Investigation of the effectiveness of the Quick Sequential Organ Failure Assessment-Troponin scores in non- ST-elevation myocardial infarction

SUMMARY OBJECTIVE: A reliable predictor is needed for non-ST-elevation myocardial infarction patients with high mortality risk. The aim of this study was to assess the effectiveness of the Global Registry of Acute Coronary Events and Quick Sequential Organ Failure Assessment-Troponin (qSOFA-T) scores on in-hospital mortality rate in non-ST-elevation myocardial infarction patients. METHODS: This is an observational and retrospective study. Patients admitted to the emergency department with acute coronary syndrome were evaluated consecutively. A total of 914 patients with non-ST-elevation myocardial infarction who met inclusion criteria were included in the study. The Global Registry of Acute Coronary Events and qSOFA scores were calculated and investigated its contribution to prognostic accuracy by adding cardiac troponin I (cTnI) concentration to the qSOFA score. The threshold value of the investigated prognostic markers was calculated by receiver operating characteristic curve analysis. RESULTS: We found the in-hospital mortality rate to be 3.4%. The area under the receiver operating characteristic curve for Global Registry of Acute Coronary Events and qSOFA-T is 0.840 and 0.826, respectively. CONCLUSION: The qSOFA-T score, which can be calculated easily, quickly, and inexpensively and obtained by adding the cTnI level, had excellent discriminatory power for predicting in-hospital mortality. Difficulty in calculating the Global Registry of Acute Coronary Events score, which requires a computer, can be considered a limitation of this method. Thus, patients with a high qSOFA-T score are at an increased risk of short-term mortality.

Role of simple inflammatory parameters in predicting the severity of coronary artery disease

SUMMARY OBJECTIVE: In our study, we aimed to find simple, useful biomarkers in patients with non-ST elevation myocardial infarction to predict coronary artery severity. METHODS: Between May 2022 and December 2022, patients diagnosed with non-ST elevation myocardial infarction according to the European cardiology guidelines were included in our study. The Synergy between PCI with Taxus and Cardiac Surgery score was calculated to determine the severity of coronary artery disease. These patients were classified into two groups according to Synergy between PCI with Taxus and Cardiac Surgery≥23 and Synergy between PCI with Taxus and Cardiac Surgery<23 scores. Biochemical markers such as platelet-to-lymphocyte ratio and neutrophil-to-lymphocyte ratio were studied in blood tests taken before coronary angiography in patients diagnosed with non-ST elevation myocardial infarction according to current guidelines. These two groups were compared in terms of the data obtained. RESULTS: There were 281 patients in group 1 and 67 patients in group 2. There was no significant difference between the two groups in terms of demographic data such as age and gender. Platelet-to-lymphocyte ratio [group 1=125 (26-134) and group 2=156 (73-293); p=0.001] and neutrophil-to-lymphocyte ratio [group 1=2.71 (1.3-30.2) and group 2=3.2 (2.1-32.1); p=0.002] were higher in the group of patients with a Synergy between PCI with Taxus and Cardiac Surgery score of <23, while lymphocyte-to-monocyte ratio [group 1=3.6 (0.56-11) and group 2=3.4 (0.64-5.75); p=0.017] was lower in group 2. CONCLUSION: We observed that elevated platelet-to-lymphocyte and neutrophil-to-lymphocyte ratios showed coronary artery severity. Multivessel disease and chronic total occlusion rates were observed to be higher in patients with high platelet-to-lymphocyte and neutrophil-to-lymphocyte ratios.

Embolismo pulmonar masivo y trombo en ventrículo derecho postinfarto agudo de miocardio / Massive pulmonary embolism and right ventricle thrombus post-acute myocardial infarct

Resumen Introducción: un trombo en ventrículo derecho y embolismo pulmonar post infarto agudo de miocardio sin elevación del ST es muy inusual. Es considerado una emergencia médica y es imperativo instaurar una opción terapéutica inmediata. Presentación del caso: paciente femenina de 80 años quien consultó en sala de emergencias por síncope, dolor torácico y disnea persistente. Se confirmó síndrome coronario agudo por electrocardiograma y troponina I elevada. En estudios complementarios se encontró hallazgo incidental de trombo en el ventrículo derecho y un angio-TAC confirmó embolismo pulmonar masivo. Discusión: el trombo en ventrículo derecho y embolismo pulmonar masivo post infarto es un fenómeno muy raro en el escenario clínico, debido a la instauración temprana de la terapia anti-isquémica. Es necesario mayor investigación para aclarar este fenómeno.

Abstract Introduction: right ventricular thrombus and pulmonary embolism after acute myocardial infarction without ST elevation is very unusual. It is considered a medical emergency and it is imperative to establish an immediate therapeutic option. Case presentation: An 80-year-old female patient visited the emergency room for syncope, chest pain, and persistent dyspnea. Acute coronary syndrome was confirmed by electrocardiogram and elevated troponin I. In complementary studies, an incidental finding of a thrombus in the right ventricle was found and a CT angiography confirmed massive pulmonary embolism. Discussion: thrombus in the right ventricle and massive post-infarction pulmonary embolism is a very rare phenomenon in the clinical setting due to the early introduction of anti-ischemic therapy. More research is needed to clarify this phenomenon.

Estrategias de antiagregación en síndromes coronarios agudos sin elevación del segmento ST / Antiplatelet Strategies in Non-ST-Segment Elevation Acute Coronary Syndrome

RESUMEN Introducción: Existe información limitada sobre estrategias de tratamiento con inhibidores del receptor P2Y12 (iP2Y12) en síndromes coronarios agudos sin elevación del segmento ST (SCASEST) en la vida real. Objetivos: Determinar la incidencia de eventos cardíacos adversos mayores (MACE)y sangrado BARC ≥2, según la estrategia de tratamiento con iP2Y12 a 6 meses. Material y métodos: Subanálisis preespecificado del registro BUENOS AIRES I (n = 1100). Se estratificó la cohorte según "pretratamiento" con iP2Y12 (antes de conocer la anatomía coronaria), o "tratamiento en sala" (luego de conocer la anatomía coronaria) y se analizó la incidencia de eventos clínicos, según: pretratamiento con clopidogrel/ticagrelor, tratamiento en sala con clopidogrel/ticagrelor. Resultados: La edad media fue 65,4 ± 11,5 años, con 77,2% de sexo masculino. El 79,72% recibió iP2Y12, el 75% como pretratamiento y 25% como tratamiento en sala. Los pacientes con pretratamiento fueron más jóvenes y con más infarto agudo de miocardio (IAM), en comparación con el subgrupo de tratamiento en sala. A los 6 meses, no hubo diferencias significativas en la incidencia de MACE (16,4% vs. 14,4%; p = 0,508), o sangrado BARC ≥2 (14,7% vs. 11,1%; p = 0,205), entre los distintos momentos de administración del iP2Y12. El tratamiento con ticagrelor presentó menos MACE en comparación con el clopidogrel (p = 0,044), sin diferencias en sangrados. No se observaron diferencias en MACE entre ticagrelor en pretratamiento o tratamiento en sala (p = 0,893). Conclusiones: El subgrupo de pacientes seleccionados para recibir pretratamiento con iP2Y12 no presentó diferencias en MACE ni sangrado en relación con los tratados en sala. Los pacientes seleccionados para su tratamiento con ticagrelor en sala presentaron un balance beneficioso entre eventos isquémicos y hemorrágicos.

ABSTRACT Background: There is limited real life information on treatment strategies with P2Y12 receptor inhibitors (P2Y12i) in nonST-segment elevation acute coronary syndromes (NSTEACS). Objectives: The aim of this study was to determine the incidence of major adverse cardiac events (MACE) and BARC bleeding ≥2, according to the treatment strategy with P2Y12i at 6 months. Methods: The study used the pre-specified subanalysis of the BUENOS AIRES I registry (n=1100). The cohort was stratified according to P2Y12i "pretreatment" (before knowing the coronary anatomy), or "ward treatment" (after knowing the coronary anatomy), and the incidence of clinical events was analyzed according to pretreatment or ward treatment with clopidogrel/ ticagrelor. Results: Mean age was 65.4 ± 11.5 years and 77.2% were male patients. In 79.72% of cases patients received P2Y12i, 75% as pretreatment and 25% as ward treatment. Pretreatment patients were younger and with greater prevalence of acute myocardial infarction (AMI) compared with the ward treatment subgroup. At 6 months, there were no significant differences in the incidence of MACE (16.4% vs. 14.4%; p = 0.508), or BARC bleeding ≥2 (14.7% vs. 11.1%; p = 0.205), between the different times of P2Y12i administration. Treatment with ticagrelor presented reduced MACE compared with clopidogrel (p = 0.044), with no difference in bleeding. No MACE differences were observed between pretreatment or in ward treatment with ticagrelor (p=0.893). Conclusions: The subgroup of patients selected to receive P2Y12i pretreatment did not present differences in MACE or bleeding relative to those treated in ward. Patients selected for ticagrelor treatment in ward presented a beneficial balance between ischemic and hemorrhagic events.

Combined effects of nutritional status on long-term mortality in patients with non-st segment elevation myocardial infarction undergoing percutaneous coronary intervention

SUMMARY OBJECTIVE: The aim of this study was to investigate the performance of controlling nutritional status (CONUT) index, geriatric nutritional risk index (GNRI), and prognostic nutritional index (PNI) scores in predicting the long-term prognosis of patients with non-ST-elevated myocardial infarction (NSTEMI) who underwent percutaneous coronary intervention (PCI). METHODS: A total of 915 patients with NSTEMI (female: 48.4%; mean age: 73.1±9.0 years) who underwent PCI at Adana Numune Training and Research Hospital, Cardiology Clinic between January 2014 and January 2015 were included in this cross-sectional and retrospective study. CONUT, GNRI, and PNI scores were calculated based on the admission data derived from samples of peripheral venous blood. The mean follow-up duration was 64.5±15.4 months. RESULTS: During follow-up (mean 64.5±15.4 months), 179 patients (19.6%) died. The mean GNRI and PNI scores were significantly lower in the nonsurvivor group; however, the median CONUT score was significantly higher in the nonsurvivor group compared with the survivor group. The receiver operating characteristic (ROC) curve analyses have shown that GNRI score has similar performance to the CONUT score and has better performance than PNI score in predicting 5-year mortality. The Kaplan-Meier curve analysis has shown that patients with lower PNI or GNRI had higher cumulative mortality than the patients with higher PNI or GNRI. Also, the patients with higher CONUT scores had higher cumulative mortality compared with those with lower scores. The multivariate analyses have shown that GNRI (HR: 0.973), PNI (HR: 0.967), CONUT score (HR: 1.527), and body mass index (BMI) (HR: 0.818) were independent predictors of the 5-year mortality in patients with NSTEMI. CONCLUSION: In this study, we have shown that CONUT score, GNRI, and PNI values were associated with the long-term mortality in patients with NSTEMI who underwent PCI, and GNRI yielded similar results to CONUT score but was better than PNI.

Red cell distribution width predicts the severity of non-ST-elevation myocardial infarction in patients / 中国基层医药

Objective:To analyze the relationship between red cell distribution width (RDW) and disease severity in patients with non-ST-elevation myocardial infarction.Methods:Seventy patients with non-ST-elevation myocardial infarction who received treatment in Chaozhou People's Hospital from June 2019 to June 2020 were included in the observation group. An additional 70 patients with ST-elevation myocardial infarction who concurrently received treatment in the same hospital were included in the control group. All patients underwent electrocardiography and blood biochemical index examination. RDW was compared between the observation and control groups. The relationship between RDW and the severity of non-ST-elevation myocardial infarction was analyzed.Results:RDW in the observation group was significantly higher than that in the control group [(14.60 ± 1.00) % vs. (13.06 ± 1.70) %, t = 5.884, P = 0.012). The detection rate of coronary artery thrombosis in the observation group was significantly higher than that in the control group [70.00% (49/70) vs. 50.00% (35/70), χ2 = 7.563, P = 0.002]. In the observation group, the area under the receiver operating characteristic (ROC) curve plotted taking RDW as the variable was 0.649 (95% CI 0.546-0.753, P = 0.006). When the critical value of RDW was 14%, the sensitivity and specificity of RDW in the prediction of non-ST-elevation myocardial infarction were 73% and 59% respectively. RDW was positively correlated with cardiac troponin I level ( r = 0.19, P = 0.006). Conclusion:In patients with non-ST-elevation myocardial infarction, the increase in RDW is related to myocardial injury and the increase in cardiac troponin I level. RDW can be used as an effective index to predict the severity of non-ST-elevation myocardial infarction.

Evaluación del algoritmo de la Sociedad Europea de Cardiología de dolor torácico en pacientes con diabetes mellitus / Performance of the European Society of Cardiology Algorithm for the Assessment of Chest Pain in Patients with Diabetes Mellitus

RESUMEN Introducción: Dado que los pacientes con diabetes tienen habitualmente niveles de troponina más elevados que la población general, nos propusimos evaluar el comportamiento del algoritmo de la Sociedad Europea de Cardiología que utiliza la medición de troponina de alta sensibilidad al ingreso y 1 hora después en estos pacientes. Material y métodos: Se evaluaron 1140 pacientes que consultaron por dolor torácico con electrocardiograma sin supradesnivel del segmento ST. El algoritmo estratifica los pacientes en tres grupos de riesgo: "externar", "observar" e "internar". Se valoró el comportamiento del algoritmo para el evento infarto a 30 d. Resultados: En total, 124 pacientes (10,8%) tenían diabetes. Ninguno de los clasificados como "externar" (40,3%) presentó infarto a 30 días. En los "internar" (23,4%), el evento se produjo en el 82,8%, mientras que en el grupo "observar" (36,3%), en el 6,8%. La sensibilidad y el valor predictivo negativo fueron similares entre pacientes con diabetes y sin esta (100% vs. 98,5% p = 0,865 y 100% vs. 99,8% p = 0,44), pero la proporción de pacientes para "externar" fue menor en diabéticos (40,3% vs. 72,1%, p <0,001). En cuanto a la precisión para "internar" pacientes, la especificidad fue menor en diabéticos, pero el valor predictivo positivo fue mayor (90,9% vs. 97,2%, p <0,001 y 83% vs. 76%, p <0,001). La proporción de pacientes para "internar" fue mayor en diabéticos (23% vs. 8,6%, p <0,001). Conclusiones: El uso del algoritmo en pacientes con diabetes mostró una alta sensibilidad y un alto valor predictivo negativo para "externar" comparable a la población general. En cuanto al grupo "internar", presentó menor especificidad, pero alto valor predictivo positivo. Esto lo transforma en una útil herramienta para la práctica diaria.

ABSTRACT Background: Patients with diabetes usually have higher troponin levels than the general population. Objective: The aim of our study was to evaluate the performance of the European Society of Cardiology algorithm which uses high sensitivity cardiac troponin levels on admission and after 1 hour in these patients. Methods: A total of 1,140 patients with chest pain and ECG without ST-segment elevation were evaluated. The algorithm stratifies patients in three risk groups: rule-out, observe and rule-in. We evaluated the performance of the algorithm to predict myocardial infarction at 30 days. Results: A total of 124 patients (10.8%) had diabetes. None of the patients in the rule-out group (40.3%) presented myocardial infarction at 30 days. In the rule-in group (23.4%), the event occurred in 82.8% of cases and in 6.8% in the observe group (36.3%). Sensitivity and negative predictive value were similar in patients with and without diabetes (100% vs. 98.5%, p= 0.865 and 100% vs. 99.8%, p=0.44), but the proportion of patients in the rule-out group was lower in diabetics (40.3% vs. 72.1%, p<0.001). The accuracy of the algorithm to rule in patients was evaluated by its specificity which was lower in diabetics, but the positive predictive value was greater (90.9% vs. 97.2%, p<0.001 and 83% vs. 76%, p<0.001). The proportion of patients in the rule-in group was higher in diabetics (23% vs. 8.6%, p<0.001). Conclusion: The use of the algorithm in patients with diabetes revealed high sensitivity and negative predictive value to rule out, which was similar to that of the general population. Regarding the rule-in group, it had lower specificity but high positive predictive value. This performance makes the algorithm a useful tool for daily practice.

Factores predictivos de complicaciones intrahospitalarias en el Síndrome Coronario Agudo sin elevación del segmento ST / Predictive factors of intra-hospital complications in Non-ST-segment elevation Acute Coronary Syndrome

Introducción: El espectro clínico de los Síndromes Coronarios Agudos sin elevación del segmento ST incluye tanto a pacientes asintomáticos como a los que presentan isquemia activa, inestabilidad eléctrica, hemodinámica o parada cardiaca. Objetivo: Evaluar probables factores predictivos de complicaciones intrahospitalarias no letales en pacientes con diagnóstico de Síndrome Coronario Agudo sin elevación del segmento ST. Material y Métodos: Estudio observacional, analítico, de corte transversal con un universo de 218 individuos ingresados en la Unidad de Cuidados Coronarios Intensivos del Hospital Clínico-Quirúrgico Manuel Fajardo en 2016 y 2017. Resultados: Predominó el sexo masculino (51.4 por ciento) y la edad media fue de 68 años. Prevaleció la Hipertensión Arterial como factor de riesgo coronario. La edad mostró asociación estadística significativa con la aparición de cualquier complicación (p=0.015) y con las complicaciones hemodinámicas (p=0,014). El riesgo intermedio-alto, según el score TIMI, tuvo asociación estadísticamente muy significativa con las complicaciones hemodinámicas (p<0.01). Conclusiones: La edad tuvo asociación estadística con la aparición de complicaciones intrahospitalarias no letales. El sexo no se asoció con las complicaciones ni los antecedentes estudiados tampoco. Los pacientes con un riesgo intermedio-alto al ingreso, se asociaron con las complicaciones hemodinámicas(AU)

Introduction: The clinical spectrum of Non-ST-segment elevation Acute Coronary Syndromes includes both asymptomatic patients and those with active ischemia, electrical instability, hemodynamic or cardiac arrest. Objective: To evaluate probable predictive factors of non-lethal intra-hospital complications in patients diagnosed with Non-ST-segment elevation Acute Coronary Syndrome. Material and Methods: An observational, analytical, cross-sectional study was conducted with a universe of 218 individuals admitted into the Intensive Coronary Care Unit of Manuel Fajardo Clinical and Surgical Hospital between 2016 and 2017. Results: Male sex predominated (51.4 percent) and the mean age was 68 years. Arterial Hypertension prevailed as a coronary risk factor. The age showed significant statistical association with the appearance of any complication (p = 0.015) and with hemodynamic complications (p =0,014). The intermediate-high risk, according to the TIMI score, had a statistically significant association with hemodynamic complications (p <0.01). Conclusions: Age was statistically associated with the appearance of non-lethal intra-hospital complications. Sex was not associated with complications, nor did the background studied either. Patients with an intermediate-high risk at admission were associated with hemodynamic complications(AU)

Prognostic significance of non-chest pain symptoms in patients with non-ST-segment elevation myocardial infarction

BACKGROUND/AIMS: Chest pain is an essential symptom in the diagnosis of acute coronary syndrome (ACS). One-third of patients with ACS present atypically, which can influence their receiving timely lifesaving therapy. METHODS: A total of 617 NSTEMI patients from the Korea Acute MI Registry (KAMIR) and the Korea Working Group on MI (KorMI) databases were analyzed. The study population was divided into two groups by symptoms at presentation (typical symptoms group, 128; atypical symptoms groups, 128). RESULTS: In this study population, 23% of patients presented without chest pain. After propensity score matching, the contact-to-device time (2,618 ± 381 minutes vs. 1,739 ± 241 minutes, p = 0.050), the symptoms-to-balloon time (3,426 ± 389 minutes vs. 2,366 ± 255 minutes, p = 0.024), and the door-to-balloon time (2,339 ± 380 minutes vs. 1,544 ± 244 minutes, p = 0.002) were significantly higher in the patients with atypical symptoms than in those with typical symptoms, respectively. Atypical symptoms were an independent predictor for 1-year mortality (hazard ratio, 2.820; 95% confidence interval, 1.058 to 7.515; p = 0.038). The Kaplan-Meier estimates showed higher risk for 12-month mortality in patients with atypical symptoms (p = 0.048) and no significant difference for 12-month major adverse cardiac events (p = 0.487). CONCLUSIONS: Acute myocardial infarction patients with atypical symptoms were not rare in clinical practice and showed a high risk of delayed reperfusion therapy. After imbalance between the groups was minimized by use of propensity score matching, patients who presented atypically had a high mortality rate.

Early Valuable Risk Stratification with Hemoglobin Level and Neutrophil to Lymphocyte Ratio in Patients with Non-ST-Elevation Myocardial Infarction Having an Early Invasive Strategy

OBJECTIVE: The complete blood count is the most widely available laboratory data in the early in-hospital period after acute myocardial infarction. We assessed the clinical utility of the combined use of hemoglobin (Hb) level and neutrophil to lymphocyte ratio (N/L) for early risk stratification in patients with non-ST-elevation myocardial infarction (STEMI). METHODS: We analyzed 6,157 consecutive patients with non-STEMI (65±12.4 years, male 69%) were included in the final analysis. Patients were categorized into 3 groups by using the median value of N/L (4.42) and the presence of anemia (Hb <13 mg/dL in men and <12 mg/dL in women): group I, low N/L & no anemia (n=3,170); group II, no group I or III (n=2,168); group III, high N/L & anemia (n=819). RESULTS: There were significant differences on clinical outcomes during 180-day follow-up among 3 groups. The prognostic discriminatory capacity of the combined use of Hb level and N/L was also significant in high-risk subgroups, such as patients with a renal dysfunction, multivessel coronary disease, low ejection fraction, and even in those having higher mortality risk based on the thrombolysis in myocardial infarction risk score. In a multi-variate logistic regression, after adjusting for multiple covariates, group III had higher incidence of major adverse cardiac events at 180-day (hazard ratio, 2.4; 95% confidence interval, 1.5–4.0;p≤0.001) compared with group I. CONCLUSIONS: The combined use of Hb level and N/L provides valuable timely information for early risk stratification in patients with non-STEMI.

Coronary arteriography under acupuncture anesthesia:a case report / 针灸推拿医学（英文版）

Acupuncture anesthesia is a technique by partially or completely replacing anesthetics with acupuncture in surgery based on the traditional acupuncture analgesia mechanism.It emerged in the 1950s,went viral in the 1970s and then gradually fell into decline.In the recent years,this technique has regained attention and further research.Acupuncture anesthesia can be classified as either pure acupuncture anesthesia or acupuncture-medication combined anesthesia.To expand the application of this technique,a patient with non-ST elevation acute coronary syndrome in urgent need of percutaneous coronary intervention (PCI) received pure acupuncture anesthesia because of an allergy to lidocaine,and the operation went successfully.This is the first time that pure acupuncture anesthesia and coronary arteriography were combined,which is of great significance in further study and development of acupuncture anesthesia.

ATYPICAL STERNAL PAIN IN A BREAST CANCER PATIENT MIMICKING ACUTE MYOCARDIAL INFARCTION / Dor esternal atípica no câncer de mama mimetizando infarto agudo do miocárdio

Radiation therapy on the left side of the chest, some chemotherapy drugs, and trastuzumab raise the risk of cardiac events. Acute chest pain associated with breast cancer is not common, but it is possible. Electrocardiogram, which can result normal in up to 80% of cases of infarction, and serial dosing of myocardial necrosis markers are fundamental for differential diagnosis. Total creatine kinase (CK), creatine kinase-MB fraction (CK-MB), and troponins are frequently used. We present the case of a patient with atypical chest pain associated with elevation of CK and CK-MB, whose evolution and complementary exams showed to be a thoracic tumor recurrence. We discuss the use of these markers for acute chest pain; possible differential diagnoses, the use of CKMB relative index and, particularly, the presence of macro CK in some breast cancer patients ­ which in the case herein presented was a marker of tumor progression.

A radioterapia do lado esquerdo do tórax, alguns quimioterápicos e o trastuzumabe elevam o risco de eventos cardíacos. A dor torácica aguda associada ao câncer de mama não é um evento frequente, mas é possível. No diagnóstico diferencial, faz-se necessário o eletrocardiograma, que pode ser normal em até 80% dos infartos, e a dosagem seriada de marcadores de necrose miocárdica, sendo frequentemente utilizados a creatinoquinase (CK) total, a creatinnoquinase fração MB (CK-MB) e as troponinas. Apresentamos o caso de uma paciente com dor torácica atípica associada à elevação sérica da CK e da CK-MB, sendo que a evolução e os exames complementares mostraram tratar-se de uma recorrência tumoral torácica. Discutem-se a utilização desses marcadores na dor torácica aguda, os diagnósticos diferenciais possíveis, a utilização do índice relativo CK-MB e, em especial, as macro CK presentes em algumas portadoras de câncer de mama, o que, nessa paciente, foi um marcador de progressão tumoral.