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The study attempts to evaluate the relationship between sex and 30-day mortality in acute coronary syndrome (ACS) and whether the relationship was modified. The results indicate that sex-based differences did exist and vary depending on clinical presentation.

Importance: Acute coronary syndromes (ACS) are characterized by a sudden reduction in blood supply to the heart and include ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina. Each year, an estimated more than 7 million people in the world are diagnosed with ACS, including more than 1 million patients hospitalized in the US.Observations: Chest discomfort at rest is the most common presenting symptom of ACS and affects approximately 79% of men and 74% of women presenting with ACS, although approximately 40% of men and 48% of women present with nonspecific symptoms, such as dyspnea, either in isolation or, more commonly, in combination with chest pain. For patients presenting with possible ACS, electrocardiography should be performed immediately (within 10 minutes of presentation) and can distinguish between STEMI and non-ST-segment elevation ACS (NSTE-ACS). STEMI is caused by complete coronary artery occlusion and accounts for approximately 30% of ACS. ACS without significant ST-segment elevation on electrocardiography, termed NSTE-ACS, account for approximately 70% of ACS, are caused by partial or intermittent occlusion of the artery and are associated with ST-segment depressions (approximately 31%), T-wave inversions (approximately 12%), ST-segment depressions combined with T-wave inversions (16%), or neither (approximately 41%). When electrocardiography suggests STEMI, rapid reperfusion with primary percutaneous coronary intervention (PCI) within 120 minutes reduces mortality from 9% to 7%. If PCI within 120 minutes is not possible, fibrinolytic therapy with alteplase, reteplase, or tenecteplase at full dose should be administered for patients younger than 75 years without contraindications and at half dose for patients 75 years or older (or streptokinase at full dose if cost is a consideration), followed by transfer to a facility with the goal of PCI within the next 24 hours. High-sensitivity troponin measurements are the preferred test to evaluate for NSTEMI. In high-risk patients with NSTE-ACS and no contraindications, prompt invasive coronary angiography and percutaneous or surgical revascularization within 24 to 48 hours are associated with a reduction in death from 6.5% to 4.9%.Conclusions and Relevance: Each year, an estimated more than 7 million people are diagnosed with ACS worldwide. For patients with STEMI, coronary catheterization and PCI within 2 hours of presentation reduces mortality, with fibrinolytic therapy reserved for patients without access to immediate PCI. For high-risk patients with NSTE-ACS without contraindications, prompt invasive coronary angiography followed by percutaneous or surgical revascularization is associated with lower rates of death. [ABSTRACT FROM AUTHOR]

Assessment of quality in health care delivery plays an increasingly prominent role in contemporary medical practice and selected care processes are increasingly being used to measure hospital quality, however, data regarding the association between hospital process performance and outcomes are limited. Government agencies, professional societies, accreditation organizations, and major insurers all have published sets of performance indicators.

The use and predictors of early invasive management strategies in high-risk patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) is determined and the association of early invasive management with mortality is examined. It is found out that an early invasive management strategy is not utilized in the majority of high-risk patients with NSTE ACS.

The association between blood transfusion and mortality among patients with acute coronary syndromes who develop bleeding, anemia or both during their hospital course are determined. It was found that blood transfusion in the setting of acute coronary syndromes is associated with higher mortality and this relationship persists after adjustment for other predictive factors and timing of events.

Unstable angina combined with non-ST-segment elevation myocardial infarction (UA/NSTEMI) acute coronary syndromes (ACS) is the most common manifestations of coronary heart disease that lead to death. More than twenty thousand patients were studied across the ACS spectrum, and it was found that enoxaparin is more effective than unfractionated heparin in preventing combined end point of death or myocardial infarction.

The Killip classification system can accurately predict which patients with a non-ST-segment heart attack may die within the following year, according to a study of 26,090 patients. Those in Killip class 3 or 4 had higher 30-day and six-month death rates than those in Killip class 1 or 2. The Killip classification is used to indicate a patient's degree of heart failure. Killip 1 or 2 indicates no heart failure or mild heart failure and Killip 3 or 4 indicates moderate to severe heart failure.

The drug bivalirudin may be as effective as heparin when used to prevent complications from coronary angioplasty, according to a study of 6,010 patients. Bivalirudin is an anticoagulant drug that can prevent blood clots from forming during coronary angioplasty.

Doctors are developing practice guidelines to use for patients with chest pain. The guidelines include techniques for classifying patients at high risk of heart attack and death. These patients could be given anticoagulant drugs.

Even a small increase in blood levels of creatine kinase-MB (CK-MB) may be an indication that a patient is having a heart attack. This compound is released from heart muscle when it is damaged and can be measured in blood samples. Researchers measured blood levels of CK-MB in 8,250 patients who came to a hospital with the symptoms of a heart attack. None had ST-segment elevation on their ECG, which is also a sign of heart attack. Mortality rates at 30 days and 6 months were greater in those with elevated CK-MB levels, even if the increase was small.

Importance: Little information exists about the anatomical characteristics and clinical relevance of non-infarct-related artery (IRA) disease among patients with ST-segment elevation myocardial infarction (STEMI).Objectives: To investigate the incidence, extent, and location of obstructive non-IRA disease and compare 30-day mortality according to the presence of non-IRA disease in patients with STEMI.Design, Setting, and Participants: Retrospective study of patients pooled from a convenience sample of 8 independent, international, randomized STEMI clinical trials published between 1993 and 2007. Follow-up varied from 1 month to 1 year. Among 68,765 patients enrolled in the trials, 28,282 patients with valid angiographic information were included in this analysis. Obstructive coronary artery disease was defined as stenosis of 50% or more of the diameter of a major epicardial artery. To assess the generalizability of trial-based results, external validation was performed using observational data for patients with STEMI from the Korea Acute Myocardial Infarction Registry (KAMIR) (between November 1, 2005, and December 31, 2013; n = 18,217) and the Duke Cardiovascular Databank (between January 1, 2005, and December 31, 2012; n = 1812).Main Outcomes and Measures: Thirty-day mortality following STEMI.Results: Overall, 52.8% (14,929 patients) had obstructive non-IRA disease; 29.6% involved 1 vessel and 18.8% involved 2 vessels. There was no substantial difference in the extent and distribution of non-IRA disease according to the IRA territory. Unadjusted and adjusted rates of 30-day mortality were significantly higher in patients with non-IRA disease than in those without non-IRA disease (unadjusted, 4.3% vs 1.7%, respectively; risk difference, 2.7% [95% CI, 2.3% to 3.0%], P < .001; and adjusted, 3.3% vs 1.9%, respectively; risk difference, 1.4% [95% CI, 1.0% to 1.8%], P < .001). The overall prevalence and association of non-IRA disease with 30-day mortality was consistent with findings from the KAMIR registry (adjusted, 3.6% for patients with non-IRA disease vs 2.5% in those without it; risk difference, 1.1% [95% CI, 0.6% to 1.7%]; P < .001), but not with the Duke database (adjusted, 4.7% with non-IRA disease vs 4.3% without it; risk difference, 0.4% [95% CI, -1.4% to 2.2%], P = .65).Conclusions and Relevance: In a retrospective pooled analysis of 8 clinical trials, obstructive non-IRA disease was common among patients presenting with STEMI, and was associated with a modest statistically significant increase in 30-day mortality. These findings require confirmation in prospectively designed studies, but raise questions about the appropriateness and timing of non-IRA revascularization in patients with STEMI. [ABSTRACT FROM AUTHOR]

IMPORTANCE Little information exists about the anatomical characteristics and clinical relevance of non--infarct-related artery (IRA) disease among patients with ST-segment elevation myocardial infarction (STEMI). OBJECTIVES To investigate the incidence, extent, and location of obstructive non-IRA disease and compare 30-day mortality according to the presence of non-IRA disease in patients with STEMI. DESIGN, SETTING, AND PARTICIPANTS Retrospective study of patients pooled from a convenience sample of 8 independent, international, randomized STEMI clinical trials published between 1993 and 2007. Follow-up varied from 1 month to 1 year. Among 68 765 patients enrolled in the trials, 28 282 patients with valid angiographic information were included in this analysis. Obstructive coronary artery disease was defined as stenosis of 50% or more of the diameter of a major epicardial artery. To assess the generalizability of trial-based results, external validation was performed using observational data for patients with STEMI from the Korea Acute Myocardial Infarction Registry (KAMIR) (between November 1, 2005, and December 31, 2013; n = 18 217) and the Duke Cardiovascular Databank (between January 1, 2005, and December 31, 2012; n = 1812). MAIN OUTCOMES AND MEASURES Thirty-day mortality following STEMI. RESULTS Overall, 52.8%(14 929 patients) had obstructive non-IRA disease; 29.6%involved 1 vessel and 18.8% involved 2 vessels. There was no substantial difference in the extent and distribution of non-IRA disease according to the IRA territory. Unadjusted and adjusted rates of 30-day mortality were significantly higher in patients with non-IRA disease than in those without non-IRA disease (unadjusted, 4.3%vs 1.7%, respectively; risk difference, 2.7%[95% CI, 2.3%to 3.0%], P < .001; and adjusted, 3.3%vs 1.9%, respectively; risk difference, 1.4% [95%CI, 1.0% to 1.8%], P < .001). The overall prevalence and association of non-IRA disease with 30-day mortality was consistent with findings from the KAMIR registry (adjusted, 3.6% for patients with non-IRA disease vs 2.5%in those without it; risk difference, 1.1%[95%CI, 0.6%to 1.7%]; P < .001), but not with the Duke database (adjusted, 4.7%with non-IRA disease vs 4.3%without it; risk difference, 0.4%[95%CI, --1.4%to 2.2%], P = .65). CONCLUSIONS AND RELEVANCE In a retrospective pooled analysis of 8 clinical trials, obstructive non-IRA disease was common among patients presenting with STEMI, and was associated with a modest statistically significant increase in 30-day mortality. These findings require confirmation in prospectively designed studies, but raise questions about the appropriateness and timing of non-IRA revascularization in patients with STEMI. [ABSTRACT FROM AUTHOR]

The article presents information on the effects of the acadesine, an adenosine-regulating agent on the morbidity and mortality associated with the coronary artery bypass grafting (CABG), which could be high in the patients with poor left ventricular function. It informs that the several drugs with purported cardioprotective effects including sodium-proton exchange inhibitor, a complement activation inhibitor and a purinergic receptor antagonist failed during the randomized control trials in the patients undergoing the CABG surgery. It further informs that there is a requirement of a fully functional therapy for this.

The article discusses a study of the safety and efficacy of a single intravenous bolus of epoetin alfa in patients with ST-segment elevation myocardial infarction (STEMI) in the U.S. conducted from October 2006 to February 2010. The risk for developing infarct expansion and left ventricular (LV) remodeling are facing patients who survive STEMI. Vital signs, hemoglobin level, reticulocyte count and clinical events were some of the factors considered as safety end points. Results show a lack of association between infarct size and time from study drug administration to first cardiac magnetic resonance (CMR). Also noted is the higher incidence of adverse events in participants who received epoetin alfa.

The author discusses the need for the proper use of the criteria for coronary revascularization and for the learning health system. It mentions the principle promoted by the Institute of Medicine on the health care system and the promotion of natural outgrowth of patient care. It discusses the programs initiated by the American Heart Association (AHA) and the American College of Cardiology on the care for patients with coronary revascularization.

The article focuses on a study testing the effectiveness and safety of the naturally occurring pyridoxine metabolite and purinergic receptor antagonist MC-1 given to patients undergoing coronary artery bypass graft (CABG) surgery. The objective of the trial was to reduce morbidity and mortality rates in CABG patients due to common complications related to ischemia-reperfusion injury and myocardial infarction (MI). Researchers concluded that MC-1 did not reduce cardiovascular death or nonfatal MI among intermediate to high-risk patients undergoing CABG surgery.

Context: Cardiogenic shock complicating acute myocardial infarction (MI) remains a common and lethal disorder despite aggressive use of early revascularization. Systemic inflammation, including expression of inducible nitric oxide synthase (NOS) and generation of excess nitric oxide, is believed to contribute to the pathogenesis and inappropriate vasodilatation of persistent cardiogenic shock. Preliminary, single-center studies suggested a beneficial effect of NOS inhibition on hemodynamics, renal function, and survival in patients with cardiogenic shock.Objective: To examine the effects of an isoform-nonselective NOS inhibitor in patients with MI and refractory cardiogenic shock despite establishment of an open infarct artery.Design, Setting, and Patients: International, multicenter, randomized, double-blind, placebo-controlled trial (Tilarginine Acetate Injection in a Randomized International Study in Unstable MI Patients With Cardiogenic Shock [TRIUMPH]) with planned enrollment of 658 patients at 130 centers. Participants were enrolled between January 2005 and August 2006 when the study was terminated early.Intervention: Tilarginine (L-N(G)-monomethylarginine [L-NMMA]), 1-mg/kg bolus and 1-mg/kg per hour 5-hour infusion, vs matching placebo.Main Outcome Measures: The primary outcome was 30-day all-cause mortality among patients who received study medication. Secondary outcomes included shock resolution and duration, New York Heart Association (NYHA) functional class at 30 days, and 6-month mortality.Results: Enrollment was terminated at 398 patients based on a prespecified futility analysis. Six-month follow-up was completed in February 2007. There was no difference in 30-day all-cause mortality between patients who received tilarginine (97/201 [48%]) vs placebo (76/180 [42%]) (risk ratio, 1.14; 95% confidence interval, 0.92-1.41; P = .24). Resolution of shock (133/201 [66%] tilarginine vs 110/180 [61%] placebo; P = .31) and duration of shock (median, 156 [interquartile range, 78-759] hours tilarginine vs 190 [100-759] placebo; P = .16) were similar. At 30 days a similar percentage of patients had heart failure (48% tilarginine vs 51% placebo; P = .51) with a similar percentage of those patients in NYHA class I/II (73% tilarginine vs 75% placebo; P = .27). After 6 months mortality rates were similar in the 2 groups (58% tilarginine vs 59% placebo; hazard ratio, 1.04; 95% confidence interval, 0.79-1.36; P = .80).Conclusions: Tilarginine, 1-mg/kg bolus and 5-hour infusion, did not reduce mortality rates in patients with refractory cardiogenic shock complicating MI despite an open infarct artery. Early mortality rates in this patient group are high. Further research is needed to develop effective therapies for patients with cardiogenic shock following acute MI.Trial Registration: clinicaltrials.gov Identifier: NCT00112281 [ABSTRACT FROM AUTHOR]

The authors discuss facets and strategies of the study reported in this issue in the article, "Routine upstream initiation vs deferred selective use of glycoprotein IIb/IIIa inhibitors in acute coronary syndromes." They feel the study provides valuable insights for clinical practice and research and suggest that, until risks linked to increases in bleeding and ischemic complications are clarified, clinical decision making should be weighed on a case-by-case basis.

The article discusses a clinical study that was conducted to examine the association between the use of the drug clopidogrel after patients received either a drug-eluting stent or a bare-metal stent for the treatment of coronary artery disease. Clopidogrel is a drug used in thienopyridine antiplatelet therapy to prevent late stent thrombosis. The authors were interested in the long-term outcomes of patients and found that the use of clopidogrel in patients with drug-eluting stents may be associated with a lower risk of death or myocardial infarction.

Context: Coronary artery bypass graft (CABG) surgery with autologous vein grafting is commonly performed. Progressive neointimal hyperplasia, however, contributes to considerable vein graft failure. Edifoligide is an oligonucleotide decoy that binds to and inhibits E2F transcription factors and thus may prevent neointimal hyperplasia and vein graft failure.Objective: To assess the efficacy and safety of pretreating vein grafts with edifoligide for patients undergoing CABG surgery.Design, Setting, and Participants: A phase 3 randomized, double-blind, placebo-controlled trial of 3014 patients undergoing primary CABG surgery with at least 2 planned saphenous vein grafts and without concomitant valve surgery, who were enrolled between August 2002 and October 2003 at 107 US sites.Intervention: Vein grafts were treated ex vivo with either edifoligide or placebo in a pressure-mediated delivery system. The first 2400 patients enrolled were scheduled for 12- to 18-month follow-up angiography.Main Outcome Measures: The primary efficacy end point was angiographic vein graft failure (> or =75% vein graft stenosis) occurring 12 to 18 months after CABG surgery. Other end points included other angiographic variables, adverse events through 30 days, and major adverse cardiac events.Results: A total of 1920 patients (80%) either died (n = 91) or underwent follow-up angiography (n = 1829). Edifoligide had no effect on the primary end point of per patient vein graft failure (436 [45.2%] of 965 patients in the edifoligide group vs 442 [46.3%] of 955 patients in the placebo group; odds ratio, 0.96 [95% confidence interval {CI}, 0.80-1.14]; P = .66), on any secondary angiographic end point, or on the incidence of major adverse cardiac events at 1 year (101 [6.7%] of 1508 patients in the edifoligide group vs 121 [8.1%] of 1506 patients in the placebo group; hazard ratio, 0.83 [95% CI, 0.64-1.08]; P = .16).Conclusions: Failure of at least 1 vein graft is quite common within 12 to 18 months after CABG surgery. Edifoligide is no more effective than placebo in preventing these events. Longer-term follow-up and additional research are needed to determine whether edifoligide has delayed beneficial effects, to understand the mechanisms and clinical consequences of vein graft failure, and to improve the durability of CABG surgery. Clinical Trial Registration ClinicalTrials.gov Identifier: NCT00042081. [ABSTRACT FROM AUTHOR]

Several letters to the editor are presented in response to the article "Are medical conferences useful? and for whom?," by J. P. Ioannidis in a 2012 issue of the periodical, and a response by J. P. loannidis to letters to the editor about his article is also presented.

This editorial examines drug-eluting stents. The rapid approval of stents and short term trials did little to prepare physicians and patients for the long-term issues that have been arising. The author maintains that drug-eluting stenting is clearly a breakthrough in the prevention of restenosis. The author calls for working towards common data standards and efficient methods of data aggregation that can be integrated into clinical practice.

The authors discuss a study about the mHealth Screening to Prevent Strokes (mSToPS) pragmatic trial published within the issue. The authors state that the results of the study demonstrate the potential and the challenges inherent in a pragmatic trial for the use of information technology (IT) in health and medicine. They discuss the limitations of the study, particularly in relation to the subjects' use of their wearable electrocardiography (ECG) patch.

In this Viewpoint, Verghese and colleagues discuss the promise and challenges of integrating artificial intelligence (AI) into clinical care and argue that AI will always need guidance by physicians if it is to improve the care of patients. [ABSTRACT FROM AUTHOR]