Introduction. Acute coronary syndrome (ACS), encompassing unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI), is a major ...global health concern due to its high morbidity and mortality. Research highlights a link between ACS and elevated acute phase reactants like C-reactive protein, emphasizing the role of inflammation and atherosclerosis. Serum fibrinogen, crucial in thrombus formation and an inflammatory marker, is significant in the coagulation process. This study investigates the predictive value of serum fibrinogen levels and the GRACE score for 3-month mortality in ACS patients. Aim. To examine the clinical profile of ACS patients and evaluate serum fibrinogen and GRACE score as prognostic markers for 3-month mortality. Methodology. A prospective observational study was conducted on 50 patients diagnosed with ACS at Saveetha Medical College Hospital. The study included adults over 18 with ACS, excluding those with severe comorbid conditions like end-stage liver disease or malignancy. Serum fibrinogen levels were measured at presentation and at 3 months using an automated coagulation analyzer. GRACE scores were calculated, and clinical assessments including ECG, cardiac markers, and ECHO were conducted. Data analysis involved IBM SPSS Statistics, utilizing descriptive statistics, t-tests, ANOVA, and Pearson's Correlation. Results. The study group had diverse demographics and a high prevalence of cardiovascular symptoms and comorbidities. The clinical profile of ACS showed a higher incidence of STEMI. Serum fibrinogen levels varied significantly across different Killip classes at presentation and at 3 months, with the highest levels in the more severe classes. Higher serum fibrinogen was linked to recurrent heart failure admissions and higher KILIPS class. However, there was no significant difference in fibrinogen levels between patients with and without interventions. The GRACE score was higher in STEMI patients, those with LV dysfunction, and correlated with higher serum fibrinogen. Lower FACIT F scores, indicating higher fatigue, were associated with higher fibrinogen levels and readmissions for heart failure. Conclusion. Higher serum fibrinogen levels and GRACE scores at presentation and at three months are indicators of severe myocardial infarction, increased heart failure readmission rates, and greater fatigue in ACS patients. These markers are valuable for evaluating morbidity in ACS and can aid in enhancing patient management strategies.
Platelet activation and aggregation play a major role in thrombosis formation of coronary arteries in patients with Acute Coronary Syndrome (ACS) and is responsible for most ischemic complications ...during PCI. There is little information on the benefits and side effects of intracoronary and intravenous injection of Eptifibatide, a potent antiplatelet agent; therefore, this study was performed with the aim to compare coronary blood flow velocity by measurement of TIMI frame count. In intravenous versus intracoronary bolus administration of Eptifibatide during PCI in ACS patients. This non-randomized clinical trial study was performed on 103 patients with acute coronary syndromes who referred to the cardiac emergency ward of Ghaem hospital, Mashhad University of Medical Sciences, and were candidates for urgent coronary angiography and PCI. Forty-eight cases received intracoronary bolus Eptifibatide and 55 intravenous Eptifibatide. TIMI Frame Count and Corrected TIMI Frame Count were used to comparing the effect of these two methods on coronary blood flow velocity. Data were analyzed by SPSS software (version 22). To compare the quantitative variables in the two groups, according to the distribution of variables, the t-test was used if it was normal or the Mann-Whitney test was used if it was not normal. A Chi-square test was also used to compare qualitative variables into two groups. P<0.05 was considered statistically significant. Mean of age, gender, and cardiovascular risk factors were similar in the two groups. There was no significant difference in terms of serum Creatine Kinase MB (CKMB) level, Left Ventricular Ejection Fraction (LVEF), coronary artery lesion length, coronary artery diameter, coronary thrombosis, and coronary artery thrombectomy in two groups. Based on Student's t-test, there was no significant difference between mean TIMI Frame Count in different coronary arteries in the intracoronary and intravenous injection groups (In LAD, P=0.518; For LCX, P=0.576; and in RCA, P=0.964). The complications were observed in 11 patients (22.9%) of the intracoronary injection group and 9 (16.4%) of the intravenous injection group; the difference was not significant (P=0.402). The effects and complications of Eptifibatide were not significantly different in Intracoronary and intravenous administration in ACS patients during PCI and at the time of patients' hospitalization.
Coronary artery disease (CAD) involves a complex atherosclerotic process, and many factors play a role in this process. Although there are studies evaluating the development and severity of CAD with ...trace elements in the blood, there is no study evaluating coronary flow to our knowledge. This study aimed to evaluate the relationship between coronary flow and trace elements after percutaneous intervention in ST-elevation myocardial infarction (STEMI). This study included 126 consecutive patients who presented to the emergency department with STEMI between May 2023 and August 2023. Thrombolysis in myocardial infarction (TIMI) flow grades were calculated after primary percutaneous coronary intervention, and patients were categorized into two groups: low TIMI flow grade and normal TIMI flow grade. The diagnosis of STEMI was defined according to European acute coronary syndrome (ACS) guidelines. Demographic and clinical data were recorded. After coronary angiography, blood tests for trace elements were obtained in addition to routine laboratory parameters. All variables were compared between the two groups. There was no significant difference between low and normal TIMI flow grade groups regarding age and gender. Killip score (p=0.004) and tirofiban (p<0.001) use were higher in the low TIMI flow grade group. Serum copper, high-density lipoprotein, low-density lipoprotein, diabetes mellitus, hypertension, and platelet variables were included in binary logistic regression analysis; low serum copper (p=0.014, OR=1.023, Cl=1.005-1.042) was found to be a risk factor for low TIMI flow grade. Regarding the outcomes of this research, we found that serum copper levels are an important risk factor for low TIMI flow grade in STEMI.
Objective: No-reflow phenomenon is one of well-known complications of percutaneous coronary intervention (PCI). The rate of no-reflow phenomenon was reported between 2-44% differing on the ...accompanying situations and more frequent in acute myocardial infarction. Predictive factors for no-reflow phenomenon have not been clearly defined. We aimed to define predictive factors for no-reflow development in patients who presented with ST-segment elevation MI (STEMI) and treated with primary (PPCI). Method: Patients who underwent PPCI between 2017 and 2021 in our clinic were included retrospectively. Demographic, clinical and laboratory findings were recorded. Two groups generated according to no-reflow development: no-reflow (+) and (-). Results: Six hundred eighty-nine patients were included. Mean age was 55.9±8.7 years and 71.8% were male. 107 patients (15.5%) were formed no-reflow (+) group and 582 patients were formed no-reflow (-) group. Left ventricular ejection fraction, troponin, fasting blood glucose, TIMI thrombus grade and TIMI thrombus category were determined as independent predictors of no-reflow development. Conclusion: Considering the relationship between no-reflow development and adverse outcomes such as in-hospital adverse cardiac events, left ventricular remodeling, malignant ventricular arrhythmia, or heart failure, it may help to identify the factors that predict the risk of no-reflow and take preventive measures to improve the long-term outcome.
Abstract Background Mortality in cardiogenic shock (CS) remains high. Early risk stratification is crucial to make adequate treatment decisions. Objectives This study sought to develop an ...easy-to-use, readily available risk prediction score for short-term mortality in patients with CS, derived from the IABP-SHOCK II (Intraaortic Balloon Pump in Cardiogenic Shock) trial. Methods The score was developed using a stepwise multivariable regression analysis. Results Six variables emerged as independent predictors for 30-day mortality and were used as score parameters: age >73 years, prior stroke, glucose at admission >10.6 mmol/l (191 mg/dl), creatinine at admission >132.6 μmol/l (1.5 mg/dl), Thrombolysis In Myocardial Infarction flow grade <3 after percutaneous coronary intervention, and arterial blood lactate at admission >5 mmol/l. Either 1 or 2 points were attributed to each variable, leading to a score in 3 risk categories: low (0 to 2), intermediate (3 or 4), and high (5 to 9). The observed 30-day mortality rates were 23.8%, 49.2%, and 76.6%, respectively (p < 0.0001). Validation in the IABP-SHOCK II registry population showed good discrimination with an area under the curve of 0.79. External validation in the CardShock trial population (n = 137) showed short-term mortality rates of 28.0% (score 0 to 2), 42.9% (score 3 to 4), and 77.3% (score 5 to 9; p < 0.001) and an area under the curve of 0.73. Kaplan-Meier analysis revealed a stepwise increase in mortality between the different score categories (0 to 2 vs. 3 to 4: p = 0.04; 0 to 2 vs. 5 to 9: p = 0.008). Conclusions The IABP-SHOCK II risk score can be easily calculated in daily clinical practice and strongly correlated with mortality in patients with infarct-related CS. It may help stratify patient risk for short-term mortality and might, thus, facilitate clinical decision making. (Intraaortic Balloon Pump in Cardiogenic Shock II IABP-SHOCK II; NCT00491036 )
Abstract Background The performance of the GRACE, HEART and TIMI scores were compared in predicting the probability of major adverse cardiac events (MACE) in chest pain patients presenting at the ...emergency department (ED), in particular their ability to identify patients at low risk. Methods Chest pain patients presenting at the ED in nine Dutch hospitals were included. The primary outcome was MACE within 6 weeks. The HEART score was determined by the treating physician at the ED. The GRACE and TIMI score were calculated based on prospectively collected data. Performance of the scores was compared by calculating AUC curves. Additionally, the number of low-risk patients identified by each score were compared at a fixed level of safety of at least 95% or 98% sensitivity. Results In total, 1748 patients were included. The AUC of GRACE, HEART, and TIMI were 0.73 (95% CI: 0.70–0.76%), 0.86 (95% CI: 0.84–0.88%) and 0.80 (95% CI: 0.78–0.83%), respectively (all differences in AUC highly statistically significant). At an absolute level of safety of at least 98% sensitivity, the GRACE score identified 231 patients as “low risk” in which 2.2% a MACE was missed; the HEART score identified 381 patients as “low risk” with 0.8% missed MACE. The TIMI score identified no “low risk” patients at this safety level. Conclusions The HEART score outperformed the GRACE and TIMI scores in discriminating between those with and without MACE in chest pain patients, and identified the largest group of low-risk patients at the same level of safety.
Objectives The study objective was to validate a new high-sensitivity troponin I (hs-TnI) assay in a clinical protocol for assessing patients who present to the emergency department with chest pain. ...Background Protocols using sensitive troponin assays can accelerate the rule out of acute myocardial infarction in patients with low-risk (suspected) acute coronary syndrome (ACS). Methods This study evaluated 2 prospective cohorts of patients in the emergency department with ACS in an accelerated diagnostic pathway integrating 0- and 2-h hs-TnI results, Thrombolysis In Myocardial Infarction (TIMI) risk scores, and electrocardiography. Strategies to identify low-risk patients incorporated TIMI risk scores = 0 or ≤1. The primary endpoint was a major adverse cardiac event (MACE) within 30 days. Results In the primary cohort, 1,635 patients were recruited and had 30-day follow-up. A total of 247 patients (15.1%) had a MACE. The finding of no ischemic electrocardiogram and hs-TnI ≤26.2 ng/l with the TIMI = 0 and TIMI ≤1 pathways, respectively, classified 19.6% (n = 320) and 41.5% (n = 678) of these patients as low risk; 0% (n = 0) and 0.8% (n = 2) had a MACE, respectively. In the secondary cohort, 909 patients were recruited. A total of 156 patients (17.2%) had a MACE. The TIMI = 0 and TIMI ≤1 pathways classified 25.3% (n = 230) and 38.6% (n = 351), respectively, of these patients as low risk; 0% (n = 0) and 0.8% (n = 1) had a MACE, respectively. Sensitivity, specificity, and negative predictive value for TIMI = 0 in the primary cohort were 100% (95% confidence interval CI: 98.5% to 100%), 23.1% (95% CI: 20.9% to 25.3%), and 100% (95% CI: 98.8% to 100%), respectively. Sensitivity, specificity, and negative predictive value for TIMI ≤1 in the primary cohort were 99.2 (95% CI: 97.1 to 99.8), 48.7 (95% CI: 46.1 to 51.3), and 99.7 (95% CI: 98.9 to 99.9), respectively. Sensitivity, specificity, and negative value for TIMI ≤1 in the secondary cohort were 99.4% (95% CI: 96.5 to 100), 46.5% (95% CI: 42.9 to 50.1), and 99.7% (95% CI: 98.4 to 100), respectively. Conclusions An early-discharge strategy using an hs-TnI assay and TIMI score ≤1 had similar safety as previously reported, with the potential to decrease the observation periods and admissions for approximately 40% of patients with suspected ACS. (Advantageous Predictors of Acute Coronary Syndromes Evaluation APACE Study, NCT00470587 ; A 2hr Accelerated Diagnostic Protocol to Assess patients with chest Pain symptoms using contemporary Troponins as the only biomarker ADAPT: a prospective observational validation study, ACTRN12611001069943 )
•The intermediate / high group risk TIMI showed a decreased methylation pattern.•Hypermethylated global DNA profile is associated with the development of ACS.•Hypermethylated global DNA profile can ...be a potential biomarker for ACS.
DNA methylation is one of the mechanisms of epigenetic regulation and is observed in mammals to maintain a normal expression pattern of the genes. Aberrant profiles of DNA methylation have already been associated with cardiovascular diseases. We evaluated 190 patients with Acute Coronary Syndrome (ACS) and 75 patients without ACS (non-ACS). Patient severity was assessed by the TIMI risk score, and both levels of global DNA methylation (ACS = 190; non-ACS = 75), stratified in expected group (male ≥ 65 years; female ≥ 55 years) and early group (male < 65 years; female < 55 years). As results, the ACS and non-ACS groups showed different levels of global DNA methylation, and patients with ACS were more methylated (p = 0.0121). Patients with ACS, showed a difference (p < 0.0001) in methylation profiles between groups. The low TIMI group had a higher level of DNA methylation, while the intermediate / high group showed a decreased methylation pattern. A negative correlation was observed between the level of global methylation and the increase in age (p = 0.0387; r = −0.15), which became hypomethylated over the years. The hypermethylated global DNA profile by its association with the development of ACS can be a potential biomarker.
Objectives
To investigate the effects of early upstream antithrombotic therapy administration (ATTA) in ST‐segment elevation myocardial infarction (STEMI) patients with prolonged transport times to ...primary percutaneous intervention (PPCI) on major clinical outcomes.
Background
It remains unclear whether early upstream administration of aspirin, ticagrelor, and unfractionated heparin (UFH) confers additional benefits compared with in‐hospital administration.
Methods
Between 2015 and 2018, we performed PPCI in 709 included consecutive STEMI patients. We compared 482 STEMI patients who received aspirin, ticagrelor, and UFH loading in a non‐PCI capable spoke hospital before transfer (NPHT) versus 227 prehospital triage setting (PTS) STEMI patients who received in‐ambulance aspirin, followed by ticagrelor and UFH in the hub catheterization laboratory. The primary outcome was the presence of a pre‐PPCI TIMI flow 2–3 in the infarct related artery (IRA). The secondary outcomes included definite acute stent thrombosis and hemorrhagic complications.
Results
The median times from ticagrelor and heparin administration to angiography in the NPHT group and the PTS group were 80.5 min (Interquartile Range (IQR) 68.5–94) and 10 min (IQR 5–15) respectively (p < .0001). Using inverse probability of treatment weighting to minimize heterogeneity between groups, we showed significant differences for the primary outcome (44.6 versus 18.5%, p < .0001) and for definite acute stent thrombosis (0.6 versus 2.6%, p = .03), with no difference in the combined in‐hospital BARC 2–5 bleeding events (1.9 versus 3.5%, p = .18) in the NPHT versus the PTS group, respectively.
Conclusion
In this single‐center retrospective cohort study, after adjusting for baseline covariates, early upstream ATTA with aspirin, ticagrelor, and UFH was associated with greater pre‐PPCI TIMI flow and less definite acute stent thrombosis in STEMI patients, without increased bleeding risk.
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