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      Spectrum of Acute Coronary Syndromes: History and Clinical Presentation in Relation to Sex and Age

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          Objectives: To study sex-based differences in the clinical presentation in relation to age and type of acute coronary syndrome (ACS) in patients under 80 years of age. Methods: The study includes 1,744 consecutive patients with the full spectrum of ACS (ST elevation myocardial infarction (MI), non-ST elevation MI, and unstable angina of high- and low-risk types) admitted to the coronary care unit in a university hospital. Results: The women were older than the men and were as likely to present with ST elevation MI. They had lower rates of prior MI and prior coronary artery bypass surgery than men but similar rates of percutaneous coronary interventions. Further, women were less likely to have a short delay before admission to hospital and they were attended to less rapidly in the emergency department. The prevalence of risk factors, prior cardiovascular disease and ongoing treatment with cardiovascular drugs were strongly associated with less severe type of ACS with no significant sex interaction. Presentation with non-ST elevation MI was significantly associated with older age while the opposite was true for unstable low-risk angina. ECG signs of acute ischemia were not associated with age. Significant interactions between age and sex were observed for the prevalence of treatment with diuretics as well as hypotension at presentation, both more prevalent among women than men below 65 years of age. Conclusions: Women are struck by ACS at a higher age than men, are less likely to present early for hospital care, and at younger age women are more likely to present with hypotension. There is a striking difference in risk factors and previous history depending on type of ACS in both sexes.

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          Most cited references 13

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          Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. The PURSUIT Trial Investigators. Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy.

          Aggregation of platelets is the pathophysiologic basis of the acute coronary syndromes. Eptifibatide, a synthetic cyclic heptapeptide, is a selective high-affinity inhibitor of the platelet glycoprotein IIb/IIIa receptor, which is involved in platelet aggregation. We tested the hypothesis that inhibition of platelet aggregation with eptifibatide would have an incremental benefit beyond that of heparin and aspirin in reducing the frequency of adverse outcomes in patients with acute coronary syndromes who did not have persistent ST-segment elevation. Patients who had presented with ischemic chest pain within the previous 24 hours and who had either electrocardiographic changes indicative of ischemia (but not persistent ST-segment elevation) or high serum concentrations of creatine kinase MB isoenzymes were enrolled in the study. They were randomly assigned, in a double-blind manner, to receive a bolus and infusion of either eptifibatide or placebo, in addition to standard therapy, for up to 72 hours (or up to 96 hours, if coronary intervention was performed near the end of the 72-hour period). The primary end point was a composite of death and nonfatal myocardial infarction occurring up to 30 days after the index event. A total of 10,948 patients were enrolled between November 1995 and January 1997. As compared with the placebo group, the eptifibatide group had a 1.5 percent absolute reduction in the incidence of the primary end point (14.2 percent, vs. 15.7 percent in the placebo group; P=0.04). The benefit was apparent by 96 hours and persisted through 30 days. The effect was consistent in most major subgroups except for women (odds ratios for death or nonfatal myocardial infarction, 0.8 [95 percent confidence interval, 0.7 to 0.9] in men, and 1.1 [0.9 to 1.31 in women). Bleeding was more common in the eptifibatide group, although there was no increase in the incidence of hemorrhagic stroke. Inhibition of platelet aggregation with eptifibatide reduced the incidence of the composite end point of death or nonfatal myocardial infarction in patients with acute coronary syndromes who did not have persistent ST-segment elevation.
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            Management of acute coronary syndromes. Variations in practice and outcome; findings from the Global Registry of Acute Coronary Events (GRACE).

            Despite advances in the treatment of acute coronary syndromes based on randomized trial data and published guidelines, the extent to which such treatments are applied in practice remains uncertain. Data from clinical trials derive from selected geographical areas and in highly selected populations of patients, and hence may not reflect the overall population. The aim of the study was to investigate variations in hospital management and outcome using unselected data collected in the prospective Global Registry of Acute Coronary Events (GRACE). The 95 hospitals in GRACE were organized into 18 population-based clusters in 14 countries. Information was recorded about patient management and outcome during hospitalization and after discharge. Data on treatments administered were analysed by baseline condition, hospital type, by the presence or absence of a catheterization laboratory, and by geographical region. Of 11543 patients, 44% had an admission diagnosis of unstable angina, 36% presented with myocardial infarction, 9% were admitted to rule out a myocardial infarction, 7% had chest pain and 4% were hospitalized for 'other cardiac' and 'non-cardiac' diagnoses. Of the total GRACE population 38% had a final diagnosis of unstable angina, 30% ST-segment elevation myocardial infarction, 25% non-ST-segment elevation myocardial infarction, and 7% of 'other cardiac' and 'non-cardiac' final diagnoses. The event rates for hospital death or reinfarction were six and 2% for non-ST-segment elevation myocardial infarction, seven and 3% for ST-segment elevation myocardial infarction, and 3% hospital death for unstable angina. The use of aspirin was similar across all hospital types and geographical regions. In contrast, the use of percutaneous coronary intervention and glycoprotein IIb/IIIa inhibitors was higher (P<0.0001) in teaching hospitals and hospitals with catheterization laboratories and was also higher in the United States. At discharge a higher percentage (P<0.0001) of patients received angiotensin-converting enzyme inhibitors in hospitals without catheterization laboratories. The use of statins was lower in non-teaching hospitals and in centres without a catheterization laboratory. The GRACE study reveals substantial differences in the management of patients based on hospital type and geographical location. Further analyses will determine whether such variations translate into differences in longer term outcomes. GRACE provides a multinational reference for the implementation of therapies of proven efficacy. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved.
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              Extent of, and factors associated with, delay to hospital presentation in patients with acute coronary disease (the GRACE registry).

              Our primary study aim was to examine extent of, and factors associated with, delay in seeking medical care in a large multinational registry of patients with acute myocardial infarction (AMI) and unstable angina pectoris. A secondary goal was to examine the relation between duration of prehospital delay and receipt and timing of coronary reperfusion strategies. Investigators from 14 countries are participating in the Global Registry of Acute Coronary Events (GRACE) project. The study sample consisted of 3,693 patients with ST-segment elevation AMI, 2,935 with non-ST-segment elevation AMI, and 3,954 patients with unstable angina hospitalized between 1999 and 2001. The average and median delay times were longest in patients with non-ST-segment elevation AMI (6.1 and 3.0 hours, respectively) followed by patients with unstable angina (5.6 and 3.0 hours) and those with ST-segment elevation AMI (4.7 and 2.3 hours). Approximately 41% of patients with ST-segment elevation AMI presented to the 94 study hospitals within 2 hours of the onset of acute coronary symptoms; this compared with approximately one third of patients with non-ST-segment elevation AMI and unstable angina. Several demographic and clinical characteristics were associated with prehospital delay. In patients with ST-segment elevation AMI, duration of prehospital delay was inversely related to the receipt of thrombolytic therapy, but was inconsistently related to the use of percutaneous coronary interventions. The results of this study demonstrate that a large proportion of patients continue to exhibit prolonged delay in seeking medical care after the onset of acute coronary symptoms and remain in need of targeted educational efforts to reduce extent of delay.

                Author and article information

                S. Karger AG
                July 2004
                09 July 2004
                : 102
                : 2
                : 67-76
                Departments of aCardiology and bClinical Physiology, Sahlgrenska University Hospital, Göteborg, Sweden
                77907 Cardiology 2004;102:67–76
                © 2004 S. Karger AG, Basel

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                Page count
                Tables: 6, References: 33, Pages: 10
                General Cardiology


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