[Adherence to guidelines on management of acute coronary syndrome in Russian hospitals and outcomes of hospitalization (data from the RECORD-2 Registry)].

BACKGROUND: Complete following existing guidelines for management of acute coronary syndrome (ACS) is known to be associated with better outcomes. Partly this is explained by lesser adherence to recommendations in high risk patients. Aim of our study was to assess relationship between degree of following current guidelines and in hospital outcomes independently from initial assessment of risk. METHODS: Each key recommendation from guidelines issued between 2008 and 2011 (13 for STE ACS, 12 for NSTE ACS) was given weight of 1. Sum of these units constituted index of guideline adherence (IGA). IGA was retrospectively calculated for 1656 patients included in Russian independent ACS registry RECORD-2 (7 hospitals, duration 04.2009 to 04.2011). The patients were divided into 2 groups according to quartiles of IGA distribution: 1) low adherence group (quartiles I-II); 2) high adherence group (quartiles III-IV). RESULTS: In low adherence compared with high adherence group there were significantly more patients more or equal 65 years (=0.0007), with chronic heart failure [CHF] (<0.0001), previous stroke (<0.0001), atrial fibrillation [AF] (=0.0002), Killip class more or equal II (=0.0065), high risk of death by GRACE score (=0.035). Inhospital mortality was 9.3 and 2.4% in low and high adherence group, respectively (p<0.0001). The following independent predictors of inhospital death were identified: IGA quartiles I-II (odds ratio [OR] 4.0; 95% confidence interval [CI] 2.3-7.1; <0.0001), high GRACE score (OR 3.3; 95% CI 1.8-6.0; <0.0001), admission systolic BP less or equal 100 mm Hg (OR 3.1; 95% CI 1.8-5.4; <0.0001), admission serum glucose more or equal 8 mmol/l (OR 2.9; 95% CI 1.8-4.7; <0.0001), age more or equal 65 years (OR 2.3; 95% CI 1.3-4.0; =0.005), ST elevation more or equal 1 mm on first ECG (OR 1.7; 95% CI 1.1-2.5; =0.013). From groups with low and high adherence to guidelines we selected pairs of patients (n=588) with similar (or close) age, type of ACS, GRACE score, Killip class, presence of other important risk factors (CHF, AF, previous stroke), and formed 2 equal subgroups without significant differences in important demographic, anamnestic, clinical and laboratory data. Hospital mortality was 7.8 and 2.7% in low and high adherence subgroup, respectively (p<0.0001). CONCLUSIONS: In RECORD-2 ACS registry low adherence to guidelines was more frequent among high risk patients and was independent predictor of inhospital death. Association between degree of guidelines adherence and outcomes persisted after equalizing groups by some factors of risk of mortality.

[Assessment of the prognostic value of the CRUSADE score in patients with acute coronary syndromes hospitalized in a noninvasive hospital].

Background. The CRUSADE score was created for assessment of bleeding risk in patients with acute coronary syndrome (ACS). However its accuracy was not confirmed in populations of patients treated in Russian hospitals, in noninvasively managed patients, in patients without myocardial infarction (MI). Aim. To assess prognostic value of the CRUSADE score in all pts with ACS, hospitalized in a noninvasive hospital in Russia. Material and methods. Study group comprised 602 patients with ACS admitted to a Moscow community noninvasive hospital (mean age 69.6+/-12.4 years, non-ST elevation ACS - 84.2%). The group was formed by inclusion of 25 consecutively hospitalized patients per month. During hospitalization we registered deaths and all bleeding events classified by TIMI and/or GUSTO criteria. The cut-off of high bleeding risk for CRUSADE score was 40. Results. Any bleedings occurred in 91 patients (15.1%), combination of major and moderate bleedings was registered in 36 patients (6.0%). In high bleeding risk group by CRUSADE score in comparison with non-high risk group bleedings were significantly more frequent (total 20.8 vs. 9.9%, respectively, p=0.0002; major 6.9 vs 1.9%, respectively, p=0.0024; moderate 5.2% vs 1.6%, respectively, p=0.013; combination of major and moderate 9.4 vs 2.9%, respectively, p=0.0007). Sensitivity and specificity of the CRUSADE score for sum of major and moderate bleedings during hospitalization were 77% and 52%, respectively, with area under ROC-curve 0.68. We selected 149 patients (24.8%) who had similar characteristic with patients of the CRUSADE derivation cohort (non-ST elevation MI, no use of vitamin K antagonists, survival and no discharge 48 hours after admission). In this CRUSADE-specific group rate of major/moderate bleedings was significantly higher among high risk compared with other patients (15.6% vs 3.5%, respectively, p=0.016), but for all bleedings difference between these groups was not significant (28.1 vs. 17.6%, p=0.16). In the CRUSADE-specific group sensitivity and specificity of the CRUSADE score for major/moderate bleedings during hospitalization were 81 and 59%, respectively, with area under ROC-curve 0.76. Conclusions. In noninvasively treated ACS patients high risk of bleeding by CRUSADE score was closely associated with occurrence of total as well as major and moderate bleedings. Prognostic accuracy of the CRUSADE score for prediction of major or moderate bleeding during hospitalization was higher in CRUSADE-specific group (patients satisfying criteria of the CRUSADE derivation cohort).

[Cystatin C and bleedings during hospitalization of noninvasively treated patients with acute coronary syndromes].

PURPOSE: To assess relationship between blood level of a marker of renal function cystatin C (CC) and bleeding events in patients with acute coronary syndromes (ACS). MATERIAL AND METHODS: CC level was measured in 160 patients from the ACS registry conducted in a noninvasive hospital in Moscow. Each month we included in this registry 25 consecutively hospitalized patients and recorded deaths and bleeding events (major and moderate by TIMI and/or GUSTO criteria) during hospitalization. CC measurement was made by ELISA in stored blood samples taken within first 24 hours after admission. The cut-off level for CC (> 1.53 mg/l) was established by ROC analysis. RESULTS: There were 10 deaths (6.3%) and 11 bleeding events (6.9%) during hospitalization (median 20 days). Inhospital mortality was 45.5 and 3.4% % among patients with and without bleeding, respectively (=0.0001). Bleeding events occurred significantly more often among patients with CC level >1.53 mg/l compared to those with CC level less or equal 1.53 mg/l (13.8 and 2.1%; respectively, p=0.008). Multifactorial regression analysis identified the following independents predictors of bleeding: thrombolysis at admission (odds ratio [OR] 9.32; 95% confidence interval [95%CI] 1.96-44.29; =0.005), CC level >1.53 mg/l (OR 7.96; 95% CI 1.34-47.26; p=0.023), initial white blood cells count (OR 1.31; 95%CI 1.10-1.57; =0.003). When CC was excluded from regression analysis creatinine clearance entered the list of independent predictors of bleeding (OR 0.95; 95% CI 0.90-0.99; =0.023). CONCLUSION: In this group of noninvasively treated patients with ACS high CC level (>1.53 mg/l) was independently related to major and moderate bleedings during hospitalization. If CC was excluded from analysis, another marker of renal function (creatinine clearance) became an independent predictor of inhospital bleeding.

[Factors associated with inhospital severe bleeding in noninvasively treated patients with non ST elevation acute coronary syndrome].

UNLABELLED: Risk factors of bleeding in acute coronary syndrome (ACS) were derived from data of clinical trials and registers with high proportion of invasively treated patients. Aim of this study was to elucidate factors associated with severe bleeding in patients with non ST-elevation (NSTE) ACS treated in a noninvasive hospital. MATERIAL AND METHODS: From November 2009 to April 2011 24 NSTEACS patients had severe GUSTO or TIMI bleeding. For each of these patients we selected 3 age matched controls without severe bleeding from hospital registry of ACS in which we included 25 consecutive patients each month during about the same period of time. RESULTS: The group of patients with severe bleeding compared with control group (n = 72) had greater portions of patients with Killip class > or = 2 (50.0% vs 16.7%; p = 0.002), with history of chronic renal failure (20.8% vs 4.2%; p = 0.02) or bleeding (16.7 vs 2.8%, p = 0.03), with admission creatinine clearance < 30 (20.8% vs 5.6%; p = 0.04), with GRACE score > 140 (75.0 vs 45.8%, p = 0.01). Patients with bleeding prehospitally less frequently received aspirin (25.0 vs 58.3%, p = 0.005) and parenteral anticoagulants (16.7 vs 38.9%, p = 0.04), while in hospital they were more frequently given diuretics (62.5 and 26.4%, p = 0.005) and less frequently--low molecular weight heparin (8.3 vs 20.8%, p = 0.045) while use of parental anticoagulants was similar in both groups (87.5 vs 91.7%, respectively). Mortality and rate of inhospital myocardial infarctions in groups with and without bleeding were 62.5 and 1.4%, 21.7 and 1.4%, respectively. CONCLUSIONS: Inhospital severe bleeding in noninvasively treated patients with NSTEACS was associated with: well known predictors (heart and renal failure, history of bleeding); high risk of ischemic events and therefore very high mortality; lesser use of some antithrombotic drugs at various stages of treatment.