Aims Age is one of the most powerful determinants of prognosis in myocardial infarction, but there is comparatively little recent data across the whole spectrum of acute coronary syndromes (ACS). We ...examined the impact of increasing age on clinical presentation and hospital outcome in a large sample of patients with ACS. Methods and results Patients (n=10 253) from the Euroheart ACS survey in 103 hospitals in 25 countries were investigated. There was a significant inverse association between the age and the likelihood of presenting with ST-elevation. For each decade of life, the odds of presenting with ST-elevation decreased by 0.82 95% confidence interval (CI) 0.79–0.84; P<0.0001. Elderly patients were considerably less often treated by cardiologists, less extensively investigated, and, when presenting with ST-elevation ACS, less likely to be treated with reperfusion. Compared with patients <55 years, the odds ratios of hospital mortality were 1.87 (1.21–2.88) at age 55–64, 3.70 (2.51–5.44) at age 65–74, 6.23 (4.25–9.14) at age 75–84, and 14.5 (9.47–22.1) among patients ≥85 years, with no major differences across different types of admission or discharge diagnoses. Conclusion Elderly ACS patients were less likely to present with ST-elevation but had substantial in-hospital mortality, yet they were markedly less intensively treated and investigated.
Aims To better delineate the characteristics, treatments, and outcomes of patients with acute coronary syndromes (ACS) in representative countries across Europe and the Mediterranean basin, and to ...examine adherence to current guidelines. Methods and Results We performed a prospective survey (103 hospitals, 25 countries) of 10484 patients with a discharge diagnosis of acute coronary syndromes. The initial diagnosis was ST elevation ACS in 42·3%, non-ST elevation ACS in 51·2%, and undetermined electrocardiogram ACS in 6·5%. The discharge diagnosis was Q wave myocardial infarction in 32·8%, non-Q wave myocardial infarction in 25·3%, and unstable angina in 41·9%. The use of aspirin, beta-blockers, angiotensin converting enzyme inhibitors, and heparins for patients with ST elevation ACS were 93·0%, 77·8%, 62·1%, and 86·8%, respectively, with corresponding rates of 88·5%, 76·6%, 55·8%, and 83·9% for non-ST elevation ACS patients. Coronary angiography, percutaneous coronary interventions, and coronary bypass surgery were performed in 56·3%, 40·4%, and 3·4% of ST elevation ACS patients, respectively, with corresponding rates of 52·0%, 25·4%, and 5·4% for non-ST elevation ACS patients. Among patients with ST elevation ACS, 55·8% received reperfusion treatment; 35·1% fibrinolytic therapy and 20·7% primary percutaneous coronary interventions. The in-hospital mortality of patients with ST elevation ACS was 7·0%, for non-ST elevation ACS 2·4%, and for undetermined electrocardiogram ACS 11·8%. At 30 days, mortality was 8·4%, 3·5%, and 13·3%, respectively. Conclusions This survey demonstrates the discordance between existing guidelines for ACS and current practice across a broad region in Europe and the Mediterranean basin and more extensively reflects the outcomes of ACS in real practice in this region.
Aims To study clinical presentation, in‐hospital course and short‐term prognosis in men and women with diabetes mellitus and acute coronary syndromes (ACS).
Methods Men (n = 6488, 21.2% with ...diabetes) and 2809 women (28.7% with diabetes) ≤ 80 years old, with a discharge diagnosis of ACS were prospectively enrolled in the Euro Heart Survey of ACS.
Results Women with diabetes were more likely to present with ST elevation than non‐diabetic women, a difference that became more marked after adjustment for differences in smoking, hypertension, obesity, medication and prior disease adjusted odds ratio (OR) 1.46 (1.20, 1.78), whereas there was little difference between diabetic and non‐diabetic men adjusted OR 0.99 (0.86, 1.14). In addition, women with diabetes were more likely to develop Q‐wave myocardial infarction (MI) than non‐diabetic women adjusted OR 1.61 (1.30, 1.99), while there was no difference between men with and without diabetes adjusted OR 0.99 (0.85, 1.15). There were significant interactions between sex, diabetes and presenting with ST‐elevation ACS (P < 0.001), and Q‐wave MI (P < 0.001), respectively. Of the women with diabetes, 7.4% died in hospital, compared with 3.6% of non‐diabetic women adjusted OR 2.13 (1.39, 3.26), whereas corresponding mortality rates in men with and without diabetes were 4.1% and 3.3%, respectively OR 1.13 (0.76, 1.67) (P for diabetes–sex interaction 0.021).
Conclusion In women with ACS, diabetes is associated with higher risk of presenting with ST‐elevation ACS, developing Q‐wave MI, and of in‐hospital mortality, whereas in men with ACS diabetes is not significantly associated with increased risk of either. These findings suggest a differential effect of diabetes on the pathophysiology of ACS based on the patient's sex.
Objective: To investigate the hypothesis that risk factors may be differently related to severity of acute coronary syndromes (ACS), with ST elevation used as a marker of severe ACS. Design: Cross ...sectional study of patients with ACS. Setting: 103 hospitals in 25 countries in Europe and the Mediterranean basin. Patients: 10 253 patients with a discharge diagnosis of ACS in the Euro heart survey of ACS. Main outcome measures: Presenting with ST elevation ACS. Results: Patients with ACS who were smokers had an increased risk to present with ST elevation (age adjusted odds ratio (OR) 1.84, 95% confidence interval (CI) 1.67 to 2.02). Hypertension (OR 0.65, 95% CI 0.60 to 0.70) and high body mass index (BMI) (p for trend 0.0005) were associated with less ST elevation ACS. Diabetes mellitus was also associated with less ST elevation, but only among men. Prior disease (infarction, chronic angina, revascularisation) and treatment with aspirin, β blockers, or statins before admission were also associated with less ST elevation. After adjustment for age, sex, prior disease, and prior medication, smoking was still significantly associated with increased risk of ST elevation (OR 1.53, 95% CI 1.38 to 1.69), whereas hypertension was associated with reduced risk (OR 0.75, 95% CI 0.69 to 0.82). Obesity (BMI > 30 kg/m2 versus < 25 kg/m2) was independently associated with less risk of presenting with ST elevation among women, but not among men. Conclusion: Among patients with ACS, presenting with ST elevation is strongly associated with smoking, whereas hypertension and high BMI (in women) are associated with less ST elevation, independently of prior disease and medication.
Aims To examine the application of the redefinition of acute myocardial infarction (AMI) published on 4 September 2000. Methods and results The Euro Heart Survey of Acute Coronary Syndromes (ACS) ...prospectively surveyed 10484 patients in 103 hospitals across 25 European and Mediterranean basin countries during 4 September 2000 to 15 May 2001. We evaluated the use of cardiac troponin assays and whether the diagnosis of unstable angina (UA) or AMI was in accordance with the results of biomarker assays (cardiac troponins, CK-MB mass, CK-MB%, or CK). Troponin assays were used in 6036 (63.3%) of the 9538 patients with available biomarker levels; of whom elevated troponin levels were recorded in 648 of 2307 (28.1%) patients with UA and in 2957 of 3729 (79.3%) patients with AMI. Of the 8871 patients with available creatine kinase values, levels above the upper limit of normal were recorded in 848 of 3625 (23.4%) patients with UA and in 3948 of 5246 (75.3%) patients with AMI. Conclusions Cardiac troponin assays are still not universally available for the evaluation of ACS patients. A substantial proportion of ACS patients receive a diagnosis of UA or AMI, irrespective of the result of biomarker assays, indicating that the redefinition of AMI has not yet been universally adopted, and that additional efforts are warranted to ensure its appropriate implementation.
Although clopidogrel and aspirin (dual therapy, DT) are used for acute coronary syndrome (ACS), sometimes treatment with warfarin (triple therapy, TT) is required.
To determine the incidence, ...complications, and outcomes of TT.
We analyzed Israeli surveys of ACS from 2000 to 2004.
In these surveys, 5,706 (96%) were discharged alive from hospital. Post-ACS TT and DT were 76 patients (1.3%) and 2,661 patients (46.7%), respectively. The TT group was older with more prior cardiac disease. During hospitalization, the TT patients received more intravenous anticoagulant and antithrombotic agents, and had more heart failure, arrhythmias, ischemia, and major bleeding (2.6 vs. 0.6%, p=0.03). There were no differences in adjusted 30-day and 6-month mortality between the 2 groups.
TT is feasible among ACS patients who require concomitant warfarin treatment.
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