RESUMEN
BACKGROUND: There is dearth of literature addressing early outcomes of acute coronary syndrome (ACS) among young patients, particularly South Asians descent who are predisposed to premature coronary artery disease (CAD). Therefore, we compared presentation, management, and early outcomes of young vs. old ACS patients and explored predictors of in-hospital mortality. METHODS: We extracted data of 23,560 ACS patients who presented at Tabba Heart Institute, Karachi, Pakistan, from July 2012-June 2020, from the Chest pain-MI-Registry™. We categorized data into young ≤ 45 and old ACS patients > 45 years. Chi-sq/Fischer exact tests were used to assess the difference between presentation, disease management, and in-hospital mortality between both groups. Logistic regression was used to determine odds ratio along with 95% confidence interval of factors associated with early mortality. RESULTS: The younger patients were 12.2% and women 23.5%. The prevalence of dyslipidemia (34.5% vs. 22.4%), diabetes (52.1% vs. 27.4%), and hypertension (68.3% vs. 42.9%) was higher in older patients. Family history of premature CAD (18.1% vs. 32.7%), smoking (40.0% vs. 22.9%), and smokeless tobacco use (6.5% vs. 8.4%) were lower in older patients compared to younger ones. Younger patients were more likely to present with STEMI (33.2% vs. 45%). The median symptom-to-door time was 125 min longer (p-value < 0.01) in the young patients compared to the older age group. In-hospital mortality (4.3% vs. 1.7%), cardiac arrest (1.9% vs. 0.7%), cardiogenic shock (1.9% vs. 0.9%), and heart failure (1% vs. 0.6%) were more common in older patients. After adjusting for other factors, younger age (AOR 0.6, 95% CI 1.5-3.7) had significantly lesser odds of in-hospital mortality. Other factors associated with early mortality included women, family history of premature CAD, STEMI, Killip class III and IV, coronary angiography, revascularization, CABG, and use of aspirin and beta blockers within the first 24 h. CONCLUSION: We found every tenth ACS patient was younger than 45 years of age despite a lesser number of comorbidities such as hypertension and diabetes. Overall, the in-hospital prognosis of young patients was more favorable than that of older patients. The study emphasizes the need for tailored primary prevention programs for ACS, considering the varying risks among different age groups.
Asunto(s)
Síndrome Coronario Agudo , Mortalidad Hospitalaria , Sistema de Registros , Humanos , Femenino , Masculino , Síndrome Coronario Agudo/terapia , Síndrome Coronario Agudo/mortalidad , Síndrome Coronario Agudo/etnología , Síndrome Coronario Agudo/diagnóstico , Persona de Mediana Edad , Factores de Tiempo , Factores de Edad , Adulto , Factores de Riesgo , Medición de Riesgo , Pakistán/etnología , Resultado del Tratamiento , Anciano , Prevalencia , Pueblo AsiaticoRESUMEN
BACKGROUND: Cytochrome P450 2C19 (CYP2C19) intermediate and poor metabolizer patients exhibit diminished clopidogrel clinical effectiveness after percutaneous coronary intervention (PCI). However, outcome studies to date have lacked racial diversity. Thus, the impact of CYP2C19 genotype on cardiovascular outcomes in patients treated with clopidogrel who identify as Black or African American remains unclear. METHODS AND RESULTS: Adults among 5 institutions who self-identified as Black or African American, underwent PCI and clinical CYP2C19 genotyping, and were treated with clopidogrel were included. Data were abstracted from health records. Major atherothrombotic (composite of death, myocardial infarction, ischemic stroke, stent thrombosis, or revascularization for unstable angina) and bleeding event rates within 1 year after PCI were compared across CYP2C19 metabolizer groups using multivariable Cox regression adjusted for potential confounders and baseline variables meeting a threshold of P<0.10. The population included 567 Black patients treated with clopidogrel (median age, 62 years; 46% women; 70% with an acute coronary syndrome indication for PCI). Major atherothrombotic events rates were significantly higher among clopidogrel-treated intermediate and poor metabolizers (24 of 125 [19.2%]) versus patients treated with clopidogrel without a no function allele (43 of 442 [9.7%]; 35.1 versus 15.9 events per 100 person-years; adjusted hazard ratio, 2.00 [95% CI, 1.20-3.33], P=0.008). Bleeding event rates were low overall (23 of 567 [4.1%]) and did not differ among the metabolizer groups. CONCLUSIONS: Black patients with CYP2C19 intermediate and poor metabolizer phenotypes who are treated with clopidogrel exhibit increased risk of adverse cardiovascular outcomes after PCI in a real-world clinical setting. Bleeding outcomes should be interpreted cautiously. Prospective studies are needed to determine whether genotype-guided use of prasugrel or ticagrelor in intermediate and poor metabolizers improves outcomes in Black patients undergoing PCI.
Asunto(s)
Negro o Afroamericano , Clopidogrel , Citocromo P-450 CYP2C19 , Hemorragia , Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Síndrome Coronario Agudo/tratamiento farmacológico , Síndrome Coronario Agudo/etnología , Síndrome Coronario Agudo/terapia , Negro o Afroamericano/genética , Clopidogrel/efectos adversos , Clopidogrel/uso terapéutico , Enfermedad de la Arteria Coronaria/etnología , Enfermedad de la Arteria Coronaria/genética , Enfermedad de la Arteria Coronaria/terapia , Citocromo P-450 CYP2C19/genética , Citocromo P-450 CYP2C19/metabolismo , Genotipo , Hemorragia/inducido químicamente , Hemorragia/genética , Variantes Farmacogenómicas , Inhibidores de Agregación Plaquetaria/efectos adversos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Little attention has been placed on language proficiency as a potential variable affecting ACS symptom knowledge, attitudes, and beliefs. OBJECTIVES: To compare the ACS symptom knowledge, attitudes, and beliefs of Hispanic and Latina/o/x/e individuals proficient in English and in those only proficient in Spanish. Secondary aims were to determine if there were differences in ACS symptom knowledge, attitudes, or beliefs based on participants' previous exposure to ACS symptom information and to evaluate instrument characteristics of the new Spanish version of the ACS Response Index. METHODS: This cross-sectional, comparative study included participants (N = 99) from a community-based clinic in Illinois. Knowledge, attitudes, and beliefs related to ACS symptoms were measured using the ACS Response Index. RESULTS: The average participant was 39.8 (SD 15.6) years of age, female (n = 56, 56.6 %), and had a high school education or less (n = 61, 61.6 %). Participants correctly classified a mean 57.5 % (SD 12.8) of symptoms and had mean attitude and belief scores of 12.1 (SD 3.3) and 17.5 (SD 2.9), respectively. There were no significant differences in knowledge, attitudes, and beliefs based on language proficiency. However, there were some statistically significant differences for knowledge and attitude scores based on exposure to ACS symptom information. The ACS Response Index (Spanish Version) also demonstrated favorable internal consistency. CONCLUSIONS: Overall knowledge, attitude, and belief scores were modest in this sample. Higher knowledge and attitude scores were observed for some types of ACS information exposure, supporting the importance of future educational efforts in this population.
Asunto(s)
Síndrome Coronario Agudo , Conocimientos, Actitudes y Práctica en Salud , Hispánicos o Latinos , Humanos , Femenino , Estudios Transversales , Hispánicos o Latinos/psicología , Hispánicos o Latinos/estadística & datos numéricos , Síndrome Coronario Agudo/psicología , Síndrome Coronario Agudo/etnología , Síndrome Coronario Agudo/diagnóstico , Masculino , Adulto , Persona de Mediana Edad , Illinois , Encuestas y CuestionariosRESUMEN
Cancer and acute coronary syndrome (ACS) are the leading causes of morbidity and mortality globally, with many shared risk factors. There are several challenges to the management of patients with cancer presenting with ACS, owing to their higher baseline risk profile, the complexities of their cancer-related therapies and prognosis, and their higher risk of adverse outcomes after ACS. Although previous studies have demonstrated disparities in the care of both cancer and ACS among patients from ethnic minorities and socioeconomic deprivation, there is limited evidence around the magnitude of such disparities specifically in cancer patients presenting with ACS. This review summarises the current literature on differences in prevalence and management of ACS among patients with cancer from ethnic minorities and socioeconomically deprived backgrounds, as well as the gaps in evidence around the care of this high-risk population and potential solutions.
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Síndrome Coronario Agudo , Disparidades en Atención de Salud , Neoplasias , Humanos , Síndrome Coronario Agudo/etnología , Síndrome Coronario Agudo/terapia , Síndrome Coronario Agudo/epidemiología , Neoplasias/etnología , Neoplasias/terapia , Neoplasias/complicaciones , Disparidades en Atención de Salud/etnología , Factores Socioeconómicos , Etnicidad/estadística & datos numéricos , Factores de Riesgo , PrevalenciaRESUMEN
BACKGROUND: East Asians (EAs), compared to white Caucasians (W), have a lower risk of ischemic heart disease and a higher risk of bleeding with antithrombotic medications. The underlying mechanisms are incompletely understood. OBJECTIVES: We sought to compare thrombotic profiles of EA and W patients with myocardial infarction (MI) and relate these to cardiovascular outcomes. METHODS: In a prospective study in the United Kingdom and Korea, blood samples from patients (n = 515) with ST- or non-ST-elevation MI (STEMI and NSTEMI) were assessed using the Global Thrombosis Test, measuring thrombotic occlusion (OT) and endogenous fibrinolysis (lysis time [LT]). Patients were followed for 1 year for major adverse cardiovascular events (MACE) and bleeding. RESULTS: EA patients showed reduced OT (longer OT) compared to W (646 seconds [470-818] vs. 436 seconds [320-580], p < 0.001), with similar LT. In STEMI, OT (588 seconds [440-759] vs. 361 seconds [274-462], p < 0.001) and LT (1,854 seconds [1,389-2,729] vs. 1,338 seconds [1,104-1,788], p < 0.001) were longer in EA than W. In NSTEMI, OT was longer (OT: 734 seconds [541-866] vs. 580 seconds [474-712], p < 0.001) and LT shorter (1519 seconds [1,058-2,508] vs. 1,898 seconds [1,614-2,806], p = 0.004) in EA than W patients. MACE was more frequent in W than EA (6.3 vs. 1.9%, p = 0.014) and bleeding infrequent. While OT was unrelated, LT was a strong independent predictor of MACE event after adjustment for risk factors (hazard ratio: 3.70, 95% confidence interval: 1.43-9.57, p = 0.007), predominantly in W patients, and more so in STEMI than NSTEMI patients. CONCLUSION: EA patients exhibit different global thrombotic profiles to W, associated with a lower rate of cardiovascular events.
Asunto(s)
Síndrome Coronario Agudo , Pueblo Asiatico , Hemorragia , Infarto del Miocardio sin Elevación del ST , Población Blanca , Humanos , Masculino , Femenino , Persona de Mediana Edad , Estudios Prospectivos , Síndrome Coronario Agudo/sangre , Síndrome Coronario Agudo/etnología , Síndrome Coronario Agudo/epidemiología , Anciano , Infarto del Miocardio sin Elevación del ST/sangre , Infarto del Miocardio sin Elevación del ST/etnología , Hemorragia/sangre , República de Corea/epidemiología , Factores de Riesgo , Reino Unido/epidemiología , Infarto del Miocardio con Elevación del ST/sangre , Infarto del Miocardio con Elevación del ST/etnología , Infarto del Miocardio con Elevación del ST/epidemiología , Trombosis/sangre , Trombosis/etiología , Infarto del Miocardio/sangre , Infarto del Miocardio/etnología , Infarto del Miocardio/epidemiología , Fibrinólisis , Pueblos del Este de AsiaRESUMEN
Impaired high-density lipoprotein (HDL) functions are associated with development of coronary artery disease. In this study, we explored the quantitative differences in HDL (i.e. HDL proteome and fatty acid profile of HDL phospholipids) underlying the functional deficits associated with acute coronary syndrome (ACS). The relationship between HDL function and composition was assessed in 65 consecutive ACS patients and 40 healthy controls. Cholesterol efflux capacity (CEC) of HDL and lecithin cholesterol acyl transferase (LCAT) activity were significantly lower in patients with ACS compared to controls. In HDL proteome analysis, HDL isolated from ACS individuals was enriched in apolipoprotein C2 (inhibitor of LCAT), apolipoprotein C4 and serum amyloid A proteins and was deficient in apolipoprotein A-I and A-II. The fatty acid profile of HDL phospholipids analyzed using gas chromatography showed significantly lower percentages of stearic acid (17.4 ± 2.4 vs 15.8 ± 2.8, p = 0.004) and omega-3 fatty acids [eicosapentaenoic acid (1.0 (0.6-1.4) vs 0.7 (0.4-1.0), p = 0.009) and docosahexaenoic acid (1.5 ± 0.7 vs 1.3 ± 0.5, p = 0.03)] in ACS patients compared to controls. Lower percentages of these fatty acids in HDL were associated with higher odds of developing ACS. Our results suggest that distinct phospholipid fatty acid profiles found in HDL from ACS patients could be one of the contributing factors to the deranged HDL functions in these patients apart from the protein content and the inflammatory conditions.
Asunto(s)
Síndrome Coronario Agudo/sangre , Lipoproteínas HDL/sangre , Fosfolípidos/sangre , Proteoma/metabolismo , Síndrome Coronario Agudo/etnología , Adulto , Pueblo Asiatico , Femenino , Humanos , India , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Acute coronary syndrome (ACS) has become a vital disease with high mortality in the Uygur populations. Clopidogrel plays an important role in reducing the risk of recurrent cardiovascular events after ACS; however, it is a prodrug that requires biotransformation by cytochrome P450 (CYP450). OBJECTIVES: To determine the effect of genetic polymorphisms in CYP2C19*2, *3, and *17, and along with clinical, demographic factors, on variation in response to clinical outcomes in Uygur patients. METHODS: A total of 351 patients with ACS were treated with clopidogrel and aspirin for at least 12 months; we recorded major adverse cardiovascular events (MACE) or bleeding within 1 year. Multivariable logistic regression analyses were carried out to identify factors associated with MACE or bleeding. RESULTS: We analyze risk factors include age, BMI (body mass index), smoking, alcohol intake, NSTEMI (non-ST-segment elevation myocardial infarction), hypertension, dyslipidemia, concomitant medication, CYP2C19*2 carriers, CYP2C19*17 carriers and metabolizer phenotype. CYP2C19*2 carriers had an odds of having MACE of 2.51 (95% CI: 1.534-4.09) compared with noncarriers (P < .001). However, no factors were significantly associated with bleeding (P > 0.05). CONCLUSION: The CYP2C19*2 gene polymorphism contributes to the risk of MACE in dual clopidogrel-treated Uygur population with ACS with or without PCI (percutaneous coronary intervention). These data may provide valuable insights into the genetic polymorphisms affecting clopidogrel metabolism among minority groups in China.
Asunto(s)
Síndrome Coronario Agudo/tratamiento farmacológico , Clopidogrel/uso terapéutico , Citocromo P-450 CYP2C19/genética , Inhibidores de Agregación Plaquetaria/uso terapéutico , Polimorfismo de Nucleótido Simple , Síndrome Coronario Agudo/etnología , Adulto , Anciano , Aspirina/efectos adversos , Aspirina/uso terapéutico , Índice de Masa Corporal , Estudios de Casos y Controles , China/etnología , Clopidogrel/efectos adversos , Clopidogrel/metabolismo , Femenino , Hemorragia/inducido químicamente , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Inhibidores de Agregación Plaquetaria/efectos adversos , Inhibidores de Agregación Plaquetaria/metabolismo , Profármacos/metabolismo , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
BACKGROUND: Patients with acute coronary syndromes often experience non-specific (generic) pain after hospital discharge. However, evidence about the association between post-discharge non-specific pain and rehospitalization remains limited. METHODS: We analyzed data from the Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education (TRACE-CORE) prospective cohort. TRACE-CORE followed patients with acute coronary syndromes for 24 months post-discharge from the index hospitalization, collected patient-reported generic pain (using SF-36) and chest pain (using the Seattle Angina Questionnaire) and rehospitalization events. We assessed the association between generic pain and 30-day rehospitalization using multivariable logistic regression (N = 787). We also examined the associations among patient-reported pain, pain documentation identified by natural language processing (NLP) from electronic health record (EHR) notes, and the outcome. RESULTS: Patients were 62 years old (SD = 11.4), with 5.1% Black or Hispanic individuals and 29.9% women. Within 30 days post-discharge, 87 (11.1%) patients were re-hospitalized. Patient-reported mild-to-moderate pain, without EHR documentation, was associated with 30-day rehospitalization (odds ratio [OR]: 2.03, 95% confidence interval [CI]: 1.14-3.62, reference: no pain) after adjusting for baseline characteristics; while patient-reported mild-to-moderate pain with EHR documentation (presumably addressed) was not (OR: 1.23, 95% CI: 0.52-2.90). Severe pain was also associated with 30-day rehospitalization (OR: 3.16, 95% CI: 1.32-7.54), even after further adjusting for chest pain (OR: 2.59, 95% CI: 1.06-6.35). CONCLUSIONS: Patient-reported post-discharge generic pain was positively associated with 30-day rehospitalization. Future studies should further disentangle the impact of cardiac and non-cardiac pain on rehospitalization and develop strategies to support the timely management of post-discharge pain by healthcare providers.
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Síndrome Coronario Agudo/complicaciones , Dolor en el Pecho/etiología , Readmisión del Paciente/estadística & datos numéricos , Síndrome Coronario Agudo/etnología , Cuidados Posteriores , Anciano , Registros Electrónicos de Salud , Femenino , Hospitalización , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Alta del Paciente , Estudios ProspectivosRESUMEN
BACKGROUND: This study aimed to assess sex and racial differences related to high-density lipoprotein cholesterol (HDL-C) levels in those presenting with acute coronary syndromes (ACS). METHODS: Records from patients with ACS presenting to the Emergency Department of University of Florida Hospital Jacksonville from 2009 to 2012, were reviewed. Detailed medical history was obtained. HDL-C levels were measured within 72 h of presentation. Pearson chi-square and Wilcoxon rank sum tests were used to compare groups in univariate analysis. Analysis of variance was performed to determine independent predictors of higher HDL-C levels using variable selection. RESULTS: Of 2400 patients screened, 614 (382 men and 232 women) met inclusion criteria. Hypertension, chronic kidney disease or prior CAD history was similar between sexes and races. Women were more likely to be older (62.4 vs 58.4 years), diabetic (56.5 vs 36.5%) and have higher body mass index (31.2 vs 30.1 kg/m2). Blacks were more likely to be diabetic (50.3 vs 41.3%). After adjusting for all clinical markers, women and blacks along with absence of CAD or diabetes, were significantly associated with higher HDL-C levels. CONCLUSIONS: High HDL-C levels (> 40 mg/dL), considered cardio-protective, were seen in women and blacks with ACS more often than in men and whites. Significant differences in HDL-C levels between sexes were seen in whites but not in blacks. Relevance and quality of HDL-C levels in racial groups need further study as this may have important implications in the interpretation of current guidelines.
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Síndrome Coronario Agudo , HDL-Colesterol/sangre , Diabetes Mellitus , Factores Raciales , Factores Sexuales , Síndrome Coronario Agudo/epidemiología , Síndrome Coronario Agudo/etnología , Población Negra , Diabetes Mellitus/epidemiología , Diabetes Mellitus/etnología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Población BlancaRESUMEN
BACKGROUND AND AIMS: In the present study, we aimed to compare the clinical and coronary angiography features between South Asian and Caucasian patients with Acute Coronary Syndrome (ACS). In particular, we focused our analysis on the evaluation of recent cardiovascular risk markers, such as remnant cholesterol, corresponding to all plasma cholesterol minus HDL-C (high-density lipoprotein cholesterol) and LDL-C (low-density lipoprotein cholesterol), and the Monocyte-to-HDL-cholesterol ratio. We also compared values of several lipoprotein ratios and the Platelet-to-lymphocyte ratio, accurate predictors of coronary events and coronary artery disease. METHODS AND RESULTS: We recruited 40 South Asian and 40 Caucasian patients admitted for ACS. Data were collected by consulting patients' medical records. We used Chi-square test and Student's t-test to analyse qualitative and quantitative variables, respectively. South Asian patients, compared to Caucasians, showed higher mean values of the parameters analysed: remnant cholesterol (32.6 ± 17 vs 26.5 ± 9.6), Monocyte-to-HDL-cholesterol ratio (26.4 ± 48.7 vs 16.5 ± 8.3), Platelet-to-lymphocyte ratio (124.7 ± 130.7 vs 120.5 ± 58.8). Moreover, higher mean values of several lipoprotein ratios were also found in South Asian patients compared to the control group. However, statistical significance was not reached for any of these differences observed. CONCLUSIONS: The evaluation of the parameters analysed in this study might provide accurate information regarding the cardio-metabolic risk in South Asian patients. However, further studies with larger samples are needed to obtain more significant results.
Asunto(s)
Síndrome Coronario Agudo/etnología , Pueblo Asiatico , HDL-Colesterol/sangre , Colesterol/sangre , Enfermedad de la Arteria Coronaria/etnología , Monocitos , Población Blanca , Síndrome Coronario Agudo/sangre , Síndrome Coronario Agudo/diagnóstico por imagen , Adulto , Biomarcadores/sangre , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/sangre , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Femenino , Factores de Riesgo de Enfermedad Cardiaca , Humanos , Italia/epidemiología , Recuento de Leucocitos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Prevalencia , Estudios Retrospectivos , Medición de RiesgoRESUMEN
Compared with Caucasian patients, East Asian patients have the unique risk-benefit trade-off and different responsiveness to antithrombotic regimens. The aim of this study was to compare pharmacodynamic profile in East Asian patients with acute coronary syndromes (ACSs) treated with prasugrel standard-dose versus a de-escalation strategy. Before discharge, ACS patients with age <75 years or weight ≥60 kg (n = 255) were randomly assigned to the standard-dose (10-mg group) or de-escalation strategy (5-mg group or platelet function test [PFT]-guided group). After 1 month, VerifyNow P2Y12 assay-based platelet reactivity (P2Y12 reaction unit [PRU]) and bleeding episodes were evaluated. Primary endpoint was the percentage of patients with the therapeutic window (85 ≤ PRU ≤ 208). The 250 patients completed 1-month treatment. The percentage of patients within the therapeutic window was significantly lower in the 10-mg group (n = 85) compared with the 5-mg (n = 83) and PFT-guided groups (n = 82) (35.3 vs. 67.5 vs. 65.9%) (odds ratio [OR]: 3.80 and 3.54; 95% confidence interval [CI]: 2.01-7.21 and 1.87-6.69, respectively). Compared with the 10-mg group, the bleeding rate was tended to be lower with de-escalation strategies (35.3 vs. 24.1% vs. 23.2%) (hazard ratio [HR]: 0.58 and 0.55; 95% CI: 0.30-1.14 and 0.28-1.09, respectively). "PRU < 127" was the optimal cut-off for predicting 1-month bleeding events (area under the curve: 0.616; 95% CI: 0.543-0.689; p = 0.005), which criteria was significantly associated with early discontinuation of prasugrel treatment (HR: 2.00; 95% CI: 1.28-3.03; p = 0.001). In conclusion, compared with the standard-dose prasugrel, the prasugrel de-escalation strategy in East Asian patients presented with ACS showed a higher chance within the therapeutic window and a lower tendency toward bleeding episodes. REGISTRATION: URL: https://clinicaltrials.gov. Unique identifier:NCT01951001.
Asunto(s)
Síndrome Coronario Agudo/tratamiento farmacológico , Plaquetas/efectos de los fármacos , Reducción Gradual de Medicamentos , Hemorragia/prevención & control , Inhibidores de Agregación Plaquetaria/administración & dosificación , Clorhidrato de Prasugrel/administración & dosificación , Antagonistas del Receptor Purinérgico P2Y/administración & dosificación , Síndrome Coronario Agudo/sangre , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/etnología , Anciano , Pueblo Asiatico , Plaquetas/metabolismo , Monitoreo de Drogas , Femenino , Hemorragia/inducido químicamente , Hemorragia/etnología , Humanos , Masculino , Persona de Mediana Edad , Inhibidores de Agregación Plaquetaria/efectos adversos , Pruebas de Función Plaquetaria , Clorhidrato de Prasugrel/efectos adversos , Prevalencia , Estudios Prospectivos , Antagonistas del Receptor Purinérgico P2Y/efectos adversos , República de Corea/epidemiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
AIM: The aim of the study was to determine the relationship between acute hyperglycaemia and in-hospital mortality in black Africans with acute coronary syndromes (ACS). METHODS: From January 2002 to December 2017, 1 168 patients aged ≥ 18 years old, including 332 patients with diabetes (28.4%), consecutively presented to the intensive care unit of the Abidjan Heart Institute for ACS. Baseline data and outcomes were compared in patients with and without hyperglycaemia at admission (> 140 mg/dl; 7.8 mmol/l). Predictors for death were determined by multivariate logistic regression. RESULTS: The prevalence of admission hyperglycaemia was 40.6%. It was higher in patients with diabetes (55.3%). In multivariate logistic regression, acute hyperglycaemia (hazard ratio = 2.33; 1.44-3.77; p < 0.001), heart failure (HR = 2.22; 1.38-3.56; p = 0.001), reduced left ventricular ejection fraction (HR = 6.41; 3.72-11.03; p < 0.001, sustained ventricular tachycardia or ventricular fibrillation (HR = 3.43; 1.37-8.62; p = 0.008) and cardiogenic shock (HR = 8.82; 4.38-17.76; p < 0.001) were predictive factors associated with in-hospital death. In sub-group analysis according to the history of diabetes, hyperglycaemia at admission was a predictor for death only in patients without diabetes (HR = 3.12; 1.72-5.68; p < 0.001). CONCLUSIONS: In ACS patients and particularly those without a history of diabetes, admission acute hyperglycaemia was a potentially threatening condition. Appropriate management, follow up and screening for glucose metabolism disorders should be implemented in these patients.
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Síndrome Coronario Agudo/mortalidad , Glucemia/análisis , Mortalidad Hospitalaria , Hiperglucemia/sangre , Admisión del Paciente , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/etnología , Síndrome Coronario Agudo/terapia , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Población Negra , Côte d'Ivoire , Estudios Transversales , Femenino , Mortalidad Hospitalaria/etnología , Humanos , Hiperglucemia/diagnóstico , Hiperglucemia/etnología , Hiperglucemia/mortalidad , Masculino , Persona de Mediana Edad , Prevalencia , Pronóstico , Medición de Riesgo , Factores de Riesgo , Adulto JovenRESUMEN
BACKGROUND: Despite guideline recommendations, dual antiplatelet therapy (DAPT) is frequently used for longer than 1 year after an acute coronary syndrome (ACS) event. In Asia, information on antithrombotic management patterns (AMPs), including DAPT post discharge, is sparse. This analysis evaluated real-world AMPs up to 2 years post discharge for ACS. HYPOTHESIS: There is wide variability in AMP use for ACS management in Asia. METHODS: EPICOR Asia (NCT01361386) is a prospective observational study of patients discharged after hospitalization for an ACS in eight countries/regions in Asia, followed up for 2 years. Here, we describe AMPs used and present an exploratory analysis of characteristics and outcomes in patients who received DAPT for ≤12 months post discharge compared with >12 months. RESULTS: Data were available for 12 922 patients; of 11 639 patients discharged on DAPT, 2364 (20.3%) received DAPT for ≤12 months and 9275 (79.7%) for >12 months, with approximately 60% still on DAPT at 2 years. Patients who received DAPT for >12 months were more likely to be younger, obese, lower Killip class, resident in India (vs China), and to have received invasive reperfusion. Clinical event rates during year 2 of follow-up were lower in patients with DAPT >12 vs ≤12 months, but no causal association can be implied in this non-randomized study. CONCLUSIONS: Most ACS patients remained on DAPT up to 1 year, in accordance with current guidelines, and over half remained on DAPT at 2 years post discharge. Patients not on DAPT at 12 months are a higher risk group requiring careful monitoring.
Asunto(s)
Síndrome Coronario Agudo/terapia , Anticoagulantes/administración & dosificación , Fibrinolíticos/administración & dosificación , Revascularización Miocárdica , Inhibidores de Agregación Plaquetaria/administración & dosificación , Pautas de la Práctica en Medicina/tendencias , Trombosis/prevención & control , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/etnología , Anciano , Anticoagulantes/efectos adversos , Asia , Pueblo Asiatico , Esquema de Medicación , Utilización de Medicamentos/tendencias , Terapia Antiplaquetaria Doble , Femenino , Fibrinolíticos/efectos adversos , Disparidades en Atención de Salud/tendencias , Humanos , Masculino , Persona de Mediana Edad , Revascularización Miocárdica/efectos adversos , Inhibidores de Agregación Plaquetaria/efectos adversos , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Trombosis/diagnóstico , Trombosis/etnología , Factores de Tiempo , Resultado del TratamientoRESUMEN
Ethnic differences in the pathobiology of acute coronary syndromes (ACS) have not been systematically studied. We compared the underlying mechanisms of ACS between Asians and Whites. ACS patients with the culprit lesion imaged by optical coherence tomography were included. Patients were stratified into ST-elevation myocardial infarction (STEMI) and non-ST-elevation-ACS (NSTE-ACS), and baseline characteristics, underlying mechanisms of ACS, and culprit plaque characteristics were compared between Asians and Whites. Of 1,225 patients, 1,019 were Asian (567 STEMI and 452 NSTE-ACS) and 206 were White (71 STEMI and 135 NSTE-ACS). Asians had more diabetes and hypertension among STEMI patients; among NSTE-ACS patients, Asians had higher prevalence of diabetes and renal insufficiency, and lower prevalence of hyperlipidemia. There were no differences in the incidence of plaque rupture, plaque erosion and calcified plaque between Asians and Whites with STEMI (61.2%, 28.6%, 10.2% vs 46.5%, 38.0%, 15.5%, respectively, pâ¯=â¯0.055). Among NSTE-ACS patients, there was a significant difference between Asians and Whites (40.5%, 47.6%, 11.9% vs 27.4%, 48.9%, 23.7%, respectively, pâ¯=â¯0.001). After adjustment for clinical confounders, the risk of plaque rupture (pâ¯=â¯0.713), plaque erosion (pâ¯=â¯0.636), and calcified plaque (pâ¯=â¯0.986) was similar between the groups with STEMI. In NSTE-ACS patients, the only difference was an increased risk of calcified plaque in Whites (odds ratio: 2.125, 95% confidence interval: 1.213 to 3.723, pâ¯=â¯0.008). In conclusion, after adjustment for clinical confounders, Asian and White patients presenting with STEMI and NSTE-ACS showed similar underlying mechanisms of ACS, except for a higher risk of calcified plaque in Whites with NSTE-ACS.
Asunto(s)
Síndrome Coronario Agudo/etnología , Pueblo Asiatico , Población Blanca , Anciano , Comorbilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Placa Aterosclerótica/etnología , Sistema de Registros , Factores de RiesgoRESUMEN
Importance: Although age, sex, and race/ethnicity are important factors when generalizing the findings of clinical trials to routine practice, trends in the representation of these groups in contemporary acute coronary syndrome (ACS) trials are not well defined. Objective: To characterize the representation of older patients, women, and racial/ ethnic minorities in ACS randomized trials. Evidence Review: A systemic search was conducted of ACS trials published in 8 major medical journals between January 2001 and December 2018. Overall, 1â¯067â¯520 patients from 460 trials were included. Findings were compared with epidemiologic studies of patients with ACS. Findings: The median number of participants per trial was 711 (interquartile range, 324-2163) and the median number of sites per trial was 21 (interquartile range, 5-73). Overall, 207 trials (45.0%) studied drug therapy, and 210 (45.7%) evaluated procedural interventions. The mean (SD) age of trial participants was 62.9 (10.7) years and increased from 62.3 (11.2) years in 2001-2006 to 64.0 (10.4) years in 2013-2018 (P = .01). The corresponding mean (SD) age was 66.4 (14.8) years in US epidemiologic studies and 70.0 (13.5) years in European epidemiologic studies. The overall proportion of women enrolled was 26.8% and decreased over time, from 27.8% in 2001-2006 to 24.9% in 2013-2018 (P = .21 for trend). The corresponding weighted proportions of women were 38.0% in US epidemiologic studies and 32.0% in European studies. The distribution of racial/ethnic groups was reported in only 99 trials (21.5%). In trials with reported data, 15.0% of the trial participants were nonwhite, which increased from 12.0% in 2001-2006 to 14.0% in 2013-2018. Black patients represented 3.7% of all patients during the entire study time frame, Asian patients represented 9.6%, and Hispanic patients represented 7.8%. Trends in the representation of black patients remained unchanged from 2001-2006 (5.2%) to 2013-2018 (4.9%), while the enrollment of Asian and Hispanic patients increased from 2001-2006 to 2013-2018 (from 1.9% to 10.8% for Asian patients and from 5.4% to 14.5% for Hispanic patients). Conclusions and Relevance: Older patients and women are underrepresented in contemporary ACS trials compared with epidemiologic studies. Over time, there has been modest improvement in the representation of older patients but not women patients. More than three-quarters of trials did not report race/ethnicity data, with available data suggesting a modest increase in the enrollment of nonwhite patients owing to the enrollment of Asian and Hispanic patients. Enrollment of black patients remained low over time.
Asunto(s)
Síndrome Coronario Agudo/etnología , Ensayos Clínicos como Asunto , Etnicidad , Grupos Minoritarios , Selección de Paciente , Grupos Raciales , Síndrome Coronario Agudo/terapia , Femenino , Humanos , Masculino , Factores Sexuales , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Acute coronary syndrome (ACS) is the most serious type of coronary heart disease and is a global medical burden. The pathogenesis of ACS is very complex and still poorly understood. Epidemiologic studies have revealed that the manifestation of ACS are the results of the interactions between multiple environmental and genetic factors. The present study aimed to investigate the role of polymorphisms of MTHFR C677T and ALDH2 Glu504Lys as risk factors for ACS in a Hakka population in southern China. METHODS: Between September 1, 2015 and October 31, 2017, a total of 1957 individuals, including 860 ACS patients and 1097 controls were recruited. Blood samples were collected and genotypes were determined by DNA microarray chip method and direct sequencing method. RESULTS: For the MTHFR C677T polymorphism, frequencies of CC, CT, and TT genotypes were 53.60% versus 55.33, 39.53% versus 38.65 and 6.86% versus 6.02% in patients with ACS versus controls, respectively(p > 0.05). The differences in genotype frequencies between the ACS patients and controls in the three genetic model were not statistically significant. For the ALDH2 Glu504Lys polymorphism, the frequencies of ALDH2*1*1, ALDH2*1*2, and ALDH2*2*2 genotypes were 48.72, 42.67 and 8.6% in the ACS patients, respectively, while these were 53.33, 39.11 and 7.57% in the controls, respectively, showing no significant difference in the distribution of the ALDH2 genotype between the groups. Using the wild genotype ALDH2*1*1 as reference, relative risk analysis revealed a slightly increased risk for ACS in individuals with the ALDH2*1*2 plus ALDH2*2*2 genotypes (odds ratio (OR) = 1.203, 95% confidence interval (CI) = 1.006-1.438, p = 0.043). In a multivariate logistic regression model, even after adjusting for potential covariates, the association between ALDH2 *2 allele and ACS remained significant (OR = 1.242, 95% CI = 1.045-1.561, p = 0.038). CONCLUSIONS: We present findings regarding the possible clinical impact of the ALDH2*2 variant on ACS patients in a Hakka population in southern China and our findings might help to stratify the high-risk ACS patients and implement appropriate strategies for this genetic subpopulation to ultimately guide the precision preventive procedures in the future.
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Síndrome Coronario Agudo/genética , Aldehído Deshidrogenasa Mitocondrial/genética , Pueblo Asiatico/genética , Metilenotetrahidrofolato Reductasa (NADPH2)/genética , Polimorfismo de Nucleótido Simple , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/etnología , Anciano , China/epidemiología , Femenino , Frecuencia de los Genes , Estudios de Asociación Genética , Predisposición Genética a la Enfermedad , Humanos , Masculino , Persona de Mediana Edad , Fenotipo , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Analyses of country or regional differences in cardiovascular (CV) trials are based on geographical subgroup analyses. However, apart from map location and related racial, ethnic, and genetic variations, identified differences may also depend on social structure and provision and access to health care, for which country income and income inequality are indicators. The aim of the study was to examine the association between country per capita income and income inequality and prognosis in patients with heart failure or an acute coronary syndrome in 3 international trials (EMPHASIS-HF, EPHESUS, and EXAMINE). METHODS: Countries were classified into high income or low-middle income (LMICs) and into low, middle, or high inequality using the Gini index. The main outcome measures were all-cause and CV death. RESULTS: Patients from LMICs and countries with higher inequality were younger, were less often white, had fewer comorbid conditions, and were less often treated with guideline-recommended therapies, including devices. These patients had higher adjusted mortality rates (+15% to +70%) compared with patients from high-income countries and countries with less inequality. Patients from countries with the combination of greater inequality and low-middle income had particularly high mortality rates (+80% to +190%) compared with those that did not have both characteristics. Living in a country that is poor and has inequality had more impact on death rates than any comorbidity. These findings were reproduced in 3 trials. CONCLUSIONS: Patients from LMICs and countries with greater inequality had the highest mortality rates. The prognostic impact of income and inequality is substantial and should be considered when looking into subgroup differences in CV trials.
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Síndrome Coronario Agudo/mortalidad , Países Desarrollados/economía , Países en Desarrollo/economía , Insuficiencia Cardíaca/mortalidad , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores Socioeconómicos , Síndrome Coronario Agudo/etnología , Síndrome Coronario Agudo/terapia , Factores de Edad , Anciano , Causas de Muerte , Femenino , Adhesión a Directriz/estadística & datos numéricos , Insuficiencia Cardíaca/etnología , Insuficiencia Cardíaca/terapia , Humanos , Renta , Masculino , Estudios Multicéntricos como Asunto , Evaluación de Resultado en la Atención de Salud , PronósticoRESUMEN
BACKGROUND AND AIMS: International guidelines recommend ticagrelor over clopidogrel as preferred antiplatelet agent in patients following coronary stenting. However, no large real-life evidence is available in East Asians in general, and Chinese in particular, with regard to associated clinical outcomes. The present study aimed to assess the early and delayed outcomes after ticagrelor versus clopidogrel in post stenting Chinese patients. METHODS: We conducted the pre-specified interim analysis of Comparison Of Efficacy and Safety Between TIcagrelor and Clopidogrel In Chinese (COSTIC), the ongoing prospective, observational, single-center trial. Primary outcomes include first occurrence of myocardial infarction, stroke, vascular death and Bleeding Academic Research Consortium (BARC) scale bleeding event. Propensity score matching (PSM) was carried out to adjust for differences in baseline characteristics between treatment arms. RESULTS: In total, 4,465 patients were enrolled. After PSM, the patients prescribed with ticagrelor had a lower incidence of primary efficacy endpoint relative to those with clopidogrel (0.6% vs. 1.4%, HRâ¯=â¯0.44, 95%CI: 0.22-0.89, pâ¯=â¯0.019) at 1 month, but similar at 7 days, 6 months and 12 months. Further analysis indicated that the difference only exists in the subgroup of acute myocardial infarction (AMI) patients. With regard to safety, ticagrelor consistently increased the risk of BARC type 2 bleeding compared to clopidogrel at 1 month, 6 months and 12 months. CONCLUSIONS: These preliminary data indicate that ticagrelor is superior to clopidogrel with regard to major vascular thrombotic outcomes at 1 month, especially in the AMI population, but both groups are similar at 7 days, 6 months and 12 months. Ticagrelor consistently caused significantly more BARC type 2 bleeding.
Asunto(s)
Síndrome Coronario Agudo/terapia , Clopidogrel/uso terapéutico , Trombosis Coronaria/prevención & control , Intervención Coronaria Percutánea/instrumentación , Inhibidores de Agregación Plaquetaria/uso terapéutico , Stents , Ticagrelor/uso terapéutico , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/etnología , Síndrome Coronario Agudo/mortalidad , Anciano , Pueblo Asiatico , China/epidemiología , Clopidogrel/efectos adversos , Trombosis Coronaria/diagnóstico por imagen , Trombosis Coronaria/etnología , Trombosis Coronaria/mortalidad , Femenino , Hemorragia/inducido químicamente , Hemorragia/etnología , Humanos , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Inhibidores de Agregación Plaquetaria/efectos adversos , Estudios Prospectivos , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Ticagrelor/efectos adversos , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Owing to the differential propensity for bleeding and ischemic events with response to antiplatelet therapy, the safety and effectiveness of potent P2Y12 inhibitor ticagrelor in East Asian populations remain uncertain. METHODS: In this multicenter trial, 800 Korean patients hospitalized for acute coronary syndromes with or without ST elevation and intended for invasive management were randomly assigned to receive, in a 1:1 ratio, ticagrelor (180 mg loading dose, 90 mg twice daily thereafter) or clopidogrel (600 mg loading dose, 75 mg daily thereafter). The primary safety outcome was clinically significant bleeding (a composite of major bleeding or minor bleeding according to PLATO (Platelet Inhibition and Patient Outcomes) criteria at 12 months. RESULTS: At 12 months, the incidence of clinically significant bleeding was significantly higher in the ticagrelor group than in the clopidogrel group (11.7% [45/400] vs 5.3% [21/400]; hazard ratio [HR], 2.26; 95% confidence interval [CI], 1.34 to 3.79; P=0.002). The incidences of major bleeding (7.5% [29/400] vs 4.1% [16/400], P=0.04) and fatal bleeding (1% [4/400] vs 0%, P=0.04) were also higher in the ticagrelor group. The incidence of death from cardiovascular causes, myocardial infarction, or stroke was not significantly different between the ticagrelor group and the clopidogrel group (9.2% [36/400] vs 5.8% [23/400]; HR, 1.62; 95% CI, 0.96 to 2.74; P=0.07). Overall safety and effectiveness findings were similar with the use of several different analytic methods and in multiple subgroups. CONCLUSIONS: In Korean acute coronary syndrome patients intended to receive early invasive management, standard-dose ticagrelor as compared with clopidogrel was associated with a higher incidence of clinically significant bleeding. The numerically higher incidence of ischemic events should be interpreted with caution, given the present trial was underpowered to draw any conclusion regarding efficacy. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02094963.
Asunto(s)
Síndrome Coronario Agudo/tratamiento farmacológico , Clopidogrel/efectos adversos , Hemorragia/inducido químicamente , Inhibidores de Agregación Plaquetaria/efectos adversos , Antagonistas del Receptor Purinérgico P2Y/efectos adversos , Ticagrelor/efectos adversos , Síndrome Coronario Agudo/etnología , Síndrome Coronario Agudo/mortalidad , Síndrome Coronario Agudo/terapia , Anciano , Anciano de 80 o más Años , Pueblo Asiatico , Causas de Muerte , Clopidogrel/uso terapéutico , Terapia Combinada , Susceptibilidad a Enfermedades , Femenino , Estudios de Seguimiento , Hemorragia/epidemiología , Hemorragia/mortalidad , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Pacientes Desistentes del Tratamiento , Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria/uso terapéutico , Premedicación , Antagonistas del Receptor Purinérgico P2Y/uso terapéutico , República de Corea/epidemiología , Tamaño de la Muestra , Ticagrelor/uso terapéuticoRESUMEN
BACKGROUND: Priority setting and decision-making in relation to self-management of multiple conditions is particularly challenging for both patients and health professionals. The aim of this study was to validate a conceptual model of self-management priority setting and decision-making in multimorbidity and confirm factors that influence self-management prioritizing and decision-making in a sample of patients with acute coronary syndrome and type 2 diabetes mellitus. METHODS: This was a qualitative study using deductive directed content analysis. A purposive sample of 21 participants with acute coronary syndrome and type 2 diabetes mellitus that were admitted to a Shanghai hospital were interviewed. RESULTS: Participants provided evidence to confirm all but one of the factors from the conceptual model. Internal factors influencing self-management predominated. Agreement with recommended treatment, functional capacity and perceived synergies, antagonistic effects, or interactions among the conditions and prescribed treatments, was emphasized. The facilitators and barriers to priority setting and decision-making were related to available resources, provider communication and, to a lesser extent, confusion about recommendations, and treatment complexity. Some participants were also concerned about treatment side effects. CONCLUSIONS: Internal factors (personal beliefs, preferences, and attitudes) and facilitators and barriers (knowledge, finances, social support, and transportation) were related to changes in priority setting and decision-making and self-management behavior in this sample. Health education, which includes case studies with shifting self-management priorities is recommended, rather than a unique disease-specific focus. Further research, exploring the relationship between these factors and changes in the dominant condition and related management, using valid and reliable instruments that capture these key factors, is recommended.