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      Outcomes in Patients with Acute and Stable Coronary Syndromes; Insights from the Prospective NOBORI-2 Study

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          Abstract

          Background

          Contemporary data remains limited regarding mortality and major adverse cardiac events (MACE) outcomes in patients undergoing PCI for different manifestations of coronary artery disease.

          Objectives

          We evaluated mortality and MACE outcomes in patients treated with PCI for STEMI (ST-elevation myocardial infarction), NSTEMI (non ST-elevation myocardial infarction) and stable angina through analysis of data derived from the Nobori-2 study.

          Methods

          Clinical endpoints were cardiac mortality and MACE (a composite of cardiac death, myocardial infarction and target vessel revascularization).

          Results

          1909 patients who underwent PCI were studied; 1332 with stable angina, 248 with STEMI and 329 with NSTEMI. Age-adjusted Charlson co-morbidity index was greatest in the NSTEMI cohort (3.78±1.91) and lowest in the stable angina cohort (3.00±1.69); P<0.0001. Following Cox multivariate analysis cardiac mortality was independently worse in the NSTEMI vs the stable angina cohort (HR 2.31 (1.10–4.87), p = 0.028) but not significantly different for STEMI vs stable angina cohort (HR 0.72 (0.16–3.19), p = 0.67). Similar observations were recorded for MACE (<180 days) (NSTEMI vs stable angina: HR 2.34 (1.21–4.55), p = 0.012; STEMI vs stable angina: HR 2.19 (0.97–4.98), p = 0.061.

          Conclusions

          The longer-term Cardiac mortality and MACE were significantly worse for patients following PCI for NSTEMI even after adjustment of clinical demographics and Charlson co-morbidity index whilst the longer-term prognosis of patients following PCI STEMI was favorable, with similar outcomes as those patients with stable angina following PCI.

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          Most cited references3

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          Baseline characteristics, management practices, and in-hospital outcomes of patients hospitalized with acute coronary syndromes in the Global Registry of Acute Coronary Events (GRACE).

          Acute coronary syndrome (ACS) represents a heterogenous spectrum of conditions. The Global Registry of Acute Coronary Events (GRACE) describes the epidemiology, management, and outcomes of patients with ACS. Data were collected from 11,543 patients enrolled in 14 countries. Of these patients, 30% had ST-segment elevation myocardial infarction (STEMI), 25% had non-ST-segment elevation myocardial infarction (NSTEMI), 38% had unstable angina pectoris, and 7% had other cardiac or noncardiac diagnoses. Over half of these patients (53%) were >/=65 years old. Reperfusion therapy was used in 62% of patients with STEMI. Percutaneous coronary intervention was performed in 40% of these subjects during the index admission. Intravenous glycoprotein IIb/IIIa blockers were used in 23%, 20%, and 7% of patients with STEMI, NSTEMI, and unstable angina, respectively (STEMI vs NSTEMI, p = 0.0018, and for either group vs unstable angina, p <0.001). Coronary artery bypass grafting was performed in 4%, 10%, and 5% of patients, respectively (p <0.0001). Hospital case fatality rates were markedly different among patients with STEMI, NSTEMI, and unstable angina (7%, 6%, and 3%, respectively; STEMI vs NSTEMI, p = 0.0459, and for either group vs unstable angina, p <0.001). Congestive heart failure complicated the hospital course in 18%, 18%, and 10% of the patients, respectively (p <0.0001), and recurrent angina with ST-segment changes occurred before discharge in 10%, 10%, and 9% of patients, respectively (p = 0.2644). GRACE provides a detailed and comprehensive global description of the spectrum of patients with ACS.
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            STEMI and NSTEMI: are they so different? 1 year outcomes in acute myocardial infarction as defined by the ESC/ACC definition (the OPERA registry).

            The ESC/ACC redefined myocardial infarction as any amount of necrosis caused by ischaemia. The aim of this study was to describe the management and outcomes using 'real-world' data taking the new definition of acute myocardial infarction into account. A total of 2,151 consecutive patients (76.0% men) with a myocardial infarction were enrolled at 56 centres in France. The median delay to presentation was shorter in patients with ST-segment elevation myocardial infarction (STEMI) vs. non-STEMI (NSTEMI) (4 vs. 7 h, P < 0.0001). STEMI patients were more likely to receive fibrinolysis (28.9 vs. 0.7%, P < 0.0001) or undergo PCI (71.0 vs. 51.6%, P < 0.0001) but less likely to have bypass surgery (3.1 vs. 4.9%, P < 0.05). At discharge, patients with STEMI received more aggressive secondary prevention therapies than those with NSTEMI, which was not supported by differences in disease severity. A total of 1878 patients were followed-up for 1 year: 36.7% of STEMI and 41.5% of NSTEMI patients were rehospitalized (P = 0.05); 16% in both groups were revascularized. In-hospital mortality was similar (4.6 vs. 4.3%), and 1-year mortality was 9.0% in STEMI patients and 11.6% in NSTEMI patients (Log-Rank P = 0.09). Independent correlates of in-hospital mortality were untreated dyslipidaemia, advanced age, diabetes, and low blood pressure. The strongest predictors of 1-year mortality were heart failure and age. Similar predictors were found in STEMI and NSTEMI subgroups. Despite different management, patients with STEMI and NSTEMI have similar prognoses and independent correlates of outcome. These findings support the new definition of myocardial infarction.
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              Mortality of patients with acute coronary syndromes still remains high: a follow-up study of 1188 consecutive patients admitted to a university hospital.

              Based on randomized clinical trials, mortality of acute coronary syndrome (ACS) has been considered to be relatively low. The prognosis of clinical presentations of ACS in real-life patient cohorts has not been well documented. The aim of this study was to evaluate actual clinical outcome across the whole spectrum of ACS in a series of unselected prospectively collected consecutive patients from a defined geographical region, all admitted to one university hospital. A total of 1188 patients with ST-elevation myocardial infarction (STEMI), non-ST-elevation MI (NSTEMI) or unstable angina pectoris (UA) were included. Results. In-hospital mortality was 9.6%, 13% and 2.6% (P<0.001) and mortality at a median follow-up of 10 months 19%, 27% and 12% (P<0.001), for the three ACS categories, respectively. In multivariate Cox regression analysis age, diabetes mellitus type 1, diuretic use at admission, creatinine level, lower systolic blood pressure, STEMI and NSTEMI ACS category were associated with higher mortality during follow-up. In an unselected patient cohort, short-term mortality of MI patients, especially those classified as NSTEMI, still was high despite increasing use of proven treatment modalities.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2014
                14 February 2014
                : 9
                : 2
                : e88577
                Affiliations
                [1 ]Manchester Heart Centre, Manchester Royal Infirmary, Manchester, United Kingdom
                [2 ]SBD Analytics, Hertstraat, Bekkevoort, Belgium
                [3 ]Division of Cardiology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
                [4 ]Department of Cardiology, Rambam Medical Center, Haifa, Israel
                [5 ]European Medical and Clinical Division, Terumo Europe, Leuven, Belgium
                [6 ]Cardiovascular Institute, University of Manchester, Manchester, United Kingdom
                College of Pharmacy, University of Florida, United States of America
                Author notes

                Competing Interests: Dr Dragica Paunovic is affiliated to Terumo Europe N.V. Leuven, Belgium, but this does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials. There are no other conflicts of interest to report.

                Conceived and designed the experiments: FF ES MM. Analyzed the data: MK DP MM. Contributed reagents/materials/analysis tools: ME DF GD. Wrote the paper: ES AR DP MM. Recruited patients for study; edited manuscript for intellectual content: FF ME DF LN.

                Article
                PONE-D-13-32074
                10.1371/journal.pone.0088577
                3925145
                24551120
                660a497b-1c0b-4907-87a9-ffd38c21c6df
                Copyright @ 2014

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 6 August 2013
                : 8 January 2014
                Page count
                Pages: 7
                Funding
                Terumo Europe N.V. Leuven, Belgium ( www.terumo-europe.com/) provided a research grant but had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Biology
                Population biology
                Population metrics
                Death rate
                Medicine
                Cardiovascular
                Acute cardiovascular problems
                Angina
                Atherosclerosis
                Coronary artery disease
                Interventional cardiology
                Myocardial infarction
                Clinical research design
                Clinical trials
                Prospective studies
                Statistical methods
                Drugs and devices
                Adverse reactions

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                Uncategorized

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