse linear associations were found between worsening eGFR category and receipt of invasive management, on a relative and absolute scale. People with an eGFR <30 mL compared with ≥90 mL/min/1.73 m 2 were half as likely to receive coronary angiography (OR 0.50, 95% CI 0.40 to 0.64) after non-ST-elevation (NSTE)-ACS and one-third as likely after STEMI (OR 0.30, 95% CI 0.19 to 0.46), resulting in 15 and 17 per 100 fewer procedures, respectively. Following multivariable adjustment, the ORs for receipt of angiography following NSTE-ACS were 1.05 (95% CI 0.88 to 1.27), 0.98 (95% CI 0.77 to 1.26), 0.76 (95% CI 0.57 to 1.01) and 0.58 (95% CI 0.44 to 0.77) in eGFR categories 60-89, 45-59, 30-44 and <30, respectively. After STEMI, the respective ORs were 1.20 (95% CI 0.84 to 1.71), 0.77 (95% CI 0.47 to 1.24), 0.33 (95% CI 0.20 to 0.56) and 0.28 (95% CI 0.16 to 0.48) (p<0.001 for linear trends). ORs were unchanged following adjustment for frailty. A positive association between the worse eGFR category and 30-day mortality was found (test for trend p<0.001), which was unaffected by adjustment for frailty., Conclusions: In people with ACS, lower eGFR was associated with reduced receipt of invasive coronary management and increased mortality. Adjustment for frailty failed to change these observations. Further research is required to explain these disparities and determine whether treatment variation reflects optimal care for people with low eGFR., Trial Registration Number: NCT03507309., Competing Interests: Competing interests: YB-S is partly funded as the Data Science co-lead by the National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West) and University of Bristol. RL reports funding unrelated to this work from the Royal Marsden Cancer charity, Cancer Research UK, Innovate UK (co-funded by Roche), RM Partners Cancer Alliance, the NIHR and NHS England and consulting fees from Royal Marsden Private Care for personal private practice and is NHS England Joint National Clinical Lead for the Targeted Lung Health Check Programme and NIHR Clinical Research Network National Specialty Lead for Screening, Prevention and Early Detection., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Telephone triage is pivotal for evaluating the urgency of patient care, and in the Netherlands, the Netherlands Triage Standard (NTS) demonstrates moderate discrimination for chest pain. To address this, the Safety First Prediction Rule (SFPR) was developed to improve the safety of ruling out acute coronary syndrome (ACS) during telephone triage., Methods: We conducted an external validation of the SFPR using data from the TRACE study, a retrospective cohort study in out-of-hours primary care. We evaluated the diagnostic accuracy assessment for ACS, major adverse cardiovascular events (MACE), and major events within 6 weeks. Moreover, we compared its performance with that of the NTS algorithm., Results: Among 1404 included patients (57.3% female, 6.8% ACS, 8.6% MACE), the SFPR demonstrated good discrimination for ACS (C-statistic: 0.79; 95%-CI: 0.75-0.83) and MACE (C-statistic: 0.79; 95%-CI: 0.0.76-0.82). Calibration was satisfactory, with overestimation observed in high-risk patients for ACS. The SFPR (risk threshold 2.5%) trended toward higher sensitivity (95.8% vs. 86.3%) and negative predictive value (99.3% vs. 97.6%) with a lower negative likelihood ratio (0.10 vs. 0.34) than the NTS algorithm., Conclusion: The SFPR proved robust for risk stratification in patients with acute chest pain seeking out-of-hours primary care in the Netherlands. Further prospective validation and implementation are warranted to refine and establish the rule's clinical utility., (© The Author(s) 2024. Published by Oxford University Press.)

The relationship between weather and acute coronary syndrome (ACS) incidence has been the subject of considerable research, with varying conclusions. Harnessing machine learning techniques, our study explores the relationship between meteorological factors and ACS presentations in the emergency department (ED), offering insights into seasonal variations and inter-day fluctuations to optimize patient care and resource allocation. A retrospective cohort analysis was conducted, encompassing ACS presentations to Dutch EDs from 2010 to 2017. Temporal patterns were analyzed using heat-maps and time series plots. Multivariable linear regression (MLR) and Random Forest (RF) regression models were employed to forecast daily ACS presentations with prediction horizons of one, three, seven, and thirty days. Model performance was assessed using the coefficient of determination (R²), Mean Absolute Error (MAE), and Mean Absolute Percentage Error (MAPE). The study included 214,953 ACS presentations, predominantly unstable angina (UA) (94,272; 44%), non-ST-elevated myocardial infarction (NSTEMI) (78,963; 37%), and ST-elevated myocardial infarction (STEMI) (41,718; 19%). A decline in daily ACS admissions over time was observed, with notable inter-day (estimated median difference: 41 (95%CI = 37-43, p = < 0.001) and seasonal variations (estimated median difference: 9 (95%CI 6-12, p = < 0.001). Both MLR and RF models demonstrated similar predictive capabilities, with MLR slightly outperforming RF. The models showed moderate explanatory power for ACS incidence (adjusted R² = 0.66; MAE (MAPE): 7.8 (11%)), with varying performance across subdiagnoses. Prediction of UA incidence resulted in the best-explained variability (adjusted R² = 0.80; MAE (MAPE): 5.3 (19.1%)), followed by NSTEMI and STEMI diagnoses. All models maintained consistent performance over extended prediction horizons. Our findings indicate that ACS presentation exhibits distinctive seasonal changes and inter-day differences, with marked reductions in incidence during the summer months and a distinct peak prevalence on Mondays. The predictive performance of our model was moderate. Nonetheless, we obtained good explanatory power for UA presentations. Our model emerges as a potentially valuable supplementary tool to enhance ED resource allocation or future predictive models predicting ACS incidence in the ED., (© 2024. The Author(s).)

Background: The life-threatening diseases known as ACS (acute coronary syndrome) continue to produce considerable rates of morbidity and mortality despite breakthroughs in therapy. The study determined clinical outcome and its predictors in patients at the University of Gondar Comprehensive and Specialized Hospital (UOGCSH), North West Ethiopia., Design, Setting, and Participants: A retrospective cohort study design was employed at UOGCSH from January 31, 2018 to February 1, 2023. The hospital used a systematic random sampling procedure to select study participants from the medical records of patients in chronic cardiac follow-up clinics., Main Outcome Measures: Exposures were optimal medical therapy (OMT) versus non-optimal medical therapy collected from May to August 2023. Descriptive and analytical statistics were employed to compare study groups. A binary logistic regression model was employed to identify candidate variables for further analysis. Cox's proportional hazard model and log-rank test were employed, with a P-value < 0.05 used to evaluate statistical significance. A five-year all-cause mortality after discharge estimate was displayed by using Kaplan-Meier curves., Results: Among 422 patients with ACS [mean age, 61.56 (SD = 9.686) years; 54.7% male], of whom only 59.2% (250) received optimal medical therapy at discharge. Age ≥ 65, atrial fibrillation, chronic kidney diseases, and cardiogenic shock were negative independent predictors of optimal medical therapy. On the other hand, male sex was independently associated with the use of optimal medical therapy. All-cause mortality occurred in 16.6% (n = 70) and major adverse cardiac events occurred in 30.8% (n = 130) of patients with a 95% CI of 0.132-0.205 and 0.264-0.355, respectively. Multivariate analyses indicated that OMT was significantly associated with reduced all-cause mortality (aHR: 0.431, 95% CI: 0.222-0.835; P = 0.013)., Conclusion: This study revealed that the use of preventive OMT in patients discharged with acute coronary syndrome was associated with a reduction in all-cause mortality. However, the use of this OMT is suboptimal., (© 2024. The Author(s).)

Coronary risk scores, such as History, Electrocardiogram, Age, Risk Factors, and Troponin (HEART) and Emergency Department Assessment of Chest Pain Score (EDACS) scores, help nurses identify suspected acute coronary syndrome (ACS) patients who have a risk for major adverse cardiac events (MACE) within 30 days., Aim: To compare the accuracy of HEART and EDACS scores in predicting major events among patients suspected of ACS in the cardiac emergency department (ED)., Design and Methods: A prospective correlational observational study design was performed on cardiac ED patients who presented with suspected ACS., Tools: Three tools were utilized to collect data pertinent to the study: Tool I comprises patients' assessment (personal characteristics, risk factors for ACS, and chest pain assessment sheet); Tool II is the risk assessment tool that includes HEART and EDACS scores; and Tool III is MACE incidence among studied patients within 30 days., Results: HEART score was significantly (P < .01) higher among patients for whom MACE was present than absent. However, EDACS score showed no significant difference (P > .05) among patients whose MACE was present or absent. HEART risk score >6 correctly predicted MACE cases with sensitivity and specificity of 77.46% and 48.28%, respectively. However, EDACS score >18 correctly predicted MACE cases with sensitivity and specificity of 42.25% and 75.86%, respectively., Conclusion: This study concludes that HEART score has better sensitivity than EDACS in predicting MACE among suspected ACS patients at the cardiac ED. The HEART score provides the nurses with a quicker and more reliable predictor of MACE shortly after the arrival of the suspected ACS patients at the cardiac ED than the EDACS score. The study recommended the implementation of a HEART score in the cardiac ED for predicting MACE in suspected ACS patients. Follow up closely for high-risk patients to MACE. An educational program should be made for nurses about the implementation of the heart score in the cardiac ED., Competing Interests: The author has no conflicts of interest in the manuscript, including financial, consultant, institutional, and other relationships that might lead to bias or a conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Multiple decision-aiding models are available to help physicians identify acute coronary syndrome (ACS) and accelerate the decision-making process in emergency departments (EDs). This study evaluated the diagnostic performance of the Manchester Acute Coronary Syndrome (MACS) rule and its derivations, enhancing the evidence for their clinical use. A systematic review and meta-analysis was performed. Medline, Embase, Scopus, and Web of Science were searched from inception until October 2023 for studies including adult ED patients with suspected cardiac chest pain and inconclusive findings requiring ACS risk-stratification. The predictive value of MACS, Troponin-only MACS (T-MACS), or History and Electrocardiogram-only MACS (HE-MACS) decision aids for diagnosing acute myocardial infarction (AMI) and 30-day major adverse cardiac outcomes (MACEs) among patients admitted to ED with chest pain suspected of ACS. Overall sensitivity and specificity were synthesized using the 'Diagma' package in STATA statistical software. Applicability and risk of bias assessment were performed using the QUADAS-2 tool. For AMI detection, MACS has a sensitivity of 99% [confidence interval (CI): 97-100], specificity of 19% (CI: 10-32), and AUC of 0.816 (CI: 0.720-0.885). T-MACS shows a sensitivity of 98% (CI: 98-99), specificity of 35% (CI: 29-42), and AUC of 0.859 (CI: 0.824-0.887). HE-MACS exhibits a sensitivity of 99% (CI: 98-100), specificity of 9% (CI: 3-21), and AUC of 0.787 (CI: 0.647-0.882). For MACE detection, MACS demonstrates a sensitivity of 98% (CI: 94-100), specificity of 22% (CI: 10-42), and AUC of 0.804 (CI: 0.659-0.897). T-MACS displays a sensitivity of 96% (CI: 94-98), specificity of 36% (CI: 30-43), and AUC of 0.792 (CI: 0.748-0.830). HE-MACS maintains a sensitivity of 99% (CI: 97-99), specificity of 10% (CI 6-16), and AUC of 0.713 (CI: 0.625-0.787). Of all the MACS models, T-MACS displayed the highest overall accuracy due to its high sensitivity and significantly superior specificity. T-MACS exhibits very good diagnostic performance in predicting both AMI and MACE. This makes it a highly promising tool for managing patients with acute chest pain., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Guidelines on myocardial infarction (MI) recommend antithrombotic and anticoagulatory treatment at time of diagnosis. MI with ST segment elevation (STEMI) is mostly a certain diagnosis. Acute coronary syndrome without ST segment elevation (NSTE-ACS) has diagnostic uncertainty and remains a working diagnosis in the prehospital setting., Objective: Assessment of prehospital loading with aspirin and heparin depending on ACS subtype and pretreatment with oral anticoagulants., Methods: The PRELOAD survey was a nationwide German study. STEMI/NSTE-ACS scenarios were designed and varied in pretreatment: I) no pretreatment, II) new oral anticoagulants (NOAC), III) vitamin K antagonist (VKA). Loading strategy was assessed and included: a) aspirin (ASA), b) unfractionated heparin (UFH), c) ASA + UFH, d) no loading., Results: A total of 708 emergency physicians were included. In NSTE-ACS without pretreatment, 79% chose loading (p < 0.001). ASA + UFH (71.4%) was the preferred option. In corresponding STEMI scenario, 100% chose loading and 98.6% preferred ASA + UFH (p < 0.001). In NSTE-ACS with NOAC pretreatment, 69.8% favored loading (p < 0.001); in VKA pretreatment the corresponding rate was 72.3% (p < 0.001). In each scenario, ASA was the preferred option. In STEMI with NOAC pretreatment, 97.5% chose loading (p < 0.001); analogous rate was 96.8% in STEMI with VKA pretreatment (p < 0.001). ASA was the preferred option again., Conclusions: Prehospital loading was the preferred treatment strategy despite the diagnostic uncertainty in NSTE-ACS and guidelines recommending loading at time of diagnosis. Pretreatment with oral anticoagulants resulted in a strategy shift to loading with only aspirin. In STEMI patients, this indicates potential undertreatment., (© 2023. The Author(s).)

Background: Lower extremity arterial disease (LEAD) and increased aortic stiffness are associated with higher mortality in patients with chronic coronary syndrome, while their prognostic significance after an acute coronary syndrome (ACS) is less known., Methods: We analyzed prevalence, clinical phenotypes and association of LEAD - assessed by the ankle-brachial index (ABI) - and increased aortic stiffness - assessed by the aortic pulse wave velocity (PWV) - with all-cause mortality and major adverse cardiovascular events (MACE) in patients admitted with an ACS., Results: Among 270 patients admitted for ACS (mean age 67 years, 80% males), 41 (15%) had an ABI ≤0.9, with 14 of them (34%) presenting with intermittent claudication (symptomatic LEAD). Patients with symptomatic LEAD, compared with those with asymptomatic LEAD or without LEAD, had higher prevalence of cardiovascular risk factors, lower estimated glomerular filtration rate and higher high-sensitivity C-reactive protein. Patients with LEAD, either symptomatic or asymptomatic, more frequently presented with non-ST-elevation myocardial infarction and more frequently had multivessel coronary artery disease. Both symptomatic and asymptomatic LEAD were significantly associated with all-cause mortality after adjustment for confounders, including multivessel disease or carotid artery disease (hazard ratio 4.03, 95% confidence interval 1.61-10.08, P  < 0.01), whereas PWV was not associated with the outcome in the univariable model. LEAD and PWV were not associated with a higher risk of MACE (myocardial infarction or unstable angina, stroke, or transient ischemic attack)., Conclusions: LEAD, either clinical or subclinical, but not increased aortic stiffness, is an independent predictor of all-cause mortality in patients admitted for ACS., (Copyright © 2024 Italian Federation of Cardiology - I.F.C. All rights reserved.)

Cardiogenic shock (CS) is a serious complication of heart attack and constitutes one of its main causes of death. To date, there is no data on its treatment and evolution in Latin America., Objectives: To know the clinical characteristics, treatment strategies, evolution and in-hospital mortality of CS in Latin America., Materials and Methods: This is a prospective, multicenter registry of patients hospitalized with CS in the context of acute coronary syndromes (ACS) with and without ST segment elevation for 24 months., Results: 41 Latin American centers participated incorporating patients during the period between October 2021 and September 2023. 278 patients were included. Age: 66 (59-75) years, 70.1 % men. 74.8 % of the cases correspond to ACS with ST elevation, 14.4 % to ACS without ST elevation, 5.7 % to right ventricular infarction and 5.1 % to mechanical complications. CS was present from admission in 60 % of cases. Revascularization: 81.3 %, inotropic use: 97.8 %, ARM: 52.5 %, Swan Ganz: 17 %, intra-aortic balloon pump: 22.2 %. Overall in-hospital mortality was 52.7 %, with no differences between ACS with or without ST., Conclusions: Morbidity and mortality is very high despite the high reperfusion used., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Study Objective: The real-world effectiveness and safety of a 0/1-hour accelerated protocol using high-sensitivity cardiac troponin (hs-cTn) to exclude myocardial infarction (MI) compared to routine care in the United States is uncertain. The objective was to compare a 0/1-hour accelerated protocol for evaluation of MI to a 0/3-hour standard care protocol., Methods: The RACE-IT trial was a stepped-wedge, randomized trial across 9 emergency departments (EDs) that enrolled 32,609 patients evaluated for possible MI from July 2020 through April 2021. Patients undergoing high-sensitivity cardiac troponin I testing with concentrations less than or equal to 99th percentile were included. Patients who had MI excluded by the 0/1-hour protocol could be discharged from the ED. Patients in the standard care protocol had 0- and 3-hour troponin testing and application of a modified HEART score to be eligible for discharge. The primary endpoint was the proportion of patients discharged from the ED without 30-day death or MI., Results: There were 13,505 and 19,104 patients evaluated in the standard care and accelerated protocol groups, respectively, of whom 19,152 (58.7%) were discharged directly from the ED. There was no significant difference in safe discharges between standard care and the accelerated protocol (59.5% vs 57.8%; adjusted odds ratio (aOR)=1.05, 95% confidence interval [CI] 0.95 to 1.16). At 30 days, there were 90 deaths or MIs with 38 (0.4%) in the standard care group and 52 (0.4%) in the accelerated protocol group (aOR=0.84, 95% CI 0.43 to 1.68)., Conclusion: A 0/1-hour accelerated protocol using high-sensitivity cardiac troponin I did not lead to more safe ED discharges compared with standard care., (Copyright © 2024 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Since the 1960s, cardiologists have adopted several binary classification systems for acute myocardial infarction (MI) that facilitated improved patient management. Conversely, for chronic stable manifestations of myocardial ischaemia, various classifications have emerged over time, often with conflicting terminology-e.g. 'stable coronary artery disease' (CAD), 'stable ischaemic heart disease', and 'chronic coronary syndromes' (CCS). While the 2019 European guidelines introduced CCS to impart symmetry with 'acute coronary syndromes' (ACS), the 2023 American guidelines endorsed the alternative term 'chronic coronary disease'. An unintended consequence of these competing classifications is perpetuation of the restrictive terms 'coronary' and 'disease', often connoting only a singular obstructive CAD mechanism. It is now important to advance a more broadly inclusive terminology for both obstructive and non-obstructive causes of angina and myocardial ischaemia that fosters conceptual clarity and unifies dyssynchronous nomenclatures across guidelines. We, therefore, propose a new binary classification of 'acute myocardial ischaemic syndromes' and 'non-acute myocardial ischaemic syndromes', which comprises both obstructive epicardial and non-obstructive pathogenetic mechanisms, including microvascular dysfunction, vasospastic disorders, and non-coronary causes. We herein retain accepted categories of ACS, ST-segment elevation MI, and non-ST-segment elevation MI, as important subsets for which revascularization is of proven clinical benefit, as well as new terms like ischaemia and MI with non-obstructive coronary arteries. Overall, such a more encompassing nomenclature better aligns, unifies, and harmonizes different pathophysiologic causes of myocardial ischaemia and should result in more refined diagnostic and therapeutic approaches targeted to the multiple pathobiological precipitants of angina pectoris, ischaemia and infarction., (Published by Oxford University Press on behalf of the European Society of Cardiology 2024.)

Background: Triglyceride-glucose index (TyG), a surrogate marker of insulin resistance (IR), could be a potential prognostic marker in patients with acute coronary syndromes (ACS). We evaluated the effect of the TyG index on major adverse cardiac and cerebrovascular events (MACCE) in patients with ACS undergoing percutaneous coronary intervention (PCI)., Methods: This registry-based cohort study was conducted at Tehran Heart Center from 2015 to 2021 and the median follow-up duration was 378 days. The primary outcome was MACCE and the secondary outcomes were MACCE components: all-cause mortality, myocardial infarction, stroke, target vessel revascularization, target lesion revascularization, and coronary artery bypass grafting. For comparison among TyG quartiles (Q), the log-rank test was used. Unadjusted and adjusted hazard ratios (HRs) and their 95% confidence intervals (CIs) were used to describe the association between TyG quartiles and MACCE. A subgroup of euglycemic patients was also evaluated., Results: A total of 13,542 patients were included. Patients in the fourth TyG quartile (Q4) were younger, had higher mean BMI, and higher prevalence of hypertension, diabetes, and dyslipidemia. The adjusted Cox model showed that a 1-unit increment of the TyG index was associated with a significantly higher risk of MACCE (aHR 1.18, 95% CI 1.08 to 1.30, p < 0.001). Among TyG quartiles, there was a higher MACCE incidence in Q4 compared to Q1 (aHR 1.29, 95% CI 1.08 to 1.53, p = 0.005). In the euglycemic subgroup of the population, there was no significant association between MACCE incidence and a 1-unit increase in TyG or among TyG quartiles., Conclusion: Based on our findings, while higher TyG levels and quartiles were associated with higher rates of MACCE in ACS, there was no such effect in the euglycemic population. If confirmed in future studies, these results can be beneficial for clinicians to risk stratify these patients with an easy-to-use index and determine clinical plans based on their risk., (© 2024. The Author(s).)

Soluble CD40 ligand (sCD40L) is a protein that plays a crucial role in the inflammatory response associated with the development and progression of acute coronary syndrome (ACS). Recent studies have suggested that sCD40L may be a useful prognostic factor for ACS, but the data are conflicting. This study aimed to investigate the potential of sCD40L as a prognostic marker among ACS patients and provide valuable insights for clinical practice. To our knowledge, this is the first study of its type in the Arabic World. A multi-center prospective case-control study was conducted in Damascus, Syria, involving 158 participants with different ACS subtypes (STEMI, NSTEMI, UA) and a control group of healthy individuals. Sociodemographic data, medical history, and sCD40L levels were collected. The predictive ability of sCD40L for ACS, STEMI, NSTEMI, and UA was assessed using receiver operating characteristic (ROC) curves. Statistical analysis was performed using IBM SPSS version 25. The study included 58 STEMI, 33 NSTEMI, 36 UA patients, and 30 healthy individuals. The mean age of participants was 55 years (SD 10.7 years). Analysis of sCD40L levels revealed significantly higher concentrations in ACS patients compared to the control group (P < .001). ROC curve analysis demonstrated that sCD40L had a significant predictive ability for ACS, STEMI, and NSTEMI (P < .05), while its predictive value for UA was not statistically significant. This study provides evidence supporting the potential of sCD40L as a prognostic factor in ACS. The elevated levels of sCD40L observed in these subtypes indicate its potential usefulness in risk stratification and predicting adverse cardiovascular events. Further investigations are warranted to establish standardized sCD40L cutoff values and evaluate its clinical implications in the management of ACS patients., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Emergency Medical Services (EMS) studies have shown that prehospital risk stratification and triage decisions in patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) can be improved using clinical risk scores with point-of-care (POC) troponin. In current EMS studies, three different clinical risk scores are used in patients suspected of NSTE-ACS: the prehospital History, ECG, Age, Risk and Troponin (preHEART) score, History, ECG, Age, Risk and Troponin (HEART) score and Troponin-only Manchester Acute Coronary Syndromes (T-MACS). The preHEART score lacks external validation and there exists no prospective comparative analysis of the different risk scores within the prehospital setting. The aim of this analysis is to externally validate the preHEART score and compare the diagnostic performance of the these three clinical risk scores and POC-troponin., Methods: Prespecified analysis from a prospective, multicentre, cohort study in patients with suspected NSTE-ACS who were transported to an ED between April 2021 and December 2022 in the Netherlands. Risk stratification is performed by EMS personnel using preHEART, HEART, T-MACS and POC-troponin. The primary end point was the hospital diagnosis of NSTE-ACS. The diagnostic performance was expressed as area under the receiver operating characteristic (AUROC), sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV)., Results: A total of 823 patients were included for external validation of the preHEART score, final hospital diagnosis of NSTE-ACS was made in 29% (n=235). The preHEART score classified 27% as low risk, with a sensitivity of 92.8% (95% CI 88.7 to 95.7) and NPV of 92.3% (95% CI 88.3 to 95.1). The preHEART classified 9% of the patients as high risk, with a specificity of 98.5% (95% CI 97.1 to 99.3) and PPV of 87.7% (95% CI 78.3 to 93.4). Data for comparing clinical risk scores and POC-troponin were available in 316 patients. No difference was found between the preHEART score and HEART score (AUROC 0.83 (95% CI 0.78 to 0.87) vs AUROC 0.80 (95% CI 0.74 to 0.85), p=0.19), and both were superior compared with T-MACS (AUROC 0.72 (95% CI 0.66 to 0.79), p≤0.001 and p=0.03, respectively) and POC-troponin measurement alone (AUROC 0.71 (95% CI 0.64 to 0.78), p<0.001 and p=0.01, respectively)., Conclusion: On external validation, the preHEART demonstrates good overall diagnostic performance as a prehospital risk stratification tool. Both the preHEART and HEART scores have better overall diagnostic performance compared with T-MACS and sole POC-troponin measurement. These data support the implementation of clinical risk scores in prehospital clinical pathways., Trial Registration Number: NCT05243485., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

A man in late adolescence of Asian descent was admitted with cardiac-sounding chest pain and a history of flu-like symptoms a week prior to presentation with negative screening for the SARS-CoV-2 virus. His ECG showed lateral T-wave changes and pre-excitation pattern suggestive of an accessory pathway. High-sensitivity troponin T peak was significantly elevated to 2550 ng/L (normal reference range 0-11). He was initially treated for a suspected perimyocarditis. Transthoracic echocardiography revealed moderate left ventricular systolic dysfunction with regional wall motion abnormalities suggestive of coronary artery disease. Cardiac magnetic resonance imaging showed subendocardial delayed gadolinium enhancement with ischaemia and viability in the left circumflex (LCx) territory. He was then sent for a CT coronary angiogram for a suspected spontaneous coronary artery dissection, and subsequently, he discussed with our team and accepted for immediate transfer. He underwent coronary angiography and intravascular ultrasound-guided percutaneous coronary intervention to his LCx artery with a drug-coated balloon. Following that, and after a discussion with the electrophysiology team, he had an attempt at ablating his accessory pathway with partial success. He was discharged home in a stable condition., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: A poor prognosis is associated with atherosclerotic plaque rupture (PR) despite after conventional therapy for patients with acute coronary syndrome (ACS). Timely identification of PR improves the risk stratification and prognosis of ACS patients., Methods: A derivation cohort of 110 patients with ACS who underwent pre-intervention optical coherence tomography (OCT) were matched 1:1 to the PR and intact fibrous cap (IFC) groups according to traditional risk factors. Candidate PR proteins were identified via mass spectrometry (MS)-based proteomics using unbiased machine learning methods and were further validated by enzyme-linked immunosorbent assay (ELISA) in an external validation cohort of 85 patients with ACS. The performance of candidate biomakers was assessed using the receiver operating characteristic curve analysis., Results: 1121 proteins were identified and 535 filtered proteins were used for analysis. Nine candidate proteins were screened by five machine learning algorithms. Three proteins (APOC3, RAB39A, and KNG1) were significantly different between the PR and IFC in validation cohort. The performance of plasm APOC3, RAB39A, and KNG1 for differentiating PR and IFC was superior to that of the conventional biomarkers and risk factors., Conclusion: The proteins (APOC3, RAB39A, and KNG1) serve as a potential novel diagnostic tool to identify PR in ACS patients., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Eighteen-lead electrocardiography (18-ECG) includes, in addition to those in standard 12-lead ECG (12-ECG), six additional chest leads: V7-V9 and V3RV5R. Leads V7-V9 require the patient to be in a lateral decubitus position for the electrodes to be attached to the back. Synthesized 18-ECG (syn18-ECG) is a method that only records 12-ECG and uses computational logic to record the posterior wall (V7-V9) and right-sided (V3R-V5R) leads. We review the clinical utility of syn18-ECG in conditions including acute coronary syndromes, arrhythmias, acute pulmonary embolism, and Duchenne muscular dystrophy. The syn18-ECG waveform correlates well with the actual 18-ECG waveform, indicating that syn18-ECG is an excellent substitute for 18-ECG, excluding negative T waves. ST elevation in leads V7-V9 has the effect of reducing missed acute coronary syndromes in the posterior wall. In cases of arrhythmia, syn18-ECG can accurately estimate the target site of radiofrequency catheter ablation using a simple algorithm. The use of additional leads in Duchenne muscular dystrophy is expected to provide new insights. To facilitate gaining more knowledge regarding diseases that have not yet been investigated, it is imperative that the cost of syn18-ECG is reduced in the future.

Backgrounds and Objective: Statins, inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A reductase, are pivotal in managing hypercholesterolemia and reducing cardiovascular risk. While rosuvastatin demonstrates superior efficacy and tolerability compared to other statins, its safety profile in elderly patients older than 75 years old with acute coronary syndrome (ACS) remains underexplored. So, the objective of this study is to evaluate the frequency of adverse reactions and investigate the efficacy of high-dose rosuvastatin on lipid profiles in elderly patients aged over 75 with ACS., Methods: In this observational study, 110 consecutive elderly ACS patients attending Modarres Hospital in Tehran, Iran, in 2019 were enrolled. The effects of high-dose rosuvastatin were assessed in elderly patients older than 75 years old by comparison of the adverse effects, lipid profile, cardiac function, and other biomarkers at the baseline and after 6 weeks of rosuvastatin therapy with a dose of 40 mg., Results: Following 6 weeks of treatment, there was a significant reduction in total cholesterol (136.2 ± 24.3 to 115.5 ± 24.0, p = 0.001) and LDL levels (72.6 ± 17.5 to 50.9 ± 18.9, p = 0.001), accompanied by a notable increase in HDL levels (38.3 ± 7.1 to 47.2 ± 7.4, p = 0.001). Cardiac function, as measured by ejection fraction (EF), significantly improved from 43.4 ± 8.8 to 48.5 ± 8.5 (p = 0.001). Adverse effects such as cramps (N = 12, p = 0.001), weakness (N = 28, p = 0.001), and anorexia (N = 12, p = 0.001) were reported but did not warrant discontinuation of therapy. Notably, no cases of jaundice were observed. Two deaths occurred due to major adverse cardiac events (MACE) during the study period, unrelated to stroke or recurrent myocardial infarction., Conclusion: Totally, high-dose rosuvastatin therapy effectively improved lipid profiles, cardiac function, and liver enzyme levels in elderly ACS patients, with manageable adverse effects. These findings underscore the importance of rosuvastatin in optimizing cardiovascular health in this vulnerable population., (© 2024. The Author(s).)

Background: Previous work has demonstrated disparities in the management of cardiovascular disease among men and women. We sought to evaluate these disparities and their associations with clinical outcomes among patients admitted with acute coronary syndromes to the Veterans Affairs Healthcare System., Methods and Results: We identified all patients that were discharged with acute coronary syndromes within the Veterans Affairs Healthcare System from October 1, 2015 to September 30, 2022. Medical and procedural management of patients was subsequently assessed, stratified by sex. In doing so, we identified 76 454 unique admissions (2327 women, 3.04%), which after propensity matching created an analytic cohort composed of 6765 men (74.5%) and 2295 women (25.3%). Women admitted with acute coronary syndromes were younger with fewer cardiovascular comorbidities and a lower prevalence of preexisting prescriptions for cardiovascular medications. Women also had less coronary anatomic complexity compared with men (5 versus 8, standardized mean difference [SMD]=0.40), as calculated by the Veterans Affairs SYNTAX score. After discharge, women were significantly less likely to receive cardiology follow-up at 30 days (hazard ratio [HR], 0.858 [95% CI, 0.794-0.928]) or 1 year (HR, 0.891 [95% CI, 0.842-0.943]), or receive prescriptions for guideline-indicated cardiovascular medications. Despite this, 1-year mortality rates were lower for women compared with men (HR, 0.841 [95% CI, 0.747-0.948])., Conclusions: Women are less likely to receive appropriate cardiovascular follow-up and medication prescriptions after hospitalization for acute coronary syndromes. Despite these differences, the clinical outcomes for women remain comparable. These data suggest an opportunity to improve the posthospitalization management of cardiovascular disease regardless of sex.

Objective: To assess the clinical presentation and evaluation of acute life-threatening chest pain in Accra, Ghana., Design: This was a cross-sectional study at the emergency departments of two leading tertiary hospitals in Accra., Settings: The study was conducted at the Korle-Bu Teaching Hospital and the 37 Military Hospital in Accra., Participants: The study participants comprised adult patients aged 18 years and above who presented with acute chest pain at the emergency departments between April and June 2018., Main Outcome: Acute coronary syndrome is the leading life-threatening cause of chest pain with poor pre- and in-hospital care., Results: 232 patients with chest pain were enrolled as respondents aged 18 to 94 years. The prevalence of life-threatening conditions causing chest pain was 31.9% of those who presented with acute chest pain. These included acute coronary syndrome (82.4%), pulmonary embolism (14.9%), and acute chest syndrome (2.7%). A few (6.6%) with life-threatening conditions such as acute coronary syndrome were transported by ambulances, and 44.3% reported to the facility within 2 to 9 days after the onset of chest pain. None of the patients with pulmonary embolism and acute chest syndrome had computer tomography pulmonary angiogram (CTPA) and echocardiogram done, respectively., Conclusion: Our study found that life-threatening conditions amongst patients presenting with acute chest pains are common; however, there is a need to improve pre-hospital care and in-hospital assessment of these cases., Funding: The study was partly funded by the Medtronic Foundation., Competing Interests: Conflict of interest: None declared, (Copyright © The Author(s).)

Consecutive suspected acute coronary syndrome (ACS) cases were categorized into three groups: Group-1 (ST-depression), Group-2 (T-inversion), and Group-3 (remaining cases). Group-3 was subclassified into isoelectric horizontal ST-segment with sharp ST-T-angle (IHST) positive and IHST negative groups. They underwent serial high-sensitive Troponin-I testing. ACS incidence was 77.96 %, with 33.02 %, 15.96 %, and (15.04 %, 35.96 %) of patients in Groups 1, 2, and 3 (IHST positive, IHST negative), respectively. The presence of IHST exhibited higher sensitivity than T-inversion and greater specificity than ST-depression in detecting ACS. The presence of IHST sign additionally detected 15.04 % of ACS. The presence of IHST was significant among group-3 (p = 0.008) as well as the overall ACS cases (p = 0.048)., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Cardiological Society of India. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.)

Aim: To identify incidence, type of drug abuse study clinical and angiographic profile in very young population presenting with acute coronary syndrome (ACS)., Materials and Methods: All consecutive patients less than 30 years with ACS included and segregated into Group 1 and 2 (with and without drug abuse respectively) RESULT: n = 153; n = 17 in group 1 of whom 35.29 % consumed opium, 17.64 % energy drinks, 17.64 % whey protein supplements, 17.64 % inhaled marijuana, 5.88 % heroin and spasmoproxyvon and 23.52 % multi-substance abusers. STEMI, Single vessel disease and urban domicile were predominant. Rising trends of drug abuse were identified in prospective (28.20 %) versus retrospective (5.30 %) timeframe (p = 0.011)., Conclusion: Rising trends of drug abuse, a potentially modifiable risk factor of ACS in the young are alarming. Strict regulations are needed to curb this menace., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr Shibba Chhabra reports was provided by Dayanand Medical College and Hospital. NONE., (Copyright © 2024 Cardiological Society of India. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.)

Objective: Lipids play key role in coronary atherosclerosis. The role of non-high-density lipoprotein cholesterol (non-HDL-C) in atherosclerotic plaques using intravascular imaging remains unclear. This study aimed to assess its relationship with coronary plaque features using intravascular ultrasound (IVUS) in acute coronary syndrome (ACS)., Methods: A total of 601 patients divided into two groups: normal non-HDL-C≤130 mg/dl (n = 410) and high non-HDL cholesterol >130 mg/dl (n = 191). IVUS performed before coronary intervention., Results: Mean age 53.18 ± 12.29 years. No significant differences in hypertension, diabetes, and smoking between groups. Plaque burden was significantly higher among normal versus high non-HDL-C groups (79.59 ± 9.98 % vs. 81.61 ± 5.39 %; p = 0.001). At minimal luminal site, fibrofatty percentage was higher in normal non-HDL-C group (p = 0.027), while necrotic core greater in high non-HDL-C group (p = 0.033). Segmental analysis, necrotic core was significantly higher in percentage (p = 0.006) and volumes (p = 0.011) in normal versus high non-HDL-C groups. Total cholesterol (r = 0.099, p = 0.015), LDL-C (r = 0.081, p = 0.046), triglycerides (r = 0.083, p = 0.041),and non-HDL-C (r = 0.099, p = 0.015) positively correlated with plaque burden. Total cholesterol (r = 0.115, p = 0.005), LDL-C (r = 0.107, p = 0.009), and non-HDL-C (r = 0.105, p = 0.010) positively correlated with necrotic core volume. Linear regression analysis showed age and non-HDL-C as predictors of higher plaque burden. Multiple linear regression analysis; age, body mass index, and non-HDL-C were predictors of larger necrotic core volume., Conclusion: Non-HDL-C levels were positively associated with plaque burden, measure of extent of atherosclerosis. It is closely associated with and is a predictor of necrotic core volume; a marker of plaque vulnerability. This IVUS study demonstrates potential role of non-HDL-C in causation of plaque in ACS., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Cardiological Society of India. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.)

Background: Limited data exist on the role of coronary collaterals circulation (CCC) in patients with ST-elevation acute coronary syndrome (STE-ACS). This study aimed to assess CCC and the in-hospital course of patients with CCC undergoing primary percutaneous coronary intervention (pPCI)., Methods: The study included consecutive STE-ACS patients undergoing pPCI. Good CCC was defined as Rentrop collateral score (RCS) of 2-3. Patients with good and poor CCC were compared regarding clinical characteristics, angiographic patterns, and hospital course., Results: In the sample of 4683 patients, mean age was 55.6 ± 11 years, and 78.8 % were male. Good CCC was observed in 499 (10.7 %) patients. The rate of intra-procedure slow-flow/no-reflow (SF/NR) was 29.9 % vs. 20.5 % (p < 0.001), and the rate of composite adverse clinical outcomes (CACO) was 21.2 % vs. 19 % (p = 0.225) for patients with good and poor CCC, respectively. Multivariable analysis identified left ventricular end-diastolic pressure (LVEDP), multi-vessel disease (MVD), and thrombus grade ≥4 as independent predictors of good CCC, with adjusted odds ratios of 0.98 [0.97-0.99], 1.69 [1.35-2.10], and 3.45 [2.64-4.52], respectively. In propensity-matched cohorts, the intra-procedure SF/NR rate was 29.9 % vs. 26.9 % (p = 0.292), and the rate of CACO was 21.2 % vs. 23.4 % (p = 0.403) for patients with good and poor CCC, respectively., Conclusion: Angiographic evidence of good CCC in STE-ACS patients was limited. Good CCC was associated with a higher prevalence of MVD, high thrombus burden, and low pre-procedure LVEDP, resulting in a higher incidence of intra-procedure SF/NR. However, the CACO did not differ significantly between patients with good and poor CCC., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier, a division of RELX India, Pvt. Ltd.)

Background: Gender differences in acute coronary syndrome (ACS) outcomes have been noted in global data, which however did not analyse Indian data. No prior systematic review and meta-analysis (SRM) has addressed this important aspect of gender bias in Indian women with ACS. Hence this SRM aimed to address this knowledge gap., Methods: Electronic databases were searched for studies in ACS comparing cardiovascular disease presentation, treatment received and outcomes in women and men from India. Primary outcomes were to evaluate gender-differences in 30-day death and major adverse cardiovascular events (MACE). Secondary outcomes were to evaluate gender-differences in presentation, management and mortality. The SRM is registered with PROSPERO (CRD42023477286)., Results: From initially screened 3753 articles, data from 9 studies (61,185 patients) were analysed. Women with ACS had higher prevalence of diabetes [Odds ratio (OR) 1.65(95%CI:1.33-2.04); p < 0.001; I 2  = 95 %] and hypertension [OR2.06(95%CI:1.88-2.25); p < 0.001; I 2  = 42 %]. Smoking was significantly lower in women [OR 0.05(95%CI:0.03-0.07); p < 0.001; I 2  = 87 %]. Non-ST elevation myocardial infarction (NSTEMI) was significantly higher in women [OR 1.92(95%CI:1.66-2.21); p < 0.001; I 2  = 0 %]. Diagnostic angiography [OR 0.64(95%CI:0.56-0.74); p < 0.001; I 2  = 46 %] and percutaneous coronary interventions [OR0.71(95%CI:0.55-0.92); p = 0.01; I 2  = 92 %] were significantly lower in women. Women had significantly higher 30-day mortality [Hazard ratio (HR)2.26(95%CI:2.01-2.55); p < 0.001; I 2  = 6 %], 1-year mortality [HR2.41(95%CI:1.89-3.07); p < 0.001; I 2  = 53 %], in-hospital death [HR1.88(95%CI:1.19-2.96); p = 0.007; I 2  = 92 %], stroke [HR 1.84 (95%CI:1.34-2.52); p < 0.001; I 2  = 0 %] and MACE outcomes [OR 2.05 (95%CI:1.78-2.35); p < 0.001]. Use of aspirin, clopidogrel, beta-blockers and nitrates were significantly lower in women., Conclusion: Our study highlights worse outcomes in Indian women with ACS. Higher burden of diabetes and hypertension, decreased used of PCI and lesser aggressive pharmacotherapy may be some of the contributing factors., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Cardiological Society of India. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.)