International guidelines recommend that for NSTEMI, the timing of invasive strategy (IS) is a function of patient's baseline risk. The extent to which this is delivered across and within healthcare ...systems is unknown.
Data were derived from 137,265 patients admitted with an NSTEMI diagnosis between 2010 and 2015 in England and Wales. Patients were stratified into low, intermediate and high-risk in keeping with international guidelines. Time to IS was categorised into early (24 h), intermediate (25–72 h) and late (>72 h). Multivariable logistic regression models were used to identify independent predictors of guidelines recommended receipt of IS.
There were 3608 (2.6%) low, 5037 (3.7%) intermediate and 128,621 (93.7%) high-risk patients. Guidelines recommended use of IS was significantly lower in high-risk (16.4%) compared to intermediate (64.7%) and low-risk (62.5%) groups. Both men and women in the low-risk category were almost twice as likely to receive early IS compared to high-risk men (28.9% vs 17%, p < 0.001) and women (26.9% vs 15%, p < 0.001). Women (OR 0.91 95%CI 0.88–0.94), troponin elevation (OR 0.39 95%CI 0.36–0.43) and acute heart failure on admission (OR 0.65 95%CI 0.61–0.70) were strong negative predictors of receiving IS within recommended time in the high-risk group.
Our study shows that IS for management of NSTEMI is not delivered according to international guidelines recommendations. Specifically, the disconnect between baseline risk and utility of IS increases with increasing risk and women achieve slower access than men to IS.
Summary of main findings of the study. Display omitted
•Invasive strategy in the management of patients admitted with NSTEMI is guided by their baseline risk.•Based on risk criteria of two international guidelines, over 90% of patients admitted with diagnosis of NSTEMI are high-risk.•Only one in ten of these high-risk patients received invasive strategy within the recommended time.•Paradoxically, both men and women with low-risk are twice as likely to receive early invasive strategy compared to high-risk men and women.
Abstract
Aims
The Global Registry of Acute Coronary Events (GRACE) score was developed to evaluate risk in patients with the acute coronary syndrome with or without ST-segment elevation. Little is ...known about its performance at predicting in-hospital mortality for ethnic minority patients.
Methods and results
We identified 326 160 admissions with non-ST-segment elevation myocardial infarction (NSTEMI) in the Myocardial Infarction National Audit Project (MINAP), 2010–17, including White (n = 299 184) and ethnic minorities (excluding White minorities) (n = 26 976). We calculated the GRACE score for in-hospital mortality and assessed ethnic group baseline characteristics by low, intermediate and high risk. The performance of the GRACE risk score was estimated by discrimination area under the receiver operating characteristic curve (AUC) and calibration (calibration plots). Ethnic minorities presented younger and had increased prevalence of cardiometabolic risk factors in all GRACE risk groups. The GRACE risk score for White AUC 0.87, 95% confidence interval (CI) 0.86–0.87 and ethnic minority (AUC 0.87, 95% CI 0.86–0.88) patients had good discrimination. However, whilst the GRACE risk model was well calibrated in White patients (expected to observed (E : O) in-hospital death rate ratio 0.99; slope 1.00), it overestimated risk in ethnic minority patients (E : O ratio 1.29; slope: 0.94).
Conclusion
The GRACE risk score provided good discrimination overall for in-hospital mortality, but was not well calibrated and overestimated risk for ethnic minorities with NSTEMI.
Structured Graphical Abstract
Structured Graphical Abstract
The performance of the GRACE (v2.0) risk score in predicting in-hospital mortality for NSTEMI by ethnicity.
to investigate whether the association between blood pressure and clinical outcomes is different in older adults with and without frailty, using observational studies.
MEDLINE, EMBASE and CINAHL were ...searched from 1st January 2000 to 13th June 2018. PROSPERO CRD42017081635. We included all observational studies reporting clinical outcomes in older adults with an average age over 65 years living in the community with and without treatment that measured blood pressure and frailty using validated methods. Two independent reviewers evaluated study quality and risk of bias using the ROBANS tool. We used generic inverse variance modelling to pool risks of all-cause mortality adjusted for age and sex.
nine observational studies involving 21,906 older adults were included, comparing all-cause mortality over a mean of six years. Fixed effects meta-analysis of six studies demonstrated that in people with frailty, there was no mortality difference associated with systolic blood pressure <140 mm Hg compared to systolic blood pressure >140 mm Hg (HR 1.02, 95% CI 0.90 to 1.16). In the absence of frailty, systolic blood pressure <140 mm Hg was associated with lower risk of death compared to systolic blood pressure >140 mm Hg (HR 0.86, 95% CI 0.77 to 0.96).
evidence from observational studies demonstrates no mortality difference for older people with frailty whose systolic blood pressure is <140 mm Hg, compared to those with a systolic blood pressure >140 mm Hg. Current evidence fails to capture the complexities of blood pressure measurement, and the association with non-fatal outcomes.
In ophthalmologic practice, retinal images are routinely obtained to diagnose and monitor primary eye diseases and systemic conditions affecting the eye, such as diabetic retinopathy. Recent studies ...have shown that biomarkers on retinal images, for example, retinal blood vessel density or tortuosity, are associated with cardiac function and may identify patients at risk of coronary artery disease. In this work we investigate the use of retinal images, alongside relevant patient metadata, to estimate left ventricular mass and left ventricular end-diastolic volume, and subsequently, predict incident myocardial infarction. We trained a multichannel variational autoencoder and a deep regressor model to estimate left ventricular mass (4.4 (–32.30, 41.1) g) and left ventricular end-diastolic volume (3.02 (–53.45, 59.49) ml) and predict risk of myocardial infarction (AUC = 0.80 ± 0.02, sensitivity = 0.74 ± 0.02, specificity = 0.71 ± 0.03) using just the retinal images and demographic data. Our results indicate that one could identify patients at high risk of future myocardial infarction from retinal imaging available in every optician and eye clinic.Routine eye clinic imaging could help screen patients with cardiovascular risk as studies indicate strong associations between biomarkers in the retina and the heart. This potential is supported by a multimodal study, employing a deep learning model, that can infer cardiac functional indices based on retinal images and demographic data.
Abstract
Aims
COVID-19 might have affected the care and outcomes of hospitalized acute myocardial infarction (AMI). We aimed to determine whether the COVID-19 pandemic changed patient response, ...hospital treatment, and mortality from AMI.
Methods and results
Admission was classified as non-ST-elevation myocardial infarction (NSTEMI) or STEMI at 99 hospitals in England through live feeding from the Myocardial Ischaemia National Audit Project between 1 January 2019 and 22 May 2020. Time series plots were estimated using a 7-day simple moving average, adjusted for seasonality. From 23 March 2020 (UK lockdown), median daily hospitalizations decreased more for NSTEMI 69 to 35; incidence risk ratios (IRR) 0.51, 95% confidence interval (CI) 0.47–0.54 than STEMI (35 to 25; IRR 0.74, 95% CI 0.69–0.80) to a nadir on 19 April 2020. During lockdown, patients were younger (mean age 68.7 vs. 66.9 years), less frequently diabetic (24.6% vs. 28.1%), or had cerebrovascular disease (7.0% vs. 8.6%). ST-elevation myocardial infarction more frequently received primary percutaneous coronary intervention (81.8% vs. 78.8%), thrombolysis was negligible (0.5% vs. 0.3%), median admission-to-coronary angiography duration for NSTEMI decreased (26.2 vs. 64.0 h), median duration of hospitalization decreased (4 to 2 days), secondary prevention pharmacotherapy prescription remained unchanged (each > 94.7%). Mortality at 30 days increased for NSTEMI from 5.4% to 7.5%; odds ratio (OR) 1.41, 95% CI 1.08–1.80, but decreased for STEMI (from 10.2% to 7.7%; OR 0.73, 95% CI 0.54–0.97).
Conclusion
During COVID-19, there was a substantial decline in admissions with AMI. Those who presented to hospital were younger, less comorbid and, for NSTEMI, had higher 30-day mortality.
Atrial fibrillation (AF) screening by age achieves a low yield and misses younger individuals. We aimed to develop an algorithm in nationwide routinely collected primary care data to predict the risk ...of incident AF within 6 months (Future Innovations in Novel Detection of Atrial Fibrillation (FIND-AF)).
We used primary care electronic health record data from individuals aged ≥30 years without known AF in the UK Clinical Practice Research Datalink-GOLD dataset between 2 January 1998 and 30 November 2018, randomly divided into training (80%) and testing (20%) datasets. We trained a random forest classifier using age, sex, ethnicity and comorbidities. Prediction performance was evaluated in the testing dataset with internal bootstrap validation with 200 samples, and compared against the CHA
DS
-VASc (Congestive heart failure, Hypertension, Age >75 (2 points), Stroke/transient ischaemic attack/thromboembolism (2 points), Vascular disease, Age 65-74, Sex category) and C
HEST (Coronary artery disease/Chronic obstructive pulmonary disease (1 point each), Hypertension, Elderly (age ≥75, 2 points), Systolic heart failure, Thyroid disease (hyperthyroidism)) scores. Cox proportional hazard models with competing risk of death were fit for incident longer-term AF between higher and lower FIND-AF-predicted risk.
Of 2 081 139 individuals in the cohort, 7386 developed AF within 6 months. FIND-AF could be applied to all records. In the testing dataset (n=416 228), discrimination performance was strongest for FIND-AF (area under the receiver operating characteristic curve 0.824, 95% CI 0.814 to 0.834) compared with CHA
DS
-VASc (0.784, 0.773 to 0.794) and C
HEST (0.757, 0.744 to 0.770), and robust by sex and ethnic group. The higher predicted risk cohort, compared with lower predicted risk, had a 20-fold higher 6-month incidence rate for AF and higher long-term hazard for AF (HR 8.75, 95% CI 8.44 to 9.06).
FIND-AF, a machine learning algorithm applicable at scale in routinely collected primary care data, identifies people at higher risk of short-term AF.
Graphical Abstract
Graphical Abstract
Domains of the 2021 EuroHeart acute coronary syndrome and percutaneous coronary intervention data standards with the number of Level 1 (mandatory) variables.
...Abstract
Standardized data definitions are essential for monitoring and benchmarking the quality of care and patient outcomes in observational studies and randomized controlled trials. There are no contemporary pan-European data standards for the acute coronary syndrome (ACS) and percutaneous coronary intervention (PCI). The European Unified Registries for Heart Care Evaluation and Randomised Trials (EuroHeart) project of the European Society of Cardiology (ESC) aimed to develop such data standards for ACS and PCI. Following a systematic review of the literature on ACS and PCI data standards and evaluation of contemporary ACS and PCI registries, we undertook a modified Delphi process involving clinical and registry experts from 11 European countries, as well as representatives from relevant ESC Associations, including the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and Acute CardioVascular Care (ACVC). This resulted in final sets of 68 and 84 ‘mandatory’ variables and several catalogues of optional variables for ACS and PCI, respectively. Data definitions were provided for these variables, which have been programmed as the basis for continuous registration of individual patient data in the online EuroHeart IT platform. By means of a structured process and the interaction with major stakeholders, internationally harmonized data standards for ACS and PCI have been developed. In the context of the EuroHeart project, this will facilitate country-level quality of care improvement, international observational research, registry-based randomized trials, and post-marketing surveillance of devices and pharmacotherapies.
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